The drug and alcohol testing and treatment industry plan to use the medical profession as a urine collection agency to bypass procedural protections: The ASAM White Paper on Drug Testing and the “Future of American Drug Policy.”

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Before the  2012 Drug and Alcohol Testing Industry Association (DATIA) annual conference, Dr. Robert Dupont delivered a speech entitled “Drug Testing and the Future of American Drug Policy.”    He describes a “New Paradigm” for substance abuse treatment that enforces “zero tolerance for alcohol and drug use”  enforced by monitoring with frequent random drug and alcohol tests in which any positive test is  “met with swift, certain” consequences.” The paradigm is based on the current Physician Health Programs blueprint.  Dupont states:

“…physician health programs , have set the standard for effective use of drug testing. These pioneering state programs provide services to health care professionals with substance use disorders. The programs are run by physicians, some of whom in recovery themselves. PHPs feature relatively brief but highly focused treatment followed by active lifelong participation in the 12-step fellowships of Alcoholics Anonymous and Narcotics Anonymous. The key to the success of the PHP system of care management is the enforcement of the standard of zero tolerance for any alcohol or other drug use by intensive long-term random testing for both alcohol and drugs with swift and certain consequences for even a single use of alcohol or any other drugs of abuse. PHPs use drug panels of 20 or more drugs. The PHPs commonly use EtG and EtS tests to detect recent alcohol use. Similar comprehensive programs have been developed for commercial pilots and attorneys. These innovative programs of care management produce unprecedented long-term, outcomes.”

Physician Health Programs use a doctor’s medical license as “leverage” in what they call “contingency management.”   What this means is that a doctor who is being monitored by a PHP must comply with any and all demands of the PHP under threat of being reported to the state Medical Board and immediate suspension of  licensure. Dupont wants to extend this model to other populations including our elderly, our pregnant mothers, college and high school students and schoolchildren.

The 2013 American Society of Addiction Medicine White Paper on Drug Testing describes the organizational structure of the “New Paradigm” and this includes utilizing the medical profession as a urine collection agency for their drug and alcohol testing and the loophole they plan to exploit is this:  When a doctor-patient relationship exists drug and alcohol testing is rendered “clinical” rather than “forensic”so the consequences of a positive test can legitimately be called  “treatment” rather than punishment.  Because addiction is currently defined as a disease, addicts must be “treated” (which in the United States is more often coercive than voluntary), and “cured” (which is defined as remaining abstinent). When the disease concept is not strictly reserved for medical conditions but is expanded to any and all drug and alcohol use.

The proposed system bypasses the strict chain-of-custody and Medical Review Officer requirements designed to ensure accuracy and minimize false-positives.  These strict protocols are used by essentially all employee assistance programs (EAPs) in workplace drug testing programs.    Forensic drug testing is tightly regulated because the results of a positive test can be grave and far reaching and erroneous results are unacceptable.

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THE ASAM PAPER DESCRIBES MANDATED DRUG-TESTING FOR PATIENTS IN A NUMBER OF SPECIALTIES INCLUDING ADOLESCENT MEDICINE, PSYCHIATRY, OBSTETRICS, AND GERIATRICS.  CONTINGENCY MANAGEMENT WILL INVOLVE “THE POTENTIAL FOR LOSS OF CURRENT OR DESIRED EMPLOYMENT, OR THREATENED LOSS OF OR RESTRICTIONS ON A PROFESSIONAL OR COMMERCIAL LICENSE, OR LEGAL AND FORENSIC NECESSITY.”
 “THIS WHITE PAPER ENCOURAGES WIDER AND “SMARTER” USE OF DRUG TESTING WITHIN THE PRACTICE OF MEDICINE AND, BEYOND THAT,BROADLY WITHIN AMERICAN SOCIETY. SMARTER DRUG TESTING MEANS INCREASED USE OF RANDOM TESTING* RATHER THAN THE MORE COMMON SCHEDULED TESTING,* AND IT MEANS TESTING NOT ONLY URINE BUT ALSO OTHER MATRICES SUCH AS BLOOD, ORAL FLUID (SALIVA), HAIR, NAILS, SWEAT AND BREATH WHEN THOSE MATRICES MATCH THE INTENDED ASSESSMENT PROCESS. IN ADDITION, SMARTER TESTING MEANS TESTING BASED UPON CLINICAL INDICATION FOR A BROAD AND ROTATING PANEL OF DRUGS RATHER THAN ONLY TESTING FOR THE TRADITIONAL FIVE-DRUG PANEL.”

Federal workplace drug testing is done in accordance with mandatory guidelines. This testing is regulated using FDA approved tests with established sensitivity, specificity and cutoff levels.  FDA approval requires rigorous research and proven validity.    The FDA requires valid scientific evidence (with both clinical and analytical validation).

The  Federation of State Physician Health Programs (FSPHP), the group currently in managerial control of state physician health programs in 47-states,  has introduced non-FDA drug testing via a loophole that removes all accountability.  The EtG, EtS, and PEth tests were introduced as  Laboratory Developed Tests (LDTs) with little to no evidence base through pathway  developed for “clinical” tests of low market potential that would not otherwise be developed due to the prohibitive cost of the FDA approval process.  An LDT  does not even require testing in humans (“in vivo”) or even proof that the test is testing what it claims to be testing (validity) for.  It is an honor system and without FDA oversight a lab can can claim anything they want about these tests with no accountability. They do not have to provide any proof of what they claim or justify what they claim.     After partnering with labs to develop these tests, the FSPHP then convinced the Federation of State Medical Boards they were valid and accurate tests that were necessary to detect a bogus cadre of drunk and drugged doctors able to hide their impairment and who were protected by a “code of silence.”    This bogus danger was then used to convince state Medical Boards to use these unvalidated tests on doctors in state physician health programs.

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(Source: ASAM Physician Health News March 2015)ASAM Physician Health News March 2015)

The ASAM white paper contains the following quote minimizing the critical role of the MRO in drug testing.   They feel clinical testing is good enough.

Unlike forensic drug testing where the test results must be able to meet rules of evidence in administrative, civil or criminal proceedings, clinical drug testing* is part of a patient examination performed by a clinician with whom the patient is in a therapeutic relationship. The testing is used for the purposes of diagnosis, treatment, and the promotion of long-term recovery. Clinical drug test results must meet the established standards of medical practice and benefit the therapeutic relationship, rather than meeting the formal legal requirements of forensic testing. Drug testing in medicine employs the same sound procedures, safeguards, and systems of information management that are used for all other health-related laboratory tests, tests on which life-and death medical decisions are commonly made.

Changing Public Policy and Regulatory Authority to Increase Power and avoid Accountability

 The Federation of State Physician Health Programs has been able to construct this scaffold with no meaningful opposition and below the public radar. They have done this by removing accountability at multiple levels.  By preventing access to information and erecting a system without oversight no consequences exist to deter misconduct and abuse.  The same tactics and strategies will be used as they expand this to other populations.

The Federation of State Physician Health Programs trumpets the the 12-step chronic relapsing brain disease model of addiction as defined by A.A. because it supports the drug and alcohol assessment, testing and treatment industries goals of more and more testing and treatment. For example  a 2011 FSMB Policy on Physician Impairment identifies, defines and essentially legitimizes “potential impairment” and “relapse without use.”

A PHP Should be empowered to conduct an intervention based on clinical reasons suggestive of potential impairment.  Unlike the Board which must build a case capable of withstanding
legal challenge, a PHP can quickly intervene based on reasonable concern."

“Empowered” to conduct an “Intervention” for reasons “suggestive” of “potential” impairment means a doctor can be pulled out of practice for anything.  It essentially gives them carte blanche authority. Due process and fundamental freedoms of choice are removed.

in 2011 The ASAM issued a Public Policy Statement on coordination between PHPs, regulatory agencies, and treatment providers recommending  that  only “PHP approved” treatment centers be used in the assessment and treatment of doctors.  A recent audit of the  North Carolina PHP found financial conflicts of interest and no  documented criteria for selecting the out of state treatment centers they used.  The common denominator the audit missed was that the 19  “PHP-approved” centers were all ASAM facilities whose medical directors can be seen on this list.

The FSMB House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting distinguishing “impairment” and “illness”  stating that Regulatory Agencies should recognize the PHP as their expert in all matters relating to licensed professionals with “potentially impairing illness.”

According to the FSPHP, physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years.”

The policy extends PHP authority to cover physical illnesses affecting cognitive, motor, or perceptive skills, disruptive physician behavior, and “process addiction” (compulsive gambling, compulsive spending, video gaming, and “workaholism”). It also defines “relapse without use” as “behavior without chemical use that is suggestive of impending relapse.”

