ADLM Updates Expert Guidance on Urine Drug Testing for Patients in Emergency Departments

Urine drug testing plays a critical role in the emergency department, particularly for patients presenting with suspected overdose or altered mental status. Accurate and timely results can directly influence clinical decisions, prevent unnecessary imaging, and trigger safeguarding actions in vulnerable populations such as children. As patterns of drug misuse and available testing technologies have changed significantly, up-to-date guidance is essential to ensure testing remains clinically meaningful.

The Association for Diagnostics & Laboratory Medicine (ADLM, Chicago, IL, USA) has released its updated guidance to help healthcare professionals navigate drug testing for patients in the emergency department. The recommendations were developed by experts from ADLM’s Academy of Diagnostics & Laboratory Medicine to help emergency clinicians and laboratory professionals choose appropriate drug tests for both adult and pediatric patients. The guidance emphasizes collaboration between laboratories and emergency departments to optimize test selection, interpretation, and patient care.

Since ADLM first issued emergency department drug testing guidance in 2003, the drug landscape has changed dramatically. Synthetic opioids such as fentanyl entered the illegal drug supply around 2013, and new designer drugs continue to emerge each year to evade regulation. At the same time, use of some medications, including tricyclic antidepressants, has declined to the point that routine testing is often no longer clinically useful.

The expert group reviewed evolving trends in drug use alongside advances in testing technology. While immunoassays remain the most common method for urine drug testing, their performance has improved over time, and access to mass spectrometry has expanded across healthcare institutions. The updated guidance integrates these developments to ensure test menus and protocols remain aligned with real-world clinical needs.

The guidance recommends close collaboration between laboratories and emergency clinicians, with laboratories actively educating providers on test limitations and interpretation. Institutions are advised to regularly review and update their drug testing menus based on local drug use patterns, removing tests that do not influence patient management. For selected cases, including pediatric patients or situations where immunoassays are insufficient, the use of mass spectrometry is encouraged when results are expected to guide care.

By aligning drug testing practices with current epidemiology and technology, the updated guidance supports more personalized and effective emergency care. The recommendations aim to reduce unnecessary testing, improve diagnostic accuracy, and ensure that results meaningfully inform clinical decisions. ADLM expects the guidance to evolve further as new drugs and testing methods continue to emerge.

The expert panel has emphasized that ongoing communication between laboratories and emergency departments is essential to keep pace with rapidly changing drug trends and to ensure that urine drug testing remains a valuable tool in emergency medicine.

"Regardless of the method(s) offered, all laboratories should collaborate with ED leadership … to ensure test menus are up to date and reasonable for the patient population," wrote the document authors. Additionally, "laboratories and EDs should collaborate on education of clinical staff regarding assay performance and limitations and regularly discuss optimal strategies to meet clinical needs."

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