The False Positive Drug Test

It’s a nightmare ending to a slam-dunk case: Everything looks solid heading into routine blood and urine requirements and a positive drug test sends the case into question or, even worse, into decline. The applicant is surprised, disappointed, perhaps even angry that he or she would test positive when they are not taking what is being suspected. And a company may be adamant about not allowing a repeat or maintaining an original decline. How can such problems be anticipated and properly explained before they even reach the problem stage?

Insurance labs are excellent and make very few errors in testing. The quandary usually becomes what is the insured taking that may have caused a false screening into a more serious drug or compound of abuse or danger? Unlike the who-dun-its on late night television, no one is slipping you a “mickey” (chloral hydrate in the days it was used as a sleep aid) or foreign substance to sabotage the test. It is much more likely another medication or substance used for a benign indication is causing the problem. What can be done to prevent this?

The number 1, 2 and 3 answer: Be sure the applicant admits to everything they are taking up front when they are asked for their list of medications. Simple prescribed or over the counter medications can occasionally test positive for drugs that raise red flags. Which drugs? Ones like THC (cannabis), opioids (both prescription and illegal), PCP, cocaine, amphetamines, benzodiazepines and barbiturates. Medications like LSD and ecstasy can also be detected in urine drug samples, even when those aren’t the ones being suspected or looked for.

Let’s go over a few that are common offenders. Certain decongestants that are commonly used (like Sudafed) may come up as a positive test result for amphetamine. Diphenhydramine (or commonly used Benadryl) can turn a test positive for PCP. Some over the counter anti-inflammatory medications (even like Aleve, Naprosyn or Advil) can rarely test positive as a barbiturate. This doesn’t happen often or half our laboratory tests would be positive. But sometimes people’s individual metabolism may fool an assay into being reported as a positive substance.

Prescribed medications for legitimate use may cause trouble even when they might not have been any cause for alarm in underwriting an application. Phentermine is a weight loss medication (one of the phens in phen-fen), but may cause a positive urine test for amphetamine. Antidepressants are not uncommon sources of positive tests for other substances. Venlafaxine (Effexor) and the newer compound desvenlafaxine (Pristiq) may result in a positive PCP test. Sertraline (the commonly prescribed Zoloft) may turn up a positive benzodiazepine test. Trazodone, sometimes given as a sleeping aid, may result in a positive amphetamine test. So may bupropion (used in smoking cessation or as a mild antidepressant) that likewise may show up as amphetamine positive.

The list is pretty extensive. A couple more to note: Proton pump inhibitors, most commonly Protonix, used to treat GERD, may test as THC positive. Quinolone antibiotics may test as opiate positive. Promethazine, often given for nausea and vomiting, may test as amphetamine positive. And finally Tramadol, a commonly prescribed pain medication given when a doctor doesn’t want to prescribe codeine, may result as a positive test for methadone.

When a positive drug test comes up out of the blue, the underwriter will immediately question its veracity or look to see if a medication is being taken or prescribed that could possibly have caused a false positive. When admitted upfront, it isn’t a problem at all. When the test comes up positive and there is no available explanation, an underwriter will more likely assume the worst and give the applicant the more difficult task of explaining it away. This also goes for legitimately prescribed drugs that aren’t admitted on application. If there is a reason codeine or amphetamine or any drug being taken for a medical reason will show up as a positive test, admission upfront almost always has no consequences. Non-admission, and the post decline “Oh yeah, I was taking “XYZ” (for whatever cause) will raise questions of honesty on all parts of the application.

There are also unusual circumstances that no one expects but are discovered with some good old-fashioned detective work. An older couple in their late 60s both tested positive for cocaine in their urine. They were aghast at the result and we were just as surprised. A second test (“of course it must be a lab mistake”) came up with the same finding. We asked the couple to be sure their daily routine was as they represented to us. Weeks later, we received a call that the couple was always prepared a calming tea by their maid before bedtime. Their maid was a trusted part of their household ever since emigrating from Columbia 20 years before. The tea was Coca tea—made with Coca leaves. Having heard similar stories, I dared them to send me the tea bag. It came Express mail the next day. The amount of coca leaf was miniscule, but enough to turn the test positive. In my 30+ years of underwriting, unbelievably this has happened three times. Each time, to paraphrase Jerry Maguire, I said “Show me the teabag.” And each time, it arrived promptly and resulted in a policy issued as applied for after a good laugh.

MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life.

Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021.

Goldstone can be reached by ­telephone at 949-943-2310. Emaill: