ADLM Guidance Urges Labs to Rethink Emergency Department Drug Testing
New recommendations highlight the limited impact of routine urine drug testing in the ED while calling on laboratories to refine test menus, expand fentanyl screening, and improve clinician education to better support trauma care, behavioral health referrals, and evolving regulatory demands.
Emergency department (ED) drug testing remains a common but often misunderstood tool. New guidance from the Association for Diagnostics & Laboratory Medicine (ADLM) underscores the need for laboratories to take a more deliberate, evidence-based role in how testing is ordered, performed, and interpreted.
“Toxicology testing in the emergency department (ED) is generally performed to detect either drugs with recreational or misuse potential, or a broad array of toxic or poisonous compounds,” the guidance notes. This document focuses on the first category, historically referred to as “drugs of abuse” (DOA). While the term “abuse” “can imply a stigma, and is not a comprehensive term given the range of intended uses for these compounds,” it remains “a well-known historical term and description.”
Although resources exist for language describing individuals who use these substances, the document emphasizes that “there is no single preferred term to describe nonmedical use of these drugs.” Alternatives such as “recreational,” “controlled,” “illicit,” or “non-prescribed” drugs were considered, but “none of these terms fully captures the range of clinically relevant scenarios involving use of these compounds.” For this guidance, the term “drugs of misuse” is used “as a parallel to the historical DOA terminology,” while acknowledging that “future efforts should prioritize development of less-stigmatizing language that more accurately reflects the range of uses for these compounds.”
Urine Drug Testing
According to ADLM’s guidance, ED and laboratory staff should work collaboratively to establish objective protocols or clearly defined clinical rationales for ordering drug testing in both adult and pediatric patients, keeping in mind that urine drug testing (UDT) results rarely alter acute emergency management. Experts note that UDT is most often used in adults to assess trauma cases, altered mental status, or possible substance use contributing to psychiatric symptoms, yet routine testing has limited clinical value.
Studies indicate that UDT can prolong ED length of stay without significantly improving detection of substance use disorders beyond patient self-report. The American College of Emergency Physicians advises against routine drug screening in alert patients or delaying psychiatric evaluation while awaiting results, though some state regulations still require testing prior to involuntary commitment. These regulatory requirements place additional responsibility on laboratories to provide rapid reporting and maintain clear communication with receiving facilities.
Laboratories should educate ED and specialty providers regarding the limitations of UDT, including the potential for false positives and false negatives, and emphasize that detection of a substance may indicate past exposure rather than current impairment or clinical effect. Assessment of which drug testing methods best support pediatric care is particularly important, given the unique clinical considerations in this population.
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Ongoing collaboration between ED and laboratory teams is essential to ensure that testing practices are aligned with clinical needs, patient populations, and available resources, while supporting downstream decisions such as resource allocation, behavioral health referrals, and patient safety.
Trauma Screening and Test Menus: Balancing Clinical Value, Regulation, and Evolving Drug Use
ADLM’s new guidance document also states that trauma care represents another frequent use case for ED drug testing, with the American College of Surgeons supporting substance use screening for all adult trauma patients. Yet laboratories are cautioned against overinterpretation. A positive drug test does not necessarily indicate impairment at the time of injury, and a negative result does not rule out intoxication. For lab professionals, this reinforces the importance of educating ED clinicians on test limitations, particularly detection windows and assay cross-reactivity.
Test menu design is a central operational issue. Strongly recommended assays for all EDs include opioids and opiates—specifically fentanyl and oxycodone—along with benzodiazepines, amphetamine-type stimulants, and cocaine. Despite decades of opioid-related morbidity and mortality, proficiency testing data show many laboratories have been slow to add fentanyl testing, which is not detected by traditional opiate immunoassays. Some states now mandate fentanyl inclusion, signaling a broader trend toward regulatory pressure as drug use patterns evolve. The guideline from ADLM recommends adding fentanyl to the test menu if the lab supports an ED.
Streamlining Panels and Specimens: Focusing ED Drug Testing on What Matters Most
At the same time, laboratories are encouraged through ADLM’s new guidance to remove assays with minimal clinical utility, such as propoxyphene and tricyclic antidepressants, which are prone to false positives and reflect outdated prescribing patterns. Testing for emerging drugs, toxic adulterants like xylazine, or novel psychoactive substances is generally not recommended due to rapidly shifting prevalence and limited impact on ED management.
The inclusion of tetrahydrocannabinol (THC) and its metabolites in ED drug testing remains debated, according to the guidance. Challenges include “evolving laws for drug scheduling, legalization or decriminalization of recreational use, and provisions for regulated medicinal use,” as well as increasing use of products containing other cannabinoids like CBD or delta-8-THC. A positive THC result can occur in patients using CBD products “due to the presence of THC in the preparation.” Overall, cannabinoid testing “provides limited clinically actionable information in the ED, except in specific populations such as pediatrics.”
Evidence shows that most studies “reported increased cannabinoid-related poisonings post-legalization, particularly in children.” THC use is also associated with conditions prompting ED visits, including “cannabinoid hyperemesis, psychosis, and trauma,” though providers should note that “THC metabolites can be detected in urine long after last use.” While some research has found negative outcomes such as “increased mortality or need for mechanical ventilation after trauma,” findings are inconsistent. Legalization appears to influence testing practices, as studies show “increasing rates of positivity as legalization progressed,” and drug test results may affect healthcare utilization, with one Canadian study reporting “fewer ED orders for imaging and laboratory testing, and increased use of observation units in THC screen-positive patients.”
The laboratory should “be aware of local and national regulations when designing panels” and provide flexible options, such as “separate drug panels with and without THC, and/or having THC as a standalone orderable test.”
Urine remains the preferred testing matrix due to availability and ease of use, though oral fluid testing offers potential advantages in witnessed collection and shorter detection windows. Blood-based testing is rarely useful for acute care outside of ethanol but retains value for epidemiological and forensic analysis. Specialized matrices, such as meconium or umbilical cord tissue, continue to play a role in newborn drug exposure assessment.
Overall, the guidance calls on laboratory leaders to move beyond passive test provision. Collaboration with EDs, regular review of test menus, provider education, and alignment with local drug trends are essential to ensuring drug testing supports patient care without adding unnecessary cost or complexity to emergency services.
This article was created with the assistance of Generative AI and has undergone editorial review before publishing.
—Janette Wider
