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Background: Drug testing is widely implemented as a work-based prevention strategy for employee substance use. However, it has raised concerns about its potential use as a punitive measure in the workplace where racialized/ethnic workers are over-represented. This study examines the rates of exposure to workplace drug testing among ethnoracial workers in the United States and the potential differences in the employers' responses to positive test results., Methods: A nationally-representative sample of 121,988 employed adults was examined using the 2015-2019 National Survey on Drug Use and Health data. The rates of exposure to workplace drug testing were estimated separately for ethnoracial workers. Then we used multinomial logistic regression to test differences in employers' responses to the first positive drug test results across ethnoracial subgroups., Results: Since 2002, Black workers reported 15-20% points higher rates of having a workplace drug testing policy than Hispanic or White workers. When tested positive for drug use, Black and Hispanic workers were more likely to be fired than White workers. When tested positive, Black workers were more likely to be referred to treatment/counseling services while Hispanic workers were less likely to be referred compared to White workers., Conclusion: Black workers' disproportionate exposure to drug testing and punitive responses in the workplace may potentially place individuals with substance use problems out of the workforce, limiting their access to treatment/other resources available via their workplaces. Also, Hispanic workers' limited accessibility to treatment and counseling services when tested positive for drug use requires attention to address unmet needs., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

ABSTRACT Aims To discuss ethical issues that may arise in using WWA to monitor illicit drug use in the general population and in entertainment precincts, prisons, schools and work-places. Method Review current applications of WWA and identify ethical and social issues that may be raised with current and projected future uses of this method. Results Wastewater analysis (WWA) of drug residues is a promising method of monitoring illicit drug use that may overcome some limitations of other monitoring methods. When used for monitoring purposes in large populations, WWA does not raise major ethical concerns because individuals are not identified and the prospects of harming residents of catchment areas are remote. When WWA is used in smaller catchment areas (entertainment venues, prisons, schools or work-places) their results could, possibly, indirectly affect the occupants adversely. Researchers will need to take care in reporting their results to reduce media misreporting. Fears about possible use of WWA for mass individual surveillance by drug law enforcement officials are unlikely to be realized, but will need to be addressed because they may affect public support adversely for this type of research. Conclusions Using wastewater analysis to monitor illicit drug use in large populations does not raise major ethical concerns, but researchers need to minimize possible adverse consequences in studying smaller populations, such as workers, prisoners and students. [ABSTRACT FROM AUTHOR]

Background. The World Anti-Doping Agency is the international body coordinating anti-doping efforts, with the mandate of harmonizing anti-doping policy worldwide. With novel performance-enhancing compounds continuously entering the market, research is necessary to develop appropriate methods for their detection. WADA-accredited laboratories are required to spend 7% of their annual budget on this research and need to obtain ethics approval for studies involving human participants. Nevertheless, these labs may face difficulties in obtaining ethics approval for anti-doping research due to its distinct differences from traditional biomedical research. Therefore, our aim was to investigate potential difficulties in obtaining ethics approval for anti-doping research. Methods. Semi-structured interviews were conducted with stakeholders in anti-doping research to investigate their experiences toward the ethics review process of their research proposals. Interviews were transcribed, de-identified, coded and analyzed. Results. The interviews indicated that large discrepancies in the evaluation of anti-doping research proposals exist. A majority of the laboratories could not acquire ethics approval for the administration of substances not approved for medical use. Some laboratories faced obstacles to obtain ethics approval for substances approved for clinical use. Respondents communicated that ethics committees often lack background knowledge about the anti-doping context. Conclusions. Disapproval of research proposals may originate from concerns over the safety of the study, the fact that there is seldom a direct benefit to the participant, the consideration that volunteers may be incentivized to use prohibited substances, a lack of background knowledge about anti-doping, or the focus of research ethics committees on health research.

