Pre-employment drug screening can help you maintain a safer, more productive workplace, but the myriad of options can be overwhelming. There are oral fluid (saliva), urine, hair follicle, and blood drug testing options available to you, each with their own unique benefits and challenges.
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In this article, we’ll explore the accuracy, detection period, and use cases of saliva drug tests and compare them to your other options. Then you can make an informed decision around which drug tests are best suited for your pre-employment screening.
A saliva drug test is a drug screening test that detects traces of substances in someone’s saliva to identify the presence of drugs or alcohol in their system.
A saliva drug test is also known as a mouth swab drug test, oral drug test, or cotton swab drug test.
A common collection method is to use a swabstick with an attached sponge or absorbent pad to swab the inside of the cheek or under the tongue. Other collection methods include spitting, draining, and suction to gather saliva for testing.
A mouth swab drug test may be conducted on-site, including in an office or at the scene of an accident, or at a dedicated lab or specimen collection site.
The individual being screened may be asked not to eat or drink anything for 10 minutes before the test to ensure better accuracy. Food, beverages, medication, and mouthwash can all interfere with accurate saliva drug test results.
The specimen will either be instantly analyzed on-site or sent to a lab to determine if traces of controlled substances are present in the individual’s body.
If the initial screen yields a non-negative test result, a more sensitive confirmation screening will be done at a lab and a thorough medical review may be performed for accuracy. This step is important. The person being tested may use a prescription or over-the-counter medication that has resulted in a false-positive drug test. A Medical Review Officer (MRO) may verify the medical records provided by the individual being tested, possibly contacting their pharmacy or doctor’s office for prescription verifications.
There are saliva tests that can detect a single substance, such as an alcohol or marijuana swab test, as well as multiple panel drug screenings that detect a combination of substances. These usually include common drugs of abuse such as:
A mouth swab drug test is relatively accurate—but only when used correctly. Mouth swabs are also typically conducted by an administrator or under supervision, making it more difficult for the person being tested to tamper with the specimen.
Accuracy can vary between instant oral fluid testing kits, instant oral fluid testing devices, and lab testing. For example, one study found that a mobile saliva test system was 97.5% accurate compared to a saliva test conducted in a lab. Accuracy may also vary by specimen collection method, drug type and concentration, and whether saliva flow was stimulated. For instance, oral fluid production agents such as citric acid candy or chewing gum have been shown to lower concentrations two- to six-fold for codeine, two- to four-fold for methamphetamine, and five-fold for cocaine.
Evidence suggests that THC is deposited in the oral cavity during cannabis smoking and high THC concentration can be found in saliva specimens immediately after smoking. This is followed by a rapid clearing and slower decline over 12 hours.
Passive cannabis exposure (when a person inhales marijuana smoke from a nearby user), on the other hand, will have negative drug test results within an hour of exposure. A positive saliva drug test for THC provides an accurate indication of active cannabis use when recent passive exposure can be ruled out.
Urine and blood drug tests are both typically more accurate than saliva—but again, they must be used correctly.
A study comparing urine and saliva drug tests found that urine drug testing was more likely to detect overall substance use than oral testing. Of the 12 positive drug test results, nine were identified via the urine test, one via saliva test, and two via both tests.
Urine drug tests also have a longer detection period, making them a better choice for determining someone’s historical drug use.
How long do drugs stay in saliva and how far back does a mouth swab go?
A mouth swab drug test detection period is generally 5–48 hours. By comparison, drugs of abuse can be detected in blood for one or two days and in urine for 1.5 to four days.
It can be challenging to get an exact detection period for any drug test, as controlled studies can be difficult to execute. As one researcher explains, “illicit products have to be given to healthy volunteers and doses administered are low compared with street doses.”
The detection period can also vary by factors such as:
For example, the marijuana (THC) swab test detection time is 72 hours, while heroin can only be detected for about an hour. Most other types of drugs and their detection period fall within that range, though some can be detected for much longer periods of time. For example:
Since most substances can’t be detected in saliva for long, testing within the appropriate window of time is crucial for accurate results. For this reason, saliva drug tests are often used to identify current or recent drug use—therefore, this use case may not be ideal for testing heavy drug users.
