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Urine drug testing is an important tool utilized by providers to assess medication compliance in all medical specialties including palliative care. Due to its superior sensitivity and specificity, confirmatory testing by liquid chromatography–tandem mass spectrometry (LC–MS/MS) is replacing urine immunoassay screens. This case demonstrates the clinical utility of targeted LC–MS/MS testing to assess medication adherence and detect simulated compliance and the value of the laboratory in assisting with result interpretation. The design of a confirmatory testing panel including specimen hydrolysis and assay cutoffs is also discussed.