What are the four fluids collected from the body can be used to test for toxicology?

Child Adolesc Psychiatr Clin N Am. Writer 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 Due east. Hadland

ⁱBoston Children's Hospital, Division of Adolescent / Young Adult Medicine, Boston Children'due south Hospital, Division of Developmental Medicine, Department of Medicine, 300 Longwood Artery, Boston, MA, United states, 02115

³Harvard Medical School, Section of Pediatrics, 25 Shattuck St., Boston, MA, Usa, 02115

Sharon Levy

²Department of Medicine, 300 Longwood Avenue, Boston, MA, USA, 02115

³Harvard Medical School, Department of Pediatrics, 25 Shattuck St., Boston, MA, Usa, 02115

Abstract

Drug testing, when carefully collected and thoughtfully interpreted, offers a critical adjunct to clinical care and substance utilize treatment. However, because examination results can exist misleading if non 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 tin can exist tampered, providers should also carefully reverberate on their own collection protocols and sample validation procedures to ensure optimal accurateness.

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

Information technology is incumbent on clinicians to discover substance use early and intervene to reduce acute risks and to ameliorate 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 arroyo endorsed by major professional bodies [i–3] including the American Academy of Pediatrics (AAP) [4]. Screening is best conducted using a validated instrument (such as the S2BI instrument [five]) that tin then prompt a give-and-take between the clinician and adolescent.

At beginning blush, routine screening of adolescents by testing urine or other bodily fluids might seem similar 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 virtually substance apply with a clinician. Abstinence from all substances is recommended throughout adolescence because of the impact of booze, marijuana and other drugs on encephalon development [six]. Routine drug testing of all adolescents, however, is insensitive for detecting sporadic apply, and risks obscuring opportunities for counseling and cursory interventions that may exist meliorate 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 data to supplement a clinical history or to regularly monitor patients in treatment for substance use disorders. Here, we review drugs ordinarily included in testing panels, actual fluids and tissues tested, indications for testing, applied concerns, and problems unique to drug testing adolescents as contrasted with its use in adults.

Drugs tested

Although information technology is possible to test for use of an private drug, multiple drugs or classes are usually tested at the aforementioned fourth dimension using a single biological sample [eight]. The nigh 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 non constructed opioids such as oxycodone, hydrocodone, buprenorphine, or methadone), and phencyclidine (PCP) [8,nine]. About drug screens available commercially have panels that expand beyond the SAMHSA-v to too include benzodiazepines, barbiturates, and additional opiates [8].

Alcohol and drugs vary substantially in their windows of detection, largely attributable to their degree of fat solubility. For instance, THC and other highly fat-soluble compounds accept a very long half-life of elimination and tin be detected in urine upwards to weeks after last use among heavy users). The diverse windows of detection for a number of commonly used substances are shown in Tabular array i [x].

Table ane

Windows of detection in urine for various substances.

Detection Windows by Drug Test Type
Substance	Urine	Pilus	Oral Fluid	Sweat
Alcohol	ten-12 hours	N/A	Upwards to 24 hours	Due north/A
	EtG -- Up to 48 hours

Amphetamines	ii to four days	Up to 90 days	1-48 hours	7-fourteen days

Methamphetamine	2 to 5 days	Up to 90 days	ane-48 hours	7-14 days

Barbiturates	Upward to 7 days	Up to xc days	Northward/A	Northward/A

Benzodiazepines	Up to vii days	Up to 90 days	N/A	North/A

Cannabis (Marijuana)	1-30 days	Up to ninety days	Up to 24 hours	vii-14 days

Cocaine	1 to B days	Upwards to xc days	1-36 hours	7-14 days

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

Morphine (Opiate)	two to 5 days	Up to ninety days	one-36 hours	vii-xiv days

Heroin (Opiate)	2 to three days	Upwards to 90 days	i-36 hours	7-14 days

PCP (Phencyclidine)	5 to vi days	Upward to 90 days	N/A	seven-xiv days

Sources for testing

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

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

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

†Every bit long every bit the patch is worn, usually seven days.

‡7–10 days after use to the time passed to grow the length of hair, but may be limited to six months hair growth. Even so, 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 [nine]. 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 return them water soluble which then 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 within the body several hours afterward. Urine offers a somewhat longer window of detection for substances, usually varying from one 24-hour interval afterward consumption to several weeks. Hair and meconium offer the longest windows of detection (weeks to months). Advantages and disadvantages of dissimilar matrices for drug testing are shown in Table 2.

Tabular array two

Advantages and disadvantages of various matrices (i.due east., 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 bespeak-of-intendance tests (POCTs) Well-researched testing techniques	Short to intermediate window of detection Easy to attenuated or substitute May require observed drove Some individuals experience "shy bladder" syndrome and cannot produce a specimen
Oral Fluid	Noninvasive specimen drove Like shooting fish in a barrel to collect Reduced take a chance of adulteration Direct observed specimen collection Parent drug rather than metabolite tin be the target of the assay Able to notice same-day use, in some cases Availability of POCTs Detect balance drug in the mouth	Limited specimen volume Possibility of contamination from residual drug in rima oris that cannot exist correlated with blood concentrations Brusk window of detection Requires supervision of patient for ten–30 minutes before sampling Salivation reduced past stimulant apply Need for elution solvent to efficiently remove drugs adsorbed to drove device Cannabinoids in oral fluid have been shown to arise from contamination of the oral cavity 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 up to 7–14 days) Noninvasive specimen collection Difficult to adulterate Requires little grooming to collect specimen May be an economic alternative to urine	Few facilities and limited expertise for testing Risk of adventitious or deliberate removal of the sweat patch collection device Unknown furnishings of variable sweat excretion among individuals Simply a unmarried sweat drove patch available and so multiple analyses cannot be done if needed (i.e., more than than ane positive initial test) May be affected past external contaminants Requires 2 visits, one for patch placement and one for patch removal
Claret	Generally detects recent use Established laboratory test method	Expensive, except to detect ethanol Limited window of detection Invasive specimen collection (venipuncture) Take a chance of infection Requires training to collect specimen May not be an option for individual with poor venous access
b
Hair	Longest window of detection May exist able to detect changes in drug use over time (from 7–ten days subsequently drug use to 3 months, depending on length of hair tested) Direct observed specimen drove Noninvasive specimen drove Four tests volition cover 1 yr Like shooting fish in a barrel storage and transport Hard to adulterate or substitute Readily available sample, depending on ength of pilus tested	Cannot notice use inside the previous seven–10 days Difficult to interpret results Costly and time consuming to set specimen for testing Few laboratories available to perform testing No POCTs currently bachelor Hard to detect depression-level utilize (east.grand., single-use episode) May exist biased with hair color (dark hair contains more of some basic drugs [cocaine, methamphetamine, opioids] due to enhanced bounden to melanin in hair) Possibility of environmental contamination Specimen tin can be removed by shaving
Breath	Well-established method for alcohol testing Readily available	Used merely for booze and other volatiles Brusk window of detection May be difficult to obtain adequate sample, especially with patients who are very intoxicated or uncooperative Uncommon in clinical setting
Meconium	Tin observe maternal drug corruption and fetal or infant exposure Wide window of drug detection (third trimester of gestation) Noninvasive collection from diaper More often than not, adequate specimen amount	Narrow collection window that tin can exist missed, specially in babies with depression birth weight Testing not bachelor in all laboratories Requires extra steps (weighing and extraction) Confirmation assays more difficult than for urine

Here nosotros review the various biologic matrices for drug testing:

(1) Urine

Of all the matrices, urine is the most commonly used for boyish drug testing and is the about thoroughly studied [9,11]. Even so, for an boyish patient, its drove is somewhat invasive since it requires either a sophisticated collection protocol which is non readily available in medical offices or direct ascertainment (e.yard., 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 [11].

Currently, the near commonly used urine drug testing approach involves automated immunoassay either alone as a betoken-of-care test or as an initial screen for a 2-step testing procedure [7,8]. Results from IA are qualitative (i.e., a drug or its metabolite is denoted either present or absent-minded, without the quantity reported). In the 2-step approach, a screening IA is followed by confirmatory gas chromatography-mass spectrometry (GC-MS). If whatsoever substances are positive on the initial IA, a separate quantity of the aforementioned sample is and then subjected to GC-MS as a confirmatory test for those same substances, with negative results on the IA overlooked. GC-MS provides a quantitative issue to assist guide the clinician, which can be used to follow serial samples and determine whether the metabolite concentration is rising or falling, which may advise ongoing utilize or abstinence, respectively. Even all the same, circumspection is warranted equally levels may vary with urine concentration, the amount of drug used, and time since last employ, thus making an absolute determination regarding whether apply is ongoing hard.

IA is often used every bit a point-of-care test given its convenience, low price, and relatively rapid results (although results are often not available quickly enough to guide clinical management in emergent situations) [7]. Most habitation urine drug test kits employ IA. Although IA has loftier sensitivity, information technology has poorer specificity than GC-MS attributable to cross-reactivity, whereby compounds in the biologic specimen other than the actual substance or its metabolite demark to the assay and trigger a false-positive result. (For instance, PCP assays tin can plow positive if an private consumes dextromethorphan, a common component of coughing syrup.) Additionally, IA drug tests performed in isolation practise not distinguish among drugs inside a class (i.e., IA cannot distinguish betwixt various amphetamines, barbiturates, benzodiazepines, or opiates) [8]. GC-MS is non performed every bit a betoken-of-care test and commonly must be sent to a laboratory, resulting in a delay [7]. Newer merely less widely used technologies include liquid chromatography-mass spectrometry and tandem mass-spectrometry, which can be used to bypass the initial screening IA and place a larger number of substances and metabolites [8].

Often, laboratories written report the urine creatinine, which helps the clinician right 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 usually divided by the urine creatinine. An case of this is THC, whose excretion in the urine can keep for upwardly to 1 calendar month after well-nigh recent utilise in heavy users [13], and urine samples positive for THC must exist advisedly 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 tin can then be compared to nomograms of THC excretion in order to make a clinical interpretation [15]. Practical bug, such as timing of the urine sample collection, specimen drove techniques, validation of the sample, and event interpretation are covered later in this affiliate.

(2) Blood

Drug testing of claret samples is normally merely performed in emergency situations, and due to the invasiveness of obtaining a blood sample, the need for specially trained phlebotomists, and the expense of blood drug testing, it is rarely performed in primary intendance settings [7,9]. An additional limitation is that obtaining blood samples requires venipuncture and locating venous access amongst injection drug users can be very difficult [nine]. Unlike urine samples, claret samples mostly notice alcohol and drug compounds themselves rather than their metabolites. Blood testing typically detects substance apply that occurred within 2 to 12 hours of the test [7].

(3) Oral (saliva)

Oral fluid testing is less unremarkably used merely oral samples stand for a convenient, promising matrix for many settings. Dissimilar urine samples, oral samples are non easily tampered with, and tin can be collected with minimal invasion of privacy [xv,16]. Oral secretions contain either the original drug compound or its metabolite for approximately 24-48 hours later last use [9,fifteen,sixteen]. Importantly, utilise of breath sprays, mouthwash or other oral rinses containing alcohol does not affect drug testing result every bit long as they are not used inside 30 minutes of sample collection [17]. To collect an oral sample, a swab is placed adjacent to the lower gums confronting the inner cheek and left in place for several minutes before being inserted into a vial for transportation to the laboratory [9]. Indicate-of-care oral testing is likewise bachelor in some settings [18].

(4) Hair

Hair drug tests have the reward of detecting substance apply days to months, or in some cases, years, later [nine,19]. Drug metabolites are present in hair as early as one week later nearly recent use, and because metabolites remain trapped in the core of the pilus every bit information technology grows, hair provides a rough timeline of use over an extended menstruum [9,xx]. Hair grows at a rate of approximately i-one-half inch per month, and and so the standard 1.v-inch pilus sample obtained close to the root in almost drug testing protocols gives information over past 3-month drug utilize [8].

Because of the long flow of detection for pilus samples, they are useful for detecting chronic substance use, agreement the elapsing of a patient's drug utilise over the long term, and indicating periods of abstinence [twenty–22]. Conversely, hair testing is not helpful in detecting sporadic use when weekly or fifty-fifty monthly drug testing is required as part of a drug handling programme [nine]. Additionally, drug utilize often must relatively heavy in order for testing to observe levels in hair. Other limitations of hair testing include that individuals can surreptitiously remove the sample through shaving, that sweat production tin can crusade drug metabolites to travel proximally up the pilus shaft thus affecting drug examination interpretation, and that drugs tin can be incorporated into pilus through simple exposure from 2nd-hand smoke [23,24]. An additional potential consideration is that drug concentrations can exist affected by the melanin content of hair, resulting in potentially higher concentrations of certain drugs in dark hair as compared to blond or red hair [15,25]. Bleaching or coloring the hair may besides alter concentrations of metabolites [26].

The hair sample is typically cut from the back of the head using scissors, cutting as close to the scalp as possible to estimate most recent drug employ [ix]. For patients who are bald or who have shaved their head, hair can be taken from the armpit, face, or other unshaven part of the body, so long every bit a sufficiently long enough sample tin be taken. No betoken-of-care pilus drug testing currently exists.

(5) Breath

Jiff testing, often referred to colloquially as the "Breathalyzer" test later the original brand name testing device, is used exclusively for instantaneous estimation of claret alcohol content [8]. Breath testing provides an accurate measure out 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 master care. The US Department of Transportation maintains an active listing of approved jiff testing devices for the interested reader (https://www.transportation.gov/odapc/approved-evidential-breath-testing-devices) [27].

(6) Sweat

The The states Food and Drug Administration (FDA) has approved a patch for collection of sweat for drug testing that is placed on the skin for 3-seven days prior to being sent to a laboratory for estimation [8,9]. In Europe. a wipe is too 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 earlier and during the time that the patch is practical [8,ix]. Currently, sweat testing is only available for the SAMHSA-5. Patches that crease or testify other testify of interference when removed have been designed in effort to reduce tampering [8].

(7) Meconium

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

Indications for drug testing

Co-ordinate to the American Society for Addiction Medicine (ASAM), drug testing should be used "to discourage nonmedical drug use and diversion of controlled substances, to encourage appropriate entry into addiction handling, to identify early relapse and to better outcomes of addiction treatment through the use of long-term post-treatment monitoring." Since substance utilize is oft secret, adolescents may not forthcoming and drug testing may be useful when history is negative in the context of clinical signs and symptoms suggesting substance utilize. [7]. Indications for adolescent drug testing are explored hither.

(1) Emergent care

Drug tests are commonly used in emergent situations, such every bit when an adolescent presents with altered mental status [7,8]. Some common clinical scenarios include attempted suicide, motor vehicle injury or other injury in which substance use may have been a contributor, 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 exist used to guide clinical direction. However, drug testing results are more often than not non available immediately and cannot reliably be used early in emergent management; therefore, initial decisions, such as whether to provide naloxone for suspected opioid overdose should be made by the clinician based on presenting signs and symptoms [7,8]. Additionally, because highly sensitive drug testing may observe substances at limits far lower than therapeutic doses, drug screens may identify boosted substances that are nowadays but not contributing to the acute intoxication or withdrawal film and may therefore be misleading [vii]. Once the patient is stabilized, however, drug testing results may exist helpful in determining subsequent direction, particularly once confirmatory testing results are bachelor.

(2) Assessment of behavioral or other mental health concerns

In primary intendance or mental health care settings, substance use past an adolescent may exist suspected as underlying or complicating symptoms of depression, anxiety, inattention, hyperactivity, or other broader concerns such as a school failure or interpersonal difficulties [7,ix]. In these situations, voluntary drug testing (i.e., 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 adolescent previously denied, leading to an opportunity for an honest conversation [7]. However, as highlighted below in the word of interpretation of results, there are a number of limitations in drug testing that might upshot in a negative result despite clinically pregnant substance utilise by an adolescent.

(3) Substance use treatment

Drug testing is performed every bit a routine component of outpatient adolescent substance use handling [7,9]. It serves multiple roles, including preventing adverse effects of pharmacotherapy (e.g., precipitating opioid withdrawal if a clinician provides naltrexone for alcohol utilise disorder if that patient were too surreptitiously using opioids), and monitoring for use of illicit substances during handling and/or adherence with prescribed medications. such as stimulants for comorbid attending deficit hyperactivity disorder (ADHD) or buprenorphine for opioid employ disorder [9]. In residential substance apply treatment, drug testing helps support the drug-free therapeutic surroundings [8].

In monitoring for illicit drug utilise during treatment, testing should be performed at random times, equally discussed below, since adolescents are often knowledge of the short window of detection in urine for many substances and might otherwise only abstain from use for the several days leading up to a scheduled exam [7,nine]. Testing should too be performed frequently enough (e.g., at to the lowest degree weekly) to discover whatsoever use occurring during handling [8]. A positive drug screen should never serve as grounds for termination from the substance employ treatment program, simply rather should prompt a careful conversation between the boyish and clinician to reconsider the electric current treatment plan [7,8]; multiple positive drug tests may bespeak the need for a higher level of care, for case [8].

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

(4) Other settings

A number of other potential settings for boyish drug testing exist. Workplace drug testing is federally mandated by the Department of Transportation (DOT) for individual-sector transportation workers, and many of the current standards for workplace testing have emerged from these regulations [nine]. For case, the SAMHSA-five urine drug screen was codified in the late 1980s for DOT workplace testing. Some adolescents and immature adults may find themselves seeking or maintaining employment in settings where drug screening is routine [7]. Drug screens from non-federal employers can and ofttimes exercise 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 by states; a full review is beyond the telescopic of this article but a complete, up-to-date listing of relevant policies is available at a toll from the Drug and Alcohol Testing Manufacture Association (DATIA), an contained manufacture organisation [35].

Some jurisdictions have proposed drug screening in school. Still, this approach is opposed by the AAP due to insufficient evidence that it discourages boyish drug use, difficulty in correctly interpreting results, and potential adverse consequences such as disciplinary action, decreased participation in sports and other school activities, breaches of confidentiality, and increased utilize of substances non included in the drug testing panel used [36]. Similarly, although home urine drug tests are commercially available for purchase from, for example, drugstores and online marketplaces, utilise of these 'over-the-counter' domicile 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 collected at domicile under the guidance of a clinician to be sent to an approved laboratory, which is frequently recommended equally part of drug treatment.) Youth involved in the criminal justice organization are typically routinely drug tested and the specifics of this practise vary from state to state [8].

Practical concerns in adolescent drug testing

(1) Adolescent assent / parental consent, and confidentiality

In one case a practitioner feels that drug testing (unremarkably urine) would be helpful clinically, he or should have a careful word with both the adolescent and parent regarding the potential benefits (i.e., supporting reducing substance use) and the limitations of testing [seven]. Whatever questions should be addressed, and and so the clinician should communicate to the adolescent the recommendation for drug testing, emphasizing the potential benefits (confirming a history of no recent substance use, improving trust with parents, etc.). Assent should ever be obtained from the boyish, and permission to share results of whatsoever drug tests with his or her parent should be sought.

In add-on to the usual privacy provisions dictated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), programs providing substance use diagnosis, treatment, or referral for handling are bailiwick to stricter confidentiality requirements under federal regulations [9]. These regulations are contained in Book 42 of the Code of Federal Regulations, Office 2 (42 CFR Part ii) – often referred to by practitioners every bit "Part 2" provisions. Whereas under HIPAA, personal health information can be disclosed amidst an boyish'south providers without written consent if done as part of routine clinical intendance, Part 2 requires written permission from the adolescent patient for any disclosure. As always, if emergent clinical treat the boyish is required, consent is implied and written permission need non be obtained. Many readers of this affiliate are unlikely to be afflicted by Part 2 regulations.

The age at which an adolescent can independently seek, consent for, and receive substance utilize treatment services varies from land to state [37]. In some cases, a minor'southward emotional, social and cognitive maturity is considered in addition to chronologic historic period. Moreover, whether an boyish's parent must by law be notified once the adolescent has consented for handling varies across states. Readers are encouraged to seek out regulations in their own states; the National District Attorneys Clan (NDAA) compiles a list of relevant land laws and regulations that providers tin can review [38].

(2) Test selection and timing

The clinician should also carefully consider what tests should exist included in a drug screen. The SAMHSA-5, though widely available, notably misses a number of usually used substances, including alcohol, opioids and synthetic 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-five also tests for certain substances that are not commonly used in many places in the U.s.a.. An example is phencyclidine (PCP), which is included in the SAMHSA-v despite very low prevalence of apply in most settings. In fact, where prevalence is low, a positive PCP screen is likely to exist faux, having been triggered by cross-reactivity by with another compound (due east.grand., dextromethorphan, a component of many cough syrups, is frequently implicated; even though technically a imitation positive, such a result may bespeak misuse of common cold medications) [xl].

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 up to one week afterwards last apply; for daily users, they can exist detected for up to one month [13]. 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 alcohol use, merely have poor specificity thus limiting their use [41]. Carbohydrate-deficient transferrin (CDT) is a more specific marker for ongoing heavy alcohol apply, just requires drinking in excess of 40 g/day of ethanol for several weeks (approximately 3 standard drinks/twenty-four hours), and may not accurately detect intermittent heavy drinking.

Random drug testing is preferred to scheduled drug testing [8]. Since the window of detection for near substances varies between 1 to 3 days, adolescents who promise to evade detection on a drug test merely need to abjure from substance use for several days beforehand (though a longer period of abstinence is required for marijuana, as highlighted above). Random testing entails notifying the adolescent (or preferably, the adolescent'south parent or guardian) of an immediate testing time. Carefully counseling the adolescent and his or her family unit beforehand nigh the expectation to immediately consummate random drug tests as part of the handling program is essential. Random tests should occasionally be done on consecutive days to avoid drug utilize immediately after testing.

(three) Specimen drove

Proper specimen collection procedures are critical for ensuring an adequate urine sample for drug testing. The net provides communication on a host of mechanisms for defeating urine drug tests that range from uncomplicated to sophisticated. A survey of practicing pediatricians found that while the big bulk take ordered urine drug tests for an adolescent patient, near often these tests are collected without supervision, making it relatively like shooting fish in a barrel for an adolescent to defeat a test [11].

The about easily accomplished methods for tampering with a urine sample are adding water or other fluids or substituting a previously nerveless sample. Simple specimen validity checks (described below) can place almost samples that accept 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 most routine workplace testing with adults, a collection protocol is used that does not involve direct observation. In this protocol, urine samples are collected in a private bathroom without running h2o, soap, or other liquids, and with toilet h2o stained blue. No outer clothing, bags or brief cases are permitted in the bath. 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 culling acceptable collection method requires direct observation of the specimen every bit it is beingness produced. This method is more invasive, though is simpler and does not crave a specialized bathroom. This alternate collection protocol is often not practical in a clinical office.

For adolescents receiving treatment for substance employ problems or disorders, urine specimens tin be collected at domicile under the supervision of a parent or guardian. First morn specimens are recommended because the bladder is reliably total and urine is most concentrated. Random, unannounced tests are difficult to prepare for and repeated testing over several weeks is likely to find ongoing use. A serial of negative drug tests over several weeks provide stiff support for a study of abstinence. Thus home urine collection may be a reasonable mechanism for monitoring an adolescent that is receiving treatment for a substance use disorder.

While urine specimens may be collected at habitation, it is recommended that all urine drug tests exist coordinated with a medical professional and only ordered in the context of an advisable clinical indication. As noted earlier, the AAP recommends confronting suspicionless drug testing – whether at home, schoolhouse, medical offices or in other settings – because these tests provide little useful clinical data and may crusade tension between an boyish and parents, school administrators, physicians, or other adults. Furthermore, the AAP discourages physicians from recommending drug tests for habitation use interpreted by families because they rely on relatively non-specific and insensitive enzyme linked panels and may generate false-positive and fake-negative results. (Once again, this is distinguished from dwelling collection of drug tests to be sent to a laboratory for formal interpretation nether the guidance of a clinician in a substance utilise treatment plan, 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 afterward voiding. Urine specimen cups with temperature strips that fluoresce between ninety and 100 degrees Fahrenheit facilitate temperature validation. Urine creatinine and specific gravity can be ordered together with a drug test panel. Many commercial labs as well offer adulterant panels that can observe many substances added to a test in vitro.

Creatinine is a product of muscle metabolism that tin can be used as a mark of urine concentration. According to DOT guidelines, urine samples with a random creatinine between 2 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.east., water has been added) [12]. Since adolescence is the menstruation in life during which musculus mass is greatest, this creatinine range may need to be adjusted for larger teens. For example, a specimen with a creatinine betwixt twenty and 50 mg/mL may be considered dilute if the specific gravity is as well low.

A dilute specimen suggests that a teen has recently consumed a big book 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 examination lonely, and clinical correlation is advised whenever interpreting negative drug test. Repeat drug testing may be warranted using first morning specimens if possible. A dilute urine sample can still exist positive, although in such cases it is possible to miss other substances nowadays in lower concentrations. For instance, 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 false positive and false negative results. Different most other laboratory results, all the same, results of urine drug tests tin exist accurate and all the same yield misleading data – in other words a test tin yield a true negative issue in the context of ongoing psychoactive substance use (east.g., if the test was performed outside the window of detection of the drug that the adolescent was using), or a true positive effect in the context of no use of psychoactive substances (eastward.k., if the exam detects substances plant in food such as poppy seeds, which can trigger an opioid screen, or in a patient's prescribed medications such equally stimulants for ADHD, which can trigger an amphetamine screen). Urine drug tests may also yield cryptic results if a test is besides dilute for estimation, or does not friction match a patient's stated history. Because of their differing backdrop, different interpretation strategies are required for IA screening tests as compared to confirmatory GC-MS tests.

a. Estimation of IA tests

Enzyme-linked IA tests are relatively quick, inexpensive, and easy to perform and as such are often used past laboratories as a first line screen. This testing format identifies drugs or metabolites above a certain threshold concentration in the urine. Typically the threshold concentration is set high enough to limit detection of low levels of drugs or metabolites that may be found in foods. For example, poppy seeds incorporate very depression levels of morphine that tin be detected by sensitive tests, simply under usual circumstances concentrations of morphine in the blood and urine from consuming typical amounts of poppy seeds will be well under the detection threshold.

IA is not-specific and cantankerous-reactions can occur. As an example, quinolone antibiotics can cantankerous react with an opioid panel yielding a faux positive exam result. To eliminate this blazon of error, IA tests should exist confirmed with a more definitive chromatographic test (east.m., GC-MS), particularly if a test result is unexpected and does non correlate with a patient's history.

b. Interpretation of confirmatory chromatography tests

Chromatographic tests generally take longer to perform, are more than 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. Notwithstanding, chromatographic tests tin detect prescribed medications (such as stimulants used for ADHD treatment) and it 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.chiliad., crushing and snorting pills).

c. Estimation of negative tests

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

The window of detection has passed. The window of detection for nigh substances is 2-three days and drug utilise will not be detected after this catamenia. Ane notable exception is heavy, chronic apply of cannabis, which tin result in prolonged excretion for up to 4 weeks [14], complicating interpretation during this menses.
The patient has used a substance not detected by the testing console. While most any substance tin be tested for in urine, standard test panels are limited to commonly used substances. For case, constructed cannabinoids are non detected by standard tests for cannabis and should be ordered separately if apply is suspected. Inhalants are excreted by the lungs and cannot be detected in a urine specimen.
The concentration of the substance is below the detection limit of the examination. 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 imitation positives from cross-reaction or trace amounts of a drug or metabolite that may be found in food products. Intentional urine dilution may event in a falsely negative test.
The specimen has been substituted or adulterated. Distinct from most instances of laboratory medicine, patients may be motivated to falsify exam results past substituting or adulterating specimens. Proper specimen collection techniques (see above), employ of temperature testing, and adulterant panels can minimize opportunities for interfering with testing in this way.

d. Presenting drug test results to adolescents

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

In almost instances it is useful to have a private conversation with the adolescent to clarify estimation of the drug test effect. Simply sharing that the drug test yielded an "unexpected result" without revealing specific details may set the stage for an honest conversation near substance use, and at times, patients will reveal utilise of substances that were not detected past the test. If the patient gives a history that is consistent with the drug exam results the conversation can motion on to a give-and-take of next steps – which could include changes to the handling program. 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 at present agreed to speak with a counselor near anxiety and marijuana use.

When a drug test event is dilute or otherwise ambiguous a clinical interview may be helpful. Starting with a simple argument most an "unexpected test result" without revealing all of the details tin serve as an open-ended fashion of offset the conversation. If a patient does not report substance utilise the clinician tin can review methods for reducing the chance of a dilute specimen – by providing a first forenoon urine if possible, or if not, limiting water 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 consequent with the observed drug exam 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 test can be interpreted as negative (i.e., consistent with a history of no illicit substance use).

In some instances an adolescent's history may be inconsistent with observed drug test results. As with all laboratory testing, drug test results provide limited data and clinical correlation is ever advised. A single positive drug test may be spurious and can exist treated that way if the patient otherwise seems to be doing well and adhering to the treatment plan. In these cases repeat urine testing is recommended; a second occurrence of a positive drug test is unlikely to be another false-positive outcome. In this case, the clinician may recommend modifications to the treatment plan.

Decision

Drug testing, when carefully collected and thoughtfully interpreted, offers a disquisitional adjunct to clinical care and substance employ handling (Box ane). Yet, considering examination results can exist misleading if non interpreted in the correct clinical context, clinicians should ever conduct a conscientious interview with boyish patients to empathise what testing is probable to show so 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 ain drove protocols and sample validation procedures to ensure optimal accuracy.

Box 1

Key Points

Routine laboratory testing of adolescents, whether in chief intendance, school or at home is not recommended though testing may be useful in a number of clinical situations.
Laboratory testing is circuitous and requires careful attention to specimen drove and interpretation of results.
Equally with all laboratory testing, drug testing offers limited information and should always be interpreted in a clinical context.

Acknowledgments

Dr. Hadland is supported by the Division of Adolescent and Young Adult Medicine at Boston Children's Hospital and the Leadership Education in Boyish Health Grooming Programme T71 MC00009 (MCH/HRSA) and by a National Research Service Honor 1T32 HD075727 (NIH/NICHD). Dr. Levy is supported by 1R01AA021913–01 (NIH/NIAAA).

Footnotes

Conflict of Interest Argument

The authors have no conflicts of interest to disclose.

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References

1. Moyer VA. Screening and behavioral counseling interventions in chief care to reduce alcohol misuse: U.S. preventive services chore force recommendation statement. Ann Intern Med. 2013;159:210–8. [PubMed] [Google Scholar]

ii. National Institute on Alcohol Abuse and Alcoholism. Alcohol Screening and Cursory Intervention for Youth: A Practitioner's Guide. Bethesda, MD: 2011. [Google Scholar]

3. Higgins-Biddle J, Hungerford D, Cates-Wessel Thou. Screening and Brief Interventions (SBI) for Unhealthy Alcohol Use: A Step-by-Pace Implementation Guide for Trauma Centers. Atlanta, GA: 2009. [Google Scholar]

4. Levy SJ, Kokotailo PK. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011;128:e1330–twoscore. [PubMed] [Google Scholar]

5. Levy S. Effects of marijuana policy on children and adolescents. JAMA Pediatr. 2013;167:600–2. [PubMed] [Google Scholar]

7. Levy S, Siqueira LM, Ammerman SD, et al. Testing for drugs of corruption in children and adolescents. Pediatrics. 2014;133:e1798–807. [PubMed] [Google Scholar]

8. American Society for Habit Medicine. Drug Testing: A White Paper of the American Order of Addiction Medicine (ASAM) Chevy Chase, Medico: 2013. [Google Scholar]

9. Substance Corruption and Mental Health Services Administration. Clinical Drug Testing in Main Care Technical Assistance Publication (TAP) 32 HHS Publication No (SMA) 12-4668. Rockville, Dr.: 2012. [Google Scholar]

xi. Levy Southward, Harris SK, Sherritt L, et al. Drug testing of adolescents in convalescent medicine: physician practices and cognition. Arch Pediatr Adolesc Med. 2006;160:146–50. [PubMed] [Google Scholar]

12. Jones RK, Shinar D, Walsh JM. Detection and Measurement of Drugs State Knowl Drug-Dumb Driving, NHTSA Rep DOT HS 809 642. Washington, DC: US National Highway Traffic Prophylactic Administration; 2003. [Google Scholar]

thirteen. Grotenhermen F. Pharmacokinetics and pharmacodynamics of cannabinoids. Clin Pharmacokinet. 2003;42:327–60. [PubMed] [Google Scholar]

14. Schwilke EW, Gullberg RG, Darwin WD, et al. Differentiating new cannabis utilise from residue urinary cannabinoid excretion in chronic, daily cannabis users. Habit. 2011;106:499–506. [PMC free commodity] [PubMed] [Google Scholar]

15. Cone EJ. New Developments in Biological Measures of Drug Prevalence. In: Harrison 50, Hughes A, editors. Validity Self-Reported Drug Utilize Improv Accuracy Surv Estim. Bethesda, Md: National Plant on Drug Corruption; 1997. [Google Scholar]

16. Dams R, Choo RE, Lambert Nosotros, et al. Oral fluid as an alternative matrix to monitor opiate and cocaine employ in substance-abuse treatment patients. Drug Alcohol Depend. 2007;87:258–67. [PMC free article] [PubMed] [Google Scholar]

19. Boumba V, Ziavrou K, Vougiouklakis T. Hair equally a Biological Indicator of Drug Utilize, Drug Abuse or Chronic Exposure to Environmental Toxicants. Int J Toxicol. 2006;25:143–63. [PubMed] [Google Scholar]

20. Dolan K, Rouen D, Kimber J. An overview of the apply of urine, hair, sweat and saliva to detect drug use. Drug Alcohol Rev. 2004;23:213–vii. [PubMed] [Google Scholar]

21. Warner E, Lorch E. Laboratory Diagnosis. In: Ries RK, Fiellin DA, Miller SC, et al., editors. ASAM Princ Aficionado Med. 5. Philadelphia, PA: 2014. [Google Scholar]

22. Pragst F, Balikova MA. State of the art in pilus analysis for detection of drug and alcohol abuse. Clin Chim Acta. 2006;370:17–49. [PubMed] [Google Scholar]

23. Henderson GL, Harkey MR, Zhou C, et al. Incorporation of isotopically labeled cocaine and metabolites into human hair: 1. dose-response relationships. J Anal Toxicol. 20:one–12. [PubMed] [Google Scholar]

24. Ropero-Miller JD, Huestis MA, Stout PR. Cocaine analytes in human pilus: evaluation of concentration ratios in different cocaine sources, drug-user populations and surface-contaminated specimens. J Anal Toxicol. 2012;36:390–viii. [PubMed] [Google Scholar]

25. Dasgupta A. Handbook of Drug Monitoring Methods: Therapeutics and Drugs of Abuse. Totowa, NJ: 2008. [Google Scholar]

26. Pötsch L, Skopp G, Moeller MR. Influence of pigmentation on the codeine content of hair fibers in republic of guinea pigs. J Forensic Sci. 1997;42:1095–viii. [PubMed] [Google Scholar]

28. Concheiro M, Jones HE, Johnson RE, et al. Maternal buprenorphine dose, placenta buprenorphine, and metabolite concentrations and neonatal outcomes. Ther Drug Monit. 2010;32:206–15. [PMC free article] [PubMed] [Google Scholar]

29. Grayness T, Huestis M. Bioanalytical procedures for monitoring in utero drug exposure. Anal Bioanal Chem. 2007;388:1455–65. [PMC free article] [PubMed] [Google Scholar]

30. Hudak ML, Tan RC. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540–60. [PubMed] [Google Scholar]

31. Stanger C, Budney AJ. Contingency management approaches for boyish substance use disorders. Child Adolesc Psychiatr Clin N Am. 2010;19:547–62. [PMC costless article] [PubMed] [Google Scholar]

32. Hartzler B, Lash SJ, Coil JM. Contingency management in substance abuse treatment: a structured review of the testify for its transportability. Drug Alcohol Depend. 2012;122:one–10. [PMC free commodity] [PubMed] [Google Scholar]

33. Shearer J, Necktie H, Byford S. Economical evaluations of contingency management in illicit drug misuse programmes: A systematic review. Drug Booze Rev. 2015;34:289–98. [PubMed] [Google Scholar]

34. Dennis M, Godley SH, Diamond G, et al. The Cannabis Youth Treatment (CYT) Study: principal findings from 2 randomized trials. J Subst Abuse Treat. 2004;27:197–213. [PubMed] [Google Scholar]

36. Levy S, Schizer 1000. Adolescent Drug Testing Policies in Schools. Pediatrics. 2015;135:782–iii. [PubMed] [Google Scholar]

37. Centre for Substance Abuse Treatment. Substance Abuse and Mental Wellness Assistants. Rockville, Doc: 1999. Chapter eight—Legal and Ethical Issues. [Google Scholar]

39. Johnston LD, O'Malley PM, Miech RA, et al. Monitoring the Future National Results on Drug Use: 2014 Overview. Key Findings on Boyish Drug Apply [Google Scholar]

40. Rengarajan A, Mullins ME. How oftentimes exercise false-positive phencyclidine urine screens occur with use of common medications? Clin Toxicol. 2013;51:493–vi. [PMC free article] [PubMed] [Google Scholar]

41. Nanau RM, Neuman MG. Biomolecules and Biomarkers Used in Diagnosis of Alcohol Drinking and in Monitoring Therapeutic Interventions. Biomolecules. 2015;5:1339–85. [PMC free article] [PubMed] [Google Scholar]

42. Warner East. Princ Aficionado Med. 3. Chevy Chase, MD: American Lodge of Addiction Medicine; 2003. Laboratory Diagnosis; pp. 337–48. [Google Scholar]

43. Eye for Substance Abuse Handling. The Role of Biomarkers in the Treatment of Alcohol Utilise Disorders. Rockville, Physician: 2006. [Google Scholar]

44. Kwong TC, Ryan RM. Detection of intrauterine illicit drug exposure by newborn drug testing. National Academy of Clinical Biochemistry. Clin Chem. 1997;43:235–42. [PubMed] [Google Scholar]

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920965/