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Emerging Issues in Drug Testing

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Presentation on theme: "Emerging Issues in Drug Testing"— Presentation transcript:

1 Emerging Issues in Drug Testing
Greg Skipper, MD Director, Professional Health Services Promises Treatment Centers Los Angeles, CA

2 Drug Testing is Effective and Underutilized
When testing is frequent, random and tied to immediate moderate consequences drug use is deterred.

3 Long-Term PHP Drug Test Results

4 Difficult Cases Patient prescribed hydrocodone
Urine test negative for opioids Urine test positive for hydromorphone only? Oxymorphone? Codeine?

5 Difficult Cases

6 Difficult Cases Patient prescribed oxycodone
Urine test negative for opioids Urine test positive for hydrocodone Oxymorphone? Codeine?

7 Anomalous 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 patients CONCLUSIONS: 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.

8 Difficult Cases Patient prescribed Valium
Urine test positive for oxazepam only Temazepam


10 Difficult Cases Patient on xanax (alprazolam) or Klonopin (Clonzaepam)
Urine test negative for benzo’s?

11 Sensitivity vs Specificity
Are they always mutually exclusive? Highly sensitive More prone to false positive? Highly specific More prone to false negative?

12 Screening vs Confirmation Tests
Immunoassays, ELISA, EMIT, DRI, Dipstick Tend to be highly sensitive Not so specific Confirmation GC/MS, LC/MS, LC/MS/MS Highly specific Not so sensitive (because of restricted panel)

13 Matrices

14 MRO function Is there a cause for positive other than illicit use?
Legitimate prescription False positive – at least two types

15 Legitimate 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 inhalation Poppy seeds

16 Poppy Seeds Over 1,000 species of poppy seeds Used in cooking
Baking Salad dressings Curry sauces Morphine level >1,000, >2,000, >5,000, >15,000 ???? Urine concentration can be a clue

17 Accidental Exposure Marijuana brownie Someone else’s medication
Took pill and didn’t know what it was Drank punch and didn’t know it had alcohol in it Vacuuming up someone else’s cocaine and turned vacuum clearner on reverse and blew it into the air

18 Crossreactivity

19 Positive Amphetamine due to l-isomer
Vics inhaler, selegiline, EMSAM patch D & L Isomer test >80% l-amphetamine consistent w/ Pseudoephedrine converted to amphetamine inside the GC/MS machine Retest

20 Dilutes Creatinine <20mg/dl and sp gr <1.003
Creatinine <20 but >10 mg/dl can be from innocent excess water Creatinine <10mg/dl but >5mg/dl not likely innocent Creatinine <5mg/dl probably substitution Creatinine <2mg/dl definitely substituted

21 What to do? Creatinine <20 but >10 mg/dl can be from innocent excess water Warn, observed, obtain hair/nails or saliva test Creatinine <10mg/dl but >5mg/dl not likely innocent Hair/nail, saliva, observed, evaluation Creatinine <5mg/dl probably substitution Assume substitution, verify observed, retest sample

22 Emerging Technologies
Quick Test Kits Better confirmation tests: LC/MS/MS More extensive testing panels Increased Use of Flex Testing Improved testing for ethanol (EtG, EtS, etc) Devices: TAD, SCRAM, Soberlink

23 Hair Testing

24 Nail Testing Good alternative to hair testing
Similar repository window Less prone to adulteration from chemicals Thicker than hair

INCREASINGLY USED (ie dilute urines)

Less invasive than hair testing

27 New Alcohol Monitoring Technologies

28 In the beginning… Blood alcohol Breath alcohol Urine alcohol GGT, MCV
Limitations when used for alcohol monitoring GGT, MCV Carbohydrate Deficient Transferrin

29 Current Technologies Random field breathalyzer
Multiple daily ID home breathalyzer Transcutaneous alcohol monitoring New markers EtG – EtS – PEth Urine – Hair/Nails – Saliva – Blood

30 Frequent / Random Breathalyzer
24/7 Program in South Dakota Random testing field programs BAT Mobile

31 24/7 South Dakota House bill 1072 Rules: Results - 2007
Type, frequency, time, location, fees ($1 for each breath test), consequences Usually twice a day on site in local police dept Results 1,021 participants, 165,456 tests, 359 no shows = 99.8% show rate Of 165,456 tests 534 failed tests

32 24/7 South Dakota Of 165,456 tests 534 failed tests
Rate of improvement for individuals - good

33 Positive ID Home Breathalyzers
New home breathalyzer technologies MEMS 3000 Smart Start In-Hom Mobile Breath


35 MobileBreath®

36 Soberlink Smart 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

37 Soberlink

38 Transcutaneous Monitors


40 Intermittent Transcutaneous Alcohol Monitoring
– to locate provider

41 Unique Alcohol Metabolites
Ethylglucuronide (EtG) Urine Hair/Nails Saliva

42 Urine EtG (and EtS) 1-4 days possible duration Normalization important
(100/uCreat) x uEtG = Normalized EtG Important to warn about things to avoid Foods, mouthwash, handgel, etc.etc. May be important to have participant sugar fast (4-6 hours) before submitting sample Juices, fruits, etc contain small amounts etoh

43 Alcohol Metabolites Phosphatidyl Ethanol (PEth) Blood
A group of phospholipids formed by alcohol on cell membranes - phospholipase D Positive only after significant alcohol exposure (approx 7 drinks over a week) Stays positive (>20ng/ml) for 2-3 weeks Level correlates well with amount of alcohol consumed

44 Alcohol Metabolites Phosphatidyl Ethanol (PEth)

45 Combination Strategies
Using PEth to confirm drinking following positive EtG/EtS when drinking denied Study: 18 positive EtGs Finding # % Conclusion Admitted drinking after positive EtG/EtS 8 44 Drinking Admitted drinking after PEth explained 3 17 Admitted drinking after positive PEth 1 6 Denied drinking after positive PEth Denied drinking - negative PEth 5 28 Not Drinking

46 Settings / Strategies Normalize values to creatinine of 100md/dl (labs should automatically make this calculation) Have participants sign consent regarding their responsibility to avoid alcohol Re-advise to avoid all alcohol (including ripe fruits, juices, anything containing sugar) on day of test.

47 HOPE Probation HOPE probationers have the most serious felony drug and crime problems and are identified as likely to violate their conditions of community supervision HOPE utilizes intensive random drug testing for up to 6 years Responds to detected violations of probation (drug use, missed probation meetings, etc.) with clear, swift, short-term sanctions

48 Randomized Control Trial of HOPE vs. Standard Probation
In one-year period, HOPE probationers were: 55% less likely to be arrested for a new crime 72% less likely to use drugs 61% less likely to skip appointments with their supervisory officer 53% less likely to have their probation revoked HOPE probationers were sentenced to, on average, 48% fewer days of incarceration than the control group

49 HOPE Drug Test Results

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