drug testing in school essay

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Revisiting Drug Testing in High Schools – Where Do We Stand?

From about 1990 to 2005, one of the most debated and controversial topics related to high school activity programs was drug testing in high schools for participation- and safety-related matters.

There was support for drug testing because there was a belief that a drug-testing protocol could identify a drug-use problem at a school, and because other methods to deal with the drug problem were seemingly not working. Voices against drug testing felt that drug testing to prove a student did not use drugs/alcohol was an unconstitutional “search and seizure” violation of the Fourth Amendment. Let’s revisit the issue.

Drug Testing A drug test is a toxicology screen that determines the approximate amount and type of legal or illegal drugs taken. Toxicology screening can be done fairly quickly. The test is most often done using a urine or blood sample. In some cases, a sample of saliva or hair may be used. The results can show the presence of one specific drug or a variety of drugs at once. Further testing may be needed to determine the exact amount of a particular drug in the body and to confirm the results.

The most common type of drug test is a urine sample test. These are seen as more private and less intrusive than a blood, hair or saliva test.

Why Drug Testing Is Used The United States Supreme Court long ago determined that drug-testing protocols adopted by public school districts do constitute a Fourth Amendment “search and seizure.” Therefore, the justification for such a search must be obvious, compelling and related to a sound and constitutionally acceptable justification of using this power.

Supporters assert that drug testing promotes a safe and drugfree environment and schools can more easily identify students at risk and provide early intervention. Opponents voice concerns about privacy, that a drug test is unnecessarily invasive and that mandatory testing without reasonable suspicion encroaches upon students’ personal lives, typically focusing on punishment rather than the underlying causes of substance abuse.

Typically, drug testing is implemented because there is demonstrably a clear need for drug and alcohol intervention in a school. Determining a “clear need” can be difficult. This can potentially stigmatize and alienate students who need support.

Current Legal Status With support by U.S. Supreme Court rulings, school districts across the country have long recognized that the districts clearly have an interest in detecting and preventing drug use among its students. As a result, drug-testing protocols must be tailored to meet existing constitutional standards. Because attending public schools is a right, there can be no drug-testing requirement to attend school. However, since participation in extracurricular activities is a privilege, drug-testing requirements can be implemented to participate. The following legal cases provide the legal framework for consideration and guidance.

The first major case on the topic was in 1995, Vernonia School District 47J v Wayne Acton (U.S. Supreme Court, 1995). In that case, student-athletes were required to undergo random urinalysis as a method of detecting use of illegal controlled substances. Use of these substances was also a violation of the school district athletics code. In this case, the U.S. Supreme Court found this practice constitutional because:

a. It did not cause athletes to be expelled from school (no property right loss);

b. Athletes had an opportunity to receive assessment and rehabilitative services (and not face punishment) pursuant to a positive test finding;

c. Athletes could refuse to take the test and although refusal resulted in temporary suspension, this disciplinary action did not constitute abridgement of a property right.

The Supreme Court held that this was not a violation of the right to attend school. Rather, it was a loss of the privilege to participate in a sports program.

The U.S. Supreme Court weighed in again in 2002. In Board of Education of Pottawatomie v. Earls (Oklahoma 2002), a lawsuit was filed challenging a school district’s policy of suspicionless drug testing for students as a precondition to participation in extracurricular athletic activities. The Supreme Court held that, because the policy reasonably serves the School District’s important interest in detecting and preventing drug use among its students, it is constitutional. The Court reasoned that the Board of Education’s general regulation of extracurricular activities diminished the expectation of privacy among students and that the Board’s method of obtaining urine samples and maintaining test results was minimally intrusive on the students’ limited privacy interest. The key language is:

“Within the limits of the Fourth Amendment, local school boards must assess the desirability of drug testing schoolchildren. In upholding the constitutionality of the Policy, we express no opinion as to its wisdom. Rather, we hold only that Tecumseh’s Policy is a reasonable means of furthering the School District’s important interest in preventing and deterring drug use among its schoolchildren….”

This means that the U.S. Constitution does not limit school districts from implementing a blanket drug-testing policy if they see fit. It need not be predicated upon an existing, identifiable and rampant drug problem.

There have been cases, however, where a State Supreme Court ruled that the State Constitution prohibited such a sweeping drugtesting policy as allowed under the Earls case.

In Theodore v. Delaware Valley School District, (Pennsylvania Supreme Court 2003), the Delaware Valley School District adopted a policy that authorized random, suspicionless drug and alcohol testing of students who held school parking permits or participated in voluntary extracurricular activities. Testing was required in five different circumstances: initial testing, random testing, reasonable suspicion testing, return-to-activity testing and follow-up testing. Students must have submitted to testing initially when they registered, as a precondition, to participate in an extracurricular activity or to apply for a parking permit.

A complaint was filed seeking to stop the testing policy on grounds that it violated students’ right to privacy under Article I, Section 8 of the Pennsylvania Constitution. The testing protocol would have been legal under the Supreme Court’s interpretation of search and seizure under the Earls case. However, Article I, Section 8 application is different. “The cases decided under Article I, [Section] 8, have recognized a ‘strong notion of privacy,’ which is greater than that of the Fourth Amendment.” The Supreme Court of Pennsylvania ruled that without a showing of a specific need, random drug testing is unconstitutional under state search and seizure law.

In York v. Wahkiakum School District (Washington State Supreme Court 2008), the Wahkiakum School District determined that there was evidence of substantial alcohol and drug use among students. Pursuant to the school district’s statutory authority and responsibility to maintain order and discipline in its schools, to protect the health and safety of its students, and to control, supervise and regulate interschool athletics, it decided to adopt and implement a random, suspicionless drug testing where all students may be tested initially and then subjected to random drug testing during the entirety of the season. Based on the Vernonia case, the trial court ruled in favor of the school district. The case was appealed to the Washington State Supreme Court and that court decided that although pursuant to the U.S. Supreme Court’s decision in Vernonia, drug-testing programs were permissible under the Fourth Amendment to the U.S. Constitution, the Washington state constitution granted greater protections to citizens against searches and seizures than did the federal constitution.

The Washington State Supreme Court ultimately ruled in York that student-athlete drug-testing programs are unconstitutional based on the state constitution. This decision illustrates that despite the Vernonia interpretation of the federal constitution, that a drug-testing program only need be “….a reasonable means of furthering the School District’s important interest in preventing and deterring drug use among its schoolchildren….” any district that operates a drug-testing program may be subject to judicial challenges based on the applicable and more restrictive state constitution.

Contemplating Drug Testing Why adolescents use drugs is compelling and complicated. Irrespective of whether an active drug-testing policy helps reduce use of drugs and alcohol, schools and school districts must decide whether an active drug-testing program would still be a good program to have and to use in their battle against high school drug and alcohol use.

Is implementing a drug-testing program prudent? There are ongoing studies of the drug use of student drug use in grades 6-12 that provide some important contextual information.

On December 13, 2023, a survey report from the “Monitoring the Future” organization was published. The survey was conducted by researchers at the University of Michigan, Ann Arbor, and funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health.

The survey report indicated the 2023 data continued to document stable or declining trends in the use of illicit drugs among these young people over many years. However, other research according to a NIDA analysis of CDC and Census data has reported a dramatic rise in overdose deaths among teens between 2010 to 2021, which remained elevated well into 2022. This increase is largely attributed to illicit fentanyl, a potent synthetic drug, contaminating the supply of counterfeit pills made to resemble prescription medications. Taken together, this data suggests that while drug use is not becoming more common among young people, it is becoming more dangerous.1 This information may heighten the interest of implementing a drug-testing program.

Answering the question whether drug testing is effective is difficult. There are many questions:

What is meant by “effective?”
What drugs are to be tested for?
What is the cost and who pays?
Is the testing protocol for rehabilitation, health help or punishment?

The typical and most frequent parent and athlete concerns expressed when contemplating adopting a drug-testing program are the following:

Concerns about the chances of a false positive result;
Concerns that any preconditions might/would deter students from joining sports or other extracurricular activities;
Concerns that only certain students would be subject to the proposed tests and not all students;
Concerns about how random is random; and
Concerns as to how anonymity and confidentiality are maintained.

These are questions with difficult answers. However, no matter how difficult it is to find answers, school districts still can, and do, contemplate and use drug testing as a tool to help deter drug use among youth in high schools. Anecdotally, a frequent comment from athletic directors and other school administrators is that the fear of being selected for a test gives the student-athlete “cover” from peerpressure; they have an “out” because they do not want to compromise participation in the sport or activity of choice.

Leadership Implications for the Athletic Director If an athletic director is asked to weigh-in on this topic in their school or district, at a minimum, the following should be considered in leading the discussion.

Strongly advocate that it is critical that parents, students and community members be heard – the key to the effectiveness of adopting controversial programs is to vet them through the community that these programs impact the most;

Be prepared to articulate that this type of program is not a panacea – that it is only one tool (of many) to be used in the battle against drug use in schools;

Canvas the impacted coaches/sponsors/program leaders to get their input;

Consider convening a panel of students to solicit input (many times students can be the best voices on topics such as these);

Understand as a building leader that the No. 1 concern and task in a building is the safety and security of all students, doing the most they can within constitutional frameworks and best understanding and leading on the issue of whether such a program can be a good fit and effective.

The wisdom of a drug-testing program in a high school will always open the disconnect between those who see no harm in it and those who see an unnecessary over-reach of government. However, building leadership will ultimately be tasked with seeing such a program through if adopted, so they do not have the luxury of debating the merits. If the community feels this is the thing to do, building leadership, most likely led by the building athletic director, must commit to implementation in the manner necessary to meet the goal of health and safety of all students.

Resource National Institute on Drug Abuse, News Release December 13, 2023.

John E. Johnson, J.D.

John E. Johnson, J.D., recently retired after 18 years as athletic director at Shawnee Mission South High School in Overland Park, Kansas, and 31 years overall in education. He was an attorney for a number of years prior to entering education and has a law degree from Washburn University in Topeka, Kansas. He is a member of the High School Today Publications Committee.

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Should Schools Perform Drug Tests on Students?

Drug testing has become a common procedure in some areas of society, from teachers and athletes to professionals in a wide range of industries. More recently, the question of drug testing for students has been raised, as some schools have begun to institute random drug testing in high schools and even middle schools. Is drug testing an effective way to keep students “clean” or is it a blatant violation of students’ privacy rights? The answer to that question may depend on who you ask.

An Overview of Drug Testing

Drug testing can be done through a variety of methods, using samples that include urine or a few strands of hair. Common drugs tested for include marijuana, cocaine, steroids, opiates and amphetamines. Alcohol is not a substance that can be detected using standard drug testing procedures, since the substance does not stay in the body long enough to show up in test results. Current use of alcohol can be tested by breathalyzers and other testing methods.

Drug testing can be performed as a standard procedure, such as prior to hiring an applicant for a job. Some schools drug test teachers and have found positive results . Testing can also be done on an individual if substance use is suspected, due to suspicious behavior or actions of the individual. Another option is random testing, which can be done on any individual at any time, without warning. It is the random testing approach that has typically come under fire in public schools today.

According to a report at the National Institute of Drug Abuse, testing can be done as a deterrent for drug use. It can also be used to detect a potential substance abuse problem in students or employees, enabling the individual to receive the help needed to get off the drug in question. In some cases, drug testing may be used to enforce disciplinary measures on drug users in a company or school.

A History of Drug Testing in Public Schools

According to USLegal.com , drug testing in public schools did not begin to make an appearance until sometime in the 1980s. At that time, some public high schools began performing drug testing on student athletes – a practice that was already carried out by college and professional sports teams. Testing was also done on Olympic athletes and those competing in major sporting events like the Tour de France. By 2001, USLegal.com cites a report by the New York Times that estimated hundreds of school districts across the country were participating in some form of drug testing.

Although testing had been implemented in many schools, controversy surrounding the practice and some legal battles were waged over the practice. In 1995, the U.S. Supreme Court upheld the rights of schools to require drug testing on students for reasons beyond suspicious behavior. The ruling was perceived as a way to combat drug usage among the nation’s youth, despite concerns that it interfered with student privacy.

That Supreme Court ruling, which allowed for random drug testing on students participating in competitive extracurricular activities, has been interrupted in different ways by different school districts. In some schools, this restricts testing to student athletes – a practice that has now been in place for decades. However, other schools are using the looser translation of the law to test student participating in any type of after-school activity, as a criterion for joining a club or academic team . The practice is also moving into the younger grades, with some middles schools now adopting drug testing procedures along with their feeder high schools.

The New York Times reported last fall on new drug testing procedures implemented in both high schools and middle schools in Maryville, Missouri. Students who wish to participate in any club or sport in Maryville schools would have to consent to drug testing prior to joining. A spokesman for the schools told the Times the idea was to raise awareness of drug prevention among all middle and high school students. However, some parents are complaining that the policy is a violation of their children’s rights.

“They’re losing their rights every day and you ask yourself, what are we teaching the kids?” one Maryville parent told the Times.

However, proponents of the practice maintain their position that testing leads to prevention. Matthew Franz, owner of a drug testing company in Ohio, told the Times, “It starts early with kids. You want to get in there and plant these seeds of what’s out there and do prevention early.”

Some Private Schools Embrace Testing

While the battle over drug testing in public schools continues, some private schools are bypassing the conflict to form their own drug testing policies. Private institutions are exempt from the laws governing public schools, so they are allowed to test any and all students through random testing practices. While testing is not prevalent at private schools nationwide, some that have adopted the policy of random drug testing have been pleased with the results.

The Kansas City Star reports that a private Jesuit school has begun testing all of its students for drugs this fall. Administrators at Rockhurst High School determined that testing the entire student population will help them take a stand against drug use and offer help to those already victims of substance abuse. The testing policy was made through a collaboration of faculty, administrators and students.

While the debate on drug testing continues, no one knows definitively how much impact testing will have on student drug use overall. As more schools continue the practice, perhaps enough evidence can be compiled to determine whether testing is providing the desired effect on students. However, the question over student privacy rights is sure to remain a key component in the debate, no matter how successful testing proves to be.

Questions? Contact us on Facebook @publicschoolreview.

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Should Schools Test Their Students for Nicotine and Drug Use?

Would such testing result in fewer students using these substances?

By Shannon Doyne

Find all our Student Opinion questions here.

Do you think schools should test their student for drugs, alcohol and nicotine? Do you think such tests would encourage students to stay away from drugs? Or do you worry these tests are an invasion of privacy, or that they might be ineffective?

In “ Ohio High School Plans to Drug-Test All Students at Least Once a Year ,” Derrick Bryson Taylor writes about Stephen T. Badin High School in Hamilton, Ohio. Starting in January, students at the high school will be tested at least once a year for illicit drugs, alcohol, nicotine and other banned substances:

Students are required to consent to the testing as a condition of their enrollment at the school, and potential consequences for violating the drug policy include suspension and expulsion, the letter said. Under the new guidelines, a first positive drug test alone would not necessarily result in disciplinary action, provided there are no other violations of the policy, like rules against intoxication during school hours or possession of drugs on campus. But a comprehensive intervention plan would be put into place after a second positive test, and expulsion might be recommended after a third.

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This Policy Statement was retired July 2017.

The effect of substance abuse on children in school, school-based drug-screening programs, drug education at school, partnership between schools, medical home providers, and drug rehabilitation programs, community collaboration with schools, recommendations for pediatricians, council on school health 2005–2006, committee on substance abuse 2005–2006, the role of schools in combating illicit substance abuse.

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Council on School Health and Committee on Substance Abuse; The Role of Schools in Combating Illicit Substance Abuse. Pediatrics December 2007; 120 (6): 1379–1384. 10.1542/peds.2007-2905

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Disturbingly high levels of illicit drug use remain a problem among American teenagers. As the physical, social, and psychological “home away from home” for most youth, schools naturally assume a primary role in substance abuse education, prevention, and early identification. However, the use of random drug testing on students as a component of drug prevention programs requires additional, more rigorous scientific evaluation. Widespread implementation should await the result of ongoing studies to address the effectiveness of testing and evaluate possible inadvertent harm. If drug testing on students is conducted, it should never be implemented in isolation. A comprehensive assessment and therapeutic management program for the student who tests positive should be in place before any testing is performed. Schools have the opportunity to work with parents, health care professionals, and community officials to use programs with proven effectiveness, to identify students who show behavioral risks for drug-related problems, and to make referrals to a student's medical home. When use of an illicit substance is detected, schools can foster relationships with established health care experts to assist them. A student undergoing individualized intervention for using illicit substances merits privacy. This requires that awareness of the student's situation be limited to parents, the student's physician, and only those designated school health officials with a need to know. For the purposes of this statement, alcohol, tobacco, and inhalants are not addressed.

Students spend the major part of their day in school. The school environment provides a standard against which young people test behavior. 1 School personnel often serve as highly influential role models by which preadolescents and adolescents judge themselves. Adolescents who perceive that their teachers care about them are less likely to initiate marijuana use, cigarette smoking, drinking to get drunk, and other health risk behaviors. 2 Relationships with teachers and counselors are among the most important and formative ones for many students, especially middle school students. 2 Students who are poorly bonded to school are also less likely to recognize that substance use may reduce the likelihood of them achieving their future goals. 3

The use of mind-altering chemicals has deleterious effects on school performance. 4 – 7 Students under the influence of such substances are not ready to learn and are at risk of long-term impairment of cognitive ability and memory. 7 , 8 Substance use is frequently associated with a lack of motivation and self-discipline as well as reduced school attendance. 9 , 10 Safety issues also are of concern. Marijuana, like alcohol, is associated with increased risk of motor vehicle crashes and death. 11 – 14 In addition, substance abuse is correlated with antisocial and violent behavior, such as bringing guns and knives to school, as well as other risk-taking behaviors. 15 – 18

Schools, working in collaboration with community partners and health care professionals, are well situated to identify students with signs and symptoms of illicit drug abuse. 19 – 21 Poor school performance, underachievement, and truancy may be manifestations of substance use and indicate the need for evaluation and referral of these students to their medical home, where causes for this behavior can be determined. Medical home providers can use screening tools and resources available from federal, state, and local agencies, many of which are categorized both geographically and topically on the Internet (see Fig 1 ). 22

Although recent data have suggested that prevalence of substance abuse has been decreasing in recent years, illicit substance abuse remains a major problem among American youth. 23 – 26 The degree of illicit substance abuse among students has translated into an ongoing societal search for ways to address this problem, including community- and school-based prevention programs, stricter law enforcement techniques, and, more recently, the use of laboratory testing programs within schools.

