New state guidance for addiction services and treatment programs in New York advises against routine screening for marijuana use, an approach designed to parallel that used for alcohol. Some clinicians see the change, which is being implemented following the state’s legalization of cannabis, as a step away from an abstinence-only view of recovery and toward a more flexible approach aimed at minimizing harm.
“With the legalization of adult-use cannabis in NYS, testing for the metabolite of THC routinely is not recommended unless the patient has identified a reduction in, or cessation of cannabis as part of their treatment goals,” says a guidance document from the New York State (NYS) Office of Addiction Services and Supports (OASAS) that was updated late last month.
“Alcohol and THC metabolites should not be included in routine toxicology panels,” it adds, “unless a clinician determines that alcohol or cannabis is a concern and toxicology testing would be appropriate clinically.”
The advisory from OASAS, which says it oversees approximately 1,700 prevention, treatment and recovery programs for substance use disorders (SUDs) across the state in addition to a dozen treatment centers it directly operates, applies to “providers working in OASAS-certified programs who use toxicology testing over the course of a patient’s treatment.” The office’s website describes its approach as “responsive, data-driven, person-centered, and prioritizes equity.”
An OASAS representative told Marijuana Moment that the advisory “is similar to guidance about alcohol use, and the same principles regarding alcohol were used to create this guidance document.”
Asked about the prudence of the shift, Bryon Adinoff, the president of the advocacy group Doctors for Drug Policy Reform (formerly known as Doctors for Cannabis Regulation), said it made him reflect on why treatment programs typically screen patients for drug use in the first place.
“As an addiction psychiatrist who worked with individuals with SUDs for several decades and was director of two [Department of Veterans Affairs] SUD programs, I appreciated getting relatively complete urine drug panels on patients,” he said in an email to Marijuana Moment. “However, NY’s guidance has got me thinking about it.”
“While I would still insist on a full screening upon admission, if there is no history of use or misuse of cannabis, then why continue to get it?” he asked. “It’s a fair question.”
Adinoff said the change is “an understandable attempt to give patients agency over their treatment and allow them input into what labs are obtained.”
He and other clinicians noted that while their goal is to help patients end problematic drug use, sometimes screening for drugs as a matter of course can actually put patients at risk. In some cases, for example, patients using medication for opioid use disorder, such as buprenorphine or methadone, might have access to those medications cut off if they test positive for THC.
“I assume that at least part of this effort,” Adinoff said, “is to address this unfortunate legacy. In that sense, I appreciate the effort.”
He noted that positive cannabis tests can also put patients at risk of employment, housing or legal consequences, even if cannabis isn’t the substance causing problems in their lives.
In general, the OASAS guidance advises against reporting positive results of presumptive drug testing to third parties, saying such reporting “should not occur prior to receiving confirmation by patient self-report or definitive/confirmatory toxicology testing.”
Despite his overall support for the change, Adinoff doubted its practical effect. “Probably the most important part of the guidelines is to get the clinician thinking about the purpose of the drug testing and how it will inform treatment,” he said, though he acknowledged that determining an individually appropriate screening panel for each patient could be “a time-consuming effort.”
On top of that, Adinoff said clinicians are so used to defaulting to in-depth screenings, many won’t heed the OASAS advice.
“Clinicians are used to ordering the full panel,” he said. “It will take a lot more than ‘guidance’ to get them to change their ways.”
Peter Grinspoon, a cannabis specialist at Massachusetts General Hospital and a Harvard Medical School instructor who’s written about the messy interaction between politics and cannabis science in the book Seeing Through the Smoke, framed the OASAS guidance as a matter of reducing harm. “This is one of those questions where you can’t really disentangle the social history and the politics from the science,” he told Marijuana moment in an interview last week.
Historically, Grinspoon noted, “a lot of this is predicated on the idea that cannabis was a gateway to addiction”—an idea he dismissed as a “foolish notion.”
