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Drug Screens-and More Security Theater (Part 2)


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In part one on drug testing, we looked primarily at the accuracy of evidence supporting drug testing—how often do you get false information from the tests. In this second part, we look at the ethics and broader societal and political context of testing.

Feel more secure?

As mentioned, I’ve been doing more traveling, and am increasingly disturbed by the growing surveillance society, from TSA’s “Security Theater” to the wider spread presence of traffic cameras and surveillance of public spaces.

Security expert Bruce⁠ Schneier has pointed out that the current system is reactive—e.g., having to remove shoes now—and so, as with malware, the “bad guys” are generally one step ahead, simply by shifting strategies. In fact, there is growing evidence that more lives are being lost because of TSA and people’s aversion to flying now that has arisen due to the hassles TSA has created, that has resulted in a return to driving, resulting in more accidents than are being saved due to any prevention of terrorist activity that might have occurred.

So some experts—and Schneier’s Harms of Post-9/11 Airline Security is a “must-read”—have urged a shift from all these scanners and examining objects as shoes, as in TSA’s drama, to more targeted focus on behavior and intelligence.

Increasing “security” surveillance are always justified by the need for more “security”.  Where is the evidence that more security makes us more secure…and at what cost?

We’ll look first at such dramatic effects in the workplace, then in other settings.

Pre-employment drug screening

Meds might trip you up...

Screening potential employees has some appeal, largely for public relations—“We are doing everything we can to provide a safe workplace!” and for perceived reduction in liability, even though there is no good data that this improves general outcomes or in medical settings.
But the downsides of such testing receive less attention.

Screening is generally conducted by a urine test. However, to avoid cheating, the specimens are obtained in humiliating ways, including either direct observation or by listening to the person void, and having the toilet contain a blue dye to avoid temptation to dilute the sample. Urine is then immediately checked for temperature and concentration. Those with “shy bladder” are commonly reported as a refusal to test.

Don't try diluting urine with this!

Screening prior to a conditional job offer has been considered a “violation of the American with Disabilities Act (ADA), which prohibits ‘‘inquiries of a job applicant as to whether such an applicant is an individual with a disability …’’⁠ Such screening is acceptable after a job has been offered, however.

Many consider screening an invasion of privacy. While safety concerns trump HIPAA, how many workers want to share all of their medical information with their employers?

Further, the implications of a falsely positive test are potentially devastating. “Despite the lack of evidence for the utility of drug testing, the impact is profound.⁠ The mere suspicion of use or, worse yet, a false positive test can have a long term, devastating impact on an individual’s life and career. Immense administrative, legal, and medical effort would be required to prove innocence once suspected of illicit use.”

Is there value to workplace drug screening?

What appears to be overlooked in the zeal for increased drug testing is that pre-employment screening tells you nothing about what is happening on the job nor if there is any impairment, which is really the key issue.
As a reminder, in the US, 42.9% of full-time workers reported that tests for illicit drug or alcohol use were required as part of “pre-hire” testing—so more than 47 million adults were subjected to testing as a condition of employment. (2004) Further, 29.6%, or 32 million full-time workers reported random drug testing at work.⁠ A 2010 study reported about 130 million drug screens⁠.

Dr. George Lundberg, former editor of the Journal of the American Medical Association and of Medscape, has long opposed screening, aptly calling it “chemical McCarthyism.” He also has criticized the “hypocrisy” of screening, given that alcohol and tobacco abuse are commonly ignored. Lundberg has noted, too, the incredible cost of screening. Tests are currently ~$45—more for confirmatory testing, and not including any administrative costs. If the 115 million full-time workers (Dec, 2012)⁠ were all tested, that would cost $5,175,000,000. As he noted some time ago, still true today, “‘This is terrific for the laboratory industry and all the attorneys who will argue these cases . . . but should we spend that kind of money?’ he wrote. ‘In fact, we have not found one proper cost-benefit analysis of this process’ in the medical literature.” Think of all the good that could be done with those monies.

Northwestern University Drs. Levine and Rennie give further excellent arguments against testing (in medicine)—again that the testing is not measuring what is really the issue, impairment:
“Drug testing is arguably less important than addressing the performance impact of overnight work, circadian rhythm disruption, and overwork. Testing does not necessarily measure impairment, abuse, or intoxication. The presence of a banned substance does not mean that cognitive impairment is present or clinical performance is impacted. Further, routinely used medicines such as decongestants, antihistamines, stimulants, and other prescribed substances can also profoundly impair functioning.”
One need only look at sleep deprivation to find considerably more impairment than that due to many drugs, yet this is a problem which is, at least in the medical field, readily dismissed or ignored by administrators or training program directors.

Drug screening as a condition of welfare?

There is understandable outrage at the thought of taxpayer monies being wasted by public assistance recipients buying drugs. (Frankly, I feel the same sort of anger when patients come in with fast food or cigarettes but say they can’t afford their meds).
Again, the wrong question is being asked. What does the data tell us? You’ll likely be surprised. First, the rate of drug use among public assistance recipients is about the same as that of the general population. Next, testing welfare recipients does not save money.
Of the 87,000 Arizonans tested for “reasonable cause,” only 1 tested positive, saving the state a whopping $560.
In Florida, where all welfare applicants were tested, 2.7% had positive screening tests. Who benefited the most from the drug testing? Not the taxpayers…

Yield of drug testing welfare recipients

The biggest winners appear to have been the owners of testing companies, such as Governor and Mrs. Rick Scott’s company, Solantic. Scott also pushed for random drug testing on state employees, although some departments found that <1% of employees failed. Ultimately, such random drug testing was ruled unconstitutional last year in Florida as being an unreasonable search.
I have found zero evidence that routine drug testing does any good for anybody other than the businesses conducting and profiting from the tests.

Drug screening as clinical research

Some have argued that widescale, untargeted drug screening is akin to conducting clinical research on an industry or population scale or to testing an individual in order to make some prediction as to their likely job performance. If examined in the context of research, we could ask if such testing would pass the muster of meeting basic ethical principles, as outlined in the Belmont report:
Respect for persons, or voluntariness—Clearly testing in order to gain employment is coercive and not freely offered. Nor is there truly an informed consent with workplace testing. There is generally no discussion either of the accuracy of the tests or of potential repercussions beyond not being hired for that specific position.
Beneficience—There is no apparent benefit to the individual being tested, so screening fails this ethical tenet.
Justice—A test or procedure is applied equally to all populations, with a fair distribution of risks and benefits among those tested. One might argue that using screening for pre-employment is unjust, as it does not predict future job performance. Selective testing “for cause” makes much more sense.

What is the value of TSA—wouldn’t real data be nice?

According to Businessweek, in “Airport Security is Killing Us,” the TSA has a budget of almost $8 billion of the $580 billion the government spent on homeland security 2002-11.
What has been the yield—the efficacy of this intervention? No terrorist was caught trying to board a plane in the US. A number of firearms were confiscated, as was one batch of explosives (apparently missed the first time). The National Academy of Science noted no data to justify the huge expenditures.

Then there is the always frustrating and intrusive experience with TSA. (I am routinely pulled aside for extra screening—my matronly appearance either seems to alarm them, or makes me an easy target for a quota.) While the unpleasantness of the TSA screening has not been shown to make us substantially safer, it has, however, been shown to increase deaths—by reducing flying and thus resulting in increased deaths from automobile accidents. Estimates vary from an increase of 242 driving fatalities per month to an excess of 500 deaths/year. TSA screenings have also had a huge negative economic impact.
Now you have to arrive at an airport two hours earlier. According to Schneier, “In 2004, the average extra waiting time due to TSA procedures was 19.5 minutes per person. That’s a total economic loss—in –America—of $10 billion per year, more than the TSA’s entire budget.”  Many—our family included—have concluded that a trip of less than about 8 hours is not worth the added aggravation and stress due to TSA, resulting in more auto travel, and increased risk.

Security theater is not limited to air travel. Since 2004 another TSA—VIPR (Visible Intermodal Prevention and Response)—troupe has emerged to perform at surface transportation hubs, including train, subway, and bus stations, as well as truck stops. Most impressively, instead of screening people boarding a train, in 2011, a VIPR team chose passengers getting off a train in Savannah, detained them and subjected them to “security” screening before allowing them to leave the station. This raised more questions about Fourth Amendment protections from unreasonable search.
In a related case involving the New York subway, MacWade vs. Kelly, the 2nd Circuit Court of Appeals ruled that random, suspicionless searches of bags were allowed as a satisfying the special needs exception to the Fourth Amendment’s protections.
Random and limited searches of bags for explosives made some sense, given reasonable concerns about terrorism in NYC subway system. That commuters could be arrested for carrying “contraband” found incidentally during such a search, seems unjustified.
Unsurprisingly, after the Savannah embarrassment, “when asked if  VIPR has ever directly resulted in discovered explosives or the arrest of suspected attackers,” the TSA response was, “Specific operational results are considered security sensitive information.” Since they are happy to trumpet their “successes,” I think we can safely take that as a “no”.

