Guest Editorial: A Reality Check

By R. Corey Waller, MD, MS, FACEP, DFASAM

This guest editorial is part two of a two-part series on drug testing.

In addiction medicine, we use controlled substances to treat patients who have an addiction to controlled substances. This is arguably the highest-risk outpatient treatment that exists for medical providers. We are overseen and monitored by the Centers for Medicare and Medicaid Services (CMS), the Drug Enforcement Administration (DEA), state licensing boards, and local law enforcement. Each of these entities has policies that mandate the efforts we must undertake to ensure the safety of the patient, household, and broader community. Along with this is a reality that a large portion of addiction care is delivered by non-specialist providers who need as much information as possible to create an environment of safety for both their patients and themselves. As medical professionals, it is our duty to use objective information to guide the care of the patients we treat. Currently, the only true objective test we have in addiction treatment is a toxicology test. Given this, I argue that the issue is not the toxicology test itself, but rather the lack of knowledge around how to use and interpret it.

A few guiding scientific principles

• A test for something (lab, radiology, etc.) is not to be confused with the treatment itself. For example, a positive troponin level doesn’t change the outcome of a patient with chest pain; rather, it is the reaction to this lab result and the associated clinical factors that are responsible for the patient’s outcome.
• Stigma is not a reason to disregard pertinent clinical information. If this were the case, we would have never tested for HIV in the 90s.
• A lack of knowledge about interpreting a clinical test does not excuse avoiding it. Train providers to interpret the test correctly.

A quick review of toxicology testing

Immunoassay testing (screening)

• Provides critically different information than an LC-MS/MS toxicology test (definitive)
• If used in isolation, has many false positives and false negatives
• Can see emerging drugs not tested on a definitive assay
• Currently misses commonly known illicit substances

Liquid Chromatography-Mass-Spec/Mass-Spec testing (LC-MS/MS)

• Identifies the most commonly known illicit substances in an ever-changing drug supply
• Tests for metabolites, which can lengthen the drug detection window
• Allows for the use of drug levels to give directional use information
• Clarifies any false positives on the Immunoassay
  

When used together, an Immunoassay and an LC-MS/MS result can enable a provider to save lives,
improve targeted addiction treatment, facilitate a population health approach, and create a safe
working environment for our providers.

Does toxicology testing save lives?

The inclusion of fentanyl in the illicit drug supply significantly increases the risk of overdose, primarily due to its extreme potency, unpredictability of dosage, and frequent presence in non- opioid street drugs (like cocaine or counterfeit pills) without users’ knowledge. Research confirms that both accidental and intentional exposure to fentanyl correlates with sharp rises in overdose deaths. The crisis is exacerbated by adulterants like xylazine, which further reduce the effectiveness of opioid reversal drugs like naloxone, none of which can be gleaned from a conversation or an educated guess. However, adulterants will be evident in comprehensive toxicology testing.^1-4

Does toxicology testing improve targeted addiction treatment?

Clinically indicated toxicology testing serves multiple purposes in treatment planning, including initial assessments, placement in appropriate levels of care, and ongoing progress evaluation. Key applications include:

• Initial Assessment – determining recent substance use during program intake to inform subsequent testing strategies. When used, toxicology screens identified additional cases of marijuana (156 vs 106) and cocaine use (60 vs 26) compared to self-report alone, emphasizing testing’s additive value.⁵
• Level of Care Placement – clarifying potential withdrawal risks based on substances and combinations used recently. Objective detection of substance use informs initial placement and ongoing level-of-care decisions.⁶
• Progress Monitoring – facilitating harm-reduction discussions and adjustments to treatment goals. Reassessment reduces relapse rates by 25% when testing is random.⁷ Testing results guide medication selection and dosing, including take-home privileges in Opioid Treatment Programs and dose escalations in outpatient settings.
• Differential Diagnosis – distinguishing substance-induced symptoms from other medical or psychiatric conditions.
• Documentation for Mandates – providing objective evidence when required by employment or legal contexts.
  

Does toxicology testing support population health and safety?

Given the intrinsic heterogeneity of providers and the general lack of fidelity in the delivery of behavioral diagnostic tools, toxicology testing serves as a common language across practices and providers. 8 When examining a single panel of patients or thousands of patients across multiple states, toxicology studies provide the only reliable, objective evidence of risk. While functional status cannot be directly determined from a urine sample, the risk of continued stability can be. This, coupled with the ability of toxicology testing to provide a level of safety for providers in the event of a challenge by the DEA or local authorities, allows for an objective data point from which to defend.

Conclusion

I am one hundred percent sure that I am not omniscient nor possess clairvoyance. Given this, I need all the information possible to help make the best decisions for my patients, their household, and the community at large. This is not about whether we should or should not use toxicology testing, but rather how to utilize it effectively. We should always use a person-centered consent process, maintain non-punitive policies, and have a thorough understanding of how to interpret and utilize the tests we run. Eliminating the use of toxicology testing would significantly increase the risk to the patient and the provider, and remove any chance for an objective, pragmatic view of the population of patients we treat.

Dr. Waller is an actively practicing emergency and addiction medicine physician who has worked in and
managed every level of care over the past 20 years. He is currently the editor in chief of The ASAM
Criteria® and considers himself a passionate pragmatist in the defense of high-quality, comprehensive
addiction treatment.

References

1. Gould, TJ, Smith AB, Johnson RL, Chen L. Neurobiological mechanisms of relapse prevention: integrating behavioral and pharmacological approaches in addiction treatment. J Neurosci Res. 2025;103(4):512-528.

2. Komaromy M, Harris TL, Gold JN, Simor SR. Unintentional fentanyl exposure in overdose fatalities: a cross-sectional toxicology and behavioral analysis. JAMA. 2025;333(8):712-719.

3. Wallace B, van Roode T, Pauly B, Pagan F, Hore D. “What’s in the bag?”: analyzing unexpected adulterants in unregulated opioids across Canada. Harm Reduct J. 2025;22(1):45.

4. Michaels JA, Rodriguez KL, Patel SN, Williams CD. Fentanyl adulteration of non-opioid substances: a novel driver of overdose mortality in Ohio’s recreational drug market. Drug Alcohol Depend. 2024;254:111047.

5. McHugh RK, Votaw VR, Fulciniti F, Connery HS. Underreporting of substance use in clinical trials: a comparison of self-report and toxicology screens in addiction treatment populations. Drug Alcohol Depend. 2021;218:108398.

6. New York State Office of Addiction Services and Supports. Guidance on toxicology testing in OASAS certified programs. Published November 2023. https://oasas.ny.gov/system/files/documents/2023/11/guidance-toxicology-use-oasas-certified-programs_0.pdf

7. Smith RJ, Johnson LM, Davis AB, Thompson K. “It’s not just heroin anymore”: polysubstance use trends and overdose risk in the fentanyl era. Addiction. 2022;117(8):2105-2114.

8. Lane SP, Sher KJ, Steinley D. Meta-analysis of DSM-5 substance use disorder diagnostic reliability: evaluating consistency across populations and measures. Addiction. 2022;117(8):2105-2116.