the
use
of numbers
or
scrutiny.
arguments that will
not stand up to
Rolley E. Johnson, PharmD The Johns Hopkins University School of Medicine Baltimore, Md Jerome H. Jaffe, MD Alcohol, Drug Abuse, and Mental Health Administration Rockville, Md Paul J. Fudala, PhD University of Pennsylvania School of Medicine Philadelphia
1. Ball JC, Ross A. Reduction in
drug abuse during methadone maintenance treatEffectiveness of Methadone Maintenance Treatment. New York, NY: NY 1991:160-175. Springer-Verlag Inc; 2. Gerstein DR, Harwood HJ, eds. Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems. Washington, DC: National Academy Press; 1990;1. Committee for the Substance Abuse Coverage Study, Division of Health Care Services, Institute of Medicine. 3. The effectiveness of treatment for drug abuse. In: Sisk JE, Hatziandreu EJ, Hughes R, eds. AIDS-Related Issues: The Effectiveness of Drug Abuse Treatment Implications for Controlling AIDS/HIV Infection. Washington, DC: US Congress, Office of Technology Assessment; September 1990:59-99. 4. General Accounting Office. Methadone Maintenance: Some Treatment Programs Are Not Effective: Greater Federal Oversight Needed. Washington, DC: General Accounting Office; March 1990. Report to the Chairman, Select Committee on Narcotics Abuse and Control, House of Representatives. Publication GAO/HRD-90-104. 5. Pickens RW, Luekefeld CG, Schuster CR, eds. Improving drug abuse treatment. Rockville, Md: National Institute on Drug Abuse Research; 1991. US Dept of Health and Human Services publication ADM 91-1754. Monograph 106. 6. Bureau of Justice Statistics. Report to the Nation on Crime and Justice. 2nd ed. Washington, DC: March 1988. US Dept of Justice publication NCJ-105506. ment. In: The
Rubella Screening at Drug Rehabilitation Centers To the Editor.\p=m-\Leeet al1 point out that drug rehabilitation programs provide an appropriate setting to perform rubella testing. They also point out that at least 24% of women in their cluster of congenital rubella syndrome had a history of illicit substance use. In 1990, we reported on the rubella immunity status of chemically dependent adolescent females admitted to a residential treatment center.2 In that study, 129 subjects were screened for rubella antibody. Of the study sample, 12.4% were found to be nonimmune by titer. No statistical relationship was found between self-reported immunization status and actual titer findings. In that study, attempts were made to give vaccine to those susceptible to rubella. Of the 16 women found to be nonimmune, only 56% were successfully vaccinated. Subjects had often left the facility before informed consent could be obtained from their parents. Our findings confirm that drug rehabilitation programs are a good place to immunize young women for rubella. However, we feel that rather than performing rubella testing first, all clients should be given the vaccine unless they can document a history of vaccination. David J. Mersy, MD Diane Madlon-Kay, MD St Paul, Minn 1. Lee SH, Ewert DP, Frederick PD, Mascola L. Resurgence of congenital rubella syndrome in the 1990s: report on missed opportunities and failed prevention policies among women of childbearing age. JAMA. 1992;267:2616-2620. 2. Mersy DJ, Madly-Kay DJ. Rubella immunity in chemically dependent adolescent
females. J Subst Abuse Treat. 1990;7:59-60.
This letter
was
shown to Dr
Ewert, who declined to reply.—Ed.
Drug Testing and the Toilet Bowl Blues To the Editor.\p=m-\Workplacedrug testing continues to be a major issue in the United States. As commentators debate the propriety of random workplace drug testing, the knowledge base about the process of drug testing continues to evolve.
The formal
drug testing programs sanctioned by the
De-
partment of Health and Human Services and the Department
of Transportation rely on a series of security procedures to discourage the dilution of a specimen or the substitution of a false specimen for a real specimen. One such measure is the placement of bluing in the toilet bowl at the collection site to prevent a specimen "donor" from either substituting toilet water for a urine specimen or diluting a real urine specimen with toilet water.1 We would like to remind practitioners in the field, especially physicians working as medical review officers, that there are legitimate medications that contain methylene blue (Prosed, Webcon Pharmaceuticals, Humacao, Puerto Rico, and Urised and Urolene Blue, Star Pharmaceuticals Inc, Pompano Beach, Fla), which will produce a urine specimen in¬ distinguishable in color from the bluing used for toilet water. One of us (K.L.S.) found that after a single standard dose of Urised, urine specimens started to be discolored blue to bluegreen after 1 hour and continued to be discolored for at least 24 hours. Consequently, physicians who prescribe méthylène bluecontaining medications to patients who may be subject to random urine drug testing should warn patients that the urine will be discolored so that the patients can alert the collection site personnel. This admonition could prevent a patient from being falsely accused of tampering with the drug test. In addition to patients with legitimate needs for méthylène blue-containing medications, physicians should be alert to
the
possibility that patients who use illicit substances may requesting medication (eg, Prosed or Urised) to re¬ lieve temporary urinary discomfort. The advantage to the drug-using patient is that overt evidence of tampering may result in the specimen's not being tested by the laboratory or accepted by the collection site, delaying a legitimate urine test long enough to reduce concentration of a proscribed substance below the cutoff point. Of course, the phenomenon of méthylène blue discolora¬ appear
tion of urine raises the issue of any substance that may discolor urine. Other examples of substances that change the color of urine are phenazopyridine hydrochloride tab¬ lets (eg, Pyridium, Parke-Davis, Morris Plains, NJ) and rifampin (eg, Rimactane, CIBA Pharmaceutical Co, Sum¬ mit, NJ), which produce an orange to red color in the urine. Just how much medically legitimate urine discolor¬ ation affects the urine collection and testing process is not clear. We have found no literature on this subject. How¬ ever, we believe that it is only a matter of time before this issue becomes important from the perspective of pro¬ tecting patients from being falsely accused and from the perspective of deceptive patients eluding the reach of
workplace drug testing.
1. 49
H. Westley Clark, MD, JD, MPH Karen L. Sees, DO Veterans Affairs Medical Center San Francisco, Calif CFR \s=s\40.25(f)(1).
Reporting Abuse of Competent Patients To the Editor.\p=m-\Thearticle by the Council
on Ethical and Judicial Affairs of the American Medical Association1 contains a contradiction regarding mandatory reporting of domestic violence. First, the authors note, "Almost every state requires physicians to report suspected child and elder abuse and neglect to local protective services or law enforcement authorities." But they conclude, "For mentally competent adult victims, physicians must not disclose an abuse diagnosis
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/21/2015
to spouses
patient."
or
any other third party without the consent of the
What happens in the case of a competent elderly woman who is being battered? State laws mandate reporting of elder abuse, regardless of the competency of the abused elderly person. Perhaps investigators need to explore the impact of mandatory reporting of abuse of competent elderly people. If this reporting contributes to the safety of competent older people or facilitates their access to appropriate resources, then why should mandatory reporting of domestic violence not provide the same benefits to younger women? If health services research demonstrates that competent older people are not being benefited, then perhaps mandatory reporting of suspected elder abuse and neglect should apply only to
incompetent elderly people.
The Council on Ethical and Judicial Affairs needs to weigh the data that support mandatory reporting of abuse of com¬ petent older people before condemning mandatory reporting of abuse of competent, albeit younger, women. Eve Wiseman, MD Little Rock, Ark 1. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence: ethical considerations. JAMA. 1992;267:3190-3193.
In Reply.\p=m-\Indeveloping its guidelines on domestic violence, the Council on Ethical and Judicial Affairs considered the experience with mandatory reporting in the context of elder abuse. A number of experts oppose mandatory reporting for elder abuse. They observe that it can deter elder adults from seeking medical care and other necessary assistance. In addition, because states often do not provide sufficient funding for meaningful interventions, mandatory reporting may increase the risk of harm without offering any countervailing benefit.1 As discussed by the Council in its report,2 similar concerns apply when mentally competent, non\p=m-\elderadults are abused by their spouses or other intimate partners. The Council also emphasized the importance of respecting the abused person's decision whether to accept an offered intervention or not. The Council Report recommends that physicians give assurances of safety and confidentiality and encourage their abused patients to consent to helpful interventions. Ultimately, however, the decision should rest with the patient. Forcing interventions on an unwilling patient not only overrides the patient's autonomy, it also exacerbates the disempowerment that victims of domestic abuse suffer. Rath¬ er than have mandatory reporting, the Council concluded that it would be more productive to increase funding for shelters, safe homes, and other resources for victims of do¬ mestic violence. Oscar W. Clarke, MD David Orentlicher, MD, JD American Medical Association
Chicago,
Ill
1. Brewer RA, Jones JS.
Reporting elder abuse: limitations of statutes. Ann Emerg Med. 1989;18:1217-1221. 2. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence: ethical considerations. JAMA. 1992;267:3190-3193.
