2.  Time Line Followback  Make a calendar to track last 30 days of use  For Alcohol, get sufficient description to determine standard drinks  Cigarettes and pills can be counted  Marijuana, cocaine, meth, probably dollar value is the way to go  Assessment gives idea of frequency, severity of use and provides comparative baseline  Demonstration

3.  Natural tendency is to under-report, partly due to saving face in front of others, but also to oneself (ever try to accurately report weight or amount of food eaten?)  Urine drug screens frequently used  Most providers believe that urine drug screens should be random and observed

4.  Who is going to be the “Pee Police”?  Who is going to collect it?  Who is going to observe it? (“Observe flow of urine from genitals”)  How can it be random if you see patient same time each week?  Sometimes outside services can collect and process, but this might not be an option for patients without insurance  Bottom line: Sometimes the providers have to observe and collect it themselves

5.  So you’re building a relationship where the patient trusts you and confides their vulnerabilities to you…  …now you’re holding out a cup to them and asking them to let you watch them pee.  How does this affect your “therapeutic relationship?”

6.  Introduce the collection of screens into the treatment contract and discuss it up front  Is UDS necessary?  Probably more so if patient is compelled to be in treatment (e.g. court order, PTI, or patient brought to tx by family member)  Probably more so if impaired sobriety introduces immediate risk

7.  “Shy bladder” can occur when people are surprised with UDS… could be nervous because positive…or just nervous because they’re watched  Possible solution: Invite patient to drink some (but not excessive amounts) of water and return later – also applicable for patients who say “I just went…”  Do you have time to do this?  You might have a rule that failure to provide urine will count as a positive

8.  Patients run out when they see the cups being prepared  Have a rule to count missed urines as positive

9.  Screens do have a method to test for dilution (looks for levels of creatinine, a normal by product in urine), so if they try to put water in the test, the test can tell.  This won’t tell you if they brought in urine, or got someone else to fill the cup for them

10.  Drugs (except marijuana) usually clear the system between three to five days  Observed urines on Monday and Friday gives very little opportunity for use between visits, M-W-F  Who will do it? Probably not you if seeing patient once per week, and can be a lot of work in an intensive program with 30+ Patients  …BUT it is good advice for parents who have kids struggling with use

11.  It is my belief that parents have to be willing to either monitor their kids or take the kids to a lab, either randomly or frequently  My very limited impression of parents dealing with kids with addiction is that they have to do a lot of the “policing” at home  My job is to encourage them to consistently enforce consequences in an even-handed manner

12.  For managing patients with chronic opioids, stakes are high  Note: many opioid pain killers don’t show up for standard Opioid screens, need to order special screens  Also note: people on opioids may try to have someone else provide urine, but if they are using meds as prescribed, they should be positive for the specific drug they are prescribed  E.g. A patient can be negative for opioids but positive for oxycodone. If negative on both, where is the drug going? Diversion?

13.  Clearly, we can’t give as much weight to UDS given unobserved or non-randomly  …but there are some people who change their behavior when the sense it is being monitored  Examples: Radar boxes on streets that display speeds, greeters at retail stores like WalMart  Often patients will find a way out of those situations (can’t provide sample, disappear)

14.  Providers are generally more uncomfortable about collecting pee than patients are about providing it – some long-term addicts are even proud to provide clean urine  In advanced state of addiction, you might beat a drug screen, but the addiction will catch up to you  If the consequence falls solely on the addict without collateral damage, one might argue that they only hurt themselves when they are dishonest  Question: Are you comfortable with that? Where do you draw the line?