Opioid Testing

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
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.

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.

Medical Screening
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
• Drowsiness
• Slow or slurred speech
• Agitation
• Nausea
• Difficulty breathing
• Delirium
• Seizures
• 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.

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.

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.

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.

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.

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.”