A drug test is an analysis of a biological sample used to determine the presence of specific substances. These tests do not usually indicate whether the subject is impaired at the time they are administered, just if the person has used any of the substances being tested for in a set period. Drug tests are a way to determine if a person is using illicit drugs, which may indicate a problem with substance abuse.
Drug testing is done pre-employment, randomly by employers, after an accident on the job, during probation, by the police, in the prison system, in recovery programs, in hospitals, and by parents. There are various types of tests including urine, saliva, breath, blood, hair, nails, and perspiration. Tests can be done in a lab, in an office, by mail, or a home.
This course will explore the types of drug tests, what each screen for, the collection procedure, and the need for consent.
There is no standard for all drug testing, although the Substance Abuse and Mental Health Services Administration (SAMHSA), along with the U.S. Department of Health and Human Services (DHHS) and the Department of Transportation have standardized procedures that federal agencies must follow. Private employers who drug test are not usually required to follow federal guidelines, although many do so for legal reasons. We will look at these standardized procedures later in the course.
Drug testing accuracy depends in part on the type of test used and standards observed. Drug tests use biological samples from the body to check for the presence of drugs and sometimes alcohol. Drug tests may test one’s:
- Saliva or oral fluids
The most common and least expensive drug tests involve urinalysis. For these tests, a urine sample is collected by the subject by urinating into a specimen cup. Levels of antigen-antibody complexes that the body produces when drugs are present are counted in nanograms per milliliter, ng/mL. Drugs can be detected through a urine drug test anywhere from one day to one month after use, depending on the type of drug abused, duration of abuse, and amount of drug abused.
There are two levels of urinalysis drug tests: immunoassay and gas chromatography or mass spectrometry. The first is the most cost-effective, produces immediate results, and generally is used as an initial test, although it may not be as accurate as other methods. False positives are possible, and certain types of drugs may be missed. Often, secondary gas chromatography or mass spectrometer test is ordered that also tests urine. It is more accurate, but also more expensive, and it takes longer to complete.
Federal drug tests use a split sample, meaning they take the urine sample, split it in two, and the first test with immunoassay methods and then gas chromatography or mass spectrometer methods if the first test was positive. This is called a confirmation test after the initial screening test. All federal drug tests are required to be performed at SAMHSA-certified labs and follow strict guidelines and chain of custody procedures, ensuring the samples are handled correctly, thus reducing the margin for error.
At-home, or portable, drug test kits can be purchased online and over the counter for as little as $10-$20. These kits are typically urine tests that check for the presence of illegal or prescription drugs. Depending on the kit, the presence of different drugs may be tested.
The U.S. Food and Drug Administration (FDA) reports that these tests are accurate in determining the preliminary presence of illicit drugs if used correctly. If an initial positive result is found, the sample is then supposed to be sent to a laboratory for further testing, which will cost additional money but provide more accurate and detailed results.
Urine drug testing may be the most common form of drug testing, but saliva testing is becoming more popular simply because it is less invasive. However, it seems that saliva drug tests should only be used to detect very recent drug use to ensure accurate results. One study, for instance, reports that saliva testing can only detect cannabinoids when the subjects have smoked cannabis only 4-10 hours beforehand.
The most expensive and invasive of all drug testing methods also happens to be the most accurate. It detects right at the time of testing the presence of the substance and its metabolites in the blood. The actual amount of drugs in the blood at the time of the test can also be measured by a blood drug test. However, its cost and invasiveness make blood drug testing used less frequently.
Hair tests probably provide the most detailed insights possible into one’s history with drugs. These tests can tell you whether a person was using drugs recreationally or quite frequently. They can tell you the type of drugs that were being abused, among many other types of details. The idea of hair drug testing is based on the premise that drug metabolites enter the blood vessels of the scalp, and the hair will filter them and keep them as a permanent record of a person’s drug use. Many people, however, object to hair testing because it does not measure current drug use. A person could have last used, say, cannabis a few months before, and still be found positive today because residues of the substance will remain in the hair for months afterward, and no amount of shampooing can take them away. For an accurate test, most labs require anywhere from 40 to 50 strands of hair. The drugs will be detectable in the hair approximately 4 to 5 days after ingestion and will remain in the hair until the hair gets shed off from the body. There is also a considerable cost and a lengthy process with hair sample testing.
Fingernail, a keratinized protein-like hair, is emerging as a popular specimen type for drug testing. Drugs can be identified in nail clippings two weeks to four weeks following ingestion. A 3-millimeter specimen of fingernail represents up to eight months of the collective history of drug exposure. Toenail clippings show over one year of drug use.
Perspiration drug testing works through a sweat patch affixed to the skin for 14 days. The patch is worn to detect the presence of drugs that a person excretes through perspiration. However, this method is more commonly used to monitor people on probation or those involved in child custody cases.
Breath is the standard matrix for alcohol testing because alcohol is volatile and substantially excreted through the lungs. Breath expelled into a Breathalyzer-style collection device can also identify amphetamine, methamphetamine, cannabis, cocaine, and heroin use up to two hours after use.
Urine drug tests most commonly screen for:
- opioids (narcotics)
Blood drug tests most commonly screen for:
Hair drug tests most commonly screen for:
Nail clipping drug tests most commonly screen for:
Saliva drug tests most commonly screen for:
Perspiration drug tests most commonly screen for:
Breath drug tests most commonly screen for:
Drug Testing Timelines
- THC: Casual use 3-4 days, chronic use 6-11 weeks
- Benzodiazepines: Up to 6 weeks
- Barbiturates: Up to 6 weeks
- Cocaine: Up to 22 days
- PCP: Casual use up to 8 days, chronic use up to 30 days
- Methadone: 2-3 days
- Amphetamines: 2 days
- Ecstasy: Up to 2 days
- Codeine: 1-2 days
- Heroin: 1-2 days
- Hydromorphone: 1-2 days
- Morphine: 1-2 days
- Propizepine: Between 6 and 48 hours
- LSD: 8 hours
- Alcohol: 5 hours (1 ounce)
The size of the dose of any given drug, a person’s metabolism and body mass, as well as fat content, how active a person is, and age may all affect the drug testing timelines.
Performing Drug Tests
Drug tests are given in many different settings. In 1991, the U.S. Congress passed the Omnibus Transportation Employee Testing Act when they recognized the need for a drug and alcohol-free transportation industry. The DOT’s drug screening rules and procedures are listed within Title 49 of the Code of Federal Regulations (CFR) Part 40, commonly known as “Part 40.” These rules are published by an office within the DOT: The Office of Drug & Alcohol Policy & Compliance (ODAPC). This standard has been adopted by other industries. All DOT drug tests use the same 5-panel tests. It tests for marijuana metabolites, cocaine metabolites, amphetamines, opioids, and phencyclidine.
The procedures can be found at:
The Division of Workplace Programs perform forensic drug testing for federal agencies and federally regulated industries. They have created mandatory guidelines for workplace testing.
The Mandatory Guidelines can be found at:
SAMHSA has created a Specimen Collection Handbook for use in federal agency workplace testing.
The Specimen Collection Handbook can be found at:
Many others beyond federal agencies also follow these guidelines and collection policies.
Specimen collection, a crucial component of drug testing, must be carefully designed and actively managed to ensure that valid results are generated. Additionally, the storage of samples, particularly urine, may be challenging if testing is delayed for several days. If the delay between collection and testing is substantial, appropriate storage is needed to help prevent drug degradation. Many recovery program staff members are untrained in collection and storage procedures, exacerbating the opportunity for patient donors to adulterate or substitute specimens or for drug degradation.
A brief overview of the collection method created in CFR Part 40 includes the requirements of restrooms where collections are received having no running water and commodes have bluing agents (so specimens cannot be diluted). Ceilings must be of a height and/or composition that doesn’t allow for the “hiding” of additional specimens. Patients are instructed to not flush after the collection (or specimens are collected with a remote-flushing commode).
Collection Procedures: (Suggested guidelines only, for full procedures please reference the SAMHSA Specimen Collection Handbook)
Before any specimen collection procedure, secure the collection facility and if necessary, perform a thorough search for hidden adulterants or substitute urine specimens. Place bluing agent in the toilet bowl or tank, remove or secure all chemicals (soaps, cleaning supplies, etc.), and secure or eliminate all water sources.
Check the identity of the donor (e.g. social security number or driver’s license number and photo I.D.). If using a drug screen test request form, note the identity on the form.
- Ask the donor to remove any unnecessary outer clothing. All personal belongings (the subject may retain a wallet) should be placed in a secure location outside the stall or partitioned area
- Do not ask the donor to remove articles of clothing such as shirts, pants, dresses, etc. If a collector notices any unusual behavior that indicates a donor may attempt to tamper with or adulterate a specimen (e.g., bulging pockets), the collector may request that the donor empty his/her pockets and explain the need for such items during collection
- Before collection, ask the donor to wash his/her hands to eliminate any possible adulterating or contaminating substances from under the donor’s fingernails
- Place the following information on the bottle label:
- Date of collection,
- Donor’s name and/or identification numbers
- Collector’s initials
- Provide the donor with a clean, unused urine specimen collection container and instruct the donor to fill the container at least half full (a minimum of 30 mL).
- Unobserved Collection: Allow the donor to enter and maintain privacy within the stall or partitioned area. The collector will wait outside the collection area until the donor is finished urinating. Complete the remainder of the test request form while the donor is collecting the specimen.
- Observed Collection: Inform the donor that collection will occur under direct observation. Accompany the donor into the collection facility (the collector must be of the same gender). Instruct the donor to urinate into the sample container with the witness observing urination. Complete the remainder of the test request form after the donor has completed collecting the specimen.
- Accept the specimen from the donor. The use of disposable gloves is recommended when handling specimens, so before accepting the specimen from the donor, be sure to wear gloves.
- Upon receipt of the specimen from the donor, immediately apply the temperature strip (if applicable) to the outside of the bottle. If using a drug screen test request form, record the urine temperature on the form.
NOTE: Urine temperature should be measured within (4) four minutes of collection and should read between 90-100°F.
The SAMHSA Specimen Collection Handbook identifies who is qualified to be an observer for a directly observed urine specimen collection, as well as what training is required. There are also limits to when direct observation methods can be used and what must be done before using this method.
Cheating on a Drug Test
There are three primary ways to attempt to fool a drug test: dilution, substitution, and adulteration.
A “dilute specimen” is a urine sample that has a higher than average water content. The goal when diluting a sample is to minimize the drug levels visible in the urine. Laboratories have specific cut-off points where, even if the drug is detected, it will not be marked as a positive result because it is very little in the sample.
Unintentional dilution is common. When a test applicant consumes excessive amounts of fluid, the concentration of urine will subsequently become dilute. This can be abused by intentionally over-consuming large amounts of water before a drug test. This will lower drug ratios in the urine. Unfortunately for cheaters, this does not guarantee a negative result, and the laboratory will immediately detect the diluted sample.
The malicious form of dilution is adding pure water directly to the urine sample. This is the reason testing laboratories add dye to their toilets and shut off faucets. This is also very easy to detect.
Some people attempt to cheat drug tests by submitting a urine sample that did not come from their bodies. Individuals who try this method may use liquid urine, synthetic urine, or urine that belongs to someone or something else, such as an animal, just to pass the test. Those who are diligent about going undetected may buy powdered urine packets online and then mix the contents with water.
It is difficult to keep substitute urine samples at the right temperature. However, those determined to do so may use devices to keep the specimen warm. They may also keep the sample warm by holding it close to their bodies in an armpit or groin area.
Urine samples that have been tampered with are called “adulterated specimens.” Some would-be drug testers attempt to pass off a sample that contains chemicals that have been added to either hide the presence of drugs or affect the equipment used in laboratory drug testing. Some of these chemicals include bleach, salt, soap, eye drops, and peroxide, among others. Both collection sites and laboratories have at their disposal several mechanisms to detect potentially invalid specimens.
Some who are up for a drug screening may just try to wait it out and delay taking the test until the drug leaves their systems. Many factors come into play here, including the kind of drug that was taken and how much of it was taken. Some substances clear the system faster than others. However, body height, weight, age, metabolism, and family history, among other factors, also affect how long a substance hangs around and whether a drug test will detect it in a person’s urine. Signs of past drug use can last for a few days or a few weeks.
Other attempts to cheat drug tests include taking various products and foods before turning over the urine for examination. The list of “home remedies” runs long and includes everything from eating fiber and certain herbs, such as red clover and burdock root, to drinking detox herbal teas or liquids that act as diuretics to flush out toxins left behind after drug use. These include apple cider vinegar and cranberry juice among others.
Some people opt to use “commercial screens to “clean” their urine samples, but if these are found, the sample will be flagged.
Drug Testing in Recovery Programs
Drug testing is not a treatment method, but rather a tool that can be used in a recovery program. With relapse being a typical phenomenon in the recovery process, 40% to 60% relapse rate, drug testing is not only an effective way to detect use but also to offer a deterrence. Many addiction treatment programs require regular drug testing or require clients to submit to random drug tests. In a program drug testing can be used in three phases of addiction treatment:
- Screening and diagnostic evaluation
- Formal Treatment
- Long-term monitoring after initial intensive phases of addiction treatment
Without drug screens, patients who are serious about their recovery are at risk from those who play at the concept of sobriety just to fulfill a temporary obligation. This practice is somewhat controversial, but it’s often used to protect clients from temptation and being triggered.
Drug testing policies differ from program to program and often depend on whether clients have access to substances. For example, residential or inpatient programs in which clients are required to stay in the facility 24 hours per day, with some exceptions, don’t typically need to do drug tests unless they have reason to suspect that drug use has occurred. On the other hand, outpatient programs that let clients stay at home and come into the treatment program a couple of times per week often perform regular drug tests.
When a drug-testing plan is carried out as part of a drug or alcohol rehabilitation, clinical specialists should take action to guarantee that clients see the treatment as a favorable tool on their recovery journey and not an infraction of trust accelerated in the therapeutic relationship.
Although programs do not always penalize clients for positive tests, some programs need the patient and therapist to prepare a list of pre-determined consequences in case of a positive drug test. Depending upon the treatment strategy, a positive test might trigger a patient to be negatively affected at home or work. In other scenarios, reporting might be needed by an employer or court. For example, to keep his job, a patient has the consent to allow the center to inform his employer if he tests positive for drug or alcohol usage, a positive test reported to the company might cause him to lose his job. In some cases, a dirty screen will change someone’s level of care or even end their place in a program, but the consequences should be discussed early in treatment.
A fundamental goal of addiction treatment is for patients to achieve abstinence from the use of alcohol and other drugs of abuse. In this context, an unexpected positive test result signals continued use of non-prescribed drugs of abuse by tested patients.
Discharging a patient from treatment for an initial positive test is seldom, if ever, appropriate. Positive test results signal the need to intensify or alter current care. There are many options to consider in response to positive test results, including more frequent testing and specialized interventions for non-compliant patients.
Continued positive test results, after the intensification of treatment, raise the question of the value of treatment and may justify discharging the patient from treatment. Each patient’s situation should be considered as a clinician determines what changes should be made to the treatment plan in the patient’s best interests in response to positive test results. A “therapeutic discharge” often can set the stage for the patient’s later return to treatment with more determination to meet the program’s expectations.
The level of care is a determining factor for the use of drug screens. Just as new information about disease severity in the treatment of another chronic medical or psychiatric illness would lead to treatment plan adjustments, usually intensification and addition of new elements, positive drug test results are a manifestation of the severity of illness, or the inadequacy of treatment, and signals the need to reevaluate and readjust treatment plans.
In residential primary treatment, drug testing helps to ensure that the integrity of the drug-free therapeutic environment has not been compromised by smuggled contraband. Most patients who use unauthorized substances in treatment do not volunteer this information to staff, so drug testing is necessary to detect such events.
In outpatient primary treatment settings, the opportunities for the use of alcohol or other drugs are much greater. Therefore, the need for frequent random drug testing is greater than for patients in residential treatment. The detection of substance use in an outpatient setting should be used to revise treatment plans, including using additional strategies to help the patient establish and maintain a drug-free state.
In outpatient OTPs, after an initial period of adjustment to the prescribed medicine (e.g. methadone or buprenorphine), drug test results are commonly used to determine the gain or loss of take-home medication privileges.
Additional responses to positive drug tests may include more frequent visits with counselors, including more intensive group or individual counseling, revising treatment plans, increased engagement in 12-step recovery programs, and increasing the frequency of drug testing. All these responses help patients work toward establishing and maintaining abstinence.
When drug testing is used in addiction treatment settings, it is best to use random, rather than scheduled, testing and to set the frequency of the random testing higher at the start of treatment, when patients are known to more frequently engage in continued drug use. When the patient has attained a substantial period of stable abstinence from drug use, the frequency of random drug testing can be lowered; however, random testing less frequently than once a month in addiction treatment is seldom wise, even for patients with established abstinence. It is important that the testing be unpredictable, even if it is infrequent, so the patient can be tested at any time, even the day after the prior test.
Even though drug testing is a central component of years-long monitoring programs for licensed health professionals, there is no agreed-to standard among states regarding the frequency or duration of testing in such programs. This lack of standardization is, in part, a reflection of the reality that most Partial Hospitalization Programs (PHP) have some connection with state regulatory and licensing authorities, and professional licensure is a state-based function under specific oversight with substantial variation among the states. In general, most PHPs set the frequency of random testing at once a week early in their monitoring. The frequency of testing is reduced to twice a month and then once a month after long-term sobriety is achieved. It is essential to recognize that in random testing a donor who is tested today can be tested again tomorrow – even if the random testing is set for only once a month. This means that donors who are being monitored cannot predict when they will be tested, regardless of the nominal frequency of the drug and alcohol testing.
Although drug testing can be a beneficial recovery tool, to protect a patient’s privacy and individual rights under the law, any effect for unfavorable drug or alcohol tests needs to be prepared under the standards supplied by the National Institute of Drug Abuse and the Clinical Laboratory Improvement Act.
Consent for drug testing and how the results are handled are important legal issues. The concern about the adverse effects that social stigma and discrimination have on patients in recovery and how those adverse effects might deter people from entering treatment led Congress to pass legislation and the Department of Health and Human Services (DHHS) to issue a set of regulations to protect information about patients’ substance abuse. The law is codified at 42 U.S.C. §290dd-2. The implementation of Federal regulations, “Confidentiality of Alcohol and Drug Abuse Patient Records,” are contained in 42 CFR Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2).
Controversies Surrounding Drug Testing
Drug testing is an invasion of privacy and sets a foundation of distrust. It is not always accurate, and false positives are common. Drug tests may also be expensive to follow up on if you have gotten a false positive and require a confirmation test. Non-standardized procedures and regulations may lead to improper testing techniques and reliability issues. Not to mention drug tests can be beaten, and many methods are used to obtain false-negative results.
Drug-testing procedures must be followed up correctly. If a positive result is obtained, for example, there needs to be a policy in place that permits necessary treatment plans. Substance abuse may indicate a larger problem, including mental health issues or addiction, which is a treatable chronic brain disease.
Drug testing is not the only way to identify drug use, misuse, diversion, or a suspected substance use disorder or relapse. Valuable information can be obtained by asking individuals about their drug use. Interviewing collateral sources of information such as family members. with patient consent, can also provide important information about drug use. However, because it is common for drug users to minimize or deny drug use, it can be important to use drug testing as an objective assessment tool and patient advocacy/support tool.
Urine testing is generally the most popular method of testing for illicit drugs, while testing breath is usually the most common way to determine the presence of alcohol. Not all testing methods test for all types of substances, and each has different accuracy levels. The different types of tests will detect the presence of different substances depending on the half-life of the substance, type of test administered, and duration of abuse. Substances are detectable for longer periods in chronic substance users.