In June 2002, the US Supreme Court broadened the authority of public schools to test students for illicit drugs by allowing random drug testing for all middle and high school students who participate in competitive extracurricular activities. 27 Some schools and districts are performing drug tests or are considering them for students in competitive sports, other physically active extracurricular activities (eg, school band, cheerleading), and, in some cases, all extracurricular activities (eg, chess club, debate team). Students may be excluded from the activity until they have been cleared through a screening process. 28 , 29 The type of screening performed varies widely (eg, urine, hair sample), as do the specific drugs included in the screen and the response to a positive drug-test result. Technical issues regarding illicit drug testing are addressed in a separate American Academy of Pediatrics (AAP) policy statement on drug testing 30 and in a forthcoming addendum to that statement concerning drug testing in schools and at home. 31

Consequences of a positive drug-test result may include punitive measures, further student assessment, counseling, therapy, and/or rehabilitation. Random drug testing of students may affect specific students or groups of students differently. The benefits and risks of drug testing as a component of a comprehensive program to prevent or reduce substance abuse in such groups as nonusers, first-time and/or occasional users, and more frequent or addicted users must be determined by scientific studies. Implementation of random drug testing of students should await these results. The optimal means of assessing the implications of a positive drug-test result is an evaluation of the student by a health care professional who is trained or experienced in this process.

Some societal leaders support broad drug testing as an aid in the prevention of drug use and possible early identification of youth who have used drugs, thereby facilitating appropriate assessment and therapeutic referral. Others, including many parents and pediatricians, are concerned that school-based drug testing could unnecessarily label or stigmatize a child and compromise personal and family privacy. The Health Insurance Portability and Accountability Act applies to medical facilities, but children and adolescents do not have the same safeguards to privacy of medical information in the school. Recording positive drug-test results on students' permanent educational records (under guidelines of the Family Educational Rights and Privacy Act), which are accessible to many school personnel, could have negative and long-term consequences. Strict attention to issues of confidentiality must be ensured.

It has not yet been established that drug testing does not cause harm. The following should be considered:

Students involved with illicit drugs may decrease their involvement in extracurricular activities to avoid drug testing. According to the National Institute on Out-of-School Time ( www.niost.org ), students who spend time in extracurricular activities are 49% less likely to use drugs. Without engagement in such activities, adolescents have a higher likelihood of dropping out of school, becoming pregnant, joining gangs, pursuing or increasing their use of drugs, and/or engaging in other risky behaviors. 32 – 34

Positive drug-test results may cause increased family conflict rather than improve the home situation for the student.

Drug testing of adolescents is not performed for public safety. Even adults have mixed responses to the idea of widely applied drug testing. Although many support the idea of drug testing as a necessary measure for public safety from intoxicated or impaired pilots, bus drivers, police officers, and others, they often voice concerns when the application becomes more pervasive and random.

Dollars spent on drug testing may be more effectively spent on drug prevention programs or well-established counseling programs.

Drug testing youth who have not been implicated in using drugs may be perceived as being unfair and, thereby, may reduce trust and connectedness with their school, which are essential for maintaining lines of communication. 2 , 33 – 35

Without evidence available to weigh the effectiveness of drug screening against the potentially harmful consequences, such programs should be limited in schools to those that are carefully controlled and comprehensive in scope. 36 , 37

Schools may adopt a variety of alternatives to drug testing to address the issue of substance abuse, including offering after-school programs, incorporating life-skills training into drug education curricula, helping parents become better informed, providing counseling, identifying problem behaviors for early intervention, and promptly referring students to health care professionals for assessment and intervention. School-based health centers should have the capacity to counsel students who are in need of such treatment plans and connect students to available community resources.

Schools are appropriate settings for drug prevention programs for 3 reasons: (1) prevention must focus on children before their beliefs and expectations about substance abuse are established; (2) schools offer the most systematic way of reaching young people; and (3) schools can promote a broad spectrum of drug-related educational policies. 36 Resources for the preparation of teachers, counselors, and other school personnel may be a valuable adjunct. 19 , 20

Educators are challenged to make the facts about drug abuse meaningful to children and adolescents without enticing them to try drugs. There are many curricula designed for school use that have been proven to be effective and are delivered to students in ways that are interesting, interactive, and developmentally appropriate. 36 , 38 , 39 Although many program approaches are available, some effective programs focus on enhancing students' problem-solving skills or aiding them to evaluate the influence of the media. Other effective programs help improve students' self-esteem, reduce stress and anxiety, or increase activities. These skills are taught by using a combination of methods including demonstration, practice, feedback, and praise. 40

Another proven approach is “life-skills training,” designed to teach skills to confront a problem-specific focus, emphasizing the application of skills directly to the problem of substance abuse. One of the most studied programs is LifeSkills Training (National Health Promotion Associates, White Plains, NY), a universal school-based prevention approach (most often focused on 7th-graders) that teaches general personal and social skills training combined with drug-refusal skills and normative education. LifeSkills Training produces positive behavioral effects on alcohol, tobacco, and illicit drug use. This approach, with booster sessions that follow the initial program, is most effective. 5 These effects continue years after the intervention. 36 , 41 , 42 Many effective curricula and drug prevention programs use interactive materials and maximize group interactions with organized activities. 36 , 38 , 39 , 43 , 44 Studies have demonstrated convincingly that the effects of school programs can be amplified substantially when community components are added. 20

Schools may partner with rehabilitation programs to provide care for a student to help successfully reintegrate him or her. Educational planning is an integral part of after-care contracts that pediatricians, mental health professionals, or rehabilitation programs form with students and their families. The school's roles in such a collaborative relationship include identifying any underlying learning disabilities that may have contributed to the problem, making special accommodations for students when necessary, providing remedial work so that students can catch up with their classmates, helping to reinforce expectations for students to attend school and to comply with follow-up or monitoring as prescribed by the health care professional or rehabilitation facility, and assisting with finding after-school programs. It is also important for students who have used substances to be assigned at least 1 trusted adult who is available in the school building to help them if they feel they need it. Those who are assigned to work with the student's drug problems must know how to respect confidentiality of treatment. This adult or another school health professional, school administrator, or designated staff member should be assigned to work with the student's pediatrician and rehabilitation personnel to communicate the student's progress or failure to progress.

The roles of pediatricians, mental health professionals, and rehabilitation programs in this collaborative relationship are to identify any mental health diagnoses and notify the schools of their relevance to the student's safety at school, to the student's educational program, and to school personnel or operations in general. Health care professionals also need to provide schools with treatment plans that may affect the school day while maintaining the student's confidentiality to the extent that is possible.

Communities can send a clear and consistent message by developing and implementing a broad, comprehensive approach to dealing with substance abuse. Schools can serve as a focal point for such a community-wide effort. Community agencies can partner with schools to help monitor illicit drug use patterns in the local region to direct specific educational and preventive programs. Substance abuse problems that are associated with other mental health conditions can best be dealt with through comprehensive mental health programs that are capable of addressing prevention and intervention of both conditions. More information is available in the AAP policy statement on mental health in schools. 45 School personnel should receive ongoing training, preferably by a health care professional who is skilled at the recognition of and risk factors for substance use and related disorders so that each staff member is able to guide faculty, parents, families, and others who are concerned about such use. As part of their community/school program to counter substance abuse, the community should provide regular activities that are supportive alternatives to the abuse of drugs.

Pediatricians should not support drug testing in schools. If testing is performed at all, it should only be done as part of a funded, comprehensive approach to addressing substance abuse in the school and in the community. Examination of alternative approaches should be carefully evaluated for effectiveness and cost.

Because of ongoing concerns about the implications of school-based drug-screening programs, the AAP membership should support and promote alternative school-based efforts to combat substance abuse. In addition, pediatricians should:

Serve as a medical home and resource for patients and their families and offer primary (ie, universal approaches designed to target all patients or potential users before a problem occurs) and secondary (ie, approaches targeted at patients who have screened positive for high-risk behaviors such as tobacco, alcohol, or inhalant use) prevention of illicit drug use.

Identify patients with personal, medical, mental health, social, or academic problems who might be at high risk for drug abuse. Consider the use of screening tools and questionnaires, such as the Guidelines for Adolescent Preventive Services surveys ( www.ama-assn.org/ama/pub/category/1980.html ) and the CRAFFT tool, 22 in the care of adolescent populations to identify patients who might need additional assessment and treatment. Mental health problems such as anxiety, depression, attention-deficit/hyperactivity disorder, and other diagnoses may coexist with substance abuse. The patient's progress should be monitored carefully so that ongoing assistance can be provided.

Support communication strategies that maintain patient/student confidentiality while coordinating treatment among the medical home provider, the family, and school-based programs.

Promote awareness of changing patterns of illicit drug use through local resources as well as through AAP chapter and district channels.

Raise awareness about mental health and rehabilitation services related to drug use that are available within the community to aid the student, family, and school.

Support and advise communities on the importance of clear and consistent community-wide messaging on illicit substance use and the promotion of activities that are free of drug and alcohol use.

Become familiar with the local school district's substance abuse prevention and health promotion programs.

