Employers have used several strategies when testing for drugs , in large part guided by the legal ramifications of each. Employee drug screening can occur at several different points in time:

1. During the application process.

2. After a job offer has been extended but before employment begins (pre-employment testing)

3. Randomly after employment has commenced (random employee drug testing)

4. After accidents or when an employee behaves in a manner suspicious for substance abuse ("for cause" drug testing).

Employee drug testing prior to being extended a conditional job offer would require applicants to disclose any prescribed prescription drugs that they take. This has been interpreted in courtrooms as a violation of the American with Disabilities Act (ADA), which prohibits "inquiries of a job applicant as to whether such an applicant is an individual with a disability ..." Such inquiries, however, can be sought after a job offer has been made, making pre-employment drug testing legally acceptable. Employers have indeed met the least legal resistance when using strategies based on "for cause" and pre-employment testing. These two forms of testing pose the least liability to employers, are less expensive than random testing, and are most acceptable to labor unions. For these reasons and not because of efficacy, pre-employment and "for cause" drug testing are the most prevalent strategies.

Random employee drug testing without suspicion of substance abuse has generated the most resistance and controversy. Such testing has been called a violation of the Fourth Amendment to the Constitution, which prohibits illegal search and seizure without just cause, and has been defeated in court. Random drug testing is more expensive because it requires a greater frequency of testing to be effective. On the other hand, random drug screening does not single out individuals for suspicious behavior or substandard performance. When applied uniformly, everyone has an equal chance of being tested, so individuals selected for testing do not risk being labeled as possible drug users. The Supreme Court has decided in favor of lower court decisions upholding various forms of random drug testing, and some employers do practice random drug screening .

There are also many arguments against employee drug testing. The evidence linking drug use and workplace difficulties is much weaker than initial estimates. Detractors of drug testing cite that there is almost no scientific data that testing is effective in achieving its goals. The monumental task of drug testing, it is argued, is of potentially greater legal and public relations benefit than benefit to patient safety. A rational and evidence based approach is necessary to ensure optimal functioning of care providers. Drug testing is arguably less important than addressing the performance impact of overnight work, circadian rhythm disruption, and overwork.

Employment drug testing does not necessarily measure impairment, abuse, or intoxication. The presence of a banned substance does not mean that cognitive impairment is present or clinical performance is impacted. Further, routinely used medicines such as decongestants, antihistamines, stimulants, and other prescribed substances can also profoundly impair functioning.

The process of employee drug testing is also intrusive, so evidence of the need is demanded. Testing can provide information about medical conditions unrelated to substance abuse, informing the employer of more than should legally be available. Involuntary drug testing has been called an unwarranted invasion of privacy, a form of "chemical McCarthyism", and a form of social control that influences lifestyle but not work performance.

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