Special Feature: What is Soberlink? and Why am I being asked to use it?

By: Raymond C. Truex Jr., MD, FAANS, FACS
In March of 2020, as the PA PHP began to plan for the coming Covid-19 pandemic, it became apparent that utilization of different methods of drug testing would be necessary, as social distancing, lockdowns, and business closures would make it difficult and unsafe for many of our participants to visit remote laboratory testing sites. We developed alternative methods of testing that could be done more conveniently and with greater safety for the participants. One of these alternatives was the Soberlink device.

The Soberlink device was introduced for general clinical use in 2010, and to date, over 150, 000 individuals have used it to validate their sobriety. Soberlink is being utilized by over 40 professional licensing organizations in the United States. The Soberlink device is a professional grade handheld breathalyzer with wireless connectivity, real-time facial recognition, robust tamper detection, and real-time alerting. It can be used wherever Wi-Fi or digital connectivity is available, which makes it possible for our participants to be tested while they travel abroad.

At this time, the PHP is utilizing the Soberlink device primarily for participants who have a diagnosis of Alcohol Use Disorder, and who have been unable to abstain from use of alcohol while undergoing drug testing. Our reasoning is based upon studies, which suggest that Soberlink is more likely to detect early alcohol relapse than standard urine drug testing 1. At first, many participants perceive this as a punitive response to their relapse. However, the PHP prefers to view it as a logical, stepwise increase in the ongoing evaluation of a chronic disease process that is not responding to less stringent treatment measures. To their surprise, many participants over time begin to see use of the Soberlink in a more positive light, as it is portable and fast, convenient to use during a bathroom break, and significantly reduces the number of necessary trips to a remote lab testing site, with all the inherent inconvenience, expense, and disruption of busy schedules.

We believe that the Soberlink may be more reliable in the detection of low level drinking than standard UDS testing, which typically employs the biomarker ethyl glucuronide (UEtG), detectable in the urine for 2-3 days after a drinking episode. Since UDS testing is typically done at a frequency of once per week, 4-5 days are untested, and it is quite possible to miss a brief alcohol relapse by this method. Skipper et al1 carried out a randomized trial of controlled drinking by twelve non-alcoholic volunteers over 5 weeks, a comparison between drinking episode detection by UEtG and Soberlink over the 5 week trial period. On the 12 volunteers, UDS testing was done once per week, and Soberlink testing four times per day. There were 84 volunteer drinking episodes over the five weeks, of which 83 (98%) were detected by Soberlink, and only 1 (1%) by UEtG. The volunteers strongly preferred the convenience of Soberlink testing to UDS testing. This study suggests that Soberlink is more likely to detect brief alcohol relapses than urine drug testing, and is easier to use.

The breathalyzer function records the alcohol concentration in expired air during mid expiration. Alcohol in the blood stream readily passes through the alveolar wall into the air cell, and is accurately recorded in the exhaled breath as the blood alcohol concentration (BAC), quite similar to what police use during traffic stops for suspected drunk driving. The Soberlink unit can detect two standard drinks from 2 to 5 hours post ingestion, or 5 drinks (binge drinking) up to 12 hours post ingestion. At the exact time the exhaled air sample is taken, the Soberlink device takes a photo of the individual blowing into the device. Using facial recognition software, the device confirms the identity of the person submitting the sample. There are also temperature recognition and other tamperproof mechanisms incorporated into the device. Once the sample BAC is recorded, the result is transmitted electronically to Soberlink and relayed almost immediately to the PHP, which is notified of a positive result.

In their first year of using the Soberlink device, our participants are asked to blow into the device four times per day on a predetermined schedule. A sample testing schedule might be: 7 AM, 12 PM, 5 PM, and 10 PM, but is adjustable to the needs of the individual participant. This poses a problem for some physicians, such as surgeons, who are involved in lengthy operations that do not lend themselves to interruption. The PHP certainly understands the problem this poses. What we then ask is for the physician who anticipates being unable to test on schedule to give the PHP a call to explain the problem, and then to test as soon as possible when the procedure is completed. The PHP will make every effort to reasonably accommodate a busy physician’s schedule.

After a year of successful drug and alcohol testing, statistics show that the risk of alcohol use relapse diminishes significantly 2, 3, and at this juncture, the participant can request a reduction in the Soberlink testing frequency.

One of the difficulties with the Soberlink device is its sensitivity, in that it can detect mouthwash, toothpaste, hand sanitizer, hair spray, and other vapors in the ambient air, which might trigger an incidental positive result with a low level BAC. The participant follows protocol to retest every 15 minutes until the Soberlink records a negative result, usually after one or two tries. Understanding this potential problem allows the user to select a testing environment free of these potential risks.

A Confirmed Positive Test is defined by the PHP as: A positive test (.005 or higher) followed by a second positive test (anything above .000). A participant is then required to adhere to the following protocol: Re-test every 15 minutes until a .000 is registered or 3 hours have elapsed. Any test for Soberlink resulting in a Confirmed Positive Test will require the participant to utilize the Self-Test feature on Affinity and provide a urine screen. A participant may activate a Self-Test at any time by logging into their Affinity account. A confirmed positive test followed by a positive Self- Test will result in a referral for an evaluation by a PHP approved provider.

To date the PHP has 23 participants who are testing on the Soberlink device, with mostly positive reviews and good compliance. The cost to the participant is roughly the same as would be experienced in a standard drug testing regimen. We think it is an effective form of accountability and supports recovery, while being easy to use and cost-effective for participants.

Skipper G, Thon N, DuPont R, Campbell M, Weinmann W, Wurst F. Cellular Photo Digital Breathalyzer for Monitoring Alcohol Use: A Pilot Study. Eur Addict Res 2014;20: 137–142

Katsukas, LA, Ammon L, Delucchi K. et al. Alcoholics Anonymous Careers: Patterns of AA involvement five years after treatment entry. Alcohol Clin Exp Res 2005;29: 1983-1990

Moos RH, Moos BS. Treated and Untreated Alcohol Use Disorders, Course and Predictors of Remission and Relapse. Evaluation Review 2007;31: 564-584