II. The Role of Drug and Breath-Alcohol Testing in Matrix IOP
Philosophy :
In the Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders (IOP) model, drug and breath-alcohol testing is viewed and presented to clients as a valuable tool to help clients become abstinent and enter recovery, not as a punitive monitoring measure. Its use should not be presented or perceived as an indication of mistrust of a client’s honesty. Instead, the counselor should help clients accept that people in outpatient treatment for substance use disorders need as many tools as possible to recover. To regain control of their lives, clients need ways to impose structure on their behavior.
Urine or saliva drug and breath-alcohol test results can provide invaluable clinical data when a lapse or relapse has occurred and the client is unable to talk about it. The occurrence of relapse and, often, denial of use make testing for substances an essential component of outpatient substance abuse treatment programs.
The goals of testing for substances in treatment include
· Deterring a client from resuming substance use
· Providing a counselor with objective information about a client’s substance use
· Providing a client who is denying use with objective evidence of use
· Identifying a substance use problem severe enough to warrant residential or hospital-based treatment
Procedure
This section assumes that the counselor’s program has established procedures for collecting, identifying, storing, ensuring chain of custody for collecting, and transporting specimens. If drug screens are required (e.g., if they have been ordered by the court), clients should be so informed.
Testing Schedule
In the Matrix IOP approach, all clients are asked to provide a urine or saliva specimen for drug analysis and to take a breath-alcohol test once each week. Occasionally, the testing day should be random but should be on a day that most closely follows a period of high risk (e.g., weekends, payday). Unexplained missed appointments, unusual behavior in sessions or groups, or family reports of unusual behavior may indicate a need for immediate testing. The counselor should be sensitive to possible client embarrassment and avoid any unnecessary public discussion or joking about the tests.
A program can screen for a client’s substance of choice or for a broad range of substances. The program may want to use Breathalyzer
screening every time or only when alcohol use is suspected. Full drug screens should be done when the counselor suspects other substance use. Addressing Tampering
Occasionally a client may attempt to conceal drug use by tampering with a urine specimen. At the time the suspect specimen is submitted, the client should be taken into a private setting and told that there is some uncertainty about the specimen. Staff members should not be accusatory and should attempt to make the client comfortable. However, staff persons should avoid tension-relieving jokes that might communicate the wrong message about the purpose or importance of urine specimen collection and testing.
Tampered urine specimens usually indicate substance use. Clients who alter their specimens rarely admit it. Specimen tampering is a critical concern in treatment and may signal a relapse. Drug use combined with denial may reflect a breakdown of the therapeutic process. If a client attempts to alter more than one specimen sample, it may be necessary to observe the client giving another sample immediately and on subsequent testing occasions until the client’s abstinence is reasonably verified. Doing so should be viewed as a last resort to establish the client’s drug use and to encourage truthfulness.
If a situation warrants observing urine collection, the counselor should consult with a supervisor for approval and direction. The counselor should follow the agency’s policy and procedures for observing urine collection. Observing urine specimen collection is uncomfortable for staff members and may be humiliating for the client. Urine collection procedures should be explained to the client at the first individual session including the possibility that urine collections may be observed occasionally.
An observed urine collection procedure is a last resort for clients who are having difficulties in the recovery process. It is important to view this procedure as a therapeutic activity. In many cases, drug testing can move clients back on track and prompt them to tell the truth about drug use.
Addressing a Positive Urine Test
A positive drug test is a significant event in treatment. It might mean one use, or it might indicate a return to chronic use. In response to a positive result, the counselor should take the following steps:
· Reevaluate the period surrounding the test. Were there other indications of a problem such as missed appointments, unusual behavior, discussions in treatment sessions or groups, or family reports of unusual activity?
· Give the client an opportunity to explain the result, for example, by stating, “I received a positive result from the lab on your urine test from last Monday. Did anything happen that weekend you forgot to tell me about?”
· Avoid discussion about the validity of the results (e.g., the lab could have made an error; the bottle might have been mixed up with another client’s).
· Consider temporarily increasing the frequency of testing to determine the extent of use.
· Reinforce a client’s honesty if he or she admits to use, and stress the therapeutic importance of the admission. This interaction may result in admissions of other instances of substance use that had gone undetected.
· Collaborate with corrections or court staff as appropriate.
Sometimes a client responds to the news of a positive urine test with a partial confession of drug involvement, for instance, that he or she was at a party and was offered drugs but did not use them. These partial confessions are often the closest the client can get to actually admitting drug use.
Occasionally a client reacts angrily to notification of positive test results. Typically, the client may accuse the counselor of lack of trust and display indignation at the suggestion of drug use. These reactions can be convincing and may cause a counselor initially to react defensively. However, the counselor calmly should inform the client that discussing a positive test result is necessary for treatment and that the counselor’s questioning is in the client’s best interest. If the client is unresponsive to these explanations, the counselor should attempt to move on to other issues. At some other time, the topic of truthfulness may be revisited and the client given another opportunity to discuss the urine test result.
A client should not be discharged from the Matrix IOP intervention because of positive drug test or Breathalyzer results. If there are repeated positive test results, however, it may be necessary for the counselor to stress that abstinence is the goal of the Matrix IOP approach and to consider increasing the frequency of a client’s visits. For example, the counselor could place a client back into the Early Recovery Skills group if the client has already completed those group sessions but has had repeated positive test results, or more individual sessions could be scheduled for a client who is at an earlier stage in the treatment process. If a client continues to have positive drug tests, the counselor may be required to refer the client to a higher level of care.
Even if the client denies drug or alcohol use, the counselor must proceed as if there were use. Lapses should be analyzed with the client (possibly in an individual session), and a plan for avoiding relapse reformulated. It may become necessary to assess the need for inpatient or residential treatment. The counselor’s confidence in and certainty of the test results are critical at this point and may be instrumental in inducing an honest explanation from the client of what has been happening. If the urine testing process succeeds in documenting out-of-control drug use and establishes the need for increasing the intensity of outpatient treatment or considering residential or hospital-based treatment, it has served a valuable function.