Oral Fluid Drug Testing and Virtual, Proctored Solutions – “A Dynamic Duo”

Blog written by Brian Feeley

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For us old-timers, a rock band from the ‘60s and ‘70s called Blood, Sweat & Tears, or BS&T, will bring back memories of songs like “You’ve Made Me So Very Happy,” “And When I Die,” and “Spinning Wheel.” From a diagnostic testing perspective, blood, sweat, & tears, as well as urine and oral fluid, were among the first sample types to be used centuries ago for a host of serious conditions that set the stage for our more modern and automated testing today.  

Relative to oral fluid or saliva, while many tend to think of this as a new sample type, it is not. In the early 18th century, researchers “looked for acid salts, crystalline salts, and glycogen as aids in the diagnosis of what were known as “diathetic” diseases’ Regarding drug testing, this same source says, “The first documented use of saliva was in 1912 when a horse called Bourbon Rose won the Gold Cup at Maison Lafitte in France but was disqualified because it yielded the first ‘positive’ drug test.”  

Thousands of publications on the use of saliva for diagnostic applications occurred in the mid-1900s, with thousands more in a shorter time period from 1970 to 1990, when some of the first publications began to appear related to human drug abuse testing applications. Then, from 2001 to 2010, numerous articles were published on the first Food & Drug Administration (FDA)-cleared oral fluid drug testing product line, the OraSure Intercept Oral Specimen Collection Device and drug screening kits. This set the stage for oral fluid drug testing in the workplace, in addition to many other applications. I was personally at OraSure Technologies during those years when the first large manufacturers, grocery chains, and hardware retailers became the early adopters of oral fluid drug testing, and it became very clear that this trend was going to continue.  

In that same time period, the Drug Testing Advisory Board (DTAB), under the funding and direction of the Substance Abuse and Mental Health Services Administration (SAMHSA), began looking closely at lab-based oral fluid drug testing (in addition to hair and sweat) as a possible addition to the federal workplace drug testing program. Due to some of the technical complexities of hair and sweat testing and the greater overall ease of use and benefits of oral fluid collection and testing, DTAB eventually prioritized oral fluid testing and finally approved it in October of 2019, when the oral fluid mandatory guidelines were published in the Federal Register.  

In these guidelines, SAMHSA made the statement that many were waiting for, which is: "The scientific basis for the use of oral fluid as an alternative specimen for drug testing has now been broadly established and the advances in the use of oral fluid in detecting drugs have made it possible for this alternative specimen to be used with the same level of confidence that has been applied to the use of urine. ii

This also set the stage for the U.S. Department of Transportation (DOT) to jump on the oral fluid wagon and put out its own Notice of Proposed Rule Making (NPRM) to add lab-based oral fluid testing to the DOT rules, allowing it to be used for all DOT modals, with the exception of the Federal Railroad Administration (FRA), as their drug testing program does not fall under DOT. In May 2023, the DOT finalized their rule-making and added oral fluid testing to their program. I would be remiss if I did not caution readers that, as of this writing, neither federal nor DOT drug testing can be done right now, as we are still waiting for at least two laboratories to be certified by the federal government before that can begin.  

When oral fluid testing was first launched into workplace drug testing, some said that the shorter window of detection (WOD), the time frame a drug can be detected in a sample from use of the drug to when it is no longer detectable, was too short and that some positive samples would be missed compared to urine, which has a longer WOD. While that might have been true in the early 2000’s, two things have become clear about oral fluid testing since then: 

1. The percent positives found in oral fluid samples are typically higher for most drugs compared to urine, and 
2. Today, many customers prefer a shorter WOD, particularly for marijuana, as it represents more recent use, which ties more closely with workplace safety program goals. 

This shorter WOD also provides employers an advantage in hiring as they will detect those recent users who represent the highest risks in the workplace, but not those users who may come up positive on a urine drug screen, which may very well be indicating past use from days or weeks ago.

