Objective Testing – Urine and Other Drug Tests

Abstract

Drug testing, when carefully collected and thoughtfully interpreted, offers a critical adjunct to clinical care and substance use treatment. However, because test results can be misleading if not interpreted in the correct clinical context, clinicians should always conduct a careful interview with adolescent patients to understand what testing is likely to show and then use testing to validate or refute their expectations. Due to the ease with which samples can be tampered, providers should also carefully reflect 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 and intervene to reduce acute risks and to improve the life course trajectory of addiction and its harms. For clinicians working with adolescents, screening for alcohol and drug use is a critical skill that allows for brief intervention and referral to treatment, an approach endorsed by major professional bodies [1–3] including the American Academy of Pediatrics (AAP) [4]. Screening is best conducted using a validated instrument (such as the S2BI instrument [5]) that can then prompt a discussion between the clinician and adolescent.

At first blush, routine screening of adolescents by testing urine or other bodily 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 about substance use with a clinician. Abstinence from all substances is recommended throughout adolescence because of the impact of alcohol, marijuana and other drugs on brain development [6]. Routine drug testing of all adolescents, however, is insensitive for detecting sporadic use, and risks obscuring opportunities for counseling and brief interventions that may be better identified by self-report [7].

While routine laboratory testing is not recommended for adolescents there are several indications for which this procedure may provide useful information to supplement a clinical history or to regularly monitor patients in treatment for substance use disorders. Here, 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 contrasted with its use in adults.

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Drugs tested

Although it is possible to test for use of an individual drug, multiple drugs or classes are usually tested at the same time using a single biological sample [8]. The most commonly used immunoassay (IA) drug test panel includes the “SAMHSA-5”, a standard panel established in the 1980s under the Drug-Free Workplace Act. The SAMHSA-5 includes amphetamines, marijuana (tetrahydrocannabinol [THC]), cocaine metabolites, opiates (including heroin, morphine, and codeine, but not synthetic opioids such as oxycodone, hydrocodone, buprenorphine, or methadone), and phencyclidine (PCP) [8,9]. Most drug screens available commercially have panels that expand beyond the SAMHSA-5 to also include benzodiazepines, barbiturates, and additional 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 half-life of elimination and can be detected in urine up to weeks after last use among heavy users). The various windows of detection for a number of commonly used substances are shown in Table 1 [10].

Windows of detection in urine for various substances.

Detection Windows by Drug Test Type
Substance	Urine	Hair	Oral Fluid	Sweat
Alcohol	10-12 hours	N/A	Up to 24 hours	N/A
	EtG — Up to 48 hours
Amphetamines	2 to 4 days	Up to 90 days	1-48 hours	7-14 days
Methamphetamine	2 to 5 days	Up to 90 days	1-48 hours	7-14 days
Barbiturates	Up to 7 days	Up to 90 days	N/A	N/A
Benzodiazepines	Up to 7 days	Up to 90 days	N/A	N/A
Cannabis (Marijuana)	1-30 days	Up to 90 days	Up to 24 hours	7-14 days
Cocaine	1 to B days	Up to 90 days	1-36 hours	7-14 days
Codeine (Opiate)	2 to 4 days	Up to 90 days	1-36 hours	7-14 days
Morphine (Opiate)	2 to 5 days	Up to 90 days	1-36 hours	7-14 days
Heroin (Opiate)	2 to 3 days	Up to 90 days	1-36 hours	7-14 days
PCP (Phencyclidine)	5 to 6 days	Up to 90 days	N/A	7-14 days

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LSD, Mushrooms, Synthetic Cannabinoids, Ecstasy (MDMA) will not be detected by typical drug testing

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Sources for testing

There are multiple sources for biologic specimens (often referred to as “biological matrices” in the scientific literature): urine, blood, saliva, hair, breath, sweat, and meconium. These various tissues and bodily fluids exhibit different rates and durations of excretion that result in different detection windows for substances, as demonstrated in Figure 1.

FIGURE 1

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

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

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

‡7–10 days after use to the time passed to grow the length of hair, but may be limited to 6 months hair growth. However, most laboratories analyze the amount of hair equivalent to 3 months of growth.

When substances are ingested, they are absorbed in the gastrointestinal tract and distributed to tissues of the body [9]. Substances that are injected, inhaled or snorted bypass 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 then allows them to be eliminated in urine. Blood 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 within the body several hours later. Urine offers a somewhat longer window of detection for substances, usually varying from one 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 2.

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Article by, Scott E. Hadland, MD, MPH^1,3 and Sharon Levy, MD, MPH^2,3.

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