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Hair Drug Testing Results and Self-reported Drug Use among Primary Care Patients with Moderate-risk Illicit Drug Use
Background
This study sought to examine the utility of hair testing as a research measure of drug use among individuals with moderate-risk drug use based on the internationally-validated Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).
Methods
This study is a secondary analysis using baseline data from a randomized trial of brief intervention for drug misuse, in which 360 adults with moderate-risk drug use were recruited from two community clinics in New Mexico, USA. The current study compared self-reported drug use on the ASSIST with laboratory analysis of hair samples using a standard commercially-available 5-panel test with assay screening and gas chromatography/mass spectrometry (GC/MS) confirmation. Both self-report and hair testing covered a 3 month period.
Results
Overall concordance between hair testing and self-report was 57.5% (marijuana), 86.5% (cocaine), 85.8% (amphetamines), and 74.3% (opioids). Specificity of hair testing at standard laboratory cut-offs exceeded 90% for all drugs, but sensitivity of hair testing relative to self-report was low, identifying only 52.3% (127/243) of self-disclosed marijuana users, 65.2% (30/46) of cocaine users, 24.2% (8/33) of amphetamine users, and 2.9% (2/68) of opioid users. Among participants who disclosed using marijuana or cocaine in the past 3 months, participants with a negative hair test tended to report lower-frequency use of those drugs (p< .001 for marijuana and cocaine).
Conclusions
Hair testing can be useful in studies with moderate-risk drug users, but the potential for under-identification of low-frequency use suggests that researchers should consider employing low detection cut-offs and using hair testing in conjunction with self-report.
Keywords: Hair testing, self-report, moderate-risk drug use, brief intervention, primary care
1. INTRODUCTION
Substance abuse treatment in the United States and many other countries is often delivered in a specialty sector, with programs serving patients whose problems have reached a critical threshold of severity. However, the last decade has seen growing integration of substance use services within the larger US healthcare system, with a corresponding shift towards addressing a wider spectrum of substance use problems to intervene before the onset of severe disorders. The screening, brief intervention, and referral to treatment (SBIRT) model promoted by the US federal government has broadened the provision of substance use services to individuals receiving care in mainstream medical settings such as hospitals, emergency departments, and primary care (Madras et al., 2009). Prioritization of behavioral health services within the context of healthcare reform is further expected to broaden eligibility for substance misuse services and encourage their delivery in outpatient and primary care venues (Buck, 2011; Mechanic, 2012). The World Health Organization likewise supports the integration of substance misuse services into primary care, and a multinational trial found that brief intervention led to reductions in illicit drug use risks (Humeniuk et al., 2012).
Within primary care settings, many patients who report illicit drug use may have risky but irregular use patterns, and may not require nor accept specialized drug abuse treatment. Individuals with drug use patterns that place them at a moderate level of risk can be very different from individuals in specialized drug abuse treatment settings, and pose unique challenges for research. Clinical trials of drug abuse interventions often gauge changes in drug consumption using self-report, and rigorous studies often include a biological measure. Use of self-report in addition to toxicology testing has been recommended (Donovan et al., 2012). Urine testing is the most common form of biological testing in drug abuse studies, due to its low cost and widespread clinical use in treatment (Moeller et al., 2008). Although urine testing provides a valuable measure of drug use among patients who use drugs regularly, it has limited utility for those exhibiting more moderate use patterns because of its short detection window (less than a few days for most drugs).
Hair testing is a promising alternative to urine testing, and has found use in a range of clinical, workplace drug testing, and forensic toxicology applications (Curtis and Greenberg, 2008; Klein et al., 2000). Although not without limitations (e.g., variable hair availability/length; participant concerns about cosmetic visibility of sample collection; and higher relative cost), hair testing has several properties that make it potentially well-suited for moderate-risk populations. It has an extended detection window of approximately 1 month per half inch of hair. Thus, a 1.5 inch section of hair captures a 90-day window of drug use. This detection window makes hair testing particularly attractive for studies with individuals whose intermittent and lower frequency drug use patterns resist detection by urine testing. Specimen collection is straightforward, does not pose a biohazard risk or require special storage to avoid spoilage, and is less intrusive than observed urine specimen collection. Given these advantages, it is no surprise that some clinical trials of brief intervention for drug use have begun to use hair testing as an outcome measure (Bernstein et al., 2005; Ondersma et al., 2014; Schwartz et al., in press).
Previous research comparing hair testing to self-report has documented substantial under-reporting of drug use in both youth and adults (Delaney-Black et al., 2010; Fendrich et al., 1999; Grekin et al., 2010; Magura and Kang, 1996). A large epidemiological study with middle-aged men found that hair testing identified more cocaine users, but fewer marijuana users, compared to self-report (Ledgerwood et al., 2008). Other studies have examined the validity of hair testing in controlled settings. For example, a study with ten volunteers in a secure research ward found that concentration of cocaine and its metabolites in hair was correlated with dose level, but affected by melanin content (Scheidweiler et al., 2005). A controlled methamphetamine administration study found good evidence of dose-related detection levels for hair, but noted substantial inter-individual differences (Polettini et al., 2012). Another study with 9 methamphetamine-dependent volunteers concluded that concentrations in hair generally reflect self-reported patterns of usage well, although the authors cautioned against extrapolating findings to light or occasional methamphetamine users (Han et al., 2011). A study with marijuana users found that only 7 of 13 participants who smoked cannabis in a controlled administration setting had a positive hair test (Huestis et al., 2007). Few studies, however, have examined hair testing among out-of-treatment individuals who access the broader healthcare system. A notable exception is a series of studies that examined patterns and predictors of non-disclosure of cocaine use among individuals who disclosed heroin use during an outpatient medical visit (Tassiopoulos et al., 2004, 2006).
The current study extends the literature on hair testing and self-reported drug use by examining their agreement in a sample of adult primary care patients who reported moderate-risk drug use on an internationally-validated screening instrument. The overarching aim of the study is to examine the utility of hair testing as a research measure in this population. Individuals who use drugs at a moderate-risk level have distinct service needs from those with severe substance use problems, and are poised to receive increased attention from clinical researchers given the emphasis on behavioral health integration and adoption of brief intervention services across healthcare settings. Researchers designing clinical services studies are faced with a number of commercially-available options for biological detection of drug use. Potentially important differences can exist in sample processing, analytical procedures, and coverage of different substances between laboratories, and even within the same laboratory across different testing products. In the current study, we examined a standard, commercially-available 5-panel hair test.
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Drug Alcohol Depend. Author manuscript; available in PMC 2015 Aug 1.
Published in final edited form as:
Drug Alcohol Depend. 2014 Aug 1; 141: 44–50.
Published online 2014 May 17. doi: 10.1016/j.drugalcdep.2014.05.001
Article by, Jan Gryczynski,a,* Robert P. Schwartz,a Shannon Gwin Mitchell,a Kevin E. O’Grady,b and Steven J. Ondersmac
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