Key Points
Part 1: Principles of Drug Testing in Addiction Treatment
Part 2: Process of Drug Testing in Addiction Treatment
Part 3: Additional Considerations for Drug Testing in Addiction Treatment
Part 4: Biological Matrices
Part 5: Settings
Part 6: Special Populations
Design and created by Guideline Central in participation with the American Society of Addiction Medicine.
ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine
American Society of Addiction Medicine
Publication Date: June 22, 2017
Key Points
Recommendations in this document are not intended to substitute for independent clinical judgement based on the particular facts and circumstances presented by individual patients.
The dramatic proliferation of potentially addictive drugs is one of the most challenging problems facing drug testing today.*
No universal standard exists in clinical drug testing for addiction identification, diagnosis, treatment, medication monitoring, or recovery.
The purpose of this Drug Testing pocket guide is to provide guidance on the effective use of drug testing in the identification, diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.
It is intended for use by providers who utilize drug testing in clinical settings and healthcare administrators in residential, outpatient, and other settings.
Inappropriate use of drug testing is both wasteful and unethical. Examples include:
This ASAM Drug Testing pocket guide is intended to aid clinicians in their clinical decision-making and patient management. It strives to identify and define clinical decision-making junctures that meet the needs of most patients in most circumstances. Clinical decision-making should involve consideration of the quality and availability of expertise and services in the community wherein care is provided. In circumstances in which the Drug Testing pocket guide is being used as the basis for regulatory or payer decisions, improvement in quality of care should be the goal.
The dramatic proliferation of potentially addictive drugs is one of the most challenging problems facing drug testing today.*
No universal standard exists in clinical drug testing for addiction identification, diagnosis, treatment, medication monitoring, or recovery.
The purpose of this Drug Testing pocket guide is to provide guidance on the effective use of drug testing in the identification, diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.
It is intended for use by providers who utilize drug testing in clinical settings and healthcare administrators in residential, outpatient, and other settings.
Inappropriate use of drug testing is both wasteful and unethical. Examples include:
- The routine use of large, arbitrary test panels.
- Unnecessarily frequent drug testing without consideration for the drug’s window of detection.
- The confirmation and quantification of all presumptive positive and negative test results.
This ASAM Drug Testing pocket guide is intended to aid clinicians in their clinical decision-making and patient management. It strives to identify and define clinical decision-making junctures that meet the needs of most patients in most circumstances. Clinical decision-making should involve consideration of the quality and availability of expertise and services in the community wherein care is provided. In circumstances in which the Drug Testing pocket guide is being used as the basis for regulatory or payer decisions, improvement in quality of care should be the goal.
* ASAM Drug Testing: A White Paper of the American Society of Addiction Medicine. Chevy Chase, MD: American Society of Addiciton Medicine; 2013. Available at: http://www.asam.org/docs/default-source/public-policy-statements/drug-testing-a-white-paper-by-asam.pdf.
Part 1: Principles of Drug Testing in Addiction Treatment
Clinical Value of Drug Testing
Principles of Biological Detection of Substance Use
Providers should understand that drug tests are designed to measure whether a substance has been used within a particular window of time.
Drug Testing and Self-Reported Substance Use
Drug testing should be used in combination with a patient's self-reported information about substance use.
Drug testing is an important supplement to self-report because patients may be unaware of the composition of the substance(s) they have used.
Drug testing is particularly appropriate for patients facing negative consequences if substance use is detected, who are therefore less likely to provide accurate self-reported substance use information.
Discrepancy between self-report and drug tests results can be a point of engagement for the provider.
Drug Testing and Patient Outcomes
Because evidence suggests that drug testing assists with monitoring adherence and abstinence in treatment and can improve patient outcomes, drug testing should be used widely in addiction treatment settings.
Drug Testing and Evidence-Based Therapy
Contingency management is the most extensively researched behavioral therapy used in conjunction with drug testing. When utilizing contingency management therapy to encourage abstinence, providers should consider incorporating drug testing.
Clinical Use of Drug Testing
Therapeutic Tool
Drug testing is recommended as a therapeutic tool as part of evidence-based addiction treatment.
Providers should utilize drug testing to explore denial, motivation, and actual substance use behaviors with patients.
If drug testing results contradict self-reports of use, therapeutic discussions should take place.
Providers should present drug testing to patients as a way of providing motivation and reinforcement for abstinence.
Providers should educate patients as to the therapeutic purpose of drug testing. To the extent possible, persuade patients that drug testing is therapeutic rather than punitive to avoid an “us versus them” mentality.
If a patient refuses a drug test, the refusal itself should be an area of focus in the patient's treatment plan.
Assessment
Treatment providers should include drug testing at intake to assist in a patient's initial assessment and treatment planning.
Results of a medical and psychosocial assessment should guide the process of choosing the type of drug test and matrix to use for assessment purposes.
Drug test results should not be used as the sole determinant in assessment for a substance use disorder (SUD). They should always be combined with patient history, psychosocial assessment, and a physical exam.
Drug testing may be used to help determine optimal placement in a level of care.
