Urine Drug Screens in the Emergency Department: The Best Test May Be No Test at All

Published:August 22, 2020DOI:https://doi.org/10.1016/j.jen.2020.06.003


      The manuscript purpose is to provide a resource for clinicians on the functionality and pitfalls of the rapid urine drug screen for clinical decision making. Many providers remain under-informed about the inherent inaccuracies. The rapid urine drug screen is the first, and often only, step of drug testing. In the majority of emergency departments the urine drug screen is a collection of immunoassays reliant on an interaction between the structure of a particular drug or metabolite and an antibody. Drugs in separate pharmacologic classes often have enough structural similarity to cause false positives. Conversely, drugs within the same pharmacologic class often have different enough structures that they may result in inappropriate negatives. This lack of sensitivity and specificity significantly reduces the test utility, and may cause decision-making confusion. The timing of the drug screen relative to the drug exposure also limits accuracy, as does detection threshold. Confirmatory steps following the initial immunoassay include chromatography and/or mass spectrometry. These are unavailable at many institutions and results rarely return while the patient is in the emergency department. In addition, institutional capabilities vary, even with confirmatory testing. Confirmation accuracy depends on a number of factors, including the extent of the catalog of drugs/metabolites that the facility is calibrated to detect and report. In summary, the standard emergency department urine drug screen is a test with extremely limited clinical utility with multiple properties contributing to poor sensitivity, specificity, and accuracy. The test should be used rarely, if ever, for clinical decision making.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Tenenbein M.
        Do you really need that emergency drug screen?.
        Clin Toxicol (Phila). 2009; 47: 286-291https://doi.org/10.1080/15563650902907798
        • Miner J.R.
        • Klein L.R.
        • Cole J.B.
        • Driver B.E.
        • Moore J.C.
        • Ho J.D.
        The characteristics and prevalence of agitation in an urban county emergency department.
        Ann Emerg Med. 2018; 72: 361-370https://doi.org/10.1016/j.annemergmed.2018.06.001
        • Nelson Z.J.
        • Stellpflug S.J.
        • Engebretsen K.M.
        What can a urine drug screening immunoassay really tell us?.
        J Pharm Pract. 2016; 29: 516-526https://doi.org/10.1177/0897190015579611
        • Riccoboni S.T.
        • Darracq M.A.
        Does the U stand for useless? The urine drug screen and emergency department psychiatric patients.
        J Emerg Med. 2018; 54: 500-506https://doi.org/10.1016/j.jemermed.2017.12.054
        • Christian M.R.
        • Lowry J.A.
        • Algren D.A.
        • Thornton S.L.
        • Deng S.
        • Garg U.
        Do rapid comprehensive urine drug screens change clinical management in children?.
        Clin Toxicol (Phila). 2017; 55: 977-980https://doi.org/10.1080/15563650.2017.1329537
        • Hammett-Stabler C.A.
        • Pesce A.J.
        • Cannon D.J.
        Urine drug screening in the medical setting.
        Clin Chim Acta. 2002; 315: 125-135https://doi.org/10.1016/s0009-8981(01)00714-8
        • Moeller K.E.
        • Lee K.C.
        • Kissack J.C.
        Urine drug screening: practical guide for clinicians [published correction appears in Mayo Clin Proc. 2008 Jul;83(7):851].
        Mayo Clin Proc. 2008; 83: 66-76https://doi.org/10.4065/83.1.66
        • Stout P.R.
        • Klette K.L.
        • Horn C.K.
        Evaluation of ephedrine, pseudoephedrine and phenylpropanolamine concentrations in human urine samples and a comparison of the specificity of DRI amphetamines and Abuscreen online (KIMS) amphetamines screening immunoassays.
        J Forensic Sci. 2004; 49: 160-164
        • Marchei E.
        • Pellegrini M.
        • Pichini S.
        • Martín I.
        • García-Algar O.
        • Vall O.
        Are false-positive phencyclidine immunoassay instant-view multi-test results caused by overdose concentrations of ibuprofen, metamizol, and dextromethorphan?.
        Ther Drug Monit. 2007; 29: 671-673https://doi.org/10.1097/FTD.0b013e318156e983
