Urine Drug Screen Before Initiating Stimulant Treatment
Collect a urine drug screen (UDS) before initiating stimulant treatment in adults with high rates of comorbid substance abuse, but it is not routinely required for children, adolescents, or adults without substance use concerns. 1
Required Baseline Evaluations
Before starting any stimulant medication, the following assessments are mandatory:
- Blood pressure and pulse measurement at baseline is required for all patients regardless of age 1
- Physical examination including vital signs, height, and weight must be completed 2
- Detailed cardiac history including syncope, chest pain, palpitations, exercise intolerance, and family history of sudden death, early cardiovascular disease, or arrhythmias 1
- Documentation of prior treatments, including previous medications, dosages, duration, response, side effects, and compliance 2
When to Consider UDS Before Stimulant Initiation
For adults with substance abuse concerns:
- A UDS may be considered in adults with high rates of comorbid substance abuse before starting stimulant medications 1
- This is particularly relevant given that stimulants are contraindicated in patients with a history of illicit use or abuse of stimulants, unless treated in a controlled setting with close supervision 2
For children and adolescents:
- No baseline blood work or UDS is required before starting ADHD medications unless clinically indicated by history or physical examination 1
Clinical Rationale and Caveats
The selective approach to pre-treatment UDS reflects several important considerations:
- Stimulants must be used with great care if there is a history of drug abuse, and are contraindicated in patients with active stimulant abuse unless closely supervised 2
- UDS should never delay treatment initiation when a patient meets clinical criteria for ADHD treatment, as delaying care represents a missed opportunity 3
- False-positive results are common with immunoassay UDS, requiring confirmatory testing before making clinical decisions that could deny necessary treatment 4, 5
Important Contraindications to Document
Beyond substance abuse screening, ensure you document and rule out:
- Previous sensitivity to stimulant medications 2
- Glaucoma, symptomatic cardiovascular disease, hyperthyroidism, or hypertension 2
- Active psychotic disorder 2
- Concomitant MAO inhibitor use 2
- Seizure disorder (should be controlled before initiating methylphenidate) 2
Monitoring After Initiation
Once stimulants are started: