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Urine Drug Screening

Drug screening involves analyzing samples like urine, blood or hair to detect illegal or prescription drug use. Urine is commonly tested due to extensive reference data and easy, non-invasive collection, though it has a longer detection window than blood and results cannot be used to determine impairment. Proper specimen handling, preservation and storage are important to ensure sample integrity and validity of results. Factors like container type, temperature, and addition of preservatives can affect analyte stability in samples over time.

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URINE DRUG SCREENING HossamaldinAlzawawi R4 - Clinical Pathology Resident
Definition Drug testing is the evaluation of a urine, blood or other type of biological sample to determine if the subject has been using the drug or drugs in question. There are many circumstances that may lead to drug testing. (2019). "Drug screening - Latest research and news | Nature." from https://www.nature.com/subjects/drug-screening. A drug screen (also called a drug test) is the collection and analysis of blood, urine, hair, or saliva to detect the presence of the chemicals and contaminants left behind in the body due to drug use. A drug screen may also be used to detect performance-enhancing drugs sometimes used by professional athletes such as steroids and HGH. Many different types of drug screens exist for multiple purposes. (2019). "What is a Drug Screen?". 2019, from https://www.concentra.com/resource-center/articles/what-is-a-drug- screen
Reasons for Drug Screening ■ Onsite drug screening is performed for a variety of medical, professional and legal reasons. A few scenarios in which screening may be done are: – Pre-employment – Suspicion of drug abuse – Military service, sports participation – Legal, criminal – Drug-therapy compliance monitoring – Drug abuse rehabilitating monitoring – Postmortem investigation Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and- sections/drug-information-group/2014/2011/february-2011-faqs
SubstancesTested in a Drug Screening Most commonly substances Amphetamines Cannabinoid metabolites Cocaine metabolites opiate metabolites phencyclidine (PCP) Expanded immunoassays Tricyclic antidepressants Barbiturate Methadone Alcohol Benzodiazepines Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy- practice/centers-and-sections/drug-information-group/2014/2011/february-2011-faqs
SPECIMEN COLLECTION AND HANDLING This Photo by Unknown Author is licensed under CC BY-NC-ND
Specimen Collection and Handling: Guidelines THE ROYAL COLLEGE OF PATHOLOGISTS HAS PUBLISHED GUIDELINES FOR HANDLING MEDICOLEGAL SPECIMENS AND PRESERVING THE CHAIN OF EVIDENCE THE FACULTY OF FORENSIC AND LEGAL MEDICINE HAS PUBLISHED RECOMMENDATION FOR THE COLLECTION FOR FORENSIC SPECIMENS FROM COMPLAINANTS AND SUSPECTS THE EUROPEAN WORKPLACE DRUG TESTING SOCIETY HAS PUBLISHED GUIDELINES ON THE COLLECTION OF URINE, ORAL FLUID AND HAIR. COOPER, A. N. A. G. (2013). CLARKE'S ANALYTICAL FORENSIC TOXICOLOGY INDIA: PHARMACEUTICAL PRESS.
Specimen Collection and Handling: SpecimensTypes Bodily specimen that can be tested include urine, blood, hair, sweat, or saliva Currently, urine remains the ideal specimen to test for clinical purposes because it has the most published scientific data. Mahajan, G. (2017). "Role of Urine DrugTesting in the CurrentOpioid Epidemic." Anesth Analg 125(6): 2094- 2104.
Specimen Collection and Handling: Blood Specimens ■ Advantages: – Widely accepted matrix: ■ Provides unique advantages over other matrices in terms of the wide variety of analytical methodologies available – Determines recent drug use (hours, days) ■ Determination of patent drug and metabolite concentrations (and their ratios) may also yield useful information pertaining to acute or chronic use – Related to pharmacological effect – Not readily adulterated – The interpretive value of the matrix from a pharmacological standpoint. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Specimen Collection and Handling: Blood Specimens ■ Disadvantages – Invasive collection – Collection requiring medical personnel – Shorter detection time – Marked difference between antemortem and postmortem analyte concentration. ■ Antemortem and postmortem blood samples are notably different, and the site of the postmortem blood draw (central or peripheral) can be of critical importance – Require specialized antiseptic collection: ■ Non-alcohol-containing antiseptic wipes such as betadine (povidone-iodine) are preferred to avoid any contamination that could interfere with alcohol analysis. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
SpecimenCollection and Handling: Urine Specimens ■ Advantage – Widely accepted matrix: – Valuable specimen for both antemortem and postmortem drug testing because it is relatively uncomplicated matrix – Easy collection – Plentiful supply – Amenable to automated analysis – Longer detection window than blood (days to weeks) – Extensive reference data ■ has the vast amount of published reference data for both antemortem and postmortem drug concentrations Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
SpecimenCollection and Handling: Urine Specimens ■ Disadvantage – Potential for donor manipulation – Minimal parent drug – Not useful for quantitative analysis – Not related to impairment or pharmacological effect ■ The multiplicity of factors influencing urine drug concentrations (urine volume, clearance, metabolism, pH, and time of last void) generally means that, in isolation, these results have limited quantitative value. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
SpecimenCollection and Handling: Urine Specimens ■ Collection – mid-stream urine sample is usually collected into a plastic container containing sodium fluoride as preservative It is necessary to take precautions against specimen adulteration Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
SpecimenCollection and Handling: Urine Specimens ■ Consideration – Urine concentration are dependent upon physiology and do not correlate with dose or serum concentrations.These result should not be used for therapeutic drug monitoring UrineToxicology Screening on labor and delivery; October 18, 2011
Specimen Collection and Handling: Time ■ Timing is an important factor in specimen collection: – Particularly in antemortem cases where some drugs have short detection times and therefore limited detection windows Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Specimen Collection and Handling: Containers Handling, Labeling andTransfer All samples should be properly marked for: Identification with the caser number, donor name, date and time o collection, signature or initials of the collector and specimen discerption. All samples containers should have: Taper-proof containers and / or tape bearing the collector’s initials and date of collection should be used. All samples transfer to laboratory should be: Forwarded to the laboratory in appropriate leak-proof and tamper-proof packaging/ shipping materials with all appropriate documentation “chain-of-custody” All samples received by laboratory should be: Inspected and appropriated documented in terms of condition and quantity during the accessioning process. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Specimen Collection and Handling: Containers ■ Container specifications – The specimen container should be appropriate for the intended use and does not compromise the analytical finding – Container size should be appropriate for the volume or weight of the specimen so that the headspace is minimized. ■ Container headspace undesired effects: Excessive headspace in the container can increase the chance of oxidative loss, volatilization of analytes (e.g. ethanol, and other low-boiling point compounds.) – Some analytes have a tendency to adhere to plastic or glass surfaces depending on their physiochemical properties. – Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Specimen Collection and Handling: Containers It is a good laboratory practice to evaluate all new specimen container prior to routine use in the laboratory. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Sample Handling, Preservation and Storage ■ Specimens should be stored at appropriate temperature with adequate preservative and in an environment accessible only to authorized personnel to ensure security and integrity. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Sample Preservation and Storage: Storage Short-term storage: recommendation for most samples is to be stored at refrigerated temperature (4C) Long-term storage: recommended for storage of tow weeks or more periods and is carried at (-20C or lower) Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Sample Preservation and Storage: Preservation Sodium fluoride (2% w/v) - Blood Samples is a routine in most laboratories. Commercial evacuated blood collection tubes (e.g. grey-top tubes) contain sodium fluoride as the preservative and potassium oxalate as the anticoagulant Inhibition of microorganisms and enzymes with sodium fluoride is important for commonly encountered analytes such as ethanol, cocaine and others. Fluoride acts as an enzyme inhibitor and helps prevent glycolysis. Potassium oxalate - Blood Samples Considered as the preferred anticoagulant over other alternatives such as EDTA, heparin or citrate Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Sample Preservation and Storage: Preservation Antioxidants Such as ascorbic acid (0.25%) or sodium metabisulfite (1% w/v) are sometimes used to prevent oxidative loss Theses agents have the potential to act as reducing agents towards some drugs, in particular N-oxide metabolites, which may be transformed into the parent drug pH adjustment: Adjustment of specimen pH is not generally favored routinely as some drugs alkali labile, while others are acid labile Antimicrobial, SodiumAzide (0.1% v/w) Used sometime as a preservative and antimicrobial agent in urine samples Should not be used if samples are to be analyzed by enzyme-linked immunosorbent assay because it can interfere with horseradish peroxidase-mediated colorimetric detection Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Specimen Stability: Intro • the physiochemical properties of the drug, characteristics of the specimen or matrix, tendency to conjugate/ deconjugate, specimen collection procedure, container selection, and the use of preservatives or other additives Drug stability can be influenced by many factors including • Specimen pH and the presence of other substances in addition to external factors • Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press. Drug instability is often matrix dependent and influenced by factors such as
Specimen Stability: Analyte Alternation In general drug instability in any toxicological specimen is due to metabolic degradation, chemical transformation, or a combination of both. After a specimen has been collected, enzymes may remain active and continue to degrade or transform the drug in vitro. In general, drug instability arises as a result of moieties or functional groups that are susceptible to Transformation, such as ester (e.g. 6- acetylmorphine, cocaine, acetylsalicylic acid), sulfur-containing drugs, photolabile drugs (e.g. phenothiazines, midazolam, lysergic acid diethylamide) or those with functional groups that are readily oxidized or reduced. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Specimen Stability: Analyte Alternation Depending on the collection, storage, use of preservative, container type, storage conditions, use of preservative, container type, matrix and other factors, the concentration of a drug at the time of assay may not be identical to the concentration at the time of collection, all toxicological results should be interpreted within this context Some drugs also exhibit a degree of thermal instability, this is a consideration for drugs that are subjected to elevated temperatures during administration (e.g. by smoking), and during analysis (e.g. GC-MS) Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
WhatTest to Perform To get the most comprehensive results, clinicians should order both a an immunoassay screening (IAS) followed by a confirmatory mass-spectrometry urine drug test (UDT). Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
WhatTest to Perform Confirmatory urine drug test, Gas or Liquid Chromatography-Mass Spectrometry, has a lower threshold of detectability and provides both qualitative and quantitative information. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
WhatTest to Perform Clinicians should understand that immunoassay screens have high false- positive and false-negative rates. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Confirmatory Urine DrugTest Confirmatory UDT involves laboratory-based testing utilize the techniques of gas chromatography-mass spectrometry (GC-MS), or liquid chromatography-mass spectrometry (LC-MS). Chromatography separates the analytes in a specimen, mass spectrometry unequivocally identifies the relevant analytes by their mass to charge ratio. Both GC-MS and LC-MS provide quantitative information about individually identified opiates, opioids, and their respective metabolites Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Confirmatory Urine DrugTest Confirmatory test advantage The ability of GC-MS and LC-MS to provide both a qualitative and quantitative answer about the parent drug and metabolite means equivocal IAS results can be potentially resolved, thereby decreasing the likelihood for false-positive results Confirmatory test disadvantage Its limitations of being available only as a laboratory-based test that has a turn around time of hours to days. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Immunoassay Screens IAS IS ONLY A QUALITATIVE TEST THAT LOOKS FOR WHICH DRUG/ DRUG CLASSES ARE PRESENT VERSUS ABSENT. at minimum the majority of IASs look for amphetamine, cocaine, marijuana, PCP , and opiates (limited to codeine, morphine, and 6- monoacetyl-morphine to test for heroin use) IN THE PAIN MANAGEMENT THE TESTING PANEL SHOULD BE CUSTOMIZED TO ALSO INCLUDE BENZODIAZEPINES, BARBITURATES, METHAMPHETAMINE, SEMISYNTHETIC OPIOIDS, METHADONE, AND BUPRENORPHINE. MAHAJAN, G. (2017). "ROLE OF URINE DRUG TESTING IN THE CURRENT OPIOID EPIDEMIC." ANESTH ANALG 125(6): 2094- 2104.
Immunoassay Screens The immunoassay is the most commonly used Urine Drug Screening because it is inexpensive and rapid. Five different immunoassays are available Cloned enzyme donor immunoassay (CEDIA) Enzyme-multiplied immunoassay (EMIT) Fluorescence polarization immunoassay (FIPA) Kinetic interaction of microparticle in solution (KIMS) Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and-sections/drug-information- group/2014/2011/february-2011-faqs
Immunoassay Screens ■ IASs suffer from added limitations that include – Cross-reactivity with other drugs and substances that can lead to higher false-positive results – The inability to distinguish a positive opiate result as being due to codeine versus morphine versus heroin versus and other combination of the aforementioned – The inconsistency or inability to detect semisynthetic opioids (hydrocodone, hydromorphone, oxycodone, oxymorphone,, buprenorphine) and synthetic opioids (fentanyl, meperidine, methadone, and pentazocine) – Higher thresholds of detection that can potentially cause one to falsely conclude that a substance is absent when it is truly present – While an IAS reliably detects opiate, it inconsistently identifies the presence of semisynthetic opioids and synthetic opioid – IAS generally does not detect opioid metabolites from the cytochrome P450 enzyme system – The inability to accurately conclude whether the identification of both the parent drug and its active metabolite means the patient is compliant versus the identification of the “active metabolite” really represents surreptitious of a nonprescribed opioid and the patient is noncompliant. – Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Immunoassay Screens ■ IASs suffer from added limitations that include – They are considered as screening assay and yield qualitative, class specific information. – Specific drugs within a class are not identified using these methods. – These assays vary in their ability to detect parent compounds and metabolites. – These assays carries the possibilities of slight variations due to change in reagents lots – UrineToxicology Screening on labor and delivery;October 18, 2011
Immunoassay Screens There are a number of advantages for always including IASs: Low cost Identification of illicit substances Potential acquisition of results in minutes to hours to enable one to make more immediate intervention Ultimately, clinicians must understand that all AISs are only helpful for making preliminary treatment decisions Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Immunoassay Screens Criteria for Legitimate Urine Samples Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and-sections/drug-information-group/2014/2011/february-2011-faqs Urine should be collected in a tamper-evident container under supervision if necessary.Criteria for legitimate urine samples include A volume of 30mL or more Temperature between 32C and 38C pH of 4.5 to 8.5 Nitrates < 500 mcg/mL Specific gravity >1.002 and <1.020 Creatinine > mg/dL
Immunoassay Screens False-Negative Results Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy- practice/centers-and-sections/drug-information-group/2014/2011/february-2011-faqs False negatives are uncommon but can occur as a result of low concentrations in the urine, tampering, and other situation Dilute urine (excess fluid intake, diuretic use, pediatric sample) Infrequent drug use Prolonged time since last use Recent ingestion Insufficient quantity ingested Metabolic factors Inappropriate test used Elevated urine lactate Tampering (discussed later)
Immunoassay Screens False-Positive Result There are examples of interfering substances producing false positive results include Opiates may be falsely detected due to poppy seed ingestion (low concentration detected) Heroin and hydrocodone are metabolized into morphine and hydromorphone respectively, and GC-MS may identify the metabolites rather than the parent compound. Immunoassay results for cannabinoid and cocaine metabolites are associated with very few false-positives while immunoassay results for amphetamines and opiates are associated with a higher number of false- positive Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and- sections/drug-information-group/2014/2011/february-2011-faqs
SAMPLE CONTAMINATIO N
Legitimate Sample ■ The normal temperature rage is 32C -38C. ■ A specimen may be considered invalid if the pH is between 3 and 4.5 or between 9 and 11. – The specimen may be adulterated if the pH is less than 3 or greater than 11 ■ A specimen is considered diluted if the creatinine concentration is less than 200mg/L and the specific gravity is less than 1.003 Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Exogenous Contaminants Phthalate Interferences ■ SPECIMENS COLLECTED INTO PLASTIC CONTAINERS ARE SOMETIMES SUSCEPTIBLE TO PHTHALATE INTERFERENCES ■ NUMEROUS PLASTICIZER INTERFERENCES SUCH AS DIBUTYL PHTHALATE MAY CO- EXTRACT AND INTERFERE WITH ANALYTICAL DETECTION BY GAS-CHROMATOGRAPHIC OR MASS-SPECTROMETRIC TECHNIQUES, YIELDING CHARACTERISTIC PHTHALATE IONS. ■ ALL PLASTIC CONTAINERS SHOULD BE EVALUATED PRIOR TO WIDESPREAD IMPLEMENTATION ■ ENVIRONMENTAL EXPOSURE TO THESE SUBSTANCES FROM HOUSEHOLD ITEMS, FOOD, BEVERAGE AND OTHER SOURCES CAN PRODUCE DETECTABLE QUANTITIES OF PHTHALATE ESTERS OR THEIR METABOLITE IN BIOLOGICAL SPECIMENS INCLUDING BLOOD, SERUM, URINE AND BREAST MILK COOPER, A. N. A. G. (2013). CLARKE'S ANALYTICAL FORENSIC TOXICOLOGY INDIA: PHARMACEUTICAL PRESS.
Exogenous Contaminants Samples Adulteration ■ How to Subvert the Tests – Clinician should always be aware that adulteration might be a possibility – Scientists at quest diagnostics discovered that patient had adulterated about 1.5% of analyzed samples through ■ Diluting them 60% ■ Adding an oxidant 21% ■ Substituting an alternate specimen 12% ■ Adding some other adulterant 7% – Various strategies can e implemented either before or at the time the patient submits a specimen. – To obtain the most concentrated specimen, have the patient submit a morning specimen – To ensure the specimen has not been adulterated, clinician should ask the laboratory to perform validity testing. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094- 2104.
Exogenous Contaminants Samples Adulteration ■ Principal concern with antemortem contamination arises from the intentional manipulation of the sample to mask the presence of drugs. ■ This include substitution, dilution or adulteration of the biological specimen with a foreign substance. – In general, in vitro adulteration can interfere with presumptive immunoassay tests, with the intention of producing false-negative results. – In vitro adulteration agents: Ascorbic acid, Alcohol, Amber-13 (hydrochloric acid), ammonia, etc.…) – On site or dipstick tests are available for nitrite, glutaraldehyde, pH, specific gravity, creatinine, bleach, PCC and oxidants. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Exogenous Contaminants Samples Adulteration ■ Principal concern with antemortem contamination arises from the intentional manipulation of the sample to mask the presence of drugs. ■ This include substitution, dilution or adulteration of the biological specimen with a foreign substance. – In general, in vitro adulteration can interfere with presumptive immunoassay tests, with the intention of producing false-negative results. – In vitro adulteration agents: Ascorbic acid, Alcohol, Amber-13 (hydrochloric acid), ammonia, etc.…) – On site or dipstick tests are available for nitrite, glutaraldehyde, pH, specific gravity, creatinine, bleach, PCC and oxidants. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Exogenous Contaminants Samples Adulteration – Specimen dilution or in vivo adulteration by ingestion of a substance to mask the presence of drugs is also encountered. – This is commonly achieved by the ingestion of large quantities of fluid prior to the test or by administration of a diuretic. – In vivo adulteration agent – Diuretics ■ prescription: thiazides and thiazide-like drugs (e.g. hydrochlorothiazide, metolazone), carbonic anhydrase inhibitors (e.g. acetazolamide), Loop diuretics (e.g. bumetanide, furosemide, torsemide), osmotic diuretics (e.g. mannitol) ■ Over the counter (OTC): aqua-ban, diurex, fem-1, midol, etc.… – Other ■ Alcoholic beverages, xanthines (e.g. caffeine, theophylline, 8-bromotheophyillne), herbals and aquaretic (e.g. golden seal root, jumpier) Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
Exogenous Contaminants Samples Adulteration ■ Other sources of contaminants or unexpected analytes include pyrolytic breakdown products due to thermal degradation of drugs. ■ Other source of contamination may arise from pharmaceutical impurities or adulterants and cutting agents that are incorporated into illicit drugs prior to sale Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Exogenous Contaminants Medical Artifacts ■ Clinical therapy can sometimes produce medical artefacts that complicate toxicological findings. – Administration of fluids (e.g. saline) during clinical care, blood is only contaminated (diluted) with the infusion solution if it is collected downstream from the intravenous line. – If downstream collection is suspected, careful review of the medical records and/ or measurement of the hematocrit to determine specimen dilution may be necessary. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Endogenous Contaminants ■ By their very nature, all biological specimens are subject to endogenous interferences, regardless of whether or not they are derived from living or deceased person. ■ In general, however, antemortem specimens are somewhat less susceptible to endogenous artifacts or contaminants – Concentration of GHB may increase in urine during storage, upon collection and storage of unpreserved blood, or in citrate-buffered antemortem blood. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
Interpreting theTest Results Result reporting standardization While the thresholds for detection have been standardized in work sitting, they have not been standardized for the pain management setting Mahajan, G. (2017). "Role of Urine DrugTesting in the CurrentOpioid Epidemic." AnesthAnalg 125(6): 2094- 2104. Factors affecting threshold detectability A drug’s pharmacokinetics, pharmacodynamics, and pharmacogenetics and how the urine specimen is collected, handled, and analyzed all can affect the threshold of detection. How long an individual continues to excrete a drug or its metabolite at or above a test’s lowest threshold of detectability determines a drug’s window of detection, and this is influenced by the drug’s pharmacokinetics, pharmacodynamics, and pharmacogenetics.
