Transcript Drug Testing Conundrums: The Tough Cases - Greg

Emerging Issues in
Drug Testing
Greg Skipper, MD
Director, Professional Health Services
Promises Treatment Centers
Los Angeles, CA
[email protected]
310-633-4595
Drug Testing is Effective
and Underutilized
• When testing is frequent, random and tied to
immediate moderate consequences drug use
is deterred.
Long-Term PHP Drug Test Results
Difficult Cases
• Patient prescribed hydrocodone
– Urine test negative for opioids
– Urine test positive for hydromorphone only?
– Oxymorphone?
– Codeine?
Difficult Cases
Difficult Cases
• Patient prescribed oxycodone
– Urine test negative for opioids
– Urine test positive for hydrocodone
– Oxymorphone?
– Codeine?
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 nonprescribedhydrocodone 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.
Difficult Cases
• Patient prescribed Valium
– Urine test positive for oxazepam only
– Temazepam
Difficult Cases
• Patient on xanax (alprazolam) or
• Klonopin (Clonzaepam)
– Urine test negative for benzo’s?
Sensitivity vs Specificity
• Are they always mutually exclusive?
• Highly sensitive
– More prone to false positive?
• Highly specific
– More prone to false negative?
Screening vs Confirmation Tests
• Screening
– 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)
Matrices
MRO function
• Is there a cause for positive other than illicit
use?
– Legitimate prescription
– False positive – at least two types
Legitimate Use?
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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
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
Accidental Exposure
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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
Crossreactivity
Positive Amphetamine due to lisomer
• Vics inhaler, selegiline, EMSAM patch
– D & L Isomer test
• >80% l-amphetamine consistent w/
• Pseudoephedrine converted to
amphetamine inside the GC/MS machine
– Retest
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
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
Emerging Technologies
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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
Hair
Testing
Nail Testing
• Good alternative to
hair testing
• Similar repository
window
• Less prone to
adulteration from
chemicals
•Thicker than hair
Saliva Testing
 DHHS - 5 DRUGS, ALCOHOL
 SIMILAR TO PLASMA
 INCREASINGLY USED
(ie dilute urines)
Sweat Testing
 DHHS - 5 DRUGS
 PAROLE/PROBATION
 Less invasive than hair testing
New
Alcohol Monitoring
Technologies
In the beginning…
• Blood alcohol
• Breath alcohol
• Urine alcohol
– Limitations when used for alcohol monitoring
• GGT, MCV
• Carbohydrate Deficient Transferrin
Current Technologies
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Random field breathalyzer
Multiple daily ID home breathalyzer
Transcutaneous alcohol monitoring
New markers
– EtG – EtS – PEth
– Urine – Hair/Nails – Saliva – Blood
Frequent / Random Breathalyzer
• 24/7 Program in South Dakota
• Random testing field programs
– BAT Mobile
24/7 South Dakota
• House bill 1072
• Rules:
– Type, frequency, time, location, fees ($1 for each
breath test), consequences
– Usually twice a day on site in local police dept
• Results - 2007
– 1,021 participants, 165,456 tests, 359 no shows =
99.8% show rate
– Of 165,456 tests 534 failed tests
24/7 South Dakota
– Of 165,456 tests 534 failed tests
– Rate of improvement for individuals - good
Positive ID Home Breathalyzers
• New home breathalyzer technologies
– MEMS 3000
– Smart Start In-Hom
– Mobile Breath
MobileBreath®
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
Soberlink
Transcutaneous Monitors
• SCRAM
• TAD
Intermittent Transcutaneous Alcohol
Monitoring
•www.alcoholmonitoring.com – to locate
provider
Unique Alcohol Metabolites
• Ethylglucuronide (EtG)
– Urine
– Hair/Nails
– Saliva
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
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
Alcohol Metabolites
• Phosphatidyl Ethanol (PEth)
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
Drinking
Admitted drinking after positive PEth
1
6
Drinking
Denied drinking after positive PEth
1
6
Drinking
Denied drinking - negative PEth
5
28
Not Drinking
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.
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
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
HOPE Drug Test Results