But often a doctor’s views of the potential benefits or harms of marijuana, he added, “depends on his or her vantage point.”
“For example, it’s hard to find an oncologist who isn’t pro-cannabis,” given the potential benefits of cannabis use in treating the symptoms of cancer and cancer treatment, Grinspoon said. “On the other end of the spectrum is the pediatric psychiatrists, who see the very rare but tragic cases.”
As for addiction treatment providers, he said they’ve “been a big part of the problem with cannabis, because they really just get in their own echo chamber about the harms, and they don’t have the context of, like, yes, sure, this can happen, and it’s tragic when it does happen, but it’s not what usually happens.”
Grinspoon said he’s happy to acknowledge that some cannabis users do develop problem use, though he noted it’s far less common—and typically less extreme—than other SUDs. Because of that, in cases where marijuana use is unrelated to or even beneficial for someone’s recovery—for example, in circumstances where cannabinoids might ease a patient’s opioid withdrawal—he said it makes sense not to screen for THC by default.
It’s all about harm reduction, Grinspoon said, emphasizing that drug screening can be useful in some cases but also potentially carry severe negative consequences. He pointed to recent reports of South Carolina authorities taking children away from mothers who test positive for cannabis use. “That’s way worse! We don’t even know that cannabis is bad for people who are pregnant,” he noted, “We just don’t know it’s safe.”
He welcomed the OASAS guidance as a sign that officials are more aware of the nuances of drug testing.
“As a clinician, there’s some circumstances where it’s helpful,” he said. “We just have to be very, very cognizant of the consequences of any screening, especially when it’s something as politicized as cannabis, or we’re going to end up harming more people than we help.”
In an email response to questions from Marijuana Moment about the new guidance, OASAS said information from drug screenings “is used in collaboration with the patient’s history, medical exam, and other information to set an approach to care.”
“These screens are done in a patient-centered way, tailored to each individual and their treatment goals,” a spokesperson said. “While urine drug screens provide information about substance use, they are not a diagnosis of a substance use disorder.”
OASAS guidance isn’t alone in focusing less on cannabis. Just last month, a major manufacturer of drug testing technology, Psychemedics, announced a new screening panel that no longer detects marijuana and instead prioritizes fentanyl and other controlled substances like cocaine and amphetamines. The company described the change as “shifting the spotlight from marijuana to the paramount threat of fentanyl.”
Amid the shifting legal landscape, an increasing number of states have also enacted protections for workers who use state-legal marijuana off duty, preventing employers from taking adverse action over state-sanctioned activities.
For example, California’s governor recently approved a bill to prohibit employers from asking job applicants about prior marijuana use.
In Michigan, a policy took effect this month that ends pre-employment drug testing for marijuana for most government job applicants, while also giving people who’ve already been penalized over positive THC tests an opportunity to have the sanction retroactively rescinded.
In May, the governor of Washington State signed a bill into law that will protect workers from facing employment discrimination during the hiring process over their lawful use of marijuana.
That means Washington has joined Nevada in prohibiting discrimination against job applicants for testing positive for marijuana. New York also provides broader employment protections for adults who legally use cannabis during off-hours and away from work.
At the congressional level, the House Rules Committee has repeatedly blocked attempts by lawmakers to end the practice of drug testing federal job applicants for marijuana as part of large-scale spending bills this session.
Over in the Senate, however, members passed defense legislation in July that contains provisions to bar intelligence agencies like the CIA and NSA from denying security clearances to applicants solely due to their past marijuana use.
The House Oversight and Accountability Committee also passed a standalone bipartisan bill in September that would prevent the denial of federal employment or security clearances based on a candidate’s past marijuana use.
At the same time, there are growing concerns about fentanyl in the drug supply. While experts have challenged claims about fentanyl-laced marijuana, there’s recognition that the potent opioid is being detected in drugs like heroin and cocaine. (Full Story)