Drug Adherence Assessment Report

Transcription

1 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Prescribed Medications: Drug Adherence Assessment Report ACTIQ, ADDERALL, AMITRIPTYLINE, BUTRANS, CYCLOBENZAPRINE, CYMBALTA, EFFEXOR, BACLOFEN, ACETAMINOPHEN, CITALOPRAM, ROBAXIN, CATAPRES (Clonidine), RISPERDAL, DEPAKOTE (Valproic Acid), CLOZARIL, DARVON, CLONIDINE CONSISTENT RESULTS - REPORTED MEDICATION DETECTED (PARENT DRUG AND/OR METABOLITE) REPORTED ANTICIPATED TEST DETECTION WINDOW PRESCRIPTION POSITIVE(S) OUTCOME ACETAMINOPHEN Acetaminophen POSITIVE Plasma Half-Life: 2-3 hours ACTIQ Fentanyl POSITIVE Plasma Half-Life: 3-12 hours ACTIQ Norfentanyl POSITIVE Plasma Half-Life: 9-10 hours ADDERALL Amphetamine POSITIVE Plasma Half-Life: 7-34 hours BACLOFEN Baclofen POSITIVE Plasma Half-Life: 3-4 hrs BUTRANS Buprenorphine Plasma Half-Life: hours BUTRANS Norbuprenorphine POSITIVE Plasma Half-Life: hours CITALOPRAM Citalopram POSITIVE Plasma Half-Life: 35 hours CLOZARIL Clozapine POSITIVE Plasma Half-Life: 14 hours CLOZARIL Clozapine_N_oxide POSITIVE Plasma Half-Life: 14 hours DEPAKOTE (Valproic Acid) Valproic Acid POSITIVE Plasma Half-Life: hours ROBAXIN Methocarbamol POSITIVE Plasma Half-Life: 1-2 hours INCONSISTENT RESULTS - REPORTED MEDICATION NOT DETECTED (NEITHER PARENT DRUG NOR METABOLITE) REPORTED ANTICIPATED TEST DETECTION WINDOW PRESCRIPTION POSITIVE(S) OUTCOME AMITRIPTYLINE CYCLOBENZAPRINE CYMBALTA EFFEXOR EFFEXOR RISPERDAL RISPERDAL DARVON DARVON Amitriptyline Cyclobenzaprine Duloxetine Venlafaxine O-Desmethyl-Venlafaxine 9-Hydroxyrisperidone Risperidone Propoxyphene Norpropoxyphene Plasma Half-Life: hours Plasma Half-Life: 8-37 hours Plasma Half-Life: 8-17 hours Plasma Half-Life: 3-7 hours Plasma Half-Life: 9-13 hours Plasma Half-Life: 5-6 days Plasma Half-Life: 3 hours Plasma Half-Life: 8-24 hours Plasma Half-Life: hours Originally Reported On: 11:14 AM Page 1 of 8 Accession: Patient ID:

2 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT INCONSISTENT RESULTS - ANALYTE DETECTED BUT NO CORRESPONDING PRESCRIPTION REPORTED DETECTED ILLICIT MEASURED CUTOFF TEST DETECTION WINDOW ANALYTE RESULT OUTCOME Oxycodone No 80 Noroxycodone No 50 Oxymorphone No 25 Gabapentin No 350 Caffeine No 450 Ethyl Glucuronide (Ethanol) No 750 Ethyl Sulfate (Ethanol) No 45 <125 POSITIVE POSITIVE POSITIVE POSITIVE POSITIVE POSITIVE POSITIVE Plasma Half-Life: 3-6 hours Plasma Half-Life: 3-6 hours Plasma Half-Life: hours Plasma Half-Life: 5-7 hours Plasma Half-Life: 5-6 hours Plasma Half-Life: 3-4 hours Plasma Half-Life: 3-4 hours SPECIMEN VALIDITY TESTING TEST TEST OUTCOME MEASURED RESULT REFERENCE RANGE ADDITIONAL MEDICATIONS REPORTED BUT NOT TESTED FOR IN THIS REPORT CATAPRES (Clonidine), CLONIDINE Originally Reported On: 11:14 AM Page 2 of 8 Accession: Patient ID:

