Drug Testing Interpretation in the Peripartum Setting: Results of Clinician Survey.

OBJECTIVES: The objectives of this study were to (1) survey obstetrical and pediatric clinicians' experience, confidence, and training in maternal and neonatal drug testing interpretation; (2) determine their proficiency in drug test interpretation; and (3) assess predictors of correct interpretation. METHODS: We conducted a cross-sectional survey of clinicians caring for pregnant people or newborns at an urban academic center. We assessed clinicians' demographic characteristics, experience, confidence, and prior training in interpretation of maternal and newborn drug tests. We assessed proficiency in interpreting drug tests using 11 clinical vignettes and categorized scores as poor (0-2), fair (3-5), and good (≥6) performance to facilitate data interpretation. We used descriptive statistics to summarize responses. Multinomial logistic regression was used to determine associations of clinician characteristics and score category (reference category: poor performance). RESULTS: In total, 103 respondents completed the survey including 60 obstetrical clinicians (58.3%), 19 family medicine physicians (18.5%), 21 pediatric clinicians (20.4%), and 3 social workers (2.9%) (response rate, ~40%). The mean correct response was 4.1 (SD, 2.17; range, 0-11). Most respondent scores were fair (n = 47.6%), followed by good (n = 28.2%) and poor (n = 24.3%). Increased frequency, confidence, and training in interpreting maternal screening and confirmatory tests were associated with higher proficiency. Increased confidence and training in interpreting neonatal screening and confirmatory tests, but not frequency, were associated with higher proficiency. CONCLUSIONS: Most clinicians demonstrated fair proficiency in interpreting drug tests. Predictors of proficiency were confidence and prior training for drug test interpretation, suggesting that educational interventions could improve proficiency.

A Retrospective Cohort Study of Disparities in Urine Drug Testing During the Perinatal Period in an Urban, Academic Medical Center.

The purpose of this study was to evaluate disparities in urine drug testing (UDT) during perinatal care at a single academic medical center. This retrospective cohort study included patients who had a live birth and received prenatal care at our institution between 10/1/2015 and 9/30/2020. The primary outcomes were maternal UDT during pregnancy (UDTPN) and UDT only at delivery (UDTDEL). Secondary outcomes included the number of UDTs (UDTNUM) and the association between a positive UDT test result and race/ethnicity. Mixed model logistic regression and negative binomial regression with clustering based on prenatal care locations were used to control for confounders. Of 6,240 live births, 2,265 (36.3%) and 167 (2.7%) received UDTPN and UDTDEL, respectively. Black (OR 2.09, 95% CI 1.54-2.84) and individuals of Other races (OR 1.64, 95% CI 1.03-2.64) had greater odds of UDTPN compared to non-Hispanic White individuals. Black (beta = 1.12, p < 0.001) and Hispanic individuals (beta = 0.78, p < 0.001) also had a positive relationship with UDTNUM. Compared to individuals with non-Medicaid insurance, those insured by Medicaid had greater odds of UDTPN (OR 1.66, 95% CI 1.11-2.49) and had a positive relationship with UDTNUM (beta = 0.89, p < 0.001). No significant associations were found for UDTDEL and race/ethnicity. Despite receiving more UDT, Black individuals were not more likely to have a positive test result compared to non-Hispanic White individuals (OR 0.95, 95% CI 0.72-1.25). Our findings demonstrate persistent disparities in substance use testing during the perinatal period.

Differences in testing for drugs of abuse amongst racial and ethnic groups at children's hospitals.