Environmental Tobacco Smoke and Heart Disease: A Correction Readers have raised questions concerning the absence of any financial disclosure following the Letter to the Editor from Dr Domingo Aviado.1 In response, Dr Aviado would like us to publish the following "clarification statement": "Atmospheric Health Sciences is an independent consulting firm for governmental agencies here and abroad, the tobacco industry, pharmaceutical industry, and petrochemical companies. However, Dr Aviado did not receive any form of compensation for writing the unsolicited Letter to the Editor on environmental tobacco smoke and heart disease." The editors would point out that on February 16,1992, Dr Aviado signed the following Financial Disclosure statement without noting any conflicts: "I certify that any affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript (eg,
employment, consultancies,
stock ownership, honoraria, exnoted below. Otherwise, my signature indicates that I have no such financial interest. All financial research or project support is identified in an acknowledg¬ ment in the manuscript." It seems clear to the editors that the two statements above cannot easily be reconciled and that Dr Aviado had a financial conflict of interest that should have been disclosed to our readers.
pert testimony)
are
Drummond Rennie, MD Bruce B. Dan, MD 1. Aviado DM. Environmental tobacco smoke and heart disease. JAMA.
1992;267:3284-3285.
Incorrect Units of Measurement. \p=m-\Inthe article entitled "Pedestrian and Hypothermia Deaths Among Native Americans in New Mexico: Between Bar and Home," published in the March 11, 1992, issue of THE JOURNAL (1992;267:1345-1348), the units of measurement for blood alcohol concentrations reported are incorrect. On page 1345 in the "Results" section of the abstract, the third sentence should read as follows: "At death, 90% of those Native Americans tested were highly intoxicated (median blood alcohol concentrations of 0.24 and 0.18 g/dL [not 0.24 and 0.18 mg/dL] for pedestrian and hypothermia deaths, respectively)." On page 1346 in the "Results" section, the fourth and fifth sentences of the fourth paragraph should read as follows: "Of those tested, alcohol was present in 229 (91%) of the pedestrians, with a median blood alcohol concentration of 0.24 g/dL [not 0.24 mg/dL] (range, 0.10 to 0.71 g/dL) [not 0.10 to 0.71 mg/dL]. Similarly, alcohol was present in 120 (90%) of those who died of hypothermia and were tested, with a median blood alcohol concentration of 0.18 g/dL [not 0.18 mg/dL] (range, 0.03 to 0.56 g/dL) [not 0.03 to 0.56 mg/dL]."
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/21/2015
use
of numbers
or
scrutiny.
arguments that will
not stand up to
Rolley E. Johnson, PharmD The Johns Hopkins University School of Medicine Baltimore, Md Jerome H. Jaffe, MD Alcohol, Drug Abuse, and Mental Health Administration Rockville, Md Paul J. Fudala, PhD University of Pennsylvania School of Medicine Philadelphia
1. Ball JC, Ross A. Reduction in
drug abuse during methadone maintenance treatEffectiveness of Methadone Maintenance Treatment. New York, NY: NY 1991:160-175. Springer-Verlag Inc; 2. Gerstein DR, Harwood HJ, eds. Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems. Washington, DC: National Academy Press; 1990;1. Committee for the Substance Abuse Coverage Study, Division of Health Care Services, Institute of Medicine. 3. The effectiveness of treatment for drug abuse. In: Sisk JE, Hatziandreu EJ, Hughes R, eds. AIDS-Related Issues: The Effectiveness of Drug Abuse Treatment Implications for Controlling AIDS/HIV Infection. Washington, DC: US Congress, Office of Technology Assessment; September 1990:59-99. 4. General Accounting Office. Methadone Maintenance: Some Treatment Programs Are Not Effective: Greater Federal Oversight Needed. Washington, DC: General Accounting Office; March 1990. Report to the Chairman, Select Committee on Narcotics Abuse and Control, House of Representatives. Publication GAO/HRD-90-104. 5. Pickens RW, Luekefeld CG, Schuster CR, eds. Improving drug abuse treatment. Rockville, Md: National Institute on Drug Abuse Research; 1991. US Dept of Health and Human Services publication ADM 91-1754. Monograph 106. 6. Bureau of Justice Statistics. Report to the Nation on Crime and Justice. 2nd ed. Washington, DC: March 1988. US Dept of Justice publication NCJ-105506. ment. In: The
Rubella Screening at Drug Rehabilitation Centers To the Editor.\p=m-\Leeet al1 point out that drug rehabilitation programs provide an appropriate setting to perform rubella testing. They also point out that at least 24% of women in their cluster of congenital rubella syndrome had a history of illicit substance use. In 1990, we reported on the rubella immunity status of chemically dependent adolescent females admitted to a residential treatment center.2 In that study, 129 subjects were screened for rubella antibody. Of the study sample, 12.4% were found to be nonimmune by titer. No statistical relationship was found between self-reported immunization status and actual titer findings. In that study, attempts were made to give vaccine to those susceptible to rubella. Of the 16 women found to be nonimmune, only 56% were successfully vaccinated. Subjects had often left the facility before informed consent could be obtained from their parents. Our findings confirm that drug rehabilitation programs are a good place to immunize young women for rubella. However, we feel that rather than performing rubella testing first, all clients should be given the vaccine unless they can document a history of vaccination. David J. Mersy, MD Diane Madlon-Kay, MD St Paul, Minn 1. Lee SH, Ewert DP, Frederick PD, Mascola L. Resurgence of congenital rubella syndrome in the 1990s: report on missed opportunities and failed prevention policies among women of childbearing age. JAMA. 1992;267:2616-2620. 2. Mersy DJ, Madly-Kay DJ. Rubella immunity in chemically dependent adolescent
females. J Subst Abuse Treat. 1990;7:59-60.
This letter
was
shown to Dr
Ewert, who declined to reply.—Ed.
Drug Testing and the Toilet Bowl Blues To the Editor.\p=m-\Workplacedrug testing continues to be a major issue in the United States. As commentators debate the propriety of random workplace drug testing, the knowledge base about the process of drug testing continues to evolve.
The formal
drug testing programs sanctioned by the
De-
partment of Health and Human Services and the Department
of Transportation rely on a series of security procedures to discourage the dilution of a specimen or the substitution of a false specimen for a real specimen. One such measure is the placement of bluing in the toilet bowl at the collection site to prevent a specimen "donor" from either substituting toilet water for a urine specimen or diluting a real urine specimen with toilet water.1 We would like to remind practitioners in the field, especially physicians working as medical review officers, that there are legitimate medications that contain methylene blue (Prosed, Webcon Pharmaceuticals, Humacao, Puerto Rico, and Urised and Urolene Blue, Star Pharmaceuticals Inc, Pompano Beach, Fla), which will produce a urine specimen in¬ distinguishable in color from the bluing used for toilet water. One of us (K.L.S.) found that after a single standard dose of Urised, urine specimens started to be discolored blue to bluegreen after 1 hour and continued to be discolored for at least 24 hours. Consequently, physicians who prescribe méthylène bluecontaining medications to patients who may be subject to random urine drug testing should warn patients that the urine will be discolored so that the patients can alert the collection site personnel. This admonition could prevent a patient from being falsely accused of tampering with the drug test. In addition to patients with legitimate needs for méthylène blue-containing medications, physicians should be alert to
the
possibility that patients who use illicit substances may requesting medication (eg, Prosed or Urised) to re¬ lieve temporary urinary discomfort. The advantage to the drug-using patient is that overt evidence of tampering may result in the specimen's not being tested by the laboratory or accepted by the collection site, delaying a legitimate urine test long enough to reduce concentration of a proscribed substance below the cutoff point. Of course, the phenomenon of méthylène blue discolora¬ appear
tion of urine raises the issue of any substance that may discolor urine. Other examples of substances that change the color of urine are phenazopyridine hydrochloride tab¬ lets (eg, Pyridium, Parke-Davis, Morris Plains, NJ) and rifampin (eg, Rimactane, CIBA Pharmaceutical Co, Sum¬ mit, NJ), which produce an orange to red color in the urine. Just how much medically legitimate urine discolor¬ ation affects the urine collection and testing process is not clear. We have found no literature on this subject. How¬ ever, we believe that it is only a matter of time before this issue becomes important from the perspective of pro¬ tecting patients from being falsely accused and from the perspective of deceptive patients eluding the reach of
workplace drug testing.
1. 49
H. Westley Clark, MD, JD, MPH Karen L. Sees, DO Veterans Affairs Medical Center San Francisco, Calif CFR \s=s\40.25(f)(1).
Reporting Abuse of Competent Patients To the Editor.\p=m-\Thearticle by the Council
on Ethical and Judicial Affairs of the American Medical Association1 contains a contradiction regarding mandatory reporting of domestic violence. First, the authors note, "Almost every state requires physicians to report suspected child and elder abuse and neglect to local protective services or law enforcement authorities." But they conclude, "For mentally competent adult victims, physicians must not disclose an abuse diagnosis
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/21/2015
to spouses
patient."
or
any other third party without the consent of the
What happens in the case of a competent elderly woman who is being battered? State laws mandate reporting of elder abuse, regardless of the competency of the abused elderly person. Perhaps investigators need to explore the impact of mandatory reporting of abuse of competent elderly people. If this reporting contributes to the safety of competent older people or facilitates their access to appropriate resources, then why should mandatory reporting of domestic violence not provide the same benefits to younger women? If health services research demonstrates that competent older people are not being benefited, then perhaps mandatory reporting of suspected elder abuse and neglect should apply only to
incompetent elderly people.
The Council on Ethical and Judicial Affairs needs to weigh the data that support mandatory reporting of abuse of com¬ petent older people before condemning mandatory reporting of abuse of competent, albeit younger, women. Eve Wiseman, MD Little Rock, Ark 1. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence: ethical considerations. JAMA. 1992;267:3190-3193.
In Reply.\p=m-\Indeveloping its guidelines on domestic violence, the Council on Ethical and Judicial Affairs considered the experience with mandatory reporting in the context of elder abuse. A number of experts oppose mandatory reporting for elder abuse. They observe that it can deter elder adults from seeking medical care and other necessary assistance. In addition, because states often do not provide sufficient funding for meaningful interventions, mandatory reporting may increase the risk of harm without offering any countervailing benefit.1 As discussed by the Council in its report,2 similar concerns apply when mentally competent, non\p=m-\elderadults are abused by their spouses or other intimate partners. The Council also emphasized the importance of respecting the abused person's decision whether to accept an offered intervention or not. The Council Report recommends that physicians give assurances of safety and confidentiality and encourage their abused patients to consent to helpful interventions. Ultimately, however, the decision should rest with the patient. Forcing interventions on an unwilling patient not only overrides the patient's autonomy, it also exacerbates the disempowerment that victims of domestic abuse suffer. Rath¬ er than have mandatory reporting, the Council concluded that it would be more productive to increase funding for shelters, safe homes, and other resources for victims of do¬ mestic violence. Oscar W. Clarke, MD David Orentlicher, MD, JD American Medical Association
Chicago,
Ill
1. Brewer RA, Jones JS.
Reporting elder abuse: limitations of statutes. Ann Emerg Med. 1989;18:1217-1221. 2. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence: ethical considerations. JAMA. 1992;267:3190-3193.
Environmental Tobacco Smoke and Heart Disease: A Correction Readers have raised questions concerning the absence of any financial disclosure following the Letter to the Editor from Dr Domingo Aviado.1 In response, Dr Aviado would like us to publish the following "clarification statement": "Atmospheric Health Sciences is an independent consulting firm for governmental agencies here and abroad, the tobacco industry, pharmaceutical industry, and petrochemical companies. However, Dr Aviado did not receive any form of compensation for writing the unsolicited Letter to the Editor on environmental tobacco smoke and heart disease." The editors would point out that on February 16,1992, Dr Aviado signed the following Financial Disclosure statement without noting any conflicts: "I certify that any affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript (eg,
employment, consultancies,
stock ownership, honoraria, exnoted below. Otherwise, my signature indicates that I have no such financial interest. All financial research or project support is identified in an acknowledg¬ ment in the manuscript." It seems clear to the editors that the two statements above cannot easily be reconciled and that Dr Aviado had a financial conflict of interest that should have been disclosed to our readers.
pert testimony)
are
Drummond Rennie, MD Bruce B. Dan, MD 1. Aviado DM. Environmental tobacco smoke and heart disease. JAMA.
1992;267:3284-3285.
Incorrect Units of Measurement. \p=m-\Inthe article entitled "Pedestrian and Hypothermia Deaths Among Native Americans in New Mexico: Between Bar and Home," published in the March 11, 1992, issue of THE JOURNAL (1992;267:1345-1348), the units of measurement for blood alcohol concentrations reported are incorrect. On page 1345 in the "Results" section of the abstract, the third sentence should read as follows: "At death, 90% of those Native Americans tested were highly intoxicated (median blood alcohol concentrations of 0.24 and 0.18 g/dL [not 0.24 and 0.18 mg/dL] for pedestrian and hypothermia deaths, respectively)." On page 1346 in the "Results" section, the fourth and fifth sentences of the fourth paragraph should read as follows: "Of those tested, alcohol was present in 229 (91%) of the pedestrians, with a median blood alcohol concentration of 0.24 g/dL [not 0.24 mg/dL] (range, 0.10 to 0.71 g/dL) [not 0.10 to 0.71 mg/dL]. Similarly, alcohol was present in 120 (90%) of those who died of hypothermia and were tested, with a median blood alcohol concentration of 0.18 g/dL [not 0.18 mg/dL] (range, 0.03 to 0.56 g/dL) [not 0.03 to 0.56 mg/dL]."
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/21/2015