G. Douglas Talbott defines  “relapse without use”  as  “emotional behavioral abnormalities” that often precede relapse or “in A A language –stinking thinking.”  AA language has entered the Medical Profession and no one seems to have even noticed.

The FSPHP political apparatus exerts a monopoly of force. It selects who will be monitored and dictates every aspect of what that entails.  It is a, in fact, a  rigged game.

The Need for Regulation, Oversight, and Accountability

Accountability is necessary to prevent corruption and requires both the provision of information and justification for actions. What was done and why?   Accountability also necessitates consequences-the ability of outside actors to punish and sanction those who commit the misconduct.  Without these constraints corruption is inevitable.

In  2012 Drs. John Knight and Wes Boyd recommended the medical community outside of PHPS provide oversight and demand accountability.  In  Ethical and Managerial Considerations Regarding State Physician Health Programs  they noted the financial conflicts of interest between PHPs and their “approved  centers,  coercion and abuse and even possible violations of the Nuremberg Code of Medical Ethics yet their paper generated little interest in the medical community.  The North Carolina PHP audit  revealed financial conflicts-of-interest and no oversight by the state medical society or board and that abuse of doctors could occur undetected due to the complete absence of accountability.  State Auditor Beth Woods told  the British Medical Journal in a recently  published article that the state program had holes in it “big enough to drive a truck through.”

In  Ethical and Managerial Considerations Regarding State Physician Health Programs Knight and Boyd state:  “Because PHP practices are unknown to most physicians before becoming a client of the PHP, many PHPs operate outside the scrutiny of the medical community at large. Physicians referred to PHPs are often compromised to some degree, have very little power, and are, therefore, not in a position to voice what might be legitimate objections to a PHP’s practices.”  And when objections do occur many take the side of the PHP, complacent in their belief that these are just altruistic and competent doctors just helping sick colleagues and protecting the public and valid complaints are deemed nothing more than “bellyaching.  In reality the ethical and criminal misconduct occurring in PHPs rivals that of Dr. Farid Fata,  the Detroit Oncologist who intentionally misdiagnosed patients with cancer so he could make money off unnecessary chemotherapy treatment.  Dr. Fata’s egregious betrayal of trust and unconscionably vile acts resulted in an appropriate response.

Screen Shot 2015-04-13 at 9.53.44 AMThe exact same misconduct is being perpetrated by PHPs but being overlooked, justified or otherwise ignored.  Dr. Fata intentionally misdiagnosed patients with cancer who did not have cancer so he could give them chemotherapy to make money.   PHPs are intentionally misdiagnosing substance abuse and behavioral disorders in physicians who do not have them in order to give them unneeded treatment and force them into monitoring contracts for profit and control.

This  undermines the very integrity of the profession.  It is particularly vile when the betrayal of trust involves doing the opposite of what was entrusted.   Abuse of positions of power, trust and influence in the field of medicine need to be both prevented, recognized and addressed.    Oversight, regulation and accountability are essential  if this is going to be accomplished.  There are no exceptions.   Policies and procedures must be enforced in a consistent manner.

The medical boards, medical societies, and departments of health have given the state PHPs carte blanche control and absolute power.  They refuse to even investigate accusations and they have convinced law enforcement that this is a parochial matter best handled by within the medical profession. As a result, valid complaints of crimes are not taken seriously.  This refusal to investigate  or even acknowledge valid and factual complaints of professional misconduct has not only prevented the exposure of  wrongdoing and corruption but deepened it.    The Federation of State Physician Health Programs and “Like-minded docs” must be recognized for what they are.  Front-groupsscreen-shot-2016-10-04-at-3-49-21-pm for the drug and alcohol assessment, testing and treatment industry.   This is glaringly obvious and you don’t have to look that deep to figure it out.  And these are the very same groups being proposed as advocacy bodies for addiction treatment and public policy change.  It is not that hard to figure out what they will be advocating for –more diagnoses, more testing and more treatment.

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The American philosopher Eric Hoffer noted:

“The only way to predict the future is to have power to shape the future. Those in possession of absolute power can not only prophesy and make their prophecies come true, but they can also lie and make their lies come true.” 

The “PHP-blueprint”  is built on the very foundation Hoffer describe and unless you want mandated randomized  non-FDA approved drug and alcohol testing with “swift and certain” consequences at future visits with your doctor you will need to speak up.

This occurred in the medical profession rapidly and with little notice and that is exactly what will happen here.

 “Every time we turn our heads the other way when we see the law flouted, when we tolerate what we know to be wrong, when we close our eyes and ears to the corrupt because we are too busy or too frightened, when we fail to speak up and speak out, we strike a blow against freedom and decency and justice.” 

Robert F. Kennedy

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Junk Science and the Need for Regulatory Oversight of Forensic Laboratory Developed Tests

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Laboratory Developed Tests

Questions about the accuracy and marketing of Laboratory Developed Tests (LDTs) have led to the current debate whether the U.S. Food and Drug Administration (FDA) should regulate a subset of diagnostic tests currently exempted from oversight. Designed to bring clinical tests to market that the costly FDA process would otherwise preclude, such as those for rare diseases, the LDT pathway bypasses Federal regulation and accountability.  Questions about the validity of these tests have raised concerns over patient safety and a call for oversight.  Among those asking for regulation are Massachusetts Senators Edward J. Markey and Elizabeth Warren.

Opponents of regulation argue the LDT  pathway enables new and pioneering tests to be developed quickly and improve patient care.  A recent viewpoint piece published in JAMA opposing regulation noted such advances have occurred “in large part because of the nimbleness of relatively small clinical and academic laboratories that can quickly respond to new medical findings and patient needs by rapidly and safely developing and improving laboratory-developed tests.”

But the LDT pathway does not require proof of test validity, that the test is actually testing for what it claims to be testing, and with no FDA oversight a lab can claim any validity it wants in marketing the test.  There is no accountability.    Proponents of  regulation argue that this lack of oversight is a direct threat to patient safety and, as an opposing viewpoint piece in JAMA notes, a “patient’s life or death could hinge on whether a single, unregulated diagnostic test result is meaningful.”

The debate has focused on the reliability and validity of a number of clinical tests currently marketed with unverified claims of accuracy such as those used for prenatal screening and Lyme disease.  Notably absent from the discussions are the vast number of  Laboratory Developed Tests tests being used for “forensic” drug and alcohol testing with the current FDA draft guidance stating simply:

  • At this time, FDA will continue to defer oversight of the use of these tests in the forensics (law enforcement) setting to the existing system of legal controls, such as the rules of evidence in judicial proceedings and other protections afforded through the judicial process.”


The Birth of EtG:  The Introduction and Marketing of Laboratory Developed Tests for “Forensic” Drug Testing  Via a Lucrative Loophole

Numerous “forensic” tests of unknown validity using urine, blood, hair, fingernails breath and saliva have been developed and brought to market as LDTs since the first one was introduced in 2003 when ASAM physician Dr. Gregory Skipper,  then Medical Director of the Alabama Physicians Health Program,  “convinced the initial lab in the USA, NMS near Philadelphia to start performing EtG testing.”1   With essentially no evidence base Skipper then claimed the alcohol biomarker “appeared to be 100 percent specific” in detecting covert use of alcohol for several days after ingestion based on a study he coauthored that involved a mere 35 forensic psychiatric inpatients in Germany, all male2  

Screen Shot 2014-02-24 at 10.08.19 PMUsing an arbitrary cutoff level of 100 ug/L the EtG was marketed as a valid and reliable test and blindly tested on those being monitored by programs not beholden to the strict protocol and procedure dictated by the Mandatory Guidelines for Federal Workplace Drug Testing that most Employee Assistance Programs (EAPs) adopted.  In other words, the test was used on those who possessed little power or had their power removed.

The test was  subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash3,4, hand sanitizer gel5, and nonalcoholic wine.6 Sauerkraut and bananas have even been shown to cause positive levels.7

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Shortly after the EtG debuted, complaints began to accumulate from individuals testing positive who adamantly proclaimed they did not drink.  Steadfast in their trust of expert opinion and the claimed accuracy of  EtG, the complaints of the accused were largely disregarded by those doing the monitoring.   People lost their licenses, jobs, careers, and reputations. Others lost their freedom or had their children taken away. It is unknown how many died by suicide.

There have been multiple  lawsuits filed since the introduction of the EtG including a class-action suit, but these were inevitably met with a well-funded and deep legal defense and their “experts.” The labs have taken a  “stand your ground” position yielding either dismissals or in favor of the defense.   As a new to the market  lab with no prior evidence-based research in forensic testing prior to its implementation and use for forensic testing, the proponents of EtG testing had no meaningful opposition in terms of a scientific body of facts and evidence and no credible voice to present it.  With the only “experts”  in EtG validity being those  who introduced and promoted its use there were no counter-forces.  Those suffering the consequences of a false-positive test had no recourse.  But as the toll of mayhem increased  it eventually reached a tipping-point where others began to take notice.