OBJECTIVES: Racial and ethnic differences in drug testing have been described among adults and newborns. Less is known regarding testing patterns among children and adolescents. We sought to describe the association between race and ethnicity and drug testing at US children's hospitals. We hypothesized that non-Hispanic White children undergo drug testing less often than children from other groups. METHODS: We conducted a retrospective cohort study of emergency department (ED)-only encounters and hospitalizations for children diagnosed with a condition for which drug testing may be indicated (abuse or neglect, burns, malnutrition, head injury, vomiting, altered mental status or syncope, psychiatric, self-harm, and seizure) at 41 children's hospitals participating in the Pediatric Health Information System during 2018 and 2021. We compared drug testing rates among (non-Hispanic) Asian, (non-Hispanic) Black, Hispanic, and (non-Hispanic) White children overall, by condition and patient cohort (ED-only vs. hospitalized) and across hospitals. RESULTS: Among 920,755 encounters, 13.6% underwent drug testing. Black children were tested at significantly higher rates overall (adjusted odds ratio [aOR]: 1.18; 1.05-1.33) than White children. Black-White testing differences were observed in the hospitalized cohort (aOR: 1.42; 1.18-1.69) but not among ED-only encounters (aOR: 1.07; 0.92-1.26). Asian, Hispanic, and White children underwent testing at similar rates. Testing varied by diagnosis and across hospitals. CONCLUSIONS: Hospitalized Black children were more likely than White children to undergo drug testing at US children's hospitals, though this varied by diagnosis and hospital. Our results support efforts to better understand and address healthcare disparities, including the contributions of implicit bias and structural racism.

Racial Inequities in Drug Tests Ordered by Clinicians for Pregnant People Who Disclose Prenatal Substance Use.

OBJECTIVE: To measure racial inequities in drug testing among pregnant people during the first prenatal visit based on their drug use disclosure pattern. METHODS: We used data from a cohort study of patient-clinician communication patterns regarding substance use in first prenatal visits from February 2011 to August 2014. We assessed racial differences (Black-White) in the receipt of urine toxicology testing, stratifying on patients' drug use disclosure to the clinician. RESULTS: Among 341 study participants (205 Black [60.1%] and 136 White [39.9%] participants), 70 participants (33 Black [47.1%] and 37 White [52.9%] participants) disclosed drug use, and 271 participants (172 Black [63.5%] and 99 White [36.5%] participants) did not disclose drug use during their first obstetric visit. Of 70 participants who disclosed drug use, 50 (28 Black [56.0%] and 22 White [44.0%] White) had urine drug testing conducted. Black pregnant patients who disclosed drug use were more likely to be tested for drugs than their White counterparts in the adjusted regression analysis (adjusted odds ratio [aOR] 8.9, 95% CI 1.3-58.6). Among the 271 participants who did not disclose drug use, 38 (18 Black [47.4%] and 20 White [52.6%] participants) had urine drug testing conducted. For those who did not disclose drug use, the adjusted model showed no statistically significant differences in urine drug testing by patients' race (aOR 0.7, 95% CI 0.3-1.6). CONCLUSION: When pregnant people disclosed drug use, clinicians were more likely to order urine drug testing for Black pregnant people compared with their White counterparts, suggesting clinician racial bias. Current practice patterns and protocols such as urine drug testing in pregnancy care deserve review to identify and mitigate areas of potential clinician discrimination.

Positive Urine Drug Screens and External Mortality in Teenagers Who Present for Medical Care.

Objective: To examine whether a positive urine drug of abuse screen in youth who receive medical care is associated with subsequent risk of external mortality (eg, overdose, suicide, homicide, accident).Methods: This was a population-based retrospective cohort study of all Olmsted County (Minnesota) residents who were 13-18 years of age at the time of urine drug screen (UDS) testing (January 1, 1999, to November 28, 2012). Cox regression models were used to examine the relationships between having a positive UDS and external mortality, adjusted for sex, race, age, alcohol exposure, psychiatric diagnoses as defined by the International Classification of Diseases (ICD-9/ICD-10), and medical setting of UDS testing. Separate analyses were done for (1) overall UDS results, (2) tetrahydrocannabinol (THC), and (3) cocaine.Results: Of the 2,772 teenagers included in this study (47.2% male), a total of 26 died of external causes during a median follow-up period of 11.8 years. Testing positive for any illicit substance was not associated with significantly increased risk of external mortality (hazard ratio [HR] = 1.9; 95% CI, 0.9-4.2). Testing positive for cocaine was associated with significantly increased risk of external mortality (HR = 7.0; 95% CI, 1.9-25.0). Testing positive for THC was associated with a marginally significantly increased risk of external mortality (HR = 2.1; 95% CI, 1.0-4.7); however, when cocaine was added as a covariate in the analysis, the relationship between THC-positive UDS and mortality was still elevated but was no longer statistically significant (HR = 1.8; 95% CI, 0.8-4.1).Conclusions: History of cocaine-positive UDS may help identify a population of young people who are at high risk of premature death.