The Athlete Biological Passport (ABP) refers to the collection of data related to an individual athlete. The ABP contains the Haematological Module and the Steroidal Module, which are used for the longitudinal monitoring of variables in blood and urine, respectively. Based on changes in these variables, a statistical model detects outliers which indicate doping use and guide further targeted testing of the athlete. Presently, athletes can access their data of the Haematological Module in the Anti-Doping Administration and Management System (ADAMS). However, granting athletes access to this data has been a matter of debate within the anti-doping community. This article investigates whether an athlete has a right to access the contents of their ABP profile. We approached this discussion by comparing the nature of ABP data with that of forensic and medical data and touched on important concerns with ABP data disclosure to athletes such as potentially allowing for the development of alternative doping techniques to circumvent detection; and making athletes vulnerable to pressure by the media to publicly release their data. Furthermore, given that ABP data may contain medically relevant information that can be used to diagnose disease, athletes may over-interpret its medical significance and wrongly see it as a free health check. We argue that safeguarding the integrity of the ABP system must be seen as the most essential element and thus a departure from immediate data disclosure is necessary. Two different strategies for delayed data disclosure are proposed which diminish the chances of ABP data being misused to refine doping techniques., (Copyright © 2018 John Wiley & Sons, Ltd.)

Through the widespread availability of location-identifying devices, geolocalisation could potentially be used to place athletes during out-of-competition testing. In light of this debate, the WADA Ethics Panel formulated the following questions: (1) should WADA and/or other sponsors consider funding such geolocalisation research projects?, (2) if successful, could they be proposed to athletes as a complementary device to Anti-Doping Administration and Management System to help geolocalisation and reduce the risk of missed tests? and (3) should such devices be offered on a voluntary basis, or is it conceivable that they would be made mandatory for all athletes in registered testing pools? In this position paper, the WADA Ethics Panel concludes that the use of geolocalisation could be useful in a research setting with the goal of understanding associations between genotype, phenotype and environment; however, it recognises that the use of geolocalisation as part of or as replacement of whereabouts rules is replete with ethical concerns. While benefits remain largely hypothetical and minimal, the potential invasion of privacy and the data security threats are real. Considering the impact on privacy, data security issues, the societal ramifications of offering such services and various pragmatic considerations, the WADA Ethics Panel concludes that at this time, the use of geolocalisation should neither be mandated as a tool for disclosing whereabouts nor implemented on a voluntary basis., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous-aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy.

The United States is experiencing an epidemic of opioid use, addiction, and neonatal abstinence syndrome. Consequentially, a great deal of public, and public health, attention has turned toward the timely recognition of pregnant women who use drugs. We explore the clinical efficacy and ethical acceptability of different methods of identification-contrasting drug testing (using biologic samples such as urine) with screening (using an instrument or questionnaire) under both universal and selective approaches within the current legal and social landscape, which is fraught with potential adverse consequences for both the woman and her child. Unlike other medical conditions such as diabetes, the sequelae of drug use in pregnancy can go beyond the clinical, because its assessment may result in child removal as well as maternal arrest, prosecution, and punishment. Although universal voluntary screening using a validated instrument is the most reasonable public health strategy, physicians should advocate for that only as strongly as they advocate for social support and addiction care services for those subsequently identified.

Neonatal nurses frequently care for babies who have been exposed in utero to potentially harmful substances, both licit and illicit. The risks to the fetus from nicotine, marijuana, alcohol, and opiates are significant. Adverse effects from environmental factors may confound pharmacologic effects of substances. Nurses are called to shift the perception of substance use disorder from that of willful harm to the fetus to that of an opportunity to provide treatment assistance that can positively affect child health and development. Concerns for unethical practices in the toxicology screening of pregnant women and their babies by risk factors that are unproven or disproven are discussed, and three goals of toxicology screening based on the ethical principles of justice and beneficence are proposed. This article will help equip neonatal nurses to fulfill their professional responsibility to advocate for just screening and referral practices in their institutions and communities.

Epigenetic testing is one of the most significant new technologies to provide insight into the behavioral and environmental factors that influence the development and reconfiguration of the human genetic code. This technology allows us to identify structural changes in the genome that occur due to exposure to a wide variety of substances including alcohol, tobacco, and cannabis. The information gained can be used to promote health but it also raises a variety of ethical, legal, and social issues. As society progresses in understanding the epigenetic mechanisms of substance use and addiction, there is an opportunity to use these use this knowledge to enable medical, behavioral, and environmental interventions to alleviate the burden of addiction. This article describes the ethical issues associated with use of epigenetic testing for alcohol, tobacco, and cannabis and the implications of this technology. A further review of the scientific basis for the relevance of epigenetics is found in the accompanying article by Philibert and Erwin in this issue., (Copyright © 2015 John Wiley & Sons, Ltd.)

In 2012, Duke University initiated a research project, funded by an unrestricted research grant from Millennium Laboratories, a drug testing company. The project focused on assessing the frequency and nature of questionable, unethical, and illegal business practices in the clinical drug testing industry and assessing the potential for establishing a business code of ethics. Laboratory leaders, clinicians, industry attorneys, ethicists, and consultants participated in the survey, were interviewed, and attended two face-to-face meetings to discuss a way forward. The study demonstrated broad acknowledgment of variations in the legal and regulatory environment, resulting in inconsistent enforcement of industry practices. Study participants expressed agreement that overtly illegal practices sometimes exist, particularly when laboratory representatives and clinicians discuss reimbursement, extent of testing, and potential business incentives with medical practitioners. Most respondents reported directly observing probable violations involving marketing materials, contracts, or, in the case of some individuals, directly soliciting people with offers of clinical supplies and other "freebies." While many study respondents were skeptical that voluntary standards alone would eliminate questionable business practices, most viewed ethics codes and credentialing as an important first step that could potentially mitigate uneven enforcement, while improving quality of care and facilitating preferred payment options for credentialed parties. Many were willing to participate in future discussions and industry-wide initiatives to improve the environment.

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are 'drug seeking', 'abusing' and 'diverting' prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient-physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient-physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient-physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients' subjective knowledge in enhancing physicians' self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Various kinds of alcohol and drug testing, such as preemployment, routine, and for-cause testing, are commonly performed by employers. While healthcare organizations usually require preemployment drug testing, they vary on whether personnel will be subjected to further testing. Recently, a call has gone out for postincident testing among physicians who are involved in serious, preventable events, especially ones leading to a patient's death. This article will offer a number of counterarguments to that proposal and discuss an alternate approach: that health institutions can better improve patient safety and employees' well-being by implementing an organizational policy of "speaking up" when system operators notice work behaviors or environmental factors that threaten harm or peril. The article will conclude with a description of various strategies that facilitate speaking up, and why the practice constitutes a superior alternative to mandatory alcohol and drug testing in the wake of serious, harm-causing medical error.

Given the current regulatory environment surrounding doping in the world, and in view of the recurring scandals linking leading athletes in a variety of sports with doping, this paper aims to provide some thoughts on the relationship between doping and public health, taking as base reference the risks doping poses to health and considering the regulatory options that have been adopted by the international community and the sports federations to control and supervise this unsporting and risky practice. The text seeks to reflect on the necessary balance between sport and health, as well as on the role of the state in preserving this balance.

Many physicians are referred to state physician health programs (PHPs) for evaluation, monitoring, and treatment of mental health and substance use disorders. Most PHPs are "diversion" or "safe haven" programs, meaning that physicians who suffer from alcohol or drug problems can have their case diverted to the PHP in lieu of being reported to the state licensing board. If the physician agrees to cooperate with the PHP and adhere to any recommendations it might make, the physician can avoid disciplinary action and remain in practice. These programs are therefore quite powerful and yet, to our knowledge, there has not been any systematic scrutiny of the ethical and management issues that arise in standard PHP practice. Given our 20 years of service as associate directors of one state PHP we analyze and evaluate the standard operating procedure of many PHPs and offer ethical critique as well as suggestions for improvement.

Alcohol use and abuse play a major role in both crime and negative health outcomes in Scotland. This paper provides a description and ethical and legal analyses of a novel remote alcohol monitoring scheme for offenders which seeks to reduce alcohol-related harm to both the criminal and the public. It emerges that the prospective benefits of this scheme to health and public order vastly outweigh any potential harms.

Alcohol is the most widely consumed toxic in Spain. Excessive alcohol intake is responsible for a significant number of visits to emergency departments (EDs), and what occurs may not only have severe medical consequences, but also serious legal implications. Most Spanish EDs lack specific protocols concerning the correct determination of blood alcohol content (BAC). The present work aims to review the technical, ethical and legal problems surrounding this test. Since ethanol is metabolized in peripheral blood, blood extraction should be standardized in order to preserve the proper chain of custody. An emergency test for BAC should be performed in two scenarios: patients with an altered level of consciousness of unknown origin (when health-care professionals act for the good of the patient), and situations which may be penalized by law (when health-care professionals act for the good of the community). The latter would include traffic controls and traffic accidents, job-related accidents, criminal activities or harmful domestic behaviour. Health-care professionals are responsible for treating patients' clinical information with due respect and confidentiality. However, professional secrecy may be overridden by legal imperative in certain situations. It is necessary to promote conscious ethical decision-taking by the health-care professional, so that this responsibility does not solely depend on the juridical context.

Background: Statistics from the National Trauma Data Bank imply that discretionary blood alcohol and urine drug testing is common. However, there is little evidence to determine which patients are appropriate for routine testing, based on information available at trauma center arrival. In 2002, Langdorf reported alcohol and illicit drug rates in Trauma Activation Patients., Methodology/principal Findings: This is a retrospective investigation of alcohol and illicit drug rates in consecutive St. Elizabeth Health Center (SEHC) trauma patients. SEHC Trauma Activation Patients are compared with the Langdorf Activation Patients and with the SEHC Trauma Nonactivation Patients. Minimum Rates are positive tests divided by total patients (tested and not tested). Activation patients: The minimum alcohol rates were: SEHC 23.1%, Langdorf 28.2%, combined 24.8%. The minimum illicit drug rates were: SEHC 15.7%, Langdorf 23.5, combined 18.3%. The minimum alcohol and/or illicit drug rates were: SEHC 33.4%, Langdorf 41.8%, combined 36.2%. Nonactivation patients: The SEHC minimum alcohol rate was 4.7% and the minimum illicit drug rate was 6.0%., Conclusions: Alcohol and illicit drug rates were significantly greater for Trauma Activation Patients, when compared to Nonactivation Patients. At minimum, Trauma Activation Patients are likely to have a 1-in-3 positive test for alcohol and/or an illicit drug. This substantial rate suggests that Trauma Activation Patients, a readily discernible group at trauma center arrival, are appropriate for routine alcohol and illicit drug testing. However, discretionary testing is more reasonable for Trauma Nonactivation Patients, because minimum rates are low.

Alcohol use during pregnancy may have severe and lasting effects on the developing fetus. Unfortunately it is often difficult to detect and address maternal drinking, as previous articles in this series have demonstrated. The difficulty is only compounded by a number of ethical quandaries and legal concerns. Underlying most of these concerns is a particularly agonizing conflict of obligations: to protect vulnerable, nascent human life on the one hand, and to preserve the privacy, dignity, and trust of one's patient on the other.