Drug testing can serve as an objective means of verifying a patient's substance use history.
Drug testing can demonstrate a discrepancy between a patient's self-report of substance use and the substances detected in testing.
For a patient presenting with altered mental status, a negative drug test result may support differentiation between intoxication and/or presence of an underlying psychiatric and/or medical condition that should be addressed in treatment planning.
Drug testing can be helpful if a provider is required to document a patient's current substance use.
Monitoring
Drug testing should be used to monitor recent substance use in all addiction treatment settings.
Drug testing should be only one of several methods of detecting substance use or monitoring treatment. Test results should be interpreted in the context of collateral and self-report and other indicators.
Part 2: Process of Drug Testing in Addiction Treatment
Choosing a Test
Clinical Necessity and Value
Before choosing the type of test and matrix, providers should determine the questions they are seeking to answer and familiarize themselves with the benefits and limitations of each test and matrix.
Test selections should be individualized based on specific patients and clinical scenarios.
- Patients’ self-reported substance use can help guide test selection.
Identifying Substance(s) of Interest
Drug testing panels should be based on the patient's drug of choice, prescribed medications, and drugs commonly used in the patient's geographic location and peer group.
Addiction treatment programs/providers should establish a routine immunoassay panel.
Providers should not rely on the NIDA 5 (also known as the SAMHSA 5) as a routine drug panel.
Test panels should be regularly updated based on changes in local and national substance use trends. Providers should collaborate with the testing laboratory when determining the preferred test selections to obtain information about local and demographic trends in substance use.
Matrix Advantages and Disadvantages
Providers should understand the advantages and disadvantages of each matrix before considering rotational strategies.
If a particular specimen cannot be collected (e.g. due to baldness, dry mouth, shy bladder), providers should consider collecting an alternative specimen.
If a given sample is likely to be prone to confounds, providers should choose an alternative matrix. For example, heavily chemically treated hair is not appropriate for drug testing.
Presumptive and Definitive Tests
Presumptive testing should be a routine part of initial and ongoing patient assessment.
Presumptive testing should be used when it is a priority to have more immediate (although less accurate) results.
Providers should know the cutoff threshold concentrations that their laboratory uses when interpreting a report of “no drug present.”
Federal cutoff threshold concentrations used for occupational testing are not appropriate for clinical use.
Definitive testing techniques should be used whenever a provider wants to detect specific substances not identified by presumptive methods, quantify levels of the substance present, and refine the accuracy of the results.
Definitive testing should be used when the results inform clinical decisions with major clinical or non-clinical implications for the patient (e.g., treatment transition, changes in medication therapies, changes in legal status).
If a patient disputes the findings of a presumptive test, a definitive test should be done.
When ordering a definitive test, providers should advise the testing laboratory if the presence of any particular substance or group of substances is suspected or expected.
Because not all laboratories automatically perform a definitive test on positive presumptive results (the common term for this is “reflex” testing), providers should be aware that laboratories may require a specific order for definitive testing.
Cost
Providers should always consider cost both to patients and insurers when utilizing drug testing.
Responding to Test Results
Providers should attach a meaningful therapeutic response to test results, both positive and negative, and deliver it to patients as quickly as possible.
Providers should not take a confrontational approach to discussing positive test results with patients.
Providers should be aware that immediate abstinence may not be a realistic goal for patients early in treatment.
When making patient care decisions, providers should consider all relevant factors surrounding a case rather than make a decision based solely on the results of a drug test. Considering all relevant factors is particularly important when using drug test results to help make irreversible patient care decisions.
Unclear Test Results
Providers should contact the testing laboratory if they have any questions about interpreting a test result or to request information about the laboratory procedures that were used.
Providers may consult with a medical toxicologist or a certified Medical Review Officer (MRO) for assistance in interpreting drug test results.
If the provider suspects the test results are inaccurate, he or she should consider repeating the test, changing the test method, changing/adding to the test panel, adding specimen validity testing, or using a different matrix.
If tampering is suspected, samples should not be discarded. Rather, further testing should be performed to help identify whether and how tampering occurred.
Providers should consider samples that have been tampered with to be presumptive positive.
Presumptive Test Results
Positive presumptive test results should be viewed as ‘presumptive positive’ results until confirmed by an independent chemical technique such as Gas Chromatography–Mass Spectrometry (GC-MS) or Liquid Chromatography–Mass Spectrometry (LC-MS).
An appropriate response to positive presumptive test results includes speaking with the patient.
Providers should seek definitive testing if the patient denies substance use.
Providers should review all medications, herbal products, foods, and other potential causes of positive results with the patient.
An appropriate response to positive presumptive test results may include speaking with the laboratory for assistance in interpreting the test results.
Because presumptive tests may use cutoff values, a negative presumptive test result should not be over-interpreted. It does not rule out substance use or SUD, as the latter is a clinical diagnosis.
It is appropriate to consider ordering a definitive test if presumptive test results are negative, but the patient exhibits signs of relapse.
Definitive Test Results
In the event of a positive definitive test result, consider intensifying treatment or adding adjunctive treatments.
An appropriate response to positive definitive test results may include speaking with the laboratory for assistance in interpretation.
Providers should use caution when using drug test results to interpret a patient’s amount or frequency of substance use. Individual metabolism and variability in absorption should be considered.
Providers should not over-interpret a negative definitive test result. It does not rule out substance use or SUD, as the latter is a clinical diagnosis.
Test Scheduling
Note: See Part 5 for testing frequency in specific settings
Test Frequency
For people in addiction treatment, frequency of testing should be dictated by patient acuity and level of care.
Providers should look to tests’ detection capabilities and windows of detection (see pages 29–35) to determine the frequency of testing.
Providers should understand that increasing the frequency of testing increases the likelihood of detection of substance use, but there is insufficient evidence that increasing the frequency of drug testing has an effect on substance use itself.
Drug testing should be scheduled more frequently at the beginning of treatment and decreased as recovery progresses.
During the initial phase of treatment,
drug testing should be done at least weekly.
When possible, testing should occur on a random schedule.
When a patient is stable in treatment,
drug testing should be done at least monthly.
Individual consideration may be given for less frequent testing if a patient is in stable recovery.
When possible, testing should occur on a random schedule.
Random Testing
Random unannounced drug tests are preferred to scheduled drug tests.
A random-interval schedule is preferable to a fixed-interval schedule because it eliminates known non-testing periods (for example, if Monday is randomly selected from a week interval, the patient knows they will not be tested Tuesday-Saturday), and it is preferable to a truly random schedule because it limits the maximum number of days between tests.
Table 1. Terms Often Used Imprecisely to Refer to Presumptive and Definitive Tests
| Presumptive | Definitive |
|---|---|
| Qualitative | Quantitative |
| Preliminary | Confirmatory |
| Immunoassay | Chromatography/mass-spectrometry |
| Point of care/in-office/lab-based | In-office/lab-based |
| Screen | Confirmation |
| Semi-quantitative/quasi-quantitative | Absolute level/creatinine-corrected |
| Simple (cup/strip/dipstick/cassette) | Complex |
| Class or category test | Specific drug identification |
Part 3: Additional Considerations for Drug Testing in Addiction Treatment
Documentation and Confidentiality
Addiction treatment programs should provide written drug testing procedures to patients. Procedures should be reviewed with the patient at the start of his or her treatment.
Providers should document the rationale for the drug tests they order and the clinical decisions that are based upon drug test results.
Providers should ask patients about and document potential sources of cross-reactivity, including various foods and current medications.
Particular characteristics of a sample with the potential to lead to problems with interpretation (e.g., hair that has been chemically treated) should be documented at the time of collection.
Test results should be documented.
Test results should be kept confidential to the extent permitted by law.
Providers should thoroughly explain to patients all rules regarding confidentiality, consent, and sharing test results with outside entities.
In general, providers should use caution when sharing test results with outside entities such as justice settings or employers. When sharing test results with outside entities, it is optimal that positive results be verified with a definitive test.
Practitioner Education and Expertise
Knowledge and Proficiency
Providers responsible for ordering tests should be familiar with the limitations of presumptive and definitive testing.
Providers responsible for ordering tests should be familiar with the potential for cross-reactivity in drug testing.
Providers responsible for ordering tests should consider the possible impact of tampering on test results. Providers should note that tampering is more likely in settings where consequences for substance use are severe, such as discharge from treatment.
Providers responsible for ordering tests should understand the potential benefits and limitations of alternative matrices to urine (e.g., oral fluid, hair, etc.).
If the provider responsible for making clinical decisions based on test results does not have training in toxicology, he or she should collaborate with a medical toxicologist, a toxicologist from the testing laboratory, or an individual with MRO certification, as needed.
Language and Attitude
Providers should communicate with patients about drug testing using non-stigmatizing language. For example, results should be discussed as "positive" or "negative" as opposed to "clean" or "dirty."
Providers should exhibit a consistent and positive attitude toward drug testing. Ambivalent attitudes toward drug testing among staff can be a barrier to its effective use.
Table 2. Potential False Positive Sources
| Cocaine | Typically no cross-reactive substances with modern testing. |
|---|---|
| Opiates | Typically no cross-reactive substances with modern testing. Note that many opioids are not detected by standard opiate assay and need separate screens (oxycodone, methadone, fentanyl, tramadol, tapentadol, buprenorphine, oxymorphone, other synthetic/designer opioids). Note poppy seed ingestion from dietary sources (bagels, pastries) may result in both codeine and morphine (opiate) detection in the urine although not when the higher cutoff of 2000 ng/mL is utilized. |
| THC | Very limited potential for any false positives with modern screens. |
| BZD | Sertraline is cross-reactive with the clonazepam assay. Clonazepam and lorazepam may not be detected with certain benzodiazepine POC assays. These benzodiazepines may require definitive testing or specific assays targeted to these benzodiazepines for sensitive detection. |
| Amphetamine/Methamphetamine | Bupropion, pseudoephedrine/ephedrine. Note that methylphenidate is not detected via amphetamine assays but targeted analysis is available from many labs. |
| PCP | Dextromethorphan. |
Test Facilities and Devices
Point of Care Tests (POCTs)
Staff training and demonstrated proficiency is particularly important for organizations that use point of care tests.