A study explored prolonged excretion of cocaine in saliva specimens collected from heavy cocaine users during abstinence. Researchers found that elimination of cocaine in saliva may take up to 10 days in chronic users. Cocaine has a half-life of approximately one hour, but it’s unclear if heavy use prolongs the effects of the drugs used.
Instant on-site drug testing kits and devices can provide results in just a few minutes, while results for specimens analyzed by a lab are generally available within 1–3 days.
Depending on the provider, presumptive positive screens may undergo a lab-based confirmation testing and a review process that requires 2–3 additional days.
Employment drug screenings are regulated at the federal and state level, and it’s important to be aware of drug test laws so you can ensure compliance. These include:
Always consult with your legal counsel if you have questions about drug tests as part of your employment screening program.
There are three ways to get a saliva drug test:
The easiest way is to use a compliant screening provider and include drug tests in your background checks. This can help you build a fair, consistent drug screening practice that helps you make more informed decisions and maintain compliance.
Saliva is just one type of drug test often used for specific circumstances such as random, reasonable suspicion, or post-accident testing. They’re not designed to tell you if a person uses drugs—only if they’ve used drugs recently. This may be problematic in pre-employment drug screening, particularly if a candidate briefly abstains from recreational drug use while they interview. Urine is typically a better specimen choice to screen for prior drug use, while hair can help you detect long-term drug abuse.
GoodHire’s employer drug screening offerings are designed to meet your company policy and drug-free workplace obligations, while helping you maintain compliance with applicable regulations. Lab-based urine tests are available with multiple panel options and lab results are verified by Medical Review Officers (MROs) for highest accuracy. Drug screening results are easy to review in the GoodHire dashboard. For more details, talk to sales.
Disclaimer
The resources provided here are for educational purposes only and do not constitute legal advice. We advise you to consult your own counsel if you have legal questions related to your specific practices and compliance with applicable laws.
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Jen Dewar is a marketing consultant in the HR technology space with a focus on developing educational content for HR professionals and recruiters. She is passionate about diversity and inclusion, lifelong learning and development, and treating people like people throughout the candidate and employee experiences.
Oral fluid is a promising new matrix for drug-testing programs for drug treatment, the workplace, pain management, and driving under the influence of drugs (DUID)7. As with any new technology, there are strengths and limitations. We discuss with international experts the role this new alternative matrix will play in diverse drug-monitoring settings, and the research, development, and legislation needed to permit oral fluid testing to best take its place in the modern laboratory armamentarium.8
Do you believe oral fluid testing will become the most prevalent matrix tested in these programs and why? What are the strengths and limitations of oral fluid testing for each type of program?
Alain Verstraete: Oral fluid will probably become the most prevalent matrix for DUID, certainly for roadside screening. Legislators and police officers want to rapidly perform DUID testing at the roadside, eliminating transport to hospitals or police stations. Oral fluid is used for DUID in 5 Australian states, Belgium, and France and is described in Swiss and United Kingdom legislation. The main advantages are ease of collection and a generally shorter window of drug detection than urine, hence a better correlation with duration of impairment Limitations include difficulty of collection following recent drug use and the potential for passive contamination. For DUID confirmation, presently only Belgium and 4 Australian states utilize oral fluid; in other jurisdictions, positive oral fluid presumptive test results are confirmed with blood tests. Oral fluid also could become the most prevalent matrix for drug treatment due to ease of sampling, despite the shorter drug-detection window. In this setting, cost may play a more important role. If additional visits are required for oral fluid testing, urine testing might remain dominant. A strong advantage of oral fluid testing for drug treatment is the greater detection of 6-acetylmorphine, a marker of heroin use. I am unsure that oral fluid will prevail as the most important matrix for workplace drug testing. Although oral fluid collection is simpler and more easily observed, reducing adulteration potential, costs are higher than with urine, with similar detection rates.