Background: In elite sports, the growing availability of doping substances identical to those naturally produced by the human body seriously limits the ability of drug-testing regimes to ensure fairness and protection of health., Content: The Athlete Biological Passport (ABP), the new paradigm in testing based on the personalized monitoring of biomarkers of doping, offers the enormous advantage of being independent of this endless pharmaceutical race. Doping triggers physiological changes that provide physiological enhancements. In the same way that disease-related biomarkers are invaluable tools that assist physicians in the diagnosis of pathology, specifically selected biomarkers can be used to detect doping., Summary: The ABP is a new testing paradigm with immense potential value in the current climate of rapid advancement in biomarker discovery. In addition to its original aim of providing proof of a doping offense, the ABP can also serve as a platform for a Rule of Sport, with the presentation before competition of the ABP to objectively demonstrate that the athlete will participate in a healthy physiological condition that is unaltered by performance-enhancing drugs. Finally, the decision-support system used today for the biological monitoring of world top-level athletes can also be advantageously transferred to other areas of clinical practice to reach the goal of personalized medicine.

The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment.

Background: There have been increasing national and international calls for the introduction of drug testing as a policy measure to address harmful drug use. Such strategies have been applied in workplaces, sporting arenas, prisons and more latterly school settings. They are predicated on a belief in their efficacy in reducing drug-related harm, a need to 'send the right' message to potential users and to reassure the community at large that 'something is being done.' Rigorous examination is required of purported benefits of drug testing in schools., Methods: A comprehensive examination was made of testing efficacy and accuracy. Australian legal and ethical issues, encompassing duty of care, rights of the child and privacy determinations, were juxtaposed with that of the United States of America., Results: Evidence examined indicates no compelling case for the application of drug testing and that caution should be applied when considering drug testing as a drug detection and prevention strategy in the school setting., Conclusion: While this review did not support school drug testing, there are alternative evidence-based strategies that schools can implement to prevent drug-related problems among student populations.

Drug and alcohol abuse is a major health problem for American women regardless of their socioeconomic status, race, ethnicity, and age. It is costly to individuals and to society. Obstetrician-gynecologists have an ethical obligation to learn and use a protocol for universal screening questions, brief intervention, and referral to treatment in order to provide patients and their families with medical care that is state-of-the-art, comprehensive, and effective. In this Committee Opinion, the American College of Obstetricians and Gynecologists' Committee on Ethics proposes an ethical rationale for this protocol in both obstetric and gynecologic practice, offers a practical aid for incorporating such care, and provides guidelines for resolving common ethical dilemmas related to drug and alcohol use that arise in the clinical setting.

Aims: A major problem in assessing the true public health impact of drug-use on driving and overall traffic safety is that the variables being measured across studies vary significantly. In studies reported in a growing global literature, basic parameters assessed, analytical techniques and drugs tested are simply not comparable due to lack of standardization in the field. These shortcomings severely limit the value of this research to add knowledge to the field. A set of standards to harmonize research findings is sorely needed. This project was initiated by several international organizations to develop guidelines for research on drugged driving., Methods: A September 2006 meeting of international experts discussed the harmonization of protocols for future research on drugged driving. The principal objective of the meeting was to develop a consensus report setting guidelines, standards, core data variables and other controls that would form the basis for future international research. A modified Delphi method was utilized to develop draft guidelines. Subsequently, these draft guidelines were posted on the internet for global review, and comments received were integrated into the final document., Results: The Guidelines Document is divided into three major sections, each focusing upon different aspects of drugged driving research (e.g. roadside surveys, prevalence studies, hospital studies, fatality and crash investigations, etc.) within the critical issue areas of 'behavior', 'epidemiology' and 'toxicology'. The behavioral section contains 32 specific recommendations; (2) epidemiology 40 recommendations; and (3) toxicology 64 recommendations., Conclusions: It is anticipated that these guidelines will improve significantly the overall quality of drugged driving research and facilitate future cross-study comparisons nationally and globally.

In this issue, Gideon Koren and colleagues review the maternal and child health implications of drug-residue testing in maternal and neonatal hair and testing for drugs in meconium. Since the 1990s, these methods have been used to varying degrees in clinical practice, but recent technological advances have increased their accuracy and usability in the clinical setting. Compared with self-reported maternal use, drug-residue testing in hair and testing for drugs in meconium are more reliable methods for detecting drug and alcohol exposure during pregnancy. These methods can also provide insights into patterns of use and abuse of these substances.