Barbara Frankowski, MD, MPH, Chairperson

Rani Gereige, MD, MPH

Linda Grant, MD, MPH

Daniel Hyman, MD

Harold Magalnick, MD

* Cynthia J. Mears, DO

George Monteverdi, MD

Robert D. Murray, MD

Evan Pattishall, MD

Michelle Roland, MD

Thomas L. Young, MD

Howard Taras, MD

Spencer Su Li, MPA

Alain Joffe, MD, MPH, Chairperson

Marylou Behnke, MD

* John R. Knight, MD

Patricia Kokotailo, MD, MPH

Tammy Harris Sims, MD, MS

Janet F. Williams, MD

Ed Jacobs, MD

Karen Smith, MS

FIGURE 1. CRAFFT screening tool for adolescent substance abuse. (Reproduced with permission from the Center for Adolescent Substance Abuse Research, Children's Hospital Boston; 2001.)

CRAFFT screening tool for adolescent substance abuse. (Reproduced with permission from the Center for Adolescent Substance Abuse Research, Children's Hospital Boston; 2001.)

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

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The Classroom | Empowering Students in Their College Journey

Arguments Against Drug Testing in Schools

Can Schools Legally Take a Student's Belongings?

When students are in school, they need to follow certain rules. This goes for students of all ages, whether they are in primary school, middle school, high school or college. Rules can be anything from following a dress code, to walking in a line in the hallway to more strict matters, such as zero tolerance policies against alcohol and drug use.

Schools strive to make their buildings a safe space for all students, and some go to what would be considered extreme measures to do so. One of these measures is drug testing students. There are many arguments for and against drug testing in schools, but most of all, the fact that it infringes on a student's right to receive an education should be enough of an argument to end it altogether.

Are Schools Allowed to Drug Test Students?

There are some circumstances in which schools are allowed to drug test students, but aside from these circumstances, it would be considered unconstitutional for schools to do so. One situation in which schools can legally drug test students is if they are student athletes. Schools are legally allowed to randomly drug test student athletes based on a 1995 Supreme Court ruling on the Vernonia School District vs. Acton case.

The second situation in which schools are legally allowed to drug test students is if they are involved in a competitive extracurricular activity , such as chess club or Intel Science. This became permitted in 2002, as an extension of the ruling in 1995. The problem with this is that some school districts have implemented their own interpretation of the ruling by using it to justify drug testing of all students for trivial circumstances, such as whether or not they should be permitted to attend a school function.

Should Students Be Randomly Drug Tested?

The deeper controversy with school's misinterpreting the Supreme Court ruling is the basis of this ruling in general. Because it permits random drug testing, or RSDT, this gives schools "the right" to drug test their athletes or student competitors whenever they feel necessary, without advising students beforehand.

Schools do this because if they advise students' beforehand about a drug test date, casual drug users can plan accordingly by choosing to avoid drugs a few weeks leading up to the test, which means that schools cannot "catch" students that use drugs. On the other hand, random drug testing can be seen as unfair overall because the argument is that a student who may try a drug one time, shouldn't be penalized in such a harsh manner. It's also considered by many a violation of the student's rights.

Do Teachers Get Drug Tested?

Most teachers who apply to work in a school district will be required to get their fingerprints done and submit a criminal background check . Contrary to what many people might believe, teachers are not typically drug tested upon an interview or during the school year.

However, schools can legally require their teachers to undergo a drug test if the school has reasonable suspicions. For instance, they sense that the teacher is working while under the influence. However, this usually begins with a search and seizure .

The fact of the matter is, even though the Fourth Amendment to the Constitution says that Americans have the right to privacy, both teachers and students essentially waive this right at school for a variety of different reasons. Yet some students may believe that since teachers are only subject to drug tests under reasonable suspicion, then the same standard should apply to students.

There are many arguments against drug testing in schools, especially random drug testing. One reason athletes get tested is for the use of performance-enhancing drugs, which many would argue is a fair reason for drug testing, so that no one player has an advantage over another. Aside from this, there are other issues with drug testing students, regardless of whether or not they are athletes:

It's considered unconstitutional.
Some students may be pressured into trying a drug.
A consistent drug user may have an addiction problem and should not be punished.
Students have the right to privacy.
It's not the school's business what the student does outside of school.
The school's budget could be put to better use than drug testing students.
Sometimes, drug tests come back positive by mistake.
Students are normally punished for failing a drug test, which in no way supports the student to recovery.
Some states have legalized the use of both medical and recreational marijuana (this especially goes for teachers).
Some would argue that occasional, social drug use (depending on the drug) may be natural to an adolescent's transition into adulthood.
Students deserve an education no matter what the circumstance is. Denying a student an education when they may be struggling, could be even worse for them, as an education is many times the only way out.

Negative Effects of Mandatory Drug Testing

Not only are there many arguments against drug testing in schools, but there are also negative effects of mandatory drug testing on the students on the school body as a whole. Students who are subject to drug testing may feel that they aren't trusted by their administrators, which can effect the student's attitude toward school overall. It also creates a stigma against students who may use drugs, when students are supposed to be taught tolerance and acceptance of their peers, regardless of their differences.

While many drug prevention programs have been implemented in school districts across the United States since the nineties, most of them have not been effective, as can be seen by the huge opioid epidemic in the United States. Ultimately, the most negative effect of mandatory drug testing on teens and college students is that it puts a label on them as a drug user, which can actually have the opposite effect and turn them against achieving their goals in school or seeking appropriate treatment if necessary.

Why Schools Shouldn't Drug Test

There are many reasons why schools shouldn't drug test: violation of privacy, it's unconstitutional, it devalues the student, it takes away opportunities, it creates a judgmental environment, etc. The list goes on and on. While many people who support drug testing in schools would say it helps make school a safe, drug-free environment and helps detect early drug-use in students thereby creating room for the student to seek help, this rarely happens.

Students who are drug tested and test positive for drugs in their system may have many reasons for having done drugs. Even though some people may disagree, it's often normal for students, especially high school students, to experiment with drugs to some degree at this age. While parents and teachers should be aware of any students showing signs of dependency, in many cases, this is not what happens.

The Consequences of Drug Testing

Sometimes, pushing too much for a drug-free campus can actually have the opposite result. Students should be trusted by their elders to make the right decisions for themselves, and at the end of the day, it's important that students stay in school no matter what because that is their best chance of having a successful future. If they are drug tested and punished, they may delve deeper into drug use.

Therefore, schools should avoid drug testing their students, and if they do under certain circumstances, for instance, within their athletic department, they should think about how to best handle that situation. This is because punishment is not always the best course of action when a student is doing drugs. Instead, students should be taught about the effects of drugs , and what to do to best handle the situation responsibly and safely if the opportunity arises.

Ways to Get Expelled From School

Backpack and Locker Searches in Public High Schools

Consequences of School Violence

What Are the Cons of Students Wearing School Uniforms?

Reasons School Should Not Be Allowed to Search Backpacks & Lockers

Positive Effects of the Zero Tolerance Policy Used in Schools

The Effects of School Uniforms on the Public School System

The Pros & Cons of the Achievements Test in Order to Graduate From ...

FindLaw: Drug Testing Student Athletes: Is It Legal?
Center on Addiction: Should Students Be Drug Tested at School?
Drug Policy: Drug Testing in Schools
Florida State University Extension: To Pee or Not To Pee
Slate: Blowing Smoke

Hana LaRock is a freelance content writer from New York, currently living in Mexico. She has spent the last 5 years traveling the world and living abroad and has lived in South Korea and Israel. Before becoming a writer, Hana worked as a teacher for several years in the U.S. and around the world. She has her teaching certification in Elementary Education and Special Education, as well as a TESOL certification. Hana spent a semester studying abroad at Tel Aviv University during her undergraduate years at the University of Hartford. She hopes to use her experience to help inform others. Please visit her website, www.hanalarockwriting.com, to learn more.

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Drug Testing in High School Athletes

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Epidemiology of antituberculosis drug resistance (the Global Project on Anti-tuberculosis Drug Resistance Surveillance): an updated analysis

Affiliation.

1 Stop TB Department, WHO, Geneva, Switzerland.
PMID: 17174706
DOI: 10.1016/S0140-6736(06)69863-2

Background: The burden of tuberculosis is compounded by drug-resistant forms of the disease. This study aimed to analyse data on antituberculosis drug resistance gathered by the WHO and International Union Against Tuberculosis and Lung Disease Global Project on Anti-tuberculosis Drug Resistance Surveillance.

Methods: Data on drug susceptibility testing for four antituberculosis drugs--isoniazid, rifampicin, ethambutol, and streptomycin--were gathered in the third round of the Global Project (1999-2002) from surveys or ongoing surveillance in 79 countries or geographical settings. These data were combined with those from the first two rounds of the project and analyses were done. Countries that participated followed a standardised set of guidelines to ensure comparability both between and within countries.

Findings: The median prevalence of resistance to any of the four antituberculosis drugs in new cases of tuberculosis identified in 76 countries or geographical settings was 10.2% (range 0.0-57.1). The median prevalence of multidrug resistance in new cases was 1.0% (range 0.0-14.2). Kazakhstan, Tomsk Oblast (Russia), Karakalpakstan (Uzbekistan), Estonia, Israel, the Chinese provinces Liaoning and Henan, Lithuania, and Latvia reported prevalence of multidrug resistance above 6.5%. Trend analysis showed a significant increase in the prevalence of multidrug resistance in new cases in Tomsk Oblast (p<0.0001). Hong Kong (p=0.01) and the USA (p=0.0002) reported significant decreasing trends in multidrug resistance in new cases of tuberculosis.

