Urine Toxicology Testing


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Urine Toxicology Testing

  1. 1. Urine Toxicology 9/22/11
  2. 2. Table of Contents <ul><li>1. Introduction </li></ul><ul><li>2. Drugs of Abuse </li></ul><ul><li>3. Screening and Confirmatory Testing </li></ul><ul><li>4. Interferences in screening tests </li></ul><ul><li>5. Problems and challenges </li></ul><ul><li>6. Detection of opiates </li></ul><ul><li>7. Ameritox </li></ul>
  3. 3. 1. Introduction <ul><li>Therapeutic drug monitoring versus drugs of abuse. Toxicology is defined as the science of poisons, including their source, chemical composition, action, tests and antidotes. </li></ul><ul><li>Pain management issues </li></ul><ul><li>Guidelines from the National Institute of drug abuse </li></ul><ul><li>Drug testing for medical management versus medico legal testing </li></ul>
  4. 4. 2. Drugs of Abuse <ul><li>Amphetamines/metamphetamines </li></ul><ul><li>Barbituarates </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Cannabinoids </li></ul><ul><li>Cocaine </li></ul><ul><li>Methadone </li></ul><ul><li>Opiates </li></ul><ul><li>PCP </li></ul><ul><li>Propoxyphene </li></ul><ul><li>Methaqualone </li></ul>
  5. 5. A. Specimen Collection <ul><li>Urine: </li></ul><ul><li>Most preferred specimen for analysis </li></ul><ul><li>Single urine drug test can detect recent drug use </li></ul><ul><li>Cannot differentiate casual use from chronic drug abuse which requires sequential drug testing </li></ul><ul><li>In addition, urine drug testing cannot determine degree of impairment, the dose of drug taken or the exact use. </li></ul>
  6. 6. SPECIMEN COLLECTION – CONT ’D. <ul><li>Blood: </li></ul><ul><li>Blood toxicology yields some information of very recent exposure and is only recommended when it is not possible to obtain a urine specimen. Two grey top tubes must be sent to the reference lab. </li></ul><ul><li>Hair: </li></ul><ul><li>Hair is used in medicolegal and forensic cases and has limited use in the clinical setting. </li></ul>
  7. 7. B. Normal Detection In Urine <ul><li>Amphetamines 3-5 days </li></ul><ul><li>Cocaine 2-3 days </li></ul><ul><li>Cannabinoids Up to 14 days or more </li></ul><ul><li>PCP Up to 10 days </li></ul><ul><li>Barbituarates 4-6 days </li></ul><ul><li>Benzodiazepines 2-7 days </li></ul><ul><li>Heroin/Morphine 72 hrs-3 days </li></ul><ul><li>Other opiates 2-4 days </li></ul><ul><li>Fentanyl 3-4 days </li></ul><ul><li>Methadone 14 days </li></ul><ul><li>Propoxyphene 7 days </li></ul>
  8. 8. C. Elimination half-lives <ul><li>Heroin 0.5 hrs </li></ul><ul><li>Morphine (and metabolites) 3 hrs </li></ul><ul><li>Codeine 3-4 hrs </li></ul><ul><li>Oxycodone 3.5-4.5 hrs </li></ul>
  9. 9. <ul><li>Initial screening tests are usually immunoassays. </li></ul><ul><li>These assays are calibrated at established cut-off concentrations. </li></ul><ul><li>Specimens yielding results greater than the cut-off (threshold) are considered positive whereas those values below the cut-off are considered negative. </li></ul><ul><li>Cut-off values are not synonymous with minimum detection limits. Cut-off values are established higher than the detection limits to ensure reliable measurement but low enough to detect drug use within a reasonable time frame. </li></ul><ul><li>Immunoassays may not be specific for the tested drug. Similar drugs may result in a positive test. Therefore it is imperative that positive screening tests be confirmed by GC/MS. </li></ul>3. Screening and Confirmatory Testing
  10. 10. <ul><li>Cut-off values in GC/MS procedures are usually lower than immunoassays. Results are reported as positive or negative with the actual concentration indicated. </li></ul><ul><li>It is recommended to normalize drug concentrations to urine creatinine levels so that fluctuations related to physiological variation in urine dilutions or concentrations can be compensated for. </li></ul>3. SCREENING AND CONFIRMATORY TESTING, CONT ’D.
  11. 11. 3. SCREENING, CONT ’D
  12. 12. 3. CONFIRMATION CONT ’D.
  13. 13. 4. Interferences in screening tests <ul><li>Immunoassays for amphetamines and metamphetamines have various cross-reactivities with other sympathomimetic amines such as ephedrine, pseudoephedrine, phenylpropanol amine and phentamine. </li></ul><ul><li>Confirmation of positive amphetamine results by GC/MS is mandatory. </li></ul><ul><li>Cross reactivity in the opiates is low in the current immunoassays. Morphine and codeine are the common compounds usually detected in GC/MS because of the pathways of common opoids breaking down to morphine. </li></ul>
  14. 14. 5. Problems and challenges <ul><li>Two categories of products commercially available to “beat” drug tests. The first category is taking specific fluids or tablets (hydrochlorothiazide, a diuretic) along with a substantial intake of water to flush out drugs and metabolites. Other products are Absolute Detox XXL drink, Absolute Carbodrinks, Ready Clean Drug Detox Drink, Fast Flush Capsules and Ready Clean Gel Capsules. </li></ul><ul><li>The second category is in vitro urinary adulterants. Stealth, Klear (nitrite), Clean ADD-IT-ive (glutaraldehyde) and Urine Luck (pyridium chlorochromate, [PCC] that is available via the internet. Synthetic urine is available for example Quick Fix Synthetic Urine. </li></ul>
  15. 15. ADULTERANTS – CONT ’D. <ul><li>Common household chemicals as urinary adulterants. </li></ul><ul><li>Agents such as ascorbic acid, vinegar, bleach, lime solvent, Visine eye drops and golden-seal teas tested caused false negatives. Both cannabinoid and opiate assays are susceptible to bleach. PCP and Benzoylcognine analysis are affected by alkaline agents. </li></ul><ul><li>Adulteration of hair and saliva specimens as well. This is by certain shampoos and mouth wash preparations. </li></ul><ul><li>On-site adulterant-devices (dipsticks) for urine specimens. </li></ul>
  16. 16. 6. Detection of opiates <ul><li>EMIT immunoassay- screening test </li></ul><ul><ul><li>Detection of morphine and codeine </li></ul></ul><ul><ul><li>Some cross-reactivity with metabolites (morphine-3-glucuronide) </li></ul></ul><ul><ul><li>Cut-off 300 ng/mL, detectable 1-4 d following morphine or heroin use </li></ul></ul><ul><li>Positive results require confirmation with GS- MS </li></ul>
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  21. 21. 6. Detection of Opiates A partial listing of opiates and opiate agonist compounds that are often abused Nonproprietary Name (trade name) Half-Life a(h) and/or Comments Unwanted Effects Morphine sulphate (AVINZA) 3-4 Sedation, respiratory depression, constipation, nausea, vomiting, tolerance and dependence Diamorphine (Heroine) Rapid metabolized to 6-monacetylmorphine Same as morphine and then to morphine. Acts more rapidly than morphine, metabolized to morphine Hydromorphone (DILAUDID) 2-4 Same as morphine Methadone (DOLOPHINE) >24 Same as morphine Pentazocine lactate (TALWIN) 2-4 Dysphoria Fentanyl (ACTIQ) 1-2 Same as morphine Codeine phosphate Acts as a precusor drug, metabolized to Mainly constipation morphine and other active opiods Hydrocodone (Vicodin, Lorcet) Pain relief and cough suppressant Same as morphine Oxycodone HCL (OXYCONTIN) ~ 3.5 Same as morphine Naloxone (NARCAN) Opioid antagonist Meperidine, also pethidine (DEMEROL) ~ 3.5 Nausea, vomiting, tremor, seizures Propoxyphene HCL (DARVON) 1-2 Similar to other opioids and also the f ollowing: KG changes, ototoxicity, delusions, hallucinations,seizure, and confusion Tramadol (ULTRAM) 4-6 Dizziness and convulsions
  22. 22. 7. Ameritox <ul><li>Urine drug monitoring with Ameritox ’s Rx Guardian SM  process goes  beyond standard urine drug testing  and features  Rx Guardian CD SM , which is derived from the most comprehensive reference database of adherent pain patients. Patients’ normalized results are compared to the reference database, allowing clinicians to make more informed assessments of whether their patients are taking medications correctly. This helps clinicians identify potential abuse, misuse, or diversion in pain patients. </li></ul>
  23. 23. 7. Ameritox <ul><li>  The  Ameritox Rx Guardian SM  process  with  Rx Guardian CD SM  is the only urine drug monitoring solution with a comprehensive reference database derived from more than one thousand adherent chronic pain patients. The patients ’ normalized results can be compared against this database, giving added assurance in assessing whether patients are taking their medication correctly. </li></ul><ul><li>Patients whose normalized drug values exceed two standard scores from the mean of the reference database, accompanied by clinical indicators of risk (such as aberrant behaviors), may have a higher likelihood of drug abuse, misuse, or diversion. Patients whose normalized drug values fall within two standard scores from the mean of the index database, and who lack clinical indicators of risk (such as aberrant behaviors), may have a lower likelihood of drug abuse, misuse, or diversion. </li></ul>