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:
- 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.
- Unlike clinical practice guidelines, which typically focus on disease-specific treatment recommendations, this pocket guide focuses on recommendations for where, when, and how often a drug test should be performed.
- 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
- 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.
- 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.
- 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.
- 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.
Note: See Part 5 for testing frequency in specific settings
- 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 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
|Point of care/in-office/lab-based||In-office/lab-based|
|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.).
- Providers responsible for ordering tests should be aware of the costs of different test methods.
- 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
- Typically no cross-reactive substances with modern testing.
- 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.
- Very limited potential for any false positives with modern screens.
- 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.
- Bupropion, pseudoephedrine/ephedrine. Note that methylphenidate is not detected via amphetamine assays but targeted analysis is available from many labs.
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.
- 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 POCT devices need to be educated about the tests.
- Users of POCTs should refer to the POC package insert and/or the manufacturer to determine the device's capabilities.
- 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.
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.