Ordering labs on drug abusers

Nov 06 2008 Published by under Drug Abuse Science, Ethics, Psychology, Public Health

PalMD poses a really interesting question regarding the medical ethics of running lab tests on a patient to determine if they are drunk:

So here's a non-life-and-death question: if a patient comes to see you and smells of alcohol, can you add an alcohol level to their blood work without specifically informing them?

As he points out, patients sign a generalized consent for treatment and generally do not expect to micromanage their doctor's recommendations for tests that need to be run. I would imagine that doctors hardly ever inform their patients, item by item, what will be run on basic blood chemistry and immune panels. I would similarly imagine that should the doctor decide on a followup or two after some initial results s/he might just run them first and tell the patient later if it was a significant health issue.
So why not add a BAL (Blood Alcohol Level; a description of measurements including the familiar blood-alcohol concentration of legal importance) if you suspect a patient has been drinking?

And for that matter, why not order up a test for THC, MDMA, Meth, Cocaine......etc?
PalMD has a few more thoughts on
immediate risk:

What if I suspect the patient is intoxicated, but they leave my office and drive into a kindergarten?

Does the doctor have any obligation in this situation different, say, from the bank teller or store clerk? I think not. Scope of obligation is just too broad and the verification is correspondingly unnecessary if you are going to assert a requirement. If the doctor is obligated to act, s/he should probably just notify the security guard that if the patient appears to be getting into the drivers seat in the hospital parking garage/lot they should be detained.
additional scenarios:

Is EtOH level different from other tests? If so, how?...What is the purpose of the test?...Is deception involved, and if so, did it serve a purpose congruent with the patient's needs?

EtOH is not different from the other tests but let us not be silly here. We know for dang sure the vast majority of patients are going to view it this way. Can you order up an HIV or other infectious disease test without consent? At least in those cases you can assert a communicable-disease public health concern. EtOH? Not so much.
knowledge of a drinking problem?

Let's say a patient comes to see you. You know they have a history of drinking. They tell you they've quit. They don't appear visibly impaired. You've drawn blood for other reasons (cholesterol, etc.).
After the patient leaves, a staff member says that the patient smelled a little soused. At that point, would it be ethical to add an ethanol level to the labs?

So this is the point where it gets pretty interesting to me. I think that the doctor is completely justified in inquiring about drug use if s/he suspects a potential dependence problem. It is no different than anything else the doctor happens to notice in the way of physical, physiological or behavioral irregularities that may indicate a treatable medical concern. However I suspect not every patient sees it that way, given the rather substantial difference in the way many people view having cancer and having a mental disorder.
On this basis, however, you have to ask what constitutes evidence of a problem. And here I think you have to parse pretty closely. Showing up to a doctor's office appointment acutely intoxicated (on any substance) is probably a halfway decent (not exclusive, just decent) indicator of a control problem. But this can be observed. Is is relevant exactly how drunk the patient is? Probably not. So running the BAL lab is probably not called for just to verify that they seem impaired. Similarly, evidence of days-prior drug use (which you could get with certain compounds in a blood or urine test; many days from a hair screen if so inclined) is not a good indicator of medically-relevant drug use patterns.

11 responses so far

  • Becca says:

    Are these magically free of cost tests for the purposes of hypothetical morality?

  • Given that knowledge of alcohol related problems could impact what diagnoses one would make or what drugs one would prescribe a test in that context makes sense. The question of doing so when one doesn't have any reason to believe that will make a difference seems more difficult.

  • TomJoe says:

    What is one going to do with said test results? If one attempts to do anything, I have a feeling "general consent form" or not, things will get mighty hairy.

  • Silver Fox says:

    A doctor shouldn't order *any* tests without informing the patient. The patient needs to know, and it is the patient and possibly the insurance company that will be paying.
    I think ordering tests to make some kind of point or to CYA is completely unethical. I say that from the point of view of a patient.
    Surely the doctor could - and maybe should -bring the subject up with the patient; that would be completely justified. I just don't get where subterfuge for tests comes in.
    If you are concerned about people leaving your office drunk, post a sign like some bars that you will call the cops, notify all patients of this change in procedure, and then follow through. Even that might get hairy come court time.

  • phisrow says:

    I'm not speaking from any systematically derived position on this one; but my inclination would be to avoid forcing diagnosis or treatment on somebody, barring likely danger to others, and assuming consent where given, or where it would be impractical to ask(unconscious bleeding guy comes in by ambulance, I suspect he'd want that fixed).
    For that reason, I'd be in favor of running the test if it were relevant to whatever brought the patient to my attention(making sure alcohol won't interact with some drug, deciding whether symptoms are alcohol related or not, etc.); but I'd be very nervous about running the test just to ferret out a drinking problem that they are trying to hide.

  • speedwell says:

    All drugs, including alcohol, may affect how other drugs (prescribed or not) work in the body. Any surgery may be affected by the effect of other drugs in the body. A drug-addicted patient may be unable to keep up with a pill schedule or a lifestyle instruction.
    This is a legitimate concern for a doctor, even if they believe in the patient's right to engage in recreational drug use. If I was a doctor, and I had reason to believe my patient was a habitual drinker or a cocaine addict, and it made a difference to my treatment protocol, you had better bet I would order the test. It would be no different than a test ordered to gauge the presence of any other chemical in the system.
    Personal liability be damned, I would not want a drug reaction or surgery complication to happen to a patient because I failed to take the patient's entire body into account.

  • llewelly says:

    Testing for the presence of illegal drugs is a highly effective way to make sure that people who get injured or sick while using said drugs do not go to the doctor.

  • Katharine says:

    llewelly, perhaps there might be conditions under where doctors, if they see fit to test for drug use, would not be able to inform the authorities so as to decrease the likelihood of these injuries going untreated.

  • Renee says:

    Maybe the person realllllly hates needles (they're getting a blood test, after all) and had a little something beforehand to deal with the anxiety?
    But yeah, you're perfectly within your right to inquire as to their state of inebriation, but doing the test is a violation of privacy. Anyway, tests cost money. Who's going to be paying for your sense of curiosity? Them? Their insurance? Yourself?

  • Steve says:

    immediate risk:
    What if I suspect the patient is intoxicated, but they leave my office and drive into a kindergarten?

    Ah yes, what about the poor children ...
    Whether or not you run the test, the kindergarten class still buys it.
    But the doctor's ass is covered so that's all right.

  • yolio says:

    I thought there was an insurance issue here, anyway this is an issue in trauma. This may have changed, but not long ago it was common for insurance companies to deny coverage of treatment of "self-inflicted" injuries, and self-inflicted was defined to include accidents that occur while intoxicated. Since most visits to the trauma center involve some form of intoxication, trauma doctors would never get paid if they tested all their patients.
    This was an issue awhile back, because trauma center visits could potentially be a pretty good way to catch people with serious substance abuse problems. But people weren't getting sent into addiction treatment, because doctors were avoiding recording intoxication status in their charts for insurance reasons.

Leave a Reply