Thanks to the Patriot Act and the NDAA⁠, the government also now has extraordinary powers to detain someone without any due process. As Schneier notes, “And if you’re on a certain secret list, you cannot fly, and you enter a Kafkaesque world where you cannot face your accuser, protest your innocence, clear your name, or even get confirmation from the government that someone, somewhere, has judged you guilty. These police powers would be illegal anywhere but in an airport, and we are all harmed—individually and collectively—by their existence.” With the Patriot Act and NDAA, there is increasingly a presumption of guilt rather than innocence, and disturbing abuses of power. Most disturbingly, when President Obama was asked recently whether he claims the authority to kill a U.S. citizen suspected of being associated with al Qaeda or associated forces on U.S. Soil, he didn’t say, “No.” Obama responded, “What I think is absolutely true is that it is not sufficient for citizens to just take my word for it that we’re doing the right thing.

There is no small irony that, in another Kafkaesque twist, people who are prevented from flying can still legally buy weapons and many of the politicians supporting security theater oppose gun control.

Broader implications and political context

DNA and Drug Testing - One Stop Shopping

Drug screens are but one example of the increase in surveillance throughout our society. Such intrusive testing inherently sets up an adversarial relationship as well. Many people likely work better in an environment of respect and trust. I’ve seen a dramatic change in the working atmosphere of some hospitals over the years, as the institutions adopt fingerprint scans to clock in and out, GPS phones that track employees’ movements, measure the response time to answer a call light, etc. These processes are dehumanizing and counterproductive.
There is one new and growing area for privacy concerns—the trend for genetic sampling of people arrested  for various crimes—and amassing a huge database, on these individuals, whether or not they are convicted of anything.

Additionally, we have no evidence that all the surveillance does anything more than have a chilling effect on society and erode our civil liberties. There is a strong push in healthcare for “evidence-based medicine.” This is the mantra of the day, and drives many decisions.

If evidence is so important for our health, why is it not the same for our civil liberties? Why do we not have to justify, with hard data, the benefits of the surveillance to anyone besides the businesses and government agencies who profit from this growing surveillance industry?

As Bruce Schneier concluded recently, “This loss of trust—in both airport security and counterterrorism policies in general—is the first harm. Trust is fundamental to society. There is an enormous amount written about this; high-trust societies are simply happier and more prosperous than low-trust societies. Trust is essential for both free markets and democracy. This is why open-government laws are so important; trust requires government transparency. The secret policies implemented by airport security harm society because of their very secrecy.”

Conclusion

The example of drug testing is but one example to illustrate the difficulty in interpreting laboratory tests and studies. More importantly, drug testing and the TSA screening processes appear structurally similar; both pretend to address large societal problems, are performances involving a lot of show, and both are ineffective sociotechnical systems.

With any test, you have to try and tease out not only the accuracy of the test in measuring the outcome you wish to examine, but also whether you are measuring the right thing or asking the right question. We need to know whether the test or intervention makes a difference, is effective, and what the cost or risk:benefit ratio is.
For example, in my field of medicine, do we want to create a culture of safety, where an RN can question a physician, or one which is authoritarian and fear-ridden?  I have worked in both, and can tell you where I would want to work or to receive care as a patient.

Do we want to have workplaces built on trust and a presumption of honesty and mutual respect, or one of constant surveillance? Do we want a presumption of innocence until proven otherwise, or one of presumed guilt?

Will we accept propaganda that all this surveillance and violations of our civil liberties—be it at the workplace, in public assistance programs, or in public spaces—somehow is for our own good, in the absence of any data?
Do we want to address the issues that have a real impact on our safety and quality of life, or hoodwink ourselves with security theater?

Readings:

Bruce Schneier’s Harms of Post-9/11 Airline Security

The Government wants your DNA-Erin Murphy

Credits:

Security cameras – Stiwwe/Flickr

Blue water in toilet – Judy Stone

Welfare drug screens – courtesy John Henry/ LowGenius

DNA-Drug testing van – courtesy SkepticalScalpel

“Molecules to Medicine” banner © Michele Banks

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Judy Stone About the Author: Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.

The views expressed are those of the author and are not necessarily those of Scientific American.





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