Tai Kwong: In clinical settings, particularly drug-treatment and pain-management programs, oral fluid testing will gain popularity. At this time, the preference for oral fluid over urine is primarily due to sample collection advantages, which include a less invasive collection protocol and no need for special collection facilities and a same-sex collector. The migration to oral fluid will accelerate when the following technical issues are resolved: inconsistent oral fluid and elution buffer volume, variable drug recoveries, inadequate oral fluid immunoassay sensitivity and specificity, and lack of homogeneous immunoassays for automated analyzers. The shorter oral fluid detection window following cannabis use is a serious limitation for all but DUID testing, if drug testing is scheduled for once a week or less frequently.
Jorg Morland: For DUID, I suppose oral fluid testing will become prevalent in countries where the legislation is based on “no presence of the drug in any body fluid” because of the convenience of sample collection. In other countries where low drug blood concentrations constitute the legal basis, oral fluid testing might be applied for screening drivers under suspicion, if rapid results covering most drugs of interest are available (e.g., as immunoassays). Workplace drug testing should perhaps focus on more recent drug use to reflect work performance. In that sense, oral fluid appears superior to urine and in my mind could become the most prevalent method for workplace testing.
Michael Vincent: Oral fluid testing will gain a substantial market share in each of the above segments because of the convenience in obtaining a noninvasive, gender-independent, observed specimen. For DUID and pain-management testing, oral fluid offers important interpretation value due to its correlation with plasma concentrations for most drug classes. For workplace and criminal justice testing, the “shy bladder” problem with urine testing could be eliminated. Oral fluid poses analytical challenges, since volume and drug concentrations are much lower than for urine. There could be inadequate specimen for multiple drug confirmations.
Raphael de la Torre: There is no doubt that oral fluid drug testing (especially on-site tests) is the preferred biological matrix for DUID. A positive finding can indicate recent drug consumption and recommend driving discontinuation. Limitations of on-site testing are the reduced number of drug classes that can be tested simultaneously. In drug-treatment programs or methadone-maintenance programs, on-site oral fluid tests may indicate drug use 24 h earlier. A shorter detection window means that signs of intoxication are enough evident that there is no need for drug testing. The main advantage of on-site oral fluid testing is the immediate availability of results and the potential introduction of corrective actions by therapists. For preemployment drug testing, recreational drug users may not be identified because of the limited oral fluid window of detection. Oral fluid drug testing in pain-management programs may check patient compliance and rule out consumption of additional drugs.
What do you think are reasonable and achievable performance requirements for oral fluid on-site tests, oral fluid– collection devices, and confirmation testing?
Alain Verstraete: I think the cutoffs proposed in Belgian and French DUID legislation and those used in the Driving Under the Influence of Drugs, Alcohol and Medicines (DRUID) project are realistic ( ). With further development, lower cutoffs can be reached for Δ9-tetrahydrocannabinol (THC), such as the 5-µg/L cutoff now claimed by the Dräger DrugTest 5000. Oral fluid– collection devices must provide good analyte recovery, a sample-adequacy indicator, reasonably low matrix effects in liquid chromatography– tandem mass spectrometry (LC-MS/MS) confirmation, and adequate sample volume. The time to collect and analyze oral fluid is an important variable, especially with DUID testing. A device that reliably collects a small sample volume (200 µL) and an analytical method to measure all targets in this small volume would be ideal and would increase the use of oral fluid testing. Confirmation testing may be performed by state-of- the-art multianalyte LC-MS/MS quantification.
Tai Kwong: First is the improvement of immunoassay (particularly homogeneous immunoassays) low-end sensitivity and consistency in detection, at least at the proposed Substance Abuse Mental Health Services Administration cutoffs. Second is a broader immunoassay immunospecificity to improve detection of opiates besides morphine and specific and sensitive assays for nonopiate opioids for pain therapy. Third is an improvement of the collection device for consistency in sample volume collected, buffer volume added, and drug recovery. Fourth is the availability of quantitative MS/MS confirmation assays with analytical sensitivity commensurate with screening cutoffs.
Jorg Morland: Oral fluid on-site tests should produce easily readable results within 1–2 min, under variable light and climate conditions. Tests should include cannabinoids, opiates, 6-acetylmorphine (separately), amphetamines, cocaine, and as many opioids and benzodiazepines as possible. Oral fluid– collection devices should be easy to handle, be nonbreakable, and minimize the chance of contaminating the surroundings or the person collecting the sample. Oral fluid confirmation testing should utilize specific methods, such as LC-MS/MS.
Michael Vincent: Oral fluid on-site tests should be able to robustly screen specimens at appropriate concentrations. Additionally, appropriate controls above and below the stated cutoff (±50%) should be discriminated with confidence. Currently, on-site and laboratory-based urine drug tests perform similarly. Unfortunately, there is a great difference in performance between on-site and laboratory oral fluid products. Oral fluid tests are marketed as detecting recent use; if an on-site test screens negative when an individual is visibly impaired or fails a Drug Recognition Experts evaluation, confidence in the matrix is greatly diminished.
Raphael de la Torre: Oral fluid on-site tests should provide quick and reliable results, with equivalent performance for all drug classes. Oral fluid devices should collect a reproducible, sufficient (1 mL) sample that is stabilized with buffers and preservatives compatible with immunoassays and LC-MS/MS methods. Currently, there is no standardization of collection devices. For oral fluid testing to grow, the device must collect a known amount of sample within a specified ± 10% tolerance to enable concentration determination. The device manufacturer must document drug-extraction efficiency (>70%) around the screening cutoff and stability in the collection buffer. Lack of adequate THC extraction contributes to false-negative cannabis tests. While drug testing in other biological matrices has “endogenous” biases (e.g., renal function in urine testing), none has a “collection” bias as seen with oral fluid, owing to the lack of standardization in oral fluid collection devices. LC-MS/MS is the most suitable approach for multianalyte confirmation, with much higher sensitivity requirements than for urine drug testing. LC-MS/MS allows laboratories to use small amounts of sample for a large multiple– drug class confirmation panel. Standardized LC-MS/MS performance criteria are needed for ion suppression, signal-to- noise ratios, and ion ratio tolerance limits.
Now that 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THCCOOH) has been shown to be present in oral fluid, albeit in nanogram-per-liter concentrations, do you think that this would be a better biomarker than THC for detection of cannabis smoking? And why? Do you think that immunoassays could achieve acceptable detection at nanogram-per-liter concentrations of THCCOOH? Or should the screen be directed toward the parent, THC?
Alain Verstraete: THCCOOH will not become the biomarker of choice in the coming years, because of low concentrations. Presently, only a few laboratories can detect oral fluid THCCOOH. Maybe in 10 years with more sensitive techniques it will become more routine, but the future I see is that THC testing will be the standard and that THCCOOH testing will be reserved for a few cases where the result is challenged, as, for example, in the detection of amphetamine enantiomers, which is not routine but is used in disputed cases.
Tai Kwong: THCCOOH is a marker of systemic exposure and can be useful in ruling out environmental contamination. An impediment to general THCCOOH screening is the lack of assays with the requisite limits of detection. Until adequate routine THCCOOH screening and confirmation assays are available, general screening for cannabis use should be directed toward THC.
Jorg Morland: THCCOOH is a nonpsychoactive metabolite of psychoactive THC. In my mind, there is no reason to measure this metabolite for DUID- and workplace-testing purposes. For treatment of patients with cannabis dependence to monitor therapeutic goals, THCCOOH measurement in oral fluid could possibly make sense, provided it had an extended detection window. Other approaches for such monitoring would probably be better.
Michael Vincent: THCCOOH would be a better marker for cannabis detection since it is not a pyrolysis byproduct; hence, its presence is a good indicator of cannabis use and not passive inhalation. ELISA products for THCCOOH detection in hair can be modified to detect THCCOOH in oral fluids in the nanogram-per- liter range. It has been demonstrated that a commercial immunoassay can screen cannabinoids in oral fluid at 20 ng/L.
Raphael de la Torre: On-site oral fluid devices have multiple limitations in the detection of cannabis consumption. In the near future, it is difficult to foresee detection of nanogram-per-liter THCCOOH. Therefore, screening should be directed to THC detection. Instrument-based immunoassays/confirmation methods have the potential to detect nanogram-per-liter THCCOOH.
Pain-management and DUID-treatment programs, among others, require identification of a wide spectrum of psychoactive compounds. Do you think it is feasible to screen oral fluid for a sufficient number of compounds at low-enough concentrations to efficiently identify drug abuse in this population?
Alain Verstraete: I am not convinced that DUID for medicinal drugs taken in normal, prescribed doses significantly increases accident risk. Recently, odds ratios (ORs) were determined for 72 685 injured French drivers on medicines classified into 4 risk levels, from 0 (no risk) to 3 (high risk). Drivers on level 2 (OR, 1.31; 95% CI, 1.24 –1.40) and level 3 (OR, 1.25; 95% CI, 1.12– 1.40) prescription medicines were at higher risk of being responsible for a crash, but the ORs were quite low. However, the illicit use of medicines (e.g., benzodiazepines) is a problem. Presently, the number of target drugs is small and feasible for one LC-MS/MS method; however, for the high number of benzodiazepines available, LC-MS/MS might not be the ideal technique, and a screening immunoassay might be warranted.
Tai Kwong: Screening a large number of drugs/metabolites in a limited volume of oral fluid is technically challenging; however, recently published assays for detecting a broad spectrum of drugs at low concentrations are promising. It will be interesting to see the inevitable adaptation of LC-MS-TOF to oral fluid testing.
Jorg Morland: For these populations, it is hard to see that immunoassays would yield results with the required sensitivity and specificity. Therefore, screening in such cases would be difficult. LC-MS/MS confirmation would yield acceptable results, but estimating doses and resulting drug effects (which require blood drug concentrations) would not be possible.
Michael Vincent: Pain-management and DUID programs want to avoid false-negative results. Current commercial immunoassays and confirmation methods can utilize lower cutoffs to demonstrate feasibility. Correlations with simultaneously collected blood specimens can be high for most drug classes. Great care should be taken in the analysis of compounds with low saliva-to-plasma ratios, such as benzodiazepines, to ensure that screening cutoffs and immunoassay cross-reactivities are relevant to oral fluid drug concentrations.
Raphael de la Torre: The number of drug classes screened in a single run limits on-site drug testing. In many situations, adequate testing can be accomplished. Alternatively, oral fluid could be collected and analyzed by instrument-based methods for a larger drug panel.
There is a move away from immunoassay screening for a large number of drugs/drug classes to multianalyte LC-MS/MS. What do you think is the best, most analytically sensitive approach to screening for drugs in oral fluid? Can LC-MS/MS handle the volume of testing required at a reasonable cost? Does biochip array technology offer advantages for oral fluid testing due to the low volume required and simultaneous analysis of multiple drug classes?
Alain Verstraete: In DRUID, LC-MS/MS (or GC-MS) was used, while in the US roadside survey an immunoassay screen was performed first, demonstrating that both strategies are possible. A disadvantage of LC-MS/ MS screening is that it was based on multitarget screening; thus, not all benzodiazepines or opiates were detected. In the DRUID study in our laboratory, the cost for analysis of 1 oral fluid sample was approximately €50 (approximately $70), with the ability of analyzing only about 80 samples per day per technician. Biochip technology could be useful for high-volume testing if the process were fully automated. In the future, LC-TOF methods may offer broad-spectrum oral fluid drug screening.
Tai Kwong: Testing for compliance and the use of non-prescribed medications and illicit drugs in pain-management and drug-treatment programs may require analyte identification at low concentrations, which cannot be achieved by immunoassays. From a clinical laboratory standpoint, sensitive multianalyte LC-MS/MS screening is more efficient than immunoassays. But LC-MS/MS is too costly and technologically prohibitive for most clinical laboratories, and it may not have the capacity and throughput necessary to replace immunoassays as the primary mode for screening. Among current immunoassays, ELISA assays are more analytically sensitive, but they cannot be integrated efficiently and cost-effectively into existing automated instrumentation in clinical laboratories, as would be possible with homogeneous immunoassays. Biochip array is a new technology with the potential advantage of reducing sample volume requirements and increasing throughput, but it must allow specific identification of structurally similar opioids.
