Reconsidering urine drug testing in reproductive health

Researchers have created a new framework to assess whether to use urine drug tests in reproductive health settings.

Clinicians commonly order urine drug tests in reproductive health settings under the assumption that the results are necessary to guide the team’s decisions. There are scenarios where the test provides useful data, however urine drug testing is often used outside of evidence-based applications. Positive results can lead to significant social and legal consequences for patients, including child welfare investigations, family separation, and prosecution of the person giving birth.

Research shows that clinicians test and report Black pregnant people more than white pregnant people, leading to a higher burden of negative outcomes for Black families. Reconsidering the test’s use is critical for effective, ethical, and equitable practice of reproductive health.

In a new paper co-authored by Bixby researchers, Noelle Martinez, MD, and colleagues present a framework to support reproductive health teams in answering clinical questions and providing excellent patient care while avoiding adverse health, social, and legal outcomes that can occur following a positive urine drug test.

  • Articulate the question the clinical team is trying to answer with the test. This can be challenging, as in many settings the practice of ordering the test is reflexive, culturally ingrained, or even automated, so the driving question has become murky.
  • Assess whether information provided by the urine drug test provides the most direct, relevant data needed to answer the question. The sensitivity and specificity of tests vary by drug and drug class. They may yield false negatives or positives (which might occur because of other substances including prescribed medications).
  • Assess whether the benefits of testing outweigh the short-term and long-term risks. The risk/benefit calculation can happen through informed consent with the patient, clinician reflection, and multidisciplinary team discussion. Although the clinician who orders the test may not be around to bear witness to the impacts of test—disengagement from care, family separation, legal charges or emotional trauma—they have a duty to consider those potential consequences.
  • If the team concludes that the urine drug test would not provide the most reliable data or deems that the risks outweigh the benefits, propose a more effective method to inform clinical decision-making. Throughout this entire process, clinical teams must reflect on the ways conscious and unconscious biases are driving decision-making. Such discussions may involve disagreements among colleagues, and clinicians may need to make decisions that directly challenge existing organizational practices, which can be uncomfortable and exhausting.

Urine drug testing is one tool within medicine. Overuse of this tool has limited clinical benefit and contributes to negative health, social and legal consequences, particularly for Black and Indigenous pregnant people. The researchers suggest limiting urine drug testing to the few settings and scenarios where the benefit for clinical care or the patient outweighs the risks.