Cost issues should be considered when deciding to initiate a POCT protocol. These include costs associated with additional staff time and training, space to perform testing, quality assurance procedures, and documentation of POCT results.
Providers performing POCTs should be evaluated for their proficiency.
POCTs should be performed only by providers who demonstrate adequate proficiency with the drug test in question.
Facilities using POCTs should periodically evaluate the accuracy of their system in comparison to a qualified laboratory.
Users of POCT devices need to be educated about the tests.
They need to understand the statistical and analytical sensitivity of the device.
They need to understand the spectrum of analytes (drugs and metabolites) detected by the device.
They need to understand any known interferences from drugs or metabolites that could affect interpretation of results.
They need to understand the nomenclature of the device.
Users of POCTs should refer to the POC package insert and/or the manufacturer to determine the device's capabilities.
Choosing a Laboratory
Providers should seek to work with a laboratory that has expertise in drug testing in addiction treatment settings.
When selecting a laboratory, providers should investigate whether state law requires a specific certification.
It is important to work with a laboratory qualified to perform accurate tests and assist in the interpretation of results.
Providers should work to create a collaborative relationship with the laboratory. Important areas for collaboration are test panel selection, detecting sample tampering, interpreting test results, and regional drug use trends.
When selecting a laboratory, providers should contact the toxicology director or a medical toxicologist at the laboratory to discuss panels, types of drug tests, testing procedures, and technical assistance.
Because drug testing should be individualized, laboratories should allow providers to order specific tests for each patient.
Part 4: Biological Matrices
Table 3. General Windows of Detection Across Matrices (from SAMHSA’s TAP 32)
| Minutes | Hours | Days | Weeks | Months | |
|---|---|---|---|---|---|
| Blood | |||||
| Breath | |||||
| Oral Fluid | |||||
| Urine | |||||
| Sweat | |||||
| Hair |
Table 4. Components of Urine Specimen Validity Testing
| Characteristic | Description |
|---|---|
| Creatinine | Creatinine is the product of muscle metabolism and is produced at a fairly constant rate by the body. Creatinine is used clinically as an indicator of renal health, with very high or very low concentrations indicating abnormal kidney function as in Diabetes Insipidus. Creatinine will be very low if an individual has over-hydrated, and very high concentrations can result from the use of some adulterants. SAMHSA has set criteria for normal creatinine concentrations in urine, with <20 mg/dL indicating a dilute sample. This limit is meant to screen out probable instances of attempted tampering among the general workplace population. Creatinine concentrations can be used to normalize drug concentrations if practitioners want to continue with definitive testing of a dilute sample. |
| Specific gravity | Specific gravity is a measure of the concentration of dissolved particles in a liquid by comparing its density to the density of water. The specific gravity of normal human urine is between 1.003 and 1.030. While a urine specific gravity of 1.000 is essentially water and suggest dilution, higher specific gravity values can indicate that an adulterant has been added to a sample. Most sources recommend that specific gravity need only be checked if creatinine is <20 mg/dL. |
| pH | pH is a measure of acid-base status and ranges between 4.5 and 8.0 in urine. It greatly affects the concentration and stability of some drug and drug metabolites in urine and therefore the likelihood that they will be detected. The pH of the sample may influence the enzymatic action and performance of immunoassay screens. Abnormal pH can indicate that a sample is dilute or adulterated. Bleach, acid, soap, detergent and vinegar all alter pH to outside the normal human range. Abnormal pH can also be the result of a kidney or urinary tract infection as well as diets extremely high in protein or low in carbohydrates. |
| Immunoglobulin (IgG) | IgG is the most common antibody in the bloodstream. Concentrations <0.5 µg/ml suggest that a sample was substituted with synthetic or animal urine. While IgG is discussed in the literature and is available as part of a specimen validity test at many lab facilities, the expert panel had mixed opinions regarding the appropriateness of its inclusion in specimen validity testing, with some commenting that it was not commonly used in their practice. |
| Adulterants | Testing for the presence of adulterants such as glutaraldehyde, pyridium chlorochromate and nitrites can be done on-site or in a laboratory. However, not all adulterants can be detected in standard adulterant test, including Visine eye drops and newer adulterants such as Urine Luck, UrinAid, Klear, and Whizzies. |
Urine
Use of Urine Drug Testing (UDT) in Addiction Treatment
Urine should be considered the most well-established and well-supported biological matrix for presumptive detection of substance use in a clinical setting.
Urine should be considered the best established matrix for POCTs.
If tampering is of high concern or appropriate measures to reduce the likelihood of tampering cannot be taken, providers should consider using an alternative specimen type.
Urine Sample Integrity
Urine should be considered the matrix most prone to sample tampering through dilution, adulteration and substitution.
Providers should choose collection methods that protect patients' dignity and privacy while minimizing opportunities for tampering.
Observed sample collection can deter urine sample tampering. If there are concerns about tampering, collection should be observed by a same-gender staff member.
Observed urine sample collection does not completely prevent sample tampering. Providers should consider other strategies to mitigate urine sample tampering.
Providers should consider the use of an unobtrusive sample collection method for patients with a history of psychological trauma, especially sexual trauma.
Providers should employ appropriate measures in the facility where patients provide specimens to decrease the likelihood of urine sample tampering during unobserved collection.
- Do not allow personal items in the collection area.
- Ensure that potential adulterants, such as soap, ammonia, or bleach are not readily available in the collection area.
- Consider placing blue dye in the toilet and turn off the water source to the collection area during collection.
If a provider suspects that a patient has engaged in substance use but continues to produce negative urine test results, sample collection should be observed and specimen validity testing should be conducted.
If a sample is suspected of having been tampered with, it should be tested for specimen validity including creatinine concentration, pH level, specific gravity and adulterants.
All samples undergoing definitive testing should be tested for creatinine concentration, pH level and specific gravity (if creatinine is low).
Signs of Urine Sample Tampering
All urine samples should be checked for unusual specimen characteristics. Characteristics include:
- Temperature outside the expected range of 90–100°F within 4 minutes of production (This can be checked using a heat sensitive strip).
- Unusual color or smell, soapy appearance, cloudiness or particles floating in the liquid.
If a urine sample exhibits unusual specimen characteristics, the sample should undergo specimen validity testing to help identify whether and how tampering occurred.
Responding to Specimen Validity Test Results
Providers should consider samples that have been tampered with to be presumptive positive.
For patients with past incidences of dilute urine samples, it is advisable to collect samples in the morning or request that patients decrease water intake prior to sample collection.
For patients with past incidences of dilute urine samples, use creative solutions, such as collecting before work, on days off, or use an alternative matrix.
Urine Testing for Specific Substances
Urine testing for the use of alcohol is appropriate with current clinical tools.
Ethyl glucuronide (EtG) is an appropriate target metabolite when monitoring a patient for complete alcohol abstinence.
Ethanol-containing products, including hand sanitizers and mouthwash, should be avoided before an EtG test.
Urine testing is helpful when assessing amphetamine use. Particular caution should be paid to the interpretation of amphetamine immunoassays due to known limitations in specificity.
Urine testing is helpful when assessing benzodiazepine use.
Particular caution should be paid to the interpretation of benzodiazepine immunoassays due to known limitations in specificity.
Immunoassay results should be used cautiously when monitoring a patient’s adherence to prescribed benzodiazepines. If a patient reports that he or she is taking the drug but a urine drug screen is negative, further analysis using definitive testing should be considered.
Urine testing is helpful when assessing opioid use.
Particular caution should be paid to the interpretation of opiate immunoassays due to known limitations in specificity.
Patients should be instructed to avoid the consumption of food items that contain poppy seeds because they can result in a positive opiate test.
Urine testing is helpful when assessing cannabis use, although it is difficult to determine the timing or cessation of consumption in chronic users due to extended windows of detection for THC.
Blood
The relevance of blood testing in addiction treatment is limited mostly to emergency situations where there is a need to assess intoxication or impairment.
Breath
No statements about the appropriateness of breath testing were endorsed by the Expert Panel.
Oral Fluid
Oral fluid testing is appropriate for presumptive detection of substance use in addiction treatment settings.
Oral fluid collection with a device that facilitates saliva collection is preferable to expectoration.
The creation of a sample for oral fluid testing should be observed.
It is recommended that patients abstain from eating for 15–60 minutes prior to oral fluid sample collection.
If a patient recently took a drug by mouth (ingestion or inhalation), it is recommended to wait ≥2 hours before collecting an oral fluid sample.
Sweat
There is insufficient evidence to support the use of sweat testing in addiction treatment. More research is needed before sweat testing can be recommended over urine testing in clinical settings.
Hair
Hair testing in addiction treatment can detect long-term patterns of use. Routine use of hair testing is not appropriate for addiction treatment.
Part 5: Settings
Outpatient Services and Intensive Outpatient/ Partial Hospitalization Services
Because the opportunity for substance use is greater in outpatient treatment than in more intensive levels of care, drug testing has a particularly important role in monitoring substance use.
Providers should implement a random unannounced schedule of testing in outpatient services whenever possible, because the patient’s opportunity for substance use is greater relative to residential treatment.
Drug testing should be scheduled on days following weekends, holidays and paydays when feasible.
Providers should communicate with patients about plans for additional drug tests around events/special occasions.
Additional drug testing should be considered if a patient is experiencing stressful psychological events.
Residential/Inpatient and Medically-Managed Intensive Inpatient Services
Drug testing plays an important role in maintaining a drug-free therapeutic environment in residential treatment.
When residents leave the treatment program on passes, they should be asked to provide a sample for drug testing shortly after their return.
Providers should communicate with patients about plans for additional drug testing following their return.
