Clinical Guidelines for the Collection of Urine Drug Tests

Dr. Joseph E. Graas, Scientific Director
Dr. Edward Moore, Medical Director

Summary 

The standard of care in the treatment of drug addiction involves monitoring the patient for use of illicit drugs and alcohol.  Urine testing remains the foremost way in which this is accomplished.  As such, it is vitally important for all those involved in the care of the patient (counselors, therapists, nurses, doctors, and directors) to be knowledgeable, aware and able to interpret urine drug test results.  It is impossible and inappropriate to rely on the presumed veracity of the patient when it involves drug use.  It is equally impossible to construct a treatment plan and conduct therapy when it is unknown if the patient is relapsing.  These facts cannot be emphasized enough, but unfortunately the average employee of treatment programs, let alone those clinicians in hospitals and clinics outside the treatment of addiction, knows little of the potential ways in which urines can be faked or invalidated.

The following guidelines can be useful in increasing awareness and reducing the number of faked urine tests in treatment programs.

1. Know your laboratory, develop a relationship with them and become knowledgeable of how long they keep urines, store urines, what testing methods they use and what common false positives and negatives exist for their methods.
2. Consider direct monitoring of sample acquisition by appropriate and trained personnel, especially when:
   a. A previous urine’s temperature was out of range.
   b. A patient presented with suspicious behavior.
   c. Previous tests were negative when inconsistent with expectations.
   d. The urine visually appeared altered.
   e. There was previous evidence of an altered urine.
   f. When patients repeatedly avoid or delay providing a specimen.
3. Monitor the temperature of the specimen and require the temperature to be between 90 and 100 degrees.
4. Consider ordering a clinical urinalysis (UA) on every specimen.
5. Always confirm positive tests using a different and more sensitive method, such as HPLC/MS/MS or GC/MS.
6. If the sample collection is unobserved, then place bluing in the toilet, turn off the water supply to faucets, allow no coats or carried objects be taken into the restroom, and have the patient empty all pockets.
7. Consider routinely ordering adulterant screening or specimen validity test.
8. If the patient is tested by a laboratory off site then have that laboratory collect samples in a manner that complies with drug testing for treatment programs.
9. If testing is done in-house then the employees conducting the tests should be well trained by persons knowledgeable with errors that can occur.
10. Do not assume that the patient will be honest in reporting drug use or excuses made for being unable to test.