Interpretation: Multidrug resistance represents a serious challenge for tuberculosis control in countries of the former Soviet Union and in some provinces of China. Gaps in coverage of the Global Project are substantial, and baseline information is urgently required from several countries with high tuberculosis burden to develop appropriate control interventions.

PubMed Disclaimer

Controlling multidrug-resistant tuberculosis in India. Gopinath K, Manisankar M, Kumar S, Singh S. Gopinath K, et al. Lancet. 2007 Mar 3;369(9563):741-742. doi: 10.1016/S0140-6736(07)60358-4. Lancet. 2007. PMID: 17336647 No abstract available.

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Bull World Health Organ
v.85(9); 2007 Sep

Language: English | French | Spanish | Arabic

Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance

Obstacles au succès du traitement de la tuberculose à tomsk (fédération de russie) : non-observance du traitement, abandon et acquisition d’une pharmacorésistance, obstáculos al éxito del tratamiento de la tuberculosis en tomsk (federación de rusia): incumplimiento y abandono del tratamiento, y adquisición de multirresistencia, عوائق نجاح معالجة السل في مدينة تومسك، بالاتحاد الروسي: عدم الامتثال، والتخلُّف عن المعالجة، واكتساب المقاومة للأدوية المتعدِّدة, iy gelmanova.

a Partners In Health Russia, Moscow, Russian Federation.

S Keshavjee

b Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital, Boston, MA, USA.

c Program in Infectious Disease and Social Change, Department of Social Medicine, Harvard Medical School, Boston, MA, USA.

d Partners In Health, Boston, MA, USA.

VT Golubchikova

e Tomsk Oblast Tuberculosis Services, Tomsk, Russian Federation.

VI Berezina

f Siberia State Medical University, Tomsk, Russian Federation.

g Tomsk Oblast Tuberculosis Hospital, Tomsk, Russian Federation.

h Division of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

To identify barriers to successful tuberculosis (TB) treatment in Tomsk, Siberia, by analysing individual and programmatic risk factors for non-adherence, default and the acquisition of multidrug resistance in a TB treatment cohort in the Russian Federation.

We conducted a retrospective cohort study of consecutively enrolled, newly detected, smear and/or culture-positive adult TB patients initiating therapy in a DOTS programme in Tomsk between 1 January and 31 December 2001.

Substance abuse was strongly associated with non-adherence [adjusted odds ratio (OR): 7.3; 95% confidence interval (CI): 2.89–18.46] and with default (adjusted OR: 11.2; 95% CI: 2.55–49.17). Although non-adherence was associated with poor treatment outcomes (OR: 2.4; 95% CI: 1.1–5.5), it was not associated with the acquisition of multi-drug resistance during the course of therapy. Patients who began treatment in the hospital setting or who were hospitalized later during their treatment course had a substantially higher risk of developing multidrug-resistant TB than those who were treated as outpatients (adjusted HRs: 6.34; 95% CI: 1.35–29.72 and 6.26; 95% CI: 1.02–38.35 respectively).

In this cohort of Russian TB patients, substance abuse was a strong predictor of non-adherence and default. DOTS programmes may benefit from incorporating measures to diagnose and treat alcohol misuse within the medical management of patients undergoing TB therapy. Multidrug-resistant TB occurred among adherent patients who had been hospitalized in the course of their therapy. This raises the possibility that treatment for drug-sensitive disease unmasked a pre-existing population of drug-resistant organisms, or that these patients were reinfected with a drug-resistant strain of TB.

Résumé

Identifier les obstacles s’opposant au traitement avec succès de la tuberculose (TB) à Tomsk en Sibérie, par une analyse des facteurs de risque individuels et programmatiques de non-observance du traitement, d’abandon et d’acquisition d’une pharmacorésistance dans une cohorte traitée contre la TB en Fédération de Russie.

Méthodes

Nous avons mené une étude rétrospective sur une cohorte d’adultes récemment diagnostiqués comme tuberculeux par examen de frottis positif et/ou par culture et débutant un traitement dans le cadre d’un programme DOTS (autrefois appelé traitement de brève durée sous surveillance directe) à Tomsk, entre le 1er janvier et le 31 décembre 2001.

Résultats

Il existe de fortes associations entre la toxicomanie et la non observance du traitement (OR ajusté : 7,3 ; IC à 95% : 2,89-18,46) et son abandon (OR ajusté : 11,2 ; IC à 95% : 2,55-49,17). Si la non-observance du traitement est associée à un résultat thérapeutique insatisfaisant (OR : 2,4 ; IC à 95% : 1,1-5,5), elle ne l’est pas avec l’acquisition d’une pharmacorésistance. Les malades ayant débuté un traitement dans un cadre hospitalier ou ayant été hospitalisés ultérieurement au cours de leur traitement présentent un risque nettement plus élevé de développer une TB multirésistante que ceux traités en ambulatoire (OR ajustés : 6,34 ; IC à 95% 1,35-29,72 et 6,26 ; IC à 95% : 1,02-38,35, respectivement).

Dans cette cohorte de malades russes, la toxicomanie était un facteur prédictif fort de non-observance et d’abandon. Les programmes DOTS peuvent tirer profit de l’incorporation de mesures de diagnostic et de traitement des abus d’alcool dans le cadre d’une prise en charge médicale des malades traités contre la TB. Les TB multirésistantes apparaissent chez des malades observant leur traitement et hospitalisés dans le cadre de celui-ci. Cette observation laisse entrevoir la possibilité que le traitement des maladies pharmacosensibles démasque une population préexistante d’organismes pharmacorésistants ou que les malades concernés aient été réinfectés par une souche pharmacorésistante de TB.

Identificar obstáculos al éxito del tratamiento de la tuberculosis (TB) en Tomsk (Siberia), analizando los factores de riesgo individuales y programáticos de incumplimiento y abandono del tratamiento y de adquisición de multirresistencia en una cohorte de pacientes tratados de TB en la Federación de Rusia.

Métodos

Hemos realizado un estudio de cohortes retrospectivo de pacientes adultos consecutivos con TB recién detectada (baciloscopia y/o cultivo positivo) en los que se inició un tratamiento con la estrategia DOTS (tratamiento breve bajo observación directa) en Tomsk entre el 1 de enero y el 31 de diciembre de 2001.

El abuso de sustancias se asoció estrechamente al incumplimiento del tratamiento (OR ajustada: 7,3; IC95%: 2,89–18,46) y a su abandono (OR ajustada: 11,2; IC95%: 2,55–49,17). El incumplimiento se asoció a malos resultados terapéuticos (OR: 2,4; IC95%: 1,1–5,5), pero no a la adquisición de multirresistencia en el curso del tratamiento. En comparación con los pacientes que recibieron tratamiento ambulatorio, el riesgo de presentar multirresistencia fue significativamente mayor en aquellos que iniciaron el tratamiento en un hospital (HR ajustada: 6,34; IC95%: 1,35–29,72) o que fueron hospitalizados posteriormente en el curso de su tratamiento (HR ajustada: 6,26; IC95%: 1,02–38,35).

Conclusión

En esta cohorte de pacientes rusos con TB, el abuso de sustancias predijo bien el incumplimiento y el abandono del tratamiento. Los programas de DOTS pueden beneficiarse de la incorporación de medidas para diagnosticar y tratar el abuso de alcohol en pacientes sometidos a tratamiento antituberculoso. Se produjeron casos de TB multirresistente en pacientes que cumplieron su tratamiento pero fueron hospitalizados en el curso de éste. Esto plantea la posibilidad de que el tratamiento de la enfermedad sensible a los antituberculosos desenmascare una población preexistente de miroorganismos resistentes o de que estos pacientes se hayan reinfectado con cepas farmacorresistentes.

ملخص

الغرض.

استەدفت ەذە الدراسة تحديد عوائق نجاح معالجة السل في مدينة تومسك، بسيبريا، عن طريق تحليل عوامل الاختطار الفردية والبرنامجية المؤدية إلى عدم الامتثال للمعالجة، والتخلُّف عنەا، واكتساب المقاومة للأدوية المتعدِّدة، وذلك في مجموعة أترابية تُعالج من السل في الاتحاد الروسي.

الطريقة

أجرينا دراسة أترابية استعادية لمجموعة من مرضى السل البالغين الإيجابيي اللطاخة و/أو الإيجابيي المزرعة، الذين اكتُشفوا حديثاً والتحقوا تباعاً ببرنامج المعالجة القصيرة الأمد للسل تحت الإشراف المباشر في مدينة تومسك، في المدة من 1 كانون الثاني/يناير إلى 31 كانون الثاني/يناير 2001.