Propranolol and metoprolol: Two comparable drugs with very different post-mortem toxicological profiles.

Propranolol is a widely used beta-blocker mainly prescribed for the treatment of hypertension and other cardiac conditions. This medicine is also a frequent finding in drug screens, but little is known about its post-mortem toxicological profile. Our aim was to examine all post-mortem toxicology cases positive for propranolol in a three-year period, between 2016 and 2018 in Finland, and to compare these cases to those positive for metoprolol, another beta-blocker commonly used to treat cardiac diseases. There were 179 cases positive for propranolol and 416 for metoprolol in the study period. In the majority of propranolol cases (53%), the drug concentration in the blood was above the typical therapeutic range, but among the metoprolol cases this proportion was 18%. Propranolol was significantly more common than metoprolol in fatal poisonings, suicides and in cases with a history of drug abuse. Alcohol, benzodiazepines, antipsychotics and antidepressants were significantly more often detected in propranolol cases than in metoprolol cases. The deceased positive for propranolol were significantly younger than those positive for metoprolol. Cardiovascular diseases as the underlying cause of death were significantly more common among the metoprolol cases than among the propranolol cases. Our results showed significant differences between the propranolol group and the metoprolol group in post-mortem toxicology cases. The two drugs were used by two very different groups of people, with propranolol use being associated with psychiatric conditions.

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

HIV testing among people with and without substance use disorder in emergency departments: A nationwide cohort study.

OBJECTIVE: To determine HIV testing trends during emergency department (ED) visits among those with and without substance use disorder (SUD) and examine factors associated with test receipt. METHODS: We identified individuals age ≥ 15 with an ED visit between 2014 and 2018 in the National Hospital Ambulatory Medical Care Survey (NHAMCS), a representative sample of United States ED visits. We examined HIV testing trends by SUD status and used multivariable logistic regression accounting for NHAMCS's complex survey design to identify factors associated with HIV testing. RESULTS: We identified 6399 SUD and 75,498 non-SUD ED visits. Of SUD visits, 1.4% [95% Confidence Interval (95%CI 0.9-1.9)] resulted in HIV testing compared to 0.6% (95%CI 0.4-0.7) of non-SUD visits. During the second half of the study (Q3, 2016 - Q4, 2018), HIV testing increased from 1.1% (95%CI 0.6-1.6) to 1.7% (95%CI 1.0-2.5) among those with SUD and from 0.5% (95%CI 0.3-0.6) to 0.6% (95%CI 0.5-0.8) among those without SUD. In adjusted models, SUD status was associated with increased odds of HIV testing [Adjusted Odds Ratio (AOR) 1.6 (95%CI 1.1-2.2)]. Those receiving toxicology testing (AOR 2.2, 95%CI 1.6-3.2), Black (AOR 3.6, 95%CI 2.6-4.9) and Hispanic people (AOR 2.7, 95%CI 1.9-3.7), insured by Medicaid (AOR 1.6, 95%CI 1.2-2.2) or self-pay (AOR 1.7, 95%CI 1.1-2.8), and with venipuncture (AOR 3.0, 95%CI 2.2-4.1) also had greater odds of HIV testing. CONCLUSION: HIV testing in the ED was rare, but slightly more common in individuals with SUD. Efforts to increase ED HIV testing among people with SUD are needed.

Development of the Perception of Opioid Use Survey Instrument.

BACKGROUND AND PURPOSE: A new instrument was designed specifically to evaluate nurses' knowledge, attitude, and practice toward patients who use opioids. This study team developed and tested the psychometric properties of the Perception of Opioid Use Survey (POUS) instrument. METHODS: The instrument was tested among 306 nurses at a 183 bed acute care community hospital, with psychometric evaluation for validity, reliability, and exploratory factor analysis. RESULTS: Internal consistency results were Cronbach's alpha = .550 for the overall scale and each subscale: Self-Efficacy = .796, Attitudes = .744, Community Impact = .806, and Causative Factors = .763. CONCLUSIONS: Psychometric testing results support that the POUS is valid, reliable, and significantly correlated with theoretically selected variables.

Association Between Alcohol, Substance Use, and Inpatient Burn Outcomes.

The use of alcohol and illicit substances has been associated with impaired judgment and health, but the effect on inpatient outcomes after burn injury remains unsettled. Our objective was to evaluate the effect of alcohol and illicit substance use on our inpatient burn outcomes. Adult patients admitted with burn injury-including inhalation injury only-between January 1, 2014 and June 30, 2019 were eligible for inclusion. Alcohol use and illicit drug use were identified on admission. Outcomes of interest included requiring mechanical ventilation, admission to the intensive care unit, length of stay, and inpatient mortality. Multivariable linear and logistic regression models were used to estimate the effects of use on inpatient outcomes. A total of 3476 patients were included in our analyses; 8% (n = 284) tested positive for alcohol, 10% (n = 364) tested positive for cocaine, and 27% (n = 930) tested positive for marijuana and at admission. Two hundred and eighty adults (18% of all positive patients) tested positive for at least two substances. Patients who tested positive for alcohol had longer lengths of stay and were more likely to be admitted to the intensive care unit. Patients who tested positive for cocaine had longer overall and intensive care unit lengths of stay. No differences in inpatient outcomes were seen among patients who tested positive for marijuana. Neither alcohol nor illicit substance use appears to affect inpatient mortality after burns. Alcohol and cocaine use significantly increased overall length of stay. Marijuana use had no impact on inpatient outcomes.

Isotope pattern deconvolution as a successful alternative to calibration curve for application in wastewater-based epidemiology.

An isotope pattern deconvolution (IPD) quantification method has been applied for the determination of five substances (amphetamine, benzoylecgonine, cocaine, methamphetamine and MDMA) in wastewater for the application in wastewater-based epidemiology (WBE). A previously validated method that used a calibration curve for quantification was modified to apply IPD. The two approaches were compared in terms of analytical uncertainty in recovery studies of quality control samples, i.e. six wastewater samples from different geographical origins spiked at two concentration levels. Both methods were reliable as they passed (z-score < 2) in an interlaboratory exercise. After 60 individual determinations, IPD provided 11 results outside recovery limits (70-120%) while the previous method produced 31 adverse results. All mean values for IPD were accurate whereas 6 out of 10 results showed RSD values higher than 30% or recoveries outside limits when using the former method. Moreover, the calculated method bias for the latter doubles that of IPD, which, in turn, makes the combined uncertainty (u(c)) much higher. Consequently, a simple change of data treatment-IPD quantification methodology-resulted in a lower uncertainty of the estimated illicit drug concentration, one of the main steps contributing to the final uncertainty in the normalized daily drug consumption through WBE. The current study demonstrated that the employment of IPD can also be very interesting for future applications of WBE, especially when matrix effects are high, complicating accurate quantification. In addition, when a high number of samples and/or compounds need to be analysed, IPD is faster than calibration and, eventually, cost-effective when isotopically labelled internal standard is highly expensive.

Emergency Contraception Administration, Toxicology Kit Use, and Postassault Reporting: A Comparison of Sexual Assault Nurse Examiner (SANE) and Non-SANE Medical Providers.

ABSTRACT: Sexual assault nurse examiners (SANEs) are specially trained to meet the postassault medical forensic needs of sexual assault patients. However, there remains a dearth of literature comparing directly postassault service provision and action in cases treated by SANEs as compared to non-SANE medical providers. In this study, we compare rates of emergency contraception administration, toxicology kit use, reports to police at the time of examination, and mandatory child abuse reports among n = 3,969 sexual assault cases treated by SANEs and non-SANE medical providers. Compared to cases treated by non-SANE medical providers, cases treated by SANEs were significantly more likely to have emergency contraception administered, less likely to have a toxicology kit collected, less likely to have a police report filed at the time of examination, and more likely to have a mandatory child abuse report filed. Observed patterns suggest that non-SANE medical providers may find it difficult to balance the needs of the criminal justice system with those of their patients, whereas SANEs provide a tailored, comprehensive first response. We discuss the importance of consistent, accurate documentation and clearly defined protocols in the medical forensic response to sexual assault patients.

