**II. The Role of Drug and Breath-Alcohol Testing in Matrix IOP**

**Philosophy**

In the Matrix Intensive Outpatient Treatment for People With Stimulant
Use Disorders (IOP) model, drug and breath-alcohol testing is viewed and
presented to clients as a valuable tool to help clients become abstinent
and enter recovery, not as a punitive monitoring measure. Its use should
not be presented or perceived as an indication of mistrust of a client's
honesty. Instead, the counselor should help clients accept that people
in outpatient treatment for substance use disorders need as many tools
as possible to recover. To regain control of their lives, clients need
ways to impose structure on their behavior.

Urine or saliva drug and breath-alcohol test results can provide
invaluable clinical data when a lapse or relapse has occurred and the
client is unable to talk about it. The occurrence of relapse and, often,
denial of use make testing for substances an essential component of
outpatient substance abuse treatment programs.

The goals of testing for substances in treatment include

-   Deterring a client from resuming substance use

-   Providing a counselor with objective information about a client's
    substance use

-   Providing a client who is denying use with objective evidence of use

-   Identifying a substance use problem severe enough to warrant
    residential or hospital-based treatment

**Procedure**

This section assumes that the counselor's program has established
procedures for collecting, identifying, storing, ensuring chain of
custody for collecting, and transporting specimens. If drug screens are
required (e.g., if they have been ordered by the court), clients should
be so informed.

***Testing Schedule***

In the Matrix IOP approach, all clients are asked to provide a urine or
saliva specimen for drug analysis and to take a breath-alcohol test once
each week. Occasionally, the testing day should be random but should be
on a day that most closely follows a period of high risk (e.g.,
weekends, payday). Unexplained missed appointments, unusual behavior in
sessions or groups, or family reports of unusual behavior may indicate a
need for immediate testing. The counselor should be sensitive to
possible client embarrassment and avoid any unnecessary public
discussion or joking about the tests.

A program can screen for a client's substance of choice or for a broad
range of substances. The program may want to use Breathalyzer™ screening
every time or only when alcohol use is suspected. Full drug screens
should be done when the counselor suspects other substance use.

***Addressing Tampering***

Occasionally a client may attempt to conceal drug use by tampering with
a urine specimen. At the time the suspect specimen is submitted, the
client should be taken into a private setting and told that there is
some uncertainty about the specimen. Staff members should not be
accusatory and should attempt to make the client comfortable. However,
staff persons should avoid tension-relieving jokes that might
communicate the wrong message about the purpose or importance of urine
specimen collection and testing.

Tampered urine specimens usually indicate substance use. Clients who
alter their specimens rarely admit it. Specimen tampering is a critical
concern in treatment and may signal a relapse. Drug use combined with
denial may reflect a breakdown of the therapeutic process. If a client
attempts to alter more than one specimen sample, it may be necessary to
observe the client giving another sample immediately and on subsequent
testing occasions until the client's abstinence is reasonably verified.
Doing so should be viewed as a last resort to establish the client's
drug use and to encourage truthfulness.

If a situation warrants observing urine collection, the counselor should
consult with a supervisor for approval and direction. The counselor
should follow the agency's policy and procedures for observing urine
collection. Observing urine specimen collection is uncomfortable for
staff members and may be humiliating for the client. Urine collection
procedures should be explained to the client at the first individual
session including the possibility that urine collections may be observed
occasionally.

An observed urine collection procedure is a last resort for clients who
are having difficulties in the recovery process. It is important to view
this procedure as a therapeutic activity. In many cases, drug testing
can move clients back on track and prompt them to tell the truth about
drug use.

**Addressing a Positive Urine Test**

A positive drug test is a significant event in treatment. It might mean
one use, or it might indicate a return to chronic use. In response to a
positive result, the counselor should take the following steps:

-   Number range level0Number range level1Number range level2Number
    range level3Number range level4Number range level5Number range
    level6Number range level7Reevaluate the period surrounding the test.
    Were there other indications of a problem such as missed
    appointments, unusual behavior, discussions in treatment sessions or
    groups, or family reports of unusual activity?

-   Give the client an opportunity to explain the result, for example,
    by stating, "I received a positive result from the lab on your urine
    test from last Monday. Did anything happen that weekend you forgot
    to tell me about?"

-   Avoid discussion about the validity of the results (e.g., the lab
    could have made an error; the bottle might have been mixed up with
    another client's).

-   Consider temporarily increasing the frequency of testing to
    determine the extent of use.

-   Reinforce a client's honesty if he or she admits to use, and stress
    the therapeutic importance of the admission. This interaction may
    result in admissions of other instances of substance use that had
    gone undetected.

-   Collaborate with corrections or court staff as appropriate.

Sometimes a client responds to the news of a positive urine test with a
partial confession of drug involvement, for instance, that he or she was
at a party and was offered drugs but did not use them. These partial
confessions are often the closest the client can get to actually
admitting drug use.

Occasionally a client reacts angrily to notification of positive test
results. Typically, the client may accuse the counselor of lack of trust
and display indignation at the suggestion of drug use. These reactions
can be convincing and may cause a counselor initially to react
defensively. However, the counselor calmly should inform the client that
discussing a positive test result is necessary for treatment and that
the counselor's questioning is in the client's best interest. If the
client is unresponsive to these explanations, the counselor should
attempt to move on to other issues. At some other time, the topic of
truthfulness may be revisited and the client given another opportunity
to discuss the urine test result.

A client should not be discharged from the Matrix IOP intervention
because of positive drug test or Breathalyzer results. If there are
repeated positive test results, however, it may be necessary for the
counselor to stress that abstinence is the goal of the Matrix IOP
approach and to consider increasing the frequency of a client's visits.
For example, the counselor could place a client back into the Early
Recovery Skills group if the client has already completed those group
sessions but has had repeated positive test results, or more individual
sessions could be scheduled for a client who is at an earlier stage in
the treatment process. If a client continues to have positive drug
tests, the counselor may be required to refer the client to a higher
level of care.

Even if the client denies drug or alcohol use, the counselor must
proceed as if there were use. Lapses should be analyzed with the client
(possibly in an individual session), and a plan for avoiding relapse
reformulated. It may become necessary to assess the need for inpatient
or residential treatment. The counselor's confidence in and certainty of
the test results are critical at this point and may be instrumental in
inducing an honest explanation from the client of what has been
happening. If the urine testing process succeeds in documenting
out-of-control drug use and establishes the need for increasing the
intensity of outpatient treatment or considering residential or
hospital-based treatment, it has served a valuable function.