what is the method drug users use to pass drug test?

Child Adolesc Psychiatr Clin N Am. Author manuscript; available in PMC 2017 Jul ane.

Published in final edited form as:

PMCID: PMC4920965

NIHMSID: NIHMS764832

OBJECTIVE TESTING – URINE AND OTHER DRUG TESTS

Scott E. Hadland

¹Boston Children'south Infirmary, Division of Adolescent / Immature Adult Medicine, Boston Children's Hospital, Division of Developmental Medicine, Section of Medicine, 300 Longwood Avenue, Boston, MA, USA, 02115

³Harvard Medical Schoolhouse, Department of Pediatrics, 25 Shattuck St., Boston, MA, USA, 02115

Sharon Levy

²Department of Medicine, 300 Longwood Avenue, Boston, MA, United states, 02115

³Harvard Medical Schoolhouse, Department of Pediatrics, 25 Shattuck St., Boston, MA, USA, 02115

Abstract

Drug testing, when carefully nerveless and thoughtfully interpreted, offers a critical adjunct to clinical care and substance use treatment. Yet, considering test results tin be misleading if not interpreted in the correct clinical context, clinicians should always conduct a conscientious interview with boyish patients to empathise what testing is probable to show and then use testing to validate or abnegate their expectations. Due to the ease with which samples can be tampered, providers should also advisedly reverberate on their own collection protocols and sample validation procedures to ensure optimal accuracy.

Keywords: Substance abuse detection, adolescents, substance-related disorders, ethanol, street drugs, urine

It is incumbent on clinicians to detect substance use early on and intervene to reduce acute risks and to improve the life course trajectory of habit and its harms. For clinicians working with adolescents, screening for booze and drug use is a disquisitional skill that allows for brief intervention and referral to treatment, an approach endorsed by major professional bodies [1–three] including the American Academy of Pediatrics (AAP) [4]. Screening is best conducted using a validated instrument (such as the S2BI instrument [5]) that can and then prompt a discussion between the clinician and adolescent.

At first blush, routine screening of adolescents by testing urine or other actual fluids might seem like a reasonable strategy for detecting substance use, but this approach is fraught with inaccurate findings and misinterpretation, and worse, leads to mistrust on the part of the adolescent and missed opportunities for nuanced discussions nigh substance use with a clinician. Forbearance from all substances is recommended throughout boyhood because of the impact of alcohol, marijuana and other drugs on brain development [vi]. Routine drug testing of all adolescents, however, is insensitive for detecting sporadic use, and risks obscuring opportunities for counseling and cursory interventions that may be better identified by cocky-study [seven].

While routine laboratory testing is not recommended for adolescents at that place are several indications for which this procedure may provide useful data to supplement a clinical history or to regularly monitor patients in treatment for substance use disorders. Hither, we review drugs commonly included in testing panels, bodily fluids and tissues tested, indications for testing, practical concerns, and issues unique to drug testing adolescents as assorted with its employ in adults.

Drugs tested

Although it is possible to test for use of an individual drug, multiple drugs or classes are usually tested at the aforementioned fourth dimension using a single biological sample [8]. The most commonly used immunoassay (IA) drug exam panel includes the "SAMHSA-5", a standard panel established in the 1980s nether the Drug-Gratis Workplace Act. The SAMHSA-5 includes amphetamines, marijuana (tetrahydrocannabinol [THC]), cocaine metabolites, opiates (including heroin, morphine, and codeine, just not synthetic opioids such as oxycodone, hydrocodone, buprenorphine, or methadone), and phencyclidine (PCP) [8,ix]. Most drug screens available commercially have panels that expand beyond the SAMHSA-five to also include benzodiazepines, barbiturates, and boosted opiates [8].

Alcohol and drugs vary substantially in their windows of detection, largely owing to their degree of fat solubility. For example, THC and other highly fat-soluble compounds have a very long one-half-life of emptying and can be detected in urine up to weeks subsequently last use among heavy users). The various windows of detection for a number of ordinarily used substances are shown in Tabular array 1 [10].

TABLE ane

Windows of detection in urine for various substances.

Detection Windows past Drug Examination Type
Substance	Urine	Hair	Oral Fluid	Sweat
Alcohol	10-12 hours	Northward/A	Up to 24 hours	N/A
	EtG -- Upwards to 48 hours

Amphetamines	ii to 4 days	Upwardly to xc days	1-48 hours	seven-14 days

Methamphetamine	ii to v days	Up to xc days	ane-48 hours	vii-14 days

Barbiturates	Up to 7 days	Up to 90 days	North/A	N/A

Benzodiazepines	Up to seven days	Upwardly to xc days	Northward/A	Northward/A

Cannabis (Marijuana)	1-xxx days	Up to 90 days	Up to 24 hours	vii-xiv days

Cocaine	1 to B days	Upwardly to xc days	ane-36 hours	7-14 days

Codeine (Opiate)	2 to 4 days	Up to 90 days	1-36 hours	7-14 days

Morphine (Opiate)	2 to v days	Up to 90 days	1-36 hours	7-14 days

Heroin (Opiate)	2 to 3 days	Up to 90 days	ane-36 hours	vii-xiv days

PCP (Phencyclidine)	5 to 6 days	Upward to 90 days	N/A	7-14 days

Sources for testing

There are multiple sources for biologic specimens (often referred to as "biological matrices" in the scientific literature): urine, blood, saliva, pilus, breath, sweat, and meconium. These various tissues and bodily fluids exhibit different rates and durations of excretion that outcome in different detection windows for substances, equally demonstrated in Figure one.

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Drug detection times for different biologic specimens used in drug testing.

*Very broad estimates that besides depend on the substance, the corporeality and frequency of the substance taken, and other factors previously listed.

†Equally long as the patch is worn, usually 7 days.

‡7–ten days after use to the time passed to abound the length of pilus, just may exist limited to half-dozen months pilus growth. However, most laboratories analyze the corporeality of pilus equivalent to 3 months of growth.

When substances are ingested, they are absorbed in the gastrointestinal tract and distributed to tissues of the torso [9]. Substances that are injected, inhaled or snorted featherbed gastrointestinal absorption and are delivered immediately to tissues. Since many drugs are lipid soluble, they must undergo metabolism in the liver to render them water soluble which so allows them to be eliminated in urine. Claret and breath reflect moment-to-moment serum levels of an ingested substance, and offer the earliest and shortest windows of detection for substances [8]. Sweat and saliva reflect the presence of a drug inside the trunk several hours later. Urine offers a somewhat longer window of detection for substances, usually varying from one mean solar day after consumption to several weeks. Hair and meconium offer the longest windows of detection (weeks to months). Advantages and disadvantages of different matrices for drug testing are shown in Table ii.

TABLE 2

Advantages and disadvantages of diverse matrices (i.eastward., actual fluids and tissues) used for drug testing.

a
Matrix	Advantages	Disadvantages
Urine	Available in sufficient quantities Higher concentrations of parent drugs and/or metabolites than in blood Availability of point-of-care tests (POCTs) Well-researched testing techniques	Short to intermediate window of detection Easy to adulterate or substitute May require observed collection Some individuals feel "shy bladder" syndrome and cannot produce a specimen
Oral Fluid	Noninvasive specimen collection Piece of cake to collect Reduced chance of cariosity Directly observed specimen collection Parent drug rather than metabolite tin be the target of the analysis Able to detect same-mean solar day use, in some cases Availability of POCTs Detect residual drug in the rima oris	Limited specimen volume Possibility of contamination from residual drug in oral fissure that cannot be correlated with blood concentrations Short window of detection Requires supervision of patient for 10–30 minutes earlier sampling Salivation reduced by stimulant utilise Demand for elution solvent to efficiently remove drugs adsorbed to collection device Cannabinoids in oral fluid have been shown to arise from contamination of the oral crenel rather than excretion in saliva from blood
Sweat	Detects recent use (fewer than 24 hours with a sweat swipe) or allows for cumulative testing with the sweat patch (worn for upward to seven–xiv days) Noninvasive specimen drove Difficult to adulterate Requires little training to collect specimen May be an economical culling to urine	Few facilities and limited expertise for testing Risk of accidental or deliberate removal of the sweat patch collection device Unknown effects of variable sweat excretion among individuals Only a single sweat collection patch available so multiple analyses cannot exist washed if needed (i.e., more than i positive initial test) May be affected by external contaminants Requires 2 visits, 1 for patch placement and one for patch removal
Blood	Generally detects recent use Established laboratory test method	Expensive, except to discover ethanol Express window of detection Invasive specimen collection (venipuncture) Take chances of infection Requires training to collect specimen May not be an choice for private with poor venous access
b
Hair	Longest window of detection May be able to detect changes in drug use over time (from vii–10 days after drug use to three months, depending on length of pilus tested) Straight observed specimen drove Noninvasive specimen collection Four tests will comprehend i twelvemonth Easy storage and transport Difficult to adulterate or substitute Readily available sample, depending on ength of hair tested	Cannot detect apply within the previous seven–10 days Difficult to interpret results Plush and time consuming to gear up specimen for testing Few laboratories available to perform testing No POCTs currently available Hard to detect low-level employ (e.thousand., unmarried-use episode) May exist biased with hair color (dark hair contains more than of some basic drugs [cocaine, methamphetamine, opioids] due to enhanced binding to melanin in hair) Possibility of environmental contamination Specimen can be removed by shaving
Jiff	Well-established method for alcohol testing Readily available	Used only for booze and other volatiles Short window of detection May be difficult to obtain adequate sample, especially with patients who are very intoxicated or uncooperative Uncommon in clinical setting
Meconium	Can find maternal drug abuse and fetal or infant exposure Broad window of drug detection (tertiary trimester of gestation) Noninvasive drove from diaper Generally, adequate specimen amount	Narrow drove window that tin be missed, especially in babies with low birth weight Testing not available in all laboratories Requires extra steps (weighing and extraction) Confirmation assays more difficult than for urine

Here we review the various biologic matrices for drug testing:

(one) Urine

Of all the matrices, urine is the most unremarkably used for adolescent drug testing and is the nearly thoroughly studied [nine,11]. Nonetheless, for an boyish patient, its collection is somewhat invasive since it requires either a sophisticated collection protocol which is not readily bachelor in medical offices or directly ascertainment (e.g., by a clinician or a parent) to prevent tampering [seven,12]. Compounding this, many pediatricians are unfamiliar with proper collection procedures and with the limitations of urine drug screening [xi].

Currently, the most commonly used urine drug testing approach involves automatic immunoassay either lonely equally a indicate-of-care test or every bit an initial screen for a ii-step testing process [7,eight]. Results from IA are qualitative (i.e., a drug or its metabolite is denoted either nowadays or absent, without the quantity reported). In the two-step approach, a screening IA is followed by confirmatory gas chromatography-mass spectrometry (GC-MS). If any substances are positive on the initial IA, a separate quantity of the same sample is then subjected to GC-MS every bit a confirmatory test for those same substances, with negative results on the IA disregarded. GC-MS provides a quantitative event to help guide the clinician, which can be used to follow serial samples and determine whether the metabolite concentration is rising or falling, which may propose ongoing apply or abstinence, respectively. Even nonetheless, caution is warranted equally levels may vary with urine concentration, the corporeality of drug used, and fourth dimension since final utilize, thus making an absolute conclusion regarding whether utilise is ongoing difficult.

IA is often used every bit a indicate-of-intendance test given its convenience, low cost, and relatively rapid results (although results are often not available quickly plenty to guide clinical management in emergent situations) [7]. Most home urine drug test kits utilise IA. Although IA has loftier sensitivity, it has poorer specificity than GC-MS owing to cantankerous-reactivity, whereby compounds in the biologic specimen other than the actual substance or its metabolite bind to the analysis and trigger a false-positive result. (For case, PCP assays tin plough positive if an private consumes dextromethorphan, a mutual component of coughing syrup.) Additionally, IA drug tests performed in isolation practice not distinguish amidst drugs within a class (i.eastward., IA cannot distinguish betwixt various amphetamines, barbiturates, benzodiazepines, or opiates) [8]. GC-MS is not performed as a point-of-care examination and unremarkably must exist sent to a laboratory, resulting in a filibuster [7]. Newer but less widely used technologies include liquid chromatography-mass spectrometry and tandem mass-spectrometry, which tin can exist used to featherbed the initial screening IA and identify a larger number of substances and metabolites [8].

Often, laboratories report the urine creatinine, which helps the clinician correct for the relative concentration or dilution of the urine. Concentration of the urine by the kidneys results in elevated levels of drug metabolites; therefore, urine concentrations of certain drugs and their metabolites are commonly divided by the urine creatinine. An example of this is THC, whose excretion in the urine tin can keep for upwards to one month later on virtually recent employ in heavy users [13], and urine samples positive for THC must be carefully interpreted to distinguish ongoing excretion from new use. Urine THC concentration should be divided by the urine creatinine concentration in order to determine whether the creatinine-normalized THC concentration is increasing or decreasing with consecutive urine samples [14] and these ratios can and so be compared to nomograms of THC excretion in order to make a clinical estimation [15]. Practical problems, such as timing of the urine sample collection, specimen collection techniques, validation of the sample, and consequence estimation are covered later in this chapter.

(2) Blood

Drug testing of blood samples is usually only performed in emergency situations, and due to the invasiveness of obtaining a claret sample, the need for especially trained phlebotomists, and the expense of blood drug testing, it is rarely performed in principal care settings [7,nine]. An additional limitation is that obtaining blood samples requires venipuncture and locating venous admission among injection drug users can be very hard [nine]. Dissimilar urine samples, blood samples generally observe alcohol and drug compounds themselves rather than their metabolites. Blood testing typically detects substance utilize that occurred within two to 12 hours of the test [7].

(3) Oral (saliva)

Oral fluid testing is less commonly used but oral samples represent a convenient, promising matrix for many settings. Unlike urine samples, oral samples are not easily tampered with, and can be collected with minimal invasion of privacy [15,sixteen]. Oral secretions contain either the original drug chemical compound or its metabolite for approximately 24-48 hours subsequently last utilize [9,15,sixteen]. Importantly, apply of breath sprays, mouthwash or other oral rinses containing booze does non affect drug testing result every bit long as they are not used within thirty minutes of sample collection [17]. To collect an oral sample, a swab is placed adjacent to the lower gums against the inner cheek and left in identify for several minutes before being inserted into a vial for transportation to the laboratory [ix]. Point-of-care oral testing is also bachelor in some settings [18].

(four) Hair

Pilus drug tests accept the advantage of detecting substance use days to months, or in some cases, years, afterward [9,nineteen]. Drug metabolites are present in hair as early as one week subsequently nigh recent utilize, and considering metabolites remain trapped in the cadre of the hair as it grows, hair provides a rough timeline of apply over an extended period [9,xx]. Pilus grows at a charge per unit of approximately one-half inch per month, and and so the standard 1.v-inch pilus sample obtained close to the root in nearly drug testing protocols gives data over past 3-month drug use [8].

Because of the long menses of detection for hair samples, they are useful for detecting chronic substance use, understanding the duration of a patient'south drug utilise over the long term, and indicating periods of abstinence [20–22]. Conversely, hair testing is not helpful in detecting sporadic utilise when weekly or even monthly drug testing is required as part of a drug treatment plan [9]. Additionally, drug use often must relatively heavy in order for testing to notice levels in hair. Other limitations of hair testing include that individuals can surreptitiously remove the sample through shaving, that sweat product can cause drug metabolites to travel proximally up the hair shaft thus affecting drug test interpretation, and that drugs can be incorporated into hair through uncomplicated exposure from second-mitt smoke [23,24]. An additional potential consideration is that drug concentrations can exist affected by the melanin content of hair, resulting in potentially college concentrations of certain drugs in nighttime hair as compared to blond or carmine hair [15,25]. Bleaching or coloring the hair may also change concentrations of metabolites [26].

The pilus sample is typically cut from the back of the caput using scissors, cutting as close to the scalp as possible to judge virtually recent drug employ [9]. For patients who are baldheaded or who have shaved their head, hair can exist taken from the armpit, confront, or other unshaven function of the body, so long as a sufficiently long plenty sample can exist taken. No point-of-care pilus drug testing currently exists.

(5) Jiff

Breath testing, frequently referred to colloquially as the "Breathalyzer" test later the original make name testing device, is used exclusively for instantaneous estimation of claret booze content [8]. Breath testing provides an accurate measure of the actual blood alcohol content at that moment in time, and is more frequently used in law enforcement or in emergency departments than in primary care. The Us Department of Transportation maintains an agile list of approved breath testing devices for the interested reader (https://www.transportation.gov/odapc/approved-evidential-jiff-testing-devices) [27].

(half dozen) Sweat

The US Food and Drug Assistants (FDA) has approved a patch for collection of sweat for drug testing that is placed on the skin for three-7 days prior to being sent to a laboratory for interpretation [8,9]. In Europe. a wipe is also available that is not currently FDA-approved due to concerns regarding its accuracy [9,12]. Sweat testing checks for substances and their metabolites in the bloodstream in the hours before and during the time that the patch is applied [viii,9]. Currently, sweat testing is just bachelor for the SAMHSA-5. Patches that crease or show other evidence of interference when removed have been designed in endeavour to reduce tampering [eight].

(vii) Meconium

Meconium is obtained from newborns and used equally a measure of maternal substance apply in the third trimester [8,12,28,29]. Meconium is present in a newborn's first several stools. Meconium testing is used as a screen in the newborn nursery or neonatal intensive care unit when maternal substance apply during pregnancy is suspected, and can have critical legal consequences for guardianship of the child [30]. Meconium testing tin also inform clinical management of neonatal abstinence syndrome and other newborn withdrawal syndromes.

Indications for drug testing

According to the American Guild for Addiction Medicine (ASAM), drug testing should be used "to discourage nonmedical drug use and diversion of controlled substances, to encourage advisable entry into habit treatment, to identify early on relapse and to improve outcomes of habit handling through the use of long-term post-handling monitoring." Since substance use is often hugger-mugger, adolescents may not forthcoming and drug testing may be useful when history is negative in the context of clinical signs and symptoms suggesting substance use. [7]. Indications for adolescent drug testing are explored here.

(1) Emergent care

Drug tests are commonly used in emergent situations, such as when an boyish presents with contradistinct mental status [7,8]. Some mutual clinical scenarios include attempted suicide, motor vehicle injury or other injury in which substance use may have been a correspondent, unexplained seizures, syncope, arrhythmia, or toxidromal signs that suggest a particular intoxication or withdrawal pattern [7]. In such cases, consent for the drug screen is inferred, and its results may be used to guide clinical management. Still, drug testing results are generally not available immediately and cannot reliably exist used early in emergent management; therefore, initial decisions, such every bit whether to provide naloxone for suspected opioid overdose should be fabricated past the clinician based on presenting signs and symptoms [7,viii]. Additionally, considering highly sensitive drug testing may detect substances at limits far lower than therapeutic doses, drug screens may identify additional substances that are present but not contributing to the acute intoxication or withdrawal picture and may therefore be misleading [7]. Once the patient is stabilized, however, drug testing results may be helpful in determining subsequent direction, particularly one time confirmatory testing results are available.

(2) Assessment of behavioral or other mental health concerns

In main care or mental health care settings, substance use by an adolescent may exist suspected as underlying or complicating symptoms of low, anxiety, inattention, hyperactivity, or other broader concerns such as a schoolhouse failure or interpersonal difficulties [seven,9]. In these situations, voluntary drug testing (i.due east., drug testing with the assent of the adolescent and the consent of a guardian) may serve as a helpful complement to a careful history. A positive drug screen might indicate substance use that an boyish previously denied, leading to an opportunity for an honest conversation [seven]. Even so, every bit highlighted beneath in the discussion of interpretation of results, in that location are a number of limitations in drug testing that might event in a negative effect despite clinically significant substance utilize by an adolescent.

(3) Substance use treatment

Drug testing is performed as a routine component of outpatient adolescent substance utilize treatment [7,9]. Information technology serves multiple roles, including preventing agin effects of pharmacotherapy (due east.k., precipitating opioid withdrawal if a clinician provides naltrexone for alcohol use disorder if that patient were likewise surreptitiously using opioids), and monitoring for apply of illicit substances during handling and/or adherence with prescribed medications. such as stimulants for comorbid attention arrears hyperactivity disorder (ADHD) or buprenorphine for opioid use disorder [9]. In residential substance use treatment, drug testing helps back up the drug-costless therapeutic environment [8].

In monitoring for illicit drug use during handling, testing should be performed at random times, every bit discussed below, since adolescents are oftentimes knowledge of the brusque window of detection in urine for many substances and might otherwise simply abstain from utilise for the several days leading up to a scheduled exam [7,9]. Testing should also exist performed frequently enough (eastward.k., at least weekly) to detect whatsoever utilize occurring during treatment [8]. A positive drug screen should never serve every bit grounds for termination from the substance utilise treatment plan, simply rather should prompt a careful conversation between the adolescent and clinician to reconsider the current handling programme [vii,viii]; multiple positive drug tests may betoken the need for a higher level of care, for example [8].

Contingency management, which relies on incentives to encourage ongoing abstinence for adolescents with a substance utilise disorder, often uses drug testing for monitoring [31]. Adolescents who nourish their scheduled visits and/or have negative urine drug tests are provided budgetary prizes or other rewards to reinforce their handling plan adherence [9,31,32]. In many settings, the value of prizes increases incrementally with each successive attended visit or negative drug screen, which farther improves the efficacy of treatment [31,33,34].

(4) Other settings

A number of other potential settings for adolescent drug testing be. Workplace drug testing is federally mandated by the Department of Transportation (DOT) for private-sector transportation workers, and many of the current standards for workplace testing have emerged from these regulations [ix]. For example, the SAMHSA-5 urine drug screen was codified in the late 1980s for DOT workplace testing. Some adolescents and young adults may find themselves seeking or maintaining employment in settings where drug screening is routine [7]. Drug screens from non-federal employers tin can and frequently do expand their drug testing panels to include substances in addition to those on the SAMHSA-5 [9]. Many policies regarding when, where and how employers can test their employees are set up past states; a total review is beyond the telescopic of this article simply a complete, up-to-date listing of relevant policies is available at a cost from the Drug and Alcohol Testing Manufacture Clan (DATIA), an independent manufacture system [35].

Some jurisdictions have proposed drug screening in school. Yet, this approach is opposed by the AAP due to insufficient testify that it discourages adolescent drug use, difficulty in correctly interpreting results, and potential agin consequences such as disciplinary activeness, decreased participation in sports and other schoolhouse activities, breaches of confidentiality, and increased employ of substances not included in the drug testing console used [36]. Similarly, although domicile urine drug tests are commercially bachelor for buy from, for example, drugstores and online marketplaces, use of these 'over-the-counter' home tests past parents without the guidance of a clinician is not recommended due to the complexities in interpreting results [7]. (Use of over-the-counter drug screens is distinguished from formal drug screens nerveless at home under the guidance of a clinician to exist sent to an approved laboratory, which is oft recommended as part of drug treatment.) Youth involved in the criminal justice arrangement are typically routinely drug tested and the specifics of this practice vary from state to state [viii].

Practical concerns in boyish drug testing

(i) Boyish assent / parental consent, and confidentiality

Once a practitioner feels that drug testing (ordinarily urine) would exist helpful clinically, he or should take a conscientious discussion with both the adolescent and parent regarding the potential benefits (i.e., supporting reducing substance use) and the limitations of testing [7]. Any questions should be addressed, and then the clinician should communicate to the adolescent the recommendation for drug testing, emphasizing the potential benefits (confirming a history of no recent substance apply, improving trust with parents, etc.). Assent should ever exist obtained from the adolescent, and permission to share results of any drug tests with his or her parent should be sought.

In addition to the usual privacy provisions dictated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), programs providing substance utilize diagnosis, treatment, or referral for handling are discipline to stricter confidentiality requirements under federal regulations [9]. These regulations are contained in Volume 42 of the Lawmaking of Federal Regulations, Part 2 (42 CFR Office ii) – often referred to past practitioners every bit "Part ii" provisions. Whereas under HIPAA, personal health data can be disclosed among an adolescent's providers without written consent if done as role of routine clinical care, Part 2 requires written permission from the adolescent patient for any disclosure. As always, if emergent clinical intendance for the adolescent is required, consent is implied and written permission need non be obtained. Many readers of this chapter are unlikely to be affected by Function 2 regulations.

The age at which an adolescent tin can independently seek, consent for, and receive substance apply treatment services varies from state to state [37]. In some cases, a pocket-size's emotional, social and cerebral maturity is considered in addition to chronologic age. Moreover, whether an adolescent's parent must by police exist notified once the adolescent has consented for handling varies across states. Readers are encouraged to seek out regulations in their own states; the National Commune Attorneys Association (NDAA) compiles a list of relevant state laws and regulations that providers can review [38].

(two) Test selection and timing

The clinician should too advisedly consider what tests should be included in a drug screen. The SAMHSA-5, though widely available, notably misses a number of usually used substances, including alcohol, opioids and constructed cannabinoids, among other drugs and their metabolites [39]; clinicians should ensure that the laboratory they work with is able to broadly test for these commonly used substances. The SAMHSA-5 also tests for sure substances that are not commonly used in many places in the U.s.. An case is phencyclidine (PCP), which is included in the SAMHSA-5 despite very low prevalence of use in most settings. In fact, where prevalence is low, a positive PCP screen is likely to exist imitation, having been triggered by cross-reactivity by with another compound (due east.g., dextromethorphan, a component of many cough syrups, is often implicated; even though technically a fake positive, such a issue may point misuse of cold medications) [40].

For adolescents who use marijuana, metabolites are detected in the urine for longer than for other substances attributable to the fat solubility of cannabinoids. For intermittent users, metabolites can be detected in the urine for upwards to one week after last use; for daily users, they tin exist detected for upwards to one month [thirteen]. For adolescents who drink alcohol, urine ethyl glucoronide (ETG) and ethyl sulfate (ETS) are helpful tests with a window of detection of several days. Liver tests, such as asparate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT) also are also somewhat sensitive to booze use, but have poor specificity thus limiting their use [41]. Saccharide-deficient transferrin (CDT) is a more than specific marker for ongoing heavy alcohol use, just requires drinking in excess of 40 g/day of ethanol for several weeks (approximately 3 standard drinks/twenty-four hour period), and may not accurately observe intermittent heavy drinking.

Random drug testing is preferred to scheduled drug testing [8]. Since the window of detection for most substances varies between ane to iii days, adolescents who promise to evade detection on a drug test simply need to abstain from substance use for several days beforehand (though a longer flow of abstinence is required for marijuana, as highlighted to a higher place). Random testing entails notifying the adolescent (or preferably, the boyish's parent or guardian) of an immediate testing fourth dimension. Advisedly counseling the adolescent and his or her family unit beforehand about the expectation to immediately complete random drug tests as part of the treatment plan is essential. Random tests should occasionally be done on consecutive days to avoid drug utilise immediately after testing.

(3) Specimen collection

Proper specimen collection procedures are critical for ensuring an acceptable urine sample for drug testing. The internet provides advice on a host of mechanisms for defeating urine drug tests that range from simple to sophisticated. A survey of practicing pediatricians institute that while the large majority have ordered urine drug tests for an adolescent patient, most often these tests are collected without supervision, making it relatively easy for an boyish to defeat a examination [11].

The most easily accomplished methods for tampering with a urine sample are calculation water or other fluids or substituting a previously collected sample. Simple specimen validity checks (described below) can identify most samples that have been adulterated. Nonetheless, supervised sample collection is recommended to discourage tampering and increase the utility of testing.

The DOT describes two adequate methods for collecting a urine sample for drug testing [12]. For almost routine workplace testing with adults, a collection protocol is used that does not involve directly ascertainment. In this protocol, urine samples are collected in a individual bathroom without running water, lather, or other liquids, and with toilet water stained blueish. No outer clothing, bags or cursory cases are permitted in the bathroom. The sample is checked for temperature immediately after information technology is produced. While effective, this protocol is expensive to implement and monitor. Some commercial laboratories may offer this service, though it must be ordered separately and adds significant expense to the cost of a test, which may not be covered by insurance.

An alternative acceptable collection method requires direct observation of the specimen as it is being produced. This method is more than invasive, though is simpler and does not require a specialized bathroom. This alternating collection protocol is often not practical in a clinical office.

For adolescents receiving treatment for substance use problems or disorders, urine specimens can exist nerveless at abode under the supervision of a parent or guardian. Beginning morning specimens are recommended because the float is reliably full and urine is most concentrated. Random, unannounced tests are difficult to prepare for and repeated testing over several weeks is likely to discover ongoing utilize. A series of negative drug tests over several weeks provide strong back up for a report of abstinence. Thus abode urine drove may be a reasonable mechanism for monitoring an adolescent that is receiving handling for a substance use disorder.

While urine specimens may be collected at home, information technology is recommended that all urine drug tests be coordinated with a medical professional and only ordered in the context of an appropriate clinical indication. As noted earlier, the AAP recommends confronting suspicionless drug testing – whether at home, school, medical offices or in other settings – because these tests provide niggling useful clinical information and may crusade tension between an adolescent and parents, school administrators, physicians, or other adults. Furthermore, the AAP discourages physicians from recommending drug tests for domicile use interpreted by families because they rely on relatively non-specific and insensitive enzyme linked panels and may generate false-positive and faux-negative results. (Again, this is distinguished from home collection of drug tests to be sent to a laboratory for formal estimation under the guidance of a clinician in a substance use treatment program, which is commonly indicated.)

(4) Specimen validation

Regardless of collection procedures, validity checks are recommended for all urine specimens. The DOT recommends checking temperature, creatinine and specific gravity on every urine sample [12]. Temperature is checked immediately later on voiding. Urine specimen cups with temperature strips that fluoresce between 90 and 100 degrees Fahrenheit facilitate temperature validation. Urine creatinine and specific gravity can be ordered together with a drug test panel. Many commercial labs also offer adulterant panels that can detect many substances added to a test in vitro.

Creatinine is a product of muscle metabolism that tin can be used as a marker of urine concentration. According to DOT guidelines, urine samples with a random creatinine between ii and 20 mg/mL should be considered dilute; a specimen with a creatinine less than 2 mg/mL should be considered substituted (i.e., not urine) or artificially diluted (i.e., water has been added) [12]. Since adolescence is the period in life during which musculus mass is greatest, this creatinine range may need to exist adjusted for larger teens. For instance, a specimen with a creatinine betwixt 20 and 50 mg/mL may be considered dilute if the specific gravity is too low.

A dilute specimen suggests that a teen has recently consumed a big volume of fluid. This may occur incidentally or intentionally in attempt to bulldoze the concentration of a drug or metabolite below the detection level of the test. It is not possible to distinguish between these possibilities based on the results of a urine test solitary, and clinical correlation is brash whenever interpreting negative drug test. Repeat drug testing may exist warranted using first morning specimens if possible. A dilute urine sample can still be positive, although in such cases it is possible to miss other substances nowadays in lower concentrations. For example, a urine specimen may be positive for marijuana but too dilute to identify low levels of cocaine.

(5) Interpretation of results

As with all laboratory tests, urine drug tests can yield imitation positive and simulated negative results. Dissimilar most other laboratory results, yet, results of urine drug tests can be accurate and withal yield misleading information – in other words a test can yield a true negative result in the context of ongoing psychoactive substance utilise (e.thousand., if the test was performed outside the window of detection of the drug that the adolescent was using), or a true positive result in the context of no utilise of psychoactive substances (due east.g., if the test detects substances found in food such equally poppy seeds, which tin can trigger an opioid screen, or in a patient'southward prescribed medications such as stimulants for ADHD, which tin can trigger an amphetamine screen). Urine drug tests may besides yield ambiguous results if a examination is too dilute for interpretation, or does not lucifer a patient'south stated history. Because of their differing properties, different interpretation strategies are required for IA screening tests as compared to confirmatory GC-MS tests.

a. Interpretation of IA tests

Enzyme-linked IA tests are relatively quick, inexpensive, and easy to perform and every bit such are often used by laboratories as a showtime line screen. This testing format identifies drugs or metabolites in a higher place a certain threshold concentration in the urine. Typically the threshold concentration is ready high plenty to limit detection of low levels of drugs or metabolites that may be plant in foods. For example, poppy seeds contain very low levels of morphine that tin exist detected by sensitive tests, but under usual circumstances concentrations of morphine in the claret and urine from consuming typical amounts of poppy seeds will be well nether the detection threshold.

IA is non-specific and cross-reactions can occur. As an example, quinolone antibiotics can cross react with an opioid panel yielding a false positive test result. To eliminate this type of fault, IA tests should be confirmed with a more definitive chromatographic test (eastward.grand., GC-MS), specially if a exam result is unexpected and does not correlate with a patient's history.

b. Interpretation of confirmatory chromatography tests

Chromatographic tests by and large take longer to perform, are more labor intensive and more expensive than IA, though newer technologies may address these issues. Chromatographic tests are specific and are not susceptible to cantankerous-reactions, thus false positive results are rare. However, chromatographic tests can discover prescribed medications (such as stimulants used for ADHD treatment) and information technology is impossible to distinguish whether a patient used the medication as prescribed or misused it by using more than prescribed or using an alternate route of administration (e.g., crushing and snorting pills).

c. Interpretation of negative tests

Whether IA or chromatographic testing is preformed, special consideration should be given to the interpretation of negative tests. A drug test will be negative despite ongoing drug use in four dissimilar circumstances:

The window of detection has passed. The window of detection for most substances is ii-3 days and drug use volition not be detected after this flow. One notable exception is heavy, chronic use of cannabis, which tin result in prolonged excretion for up to 4 weeks [fourteen], complicating estimation during this period.
The patient has used a substance not detected by the testing panel. While nearly whatsoever substance can exist tested for in urine, standard test panels are express to usually used substances. For example, synthetic cannabinoids are not detected by standard tests for cannabis and should be ordered separately if use is suspected. Inhalants are excreted by the lungs and cannot be detected in a urine specimen.
The concentration of the substance is beneath the detection limit of the exam. This is uncommon with chromatographic tests which are typically very sensitive, but may occur with IA tests which have a set cut-off threshold typically designed to eliminate false positives from cross-reaction or trace amounts of a drug or metabolite that may be institute in food products. Intentional urine dilution may issue in a falsely negative test.
The specimen has been substituted or adulterated. Singled-out from most instances of laboratory medicine, patients may be motivated to falsify test results by substituting or adulterating specimens. Proper specimen collection techniques (meet above), use of temperature testing, and adulterant panels tin minimize opportunities for interfering with testing in this way.

d. Presenting drug examination results to adolescents

Reviewing positive urine drug test results presents the simultaneous challenges of sharing relevant information while maintaining a therapeutic alliance with an boyish patient and his or her family unit. Prior to ordering a drug test, a discussion of how results will exist reported and to whom can help maximize the utility of drug testing.

In most instances information technology is useful to have a private conversation with the adolescent to analyze interpretation of the drug exam issue. Simply sharing that the drug test yielded an "unexpected issue" without revealing specific details may set the stage for an honest conversation about substance apply, and at times, patients will reveal use of substances that were not detected by the test. If the patient gives a history that is consistent with the drug test results the chat tin movement on to a give-and-take of next steps – which could include changes to the treatment plan. Sharing drug test results together with a plan may facilitate a positive chat. For example, a clinician may report to a parent that their son has recently used marijuana and has now agreed to speak with a counselor about anxiety and marijuana utilise.

When a drug test result is dilute or otherwise ambiguous a clinical interview may be helpful. Starting with a simple statement about an "unexpected test result" without revealing all of the details tin serve as an open-ended style of beginning the conversation. If a patient does not report substance use the clinician can review methods for reducing the risk of a dilute specimen – by providing a offset morning urine if possible, or if non, limiting h2o intake in the hour prior to giving a sample. Echo testing may be useful.

During a clinical interview an adolescent may offer an explanation that is consistent with the observed drug test results, such as a new prescription medication or supervised use of common cold medication. This history tin can be confirmed with a parent and the drug examination tin be interpreted as negative (i.e., consistent with a history of no illicit substance employ).

In some instances an adolescent'southward history may be inconsistent with observed drug test results. As with all laboratory testing, drug exam results provide express information and clinical correlation is always brash. A single positive drug test may be spurious and can be treated that way if the patient otherwise seems to be doing well and adhering to the treatment plan. In these cases echo urine testing is recommended; a second occurrence of a positive drug examination is unlikely to be some other false-positive result. In this case, the clinician may recommend modifications to the treatment plan.

Conclusion

Drug testing, when carefully collected and thoughtfully interpreted, offers a critical adjunct to clinical care and substance use treatment (Box i). However, because test results can be misleading if not interpreted in the correct clinical context, clinicians should always conduct a careful interview with boyish patients to understand what testing is likely to prove then use testing to validate or abnegate their expectations. Due to the ease with which samples tin can be tampered, providers should likewise carefully reflect on their ain collection protocols and sample validation procedures to ensure optimal accuracy.

Box ane

Key Points

Routine laboratory testing of adolescents, whether in main care, schoolhouse or at home is not recommended though testing may be useful in a number of clinical situations.
Laboratory testing is complex and requires careful attention to specimen collection and interpretation of results.
As with all laboratory testing, drug testing offers limited information and should always exist interpreted in a clinical context.

Acknowledgments

Dr. Hadland is supported past the Division of Adolescent and Young Adult Medicine at Boston Children's Hospital and the Leadership Teaching in Adolescent Wellness Training Program T71 MC00009 (MCH/HRSA) and by a National Research Service Award 1T32 HD075727 (NIH/NICHD). Dr. Levy is supported by 1R01AA021913–01 (NIH/NIAAA).

Footnotes

Disharmonize of Interest Statement

The authors accept no conflicts of involvement to disclose.

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