- To monitor compliance with prescribed medications
- To screen for opioid abuse or drug diversion (when a person gives, trades, or sells the prescription to another individual)
- To monitor someone with an opioid addiction
- To detect and evaluate opioid overdose
- When you are prescribed opioids for long-term (chronic) pain
- When required prior to the start of a new job or insurance policy, at various times as part of workplace drug testing, or when it is mandated by a court order
- When you are being treated for substance abuse or addiction
- When you have signs and symptoms suggesting drug intoxication or overdose
- Urine is the most frequently tested sample for opioids. Urine is collected in a clean container.
- Alternatively, a blood sample is obtained by inserting a needle into a vein in the arm and drawing blood into a tube.
- Hair may be tested and is usually collected from the crown of the head, although hair may also be collected from other locations, such as the chest or underarm.
- Saliva is collected in an absorbent pad or swab placed between the lower cheek and gums for a few minutes.
- A sweat sample is collected with a patch that may be worn for several days.
Prior to testing, you should declare any prescription or over-the-counter medications or supplements that you are taking so that test results will be correctly interpreted. Certain prescription and over-the-counter medications may give positive opioid results. These include quinolone antibiotics and the antibiotic rifampin. Verapamil, quetiapine, diphenhydramine, and doxylamine have been reported to give false-positive results for methadone testing.
Opioids are a class of drugs that are used to reduce pain (narcotic analgesics). Opioid testing is used to confirm the presence of opioids in the urine, blood, saliva, hair, or sweat.
Opioids include opiates that are derived from natural sources (e.g., heroin and morphine) and semi-synthetic and synthetic opioids (e.g., oxycodone, hydrocodone and fentanyl). Testing methods may detect only a few opiates or may include testing for a large number of specific opioids.
Opioid tests may be ordered for medical reasons, for example, to determine compliance with opioid prescription medications, to determine adherence to a chemical dependency rehabilitation program, or for legal reasons, for example, as part of a court-ordered probation requirement.
Opioid addiction is currently an epidemic and is considered a public health emergency in the United States. According to the Centers for Disease Control and Prevention (CDC), opioid overdose deaths have quadrupled since 1999. To combat opioid addiction, the CDC's 2016 guidelines on prescribing opioids for chronic pain include annual urine testing to monitor patients for signs of opioid misuse and/or diversion. Most medical guidelines recommend that patients prescribed opioids for longer than 90 days be urine drug tested at least annually and prior to starting therapy.
People who use opioids may ingest, inhale, smoke, or inject them. The effect of an opioid depends on the particular opioid used, the amount used, its purity, and the method of use, such as whether it is taken in tablet form or injected.
To test for opioids, healthcare practitioners may send urine samples to a laboratory for screening or they may perform a test in their office. Testing may be performed as point-of-care tests, which are typically small strips that are dipped into the urine and interpreted by the appearance of a colored line on the strip. Most tests will detect the drug in urine if someone has taken an opioid in the previous 1 to 3 days, but this timeframe depends on the specific opioid consumed and the individual's ability to metabolize the drug.
Some opioids may be difficult to detect with the routine screening tests because the test may not be designed to detect the specific drug of interest. Healthcare practitioners may identify which opioid they want to detect when they order the test. Often, laboratories will offer a pre-determined panel test that will include several individual screens that target commonly prescribed opioids. The following table lists some examples of opioids or opioid metabolites that may be tested.Opioid TypeExamplesOpiates (from natural sources)Codeine, morphine, heroin and heroin metabolite (6-monoacetylmorphine)Semi-synthetic opioidsHydrocodone, hydromorphone, oxycodone, oxymorphoneSynthetic opioidsFentanyl and fentanyl analogs, meperidine, methadone, propoxyphene, tramadol, tapentadolOther drugs loosely referred to as opioids (antagonists and agonist/antagonist)Buprenorphine, naloxone, naltrexone
Positive screening tests are presumptive. This is because some screening tests have the potential for false-positive results. Therefore, screening tests that are positive are often confirmed with a second test that identifies the exact substance that is present. Confirmatory tests are usually more sensitive than screening tests and will detect lower levels of specific opioids. Confirmatory testing is usually performed with an instrument called a mass spectrometer. Types of mass spectrometry tests used for confirmatory testing include gas chromatography/mass spectrometry (GC/MS) and liquid chromatography-tandem mass spectrometry (LC-MS/MS).
Both screening and confirmatory tests are interpreted based on a cut-off. If a drug is not present, or if the drug is present at a concentration below the test cut-off, the test will be reported as "undetected," "absent" or "negative." If a drug is present at a concentration equal to or above the cutoff, the test will be reported as "detected," "present" or "positive."
Testing may also be performed to identify whether anything has been added to the urine sample, such as water, bleach or other types of chemicals (adulterants) that may have been added in an attempt to interfere with the test. If adulteration is suspected, the test may be reported as invalid or adulterated.
Urine samples may also be identified as dilute. Dilute urine may be produced if an individual consumes large amounts of water or other liquids prior to testing. Dilute urine may also result from some medical conditions. If an individual adds liquid such as water to a urine sample, this may also cause dilute urine. It may not always be possible to determine how the urine was diluted. If the urine is so dilute that the results are not reliable, the test may be reported as invalid or adulterated.
- How is the test used?
Opioid testing is used to detect the presence of one or more opioids in urine, saliva, blood or hair.
Opioid testing may be used for:
Monitoring Pain Medication Use
Opioid testing of urine is used to monitor adherence of patients to prescribed opioids for chronic pain. A health practitioner may periodically order a full drug testing panel to ensure that a patient is taking the prescribed opioid and to check that the patient is not taking any other non-prescribed opioids or other illegal substances.
Urine drug screening is recommended by the CDC and other medical organizations in order to confirm patient adherence with prescription opioids in combination with other screening tools, such as pill counts or prescription drug monitoring programs (PDMPs). The purpose is to minimize risks associated with prescribing opioids.
Medical screening for opioids is used to determine what drugs or combination of drugs a person may have taken or been exposed to so that the person can receive proper medical treatment. A drug's overall effect on an individual may depend on how that person's body responds to the drug, how often the individual is exposed to the drug, on the quantity of the drug taken, and whether the drug is taken in combination with other drugs.
A health practitioner may order drug testing for medical reasons if an individual:
- Experiences symptoms that may be drug-related or shows signs of intoxication, such as unconsciousness, nausea, delirium, panic, paranoia, increased temperature, chest pain, respiratory failure, seizures, and/or headaches
- Is involved in an accident that an emergency room physician suspects may be due to drug intoxication
- Is suspected of drug use or is known to use legal and/or illegal drugs
- Is being treated in an addiction recovery or chemical dependency program
For a more in-depth discussion of this, see the article Emergency and Overdose Drug Testing.
Legal or Forensic Testing
Drug testing for legal purposes or forensic testing differs from clinical testing primarily in sample collection procedures. Sample collection for forensic testing is strictly controlled, with the custody of a sample continuously documented to maintain a legal "chain-of-custody." After a sample is provided, it is closed and secured with a tamperproof seal. A custody and control form accompanies the sample throughout all handling, testing, and storage. This creates a continuous record for the sample and links it to the person who is being tested.
Examples of this type of testing include:
- Court-mandated testing for someone who has been convicted of illegal drug use
- Testing or monitoring of a parent in a custody case
- Forensic toxicology testing using a variety of body fluids and tissues that may be tested during a crime investigation; the goal may be to determine whether opioids were a contributing factor to an accident or crime, such as DUI (driving under the influence). Testing may also determine whether someone died of a drug overdose or drug-related condition.
- Applicants for life insurance policies may undergo general drug screening, possibly including tests for opioids.
- Some athletic programs may test for opioids as part of a general toxicology screen to detect drug abuse in athletes.
For additional information on this type of testing, see the article on The World of Forensic Laboratory Testing.
Employment Drug Testing
Opioid testing may be part of a job requirement. This is also referred to as "workplace drug testing," a specific type of forensic testing (see above). It may be done prior to employment, on a random basis, following an accident, or if an employer has a reasonable suspicion that an employee is using illegal drugs. Employment drug testing is not uncommon. It is required for employees of the U.S. Department of Transportation, military personnel, and other federal employees, and is an accepted practice in many other industries.
As with legal or forensic drug testing, the sample collection and testing procedures for employment drug testing are often strictly controlled and documented to maintain a legal "chain-of-custody." Test results are also reviewed by a specially trained and licensed physician called a medical review officer prior to reporting.
- When is it ordered?
Monitoring Pain Medication Use
Opioid testing may be ordered by a health practitioner when a person is prescribed opioids for more than 90 days for pain in order to determine whether the person is taking the prescribed opioids and make sure the person is not taking any additional non-prescribed opioids or illicit drugs.
Opioid testing may also be ordered by a health practitioner when a person is known or suspected of substance abuse or when a person has signs and symptoms that suggest opioid use or withdrawal. These symptoms may affect an individual's mood, behavior and physical state in the following ways:
- Dilated or small pupils
- Slow or slurred speech
- Difficulty breathing
- Changes in blood pressure or heart rhythm
Symptoms associated with opioid abuse and overdose may vary from person to person and cannot be determined strictly from dose.
Legal, Forensic or Employment Testing
Forensic opioid testing is performed when an employer or legal entity needs to determine if a person may have taken non-prescribed opioids. Testing may be ordered prior to the start of some new jobs and insurance policies and at random to satisfy workplace, court-ordered monitoring, or probation requirements.
- What does the test result mean?
A positive or detected initial drug screening means that the person tested may have taken an opioid. Screening tests are not definitive, and confirmatory testing may be ordered to confirm the screening test result.
Drug testing of urine cannot be used to determine when or how much drug was consumed, nor can testing prove what influence the drug is having on the person tested.
A negative result does not necessarily mean that the person did not take an opioid. The drug may be present but below the established cutoff, the drug may have been already metabolized and eliminated from the body, or the testing method may not detect the particular drug that is present in the sample.
Tests of different body samples reveal drug use within varying windows of time. For example:
- Urine testing shows drug use over the last 1 to 3 days for opioids, depending on the specific drug. Certain opioids may be detectable for less than 1 day after use, and some opioids will be detected for longer than 3 days after last use. This time frame will depend on the specific test cutoff used too.
- Blood testing will identify the level of drug that is present in the blood. Drugs are detected for a shorter amount of time in blood compared to urine.
- Hair samples, which test the root end of the hair, typically cover drug use within the last 90 days. This average window may vary based on an individual's hair growth rate and other factors.
- Saliva testing shows opioid use ranging from within the last few hours up to 50 hours, depending on the drug.
- Samples of sweat may be collected on an absorbent patch worn for several days and positive results may indicate opioid use at any point during sweat collection.
- Why might a healthcare practitioner test for only one specific opioid?
If a health practitioner strongly suspects that a person has taken a specific opioid or is monitoring the person for previous misuse or abuse of an opioid, then the practitioner may only order a single drug test. Another reason for ordering a single test is if the suspect drug is not offered in a panel drug test.
- Why would someone be tested for a drug that is legal?
A substance can be legal but may be banned or controlled in certain circumstances. In the case of prescription opioids, there is a high addictive potential for these medications and also a risk for diversion of the drugs (when an individual gives, trades, or sells the prescription to another individual). Prescription drug monitoring is recommended by many medical experts in order to evaluate patient adherence to therapy. Drug testing for people undergoing chronic pain treatment with opioids should be part of an open and honest relationship between the patient and healthcare practitioner.
- What should I ask my healthcare practitioner before taking prescription opioids?
Be sure to learn about the potential risks and benefits of prescription opioids before you consider using them. Ask your healthcare provider about the role of opioid pharmaceuticals in your overall treatment goals and pain management plan. Share your concerns about taking opioids. If you are uncomfortable with the risks, there are other tools available for pain management.
The CDC's 2016 guidelines on opioids in chronic pain management recommends managing chronic pain with non-pharmacologic therapy such as such as exercise therapy, cognitive behavioral therapy, and the use of non-opioid therapies such as non-steroidal anti-inflammatory drugs as first-line medications. Opioids are not recommended as a first-line treatment for chronic pain management. Managing chronic pain is challenging, but individuals may experience improvement in wellbeing if they take an active role in their healthcare.
- Is there anything else I should know?
Elements of a urine drug screen may include testing to ensure the sample is valid and that the urine sample and has not been tampered with or otherwise adulterated. This testing may include a visual inspection of the urine, a temperature check of urine immediately after collection, measurement of urine creatinine, urine specific gravity (urine concentration), and urine pH. Urine may also be tested for oxidants, nitrite, glutaraldehyde, or other possible adulterants.
Urine collection rooms may be altered to prevent tampering of the sample, including absence of hot or running water or the addition of blue coloring in the toilet water. In some workplace drug testing programs, observed re-collection may be requested when there is high suspicion of cheating. Some states and cities prohibit observed collections for workplace drug testing. Federal laws may supersede state laws for federally-regulated testing.
For some types of testing, such as workplace testing of federal employees, there are many regulations that cover the testing process, from collection through interpretation and reporting of results. It is important for the ordering physician, law enforcement representative, forensic professional, government entity, insurance agent, employer, and sports organization as well as for the person being tested to understand what exactly is included in the testing, how testing is performed, and how the results are interpreted, including whether the individual was given any medically necessary drugs prior to the test. This process is not nearly as simple or straightforward as collecting a sample and requesting "drug testing."