Missed Opportunities: Toxicology Screening Remains Incomplete Among Firearm-Injured Adolescents

BackgroundFirearm injury remains the leading cause of death among children and adolescents in the United States. Firearm-injured adolescents are at increased risk for substance use and behavioral disorders, yet toxicology testing remains inconsistent despite national recommendations. We evaluated toxicology testing among firearm-injured adolescents compared with adults and temporal trends.MethodsWe retrospectively studied firearm-injured patients treated at an urban Level I trauma center from 2013-2024. Adolescents were classified as early (11-14), middle (15-17), or late (18-21) and compared with adults ≥22 years. Testing and substance-specific results were evaluated using multivariable logistic regression.ResultsAmong 10,853 patients, 2713 (25.0%) were adolescents. EtOH and illicit drug testing occurred in 37.7 and 15.5% of patients, respectively. Adolescents had lower rates of EtOH (33.9 vs 39.1%) and illicit drug testing (12.2 vs 16.6%) than adults, decreasing among younger adolescent age groups. After adjustment for sex, race, and clinical severity, adolescents remained less likely to undergo EtOH (aOR 0.77, 95% CI 0.70-0.85) and illicit drug (aOR 0.69, 95% CI 0.60-0.78) testing. White patients had higher odds of EtOH (aOR 1.67, 95% CI 1.44-1.95) and illicit drug testing (aOR 1.66, 95% CI 1.39-1.97) than Black/African American patients. Among those tested for illicit drugs, 67.9% had at least one non-prescription substance detected. Adolescent testing declined substantially over time.ConclusionsBiochemical toxicology testing remains inconsistent among firearm-injured adolescents, with persistent age- and race-based differences and declining testing. Standardized toxicology screening may improve identification of at-risk populations and facilitate linkage to evidence-based interventions following injury.