3 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 Drug-Drug Interactions Clozaril & Diazepam SERIOUS The concurrent use of clozapine with benzodiazepines should be approached with caution, especially in patients who have recently started or restarted clozapine therapy.monitor patients for excessive sedation, decreased respiratory rate, and ataxia. Actiq & BuTrans SERIOUS Use buprenorphine with caution in patients maintained or dependent on other opioids and monitor for signs of withdrawal. In other patients, also monitor for changes in analgesic effects. Adderall & Amitriptyline SERIOUS Use of tricyclic compounds and indirect-acting sympathomimetics should be approached with caution. Montior patients receiving concurrent therapy for decreased sympathomimetic efficacy. ALCOHOL & Diazepam SERIOUS Patients should be informed that alcohol consumption may result in significant decreased psychomotor performance and its associated risks.use of a short acting benzodiazepine may minimize the potential for extreme effects.if suicide or drug abuse is a concern, benzodiazepine use may be ill advised, since alcohol tends to greatly increase benzodiazepine-induced CNS depression in acute overdosage.patients should be informed about unsuspected sources of alcohol such as medications.alcohol is used to improve docetaxel and paclitaxel solubility.- The quantity of alcohol in paclitaxel injection formulations is similar across manufacturers. A paclitaxel 200 mg dose contains approximately 13 grams of alcohol.- The quantity of alcohol in docetaxel formulations varies approximately 3-fold depending upon the manufacturer. FDA data on alcohol content :Product Manufacturer Alcohol/200 mg dosedocetaxel Inj. Pfizer 6.4 gramsdocetaxel Inj. Sandoz 5.5 gramsdocetaxel Inj. Accord 4.0 gramstaxotere-one vial Sanofi 4.0 gramsformulationdocetaxel Inj. Hospira 3.7 gramsdocefrez Sun Pharma 2.9 gramstaxotere-two vial Sanofi 2.0 gramsformulation Oxycodone & BuTrans SERIOUS Use buprenorphine with caution in patients maintained or dependent on other opioids and monitor for signs of withdrawal. In other patients, also monitor for changes in analgesic effects. Oxycodone & Baclofen Clozaril & Citalopram Clozapine levels should be monitored in patients receiving concurrent therapy with clozapine and a selective serotonin reuptake inhibitor and patients should be monitored for signs of clozapine toxicity. The dosage of either clozapine or the selective serotonin reuptake inhibitor may need to be adjusted or one or both agents may need to be discontinued. Clozapine levels should also be monitored following the discontinuation of a selective serotonin reuptake inhibitor from concurrent therapy.if concurrent therapy is warranted in patients receiving clozapine and either citalopram or escitalopram, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting.

4 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 Darvon & Diazepam Limit prescribing opioid analgesics with CNS depressants such as benzodiazepines to patients for whom alternatives are Darvon & Baclofen Darvon & BuTrans Use buprenorphine with caution in patients maintained or dependent on other opioids and monitor for signs of withdrawal. In other patients, also monitor for changes in analgesic effects. Actiq & Diazepam Limit prescribing opioid analgesics with CNS depressants such as benzodiazepines to patients for whom alternatives are Actiq & Baclofen Actiq & Risperdal Limit prescribing opioid analgesics with CNS depressants such as antipsychotics to patients for whom alternatives are inadequate.if concurrent use is necessary, limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. If starting a CNS depressant (for an indication other than epilepsy) with an opioid analgesic, prescribe a lower initial dose of the CNS depressant than indicated in the absence of an opioid and titrate based upon clinical response. If an opioid

5 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 Adderall & Effexor The concurrent use of amphetamines with SSRIs or SNRIs should be approached with appropriate monitoring.instruct patients receiving concurrent therapy to report any signs or symptoms of serotonin syndrome immediately.monitor blood pressure during concurrent therapy and adjust dosage or change medication for persistent increases in blood pressure. BuTrans & Clozaril Limit prescribing opioid analgesics with CNS depressants such as antipsychotics to patients for whom alternatives are inadequate.if concurrent use is necessary, limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. If starting a CNS depressant (for an indication other than epilepsy) with an opioid analgesic, prescribe a lower initial dose of the CNS depressant than indicated in the absence of an opioid and titrate based upon clinical response. If an opioid BuTrans & Robaxin BuTrans & Risperdal Limit prescribing opioid analgesics with CNS depressants such as antipsychotics to patients for whom alternatives are inadequate.if concurrent use is necessary, limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. If starting a CNS depressant (for an indication other than epilepsy) with an opioid analgesic, prescribe a lower initial dose of the CNS depressant than indicated in the absence of an opioid and titrate based upon clinical response. If an opioid Citalopram & Effexor Concurrent use with agents known to prolong the QT interval is not recommended. The manufacturer recommends ECG monitoring in patients for whom citalopram is not recommended, including those receiving concurrent therapy with agents known to prolong the QT interval. Citalopram should be discontinued in patients with persistent QTc measurements greater than 500 ms.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Amitriptyline & Depakote Patients receiving concurrent therapy should be monitored for signs of toxicity. Monitor tricyclic levels carefully during initiation, titration, and discontinuation of valproic acid. The dosage of the tricyclic antidepressant may need to be adjusted. Cymbalta & Actiq Most patients tolerate the combination of fentanyl with serotonin-increasing agents. Serotonin syndrome constitutes a range of toxicities from mild to life threatening. Monitor patients on multiple serotonergic agents for symptoms of serotonin toxicity. Patients in whom serotonin syndrome is suspected should receive immediate medical attention.

6 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 Cymbalta & Cyclobenzaprine Patients should be observed for increased adverse effects and clinical effects of tricyclic compounds at the initiation of concurrent therapy with selected SSRIs or SNRIs. Plasma concentrations of the tricyclic compound should be monitored and the dosage adjusted accordingly.if the SSRI or SNRI is discontinued in a patient receiving a tricyclic compound, the dosage of the tricyclic compound may need to be adjusted.the US manufacturer of desvenlafaxine recommends the dose of desipramine be reduced by up to one-half when administered with desvenlafaxine 400 mg.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Effexor & Amitriptyline Patients should be observed for increased adverse effects and clinical effects of tricyclic compounds at the initiation of concurrent therapy with selected SSRIs or SNRIs. Plasma concentrations of the tricyclic compound should be monitored and the dosage adjusted accordingly.if the SSRI or SNRI is discontinued in a patient receiving a tricyclic compound, the dosage of the tricyclic compound may need to be adjusted.the US manufacturer of desvenlafaxine recommends the dose of desipramine be reduced by up to one-half when administered with desvenlafaxine 400 mg.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Risperdal & Clozaril The UK manufacturer of risperidone states that risperidone should be used with caution when given with other agents known to prolong the QT interval.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Risperdal & Cymbalta Patients receiving concurrent therapy with duloxetine, fluoxetine or paroxetine with risperidone should be observed for increases in risperidone side effects, including extrapyramidal and Parkinsonian symptoms.the US manufacturer of risperidone (Risperdal) recommends that when fluoxetine or paroxetine is co-administered with risperidone that the dose should be reduced. The risperidone dose should not exceed 8 mg per day when co-administered with fluoxetine or paroxetine. When initiating therapy with risperidone, the dose of risperidone should be titrated slowly. It may be necessary to increase the risperidone dose, when fluoxetine or paroxetine is discontinued.the US manufacturer of extended release risperidone microspheres for injection (Risperdal Consta) recommends that patients maintained on this product continue to receive the recommended 25 mg dose when fluoxetine or paroxetine is initiated, unless clinical judgment necessitates lowering the dose or interrupting therapy. If a decision is made to lower the dose, the dose may be lowered to 12.5 mg 2 to 4 weeks before the initiation of fluoxetine or paroxetine. When initiating the product in patients maintained on fluoxetine or paroxetine, a starting dose of 12.5 mg can be considered. The efficacy of this dose has not been confirmed in clinical trials.one set of authors recommended a low initial dose of paroxetine of 10 mg/day to 20 mg/day in patients receiving risperidone. Risperdal & Effexor The UK manufacturer of risperidone states that risperidone should be used with caution when given with other agents known to prolong the QT interval.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Risperdal & Darvon The UK manufacturer of risperidone states that risperidone should be used with caution when given with other agents known to prolong the QT interval.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting.

