CLINICAL REPORT

Testing for Drugs of Abuse in Children and Adolescents

abstractDrug testing is often used as part of an assessment for substance usein children and adolescents. However, the indications for drug testingand guidance on how to use this procedure effectively are not clear. Thecomplexity and invasiveness of the procedure and limitations to theinformation derived from drug testing all affect its utility. The objectiveof this clinical report is to provide guidance to pediatricians and otherclinicians on the efficacy and efficient use of drug testing on the basisof a review of the nascent scientific literature, policy guidelines, andpublished clinical recommendations. Pediatrics 2014;133:e1798–e1807

INTRODUCTION

The recreational use of drugs is an underrecognized cause of mortalityand morbidity in children and adolescents. It is, in fact, a public healthpriority.1 Although annual surveys of drug use by children and adoles-cents may show fluctuation, the underlying rates remain high.2 Numer-ous adverse consequences accompany use, not the least of which is theincreased risk of dependence among those who began smoking, drink-ing, and using drugs before 18 years of age.3,4 Furthermore, most adultswith substance use disorders initiated use during childhood or adoles-cence.5 Pediatricians are on the front lines for deterring, delaying,detecting, and diminishing the use of drugs by children. It is imperativethat all pediatricians understand and are ready to use the tools andstrategies effective for these endeavors.

Drug testing has been recommended in a variety of settings and clinicalsituations to avert substance use, to identify use as part of an as-sessment, or as part of treatment of individuals with substance usedisorders. To date, there is little consensus among physicians regardingthe indications for drug testing and little guidance on how to use thisprocedure effectively for any indication.6 The federal government hasissued extensive guidance on the use of urine drug testing with federaland other employees,7 although this guidance is not applicable for allsituations and age groups. Experts have called for further evidence-based studies to guide best practices with adolescents.8

The complexity and invasiveness of the procedure and limitations tothe information derived from drug testing all affect its utility. Theobjective of this clinical report is to provide guidance on the efficacyand efficient use of drug testing on the basis of a review of the nascentscientific literature, policy guidelines, and published clinical recom-mendations.

Sharon Levy, MD, MPH, FAAP, Lorena M. Siqueira, MD,MSPH, FAAP, and COMMITTEE ON SUBSTANCE ABUSE

KEY WORDSdrug testing, drug testing results, positive and negative drugtesting results

ABBREVIATIONSAAP—American Academy of PediatricsTHC—tetrahydrocannabinol

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0865

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SPECIMEN TYPES

Six biological matrices are commonlyused for drug assays: urine, blood,breath, saliva, sweat, and hair. Neonatesmay also be tested using meconium. Thechoice of sample is influenced by thecost, ease of sample collection, risk ofadulteration, test type (instant or labo-ratory based), scope of drugs beingtested, time frame (acute or chronicuse), time since last use, and indicationsfor testing. Practices and laboratoriesshould only conduct tests for which theyare certified by the Clinical LaboratoryImprovement Amendments.

Breath testing is mainly used by lawenforcement and alcohol treatmentprograms for detection of recent alcoholuse; it is not, however, routinely used inprimary care. It is an easy-to-use, non-invasive test that is considered a goodproxy for blood alcohol concentrations;urine alcohol concentrations, on theother hand, do not correlate well withblood alcohol concentrations or corre-sponding central nervous system im-pairment. Alcohol mouthwash or breathsprays used immediately before testingmay result in false-positive test results.

Carbon monoxide and a nicotine me-tabolite known as cotinine are the 2products in tobacco that are used forscreening. Carbon monoxide can bemeasured in the breath up to 24 to 48hours after smoking and then falls tononsmoker levels. Cotinine is regardedas the best biomarker of tobacco ex-posure because it has a long half-lifeand can be measured in blood, saliva,hair, and urine.9,10

Blood concentrations are most usefulfor detecting alcohol and other druguse that occurred within 2 to 12 hoursof the test and are best correlated withthe level of impairment and morbidityseen in emergency situations. Bloodtesting is costly because of the need forspecially trained personnel and equip-ment and is intrusive. Because of these

drawbacks, blood testing is rarely usedin the primary care setting.

Saliva (oral fluid) and sweat testingprovide similar information to bloodtesting but are less invasive and do notrequire extensive training for samplecollection. Saliva allows for detection ofdrug excreted from the blood after re-cent use (ie, within 24–48 hours) thatmay not yet be detectable in urine. It isless subject to contamination thanurine; smoking and methods used tostimulate saliva production to increasespecimen volume may affect the results.Therefore, this method requires patientsupervision in the 30 minutes beforesampling.11 Point-of-care tests are avail-able for saliva testing.12

Sweat may be used to detect drug use in2 ways. First is a patch that is worn from3 to 7 days and detects drug use thatoccurred just before the patch wasapplied (most drugs will be excretedwithin 48 hours) and drug use thatoccurs while the patch is in place.Second, a swipe may detect drug usewithin the past 24 hours (collectiondevice not approved by the US Food andDrug Administration). The collection isnoninvasive and has a similar cost tourine. Although difficult, environmentalcontamination can occur and lead tofalse-positive results.13 Specimen vol-ume may be affected both by thepatient’s sweat secretion rates or re-moval of the patch during the collectionperiod. The sample size obtained withoral fluid and sweat patch tests limitsthe ability to repeat tests and performconfirmatory testing. Both saliva andsweat assays are less standardizedthan urine or blood tests, and the ac-curacy of sweat testing remains con-troversial.14–16

Hair testing allows for detection ofpast use that has occurred over anextended time because drugs andmetabolites are incorporated into thehair matrix over time. Hair cannot beused for detection of use in the pre-

vious 7 to 10 days. It is most reliablefor heavy, frequent past use and notfor detection of recent or occasionaldrug use. The hair needs to be cut asclose to the scalp as possible, andusually the first 3 cm is used fortesting, which covers a 90-day period(hair grows 1 cm a month). If longerhair is sent, the laboratory will cut itinto segments before testing, and 4tests will allow for screening overa period of a year. If the scalp isshaved, hair from other body areasmay be sent instead. However, hairgrows at a slower rate on the body,and a time frame cannot be used inthis circumstance. Hair collection canbe directly observed and is non-invasive, hair is easily stored andtransported, and adulteration andsubstitution is difficult. However, hairtesting is not useful clinically, becauseit has a long window of detection. Inaddition, hair structure, growth rate,melanin content, hygiene, and cosmetictreatment can affect the results. Drugconcentrations in hair can be altered byshampoos, bleaches, or dyes, and false-positive results may be obtained withvolatile drugs such as marijuana, whichmay adhere to hair.17,18 No point-of-caretests are available; laboratory testingis costly, and it takes a long time toobtain results.

Urine testing is invasive and highlysusceptible to tampering. Nonetheless,because it is well standardized andstudied, less invasive than blood testing,and provides a longer window of de-tection for some substances, it is themost common sample used for drugtesting in primary care. A physiciansurvey6 found that >90% of pediatricianand family physician respondents hadused urine testing with adolescentpatients in their office, suggesting thatthe practice is quite common. In theremainder of this report, “drug testing”will refer to urine drug testing unlessotherwise indicated.

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URINE DRUG TESTS

Two types of drug testing assays areavailable: qualitative tests usually usedfor screening and quantitative testsused for confirmation. Qualitative testsare point-of-care tests and home drugtest kits. They are easy to perform,relatively inexpensive, and use immu-noassays, such as enzyme-linked im-munoassay or radioimmunoassay, thatgive instant positive or negative re-sults. Although they are sensitive andfunction well as screening tests, theyare susceptible to cross-reactions, re-sulting in false-positive results, whichlimit their specificity. Some laborato-ries use qualitative tests as a “screen-ing procedure”; in this method, negativetest results are discarded, and onlypositive test results are run throughmore expensive confirmatory testing,although the 2-step procedure hasbecome less common as the cost ofconfirmatory testing has decreased.Confirmatory tests are performed inlaboratories and not at the point ofcare. Most laboratories use a combi-nation of gas chromatography andmass spectrometry and can positivelyidentify a substance and generatequantitative concentrations.

INDICATIONS FOR DRUG TESTING

The illicit and often secretive nature ofsubstance use may result in adoles-cents being unwilling to give accurateinformation about their substance use,and thus drug testing may yield im-portant information, as in the varioussituations discussed below.

Emergent Clinical Care

Drug testing may identify possibletoxins when a patient presents withaltered mental status. In truly emer-gent situations, consent may beinferred, and testing should be con-sidered in accident victims, aftera suicide attempt, for unexplained

seizures, for syncope or arrhythmias,or in the presence of toxidromal signsand symptoms that render the patientincapable of informed consent. In thecase of a toxidrome, physical findingsshould guide the clinician to test fora specific panel of substances, evenwith minimal or no history available. Apositive test result for a substancesuspected on the basis of clinicalfindings is less likely to be a false-positive or spurious result becauseof the higher pretest probability in thissetting. However, drug testing hassignificant limitations, even in theemergency setting. Standard labora-tory tests detect drug metabolites withan unreliable frequency and often havereference ranges far lower thantherapeutic dosages; thus, they mayidentify substances that are presentbut not causing the observed symp-toms. Emergency management of anobtunded patient, such as the decisionto give naloxone, is made on clinicalgrounds and not on the basis of resultsof a laboratory test. Nonetheless, theresults of a drug test may be helpful indetermining management once thepatient is stabilized.19

Assessment of Behavioral orMental Health Symptoms

Drug use by teenagers often presentsto medical attention with nonspecificsigns and symptoms (such as fatigue,excessive moodiness, school failure)and, as such, may be hard to diagnosedefinitively. Voluntary drug testing maybe a useful part of an assessmentwhen a parent, clinician, or other adultsuspects recent or ongoing drug useon the basis of observed symptoms.Like any other laboratory procedure,drug testing should be an adjunct toa thorough history rather than a re-placement. In cases in which an ado-lescent denies use, a positive drug testresult may afford an opportunity tobegin an honest conversation. Drugtesting may be unnecessary if a patient

is forthcoming regarding his or herdrug use history. Unfortunately, sig-nificant limitations to laboratory drugtesting limit the information garneredfrom the procedure (see “Sources ofError in Interpreting Urine DrugTests”). Like any other laboratory test,drug test results must always beinterpreted within the context of his-tory, including both collateral and self-reports when possible.

THERAPY AND MONITORING

Drug testing programs that use con-tingency management strategies maybe an effective therapeutic adjuvantfor patients with substance useproblems or disorders.20,21 Patientstypically receive either positive re-inforcement, such as cash rewards orsmall gifts, when a drug test result isnegative or negative consequenceswhen a drug test result indicates on-going drug use.22 Research has con-sistently demonstrated the efficacy ofthese programs among adults, andemerging research suggests thatdrug testing is acceptable and effec-tive with adolescents and youngadults participating in drug abusetreatment programs.23 Drug testing isalso frequently used as a deterrentfor juveniles in the probation system.Juvenile drug courts, which includefrequent drug testing, have beenshown to decrease substance usemore so than traditional familycourts. It has been suggested thateven in the absence of additionaltherapies, the monitoring function oftesting can be an effective discour-agement from use.24,25 The effectivedrug testing programs that have beendescribed in the literature are rela-tively expensive, are staff intensive,and may not be well suited for pri-mary care. Engaging parents andsupporting them in implementing ap-propriate contingencies could de-crease the overall expenses of such

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a program; when appropriate, paren-tal monitoring may also serve asa contingency, with negative resultsintrinsically rewarding. One studyfound that a drug-testing program inwhich parents received test resultsfrom the physician would be accept-able to adolescents,26 although todate, no study has demonstrated theeffectiveness of such an approach.

SCREENING

A national survey of physicians foundthat few respondents use “suspicion-less” drug testing as a means ofscreening for drug use in the medicalhome,6 and most experts agree thatdrug tests are not a useful screeningprocedure for general clinical pop-ulations because their sensitivity fordetecting drug use in unselected pop-ulations is low.27,28 However, home-,school-, or employment-based pro-grams may include a screening com-ponent (ie, unselected or generalpopulations may be tested) to detector deter drug use. Participant consentshould be required for all of theseprograms, as it would be in a clinicalsetting.

Results of studies of school-baseddrug testing programs are mixed:drug testing has poor sensitivity fordetecting drug use, although somestudies have found a deterrent effect.The American Academy of Pediatrics(AAP) does not endorse widespreadimplementation of school-based drugtesting because of the limited efficacy,its cost, and the potential for unin-tended effects, such as breach of con-fidentiality. School-based drug testingis discussed in greater detail in a sep-arate AAP statement.29

HOME DRUG TESTING

Drug tests have been commerciallyavailable and marketed to parents toprevent adolescent drug use for the

past 15 years. Marketing Web sitesoften include “home drug testing pol-icies” that recommend drug testingon either a routine basis to preventdrug use or when a parent has spe-cific concerns.30 Home drug testinghas been endorsed by several schooldistricts and police departmentsaround the country. To date, the effi-cacy of home drug testing for re-ducing substance use by adolescentshas not been rigorously tested. TheAAP does not endorse home drugtesting because of concerns about thecomplexity of testing with significantpotential for parents to misinterprettest results, limited evidence thathome drug testing reduces drug use,and theoretical concerns about a neg-ative effect on the relationship be-tween parents and their children. Aprofessional evaluation should beconsidered whenever a parent hasconcerns about substance use.31

SCHOOL CLEARANCE

Some schools require “medical clear-ance,” including a negative drug testresult, before readmitting a studentwho has been suspended for drug useor possession. In these cases, the AAPsuggests that the pediatrician conducta thorough history to understand thestudent’s level of drug involvement.Although there are no specific guide-lines for “medical clearance,” the AAPsuggests that students who have beencaught with drugs or paraphernaliaor who were impaired at schoolshould be allowed to return to school(after disciplinary consequences setby the school). At the conclusion ofa medical evaluation, it is importantto include a plan for follow-up and/ortreatment in addition to consideringa return to school, unless assessmentsuggests a serious substance usedisorder requiring a more restrictivetreatment setting, in which case theadolescent should be referred. TheAAP cautions that “clearance” has no

uniformly accepted definition in themedical or legal literature; variousindividuals, such as parents, teachers,and school administrators may havedifferent interpretations of clearancethan do pediatricians. Pediatricianscould, therefore, report the followingas appropriate: (1) the student hasreceived an appropriate medical evalu-ation and (2) reasonable medical stan-dards indicate that return to school isa reasonable option. Furthermore, par-ents must consider their adolescent’sindividual risks and benefits whilecontinuing to monitor their adolescent’sbehaviors.

A drug test may be particularly usefulfor adolescents who report limited orinfrequent drug use. In these cases,a negative test result would be ex-pected and would support the ado-lescent ’s history. A brief period ofmonitoring with random tests mayfurther support the student’s historyof limited use. Adolescents who reportheavy use, particularly of marijuana,are likely to have a positive drug testresult even several days to weeks af-ter termination of use. In these cases,a period of monitoring until a negativetest result is obtained may be useful,although the AAP suggests that theadolescent return to school whileawaiting a negative test result. Quan-titative tetrahydrocannabinol (THC)concentrations may be followed todistinguish between prolonged excre-tion and ongoing drug use. Theselevels should be corrected for urineconcentration to improve accuracy;one common method is to calculatea THC-to-urine creatinine ratio.32

A student or parent may refuse a drugtest and instead accept the school’sconsequences or fight them. There islittle legal precedent with regard towhether a school has the right to insiston a drug test from an individual stu-dent in this situation; however, 2 Su-preme Court decisions both supported

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a school’s right to require drug testingfor students who participate in sportsor other extracurricular activities.33,34

The AAP suggests that the pediatricianadvise the student and family in thissituation to submit to a drug test andthen advocate for returning to schoolas outlined previously, although ulti-mately, the student and his or herparent determine how to proceed.

SOURCES OF ERROR ININTERPRETING URINE DRUG TESTS

False-Positive Results

Like any medical laboratory test, drugtesting can yield false-positive or false-negative results. In urine drug testing,a “clinical” false-positive result (ie,drug detection in the absence of illicitdrug use) is more likely to occur ona screening test because of cross-reactivity with an unrelated substancein the urine. For example, fluoroquin-olone antibiotics have been reported tocross-react with immunoassay opiatescreens.35,36 Confirmatory tests arehighly unlikely to yield false-positiveresults but can yield a “clinical false-positive” result when a patient takesa certain prescription medication oringests a food that metabolizes intoa substance included in the drug test-ing panel. For example, a patient takingamphetamine and dextroamphetaminefor attention-deficit/hyperactivity dis-order will have a positive test resultfor amphetamines, which may befalsely positive for substance abuse.Unfortunately, drug testing cannotdistinguish between appropriate useand misuse of prescribed medica-tions. To interpret drug test resultsaccurately, it is necessary to know anindividual’s complete medical history,including prescribed medications. Inaddition, the practitioner needs toknow the limitations of the selectedmatrix, the substances for which thedrug panel tests, and potential cross-reactivity. The practitioner should not

hesitate to ask for assistance in or-dering the correct test or interpretingresults.

False-Negative Results

A negative drug test result does notnecessarily mean that an adolescent isnot using a particular substance. Theurine specimen submitted may not bea valid sample, as when an adolescentattempts to evade a positive test bysubmitting someone else’s urine, diluteshis or her own urine, or adds an adul-terating (or “masking”) agent to thesample to interfere with the screeningimmunoassay (eg, soap, bleach, ammo-nia). Even in the absence of adulteration,use may escape detection because of thetiming of use relative to the testing, or ifthe cutoff concentration for a positivetest result is set too high, small amountsof drug or metabolite may be missed.Another example occurs when the psy-choactive substance used is not part ofthe standard test panel, resulting ina “clinical false-negative” test result (eg,“spice” and newer designer drugs). Testpanels often use a common metaboliteto identify an entire class of substances(see Table 1). However, individual sub-stances with variant metabolism can stillbe missed. For example, benzodiazepinepanels that identify oxazepam will notidentify clonazepam, which is commonlymisused by adolescents but not metabo-lized through this pathway. Thus, inter-preting drug test results can beexquisitely complex, even for experiencedclinicians, and should be done with cau-tion. Seeking assistance from the testinglaboratory is important, particularlywhen test results do not correlate withclinical findings and when a physiciansuspects the use of a particular sub-stance that is not included in a test panel.

URINE SPECIMEN COLLECTION

An accurate test result is dependent onobtaining a proper specimen. Directobservation is the most reliable

method for specimen collection. It isrecommended that each treatmentfacility have a protocol in place thatdescribes how urine specimensintended for drug testing will be col-lected from both male and femalepatients. It is also recommended thatrandom specimens or those takenwithout supervision be labeled assuch. Specimens that may havepertinence to a legal matter (eg,those taken after a motor vehiclecrash or as part of a court-orderedprogram) may require collection ina tamper-proof container and alsorequire chain of custody. When this isnot practical, the patient should bereferred to a laboratory facility thathas this capability.

A less-invasive collection methodinvolves excluding coats and bags andusing a specially prepared restroomwithout running water, soap, or otherchemicals. Toilet water should be tinted.The specimen’s appearance and colorshould be documented and the tem-perature should be taken within 4minutes, preferably by use of a collectioncontainer with a temperature-sensitivestrip on the outside. The tempera-ture should be recorded within 4minutes of collection and shouldrange from 90°F to 100°F (32°–38°C).The procedure should be explained tothe patient before any collection. Anational survey of physician practicesfound that most offices use none ofthese procedures (although many pro-vide a staff member outside the door tolisten for running water).37 If un-supervised collection is used, resultsshould be interpreted with caution.

Modesty

In all cases, the need to obtain in-formation from a drug test must bebalanced with protecting an adolescent’sdignity. If a reasonable balance cannotbe attained, the pediatrician might con-sider forgoing a drug test and basing

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clinical decisions on history and physicalexamination alone. This may include re-ferring a patient for further evaluationor treatment on the basis of a highindex of suspicion of drug use. Signsand symptoms of a mental health, be-havioral, or substance use disorder

should not be discounted because ofinability to obtain a drug test.

CONFIDENTIALITY

Many national organizations, includingthe AAP, have consistently cautioned

against involuntary drug testing inadolescents.31 Adolescents should beengaged in their own care and, in moststates, can consent to substance abusetreatment on their own.38,39 Drug testingof a competent adolescent without hisor her consent is, at best, impractical

TABLE 1 Approximate Duration of Detectability and Common Cutoffs for Selected Drugs

Drug Metabolite Window of Detection Comments

Alcohol Alcohol 7–12 h Ethyl succinate and ethyl glucuronide can persist in theurine up to 5 d after heavy alcohol use. However, useof hand sanitizer, mouthwash, cough syrup, etc, canresult in low levels without “alcohol use.”

Ethyl succinate, ethyl glucuronide Up to 5 dAmphetaminesAmphetamine (AMP) MAMP 1–3 d Note that methylphenidate is not detected on a routine

amphetamine panel; therefore, a positiveamphetamine test result cannot be explained by useof a methylphenidate preparation.

Methamphetamine(MAMP)

>100 ng/mL of AMP+MAMP 1–2 d

3,4-MethylenediozyAMP MDA 1–2 d3,4-MethylenediozyMAMP MDMA 1–2 d

BarbituratesPento/secobarbital Secobarbital Short-acting, 4–6 dButalbital Secobarbital Intermediate, 3–8 dPhenobarbital Secobarbital Long-acting, 10–30 d

BenzodiazepinesTriazolam Hydroxyethyl flurazepam Short-acting, 1 d Most benzodiazepine screens identify oxazepam and will not

pick up all benzodiazepines. If evaluating a patient forbenzodiazepine use, it is important to find the specific drugon the test panel or speak with the laboratory personnel.

Clonazepam 7-amino Clonazepam Intermediate, 1–12.5 dDiazepam Oxazepam Long-acting, 5–8 dChronic use Can last 30 d after last use

Cocaine Benzoylecgonine 1–3 dCannabinoids Carboxy-THC Single use, 1–3 d Note that synthetic cannabinoids will not be picked up

on a cannabinoid screen. If use of syntheticcannabinoids is suspected, speak to the laboratoryregarding availability of tests for these substances.

Moderate use, 4 d; heavy use, 10d

Chronic, 3–5 wk after last useLysergic acid diethylamide

(LSD)Nor-LSD 4 h

Methadone Methadone and metabolite2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine

1 d–1 wk

OpiatesMorphine (M) Morphine 1–2 dCodeine (C) Morphine and codeine 1–2 d

Semisynthetic opiates Hydrocodone 1–2 dHydromorphone 1–2 dOxycodone 1–3 dOxymorphone 1.5–2.5 d

Heroin 6-acetyl-morphine +morphine <24 h up to 1–2 d 6-acetyl-morphine is pathognomonic for heroin use buthas a narrow time window and is most often notdetected on a drug test. A test that is positive formorphine outside of the use of prescribed morphineis suggestive of heroin use.

Phencyclidine (PCP) Phencyclidine Casual use, 2–10 dChronic use, several weeks

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and without his or her knowledge isunethical and illegal. However, an ado-lescent’s refusal to consent to a drugtest should not prematurely concludean evaluation of a substance useproblem or disorder. If a pediatriciansuspects that an adolescent is usingdrugs and that adolescent is refusinga drug test, his or her refusal should bedocumented, and referral to an addic-tion or mental health specialist is war-ranted. Pediatricians may also coachparents on appropriate limit setting ordiscipline. For example, a parent maysuspend driving privileges if there issuspicion that an adolescent is usingpsychoactive substances; privileges maybe restored if the teenager can rea-sonably demonstrate that he or she isnot using substances.

Adults who have a long-term re-lationship with an adolescent are oftenaware of early behavioral, mentalhealth, and physical changes that mayprompt the request for drug testing.Before drug testing, the pediatricianshould get a detailed description of theconcerns to formulate a differentialdiagnosis and determine whethera drug test may be a helpful part of anassessment. If so, a discussion aboutthe limited scope of informationavailable from testing as well as theneed to reach a consensus on an ac-tion plan for both positive and negativeresults should be undertaken. This willmake any intervention easier to im-plement. The concerns raised by theadult and the recommendation fora drug test should then be discussedwith the adolescent, and assent, in-cluding permission to share results,should be obtained before testing. If anadolescent refuses to consent tosharing the drug test results witha parent then they should not beshared. If the drug test was requestedby the parents, the pediatrician shouldexplain to them that their son ordaughter has not consented to release

drug test results. However, as in allsituations, if an adolescent’s behaviorputs him or her at acute risk of harm toself or others, the pediatrician shouldconsider breaching confidentiality.

MANAGEMENT

Ideally, drug test results may reassureparents or lead to an honest conver-sation about drug use that can guidefurther intervention. Unfortunately, ifmanaged poorly, drug test results maybe contentious, cause friction betweenan adolescent and his or her parents,and create a difficult situation for theclinician to manage. The AAP believesgood outcomes are more likely if thepediatrician reviews how test resultswill be managed before a test is sentto the laboratory.

In most instances in which a drug testis ordered for an adolescent patient,parents will want to know the results,and with few exceptions, sharing drugtest results with parents is a helpfulpart of the process of drug testing. Oneexception would be a treatment-seeking adolescent who does notwant to inform parents, and testing isused as a form of therapy. This situ-ation is rare in primary care, but ifencountered, the pediatrician shouldrespect the engaged adolescent’s au-tonomy. Adolescents younger than 18years are able to consent to sub-stance use treatment without parentalconsent in more than half of theUnited States. It is important for thepractitioner to learn about laws gov-erning confidentiality in the states inwhich they practice.

Positive Test Results

Because drug tests may yield false-positive test results, we suggestthat the clinician always reviewpositive results first with the ado-lescent to determine whether some-thing other than substance misusemay explain the observed results. The

pediatrician should consider both thelaboratory results and the historybefore assessing the likelihood ofsubstance use and presenting infor-mation back to parents.

The pediatrician may begin the inter-action by informing the adolescentthat the drug test gave unexpectedresults (which could refer to a testinterpreted by the physician as posi-tive, dilute, or adulterated) and askingfor more information. In some in-stances, the adolescent may reportsubstances not detected on the panel,ultimately yielding more informationthan the test results alone conveyed. Ifthe adolescent’s report matches thedrug test results, the pediatrician canbegin a conversation about the nextsteps, which may include an absti-nence trial, ongoing testing, and/ora referral to counseling or other treat-ment. If reports of drug use match theresults of a point-of-care test, confir-matory testing, which adds consider-able expense, could reasonably beomitted.

If an adolescent denies substanceuse despite a positive drug test re-sult without a reasonable alternativeexplanation, the pediatrician canpresent available information to par-ents (assuming consent has been ob-tained). Laboratory testing is not perfect,and spurious results are possible.Repeat drug testing may be of value;adolescents with serious drug dis-orders are likely to ultimately havemultiple positive drug test results.

Negative Test Results

A negative drug test result can supporta history of no recent drug use and maybe reassuring to parents and pediatri-cian. However, the pediatrician shouldnot dismiss ongoing behavioral ormental health symptoms just becausea drug test result is negative. Rather,a referral for a more in-depth mental

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health evaluation is warranted in suchcases.

A single negative drug test resultdoes not exclude the possibility ofdrug use or a substance use disor-der. If a substance use disorder ishighly suspected on a clinical basis,the pediatrician should consider thepossibility of a substituted, adulter-ated, or diluted sample; use ofa substance not detected by the testpanel; or a missed window of de-tection. If one of these conditions issuspected, other testing consid-erations include repeating the urinetest serially, using a different matrix,changing the method (eg, to labo-ratory testing if a point-of-care testwas used), adding specimen validitytesting, or changing/adding to thetest panel. In addition, the pediatri-cian should consider referral to anaddiction or mental health specialistfor further evaluation. Paradoxically,a “falsely” negative drug test result(ie, a test result that is negativedespite ongoing drug use) mightinadvertently delay detection andtreatment of a substance use disor-der if symptoms are dismissed andfurther evaluation is not pursued.

Dilute Specimens

All urine drug test orders shouldinclude a check for specimen in-tegrity. Creatinine, which is a productof muscle metabolism, is used asa marker of urine concentration andshould be ordered with each sample.Urine samples with a random cre-atinine concentration between 2 and20 mg/mL should be considered di-lute. Some of these samples may bepositive for one or more 1 sub-stances and should be consideredboth positive and dilute because it ispossible to miss substances presentin lower concentrations (eg, a urinespecimen may test positive for marijuana

but be too dilute to identify low levelsof cocaine).

Dilute specimens present a difficultclinical challenge in interpreting drugtest results. Smaller adolescents orthose with less muscle mass are morelikely to have lower random urinecreatinine concentrations. Adolescentsmay consume a large volume of fluidbefore the test either spuriously to beable to produce a urine specimenrapidly, or intentionally to attempt todefeat the test. These different sce-narios cannot be distinguished on thebasis of drug test results alone, andclinical correlation is warranted. Inthese cases, a repeat drug test may alsobe helpful. First-morning specimensgenerally result in samples with ade-quate concentration. If a first-morningspecimen is not possible, the adoles-cent can limit fluid intake in the fewhours before providing a specimen.

Substituted or AdulteratedSpecimens

Urine specimens that have beensubstituted or adulterated in vitroshould always be considered “posi-tive” and may represent a serioussubstance use disorder and/or co-occurring mental health or behav-ioral disorder. In these cases, referralto an addiction specialist or mentalhealth expert is warranted. Substitutedspecimens may be cold, may havea urine creatinine concentration≤2 mg/mL, or may be found in theadolescent’s possessions. Adulteratedspecimens may have an unusual coloror smell, may have out-of-range pH, ormay result in a positive “adulterantpanel” (available from some com-mercial laboratories). In these cases,if drug testing is to be repeated, ob-served urine collection may reducethe opportunity to tamper with thespecimen.

Managing Confidentiality BetweenPatients and Outside Entities

Care should be taken to protect allinformation about substance use, in-cluding historical reports and drug testresults that are recorded in the medicalrecord. In primary care, the Health In-surance Protection and AccountabilityAct of 1996 (Pub L No. 104-191) stip-ulates how all medical records must beprotected and can only be released viasigned informed consent or other le-gally authorized means. For care pro-vided in a substance abuse treatmentprogram, federal substance abuseconfidentiality regulations (CFR 42 Part 2)supersede the Act and provide evenmore stringent criteria for release ofinformation (the form must designatethe specific information to be released).

Before releasing any information to anyoutside entity, the AAP recommends thatthe clinician consider potential advan-tages and risks of doing so. Pediatriciansoften have an opportunity to play the roleof an intermediary between schools,probation officers, or other organizationsand their adolescent patients, and havinginformation pass through the pediatri-cian can offer a number of advantages.For example, the pediatrician can in-terview the adolescent and parent to helpinterpret drug test results before re-leasing information from the laboratory.In the case of a true positive result in-dicating recent drug use, the pediatriciancan discuss a plan for monitoring and/ortreatment that can be provided alongwith the drug test results. The recipient ofthe information will likely appreciateexpert advice on level of care, and thistype of input may help to prevent con-sequences such as school expulsion orcustody for probation violations and in-stead direct adolescents into appropriatecare for substance use disorders. Ulti-mately, however, patients, in conjunctionwith parents, decide to whom drugtesting and other information may bereleased.

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SUMMARY

Drug testing is a complex procedurethat, when used properly, may havea number of clinical indications.However, drug testing also hasa number of drawbacks; it can beinvasive, it yields only limited in-formation, and results are easilymisinterpreted. Drug testing shouldnever be the sole basis for makinga diagnosis of a substance use dis-order; rather, test results should beused to supplement informationobtained by history and physicalexamination. Signs and symptoms of

a mental health, behavioral, or sub-stance use disorder should not bedismissed solely on the basis ofa negative drug test result or in-ability to obtain a test; these symp-toms always require further evaluation,and referral to a specialist should beconsidered.

LEAD AUTHORSSharon Levy, MD, MPH, FAAPLorena M. Siqueira, MD, MSPH, FAAP

COMMITTEE ON SUBSTANCE ABUSE,2013–2014Sharon Levy, MD, MPH, FAAP, Chairperson

Seth D. Ammerman, MD, FAAPPamela K. Gonzalez, MD, FAAPSheryl A. Ryan, MD, FAAPLorena M. Siqueira, MD, MSPH, FAAPVincent C. Smith, MD, FAAP

LIAISONSVivian B. Faden, PhD – National Institute ofAlcohol Abuse and AlcoholismGregory Tau, MD, PhD – American Academy ofChild and Adolescent Psychiatry

STAFFRenee Jarrett, MPHJames Baumberger, MPPKatie Crumley, MPP

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