Jorg Morland: LC-MS/MS multianalyte approaches have the advantage of including many psychoactive drugs present at low concentrations that cannot be adequately screened by immunoassays. Our experience is that this is feasible as long as the volume of samples submitted for analysis is limited. Robots and automation coupled to LC-MS/MS might (hopefully) increase throughput substantially, but we are not there yet. We have so far no experience with biochip array technology.
Michael Vincent: ELISA methodology has a faster throughput and is far more sensitive than current commercially available LC-MS/MS assays. However, care should be taken to ensure that the appropriate cross-reactivity and cutoffs are employed. Workload is important for selecting the appropriate primary screen. LC-MS/MS requires a high capital expenditure and high operating costs due to the need for highly skilled operators, service contracts, columns, and solvents. In the US commercial market, if a laboratory encounters few specimens, screening is performed by LC-MS/MS, but as the number of specimens increases, immunoassay screening followed by LC-MS/MS confirmation becomes necessary. Biochip array technology requires lower specimen amounts than conventional ELISA testing. However, confirmation analysis is currently the major limiting factor on throughput.
Raphael de la Torre: New-generation LC-MS/MS instruments have the potential to analyze large drug panels with adequate sensitivity and specificity. Equipment costs are decreasing, and costs per run are competitive if the sample number is large. Additionally, LC-MS/MS is amenable to high-throughput analysis, and the turn-around time per sample is similar to automated immunoassays (excluding sample preparation). Alternative approaches, such as ELISA tests or biochip arrays, suffer in that further identification and confirmation are needed.
What is needed to improve interpretation of oral fluid drug test results?
Alain Verstraete: Further research on: (1) passive smoking and external contamination; (2) adulteration and THC washout from the mouth; (3) development of on-site devices with a small sample volume (like the DrugWipe) and results in <5 min (the DrugWipe in Belgium requires 12 min, but 5 min in Australia for only 2 analytes and with lower THC sensitivity); (4) reproducibility of multiple sampling; (5) finding a marker for concentration normalization, similar to creatinine measurements in urine; (6) more toxicokinetic controlled-administration studies to provide concentration–time data and detection windows (concentrations are sampling dependent, with results from one sampling method not necessarily representative for another method); and (7) more studies on the relationship between oral fluid drug concentrations and impairment, or crash risk.
Tai Kwong: Our ability to interpret urine drug test results is based on published controlled drug-administration studies. We need similar studies on oral fluid before we can interpret oral fluid drug test results properly.
Jorg Morland: An oral fluid test tells us that a particular drug was recently used, but no interpretation of blood or brain concentrations can be made. Oral fluid pH and secretion rate markedly influence drug concentrations. A reference substance (similar to creatinine in urine) for normalization of oral fluid results is needed. This could at least be helpful when serial samples from a single individual are evaluated over time to detect new drug intake.
Michael Vincent: Currently, most work has focused on analytical-method development, rather than result interpretation. Pain-management and DUID testing are areas where drug and metabolite concentrations can provide valuable information. Further research is needed for oral fluid and blood concentration correlations and for correlations with motor skill impairment and brain activity. Another area of concern with interpretation is the presence of multiple drugs in numerous cases. Most research involves single-drug administration in a controlled environment, making it difficult to predict effects when multiple drugs are present with and without alcohol.
Raphael de la Torre: Oral fluid drug testing was approached as urine drug testing, with some cosmetic changes. Most companies forgot that there is strong science and experience behind urine drug testing. In this context, it has been possible over time to define new target biomarkers and change cutoff concentrations based on scientific evidence. In the case of oral fluid testing, we need to follow the same approach. Manufacturers developed oral fluid analytical devices (particularly for on-site analysis) without knowing sensitivity and performance requirements. As the market was not yet mature, many initiatives were halted. There is a need for well-designed controlled clinical studies to guide selection of target biomarkers and cutoff concentrations (in the context of a given application). This is relevant not only for diagnostic companies, but also for law-enforcement authorities and clinicians. Interpretation of results is at an early stage.
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