A Therapeutic Community's Experience with a Urine Surveillance System for Addiction

Abstract

The most important gain which can be attributed to EHRC's urine surveillance system was that the number of positives dropped dramatically. Whereas in August 1971 the main percentage of positives was 30.3% for residents diagnosed as having a primary drug addiction, by June 1973 the comparable monthly figure was 2.5%. EHRC had, in effect, demonstrated that an open, therapeutic community, with minimal surveillance, could maintain a relatively drug-free campus.

The community also learned that the positives reported by the lab were usually for the same substance the resident had abused before being admitted to EHRC. The lab reports, however, also indicated considerable experimentation and/or opportunism, i.e., people used whatever was available.

Many technical questions also were resolved through EHRC's urine surveillance system. For example.

1. Diphenylhydantoin sodium was discovered to produce a positive reaction for barbiturates when the urine specimen was analyzed by the lab's usual thin-layer chromatography technique. As a result of EHRC's inquiry, the lab modified its process so that diphenylhydantoin sodium was distinguishable from barbiturates (Rieders, 1971–1973).

2. Alcoholics may retain barbiturates in their urine for periods as long as 30 days after the last ingestion of barbiturates (Keyser, 1973; Rieders, 1971–1973). This may be due to either extensive liver damage or impairment of renal function.

3. Major tranquilizers will not result in a positive for amphetamines (Rieders, 1971–1973.)

4. Certain “cold” remedies, especially those containing phenylpropanolamine and phenylisoproanolamine, will result in a positive for amphetamines. EHRC has discontinued prescribing such medications (Rieders, 1971–1973.)

The tendency for residents who have used unauthorized drugs to adamantly deny having used with much feigned indignation and “sincerity” is now more clearly understood and appreciated by the community. One woman, for example, spent nearly a half-hour trying to convince the committee that she had never used drugs. The lab had reported nine positives for morphine and/or quinine for this resident. Her performance was truly remarkable, though far from atypical. The committee's experience, however, was that it often received information that residents who had been discharged for two positives later did admit to having used drugs.

The community also learned that the most commonly encountered “lab error” is the “false negative.” A number of residents, after leaving EHRC, did admit to having used and beaten the system. In part, this was due to the community's insistance that only the most clearcut lab findings be reported as positives. Trace findings which did not meet the established lab criteria for positive were reported as questionables and did not count against the residents.

Communications and cooperation between the medical and therapy departments have much improved as a result of the urine surveillance system. Physicians, for example, who prescribe sedatives, hypnotics, or tranquilizers for a period in excess of 24 hours now routinely notify the therapist of the resident who will use such medication. In addition, residents seeking nonernergency medical care must notify either their therapist or their unit administrative assistant.

Due to this increased contact between physician and therapist, it is now much more difficult for a resident to attempt to “mask” his/her using nonprescribed drugs. It is also more difficult now for residents to successfully manipulate the medical staff to obtain medications which may indirectly support his/her addiction.

The medical staff launched a special series of intradepartmental meetings to carefully re-examine its policies and practices relating to the prescription of various medications. Special attention was focused on the preventive medicine approach to convulsive activity, a major problem with the addicted populace in general. These discussions did much to enhance the medical department's efforts to articulate its practices with the overall program of rehabilitation at EHRC.

Some of the isolation and misperceptions inherent in any complex system with specialized roles and functions were mitigated. Both professionals and paraprofessionals began to communicate and work more interdependently as a result of the urine surveillance system.

Trust and confidence in the system is now relatively high, especially among staff. Since October 1972 through June 1, 1973, for example, 4,773 urine specimens have been obtained. Of these, 168 were positive, but only 11 (6.5 76) of the positives were referred to the committee for consideration. Therapists apparently have accepted the lab results as valid and/or have become more adroit in evaluating the various reasons given by residents who claimed their positive lab results were mistaken.

The community also realized, by way of retrospection, how far it had gone to guard against the fear that EHRC, through its urine surveillance system, might be beginning to treat its residents in a machine-like, depersonalized fashion. Actually, the urine surveillance system taught the community that its commitment to a humane philosophy of rehabilitation was realistic—that EHRC's cardinal principles of openness, honesty, and responsible concern for self and others had not been compromised by its efforts to achieve a relatively drug-free community. A urine surveillance system, in other words, can be considered an important and compatible therapeutic ingredient within a therapeutic community.