Wednesday September 28th 2016

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Testing teenage drug use: Do’s and Don’ts

Drug Testing : An Appropriate Intervention for Teens?

It is not uncommon to consider using drug testing or urine drug screens (UDS) for monitoring a teen with known drug and alcohol use problems. This is not a bad idea but it is important to use urine drug screens appropriately and as a part of a comprehensive plan.

Here, we’ll review some of the basic protocols and best practices in drug testing. Then, we invite your questions or comments at the end. In fact, we try to respond to all legitimate questions with a personal and prompt reply.

Drug testing can be helpful when used correctly

Research shows that when combined with certain other therapeutic approaches and interventions, drug testing can be helpful. It is also important to know how drug and alcohol testing work. For example, if the teen is drug tested at a clinic, office, or elsewhere, it may only be necessary for the test to discriminate the presence or absence of drugs (positive or negative) and not necessarily the amount or concentration of drug present.

Marijuana is a good example of a common drug used by teens that can be monitored by drug testing. Marijuana may remain detectable at a standard cannabinoid cutoff level of 50 ng/ml for two to three weeks after initiation of abstinence (stop using) in persons who have been using the drug frequently (daily or almost daily) prior to stopping. However, once a negative urine test result is achieved, subsequent isolated episodes of use (e.g. once or twice a week use) will likely yield positive test results at this cutoff level for only three to four days (Huestis, Mitchell, & Cone, 1996). Hence, to measure continuous abstinence, teens may need to participate in a regular random drug testing program.

Best practices for clinical drug testing of teens

Usually the clinician will ask the teen (and sometimes the parent) about how much drug they have used since the last visit. Additionally, they will order a urine or other screening test for marijuana, cocaine, opioid prescription drugs, heroin, benzodiazepines, amphetamines, and methamphetamines, and results can be provided during the next clinical visit.

If the results for substance use are negative (i.e., drugs were not present), these findings offer an opportunity to provide positive reinforcement. When applicable, the teen is encouraged to continue his/her involvement in activities that are incompatible with drug use, as well as association with individuals who do not place the teen at risk for drug use.

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Also, the clinician can ask about problems encountered during this period of abstinence, particularly problems frequently associated with these times, such as emotional distress or cravings for specific drugs and the riskiness of certain social situations. They can then discuss what strategies or problem-solving steps the teen used to cope with these problems or other high-risk situations (e.g., identified the existence of a problem, generated a list of possible solutions, and implemented one of the solutions). The therapist can emphasize the importance of continuing to practice problem solving and to identify and respond differently to thoughts, people, places and things which can serve as drug use triggers.

Teens whose urine test results are positive for one or more illicit drugs can be asked to briefly review the circumstances and context of their drug use. This provides an opportunity to identify triggers and enhance coping. Inquiring about potential external factors (persons, places, things) and internal factors (emotional distress, cravings) associated with recent use is helpful for analyzing how to respond to those triggers The clinician could use a brief reflective statement, such as the following, summarizing some aspects of the teen’s viewpoint:

You have said that alcohol or drugs have caused some problems for you at your school, you enjoy getting high and you do not want to stop using completely at this time. But I think I heard you say you don’t want to smoke on school days any more. What are some of the strategies that can help do that?

The main point is that the clinician does not have to fight with the teen or try to make them feel badly about positive urine test results. The goal is to use motivational strategies and support the adolescent in articulating their own ideas and strategies for change (i.e. Change Talk).

What to do in cases of “false positive” drug testing?

When a teen disagrees with the results (or even flat out denies using) but has a positive drug screen result, the clinician may explain that there can be a few different reasons for the discrepancy and that it may never be entirely clear which applies in this case. The following explanations may apply and can be offered:

  • The positive result may simply mean that previously reported use has left physical traces that are showing up on the test. If the teens continues to abstain from alcohol or drugs, their drug test results will eventually be negative. Obviously this explanation is less likely to be plausible when a teen reports more than four to six weeks of abstinence.
  • For a number of reasons, the teen may not believe that it is safe to be honest about recent use and that can be explored.
  • It may be possible that something has gone wrong with the test, but this is an infrequent occurrence.

Drug testing teens can open therapeutic conversations

Drug testing can determine when an individual is having difficulties with recovery. The first response to drug use detected through urinalysis or through any other method should be a clinical one—for example, increasing treatment intensity or switching to an alternative treatment that may be more helpful.

At times, teens may express that they have to use substances because otherwise their anxiety, depression, anger, traumatic stress, or other emotional state gets worse. That can be quite possible, as depression and anxiety can feel worse especially when combined with withdrawal symptoms or if the drug numbs emotions.

Here, once again, the therapist can be empathetic and supportive but be explicit about eliciting other ways the teens may be able to reduce these symptoms. They can examine further analysis of the triggers that affect their PTSD symptoms and explore strategies for addressing them. Again, the aim is to work collaboratively, with compassion and without judgment, and to be mindfully present to new opportunities that emerge for the teen in regard to responding to daily triggers (people, places, and things), thoughts, and feelings.

Rewards and punishments need to be fair!

It is important to recognize and reinforce progress towards change and abstinence as part of the clinical process. The systematic application of behavioral management principles underlying reward and punishment can help teens reduce their drug use. Rewards and sanctions are most likely to change behavior when they are certain to follow the targeted behavior, when they follow swiftly, and when they are perceived as fair. It is important to recognize and reinforce progress toward abstinent behavior. Rewarding positive behavior is more effective in producing long-term positive change than punishing negative behavior.

Indeed, punishment alone tends to be ineffective for addressing teen addictions yet is the primary way we tend to react to the problem. Of course, limits and sanctions have to be put in place. But what kind of rewards can be offered to teens under the circumstances of drug use to help them progress towards change?

1. Nonmonetary rewards such as social recognition can be as effective as monetary ones.

2. A graduated range of rewards given (increasing the value of rewards over time) for meeting predetermined goals (e.g. weeks of negative drug screens, or school attendance) can be an effective strategy and in research has been shown to work very well with teens (Stanger & Budney, 2010).

3. Contingency management strategies, proven effective in community settings, use voucher-based incentives or rewards, such as bus tokens, to reinforce abstinence (measured by negative drug tests) or to shape progress toward other treatment goals, such as program session attendance or compliance with medication regimens and treatment. Contingency management is most effective when the contingent reward closely follows the behavior being monitored.

Drug testing combined WITH therapy and behavioral treatment

All of these strategies suggest that drug screening can be helpful especially if it is not just used for monitoring but rather combined with different therapeutic and behavioral strategies. It also offers an opportunity to work with the adolescent in understanding why, when, how and in what circumstances they use drugs and motivate and reward progress towards change. In this way drug testing and monitoring extends a whole new opportunity.

Reference Sources: Stanger, C., & Budney, A. J. (2010). Contingency Management Approaches for Adolescent Substance Use Disorders. Child and Adolescent Psychiatric Clinics of North America, 19(3), 547–562. 

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About Dr. Lisa Fortuna, MD, MPH

Lisa R. Fortuna, MD, is board-certified in child and adolescent psychiatry and in addiction medicine, with over fifteen years of clinical experience with children, adolescents, and families. She is currently faculty at Boston University School of Medicine and medical director of Child and Adolescent Psychiatry at Boston Medical Center. She has published highly cited articles in the areas of post-traumatic stress disorder (PTSD), adolescent substance abuse, and Latino and immigrant mental health. She is the author of (with Zayda Vallejo M. Litt), Treating Co-Occurring PTSD and Addiction: Mindfulness Based Cognitive Therapy for Adolescents with Trauma and Substance Use Disorders (New Harbinger, 2015).

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