7 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 Effexor & Cyclobenzaprine Patients should be observed for increased adverse effects and clinical effects of tricyclic compounds at the initiation of concurrent therapy with selected SSRIs or SNRIs. Plasma concentrations of the tricyclic compound should be monitored and the dosage adjusted accordingly.if the SSRI or SNRI is discontinued in a patient receiving a tricyclic compound, the dosage of the tricyclic compound may need to be adjusted.the US manufacturer of desvenlafaxine recommends the dose of desipramine be reduced by up to one-half when administered with desvenlafaxine 400 mg.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Effexor & Actiq Most patients tolerate the combination of fentanyl with serotonin-increasing agents. Serotonin syndrome constitutes a range of toxicities from mild to life threatening. Monitor patients on multiple serotonergic agents for symptoms of serotonin toxicity. Patients in whom serotonin syndrome is suspected should receive immediate medical attention. Cymbalta & Amitriptyline Patients should be observed for increased adverse effects and clinical effects of tricyclic compounds at the initiation of concurrent therapy with selected SSRIs or SNRIs. Plasma concentrations of the tricyclic compound should be monitored and the dosage adjusted accordingly.if the SSRI or SNRI is discontinued in a patient receiving a tricyclic compound, the dosage of the tricyclic compound may need to be adjusted.the US manufacturer of desvenlafaxine recommends the dose of desipramine be reduced by up to one-half when administered with desvenlafaxine 400 mg.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Cyclobenzaprine & Amitriptyline The US manufacturer of cyclobenzaprine recommends limiting use to short term duration, no more than two to three weeks. Use alternative therapy whenever possible, particularly in patients with hepatic impairment.based on serotonin receptor affinity, clomipramine would be expected to have higher risk of serotonin syndrome than imipramine followed by amitriptyline. Amitriptyline at low doses would be expected to have the lowest risk of serotonin syndrome. Cyclobenzaprine is structurally similar to tricyclic antidepressants (TCAs) and may affect serotonin receptors synergistically.if concurrent therapy is warranted, patients should be monitored for signs and symptoms of serotonin syndrome, and seizure activity. Instruct patients to report muscle twitching, tremors, shivering and stiffness, fever, heavy sweating, heart palpitations, restlessness, confusion, agitation, trouble with coordination, or severe diarrhea. Citalopram & Risperdal Concurrent use with agents known to prolong the QT interval is not recommended. The manufacturer recommends ECG monitoring in patients for whom citalopram is not recommended, including those receiving concurrent therapy with agents known to prolong the QT interval. Citalopram should be discontinued in patients with persistent QTc measurements greater than 500 ms.if concurrent therapy is warranted, consider obtaining serum calcium, magnesium, and potassium levels and monitoring ECG at baseline and at regular intervals. Correct any electrolyte abnormalities. Instruct patients to report any irregular heartbeat, dizziness, or fainting. Citalopram & Actiq Most patients tolerate the combination of fentanyl with serotonin-increasing agents. Serotonin syndrome constitutes a range of toxicities from mild to life threatening. Monitor patients on multiple serotonergic agents for symptoms of serotonin toxicity. Patients in whom serotonin syndrome is suspected should receive immediate medical attention. BuTrans & Cyclobenzaprine