Page from the Talbott Recovery Center  list of products containing alcohol that doctors are required to avoid due to interference with EtG testing

Page from the Talbott Recovery Center list of products containing alcohol that doctors are required to avoid due to interference with EtG testing

In 2006 the Wall Street Journal reported the problems with the EtG to the general public,8 and SAMHSA issued an advisory stating that “legal or disciplinary action based solely on a positive EtG…. is inappropriate and scientifically unsupportable at this time. These tests should currently be considered as potential valuable clinical tools, but their use in forensic settings is premature.”9

Since that time Skipper has served as expert witness in close to 46 administrative hearings 22 criminal  14 custody and 1 Federal class action suit.

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But this did not stop the Federation of State Physician Health Programs  from using the EtG on physicians being monitored. Instead they instructed doctors to avoid anything potentially containing alcohol including hand sanitizer which a 2011 study found could result in EtG concentrations of almost 2000 ug/L. 10 To continue to justify the use of EtG they added other LDTs as confirmation tests of LDTs such as EtS and PEth– Junk Science to confirm  junk science. Nonsensical smoke-and-mirrors antithetical to science and evidence-based medicine.

Since the birth of the EtG a variety of tests have been introduced and marketed as LDTs utilizing nails, blood, hair, breath and urine—all with unknown validity but marketed without constraint.  No regulation, oversight or accountability exists.

The newest gadget they are using on doctors is the Cellular Digital Photo Breathalyze which he is promoting in the same manner as the EtG after a study he co-authored with Robert Dupont on just 12 subjects.


Expanding Laboratory Developed Tests to Test Everyone:   The ASAM White Paper on Drug-Testing and the  “New Paradigm” 

Although the current use of these tests is limited to the criminal justice system and professional monitoring programs this may soon change as the American Society of Addiction Medicine is proposing a “new paradigm” of zero-tolerance random widespread drug and alcohol testing. This is outlined  in the ASAM White Paper on Drug Testing and described by Robert Dupont in his keynote speech  before the Drug and Alcohol Testing Industry Association (DATIA) annual conference in 2012.

The ASAM White paper states drug testing is “vastly underutilized” throughout healthcare and describes the use of drug testing “within the practice of medicine and, beyond that, broadly within American Society.”

As the consequences of a single unregulated “forensic” test result can be grave, far-reaching and even permanent it is critical that these tests be included in the debate on regulation of LDTs.

Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.11

Expert opinion is the lowest level of evidence available in the EBM paradigm.12,13   Fortunately, the scientific method and Cochrane type critical analysis of the available evidence is  a tool to help people progress toward the truth despite their susceptibilities to unconscious confirmatory bias or conscious confirmatory distortion .14  Unfortunately, no one has used these tools address they panoply of tests of unknown validity that have already entered the market ; poised to be used on virtually everyone.

  1. Skipper G. Exploring the Reliability, Frequency, and Methods of Drug Testing: What is Enough to Ensure Compliance?:   Alcohol Markers and Devices. 2013; http://www.fsphp.org/Skipper, Exploring the Reliability Frequency and Methods 2 Presentation.pdf.
  2. Wurst FM, Vogel R, Jachau K, et al. Ethyl glucuronide discloses recent covert alcohol use not detected by standard testing in forensic psychiatric inpatients. Alcohol Clin Exp Res. Mar 2003;27(3):471-476.
  3. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. Journal of analytical toxicology. Nov-Dec 2006;30(9):659-662.
  4. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. Journal of analytical toxicology. Jun 2011;35(5):264-268.
  5. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. Journal of analytical toxicology. Oct 2008;32(8):594-600.
  6. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  7. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  8. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  9. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  10. Reisfield GM, Goldberger BA, Crews BO, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after sustained exposure to an ethanol-based hand sanitizer. Journal of analytical toxicology. Mar 2011;35(2):85-91.
  11. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. Jan 13 1996;312(7023):71-72.
  12. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. Feb 25 2009;301(8):868-869.
  13. Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. Oct 30 2004;329(7473):1029-1032.
  14. Haack S. Defending Science–Within Reason: Between Scientism and Cynicism. Amherst, N.Y.: Prometheus Books; 2003.

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