You Should Not Perform Drug Testing Without the Adolescent's Knowledge and Consent
Drug testing of a competent adolescent without his or her consent is, at best, impractical, and testing without his or her knowledge is ethically inappropriate and undermines the patient-provider relationship. 1
The Ethical Framework
The American Academy of Pediatrics explicitly opposes involuntary testing of adolescents for drugs of abuse and states that adolescents should not be drug tested without their knowledge and consent. 1 This position is grounded in protecting adolescent autonomy, maintaining trust in the therapeutic relationship, and recognizing that competent adolescents can consent to substance abuse treatment on their own in most states. 1
What You Should Do Instead
Step 1: Meet with the Mother Separately First
- Obtain a detailed description of her specific concerns about behavioral, mental health, or physical changes that prompted the request. 1
- Explain that drug testing without the adolescent's knowledge and consent is ethically inappropriate and likely to damage the therapeutic relationship. 1
- Discuss the limited scope of information available from testing and the need for an action plan for both positive and negative results before any testing occurs. 1
Step 2: Discuss Concerns Directly with the Adolescent
- The concerns raised by the mother and the recommendation for a drug test should then be discussed with the adolescent directly. 1
- Obtain the adolescent's assent, including explicit permission to share results with the parent. 1
- If the adolescent refuses to consent to sharing drug test results with the parent, then results should not be shared, and you should explain this to the mother. 1
Step 3: If the Adolescent Refuses Testing Entirely
- Clinical decisions based on history and physical examination alone should not be discounted because of inability to obtain a drug test. 1
- You can refer the patient for further evaluation or treatment based on a high index of suspicion of drug use, even without testing. 1
- If a reasonable balance between obtaining information and protecting the adolescent's dignity cannot be attained, consider forgoing the drug test entirely. 1
Critical Pitfalls to Avoid
Never disguise the purpose of the test. Deception fundamentally violates medical ethics and will destroy trust when discovered—and adolescents will discover it. 1
Do not proceed with "routine urinalysis" as a cover. This represents testing without knowledge and consent, which the AAP explicitly opposes. 1
Recognize that poorly managed drug testing may cause friction between the adolescent and parents and create a difficult situation for you to manage. 1 Good outcomes are more likely if you review how test results will be managed before any test is sent to the laboratory. 1
The Only Exception
The only circumstance where you might consider breaching confidentiality is if the adolescent's behavior puts him or her at acute risk of harm to self or others. 1 Even in this scenario, you should still inform the adolescent that you are ordering the test and explain why confidentiality must be breached.
Alternative Approach: Clinical Assessment Without Testing
- Engage the adolescent in conversation about substance use using validated screening tools during a confidential portion of the visit. 1
- Look for acute indicators of use: increased fluid intake, dental symptoms, fruit/sweet-like smells for e-cigarettes; dry or red eyes, increased appetite for cannabis; miosis, drowsiness, slowed breathing for opioids. 1
- Build ongoing rapport—adolescents are more likely to disclose substance use in subsequent visits with trusted providers. 1
- Refer for mental health evaluation if behavioral symptoms persist, regardless of drug testing. 1