One nurse measured 270 ng/mL on the EtG test, while the other measured 215 ng/mL, levels that might be considered fairly low for a substance abuser who has fallen off the wagon, since two drinks can produce a level of 23,000 ng/mL, Dr. Liepman said.
Both nurses reported washing their hands with sanitizer on the job upward of 30 times a day, a frequency that might explain why, among health care workers, so many of those who have been tripped up by the test have been nurses.
Dr. Skipper said that he does not want to see the test abandoned. He finds it frequently picks up monitored physicians whose alcohol use would not be detected otherwise, and even among those who deny drinking at first, 50%–80% later admit to it.
Random EtG testing surveys of physicians who are not supposed to be drinking in monitoring programs have found that around 7% will have a positive test result. It is important to catch those physicians to get them help, Dr. Skipper said.
Given the gathering evidence, however, the test needs to be used with some clinical judgment of the individual, he added.
“I am urging no use in administrative hearings and courts,” he said. “It is a clinical test.”
Moreover, if hand sanitizer can cause measurable EtG levels, then probably any product containing alcohol could, he noted. And products that contain alcohol are everywhere, ranging from the cold medicine NyQuil to asthma inhalers, topical testosterone, and bug spray.
In the laboratory, Dr. Skipper said he has found that two nonalcoholic beers will cause a level of 93 ng/mL and gargling with Listerine can trigger a level of 100 ng/mL.
“We have to expect that all recovering doctors are going to be using these products,” noted Dr. Michael M. Miller of Madison, Wis., president of the American Society of Addiction Medicine, who attended the session on ethyl glucuronide at which Dr. Liepman's study was presented.
The EtG test appears to be used widely by physician monitoring programs. In a survey of physician health programs conducted this year, 29 of 31 responding programs reported that they use the test, compared with 17 of 46 programs that reported using it in 2004, said Dr. Michael Sucher, who serves as medical director of the physician health program in Scottsdale, Ariz.
Some of those states use it routinely, others just for cause.
Michigan, which is one of the states that does not use the test, did use it previously but stopped because there were too many challenges to cases of positive test results.
Dr. Sucher agrees with Dr. Skipper that a positive test result should not be used as the sole basis of punitive action.
“We all learned in medical school that you don't treat a number or a test result,” he said at the meeting. “You have to have clinical correlation.”
Meanwhile, Ms. Clark, who came to the meeting with two other nurses and a pharmacist who also have had their licenses suspended because of EtG testing, has been out of work for 6 months.
She noted that, without the positive results on the second test, her 3-year probation period would have been over 2 months ago.