Opioid Treatment Services (OTS)
The primary purposes of drug testing in the context of OTS are:
Drug testing has potential application across all stages of OTS including pre-induction assessment and treatment planning, active treatment, and during maintenance and recovery.
- detecting substance use that could complicate treatment response and patient management;
- monitoring adherence with the prescribed medication; and
- monitoring possible diversion.
Drug testing has potential application across all stages of OTS including pre-induction assessment and treatment planning, active treatment, and during maintenance and recovery.
Providers should utilize drug testing during the assessment phase and throughout treatment.
Providers should utilize drug testing as an aspect of contingency management in OTS.
Provider education should include knowledge of the metabolic pathways of commonly prescribed opioids.
Testing Schedule
Drug testing frequency is determined by stage of treatment as well as other patient factors and should be individualized.
Testing should be more frequent during the stabilization period, and less frequent during the maintenance period.
Drug testing during and after tapering from methadone or buprenorphine continues to be an important way to support a patient’s recovery. Providers may want to consider increasing drug testing frequency during tapering and in the period after tapering.
Responding to Test Results
Expected drug test results (i.e., positive for prescribed medication and negative for unexpected substances) should be praised and responded to with tangible contingencies such as take-home doses of medication.
High concentration of a parent drug in the absence of its metabolites is consistent with sample tampering in the form of post-collection addition of the drug to the sample and potential diversion. In this case, a follow-up assessment should be conducted with the patient.
A test that is negative for the prescribed medication (e.g., negative for buprenorphine in a patient prescribed buprenorphine) should not be used on its own to determine that diversion is occurring. However, the cause of the test results should still be explored with the patient. Potential scenarios include but are not limited to overuse of medication, incorrect drug test used, or an unfulfilled prescription.
Unexpected drug test results could indicate the need for one or more of the following responses:
- a higher level of care
- a higher dose of medication
- a different schedule of testing, such as random rather than scheduled and/or more frequent; and/or increased education for the patient.
Considerations for OTP Settings
For patients in OTP settings, the federally mandated “eight tests per year” should be seen as a minimum, and it is often appropriate to perform testing more frequently than eight times per year. Determinations about testing frequency and duration should be made with consideration of individual patients, as noted above.
For patients in OTP settings, provider response to unexpected test results can include discontinuation or reduction of take home doses of medication, more frequent or random schedule of drug testing, and increased counseling and peer group sessions
Considerations for Office-Based Opioid Treatment (OBOT) Settings
For patients in OBOT settings, the drug test panel should include the therapeutic drug and/or its metabolites.
In addition to drug testing, diversion can be reduced or prevented by frequent office visits, Prescription Monitoring Programs, observed dosing, and medication counts.
In order to provide buprenorphine or naltrexone treatment, providers must have access to drug testing laboratories.
Frequency of drug testing in buprenorphine treatment should be at least monthly, unless otherwise clinically indicated (e.g., patients who have become stable in recovery may require less frequent testing).
Drug testing (and negative test result for opioids) is indicated before starting treatment of opioid use disorder using naltrexone. Drug testing also is indicated throughout treatment using naltrexone.
Frequency of drug testing in treatment of opioid use disorder using naltrexone should be at least monthly, unless otherwise clinically indicated.
Recovery Residences
Weekly random drug testing is appropriate in a recovery residence.
Any patient expelled from a recovery residence should be able to continue an ongoing therapeutic relationship with his or her outpatient addiction treatment provider.
Part 6: Special Populations
Adolescents
When to Test Adolescents
Use drug testing to assist in early identification of substance use in high-risk populations of adolescents including but not limited to those with known past substance use and those in treatment for mental health disorders.
Drug testing to monitor adolescents in addiction treatment or recovery from an SUD can be performed by providers in primary care.
When an adult observes symptoms characteristic of substance use in an adolescent, providers should use drug testing as part of an assessment for a possible addiction.
Adolescents and Self-reported Substance Use
Even if an adolescent reports substance use, providers should consider drug testing for additional information because adolescents are less likely to self-report accurately.
Adolescents and Home Testing Kits
Because of a variety of limitations with home drug testing process and interpretation, providers should not encourage the use of home drug testing for adolescents.
Adolescent Consent
Before beginning the drug testing process with an adolescent, providers should explain drug testing protocols in full.
Drug testing an adolescent without his or her consent is not appropriate, except in emergency situations (e.g., accidents, suicide attempts, and seizures).
Providers should acquire consent before drug testing an adolescent with symptoms such as school failure, fatigue, or excessive moodiness. Because these are not emergency situations, they are not hazardous enough to warrant skipping this step.
If an adolescent refuses to consent to a drug test, the provider should clearly document refusal and continue to evaluate the possibility of SUD through other methods and refer the patient to a specialist with additional mental health or substance use expertise.
Adolescent Confidentiality
Before beginning the drug testing process, providers should ask the adolescent for permission to share the results with parents/guardians and discuss confidentiality with parents/guardians in order to encourage parental involvement.