Characteristics of Oral Fluid Testing

• Collections—May be conducted on-site at the workplace by non-professional collectors.  Collector training is available online and collectors can begin collecting immediately after training.
• Drug test cheating—Every specimen collection is 100 percent observed, thus eliminating most, if not all, traditional drug test cheating methods. 
• Easy to administer—Oral fluid collections eliminate the need for the myriad precautions typically required for the collection of a urine sample. Oral fluid collections do not require a private bathroom and are often preferred by those who administer tests.  
• Eliminates “yuck” factor— Many consider handling a urine specimen to be an unpleasant experience and prefer the oral fluid collection process.  
• Gender collector issues are eliminated—Because oral fluid collections do not require a donor to use a bathroom stall, the collector and donor genders are not a consideration, regardless of the reason for the test. 
• Safeguards the dignity of the donor—Oral fluid collections are less invasive, thus reducing embarrassment for the donor.
• Time savings—On-site collections significantly reduce time away from work for the donor and supervisor, which means more time on the job, improving productivity.
• Shy bladder—Eliminates shy bladder issues, speeding up the process.  
• Union-friendly—Unions have historically favored oral fluid testing because of the shorter window of detection with oral fluids and the less-invasive nature of the collection process.
• Legal marijuana-friendly— As legal marijuana use increases, employers are increasingly pressed to identify only recent use and not historical use. The new laws in California & Washington are great examples of where employers can no longer discriminate against employees based on a drug test method that tests for the non-psychoactive form of THC, exactly what urine detects, leaving oral fluid as the best option to use in these states since it tests for the parent THC (psychoactive form).  
• Recent use detection & marijuana’s window of impairment—A recent report from the University of Sydney concluded that marijuana’s window of impairment is 3-10 hours, much longer than typically promoted by legalization advocates.iii Oral fluid testing, with its ability to detect drugs within minutes after ingestion, is the only drug testing method that can detect marijuana throughout the entire window of impairment.
• Offers flexibility—Samples can be collected anytime, anywhere; oral fluid testing can be implemented in place of or in combination with urine testing; oral fluid testing is ideal in unique testing circumstances, such as post-accident and reasonable suspicion situations, remote areas where collection of a urine specimen is impractical or cost-prohibitive, third shifts, etc.

Virtual Drug Tests

Many of you have probably been exposed to virtual or proctored collections and testing, and the fit here with oral fluid is ideal. Prior to COVID, these technologies were beginning to evolve and advance, becoming methods that could be practically and accurately implemented for diagnostic testing applications, including drug testing.  

However, as a result of COVID and the need for testing solutions to be available outside of occupational health/collection sites and doctor offices, virtual doctor visits and testing became paramount to effectively dealing with the onslaught of the disease and patient treatment. Due to this, virtual collections and technologies surrounding these further advanced and improved, from kitting of the tests to rapid deployment, use of security seals, appointment scheduling, running tests under directly observed conditions by trained professionals, and tightly controlled packaging of samples for shipment to the laboratory when necessary.  

A host of companies, including eMed Screen, are now specializing in these solutions and offering them for non-regulated drug and alcohol testing applications. Use of this technology has many positive outcomes in testing programs, including:

1. Improved compliance of testing programs via 24/7 availability of collections that are not subject to limited appointment slots often experienced at collection sites.
2. Solves difficult collection situations, such as remote workplaces, weekends, holidays, and other situations, with no scheduling needed.
3. Reduces burdens on collection sites so they can prioritize the more important clinical work they perform.
4. Reduces contact between healthy individuals needing a drug test and individuals who may be sick and waiting at occupational health and collection sites, which is particularly important during peak COVID and flu outbreaks. 
5. Accelerates the hiring process in pre-employment testing situations.
6. Video and audio files generated during the process can be retained for extended periods of time on secure servers, should the need arise to revisit those important recordings.
7. Importantly, it typically utilizes oral fluid with its many benefits, which is the most practical sample type for this application. 

Conclusion

In conclusion, oral fluid is much easier and more practical to collect than blood, sweat, and tears, and it certainly seems to have the most momentum in the drug testing industry of any other sample type today. Add that to the many benefits cited above, the close fit it has with the changing laws requiring the use of testing for psychoactive THC, the ability to collect and test remotely via proctored collections, and we really do have a dynamic duo that could be a knock-out punch for all, or at least part of your drug testing program.

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iSaliva as a Diagnostic Fluid: Annals of the New York Academy of Sciences, Vol. 694, p. 2

ii SAMHSA “The Mandatory Guidelines for Federal Workplace Drug Testing Programs using Oral Fluid (OFMG),” Federal Register, Vol. 84, No. 207, p. 57554

iii “Determining the magnitude and duration of acute Δ9-tetrahydrocannabinol (Δ9-THC)-induced driving and cognitive impairment: A systematic and meta-analytic review,” Neuroscience & Biobehavioral Reviews, Vol. 126