Toxicology Testing Guidance for OASAS-Certified Programs

About 

Toxicology testing, when used effectively and in a person-centered framework, can be a valuable part of substance use disorder treatment. Toxicology testing should always be used as a clinical tool rather than a surveillance mechanism. 

OASAS-certified programs should integrate the following toxicology testing principles into their treatment practices and use them as guidance in policy and procedure development.

Program Competency

• Program medical directors should be involved in creating, reviewing, and approving toxicology testing policies and procedures
• Programs’ toxicology testing policies should include:
  • Reasons for testing
  • How test results will be used to inform treatment
  • Testing frequency
  • Circumstances for ordering confirmatory tests
• Testing policies and procedures should be person centered, culturally responsive, trauma informed, non-judgmental, and non-punitive
• Testing should not be used as substitute for a therapeutic relationship
• Testing should not be a replacement for asking patients about their substance use
• Test results are a complement to patient self-report, collateral report, and provider assessment
• Procedures for orienting patients to testing should include:
  • Why testing is performed
  • Where, when, and how samples for testing will be collected
  • Patients’ role and rights in testing
  • Education about the therapeutic uses of testing
• Program staff should be trained to understand toxicology test results, including the:
  • Difference between a screening/presumptive/qualitative test and a confirmatory/definitive/quantitative test
  • Importance of consulting medical staff when test results are not consistent with patient self-report or their current medications

Reasons for Testing

A person-centered, culturally responsive, trauma-informed approach should be used when determining if toxicology testing will be part of a patient’s initial assessment or ongoing treatment plan.

When testing is performed, it can be used for:

• Determining, when clinically indicated, if substances have been used recently as part of a program’s initial assessment
• Assisting providers in level of care determinations
• Monitoring progress in treatment as clinically indicated
• Helping discussions about reducing harms from or preventing future substance use
• Helping determine if a patient’s symptoms are related to substance use or a medical or mental health condition
• Providing documentation, when needed, about whether substances are currently being used

When to Test

Considerations for when to test include:

• At intake or admission as clinically indicated
• When requested by the patient
• At predetermined or intermittent intervals during treatment with less frequent testing as treatment progresses
• As clinically indicated during treatment, which may include:
  • Changes in behavior
  • Returning to the program after an absence from treatment

Specific substances’ windows of detection should be considered when determining the frequency of toxicology testing.

• For example, if a patient with opioid use disorder (OUD) reports regular fentanyl use, weekly testing may not be indicated clinically because fentanyl and its metabolite may take several weeks to be cleared from the body.

Toxicology Testing for Drug Court Participants  

• In OASAS programs, toxicology testing is conducted for clinical purposes only and should not be conducted for the sole purpose of satisfying NYS Drug Courts’ requirements for court-involved patients.
• Conducting toxicology tests to satisfy Drug Court requirements can negatively affect the therapeutic relationship the patient has with the OASAS program.  
• Toxicology testing required by the Drug Court is the responsibility of the Drug Court and should be arranged by the Drug Court.  
• Drug Courts may request the results from clinically indicated toxicology tests from OASAS programs to help them monitor a court-involved patient’s progress, but the results can only be disclosed in accordance with federal regulations regarding confidentiality of records related to patients receiving treatment for substance use disorder, as set forth in 42 Code of Federal Regulations (CFR) Part 2, and other applicable state and federal laws.  
  • The Consent to Release Information Concerning Substance Use Disorder Treatment for Criminal Justice Clients is available on the OASAS website.

Toxicology Testing in Opioid Treatment Programs

NYS OASAS regulations Part 822.7(f)(5)(i) and federal regulations 42 CFR 8.12(f)(6) indicate that OTPs must provide adequate toxicology testing or analysis for “commonly used and misused substances…at a frequency that is in accordance with accepted clinical practice and as indicated by a patient’s response to and stability in treatment, but no fewer than eight random toxicology tests per year.”  

Providers should use qualitative indicators of treatment progress, such as how the patient is functioning in their personal or professional life, to determine patient stability. Toxicology test results are just one factor in determining patient stability.

• Testing matrices include urine, blood, breath, oral fluid, sweat and hair
  • Urine is the most common and validated testing matrix
• Programs should consider collecting a specimen through an alternative method or matrix if a patient is unable to provide a specific sample
• Patients should be asked in a non-judgmental manner if they have used any substances prior to testing
• Programs should have infection control policies for sample collection that reduce health and safety risks to those handling the samples
• Samples should be collected in a person-centered, respectful, culturally responsive and trauma-informed manner
• Samples should be collected in a manner that minimizes the risk of adulteration, substitution, or dilution
  • Staff should be trained in collection techniques that protect the integrity of the test results
• Programs should develop protocols, such as temperature measurement or urine specific gravity analyses, with their laboratory provider for testing urine sample integrity when questions about sample integrity arise
  • These tests should only be used when there is a question about sample integrity rather than routinely
  • Other testing matrices may also be used when urine sample integrity is in question
• Direct observation of urine sample collection should not be part of usual clinical practice
  • Direct observation can be considered but should be a last resort in rare instances when sample integrity confirmation techniques do not resolve suspected problems with submitted urine samples
  • Peers and any staff directly involved in the patient’s clinical care should not observe urine sample submission  
  • Programs should have policies and procedures for those rare circumstances when direct observation is utilized that are:
    • Person centered
    • Respectful
    • Culturally responsive
    • Trauma  informed
      • Staff should be trained in these policies and procedures
  • Referring patients to a community-based laboratory that will directly observe urine sample collection is another way of providing direct observation if needed
• The program’s medical director or other medical staff should be consulted when:
  • Test results are not consistent with a patient’s self-reported substance use or current medications
  • Questions arise about which substances, environmental exposures, or testing procedures may cause false-positive or false-negative test results
• The program’s medical director and other medical staff should know when and how to consult with the testing laboratory’s personnel about test results

Substances to Include in Toxicology Testing and Interpretation of Toxicology Test Results

• It is recommended that initial screening toxicology panels include:
  • Most common substances used in the local community
  • Any substances of particular health concern
  • Any substances of particular concern for a given patient
  • Medications such as methadone, buprenorphine, and benzodiazepines
• Only substances that have a reasonable degree of specificity and sensitivity should be included in screening toxicology panels
  • For example, screening tests for fentanyl and its analogues are reliable, but tests for synthetic cannabinoids are not reliable because the sensitivity of the tests are poor given the variations in synthetic cannabinoid compounds
• Providers should understand factors that may affect test results, such as:
  • Substance metabolism and removal from the body
  • Cross-reactivity of prescribed and over-the-counter medications, supplements, and foods with a specific urine drug test
• Providers should be aware that certain substances may not be detected by toxicology tests, for example:
  • Buprenorphine, fentanyl, and methadone are not detected by urine tests for opioids
  • Alprazolam, lorazepam, and clonazepam may not be reliably detected by urine tests for benzodiazepines
• Programs can consider confirmatory tests when a patient denies substance use but has a positive test result that may have implications for their care
• Positive screening test results that are not verified by the patient should be considered preliminary until confirmatory test results are received
• Negative screening test results do not need to be sent for confirmatory testing unless there are specific clinical reasons, such as suspicion of a return to use
• Quantitative substances’ levels obtained from confirmatory testing are rarely clinically meaningful or helpful and should generally be avoided
  • Exceptions include testing for norbuprenorphine if it is necessary to confirm that a patient is taking prescribed buprenorphine rather than adulterating a sample 

• Toxicology testing should be normalized as a therapeutic tool that supports a patient’s treatment goals
• Policies and procedures should clearly specify that test results are used for person-centered purposes, such as discussing progress towards treatment goals and not for surveillance or punishment
• Toxicology test results:
  • Should be discussed with patients from a supportive, clinical perspective
  • Should be used to inform treatment plans and for ongoing reassessment in treatment
  • Should not be used punitively or as the only source of information guiding treatment decisions
• Both positive and negative test results should be discussed with patients and the discussions documented in the patients’ records
  • Patients should have the opportunity to discuss their reactions to test results and how test results will inform their treatment going forward
  • Discrepancies in self-reported versus laboratory results should be discussed
    • For example, a patient reported only using heroin, but their urine sample was positive for opioids, fentanyl, and amphetamines, suggesting that they may have unknowingly used heroin that had fentanyl and amphetamines mixed in
• Test results should be reported to patients in a non-punitive and non-confrontational manner that:
  • Provides objective feedback
  • Enhances motivation
  • Reinforces a patient’s treatment goals
• Providers should use non-stigmatizing language and clinically appropriate terms when discussing and documenting test results
  • “Positive” or “unexpected” or “unanticipated” test results rather than “dirty urine”
• Test results should not be used as a reason for program discharge or administrative taper of medication for addiction treatment
• Pattern of test results can assist in modifying treatment plans when needed  
  • For example, increasing a patient’s buprenorphine dose when they report ongoing opioid use and have frequent opioid positive urine test results
• Refusal to participate in toxicology testing should be viewed as a clinical issue to be addressed in the patient's treatment plan rather than an administrative issue
• Negative confirmatory test results for a medication the patient is being treated with, such as methadone, should not be grounds for program discharge due to concerns over diversion
  • Staff should have a non-punitive, non-judgmental conversation with the patient about the negative confirmatory test results 

1. Clinical Drug Testing in Primary Care, Technical Assistance Publication (TAP) Series 32. HHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.  
2. ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine. American Society of Addiction Medicine, 2025.
3. Urine Collections and Testing Procedures and Alternative Methods for Monitoring Drug Use in Center for Substance Abuse Treatment. In Substance Abuse Clinical Issues in Intensive Outpatient Treatment, Treatment Improvement Protocol (TIP) Series 47. DHHS Publication No. (SMA) 06-4182. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006.  
4. OASAS Plan of Safe Care for Infants and Their Caregivers Local Services Bulletin
5. Screening and Testing for Substance Use in Pregnancy. New York State Department of Health and New York State Office of Addiction Services and Supports, 2025.