If an adolescent declines to share drug test results, the provider should not share them unless there is an acute risk of harm to the patient or others.
Choosing a Test Panel for Adolescent Patients
Drug test panels for adolescents should include the substances most used by the demographic.
Responding to Positive Test Results
If a positive definitive drug test result indicates that an adolescent is engaging in high-risk substance use, the provider should assist the patient and his or her parent or guardian in developing a plan for monitoring and treatment.
Pregnant Patients
Consequences and Confidentiality
Providers should be aware of the adverse legal and social consequences of detecting substance use among pregnant women. They should familiarize themselves with local and state reporting requirements before conducting a drug test and relay this information to their patient before conducting a drug test.
Screening, Assessment, and Monitoring
Comprehensive substance use assessment, which may include drug testing, is part of obstetrical best practices. Providers working with this population should learn about and appropriately use clinical laboratory tests.
For a pregnant patient with a history of addiction, providers should be aware that the postpartum period is a time of increased vulnerability. Therefore, assessment for relapse, which may include drug testing, should be part of the postpartum visit.
Providers should keep drug test results and associated diagnoses confidential to the extent permitted by law.
Patient-provider Relationship
When speaking with patients, providers should emphasize the therapeutic reasons for drug testing to avoid stigmatization.
Table 5. State Policies on Substance Use During Pregnancy
a The Alabama Supreme Court held that drug use while pregnant is considered chemical endangerment of a child. The South Carolina Supreme Court held that a viable fetus is a "person" under the state's criminal child-endangerment statute and that "maternal acts endangering or likely to endanger the life, comfort, or health of a viable fetus" constitute criminal child abuse.
b Indiana law prohibits a medical provider from releasing information about a pregnant woman's drug or alcohol test without her consent.
c Priority applies to pregnant women referred for treatment.
d Establishes requirements for health care providers to encourage and facilitate drug counseling.
e Missouri child abuse law considers a parent to be unfit if the woman tests positive for substances within 8 hours after delivery and she has previously been convicted of child abuse or neglect or if she failed to complete a drug treatment program recommended by Child Protective Services.
f West Virginia substance use providers that accept Medicaid must give pregnant women priority in accessing services.
g Wisconsin provides priority access to pregnant women in both general and private programs.
b Indiana law prohibits a medical provider from releasing information about a pregnant woman's drug or alcohol test without her consent.
c Priority applies to pregnant women referred for treatment.
d Establishes requirements for health care providers to encourage and facilitate drug counseling.
e Missouri child abuse law considers a parent to be unfit if the woman tests positive for substances within 8 hours after delivery and she has previously been convicted of child abuse or neglect or if she failed to complete a drug treatment program recommended by Child Protective Services.
f West Virginia substance use providers that accept Medicaid must give pregnant women priority in accessing services.
g Wisconsin provides priority access to pregnant women in both general and private programs.
State policies current as of May 1, 2017.
Guttmacher Institute. Substance Abuse During Pregnancy. 2017. Available at: https://www.guttmacher.org/state-policy/explore/substance-abuse-during-pregnancy
Test Considerations
In a prenatal care setting, routine Screening and Brief Intervention (SBI) for alcohol use should be conducted.
Laboratory testing for alcohol use is not recommended except in cases of suspected or known risk factors for Alcohol Use Disorder (AUD).
Since pregnant women who use substances are less willing to disclose use of opioids and benzodiazepines than other substances, testing for opioids and benzodiazepines helps identify an often underreported behavior.
Urine is an appropriate matrix for drug testing women who are pregnant.
Test Results
As a follow up to a presumptive positive test result, providers should use definitive tests to clearly identify individual drugs.
Responses to positive drug test results can include: patient education, referral to treatment, and the creation of a treatment plan.
Providers should be familiar with local treatment resources and programs for pregnant women.
People in Recovery
It is appropriate to conduct drug testing for a minimum of five years in healthcare settings for most patients in stable recovery. The frequency of drug testing for patients in stable recovery should depend on the severity and chronicity of the patient's addiction.
It is appropriate for patients in stable recovery to receive periodic Recovery Management Checkups that include a drug testing component.
Immediate evaluation for treatment or treatment intensification as a response to a positive drug test result is appropriate for most patients in stable recovery.
Health and Other Professionals
Drug testing is especially useful in supporting recovery of individuals who have increased access to psychoactive substances, including healthcare professionals and professionals in safety sensitive positions. Additional testing should be considered for those in recovery who have significant occupational exposure to addictive substances.
Table 6. Physicians Health Programs
| Scope |
|---|
|
| Approach |
|
| Monitoring |
|
| Drug Testing Protocol |
|
| Responding to a Positive Result |
|
Windows of Detection Table
Table 7. Windows of Detection Table
Alcohol
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| EtOH | 10–12 hours [NS 1 ] | 24 hours [NS] | |
| EtG | 1–2 days [500] (one drink) | ||
| EtS | 1–2 days [100] (one drink) | ||
| PEth | 1–2 weeks [NS] (heavy use) |
Cocaine
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Cocaine | Up to 24 hours [50] | 5–12 hours [1] (single use) 8–48 hours [1] (chronic use) | 12 hours [10] |
| BZE |
|
| 2 days [10] |
Amphetamines
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Amphetamine |
|
| 2 days [4] |
Methamphetamine
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
|
| |
| Amphetamine | 2–4 days [1000; 200] | 24 hours [50; 2.5] | |
| Methamphetamine |
| 24 hours [2.5] | 2 days [3] |
MDMA (Ecstasy)
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
| ||
| MDMA | 2 days [20] | 24 hours [125] | 24 hours [20] |
Opiates
Morphine
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
|
|
Codeine
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
|
| |
| Morphine | 1–3 days [300; 300] |
Oxymorphone
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Formulation Not Specified Analyte Not Specified | 3 days [25] | ||
| Immediate-release Analyte Not Specified | 36–60 hours [100] | ||
| Extended-release Analyte Not Specified | 1–4 days [100] |
Oxycodone
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Formulation Not Specified Analyte Not Specified |
| ||
| Immediate-release Analyte Not Specified | 1–1.5 days [100] | ||
| Extended-release Analyte Not Specified | 1.5–3 days [100] |
Hydromorphone
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
| 6 hours [1] (single use) |
Hydrocodone
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
|
Fentanyl
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
|
Heroin
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| 6-MAM (Indicates heroin use) | 2–8 hours (single use) 2 [10] Up to 24 hours (chronic use) 2 [10] |
| |
| Morphine |
|
| 20 hours [1] |
Methadone
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified | 3–11 days [300] (maintenance dose) |
| |
| Methadone |
| 24 hours [20] | |
| EDDP | 7 days [100] |
Buprenorphine
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified | 4 days [0.5] | ||
| Buprenorphine | 7 days [0.5] | 5 days [1] | |
| Norbuprenorphine | 7 days [0.5] |
Benzodiazepines
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Short Acting Analyte Not Specified |
| ||
| Intermediate Acting Analyte Not Specified |
| ||
| Long Acting Analyte Not Specified | 30 days [200; 200] |
Diazepam
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
|
| |
| Nordiazepam |
|
Barbiturates
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Formulation Not Specified Analyte Not Specified | 1–2 days [20] | ||
| Short Acting Analyte Not Specified |
|
Pentobarbital, Secobarbital
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified | 3 days [100] | ||
| Intermediate Acting Analyte Not Specified | 3–8 days [300] | ||
| Amobarbital Analyte Not Specified | 3 days [100] |
Butalbital
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified | 7 days [100] | ||
| Long Acting Analyte Not Specified |
| ||
| Phenobaribital Analyte Not Specified | 15 days [100] |
Cannabis
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| THC |
|
| 5 hours [10] |
| THCCOOH |
|
| 36 hours [10] |
Phencyclidine
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified |
| 1–2 days [1] |
LSD
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified | 36 hours [0.2] | ||
| LSD | 24 hours [0.5] | ||
| O-H-LSD | 5 days [5] |
GHB
| Drug / Target Analyte | Detection Time in Urine [cutoff (ng/mL) initial; confirm] | Detection Time in Oral Fluid [cutoff (ng/mL) initial; confirm] | Detection Time in Blood [cutoff (ng/mL)] |
|---|---|---|---|
| Analyte Not Specified | 12 hours [10,000] | 5 hours [4,000] | 5 hours [4,000] |
1 Not stated
2 Cone EJ, et al. Forensic Drug testing for opiates: 1. Detection of 6-acetylmorphine in urine as an indicator of recent heroin exposure; drug and assay considerations and detection times. J Analytical Toxicology. 1991 Jan-Feb 15(1): 1-7.
2 Cone EJ, et al. Forensic Drug testing for opiates: 1. Detection of 6-acetylmorphine in urine as an indicator of recent heroin exposure; drug and assay considerations and detection times. J Analytical Toxicology. 1991 Jan-Feb 15(1): 1-7.
Abbreviations
- 6-MAM
- 6-monoacetylmorphine
- AAP
- American Academy of Pediatrics
- ACOG
- American Congress of Obstetricians and Gynecologists
- ASAM
- American Society of Addiction Medicine
- BZE
- benzoylecgonine
- CLIA
- Clinical Laboratory Improvement Amendments
- EtG
- ethyl glucuronide
- EtOH
- ethyl alcohol or ethanol
- EtS
- ethyl sulfate
- MRO
- Medical Review Officer
- NIDA
- National Institute on Drug Abuse
- OBOT
- Office-Based Opioid Treatment
- OTP
- Opioid Treatment Program
- OTS
- opioid treatment services
- PCP
- phencyclidine
- PHP
- Physician Health Program
- POCT
- point of care testing
- RAM
- RAND/UCLA Appropriateness Method
- SAMHSA
- Substance Abuse and Mental Health Services Administration
- SBI
- Screening and Brief Intervention
- SBIRT
- Screening, Brief Intervention, and Referral to Treatment
- SUD
- substance use disorder
- UDT
- urine drug testing
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
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