8 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 BuTrans & Baclofen BuTrans & Diazepam Limit prescribing opioid analgesics with CNS depressants such as benzodiazepines to patients for whom alternatives are inadequate.for buprenorphine patients newly starting a benzodiazepine, consider beginning the benzodiazepine at a lower than usual dose, especially if predisposing factors (e.g. COPD, sleep apnea, debilitation, elderly) are present. High doses of benzodiazepines are associated with a greater risk for respiratory depression. Use the lowest effective dose and monitor for excessive sedation or respiratory depression, particularly in patients with predisposing risk factors for respiratory compromise.buprenorphine-naloxone combination products are used for maintenance treatment of opioid dependence. Patients with comorbid benzodiazepine dependence, on high doses of benzodiazepines, or a history of benzodiazepine abuse may require benzodiazepine detoxification prior to initiation of office-based buprenorphine treatment. For patients receiving opioid maintenance treatment, it would be prudent to assure all controlled substance prescriptions are approved or written by the buprenorphine-naloxone provider.monitor patients receiving concurrent therapy for unusual dizziness or lightheadedness, extreme sleepiness, Adderall & Cymbalta The concurrent use of amphetamines with SSRIs or SNRIs should be approached with appropriate monitoring.instruct patients receiving concurrent therapy to report any signs or symptoms of serotonin syndrome immediately.monitor blood pressure during concurrent therapy and adjust dosage or change medication for persistent increases in blood pressure. Adderall & Citalopram The concurrent use of amphetamines with SSRIs or SNRIs should be approached with appropriate monitoring.instruct patients receiving concurrent therapy to report any signs or symptoms of serotonin syndrome immediately.monitor blood pressure during concurrent therapy and adjust dosage or change medication for persistent increases in blood pressure. Actiq & Cyclobenzaprine Actiq & Robaxin

9 PATIENT INFORMATION SPECIMEN DETAILS ORDERED BY Alcala Testing and Analysis Services 3703 Camino del Rio South, 100-A San Diego, CA NAME: ACC #: DOB: 3/9/1982 SEX: Female SPECIMEN TYPE: COLLECTION DATE: RECEIVED DATE: REPORT DATE: Blood 4/10/2018 Actiq & Clozaril Limit prescribing opioid analgesics with CNS depressants such as antipsychotics to patients for whom alternatives are inadequate.if concurrent use is necessary, limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. If starting a CNS depressant (for an indication other than epilepsy) with an opioid analgesic, prescribe a lower initial dose of the CNS depressant than indicated in the absence of an opioid and titrate based upon clinical response. If an opioid Darvon & Risperdal Limit prescribing opioid analgesics with CNS depressants such as antipsychotics to patients for whom alternatives are inadequate.if concurrent use is necessary, limit the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect. If starting a CNS depressant (for an indication other than epilepsy) with an opioid analgesic, prescribe a lower initial dose of the CNS depressant than indicated in the absence of an opioid and titrate based upon clinical response. If an opioid Darvon & Cyclobenzaprine Darvon & Robaxin

10 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Test Name Outcome Measured Result Cutoff Units Illicit? Status 1.NARCOTIC ANALGESICS-OPIODS/OPIATES Acetaminophen Positive No Buprenorphine Negative 0 No Norbuprenorphine Positive 35 No Codeine Negative No Fentanyl Positive 8 Norfentanyl Positive 6 Hydrocodone Negative Norhydrocodone Negative Hydromorphone Negative No Morphine Negative No Levorphanol Negative Meperidine Negative Methadone Negative EDDP Negative Oxycodone Positive 80 Noroxycodone Positive 50 No Oxymorphone Positive 25 No Propoxyphene Negative No Norpropoxyphene Negative No Tapentadol Negative No Tramadol Negative N-Desmethyl-Tramadol Negative O-Desmethyl-Tramadol Negative 2.BENZODIAZEPINES Alprazolam Negative No Alpha-hydroxyalprazola Negative m Clonazepam Negative 7-Aminoclonazepam Negative Diazepam Negative Nordiazepam Negative Temazepam Negative Oxazepam Negative Lorazepam Negative <125 No Alpha-Hydroxytriazola Negative m Chlordiazepoxide Negative Clobazam Negative Estazolam Negative Flunitrazepam Negative N-Desmethyl-Flunitraz Negative epam Norchlordiazepoxide Negative No Prazepam Negative No Triazolam Negative Originally Reported On: 11:14 AM Page 3 of 8 Accession: Patient ID:

11 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Test Name Outcome Measured Result Cutoff Units Illicit? Status 2.BENZODIAZEPINES Buspirone Negative No 3.ANTIPSYCHOTICS Aripiprazole Negative <125 No Chlorpromazine Negative <250 No Clozapine Positive 125 Clozapine_N_oxide Positive 65 No Fluphenazine Negative Quetiapine Negative Thioridazine Negative No Ziprasidone Negative No 9-Hydroxyrisperidone Negative Haloperidol Negative Olanzapine Negative No Risperidone Negative 4.ANTIDEPRESSANTS Amitriptyline Negative 0 No Bupropion Negative Citalopram Positive 55 No Doxepin Negative Duloxetine Negative 0 No Fluoxetine Negative Mirtazapine Negative Paroxetine Negative No Sertraline Negative Trazodone Negative Venlafaxine Negative No O-Desmethyl-Venlafaxi Negative ne Clomipramine Negative Desipramine Negative Fluvoxamine Negative Imipramine Negative N-Desmethyl-Clomipra Negative mine Nortriptyline Negative Methysticin Negative Dihydrokavain Negative 0 No Dihydromethysticin Negative Desmethoxyyangonin Negative 0 No Yangonin Negative No D-L-Kavain Negative No 5.DEPRESSANTS Zolpidem Negative Zopiclone-N-Oxide Negative <125 No Alpha-Hydroxymidazol Negative Originally Reported On: 11:14 AM Page 4 of 8 Accession: Patient ID:

12 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Test Name Outcome Measured Result Cutoff Units Illicit? Status 5.DEPRESSANTS am Desalkylflurazepam Negative Flurazepam Negative Midazolam Negative Zaleplon Negative No 6.ANTICONVULSANTS Carbamazepine Negative No Gabapentin Positive 350 Lamotrigine Negative No Levetiracetam Negative Oxcarbazepine Negative No Dihydro-10-Hydr Negative oxycarbamazepine Pregabalin Negative No Tiagabine Negative No Zonisamide Negative <125 No Valproic Acid Positive 45 No 7.MUSCLE RELAXANTS Carisoprodol Negative 0 No Meprobamate Negative No Cyclobenzaprine Negative Baclofen Positive 25 No Methocarbamol Positive 65 0 No 8.STIMULANT Amphetamine Positive 140 Caffeine Positive 450 <125 No Methylphenidate Negative Ritalinic Acid Negative Ephedrine Negative No Lisdexamfetamine Negative 9.DECONGESTANTS Dextromethorphan Negative Pseudoephedrine Negative No 10.APPETITE STIMULANTS Marinol Negative 0 No Phentermine Negative No 11.ANTIDOTES Naloxone Negative Naltrexone Negative 12.ILLICITS MDA Negative <125 MDEA Negative MDMA Negative 0 Mephedrone Negative Cocaine Negative Benzoylecgonine Negative Originally Reported On: 11:14 AM Page 5 of 8 Accession: Patient ID:

13 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Test Name Outcome Measured Result Cutoff Units Illicit? Status 12.ILLICITS THC (Marijuana Negative 0 metabolite) AM2201 (Spice Negative 0 Cannabinoid) HU-210 (Spice Negative 0 Cannabinoid) JWH-019 (Spice Negative 0 Cannabinoid) JWH-073 Negative 4-Hydroxybutyl (Spice Cannabinoid) JWH-081 (Spice Negative Cannabinoid) JWH-122 (Spice Negative Cannabinoid) JWH-18-5-pentanoic Negative acid (Spice Cannabinoid) JWH-18-5-pentanyl Negative (Spice Cannabinoid) JWH-250-5OH-pentany Negative l (Spice Cannabinoid) Methamphetamine Negative 6-monoacetyl morphine Negative (heroin metabolite) PCP Negative 5-MeO-DMT Negative 7-HydroxyMitragynine Negative (Kratom) DMT Negative MDPV Negative Methylone Negative Mitragynine (Kratom) Negative 5-Fluoro-NPB-22 Negative 0 AB-FUBINACA Negative Acetyl-Fentanyl Negative Carfentanil Negative Didesmethyl-U Negative N-Desmethyl-U Negative FDU-PB-22 Negative MMB-CHMICA Negative 13.BARBITURATES Amobarbital Negative Butabarbital Negative 0 Butalbital Negative 0 Phenobarbital Negative Pentobarbital Negative No No No No No No No Originally Reported On: 11:14 AM Page 6 of 8 Accession: Patient ID:

14 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Test Name Outcome Measured Result Cutoff Units Illicit? Status 13.BARBITURATES Secobarbital Negative 14.DIRECT BIOMARKERS (-)-Cotinine Negative Ethyl Glucuronide Positive 750 (Ethanol) Ethyl Sulfate (Ethanol) Positive 45 Morphine is a commonly detected metabolite among patients taking codeine. An active molecule of Opana, Oxymorphone is a commonly detected metabolite among patients taking Oxycodone. Opana (Oxymorphone) will not metabolize to Noroxycodone or Oxycodone. Hydromorphone is a commonly detected metabolite among patients taking Hydrocodone and Morphine. Oxazepam is commonly detected metabolite among patients taking Diazepam, Nor-Diazepam or Temazepam. Temazepam and Nor-Diazepam are commonly detected metabolites among patients taking Diazepam. Alprazolam, Alpha-OH-Alprazolam, Clonazepam, and 7-amino-Clonazepam are not detected in patients taking Diazepam, Nor-diazepam, Lorazepam, Oxazepam, and Temazepam. Meprobamate is a commonly detected metabolite among patients taking Carisoprodol and its presence is consistent with the use of Carisoprodol. An active (drug) or metabolite may be listed as a Negative Outcome, however, if either the active or any metabolite(s) are present (Positive), then the result is listed as Consistent for that reported prescribed medication. Metabolites can remain longer in the body than the parent drug. Sometimes only the metabolite may be detected in the urine and not the parent drug. In case of patients consuming HYDROCODONE-containing medications: Norhydrocodone is the major metabolite of Hydrocodone indicating presence of Hydrocodone in the urine. While Hydrocodone can also be metabolized to Hydromorphone, identification of just Hydromorphone by itself is not a confirmation of Hydrocodone being present, since recent studies suggest that urine specimens of patients taking Hydrocodone always show presence of Hydrocodone or Norhydrocodone in combination with Hydromorphone. FOR PATIENT RESULTS INDICATING JUST THE PRESENCE OF HYDROMORPHONE: THIS MAY BE DERIVED FROM MORPHINE-CONTAINING PRESCRIPTION DRUGS OR HYDROMORPHONE-ONLY PRESCRIPTIONS (FOR EXAMPLE, DILAUDID). Further reading: Valtier,S. and Bebarta,V.S. (2012) Excretion profile of hydrocodone, hydromorphone and norhydrocodone in urine following single dose administration of hydrocodone to healthy volunteers. J. Anal. Toxicol., 36, and Barakat,N.H., Atayee,R.S., Best,B.M. and Ma,J.D. (2014) Observations of Urinary Hydrocodone and Metabolite Distributions in Pain Patients. J. Anal. Toxicol., 38, ) Notes: Specimen collected by CleanAssure: Dried Blood Spot Mitra Microsampling. This procedure is to determine the presence and concentration of prescription/non-prescription drugs from dried blood spots collected using Mitra Microsampling devices by finger pricks. This method and associated validation is intended for patient compliance testing only (i.e. determination of the presence or absence and concentrations of prescribed and illicit drugs in dried blood spots) and is not validated for therapeutic drug monitoring (TDM) of drug plasma levels. Mitra Microsampling devices improve patient comfort and increase operational efficiencies. Originally Reported On: 11:14 AM Page 7 of 8 Accession: Patient ID:

15 Collection Date: 11:13 AM Gender: Female Received in Lab: 12:13 PM CT Reviewed By: Date: Originally Reported On: 11:14 AM Page 8 of 8 Accession: Patient ID: