Journal Club--Testing for Drugs of Abuse in Children and Adoescents
The Committee on Substance Abuse for the American Academy of
Pediatrics recently published a statement on testing for drugs of abuse in
children and adolescents (Pediatrics. 1996; 98: 305-307.). There are a
number of important recommendations for the clinician to keep in mind as
these young people are encountered (see appended article summary)
These recommendations seem straightforward, but how will the
clinician apply them to real-life encounters that come through our
emergency departments and offices every day? How would you manage the
a. 14 year old girl allowed her 14 year old male friend through
her bedroom window the night before. She remembers "drinking a little",
but not much else, and mother roused her at about 11:00 am the following
morning, aghast to note that her daughter was hung over, nauseous, and
bearing a shiny new "hickey" on the left side of her neck. Mom requests,
among other things, a drug screen. Child just wants to go home. Should the
drug screen be run?
b. 15 year old girl runs away from home for two days and stays
with a "friend". She returns on her own, and mom promptly brings her to
the emergency department to get her screened for drugs. Asymptomatic, the
child privately tells you that she "smoked some pot". Exam is normal.
Patient does not wish to be tested. Should the screen be run anyway?
c. 14 year old male in foster care all his life comes to the
emergency department with a child protective services worker, who says he
ran from his "Half-way" house for the fourth time this year. The case
worker says the patient needs to be screened for medical clearance before
the adolescent can be placed. Patient says he does not care what is done.
Run the screen?
d. A local pediatrician calls the emergency department exasperated
because a mother is seeking the physician's help with a 15 year old girl.
The girl has been losing weight, performing poorly in school, and is having
many near violent encounters with parents at home. Mother has been told
that the child is being sent for "medical testing", but the primary
physician suspects drug abuse, and requests that a drug screen be done in
addition to urinalysis, CBC, pregnancy testing, etc.The teen is willing to
be screened as long as the mother is not informed of results. Mother, of
course, tells you that she wants results of all tests. What should be done?
1. The difference between screen testing and diagnostic testing.
Screen testing is performed on apparently well individuals for the purpose
of early detection and treatment. Diasgnostic testing is performed when
history and exam have raised the possibility of a disease or condition.
2. The difference between voluntary and involuntary testing.
Voluntary testing applies to individuals who have attained decisional
competency, and the article points out that truly voluntary
testing is unlikely to detect most drug users.
3. Diagnostic drug testing is acceptable if it is clearly for the
purpose of drug abuse treatment.
4. Truly involuntary testing is necessary only if the adolescent
is at risk of serious harm that could be averted if the drug is identified.
5. There are potential legal consequences of drug testing; there
needs to be a candid discussion of confidentiality and informed consent:
"a competent adolescent may consent to drug testing and counseling without
the knowledge of parents, police, or school administration".
6. Parental permission (or request) is not sufficient for
involuntary screening of the older (they do not specify how old),
competent adolescent. "...Testing adolescents requires their consent
unless: 1) the patient lacks decision-making capacity, 2) there are strong
medical or legal requirements to do so.
Gregory Lockhart, MD
Department of Emergency Medicine
Rhode Island Hospital, Providence RI
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