        • Rollins D.E.
        • Jennison T.A.
        • Jones G.
        Investigation of interference by nonsteroidal anti-inflammatory drugs in urine tests for abused drugs.
        Clin Chem. 1990; 36 (https://doi.org/10.1093/clinchem/36.4.602): 602-606
        • Sorisky A.
        • Watson D.C.
        Positive diphenhydramine interference in the EMIT-st assay for tricyclic antidepressants in serum.
        Clin Chem. 1986; 32 (https://doi.org/10.1093/clinchem/32.4.715): 715
        • Cole J.B.
        • Stellpflug S.J.
        • Ellsworth H.
        • Harris C.R.
        Reversal of quetiapine-induced altered mental status with physostigmine: a case series.
        Am J Emerg Med. 2012; 30: 950-953https://doi.org/10.1016/j.ajem.2011.05.015
        • Hendrickson R.G.
        • Morocco A.P.
        Quetiapine cross-reactivity among three tricyclic antidepressant immunoassays.
        J Toxicol Clin Toxicol. 2003; 41: 105-108https://doi.org/10.1081/clt-120019122
        • Mazor S.S.
        • Mycyk M.B.
        • Wills B.K.
        • Brace L.D.
        • Gussow L.
        • Erickson T.
        Coca tea consumption causes positive urine cocaine assay.
        Eur J Emerg Med. 2006; 13: 340-341https://doi.org/10.1097/01.mej.0000224424.36444.19
        • Moeller K.E.
        • Kissack J.C.
        • Atayee R.S.
        • Lee K.C.
        Clinical interpretation of urine drug tests: what clinicians need to know about urine drug screens.
        Mayo Clin Proc. 2017; 92: 774-796https://doi.org/10.1016/j.mayocp.2016.12.007
        • Monte A.A.
        • Hopkinson A.
        • Saben J.
        • et al.
        The Psychoactive Surveillance Consortium and Analysis (PSCAN): the first year.
        Addiction. 2020; 115: 270-278https://doi.org/10.1111/add.14808
        • Tenore P.L.
        Advanced urine toxicology testing.
        J Addict Dis. 2010; 29: 436-448https://doi.org/10.1080/10550887.2010.509277
        • Dean B.V.
        • Stellpflug S.J.
        • Burnett A.M.
        • Engebretsen K.M.
        2C or not 2C: phenethylamine designer drug review.
        J Med Toxicol. 2013; 9: 172-178https://doi.org/10.1007/s13181-013-0295-x
        • Stellpflug S.J.
        • Kealey S.E.
        • Hegarty C.B.
        • Janis G.C.
        2-(4-Iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine (25I-NBOMe): clinical case with unique confirmatory testing.
        J Med Toxicol. 2014; 10: 45-50https://doi.org/10.1007/s13181-013-0314-y
        • Topeff J.M.
        • Ellsworth H.
        • Willhite L.A.
        • Bangh S.A.
        • Edwards E.M.
        • Cole J.B.
        A case series of symptomatic patients, including one fatality, following 2C-E exposure [abstract].
        Clin Toxicol. 2011; 49: 526https://doi.org/10.3109/15563650.2011.598695
        • Olives T.D.
        • Orozco B.S.
        • Stellpflug S.J.
        Bath salts: the ivory wave of trouble.
        West J Emerg Med. 2012; 13: 58-62https://doi.org/10.5811/westjem.2011.6.6782
        • Harris C.R.
        • Brown A.
        Synthetic cannabinoid intoxication: a case series and review.
        J Emerg Med. 2013; 44: 360-366https://doi.org/10.1016/j.jemermed.2012.07.061
        • Arens A.M.
        • Olives T.D.
        • Simpson N.S.
        • et al.
        An outbreak of synthetic cannabinoid exposures reported to a regional poison center: “K2” identified as 5F-ADB.
        Clin Toxicol (Phila). 2019; 57: 69-71https://doi.org/10.1080/15563650.2018.1497170
        • Jones M.J.
        • Hernandez B.S.
        • Janis G.C.
        • Stellpflug S.J.
        A case of U-47700 overdose with laboratory confirmation and metabolite identification [published correction appears in Clin Toxicol (Phila). 2017 Jan;55(1):76].
        Clin Toxicol (Phila). 2017; 55: 55-59https://doi.org/10.1080/15563650.2016.1209767
        • Arens A.M.
        • van Wijk X.M.R.
        • Vo K.T.
        • Lynch K.L.
        • Wu A.H.
        • Smollin C.G.
        Adverse effects from counterfeit alprazolam tablets.
        JAMA Intern Med. 2016; 176: 1554-1555https://doi.org/10.1001/jamainternmed.2016.4306
        • Naglich A.C.
        • Brown E.S.
        • Adinoff B.
        Systematic review of preclinical, clinical, and post-marketing evidence of bupropion misuse potential.
        Am J Drug Alcohol Abuse. 2019; 45: 341-354https://doi.org/10.1080/00952990.2018.1545023
        • Klein L.
        • Bangh S.
        • Cole J.B.
        Intentional recreational abuse of quetiapine compared to other second-generation antipsychotics.
        West J Emerg Med. 2017; 18: 243-250https://doi.org/10.5811/westjem.2016.10.32322
        • Olives T.D.
        • Arens A.M.
        • Kloss J.S.
        • Apple F.S.
        • Cole J.B.
        The new face of heroin.
        Am J Emerg Med. 2017; 35: 1978-1979https://doi.org/10.1016/j.ajem.2017.06.042
        • Cole J.B.
        • Nelson L.S.
        Controversies and carfentanil: we have much to learn about the present state of opioid poisoning.
        Am J Emerg Med. 2017; 35: 1743-1745https://doi.org/10.1016/j.ajem.2017.08.045
        • Ciccarone D.
        • Ondocsin J.
        • Mars S.G.
        Heroin uncertainties: exploring users’ perceptions of fentanyl-adulterated and -substituted “heroin.
        Int J Drug Policy. 2017; 46: 146-155https://doi.org/10.1016/j.drugpo.2017.06.004
        • Arens A.
        • Olives T.
        • Laes J.
        • Cole J.
        It’s not just heroin anymore.
        Clin Toxicol (Phila). 2017; 55: 608https://doi.org/10.1080/15563650.2017.1286015
        • Melanson S.E.
        • Ptolemy A.S.
        • Wasan A.D.
        Optimizing urine drug testing for monitoring medication compliance in pain management.
        Pain Med. 2013; 14: 1813-1820https://doi.org/10.1111/pme.12207
        • Cole J.B.
        • Dunbar J.F.
        • McIntire S.A.
        • Regelmann W.E.
        • Slusher T.M.
        Butyrfentanyl overdose resulting in diffuse alveolar hemorrhage.
        Pediatrics. 2015; 135: e740-e743https://doi.org/10.1542/peds.2014-2878
        • Kranenburg R.F.
        • Peroni D.
        • Affourtit S.
        • Westerhuis J.A.
        • Smilde A.K.
        • van Asten A.C.
        Revealing hidden information in GC–MS spectra from isomeric drugs: chemometrics based identification from 15 eV and 70 eV EI mass spectra.
        Forensic Chem. 2020; 18: 100225https://doi.org/10.1016/j.forc.2020.100225
        • Akosile W.
        • McDermott B.M.
        Use of the urine drug screen in psychiatry emergency service.
        Australas Psychiatry. 2015; 23: 128-131https://doi.org/10.1177/1039856214568213
        • Yun B.J.
        • Chou S.C.
        • Nagurney J.M.
        • White B.A.
        • Wittmann C.W.
        • Raja A.S.
        ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis.
        Am J Emerg Med. 2018; 36: 745-748https://doi.org/10.1016/j.ajem.2017.10.002
        • Vakkalanka P.
        • Rushton W.F.
        • Hardison L.S.
        • Bishop M.C.
        • Haverstick D.M.
        • Holstege C.P.
        Evaluation of the initiation of urine drug screens intended for use in transfer patients.
        Am J Emerg Med. 2014; 32: 1037-1040https://doi.org/10.1016/j.ajem.2014.06.011
        • Shihabuddin B.S.
        • Hack C.M.
        • Sivitz A.B.
        Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one?.
        Pediatr Emerg Care. 2013; 29: 903-906https://doi.org/10.1097/PEC.0b013e31829e8050
        • Schiller M.J.
        • Shumway M.
        • Batki S.L.
        Utility of routine drug screening in a psychiatric emergency setting.
        Psychiatr Serv. 2000; 51: 474-478https://doi.org/10.1176/appi.ps.51.4.474
        • Belson M.G.
        • Simon H.K.
        Utility of comprehensive toxicologic screens in children.
        Am J Emerg Med. 1999; 17: 221-224https://doi.org/10.1016/s0735-6757(99)90109-2
        • Sugarman J.M.
        • Rodgers G.C.
        • Paul R.I.
        Utility of toxicology screening in a pediatric emergency department.
        Pediatr Emerg Care. 1997; 13: 194-197https://doi.org/10.1097/00006565-199706000-00005


      Samuel J. Stellpflug is a faculty physician, Department of Emergency Medicine, Regions Hospital, Saint Paul, MN. Twitter: @SamStellpflug. ORCID identifier: https://orcid.org/0000-0002-2378-5280.


      Jon B. Cole is a faculty physician, Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN. Twitter: @jonbcole2. ORCID identifier: https://orcid.org/0000-0002-7714-8826.


      Howard A. Greller is a faculty physician, Department of Emergency Medicine, SBH Health System, Bronx, NY. Twitter: @heshiegreshie. ORCID identifier: https://orcid.org/0000-0003-2373-7163.