Drug use and pattern of injuries sustained by drivers involved in road traffic crashes.

OBJECTIVE: Road traffic crashes are one of the global public health concerns and remain at high priority in many countries. Driving under the influence of drugs increases the risk of crashes through altering the driver's mental state and reactions. This study was conducted to determine the relationship between driving pattern and substance abuse among drivers in Kerman, a city in Iran, in order to enable policy makers to make the necessary decisions in planning and executing guidelines. METHODS: The population of this descriptive study was drivers involved in road traffic crashes admitted to the emergency department of Shahid Bahonar university hospital in summer 2019. After obtaining demographic information, type of vehicle, type of collision and pattern of serious injury, 222 eligible drivers were tested for tramadol, cannabis, amphetamine, methamphetamine, morphine and methadone using one step urine test strips. Chi-square test, Fisher's exact test, Whitney-Mann and Kruskal-Wallis tests and one-way Anova test was performed using SPSS version 22. RESULTS: The statistics showed that most drivers were male (90.5%), married (63.5%), age group (18-30) and had positive urine test (76.6%). In addition to uniqueness of dual-drug detection among male drivers (7.7%), the most common substances detected were methadone and morphine with 34.7% and 27.5% respectively. The most common injuries were lower limb and hip injuries mostly among motorcyclists. The results indicated that characteristics of being under 30's, married, school dropout, self-employed and motorcyclist had significant relationship with substance use. CONCLUSIONS: Substance use, especially methadone, has undoubtedly a significant role in both road traffic crashes and resulted injuries. The high rate of injuries on drivers influenced by methadone in traffic crashes needs to be screened and prevented. It is recommended to not only authoritatively deal with the excessive supply of methadone in the community but also restricting the driving of people receiving methadone treatment.

Cannabis, alcohol and other drug findings in fatally injured drivers in Ontario.

OBJECTIVE: The purpose of this study was to determine the prevalence of cannabis, alcohol and other drug use in drivers of motor vehicles who died in crashes in the Canadian province of Ontario from January 2016 through December 2018 along with the characteristics of these drivers and some of the circumstances of the crash in which they were involved. METHODS: Toxicological tests were performed on blood samples obtained from 921 driver fatalities for whom postmortem blood samples were submitted to the Center of Forensic Sciences for analysis. The results were coded into a database along with basic demographic and crash characteristics and examined for prominent characteristics and patterns. RESULTS: Overall, among the 921 cases examined, 495 (53.7%) tested positive for alcohol, cannabis (tetrahydrocannabinol or THC), or another psychoactive drug. The number of cases that tested positive for THC (251) exceeded the number of cases that tested positive for alcohol (241) as well as the number that tested positive for a drug other than THC (235). In 38% of positive cases, more than one substance was detected. Alcohol and THC were most commonly detected among males; females most frequently tested positive for a drug other than THC, notably medications with depressant effects. Alcohol-involved driver fatalities were most common on weekends and most likely involved single vehicle crashes. Driver fatalities that tested positive for THC or another drug were more evenly distributed throughout the week and were more likely to have been in multi-vehicle crashes. CONCLUSIONS: The present study highlights the use of cannabis and other drugs by drivers. The patterns of crashes and the characteristics of drivers involved indicate that the characteristics of driver fatalities involving cannabis and/or other drug use differ from those of alcohol and require new, innovative approaches targeting high-risk times, groups and behaviors. Continued monitoring of the toxicological findings from blood samples obtained from drivers killed in motor vehicle crashes will be a key element in efforts to reduce the impact of drug use by drivers on road safety.

The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing in 2020.

The convergence of the opioid epidemic and the coronavirus disease 2019 (COVID-19) pandemic has created new health care challenges. The authors analyzed changes in clinical drug testing patterns and results at a national clinical laboratory, comparing data obtained before and during the pandemic. Testing for prescription and illicit drugs declined rapidly during the pandemic, with weekly test volumes falling by approximately 70% from the baseline period to the trough (the week beginning March 29) before rising in subsequent weeks. Among individuals tested, positivity increased by 35% for non-prescribed fentanyl and 44% for heroin during the pandemic. Positivity for non-prescribed fentanyl increased significantly among patients positive for other drugs: by 89% for specimens positive for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (P < 0.01 for all comparisons). These findings suggest significant increases in dangerous drug combinations. Positivity for non-prescribed use of many other drugs remained consistent or declined for some drugs, relative to pre-pandemic patterns. Models adjusting for potential confounding variables, including medication-assisted treatment and treatment at a substance use disorder facility indicated that the risk for non-prescribed fentanyl positivity rose by more than 50% during the pandemic. In summary, these findings demonstrate decreased drug testing overall, with increased positivity for high-risk drugs and dangerous drug combinations. The convergence of the drug abuse epidemic and COVID-19 pandemic has led to an increased need for health care and public health resources dedicated to supporting vulnerable patients and addressing the underlying causes of these disturbing trends.

Why Are Patients With COVID-19 at Risk for Drug-Drug Interactions?

The goal of this column is to provide information to health care professionals about drug-drug interactions (DDIs) and why DDIs are important to consider in those at serious risk of illness with Coronavirus Disease 2019 (COVID-19). Important considerations discussed in this column include the frequency and complexity of multiple medication use, particularly important for the older patient who often has multiple comorbid illnesses. The column covers the following issues: (1) Why patients at high risk for serious illness from COVID-19 are also at high risk for DDIs. (2) Application of results of pharmacoepidemiological studies to the population at risk for serious COVID-19 illness. (3) Mechanisms underlying DDIs, frequency and potential complexity of DDIs, and how DDIs can present clinically. (4) Methods for preventing or mitigating DDIs. (5) An introduction to the University of Liverpool drug interaction checker as a tool to reduce the risk of adverse DDIs while treating patients for COVID-19. Commentary is also provided on issues related to specific psychiatric and nonpsychiatric medications a patient may be taking. A subsequent column will focus on DDIs between psychiatric medications and emerging COVID-19 treatments, as a detailed discussion of that topic is beyond the scope of this column.

Random drug and alcohol testing for preventing injury in workers.

BACKGROUND: Drug- and alcohol-related impairment in the workplace has been linked to an increased risk of injury for workers. Randomly testing populations of workers for these substances has become a practice in many jurisdictions, with the intention of reducing the risk of workplace incidents and accidents. Despite the proliferation of random drug and alcohol testing (RDAT), there is currently a lack of consensus about whether it is effective at preventing workplace injury, or improving other non-injury accident outcomes in the work place. OBJECTIVES: To assess the effectiveness of workplace RDAT to prevent injuries and improve non-injury accident outcomes (unplanned events that result in damage or loss of property) in workers compared with no workplace RDAT. SEARCH METHODS: We conducted a systematic literature search to identify eligible published and unpublished studies. The date of the last search was 1 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, two other databases, Google Scholar, and three trials registers. We also screened the reference lists of relevant publications known to us. SELECTION CRITERIA: Study designs that were eligible for inclusion in our review included randomised controlled trials (RCTs), cluster-randomised trials (CRTs), interrupted time-series (ITS) studies, and controlled before-after (CBA) studies. Studies needed to evaluate the effectiveness of RDAT in preventing workplace injury or improving other non-injury workplace outcomes. We also considered unpublished data from clinical trial registries. We included employees working in all safety-sensitive occupations, except for commercial drivers, who are the subject of another Cochrane Review. DATA COLLECTION AND ANALYSIS: Independently, two review authors used a data collection form to extract relevant characteristics from the included study. They then analysed a line graph included in the study of the prevalence rate of alcohol violations per year. Independently, the review authors completed a GRADE assessment, as a means of rating the quality of the evidence. MAIN RESULTS: Although our searching originally identified 4198 unique hits, only one study was eligible for inclusion in this review. This was an ITS study that measured the effect of random alcohol testing (RAT) on the test positivity rate of employees of major airlines in the USA from 1995 to 2002. The study included data from 511,745 random alcohol tests, and reported no information about testing for other substances. The rate of positive results was the only outcome of interest reported by the study. The average rate of positive results found by RAT increased from 0.07% to 0.11% when the minimum percentage of workers who underwent RAT annually was reduced from 25% to 10%. Our analyses found this change to be a statistically significant increase (estimated change in level, where the level reflects the average percentage points of positive tests = 0.040, 95% confidence interval 0.005 to 0.075; P = 0.031). Our GRADE assessment, for the observed effect of lower minimum testing percentages associating with a higher rate of positive test results, found the quality of the evidence to be 'very low' across the five GRADE domains. The one included study did not address the following outcomes of interest: fatal injuries; non-fatal injuries; non-injury accidents; absenteeism; and adverse effects associated with RDAT. AUTHORS' CONCLUSIONS: In the aviation industry in the USA, the only setting for which the eligible study reported data, there was a statistically significant increase in the rate of positive RAT results following a reduction in the percentage of workers tested, which we deem to be clinically relevant. This result suggests an inverse relationship between the proportion of positive test results and the rate of testing, which is consistent with a deterrent effect for testing. No data were reported on adverse effects related to RDAT. We could not draw definitive conclusions regarding the effectiveness of RDAT for employees in safety-sensitive occupations (not including commercial driving), or with safety-sensitive job functions. We identified only one eligible study that reflected one industry in one country, was of non-randomised design, and tested only for alcohol, not for drugs or other substances. Our GRADE assessment resulted in a 'very low' rating for the quality of the evidence on the only outcome reported. The paucity of eligible research was a major limitation in our review, and additional studies evaluating the effect of RDAT on safety outcomes are needed.

Prevalence of drugs of abuse found in forensic testing of illicit drug seizures and urine samples from offenders/probationers in Hong Kong: A 3-year update.

The study investigates the prevalence of drugs of abuse detected from 2016 to 2018 through i) forensic drug testing of seizures from law enforcement agencies, and ii) common drugs of abuse for urinalysis of samples obtained from offenders/probationers under mandatory drug-use surveillance programmes. Under the selected drug testing groups, an average of 4677 cases/year (c.f. 5334 cases/year in 2011-2015) of illicit drug seizures and 19,501 samples/year (c.f. 28,438 samples/year in 2011-2015) for urinalysis, were examined from 2016 to 2018. The three most commonly encountered abused drugs in the period in both types of examinations were methamphetamine (MA), cocaine and heroin. The occurrence of ketamine, the most prevalent drug [1815 (34.0%) cases/year (for drug seizures), 2074 (7.3%) samples/year (for urinalysis)] in 2011-2015, had dropped significantly to 487 (10.4%) cases/year and 350 (1.8%) samples/year respectively. The drug positive rates for urinalysis in the selected population group (i.e., offenders/probationers requiring mandatory drug testing) increased steadily from 27.3% in 2016 to 30.8% in 2018 (an average of 29.0% vs. 22.1% in 2011-2015). The ratio of single drug use to more than one drug was about 4:1, showing predominant use of single drug. While MA was the most prevalent drug in the period, cases found with cocaine and cannabis increased steadily over the past 3 years. A rising trend was noted for cases identified with new psychoactive substances (NPS) in illicit drug seizures from an average of 87 cases/year in 2011-2015 to 211 cases/year in 2016-2018 although NPS cases still contributed to less than 5% of overall drug seizures. A total of 69 substances classified as NPS were encountered with 47 NPS newly encountered in 2016-2018 but 25 NPS found in 2011-2015 disappeared in this 3-year period. Cathinones, including both synthetic and plant-based, continued to be the major category of NPS cases (∼72%) in the region followed by synthetic cannabinoids, ketamine/PCP analogs and synthetic opioids.