Drug Testing in the Veterinary Practice

A surgical nurse takes a 1 ml vial of unopened fentanyl, carefully removes the sealed cap, and injects himself intravenously. Then, using the same syringe and needle, he replaces the contents with sterile water and glues the tamper-proof cap back on so the vial appears unopened.

Sound improbable? This actually happened at Denver’s Swedish Medical Center in January 2016, when nurse Rocky Allen admitted to potentially infecting hundreds of human patients with HIV and hepatitis C.¹ Many patients also underwent orthopedic surgery with an infusion of sterile water instead of fentanyl.¹

Similar incidents at other US human hospitals are well-documented^2-4; veterinary drug diversion incidents rarely make the news.

Vulnerability & Access

The stresses of veterinary work, including long hours, difficult cases, financial challenges, and the emotional impact of euthanasia, take their toll. As a result, the veterinary practice can become a high-risk environment for the abuse of psychoactive drugs, especially opioids and other drugs (eg, ketamine, benzodiazepines) that are relatively accessible. The illicit use of noncontrolled medications (eg, propofol, dexmedetomidine, gabapentin²) also has been reported by individuals inside and outside the US healthcare industry. Despite protocols put in place to limit the availability of psychoactive drugs, the controls are sometimes lax and easily bypassed. The power of addiction cannot be underestimated, as Rocky Allen’s actions indicated.¹

The Opioid Crisis

An estimated 21.4 million drug addicts live in the US, of whom only 4.1 million are receiving treatment for their addiction, according to estimates by Dr. Thomas McLellan, former deputy director of the White House Office of National Drug Control Policy.⁵ Another estimated 40 million are drug abusers and misusers.⁵ Deaths from opioids, now more than 70,000 per year in the US, exceed those from traffic deaths and guns combined.³

The only way to identify those already using illicit drugs is through drug testing, but relatively few veterinary practices do so, even when hiring new team members. For example:

• Only 28% of respondents to a recent VIN survey indicated that their practice tested employees for drugs.

• A confidential 2015 JAVMA News survey showed only 30% of veterinary practices performed drug testing, compared with 70% of US businesses,⁶ confirming the general attitude that drug abuse and addiction is not a serious problem in veterinary medicine.

However, in the JAVMA poll, about 73% of those surveyed had worked in a veterinary workplace with someone they suspected or knew had an abuse or addiction problem involving illicit or prescription drugs.⁶

Quest Diagnostics, the largest drug-testing firm in the US, reports that positive drug tests are the highest in 12 years, with an overall average of 4.2% of all tests resulting in positive.⁷ Marijuana is the most common drug, followed by cocaine, opiates, and methamphetamine.⁷

Drug Testing

Employers have a moral obligation to keep their staff safe, and drug testing is a key strategy to ensure the practice does not hire anyone addicted to drugs. Three types of drug testing generally are available: pre-employment, random, and upon reasonable suspicion/post-accident.

Pre-employment

Drug testing job applicants can be an effective deterrent to addicts or regular users of illicit drugs. Applicants should not be informed about drug-testing requirements until they have completed their interview and are tentatively hired to avoid attempts to “wash out” the drug from their system. They should be required to complete drug testing within 48 hours of hiring.

Random

The frequency of, and employee selection for, random drug testing are arbitrary decisions usually determined in collaboration with a drug-testing company. Typically, 50% of employees are randomly tested during a year, and testing is performed quarterly.⁸

Reasonable suspicion

Also known as for-cause drug testing, reasonable suspicion testing is performed when supervisors have evidence or reasonable cause to suspect an employee of drug use. Evidence may be based on direct observation, either by a supervisor or another employee, of specific behaviors (eg, physical evidence of illicit substances, patterns of erratic or abnormal behavior, disorientation or confusion, an inability to complete routine tasks).⁹

When serious medical errors or accidents occur that may be the result of impaired judgment, or when a team member behaves abnormally (eg, overt hostility, seeking isolation, apparent disorientation), there is just cause for that person to be drug tested as soon as possible. This is an arbitrary judgment made by supervisors who must be well-trained and consistent. Employers may face potential liability if a medical error occurs that involves a veterinarian or team member who is impaired due to drugs or alcohol.

Many veterinary employers forgo random drug testing because it can be considered invasive and can create an atmosphere of distrust.

The Marijuana Dilemma

The legalization of marijuana for recreational use in 10 states plus Washington, DC, and its approval for medical use in 33 states has complicated the drug-testing issue. Because the federal Drug Enforcement Administration still considers tetrahydrocannabinol (ie, THC, the chemical compound in marijuana responsible for the high) a Schedule 1 drug, employers have the right to refuse to hire or terminate anyone testing positive for THC before or during employment.

This has created a dilemma for many veterinary employers, including corporations that must apply the same requirements to their many hospitals.¹⁰ In addition, with the current general shortage of skilled veterinary personnel,¹¹ requiring a negative drug screen for THC can significantly reduce the number of qualified applicants. Low unemployment rates are another reason for the increasing trend among US employers to forgo drug testing.¹¹

After-Hours THC Use

In one study of airline pilots, impairment on flight simulators persisted up to 24 hours after smoking a marijuana cigarette, even though the subjects were unaware of any effects.¹² Another study showed long-time marijuana users made wrong decisions 50% to 70% of the time compared with nonusers, who made errors 8% of the time.¹³

Workplace impairment, however, cannot be correlated with either urine or blood drug screening. Even the legal limit of THC in the blood, 5 ng/ml, is arbitrary—there is no correlation between test values and the degree of actual impairment.¹⁴ Assessing job performance, and monitoring for changes, is probably the best way to detect impairment—a positive urine or blood test is the indication that a person has used marijuana.

The Drug-Testing Standard

AAHA now lists employee drug testing as a standard for practice accreditation, although it is not mandatory: The practice utilizes a drug-testing program to support a drug-free environment and verifies compliance with state/provincial and national regulations regarding drug testing. (HR07.2)

Conclusion

Drug testing, including testing for THC, is a challenging issue for veterinary practices because of variations in state laws and conflicting federal laws. However, for practices wanting to maintain a drug-free workplace, and because of liability and safety concerns, implementation of some form of drug testing, especially pre-employment testing, may be in the best interest of every veterinary practice.