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. 2025 Apr 23:37:16-27.
doi: 10.1016/j.jmsacl.2025.04.008. eCollection 2025 Aug.

Definitive urine drug testing in emergency medicine: Recreational and psychiatric drug findings

Thomas G Rosano  1   2 , S M Touhidul Islam  2 , John M Rumberger  1 , Robert M Konetchy Jr  1 , Michelle Wood  1 , Joseph A Sorce  2 , Karl A Robstad  2 , Heather Long  3
Affiliations

Definitive urine drug testing in emergency medicine: Recreational and psychiatric drug findings

Thomas G Rosano et al. J Mass Spectrom Adv Clin Lab. .

Abstract

Introduction: Clinical management of drug-related emergency department (ED) visits relies on available history, toxidrome findings and drug screening. In this study, definitive drug testing is used to assess ED drug prevalence and immunoassay drug screening performance.

Methods: Definitive testing for 116 drugs and metabolites was performed on urine from 400 ED patients, with comparison to immunoassay drug screening.

Results: Definitive testing resulted in 1,350 drug findings with prevalent use of nicotine (63%), cocaine (34%), ∆9 tetrahydrocannabinol (34%), fentanyl (17%), morphine or heroin (11%) and methamphetamine (6%). Forty percent of patients were also positive for antidepressants and 24% positive for antipsychotics. Significant patterns of co-drug use were found for cocaine, fentanyl, morphine and nicotine. Multi-serotonergic drug use was frequent, suggesting a risk for serotonin syndrome. Immunoassay performance showed high false negative rates for benzodiazepines (40%), amphetamines (38%), barbiturates (33%), opiates (25%), methadone (20%) and cocaine (16%), along with inaccuracy in phencyclidine detection. Immunoassay missed 890 of the 1,350 drug findings by definitive testing, due to either high cutoff thresholds or limited testing scope.

Discussion: A high prevalence of drugs use by ED patients is evidenced with frequent co-use of illicit and therapeutic drugs and with potential for unrecognized multi-serotonergic drug interactions. This study also shows the limitations of immunoassay drug testing in both scope and sensitivity, with a high rate of undetected drug use.

Conclusion: The study provides evidence-based support for recommended implementation of definitive drug testing in emergency medicine as a guide to clinical management in drug-related ED visits.

Keywords: Definitive urine drug testing; Drug prevalence; Emergency medicine; Polydrug use; Serotonin syndrome risk.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Ranked frequency of positive test findings for 400 ED patients determined by definitive drug testing.
Fig. 2
Fig. 2
Association frequency, statistical significance and odds ratio for co-use of drugs in patients using nicotine.
Fig. 3
Fig. 3
Association frequency, statistical significance and odds ratio for co-use of drugs in patients using fentanyl.
Fig. 4
Fig. 4
Association frequency, statistical significance and odds ratio for co-use of drugs in patients using cocaine.
Fig. 5
Fig. 5
Association frequency, statistical significance and odds ratio for co-use of drugs in patients using morphine.
Fig. 6
Fig. 6
Frequency of co-used serotonergic drugs in patients on SSRI and SNRI antidepressants.
Fig. 7
Fig. 7
Frequency of undetected drug findings by immunoassay. Solid bars show testing performance outside the drug classes tested by immunoassay and open bars show results for testing within the drug classes tested by the immunoassays used in clinical testing.
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