A positive result on preoperative cocaine toxicology screening has traditionally been a contraindication to immediate nonemergency surgery. We describe a case of major but not emergency head and neck surgery on a patient with a massive ossifying fibroma whose preoperative toxicology screen was positive for cocaine. The surgery was completed without complication, and the patient recovered uneventfully. The decision to proceed with surgery was based on the fact that the results of urine cocaine screening can remain positive long after the cocaine itself has become metabolically inactive, and thus the results may not reflect the actual presence of cocaine or the degree of current intoxication. Our institution has concluded that elective head and neck surgery may be safely performed in carefully selected, hemodynamically stable patients who have tested positive for cocaine ingestion provided that they have been closely observed for 8 hours preoperatively and that they have provided informed consent. Outcome studies are needed.