How can I politely confront a patient about a positive benzodiazepine drug screen?

How to Politely Confront a Patient About a Positive Benzodiazepine Drug Screen

Begin the conversation by informing the patient that the drug test showed "unexpected results" and ask for more information, rather than immediately accusing them of substance misuse. This non-confrontational approach, recommended by the American Academy of Pediatrics, acknowledges that false-positive results are possible and creates space for honest dialogue 1.

Initial Approach: Frame as "Unexpected Results"

• Use neutral, non-judgmental language such as "Your drug test gave unexpected results" rather than "You tested positive for benzodiazepines" 1.
• This phrasing applies whether the result is positive, dilute, or adulterated, and avoids immediately putting the patient on the defensive 1.
• Ask open-ended questions like "Can you help me understand these results?" or "Is there anything you can tell me that might explain this finding?" 1.

Critical First Step: Rule Out False Positives and Prescribed Medications

Before making any clinical decisions, obtain a complete medication history including all prescription medications, over-the-counter drugs, and supplements 2.

• Standard benzodiazepine immunoassays have significant limitations and can produce false-positive results due to cross-reactivity with structurally similar compounds 2, 3, 4.
• Point-of-care immunoassays for benzodiazepines yield false-negative results nearly 20% of the time, particularly for lorazepam and clonazepam 4.
• Designer benzodiazepines (flubromazolam, flualprazolam, etizolam, clonazolam) may trigger positive screens but are not detected on standard confirmatory panels 3.
• Never make consequential clinical decisions based solely on immunoassay results without confirmation 2.

The Conversation Structure

Start by reviewing the positive result privately with the patient first, before involving family members or other parties 1.

Opening Statement:

• "I received your drug test results, and they showed something unexpected. The test was positive for benzodiazepines. Can you help me understand this result?" 1.

Listen for Alternative Explanations:

• The patient may report prescribed medications you weren't aware of 1.
• They may disclose use of substances not detected on the panel, potentially yielding more information than the test alone 1.
• They may identify over-the-counter medications or supplements that could cause cross-reactivity 2.

If the Patient Acknowledges Use:

• Transition to a collaborative discussion about next steps, which may include abstinence trial, ongoing testing, or referral to counseling or treatment 1.
• If their report matches the drug test results, confirmatory testing (which adds considerable expense) can reasonably be omitted 1.

If the Patient Denies Use:

• Acknowledge that "laboratory testing is not perfect, and spurious results are possible" 1.
• Explain that confirmatory testing using gas chromatography-mass spectrometry can definitively identify specific substances and rule out false positives 5, 2.
• Request confirmatory testing before making any clinical decisions that could harm the therapeutic relationship 2.

Use Motivational Interviewing Principles

Employ open-ended questions and reflective listening rather than confrontational statements 1.

What NOT to Say:

• ❌ "Don't you see that your benzodiazepine use is hurting you?" 1
• ❌ "You need to stop using benzodiazepines immediately" 1
• ❌ "I'm going to refer you to drug treatment" (without patient input) 1

What TO Say:

• ✓ "What do you know about how benzodiazepines might be affecting your health?" 1
• ✓ "How does it feel when you hear these test results?" 1
• ✓ "What are your thoughts about what we should do next?" 1
• ✓ "Is there anything about your medication use that concerns you?" 1

Address the Possibility of Prescribed vs. Non-Prescribed Use

Definitive testing is necessary to determine whether a patient is taking prescribed benzodiazepines appropriately, whether non-prescribed benzodiazepines are being used, or whether this represents a documentation error 5.

• Standard immunoassays primarily detect oxazepam and may not detect all prescribed benzodiazepines 6.
• The presence of specific benzodiazepines or metabolites can confirm whether the source is prescribed medication or illicit use 5, 2.
• Document all prescribed medications on the laboratory request form to help interpret results accurately 2.

Common Pitfalls to Avoid

• Never dismiss patients from care based on urine drug test results alone, as this constitutes patient abandonment 2.
• Do not breach confidentiality by sharing results with family members without the patient's consent, unless the patient is at acute risk of harm to self or others 1.
• Avoid making the conversation contentious, as poorly managed drug test discussions can cause friction and damage the therapeutic relationship 1.
• Do not assume the patient is being dishonest—false positives are common, and patients may be taking medications you're unaware of 1, 2, 3.

When Confirmatory Testing is Indicated

The Centers for Disease Control and Prevention recommends definitive testing when a presumptive test was positive for a prescription drug that wasn't prescribed to the patient, when results were inconclusive or inconsistent, or when the patient disputes positive results for illegal drugs 5.

• Gas chromatography-mass spectrometry (GC-MS) or liquid chromatography-tandem mass spectrometry (LC-MS/MS) can positively identify specific substances and differentiate them from cross-reacting compounds 5, 2.
• Confirmatory testing should be performed when results will directly inform clinical decision-making 5, 6.
• Discuss unexpected results with the patient before ordering expensive confirmatory testing, as this conversation can sometimes obviate the need for additional testing 5.

Follow-Up Actions Based on Results

If Prescribed Benzodiazepine Use is Confirmed:

• Assess for signs of dependence, tolerance, or inappropriate use 7, 8.
• Consider whether long-term benzodiazepine use is appropriate, as guidelines recommend limiting use to 2-4 weeks when possible 8.
• Discuss risks of long-term use including cognitive impairment, withdrawal effects, and increased risk when combined with opioids 7, 9, 4.

If Non-Prescribed Benzodiazepine Use is Confirmed:

• Explore the patient's reasons for use without judgment 1.
• Assess for underlying anxiety, insomnia, or substance use disorder 1.
• Discuss treatment options collaboratively, asking "What do you think would work for you?" rather than imposing a treatment plan 1.
• Consider referral to addiction medicine or psychiatry for comprehensive evaluation 1.

If Results Remain Unclear:

• Repeat drug testing may be valuable, as patients with serious substance use disorders are likely to ultimately have multiple positive results 1.
• Consider using a different testing matrix or adding specimen validity testing 1.
• Do not dismiss ongoing behavioral or mental health symptoms just because results are unclear—referral for mental health evaluation may be warranted 1.