In most states, adolescent patients have legal capacity to consent to substance abuse treatment. However, in a small minority of states, parents have a right to seek substance abuse treatment for their child, even when the child objects. Additionally, some states allow providers to notify the parents about treatment to which a minor has consented (or disclose information about the treatment), even without the minor’s consent to such disclosure.1 Consequently, consent for diagnosis and treatment associated with substance abuse should be handled carefully. Consider the following case.
Case File
The mother of a 15-year-old patient called a family practice physician and asked him to perform a drug test on her daughter during an upcoming annual physical, even if the daughter refused to consent to it. The mother reported that she had observed behavioral changes that indicated her daughter might be vaping and using drugs, although the daughter denied substance use. The mother planned to have her daughter enter a drug treatment program depending on the results. The physician called the NORCAL Risk Management department to ask if he could comply with the mother’s request.
Discussion
The answer to this question varies depending on the state in which a practice is located. Assuming the law in this state allowed the physician discretion in deciding whether to test without the minor’s consent, there are many different issues that would play a role in his determination. For example, even when state law allows parents to have a drug test performed on their adolescent child without consent of the adolescent, the American Academy of Pediatrics (AAP) cautions against involuntarily drug testing adolescents except in particular emergency situations.2 Also, in this particular case the parents planned to admit their child to substance abuse treatment based on a positive result to one test. Their plan provided an opportunity for the physician to educate the parents about the limited value of a single test result, which cannot indicate a pattern of abuse, dependence, or impairment, and might yield false-positive results.2 Furthermore, a negative result would not rule out substance abuse.3 The physician also had to consider the potential damage that testing without the patient’s consent would have on his therapeutic relationship with the patient. In this case, the physician would have to determine which course represented the best interest of his patient.
Medical Liability Risk Management Recommendations
Consider the following recommendations:2,4
- Know the minor consent laws about substance abuse diagnosis and treatment in the state in which you practice.
- Obtain a detailed description of the parents’ concerns prompting the drug test request.
- Advise parents that a single positive drug test does not indicate substance abuse, and a negative test does not prove its absence.
- Discuss parental concerns with the patient without the parents present.
- When appropriate, obtain patient assent and permission to conduct the drug test and to share the results of the test before ordering the test.
- Consider referring the minor to an addiction or mental health specialist if you suspect substance abuse.
In addition:
- Maintain current awareness of emerging adolescent public health issues and take opportunities to educate patients and parents.5,6 For example, in late 2019, the Centers for Disease Control (CDC) identified a thickening agent (Vitamin E acetate) as a factor in lung injuries associated with vaping.5
- Pediatricians may find themselves in a position of identifying depression (or other mental health-related diagnoses), but without sufficient referral sources to support the patient. When medication is a part of that treatment:
- Obtain appropriate consent for treatment with psychotropic medications (e.g., for depression and ADHD).
- Because of the increased potential for diversion (i.e., selling drugs to peers), ensure that the education and consent process includes discussing the potential risks of harm to self or others.
- Have a substance abuse contract in place and follow your state’s prescription drug monitoring program (PDMP) requirements for tracking patients.
References
1. Richard C. Boldt. “Adolescent Decision Making: Legal Issues with Respect to Treatment for Substance Misuse and Mental Illness.” Journal of Health Care Law & Policy, 2012 75-115.
2. Sharon Levy, et al. “Testing for Drugs of Abuse in Children and Adolescents.” , 2014; 133: e1798-e1807.
3. American Society of Addiction Medicine. “Consensus Statement: Appropriate Use of Drug Testing in Clinical Addition Medicine.” 4/5/2017.
4. Melissa Weddle, et. al. “Confidentiality and Consent in Adolescent Substance Abuse: An Update.” Virtual Mentor, 2005. 7(3).
5. National Institutes of Health. National Institute on Drug Abuse for Teens.
6. U.S. Dept. of Health & Human Services. Office of Disease Prevention and Health Promotion. “Adolescent Health.”