Interpreting theTest Results: Consideration Presence of positive results never correlate with medical condition There is no scientific correlation between drug concentrating versus drug dose, frequency of drug use, and when the last dose was taken. Importance of selection of threshold level by requesting clinicians The consequence of requesting the lowest threshold of detectability means there is a greater likelihood of picking up an impurity due to another opioid being manufactured using the same equipment. Therefore, caution must be exercised when interpreting test results Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Interpreting theTest Results: Consideration Factors affecting right interpretation of results A correct interpretation of the results requires clinicians understand that results can be affected by drug interference patterns, cross-reactivity, and drug metabolism Importance of clinician to lab communication Clinicians should always contact the laboratory when uncertain about the meaning of the results Mahajan, G. (2017). "Role of Urine DrugTesting in the Current Opioid Epidemic." Anesth Analg 125(6): 2094- 2104.
Interpreting theTest Results:Types of LaboratoryTest Results Reporting Negative results True-negative False-negative Pseudo-false-negative Negative due to inherent limitations of a test Positive results True-positive False-positive Pseudo-false-positive Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
Interpreting theTest Results:Types of LaboratoryTest Results Reporting True negative The absence of a drug is considered a true-negative result False negative When a drug whose concentration is anticipated to fall at or above the threshold of detection is undetected Pseudo-false- negative Rapid metabolization of an opioid, either due to polypharmacy or a patient’s genetic predisposition, can prevent identification of the opioid on testing. This defines a pseudo-false- negative because the test correctly failed to confirm the presence of the opioid even though the patient is taking it. Pseudo-false- negative or some true negative result This is usually due to negative results in spite of expected positive results. Possible explanations include laboratory error due to mislabeling the specimen, mishandling specimen, or using faulty equipment, or patient missing dose of treatment. Method inherent limitation The likelihoods of this occurring may be greater with an IAS compared to UDT because of the IAS’s relatively higher threshold of detectability Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094- 2104.
Interpreting theTest Results:Types of LaboratoryTest Results Reporting Positive results Presence of a drug above the threshold of detectability defines a true-positives results Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104. False positive When a drug that is truly absent is identified as present Laboratory error, e.g. performing the test incorrectly or analyzing the wrong patient’s specimen, or drug interference / cross-reactivity are possible explanations. A pseudo-false-positive result This means the test correctly identifies the presence of a drug but it is not due to the patient taking that specific drug. This can be occur in the following setting •Cross over of metabolites: the metabolism of a parent opioid to a secondary opioid •Poppy seeds ingestion: foods that contain poppy seeds can lead to an IAS result that is positive for opiates •Marijuana and the synthetic cannabinoids (contain 11-not- delta-9-tetrahydrocannabiol •Impurity in the manufacturing process: can led to identification of a small amount of codeine when morphine is the prescribed opioid or a small amount of hydrocodone when oxycodone is the prescribed opioid
Interpreting the Test Results: Important Question to Ask for Excluding False Results ■ To minimize the challenges that can occur with interpreting unexpected results , the clinical should document the patient’s responses to the following questions – If you are prescribed an opioid, which one are you taking, what dose are you taking, how often are you taking it, and when did you last take it – If you are taking an d other prescribed, nonprescribed, or over-the-counter drug or any illicit substance, which one are you taking, what dose are you taking, how often are you taking it, and when did you last take it. Mahajan,G. (2017). "Role of Urine DrugTesting in the CurrentOpioid Epidemic." AnesthAnalg 125(6): 2094-2104.
Reporting Screening Results screening results are reported as “presumptive positive” if the screening results is more than the cutoff value The presumptive result only indicate the presence of the drug or metabolite in urine and do not indicate or measure intoxication or efficacy of elimination. Screening results are reported as “indicative of negative” if the screening results are less than the cutoff value. Negative result reflect the concentration that fall below the cut off and do not necessarily exclude the presence of the drug or metabolite. UrineToxicology Screening on labor and delivery; October 18, 2011
REPORTING SCREENING RESULTS Therefore, confirmation testing must be requested to be performed Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
References… ■ Mahajan, G. (2017). "Role of Urine DrugTesting in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104. ■ Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India, Pharmaceutical Press. ■ Ertmer, B. (2019). "February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago." from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and- sections/drug-information-group/2014/2011/february-2011-faqs ■ UrineToxicology Screening on labor and delivery; October 18, 2011 ■ (2019). "What is a Drug Screen?". 2019, from https://www.concentra.com/resource- center/articles/what-is-a-drug-screen. ■ (2019). "Drug screening - Latest research and news | Nature." from https://www.nature.com/subjects/drug-screening.

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Urine Drug Screening

  • 1.
  • 2.
    Definition Drug testing isthe evaluation of a urine, blood or other type of biological sample to determine if the subject has been using the drug or drugs in question. There are many circumstances that may lead to drug testing. (2019). "Drug screening - Latest research and news | Nature." from https://www.nature.com/subjects/drug-screening. A drug screen (also called a drug test) is the collection and analysis of blood, urine, hair, or saliva to detect the presence of the chemicals and contaminants left behind in the body due to drug use. A drug screen may also be used to detect performance-enhancing drugs sometimes used by professional athletes such as steroids and HGH. Many different types of drug screens exist for multiple purposes. (2019). "What is a Drug Screen?". 2019, from https://www.concentra.com/resource-center/articles/what-is-a-drug- screen
  • 3.