الموجودات

لوحظ ارتباط قوي بين معاقرة مواد الإدمان وبين عدم الامتثال (نسبة الاحتمال المصحَّحة: 7.3؛ عند فاصلة ثقة 95 %: 2.89 – 18.46)، وكذلك بين التخلُّف عن المعالجة (نسبة الاحتمال المصحَّحة: 11.2؛ عند فاصلة ثقة 95 %: 2.55 – 49.17). وبرغم ارتباط عدم الامتثال بضعف حصائل المعالجة (نسبة الاحتمال المصحَّحة: 2.4؛ عند فاصلة ثقة 95 %: 1.1 – 5.5)، إلا أن عدم الامتثال لم يرتبط باكتساب المقاومة للأدوية المتعدِّدة أثناء المعالجة. ولوحظ أن المرضى الذين بدأوا المعالجة في المستشفى أو أُدخلوا المستشفى بعد ذلك أثناء المعالجة، كانوا أكثر تعرُّضاً لمخاطر اكتساب السل المقاوم لأدوية متعدِّدة (معدل المخاطرة المصحَّح: 6.34؛ عند فاصلة ثقة 95 %: 1.35 – 29.72)، بالمقارنة مع من عولجوا كمرضى خارجيـين (معدل المخاطرة المصحَّح: 6.26؛ عند فاصلة ثقة 95 %: 1.02 – 38.35).

الاستنتاج

في ەذە المجموعة من مرضى السل الروسيـين، كانت معاقرة مواد الإدمان عاملاً قوياً في التنبُّؤ بعدم الامتثال للمعالجة والتخلُّف عنەا. ويمكن لبرامج المعالجة القصيرة الأمد للسل تحت الإشراف المباشر أن تستفيد من عملية إدماج تدابير تشخيص ومعالجة إساءة استعمال الكحول في المعالجة الطبية للمرضى الذين يُعالجون من السل. وقد لوحظ وقوع السل المقاوِم لأدوية متعدِّدة بين المرضى الممتثلين للمعالجة الذين أُدخلوا المستشفى أثناء المعالجة. وەذا يطرح إمكانية أن تكون معالجة الأمراض الحساسة للأدوية قد كشفت عن وجود كائنات حيَّة مقاومة للأدوية، أو أن يكون ەؤلاء المرضى قد عاودتەم العدوى بذرية لجراثيم السل مقاومة للأدوية.

Introduction

After a long period of decline, tuberculosis (TB) incidence and mortality in the Russian Federation rose dramatically in the 1990s and peaked in 2000. 1 During the same period, the proportion of notified TB patients cured by therapy fell precipitously from 90% in 1985 to an estimated 72% in 2000. Despite the Russian Federation’s introduction and gradual uptake over the past decade of the DOTS strategy, treatment success rates have remained consistently low even though case notifications have declined. 2 WHO attributes these high failure rates to drug resistance and high rates of default and death among Russian patients receiving DOTS. 3

Before addressing these problems to improve DOTS outcomes, it is necessary to identify the proximal causes of death, default and the acquisition of drug resistance among TB therapy patients. In an earlier study, we reported the causes of death of patients undergoing DOTS treatment in Tomsk, Siberia, from January 2002 to December 2003. 4 We observed a 9.6% death rate during TB treatment – due not only to TB but also to co-morbid conditions such as alcoholism and cardiovascular disease. We also found that both alcoholism and late presentation contributed substantially to mortality.

Here, we present data on programmatic and individual risk factors for non-adherence, default and the acquisition of multidrug resistance (MDR) in a DOTS treatment cohort in Tomsk. Based on our findings, we propose several specific interventions that may improve treatment outcomes and reduce the acquisition of drug resistance in patients undergoing TB therapy in this setting.

Setting and programme description

We conducted this study in the Tomsk oblast of western Siberia, where the incidence and mortality rates for TB in 2001 were 109.3 and 18.3 per 100 000, respectively. Rates of MDR in Tomsk were among the highest reported worldwide; MDR among newly diagnosed patients rose from 6.5% in 1999 to 12.1% by 2002. In 1995 Tomsk was one of the first Russian Federation oblasts to implement the DOTS strategy.

Tomsk City TB Services (TTBS) oversees diagnosis, treatment and reporting of adult patients with TB. Suspects undergo sputum smear microscopy and culture at the time of diagnosis. Those who are culture-positive also undergo drug sensitivity testing to isoniazid, rifampicin, ethambutol, streptomycin and kanamycin. Susceptibility is determined using the absolute concentration method on Lowenstein-Jensen medium, based on the following drug concentrations: isoniazid 1 μg/ml, rifampicin 40 μg/ml, ethambutol 5 μg/ml and streptomycin 10 μg/ml. Massachusetts State Laboratory Institute, a supranational reference laboratory, provides external quality control.

Patients diagnosed with active TB are treated according to WHO recommendations. 5 Those with multidrug-resistant TB (MDR-TB) are switched to an individualized regimen based on the drug resistance profile. Treatment is offered three ways: under direct supervision in an inpatient setting, at one of three outpatient clinics or through home-based care. Patients receive drugs daily in each of the outpatient settings. Home-based care is provided for those who are unable to attend outpatient clinics, with nurses delivering drugs directly to the patients. Some patients self-administered drugs during weekends and holidays, and a small proportion self-administered over half of their medications. Government social services provide free passes for public transport to all patients treated in ambulatory settings. Travel expenses are not provided for patients who have no public transport services. Patients undergoing TB treatment are assessed with repeat sputum smear, culture and drug-sensitivity testing (DST) in months 2, 3 and 5 as well as at the end of treatment and at six-month intervals thereafter.

Study design

We conducted a retrospective cohort study of newly detected smear- and/or culture-positive TB patients aged over 17 who were notified under DOTS and began TB treatment during the period from 1 January to 31 December 2001. We excluded patients who were admitted to psychiatric hospitals, were in prison, died within one month of beginning therapy or did not live within Tomsk city limits. Individual and programmatic risk factors as well as outcomes were assessed by reviewing patients’ charts and TB treatment records, and through a TB database set up by the TTBS. We then assessed risk factors for non-adherence, default and the development of MDR during therapy.

Exposure assessment

For each patient, we recorded the following information collected routinely for all patients undergoing TB therapy under the TTBS: age, gender, address, history of previous TB treatment, clinical signs at presentation, date of diagnosis, all sputum-smear results, all culture results, all drug-sensitivity profiles, number of missed doses, dates of missed doses, date of end of treatment, date of default, date of death, co-morbidities including HIV, employment status at beginning of treatment, history of previous incarceration and diagnosis of chronic alcoholism and/or drug addiction by a narcologist. Alcoholism is often underdiagnosed in the Russian Federation, therefore we also recorded any note of alcohol abuse that occurred during the treatment period. We classified patients’ proximity to their assigned clinic on the basis of their home address and the accessibility of public transport. Patients were classified as having co-morbidities potentially associated with side effects if they reported renal insufficiency, liver disease, diabetes mellitus, gastric ulcers, malignancies, cholecystitis or neurosyphilis.

Outcome assessment

We classified patients as non-adherent if they missed more than 20% of the prescribed doses during the treatment period recommended by WHO. In a sensitivity analysis, we identified patients who missed more than 50% of their prescribed doses. Treatment outcomes, including default, were classified according to WHO guidelines. 6 Patients were classified as having acquired MDR during or subsequent to therapy if they were sensitive to either isoniazid or rifampicin on their first DST but were noted to be resistant to both agents on any later DST.

Statistical analysis

For univariate analyses of non-adherence and default, we used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). The Mantel-Haenszel χ² method or Fisher’s exact test were used to calculate p-values. Statistical tests were two-sided. We used separate logistic regression models to perform multivariate analyses of the outcomes, adherence and default. The multivariate model included relevant variables with p-values less than 0.2 in univariate analysis, and those for which we had strong expectation of an association. As a sensitivity analysis we repeated the multivariate analysis of risk factors for non-adherence, excluding those people who had self-administered more than 40% of their doses. We also assessed the univariate association between non-adherence and a binary variable, summarizing treatment outcomes as either poor (death, default or failure) or good (cure or treatment completion).

Kaplan–Meier survival analysis was used to estimate the time from initiation of therapy to acquisition of MDR-TB. For patients who did not reach the end-point, the data were censored at the time of their last DST. The MDR acquisition time was taken as the mid-point between the last DST without MDR and the first DST with MDR. The log rank test was used to compare time to MDR between strata. The Cox proportional hazards model was used for multivariate analysis. In a sub-analysis, we also assessed risk factors for early (within four months of treatment initiation) and late (6 months after treatment initiation) acquisition of MDR. Patients who acquired early MDR were excluded from the analysis of risk factors for late MDR. Analyses were performed using Stata (version 9.0) and SAS (version 9.1) software.

Ethics approval

This study was approved by the respective institutional review boards at Tomsk State Medical University on 21 June 2004 and at Brigham and Women’s Hospital on 17 September 2004.

Of the 260 civilian adult patients enrolled in the DOTS treatment programme during the study period, 3 were residents of psychiatric facilities, 8 died during the first month of therapy and 12 had missing treatment records ( Fig. 1 ). The remaining 237 patients were included in the analysis of non-adherence and default; there were 148 men and 89 women and the mean age was 40. Primary MDR was found in 20 (8.4%) of the patients, and 82 (34.5%) were found to be resistant to at least one drug at the time of diagnosis. Excluded patients were more likely to be male, unemployed, homeless and substance abusers. Among the 237 patients included in the study, 20 had MDR on initiation of therapy and 10 had missing initial DSTs; the remaining 207 participants were included in the analysis of MDR acquisition. The 30 patients with initial MDR or missing DSTs were more likely to be male and illicit drug users. All patients were HIV tested, but since only two were found to be HIV-positive we did not include HIV in our subsequent analyses.

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Flow chart of study participants

DSTs, drug-sensitivity testing; MDR-TB, multidrug resistant TB.

Treatment outcomes are presented in Table 1 (available at http://www.who.int/bulletin/volumes/85/9/06-038331/en/index.html ). More than half of those who died (8/14) did so within the first month of treatment. The overall mortality of patients undergoing DOTS therapy for TB is underestimated, as the data presented in Table 1 exclude results on these patients. Twenty-one (8.8%) of the patients in our cohort defaulted on therapy and 37 (15.6%) took fewer than 80% of their observed prescribed doses. Fifteen patients (6.3%) acquired MDR during the study period, seven during the course of treatment and eight during post-treatment follow-up.

Treatment resolution	Adherent	Not-adherent	Total	Proportion
Cured	137	19	156	0.66
Treatment completed	2	0	2	0.01
Failed	30	6	36	0.15
Default	13	8	21	0.09
Died	5	1	6	0.03
Transferred out	8	3	11	0.05
Transferred to DOTS Plus	5	0	5	0.02

a Crude odds ratio, OR, for poor outcome given non-adherence = 2.43 (95% confidence interval, CI: 1.05–5.53).

Baseline characteristics of those who defaulted or were non-adherent are given in Table 2 . In a multivariate model, substance abuse was identified as the only factor that was strongly associated with non-adherence with odds ratios for baseline alcohol dependence – 4.38 (95% CI: 1.58–12.60); reported alcohol use in a patient during therapy – 6.35 (95% CI: 2.27–17.75); and intravenous drug use – 16.64 (95% CI: 3.24–85.56) ( Table 3 ). The adjusted odds ratio of non-adherence for those with any kind of substance abuse was 7.30 (95% CI: 2.89–18.46). Substance abuse was also strongly associated with default, with an odds ratio of 15.57 (95% CI: 3.46–70.07) among those with baseline alcoholism and 5.14 (95% CI: 0.87–30.25) for those with reported alcohol use. Patients with any form of substance abuse had an adjusted odds ratio for default of 11.20 (95% CI: 2.55–49.17). When this analysis was repeated, excluding patients for whom more than 40% of doses were self-administered, the odds ratios changed by less than 20%. Table 1 (available at http://www.who.int/bulletin/volumes/85/9/06-038331/en/index.html ) shows that non-adherence was associated with poor treatment outcomes (OR: 2.43, 95% CI: 1.05–5.53).

Characteristics	Non-adherent = 38	Adherent = 199	-value	Defaulter = 21	Non-defaulter = 216	-value
Gender			0.92			0.68
male	24	124		14	134
female	14	75		7	82
Age group			0.36			0.21
≤ 40	16	100		13	103
> 40	22	99		8	113
Unemployed			0.02			< 0.01
yes	25	91		16	100
no	13	108		5	116
Previously incarcerated			0.11			0.41
yes	10	31		5	36
no	28	168		16	180
Alcoholism noted on treatment initiation			0.11			< 0.01
yes	13	44		14	43
no	25	155		7	173
Alcohol abuse noted after treatment initiation			< 0.01			0.90
yes	12	24		3	33
no	26	175		18	183
Intravenous drug user at treatment initiation			< 0.01			0.90
yes	6	4		1	9
no	32	195		20	207
Any substance abuse			< 0.01			< 0.01
yes	30	71		18	33
no	8	128		3	183
Impaired mobility			0.35			0.97
yes	2	20		2	20
no	36	179		19	196
Co-morbid conditions associated with side-effects			0.66			0.02
yes	7	31		7	31
no	31	168		14	185
MDR at treatment initiation			0.65			0.88
yes	4	16		2	18
no	34	177		19	192
Sputum smear positivity at treatment initiation			0.46			0.26
yes	17	102		13	106
no	21	97		8	110
Cavitary disease			0.76			0.92
yes	26	141		15	152
no	12	58		6	64
Transport time to clinic			0.85			0.63
< 20 minutes	11	65		7	69
20–40 minutes	21	100		12	109
> 40 minutes	6	34		2	38

MDR, multidrug resistant (TB).

	Outcome
	Non-adherence multivariate OR (95% CI)		Default multivariate OR (95% CI)
Male	0.66	0.28–1.55	0.85	0.27–2.61
Age > 40	0.84	0.37–1.90	1.98	0.65–6.08
Unemployed	1.15	0.49–2.69	2.62	0.76–9.06
Previously incarcerated	1.06	0.39–2.86	0.69	0.20–2.41
Baseline alcoholism noted on initiation of treatment	4.48	1.58–12.68	15.57	3.46–70.02
Alcohol abuse first noted after initiation of treatment	6.35	2.27–17.75	5.14	0.87–30.25
Intravenous drug user at initiation of treatment	16.64	3.24–85.56	2.58	0.21–30.96
Any substance abuse	7.30	2.89–18.46	11.20	2.55–49.17
Co-morbid conditions associated with side-effects	NI		7.20	1.94–26.75

CI, confidence interval; OR, odds ratio. a Included in default model only. Other variables included in both models. b Included in model excluding alcoholism and drug use variables. c Not included.

Sputum-smear positivity was the only factor associated significantly with baseline MDR in both a univariate analysis (OR=2.4, 95% CI: 1.04–5.57) and in a multivariate logistic regression model that included age and substance abuse (OR = 3.28, 95% CI: 1.24–8.68). Factors associated significantly with MDR acquisition in a univariate analysis included substance abuse, hospitalization (both at initiation of treatment and later in the course of therapy) and failure to self-administer therapy ( Figs. 2 , ,3, 3 , ,4; 4 ; and Table 4 , available at http://www.who.int/bulletin/volumes/85/9/06-038331/en/index.html ). In the multivariate Cox proportional hazards model, treatment received in the hospital setting (either at initiation of therapy or later) was the only remaining independent risk factor for MDR acquisition. Patients who received treatment in the hospital setting had a substantially higher risk of developing MDR-TB than those whose treatment was confined to the outpatient sector. This was true for those who began DOTS treatment in the hospital setting (adjusted hazard ratio, HR: 6.34; P = 0.02) and those who were hospitalized only later in their treatment course (adjusted HR: 6.26; P = 0.04).

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Kaplan-Meier survival curves for substance abuse as a factor associated with time to acquisition of multidrug resistance

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Kaplan-Meier survival curves for hospitalization as a factor associated with time to acquisition of multidrug resistance

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Kaplan-Meier survival curves for failure to self-administer therapy as a factor associated with time to acquisition of multidrug resistance

Cohort characteristics	Number of events	Person time in months	Univariate hazard ratio	-value	Multivariate hazard ratio	-value
Age
≤ 40	7	2442	1.06	0.90	0.70	0.52
> 40	8	2586
Gender
male	11	2920	1.93	0.24	1.67	0.39
female	4	2108
Not-adherent
yes	2	736	0.81	0.77	1.61	0.53
no	13	4267
Substance abuse
yes	10	1944	2.88	0.04	1.96	0.26
no	5	3084
Side-effects					NI
yes	4	855	1.69	0.39
no	11	4173
Baseline cavity present					NI
yes	11	3432	1.25	0.69
no	4	1596
Previously incarcerated					NI
yes	3	656	1.56	0.51
no	12	4372
Smear ++ or +++					NI
yes	4	1584	0.79	0.68
no	11	3444
Began treatment in hospital
yes	10	1703	3.8	0.01	6.34	0.02
no	5	3325
Hospitalized later during therapy only
yes	13	2195	8.18	< 0.001	6.26	0.047
no	2	2833
Self-administered treatment					NI
yes	2	1847	0.25	0.03
no	13	3181

a Individuals who were hospitalized at initiation of therapy as well as later were included only in the hospitalized at initiation category.

Table 5 (available at http://www.who.int/bulletin/volumes/85/9/06-038331/en/index.html ) demonstrates the differing risk factors for early and late acquisition of MDR – of the seven patients who developed MDR within four months of initiating treatment, all had cavitary disease at baseline and six began treatment in the hospital. In a multivariate analysis, those who initiated treatment in the hospital were more likely to develop early MDR, but this finding failed to achieve statistical significance (adjusted HR: 7.18, P = 0.07). In contrast, univariate risk factors for MDR after 6 months of treatment included male gender (HR: 5.12, P = 0.06), substance abuse (HR: 11.22, P = 0.004) and absence of smear positivity (HR: 0, P = 0.01). In a multivariate Cox proportional hazards model substance abuse was the only statistically significant factor (adjusted HR: 9.09, P = 0.04), although patients who had been hospitalized at some point during their illness were also more likely to develop late MDR (HR: 4.52, P = 0.07).

Cohort characteristics	Early MDR ( = 7)				Late MDR ( = 8)
Cohort characteristics	Univariate HR	-value	Multivariate HR	-value	Univariate HR	-value	Multivariate HR	-value
Age			NI				NI
≤ 40	1.28	0.74			0.90	0.89
> 40
Gender			NI
male	0.89	0.88			5.12	0.06	2.58	0.389
female
Not-adherent							NI
yes	0	0.12	0	NA	1.86	0.47
no
Substance abuse			NI
yes	1.04	0.96			11.22	0.004	9.09	0.046
no
Side effects
yes	3.53	0.12	2.92	0.16	0.65	0.67	NI
no
Baseline cavity present			NI				NI
yes	Inf	0.025	Inf	NA	0.47	0.30
no	0
Previously incarcerated			NI				NI
yes	0.97	0.98			2.20	0.37
no
Smear ++ or +++
yes	2.86	0.17	1.16	0.84	0	0.01	0
no
Began treatment in hospital							NI
yes	10.87	0.006	7.18	0.07	1.98	0.34
no
Hospitalized later during therapy only			NI
yes	1.50	0.72			3.53	0.17	4.52	0.07
no

MDR, multidrug resistant (TB). a No early cases of acquired MDR were non-adherent. b All early cases of acquired MDR had cavitary disease. c No late cases were smear-positive.

Notably, non-adherence was not a risk factor for either early or late acquisition of MDR. This finding remained true when we conducted a sensitivity analysis in which patients were classified non-adherent if they missed 40% or more of their prescribed doses.

In this study of non-adherence, default and acquisition of MDR among TB patients in Tomsk, substance abuse and in-hospital care were identified as two potential obstacles to effective treatment. These results suggest that DOTS programmes might be more likely to achieve TB control targets if they include interventions aimed at improving adherence by diagnosing and treating substance abuse concurrently with standard TB therapy. They also raise the possibility that some patients with apparent drug-sensitive disease also may be infected with drug-resistant strains that are unmasked upon initiation of therapy. Some patients also might be reinfected with drug-resistant strains in the hospital setting, a possibility which emphasizes the need for effective infection-control measures within facilities that care for patients with active disease.

Despite the implementation of a DOTS programme and the provision of extensive social services to patients undergoing TB therapy, non-adherence and default continued in a substantial proportion of those who initiated treatment in Tomsk. Like TB patients throughout the world, these patients were burdened with a wide array of social and medical problems: many were unemployed, had been in prison or had significant co-morbid conditions. Despite this, alcohol and injection drug use were the only independent risk factors for non-adherence and default that we identified. These findings echo those of numerous previous studies that found substance abuse to be the single major factor associated most strongly with non-compliance with TB regimens. 7 – 15 Our results also agree with these previous studies’ findings that non-adherence has important adverse effects on the outcomes of TB treatment 16 , 17 – 66% of all poor outcomes experienced in our cohort occurred among the 16% of patients who did not adhere to therapy.

Despite the clear need for new approaches to this problem, to date there has been relatively little research on treatment options for patients with chronic infectious diseases and concomitant substance misuse or psychiatric problems. The few TB programmes that have explicitly offered patients treatment for substance abuse generally have demonstrated better outcomes than “unexpanded” DOTS programmes. 18 Some even achieve very high cure rates among patient populations in which alcoholism or injection drug use are common. 19 Disappointingly, these successes have not yet led to widespread integration of substance-abuse care for these patients.

This failure has at least three possible explanations. The first is the general reluctance to tinker with the specialized “vertical” DOTS approach, given its success in improving case completion and cure rates in developing and less-developed countries over the past two decades. 20 Closely related to this are the numerous obstacles faced by multidisciplinary approaches to research and patient care, including the lack of a shared language and space among care providers from different specialties and mutual lack of knowledge of other treatment approaches. 21 Often the care of TB patients and those with substance-use disorders is relegated to highly specialized practitioners; this offers little opportunity for meaningful interaction or exchange between disciplines. Finally, until recently many physicians without specific expertise in managing alcohol disorders and injection drug misuse have assumed that these conditions’ treatments are too complex and intensive to be carried out simultaneously with the treatment of another complex disease. However, recent evidence suggests that brief interventions, social skills training, behaviour contracting and pharmacotherapy are among the most effective approaches for treatment of substance-use disorders. 22 – 24 These data raise the possibility that integrated management of these most vulnerable TB patients may be within the reach of a unified TB care facility.

Our study also suggests that non-adherence did not contribute to either the early or late occurrence of MDR among patients receiving DOTS in this setting. We considered several other possible explanations for the observation that a group of adherent patients developed MDR-TB within 24 months of initiating therapy. First, we speculated that MDR acquisition might be associated with disease severity, which might in turn be linked to hospitalization. Since the number of new mutations that code for drug resistance will be a function of the bacterial load, it follows that those with a greater disease burden would be at higher risk of developing these mutations. 25 Having adjusted for disease severity by controlling for the presence or absence of cavitary disease and sputum-smear status, we found that these markers of disease severity were strongly correlated with early acquisition of MDR but not associated with late acquisition. These data suggest that these patients may harbour multiple different strains of Mycobacterium TB, some of which may be drug-resistant. In these mixed infections, standard short-course therapy may have unmasked the drug-resistant strain population by suppressing the previously dominant drug-sensitive strain. Indeed, van Rie et al. have described this mechanism in a high-burden population in South Africa. 26 In that study, adherence to a first-line drug therapy was shown to select for a resistant population, while non-adherence led to re-emergence of the drug-susceptible strains.

We also assessed the possibility that patients who developed MDR did so through “amplification” of existing drug resistance. While this mechanism may have accounted for MDR acquisition in some cases, eight of the thirteen hospitalized patients with this outcome had fully susceptible disease on initiation of therapy.

Finally, we considered the possibility that some of these patients developed MDR-TB as a result of reinfection with a drug-resistant strain of TB. Reinfection of patients on therapy for drug-sensitive disease has been described in several different high-incidence settings and has been associated with nosocomial transmission. 27 – 31 Usually, MDR-TB patients in the Russian Federation are not placed on respiratory precautions in the hospitals or clinics where they receive care, so there is opportunity for further spread of drug-resistant strains among patients receiving therapy for drug-sensitive disease. The finding that substance abuse was a risk factor for late occurrence of MDR also raises the possibility that these patients are at higher risk of exposure to drug-resistant disease or are more susceptible to reinfection than other patients. Future studies on the association between adherence and development of MDR would benefit from molecular typing of sequential isolates in patients undergoing therapy.

This study was limited by its retrospective study design, as sociodemographic and behavioural variables were abstracted from routine medical assessments conducted upon initiation of therapy. In particular, the diagnoses of alcohol and drug disorders were based on clinicians’ reports and were not made using a standardized instrument. Hence, it is likely that alcohol disorders were underreported and that only more severe cases came to clinical attention. This could have resulted in an underestimation of the effect of alcoholism if less severe cases were also associated with non-adherence. Systematic studies using standardized and validated alcohol assessment instruments will be needed to ascertain the full impact of alcohol disorders on patients’ ability to comply with TB treatment. ■

Acknowledgements

The authors wish to thank Natasha Arlyapova, Donna Barry, Doreen Balbuena, Lauren Doctoroff, Paul Farmer, Jennifer Furin, Timothy Holtz, Gwyneth Jones, Jim Yong Kim, Tatyana Lyagoshina, Sergey Pavlovich Mishustin, Joia Mukherjee, Ed Nardell, Michael Nikiforov, Alexander Pasechnikov, Genady Giorgevich Peremitin, Oksana Ponomarenko, Michael Rich, Sonya Shin, Olga Sirotkina, Tamara Tonkel and Askar Yedilbayev for their contributions to this study.

Funding and competing interests: Two authors (Keshavjee and Gelmanova) received partial salary support and/or travel support from the Bill & Melinda Gates Foundation and from the Eli Lilly International Foundation. Keshavjee received salary support from the Frank Hatch Scholars Program at Brigham & Women’s Hospital. No funder played any role in study design, data collection, analysis or interpretation; or in preparing, reviewing or approving the manuscript.

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Persuasive Essay On Drug Testing In Schools. 858 Words4 Pages. As a high school student athlete, I believe that drug testing should be enforced in high schools across the United States. All kinds of drugs have been known to not only slow down physical activity, but slow down mental activity also. Drugs are scientifically proven to kill nerve ...
Epidemiology of antituberculosis drug resistance (the Global Project on
Methods: Data on drug susceptibility testing for four antituberculosis drugs--isoniazid, rifampicin, ethambutol, and streptomycin--were gathered in the third round of the Global Project (1999-2002) from surveys or ongoing surveillance in 79 countries or geographical settings. These data were combined with those from the first two rounds of the ...
PDF Treatment outcomes in an integrated civilian and prison MDR-TB
Bacteriologic studies and drug susceptibility testing Smear microscopy and culture on Löwenstein-Jensen media are performed according to international stan-dards in local mycobacteriology ...
Barriers to successful tuberculosis treatment in Tomsk, Russian
Those who are culture-positive also undergo drug sensitivity testing to isoniazid, rifampicin, ethambutol, streptomycin and kanamycin. Susceptibility is determined using the absolute concentration method on Lowenstein-Jensen medium, based on the following drug concentrations: isoniazid 1 μg/ml, rifampicin 40 μg/ml, ethambutol 5 μg/ml and ...
Drug Testing In Schools Essay
Drug Testing In Schools Essay; Drug Testing In Schools Essay. 1752 Words 8 Pages "The opioid epidemic has ravaged communities around the nation — deaths from overdoses now outnumber deaths from car crashes" (Spencer). This quote from a recent New York Times article provides some evidence towards the idea that the United States of America ...
Treating Multidrug-Resistant Tuberculosis in Tomsk, Russia
Currently, drug-resistant strains of M. tuberculosis have been found in more than 100 countries. 1 A growing body of data confirms that multidrug-resistant TB (MDR-TB) is emerging as an increasingly important cause of TB morbidity and death. 8-16 In the United States, Europe, and Latin America, highly resistant strains of TB have caused ...