6Difficult Cases Patient prescribed oxycodone Urine test negative for opioidsUrine test positive for hydrocodoneOxymorphone?Codeine?
7Anomalous observations of hydrocodone in patients on oxycodone. West R et al, Clin Chim Acta. 2010 Aug 27.BACKGROUND: Oxycodone preparations are known to have small amounts of hydrocodone as an impurity estimated to be <0.1%. We established the concentration of unexpected hydrocodone in patients taking oxycodone.METHODS: 30,000 pain patientsCONCLUSIONS: When oxycodone is >100,000ng/ml, hydrocodone should be <1500ng/ml. When oxycodone is <100,000ng/ml then hydrocodone should be <500ng/ml. Values greater than these indicate non-prescribedhydrocodone use. Clinicians and laboratories testing urine for drugs should be aware of the possibility of low concentrations of hydrocodone in the urine of patients taking high doses of oxycodone.
8Difficult Cases Patient prescribed Valium Urine test positive for oxazepam onlyTemazepam
10Difficult Cases Patient on xanax (alprazolam) or Klonopin (Clonzaepam) Urine test negative for benzo’s?
11Sensitivity vs Specificity Are they always mutually exclusive?Highly sensitiveMore prone to false positive?Highly specificMore prone to false negative?
12Screening vs Confirmation Tests Immunoassays, ELISA, EMIT, DRI, DipstickTend to be highly sensitiveNot so specificConfirmationGC/MS, LC/MS, LC/MS/MSHighly specificNot so sensitive (because of restricted panel)
14MRO function Is there a cause for positive other than illicit use? Legitimate prescriptionFalse positive – at least two types
15Legitimate Use? Coca tea? Cocaine positive from sex? ENT procedure? Hemp oil? Hemp cereal? Hemp cosmetics? Hemp granola bars? Hemp lip balm?Sprained ankle and was given heroin while visiting Great Britain?THC? Ever legal in US?Passive inhalationPoppy seeds
16Poppy Seeds Over 1,000 species of poppy seeds Used in cooking BakingSalad dressingsCurry saucesMorphine level >1,000, >2,000, >5,000, >15,000 ????Urine concentration can be a clue
17Accidental Exposure Marijuana brownie Someone else’s medication Took pill and didn’t know what it wasDrank punch and didn’t know it had alcohol in itVacuuming up someone else’s cocaine and turned vacuum clearner on reverse and blew it into the air
19Positive Amphetamine due to l-isomer Vics inhaler, selegiline, EMSAM patchD & L Isomer test>80% l-amphetamine consistent w/Pseudoephedrine converted to amphetamine inside the GC/MS machineRetest
20Dilutes Creatinine <20mg/dl and sp gr <1.003 Creatinine <20 but >10 mg/dl can be from innocent excess waterCreatinine <10mg/dl but >5mg/dl not likely innocentCreatinine <5mg/dl probably substitutionCreatinine <2mg/dl definitely substituted
21What to do?Creatinine <20 but >10 mg/dl can be from innocent excess waterWarn, observed, obtain hair/nails or saliva testCreatinine <10mg/dl but >5mg/dl not likely innocentHair/nail, saliva, observed, evaluationCreatinine <5mg/dl probably substitutionAssume substitution, verify observed, retest sample
22Emerging Technologies Quick Test KitsBetter confirmation tests: LC/MS/MSMore extensive testing panelsIncreased Use of Flex TestingImproved testing for ethanol (EtG, EtS, etc)Devices: TAD, SCRAM, Soberlink
28In the beginning… Blood alcohol Breath alcohol Urine alcohol GGT, MCV Limitations when used for alcohol monitoringGGT, MCVCarbohydrate Deficient Transferrin
29Current Technologies Random field breathalyzer Multiple daily ID home breathalyzerTranscutaneous alcohol monitoringNew markersEtG – EtS – PEthUrine – Hair/Nails – Saliva – Blood
30Frequent / Random Breathalyzer 24/7 Program in South DakotaRandom testing field programsBAT Mobile
3124/7 South Dakota House bill 1072 Rules: Results - 2007 Type, frequency, time, location, fees ($1 for each breath test), consequencesUsually twice a day on site in local police deptResults1,021 participants, 165,456 tests, 359 no shows = 99.8% show rateOf 165,456 tests 534 failed tests
3224/7 South Dakota Of 165,456 tests 534 failed tests Rate of improvement for individuals - good
33Positive ID Home Breathalyzers New home breathalyzer technologiesMEMS 3000Smart Start In-HomMobile Breath
36SoberlinkSmart Phone Compatible and Required: Requires Android OS 2.2 or higher, or Blackberry OS 5.0 or higher (device must be Bluetooth enabled). Apple iPhone compatibility coming soon.Photo Identification: Guarantee's the identity of the user. Facial recognition coming soon.Fuel Cell Sensor: Provides highly accurate and reliable results.DIMENSIONS:Product Height: 4.75" (121mm)Product Width: 1.5" (38mm)Product Depth: 2.875" (73mm)WEIGHT:Product Weight: 6oz (190g)WARRANTY:1 Year Limited Warranty
42Urine EtG (and EtS) 1-4 days possible duration Normalization important (100/uCreat) x uEtG = Normalized EtGImportant to warn about things to avoidFoods, mouthwash, handgel, etc.etc.May be important to have participant sugar fast (4-6 hours) before submitting sampleJuices, fruits, etc contain small amounts etoh
43Alcohol Metabolites Phosphatidyl Ethanol (PEth) Blood A group of phospholipids formed by alcohol on cell membranes - phospholipase DPositive only after significant alcohol exposure (approx 7 drinks over a week)Stays positive (>20ng/ml) for 2-3 weeksLevel correlates well with amount of alcohol consumed
45Combination Strategies Using PEth to confirm drinking following positive EtG/EtS when drinking deniedStudy: 18 positive EtGsFinding#%ConclusionAdmitted drinking after positive EtG/EtS844DrinkingAdmitted drinking after PEth explained317Admitted drinking after positive PEth16Denied drinking after positive PEthDenied drinking - negative PEth528Not Drinking
46Settings / StrategiesNormalize values to creatinine of 100md/dl (labs should automatically make this calculation)Have participants sign consent regarding their responsibility to avoid alcoholRe-advise to avoid all alcohol (including ripe fruits, juices, anything containing sugar) on day of test.
47HOPE ProbationHOPE probationers have the most serious felony drug and crime problems and are identified as likely to violate their conditions of community supervisionHOPE utilizes intensive random drug testing for up to 6 yearsResponds to detected violations of probation (drug use, missed probation meetings, etc.) with clear, swift, short-term sanctions
48Randomized Control Trial of HOPE vs. Standard Probation In one-year period, HOPE probationers were:55% less likely to be arrested for a new crime72% less likely to use drugs61% less likely to skip appointments with their supervisory officer53% less likely to have their probation revokedHOPE probationers were sentenced to, on average, 48% fewer days of incarceration than the control group