    Reasons for Drug Screening ■Onsite drug screening is performed for a variety of medical, professional and legal reasons. A few scenarios in which screening may be done are: – Pre-employment – Suspicion of drug abuse – Military service, sports participation – Legal, criminal – Drug-therapy compliance monitoring – Drug abuse rehabilitating monitoring – Postmortem investigation Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and- sections/drug-information-group/2014/2011/february-2011-faqs
  • 4.
    SubstancesTested in aDrug Screening Most commonly substances Amphetamines Cannabinoid metabolites Cocaine metabolites opiate metabolites phencyclidine (PCP) Expanded immunoassays Tricyclic antidepressants Barbiturate Methadone Alcohol Benzodiazepines Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy- practice/centers-and-sections/drug-information-group/2014/2011/february-2011-faqs
  • 5.
    SPECIMEN COLLECTION AND HANDLING This Photo byUnknown Author is licensed under CC BY-NC-ND
  • 6.
    Specimen Collection andHandling: Guidelines THE ROYAL COLLEGE OF PATHOLOGISTS HAS PUBLISHED GUIDELINES FOR HANDLING MEDICOLEGAL SPECIMENS AND PRESERVING THE CHAIN OF EVIDENCE THE FACULTY OF FORENSIC AND LEGAL MEDICINE HAS PUBLISHED RECOMMENDATION FOR THE COLLECTION FOR FORENSIC SPECIMENS FROM COMPLAINANTS AND SUSPECTS THE EUROPEAN WORKPLACE DRUG TESTING SOCIETY HAS PUBLISHED GUIDELINES ON THE COLLECTION OF URINE, ORAL FLUID AND HAIR. COOPER, A. N. A. G. (2013). CLARKE'S ANALYTICAL FORENSIC TOXICOLOGY INDIA: PHARMACEUTICAL PRESS.
  • 7.
    Specimen Collection andHandling: SpecimensTypes Bodily specimen that can be tested include urine, blood, hair, sweat, or saliva Currently, urine remains the ideal specimen to test for clinical purposes because it has the most published scientific data. Mahajan, G. (2017). "Role of Urine DrugTesting in the CurrentOpioid Epidemic." Anesth Analg 125(6): 2094- 2104.
  • 8.
    Specimen Collection and Handling: BloodSpecimens ■ Advantages: – Widely accepted matrix: ■ Provides unique advantages over other matrices in terms of the wide variety of analytical methodologies available – Determines recent drug use (hours, days) ■ Determination of patent drug and metabolite concentrations (and their ratios) may also yield useful information pertaining to acute or chronic use – Related to pharmacological effect – Not readily adulterated – The interpretive value of the matrix from a pharmacological standpoint. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 9.
    Specimen Collection and Handling: BloodSpecimens ■ Disadvantages – Invasive collection – Collection requiring medical personnel – Shorter detection time – Marked difference between antemortem and postmortem analyte concentration. ■ Antemortem and postmortem blood samples are notably different, and the site of the postmortem blood draw (central or peripheral) can be of critical importance – Require specialized antiseptic collection: ■ Non-alcohol-containing antiseptic wipes such as betadine (povidone-iodine) are preferred to avoid any contamination that could interfere with alcohol analysis. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 10.
    SpecimenCollection and Handling: Urine Specimens ■Advantage – Widely accepted matrix: – Valuable specimen for both antemortem and postmortem drug testing because it is relatively uncomplicated matrix – Easy collection – Plentiful supply – Amenable to automated analysis – Longer detection window than blood (days to weeks) – Extensive reference data ■ has the vast amount of published reference data for both antemortem and postmortem drug concentrations Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 11.
    SpecimenCollection and Handling: Urine Specimens ■Disadvantage – Potential for donor manipulation – Minimal parent drug – Not useful for quantitative analysis – Not related to impairment or pharmacological effect ■ The multiplicity of factors influencing urine drug concentrations (urine volume, clearance, metabolism, pH, and time of last void) generally means that, in isolation, these results have limited quantitative value. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 12.
    SpecimenCollection and Handling: Urine Specimens ■Collection – mid-stream urine sample is usually collected into a plastic container containing sodium fluoride as preservative It is necessary to take precautions against specimen adulteration Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 13.
    SpecimenCollection and Handling: Urine Specimens ■Consideration – Urine concentration are dependent upon physiology and do not correlate with dose or serum concentrations.These result should not be used for therapeutic drug monitoring UrineToxicology Screening on labor and delivery; October 18, 2011
  • 14.
    Specimen Collection and Handling: Time ■Timing is an important factor in specimen collection: – Particularly in antemortem cases where some drugs have short detection times and therefore limited detection windows Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 15.
    Specimen Collection andHandling: Containers Handling, Labeling andTransfer All samples should be properly marked for: Identification with the caser number, donor name, date and time o collection, signature or initials of the collector and specimen discerption. All samples containers should have: Taper-proof containers and / or tape bearing the collector’s initials and date of collection should be used. All samples transfer to laboratory should be: Forwarded to the laboratory in appropriate leak-proof and tamper-proof packaging/ shipping materials with all appropriate documentation “chain-of-custody” All samples received by laboratory should be: Inspected and appropriated documented in terms of condition and quantity during the accessioning process. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 16.
    Specimen Collection and Handling: Containers ■Container specifications – The specimen container should be appropriate for the intended use and does not compromise the analytical finding – Container size should be appropriate for the volume or weight of the specimen so that the headspace is minimized. ■ Container headspace undesired effects: Excessive headspace in the container can increase the chance of oxidative loss, volatilization of analytes (e.g. ethanol, and other low-boiling point compounds.) – Some analytes have a tendency to adhere to plastic or glass surfaces depending on their physiochemical properties. – Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 17.
    Specimen Collection and Handling: Containers Itis a good laboratory practice to evaluate all new specimen container prior to routine use in the laboratory. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 18.
    Sample Handling, Preservation andStorage ■ Specimens should be stored at appropriate temperature with adequate preservative and in an environment accessible only to authorized personnel to ensure security and integrity. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 19.
    Sample Preservation andStorage: Storage Short-term storage: recommendation for most samples is to be stored at refrigerated temperature (4C) Long-term storage: recommended for storage of tow weeks or more periods and is carried at (-20C or lower) Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 20.
    Sample Preservation andStorage: Preservation Sodium fluoride (2% w/v) - Blood Samples is a routine in most laboratories. Commercial evacuated blood collection tubes (e.g. grey-top tubes) contain sodium fluoride as the preservative and potassium oxalate as the anticoagulant Inhibition of microorganisms and enzymes with sodium fluoride is important for commonly encountered analytes such as ethanol, cocaine and others. Fluoride acts as an enzyme inhibitor and helps prevent glycolysis. Potassium oxalate - Blood Samples Considered as the preferred anticoagulant over other alternatives such as EDTA, heparin or citrate Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 21.
    Sample Preservation andStorage: Preservation Antioxidants Such as ascorbic acid (0.25%) or sodium metabisulfite (1% w/v) are sometimes used to prevent oxidative loss Theses agents have the potential to act as reducing agents towards some drugs, in particular N-oxide metabolites, which may be transformed into the parent drug pH adjustment: Adjustment of specimen pH is not generally favored routinely as some drugs alkali labile, while others are acid labile Antimicrobial, SodiumAzide (0.1% v/w) Used sometime as a preservative and antimicrobial agent in urine samples Should not be used if samples are to be analyzed by enzyme-linked immunosorbent assay because it can interfere with horseradish peroxidase-mediated colorimetric detection Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 22.
    Specimen Stability: Intro • thephysiochemical properties of the drug, characteristics of the specimen or matrix, tendency to conjugate/ deconjugate, specimen collection procedure, container selection, and the use of preservatives or other additives Drug stability can be influenced by many factors including • Specimen pH and the presence of other substances in addition to external factors • Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press. Drug instability is often matrix dependent and influenced by factors such as
  • 23.
    Specimen Stability: Analyte Alternation Ingeneral drug instability in any toxicological specimen is due to metabolic degradation, chemical transformation, or a combination of both. After a specimen has been collected, enzymes may remain active and continue to degrade or transform the drug in vitro. In general, drug instability arises as a result of moieties or functional groups that are susceptible to Transformation, such as ester (e.g. 6- acetylmorphine, cocaine, acetylsalicylic acid), sulfur-containing drugs, photolabile drugs (e.g. phenothiazines, midazolam, lysergic acid diethylamide) or those with functional groups that are readily oxidized or reduced. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 24.
    Specimen Stability: Analyte Alternation Dependingon the collection, storage, use of preservative, container type, storage conditions, use of preservative, container type, matrix and other factors, the concentration of a drug at the time of assay may not be identical to the concentration at the time of collection, all toxicological results should be interpreted within this context Some drugs also exhibit a degree of thermal instability, this is a consideration for drugs that are subjected to elevated temperatures during administration (e.g. by smoking), and during analysis (e.g. GC-MS) Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 25.
    WhatTest to Perform To getthe most comprehensive results, clinicians should order both a an immunoassay screening (IAS) followed by a confirmatory mass-spectrometry urine drug test (UDT). Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 26.
    WhatTest to Perform Confirmatory urinedrug test, Gas or Liquid Chromatography-Mass Spectrometry, has a lower threshold of detectability and provides both qualitative and quantitative information. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 27.
    WhatTest to Perform Clinicians shouldunderstand that immunoassay screens have high false- positive and false-negative rates. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 28.
    Confirmatory Urine DrugTest ConfirmatoryUDT involves laboratory-based testing utilize the techniques of gas chromatography-mass spectrometry (GC-MS), or liquid chromatography-mass spectrometry (LC-MS). Chromatography separates the analytes in a specimen, mass spectrometry unequivocally identifies the relevant analytes by their mass to charge ratio. Both GC-MS and LC-MS provide quantitative information about individually identified opiates, opioids, and their respective metabolites Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 29.
    Confirmatory Urine DrugTest Confirmatorytest advantage The ability of GC-MS and LC-MS to provide both a qualitative and quantitative answer about the parent drug and metabolite means equivocal IAS results can be potentially resolved, thereby decreasing the likelihood for false-positive results Confirmatory test disadvantage Its limitations of being available only as a laboratory-based test that has a turn around time of hours to days. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 30.
    Immunoassay Screens IAS ISONLY A QUALITATIVE TEST THAT LOOKS FOR WHICH DRUG/ DRUG CLASSES ARE PRESENT VERSUS ABSENT. at minimum the majority of IASs look for amphetamine, cocaine, marijuana, PCP , and opiates (limited to codeine, morphine, and 6- monoacetyl-morphine to test for heroin use) IN THE PAIN MANAGEMENT THE TESTING PANEL SHOULD BE CUSTOMIZED TO ALSO INCLUDE BENZODIAZEPINES, BARBITURATES, METHAMPHETAMINE, SEMISYNTHETIC OPIOIDS, METHADONE, AND BUPRENORPHINE. MAHAJAN, G. (2017). "ROLE OF URINE DRUG TESTING IN THE CURRENT OPIOID EPIDEMIC." ANESTH ANALG 125(6): 2094- 2104.
  • 31.
    Immunoassay Screens The immunoassayis the most commonly used Urine Drug Screening because it is inexpensive and rapid. Five different immunoassays are available Cloned enzyme donor immunoassay (CEDIA) Enzyme-multiplied immunoassay (EMIT) Fluorescence polarization immunoassay (FIPA) Kinetic interaction of microparticle in solution (KIMS) Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and-sections/drug-information- group/2014/2011/february-2011-faqs
  • 32.
    Immunoassay Screens ■ IASs sufferfrom added limitations that include – Cross-reactivity with other drugs and substances that can lead to higher false-positive results – The inability to distinguish a positive opiate result as being due to codeine versus morphine versus heroin versus and other combination of the aforementioned – The inconsistency or inability to detect semisynthetic opioids (hydrocodone, hydromorphone, oxycodone, oxymorphone,, buprenorphine) and synthetic opioids (fentanyl, meperidine, methadone, and pentazocine) – Higher thresholds of detection that can potentially cause one to falsely conclude that a substance is absent when it is truly present – While an IAS reliably detects opiate, it inconsistently identifies the presence of semisynthetic opioids and synthetic opioid – IAS generally does not detect opioid metabolites from the cytochrome P450 enzyme system – The inability to accurately conclude whether the identification of both the parent drug and its active metabolite means the patient is compliant versus the identification of the “active metabolite” really represents surreptitious of a nonprescribed opioid and the patient is noncompliant. – Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 33.
    Immunoassay Screens ■ IASs sufferfrom added limitations that include – They are considered as screening assay and yield qualitative, class specific information. – Specific drugs within a class are not identified using these methods. – These assays vary in their ability to detect parent compounds and metabolites. – These assays carries the possibilities of slight variations due to change in reagents lots – UrineToxicology Screening on labor and delivery;October 18, 2011
  • 34.
    Immunoassay Screens There area number of advantages for always including IASs: Low cost Identification of illicit substances Potential acquisition of results in minutes to hours to enable one to make more immediate intervention Ultimately, clinicians must understand that all AISs are only helpful for making preliminary treatment decisions Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 35.
    Immunoassay Screens Criteria forLegitimate Urine Samples Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and-sections/drug-information-group/2014/2011/february-2011-faqs Urine should be collected in a tamper-evident container under supervision if necessary.Criteria for legitimate urine samples include A volume of 30mL or more Temperature between 32C and 38C pH of 4.5 to 8.5 Nitrates < 500 mcg/mL Specific gravity >1.002 and <1.020 Creatinine > mg/dL
  • 36.
    Immunoassay Screens False-Negative Results Ertmer,B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy- practice/centers-and-sections/drug-information-group/2014/2011/february-2011-faqs False negatives are uncommon but can occur as a result of low concentrations in the urine, tampering, and other situation Dilute urine (excess fluid intake, diuretic use, pediatric sample) Infrequent drug use Prolonged time since last use Recent ingestion Insufficient quantity ingested Metabolic factors Inappropriate test used Elevated urine lactate Tampering (discussed later)
  • 37.
    Immunoassay Screens False-Positive Result Thereare examples of interfering substances producing false positive results include Opiates may be falsely detected due to poppy seed ingestion (low concentration detected) Heroin and hydrocodone are metabolized into morphine and hydromorphone respectively, and GC-MS may identify the metabolites rather than the parent compound. Immunoassay results for cannabinoid and cocaine metabolites are associated with very few false-positives while immunoassay results for amphetamines and opiates are associated with a higher number of false- positive Ertmer, B. (2019). February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago. Retrieved from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and- sections/drug-information-group/2014/2011/february-2011-faqs
  • 38.
  • 39.
    Legitimate Sample ■ Thenormal temperature rage is 32C -38C. ■ A specimen may be considered invalid if the pH is between 3 and 4.5 or between 9 and 11. – The specimen may be adulterated if the pH is less than 3 or greater than 11 ■ A specimen is considered diluted if the creatinine concentration is less than 200mg/L and the specific gravity is less than 1.003 Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 40.
    Exogenous Contaminants Phthalate Interferences ■SPECIMENS COLLECTED INTO PLASTIC CONTAINERS ARE SOMETIMES SUSCEPTIBLE TO PHTHALATE INTERFERENCES ■ NUMEROUS PLASTICIZER INTERFERENCES SUCH AS DIBUTYL PHTHALATE MAY CO- EXTRACT AND INTERFERE WITH ANALYTICAL DETECTION BY GAS-CHROMATOGRAPHIC OR MASS-SPECTROMETRIC TECHNIQUES, YIELDING CHARACTERISTIC PHTHALATE IONS. ■ ALL PLASTIC CONTAINERS SHOULD BE EVALUATED PRIOR TO WIDESPREAD IMPLEMENTATION ■ ENVIRONMENTAL EXPOSURE TO THESE SUBSTANCES FROM HOUSEHOLD ITEMS, FOOD, BEVERAGE AND OTHER SOURCES CAN PRODUCE DETECTABLE QUANTITIES OF PHTHALATE ESTERS OR THEIR METABOLITE IN BIOLOGICAL SPECIMENS INCLUDING BLOOD, SERUM, URINE AND BREAST MILK COOPER, A. N. A. G. (2013). CLARKE'S ANALYTICAL FORENSIC TOXICOLOGY INDIA: PHARMACEUTICAL PRESS.
  • 41.
    Exogenous Contaminants Samples Adulteration ■How to Subvert the Tests – Clinician should always be aware that adulteration might be a possibility – Scientists at quest diagnostics discovered that patient had adulterated about 1.5% of analyzed samples through ■ Diluting them 60% ■ Adding an oxidant 21% ■ Substituting an alternate specimen 12% ■ Adding some other adulterant 7% – Various strategies can e implemented either before or at the time the patient submits a specimen. – To obtain the most concentrated specimen, have the patient submit a morning specimen – To ensure the specimen has not been adulterated, clinician should ask the laboratory to perform validity testing. Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094- 2104.
  • 42.
    Exogenous Contaminants Samples Adulteration ■Principal concern with antemortem contamination arises from the intentional manipulation of the sample to mask the presence of drugs. ■ This include substitution, dilution or adulteration of the biological specimen with a foreign substance. – In general, in vitro adulteration can interfere with presumptive immunoassay tests, with the intention of producing false-negative results. – In vitro adulteration agents: Ascorbic acid, Alcohol, Amber-13 (hydrochloric acid), ammonia, etc.…) – On site or dipstick tests are available for nitrite, glutaraldehyde, pH, specific gravity, creatinine, bleach, PCC and oxidants. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 43.
    Exogenous Contaminants Samples Adulteration ■Principal concern with antemortem contamination arises from the intentional manipulation of the sample to mask the presence of drugs. ■ This include substitution, dilution or adulteration of the biological specimen with a foreign substance. – In general, in vitro adulteration can interfere with presumptive immunoassay tests, with the intention of producing false-negative results. – In vitro adulteration agents: Ascorbic acid, Alcohol, Amber-13 (hydrochloric acid), ammonia, etc.…) – On site or dipstick tests are available for nitrite, glutaraldehyde, pH, specific gravity, creatinine, bleach, PCC and oxidants. Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 44.
    Exogenous Contaminants Samples Adulteration –Specimen dilution or in vivo adulteration by ingestion of a substance to mask the presence of drugs is also encountered. – This is commonly achieved by the ingestion of large quantities of fluid prior to the test or by administration of a diuretic. – In vivo adulteration agent – Diuretics ■ prescription: thiazides and thiazide-like drugs (e.g. hydrochlorothiazide, metolazone), carbonic anhydrase inhibitors (e.g. acetazolamide), Loop diuretics (e.g. bumetanide, furosemide, torsemide), osmotic diuretics (e.g. mannitol) ■ Over the counter (OTC): aqua-ban, diurex, fem-1, midol, etc.… – Other ■ Alcoholic beverages, xanthines (e.g. caffeine, theophylline, 8-bromotheophyillne), herbals and aquaretic (e.g. golden seal root, jumpier) Cooper, A. N. a. G. (2013). Clarke's Analytical Forensic Toxicology India: Pharmaceutical Press.
  • 45.
    Exogenous Contaminants Samples Adulteration ■Other sources of contaminants or unexpected analytes include pyrolytic breakdown products due to thermal degradation of drugs. ■ Other source of contamination may arise from pharmaceutical impurities or adulterants and cutting agents that are incorporated into illicit drugs prior to sale Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 46.
    Exogenous Contaminants Medical Artifacts ■Clinical therapy can sometimes produce medical artefacts that complicate toxicological findings. – Administration of fluids (e.g. saline) during clinical care, blood is only contaminated (diluted) with the infusion solution if it is collected downstream from the intravenous line. – If downstream collection is suspected, careful review of the medical records and/ or measurement of the hematocrit to determine specimen dilution may be necessary. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 47.
    Endogenous Contaminants ■ Bytheir very nature, all biological specimens are subject to endogenous interferences, regardless of whether or not they are derived from living or deceased person. ■ In general, however, antemortem specimens are somewhat less susceptible to endogenous artifacts or contaminants – Concentration of GHB may increase in urine during storage, upon collection and storage of unpreserved blood, or in citrate-buffered antemortem blood. Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India: Pharmaceutical Press.
  • 48.
    Interpreting theTest Results Resultreporting standardization While the thresholds for detection have been standardized in work sitting, they have not been standardized for the pain management setting Mahajan, G. (2017). "Role of Urine DrugTesting in the CurrentOpioid Epidemic." AnesthAnalg 125(6): 2094- 2104. Factors affecting threshold detectability A drug’s pharmacokinetics, pharmacodynamics, and pharmacogenetics and how the urine specimen is collected, handled, and analyzed all can affect the threshold of detection. How long an individual continues to excrete a drug or its metabolite at or above a test’s lowest threshold of detectability determines a drug’s window of detection, and this is influenced by the drug’s pharmacokinetics, pharmacodynamics, and pharmacogenetics.
  • 49.
    Interpreting theTest Results: Consideration Presenceof positive results never correlate with medical condition There is no scientific correlation between drug concentrating versus drug dose, frequency of drug use, and when the last dose was taken. Importance of selection of threshold level by requesting clinicians The consequence of requesting the lowest threshold of detectability means there is a greater likelihood of picking up an impurity due to another opioid being manufactured using the same equipment. Therefore, caution must be exercised when interpreting test results Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 50.
    Interpreting theTest Results: Consideration Factorsaffecting right interpretation of results A correct interpretation of the results requires clinicians understand that results can be affected by drug interference patterns, cross-reactivity, and drug metabolism Importance of clinician to lab communication Clinicians should always contact the laboratory when uncertain about the meaning of the results Mahajan, G. (2017). "Role of Urine DrugTesting in the Current Opioid Epidemic." Anesth Analg 125(6): 2094- 2104.
  • 51.
    Interpreting theTest Results:Typesof LaboratoryTest Results Reporting Negative results True-negative False-negative Pseudo-false-negative Negative due to inherent limitations of a test Positive results True-positive False-positive Pseudo-false-positive Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 52.
    Interpreting theTest Results:Typesof LaboratoryTest Results Reporting True negative The absence of a drug is considered a true-negative result False negative When a drug whose concentration is anticipated to fall at or above the threshold of detection is undetected Pseudo-false- negative Rapid metabolization of an opioid, either due to polypharmacy or a patient’s genetic predisposition, can prevent identification of the opioid on testing. This defines a pseudo-false- negative because the test correctly failed to confirm the presence of the opioid even though the patient is taking it. Pseudo-false- negative or some true negative result This is usually due to negative results in spite of expected positive results. Possible explanations include laboratory error due to mislabeling the specimen, mishandling specimen, or using faulty equipment, or patient missing dose of treatment. Method inherent limitation The likelihoods of this occurring may be greater with an IAS compared to UDT because of the IAS’s relatively higher threshold of detectability Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094- 2104.
  • 53.
    Interpreting theTest Results:Typesof LaboratoryTest Results Reporting Positive results Presence of a drug above the threshold of detectability defines a true-positives results Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104. False positive When a drug that is truly absent is identified as present Laboratory error, e.g. performing the test incorrectly or analyzing the wrong patient’s specimen, or drug interference / cross-reactivity are possible explanations. A pseudo-false-positive result This means the test correctly identifies the presence of a drug but it is not due to the patient taking that specific drug. This can be occur in the following setting •Cross over of metabolites: the metabolism of a parent opioid to a secondary opioid •Poppy seeds ingestion: foods that contain poppy seeds can lead to an IAS result that is positive for opiates •Marijuana and the synthetic cannabinoids (contain 11-not- delta-9-tetrahydrocannabiol •Impurity in the manufacturing process: can led to identification of a small amount of codeine when morphine is the prescribed opioid or a small amount of hydrocodone when oxycodone is the prescribed opioid
  • 54.
    Interpreting the Test Results: Important Questionto Ask for Excluding False Results ■ To minimize the challenges that can occur with interpreting unexpected results , the clinical should document the patient’s responses to the following questions – If you are prescribed an opioid, which one are you taking, what dose are you taking, how often are you taking it, and when did you last take it – If you are taking an d other prescribed, nonprescribed, or over-the-counter drug or any illicit substance, which one are you taking, what dose are you taking, how often are you taking it, and when did you last take it. Mahajan,G. (2017). "Role of Urine DrugTesting in the CurrentOpioid Epidemic." AnesthAnalg 125(6): 2094-2104.
  • 55.
    Reporting Screening Results screeningresults are reported as “presumptive positive” if the screening results is more than the cutoff value The presumptive result only indicate the presence of the drug or metabolite in urine and do not indicate or measure intoxication or efficacy of elimination. Screening results are reported as “indicative of negative” if the screening results are less than the cutoff value. Negative result reflect the concentration that fall below the cut off and do not necessarily exclude the presence of the drug or metabolite. UrineToxicology Screening on labor and delivery; October 18, 2011
  • 56.
    REPORTING SCREENING RESULTS Therefore, confirmation testing must berequested to be performed Mahajan, G. (2017). "Role of Urine Drug Testing in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104.
  • 57.
    References… ■ Mahajan, G.(2017). "Role of Urine DrugTesting in the Current Opioid Epidemic." Anesth Analg 125(6): 2094-2104. ■ Cooper, A. N. a. G. (2013). Clarke's Analytical ForensicToxicology India, Pharmaceutical Press. ■ Ertmer, B. (2019). "February 2011 FAQs | College of Pharmacy | University of Illinois at Chicago." from https://pharmacy.uic.edu/departments/pharmacy-practice/centers-and- sections/drug-information-group/2014/2011/february-2011-faqs ■ UrineToxicology Screening on labor and delivery; October 18, 2011 ■ (2019). "What is a Drug Screen?". 2019, from https://www.concentra.com/resource- center/articles/what-is-a-drug-screen. ■ (2019). "Drug screening - Latest research and news | Nature." from https://www.nature.com/subjects/drug-screening.