Urine Drug Screening (UDS) Dr. Erica L. Weinberg December 2017

Transcription

1 Urine Drug Screening (UDS) Dr. Erica L. Weinberg December 2017

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Conflict of Interest Disclosure Presenter/Faculty: Dr. Erica L. Weinberg Relationships with Commercial Interests: Grants/research support: Speaker bureau/honoraria: Consulting fees: Other: none Sea Courses none none

4 Potential for Conflict of Interest I have been Medical Inspector (MI)/Independent Opinion (IO) Provider at the College of Physicians and Surgeons of Ontario (CPSO, College ) frequently regarding opioid prescribing practices I have been a member of the National Faculty at the Michael G. Degroote National Pain Centre since 2012 I am one of the many authors on the Canadian Pain Society s revised consensus statement on the pharmacological management of chronic neuropathic pain

5 Mitigating Potential Bias Information presented or recommendations made are evidence/guideline/consensus-based I have completed the CPFC Mainpro+/Cert+ Declaration of Conflict of Interest form evidencing compliance with Mainpro+/Cert+ requirements, a requisite for this program to be given accredited status I will be discussing off-label uses of medications

6 The Guideline - Risk Mitigation Expert Guidance Statement 6: Urine Drug Screening A baseline UDS may be useful for patients currently receiving or being considered for a trial of opioids. Clinicians may repeat UDS on an annual basis and more frequently if the patient is at elevated risk or in the presence of any ADRBs. When ordering a UDS, clinicians should ask patients about all medications/drugs recently taken, and be aware of local resources to assist them in assessing for potential false positive and false negative results. Available at

7 How Often Do You Think a UDS Should be Done?

8 How Often Do You Think a UDS Should be Done?

9 Should You Do Random UDS?

10 Should You Do Random UDS?

11 What about collecting UDS at every visit, but not necessarily testing every time?

12 UDS Why Bother To improve patient care and communication To help verify self-report of medication history To encourage or reinforce healthy behavioural change, sometimes as a requirement of continued treatment Everyone has a role to play in safe medication use

13 Learning Objectives After this session, participants will be able to: Develop a plan for urine drug screening (UDS)/urine drug testing (UDT) in the office/clinic Interpret UDS results with more confidence Manage unexpected UDS results more effectively

14 Things to Know Before you Start You are not a police officer UDS is an imperfect tool, yet it can assist you in managing your patients The UDS test available to us is not performed up to forensic standards You must document your interpretation of the results and your subsequent plan for action You must have standard operating procedures for UDS

15 Have Standard Operating Procedures Inform the patient of the routine nature of the test Is it part of your Opioid Treatment Agreement? Take a careful history of medication/drug use for the past week Consider asking, What should I expect to see in the results? Collect the urine sample in the your office/clinic, if possible Be consistent on what a patient can/cannot take into the washroom with them E.g. Bulky clothing, bags

16 Have Standard Operating Procedures Ensure proper labelling What is the urine temperature ensure it is checked within a few minutes Does the urine sample feel body temperature Have a protocol in place if it feels cold

17 Have Standard Operating Procedures If you are doing Point of Care (POC) Testing: Ensure you have read the instructions thoroughly Consider occasionally verifying your POC UDS results with a laboratory immune assay (IA) UDS If you are Delegating the Act of POC Testing: Be aware of your College s equivalent of a Delegation of Controlled Acts Policy and ensure that your staff are adequately trained E.g. evaluation of the delegate, quality assurance, supervision of the delegation, ongoing monitoring and evaluation

18 Know the Limits of the Test You Are Ordering/Performing

19 Types of UDS Point of Care (POC) Enzyme Immunoassay (EIA) Immunoassay (IA) Laboratory Gas Chromatography/Mass Spectrometry (GC/MS)

20 POC UDS Advantages Portable Immediate results Urine collected & tested at clinician s office/clinic Concurrently tests for multiple drug classes Very responsive for morphine and codeine Disadvantages Cost of POC test kit/dipstick Less sensitive and specific than laboratory test Will NOT identify specific drugs or metabolites, except for some exception Subjective nature of the qualitative assay Drug concentration in urine and assay s concentration cut-offs will affect detection More definitive testing may be required to identify a specific drug or metabolite

21 Laboratory IA UDS Advantages Rapid turnaround time Less expensive than GC/MS Detects drugs for a longer time than GC/MS e.g. (5-7days vs. 1-2 days) Concurrently tests for multiple drug classes Very responsive for morphine and codeine Disadvantages Does not, usually, differentiate between various opioids Often misses synthetic and semisynthetic opioids Cross reactivity: will show false positives with poppy seeds, quinolone antibiotics Drug concentration in urine and assay s concentration cut-offs will affect detection More definitive testing may be required to identify a specific drug or metabolite

22 Some Limitations to UDS by IA/EIA Cocaine is highly specific as the antibody reacts only to cocaine and its principle metabolite Amphetamine/methamphetamine are highly cross reactive and detects other sympathomimetic amines e.g. ephedrine and pseudoephedrine Opiate testing does not distinguish between morphine, heroin and codeine Opiate testing does not always detect semi-synthetics e.g. hydromorphone Oxycodone, methadone and buprenorphine need their own specific antibody Patients who are on fentanyl ONLY and show positive for opiates using standard IA/EIA test are using other opioids which react with the standard IA/EIA testing

23 Opioids in Canada Natural (extracted from opium) Semi-synthetic (derived from opium extracts) Synthetic (man made) Buprenorphine Fentanyl Codeine Hydrocodone Loperamide Morphine Hydromorphone Meperidine Oxycodone Diamorphine (Heroin) Methadone Tapentadol Tramadol Speak to your laboratory if you are not sure what opioids their IA UDS is directed towards

24 Laboratory GC/MS* UDS Advantages More accurate for semisynthetic and synthetic opioids Identifies specific drugs Differentiates: codeine, fentanyl, heroin, hydrocodone, hydromorphone, morphine, oxycodone Doesn t react to poppy seeds May also detect non-opioid medications Disadvantages More expensive Takes longer to get results Requires caution in interpretation * e.g. codeine metabolized to morphine

25 Some Limitations to UDS QUALITATIVE only CANNOT determine the amount and frequency of use, time of last use, route of administration or the source of the drug Adherence Presence of a prescribed drug CANNOT distinguish whether the patient has been taking the drug AS DIRECTED Window of test detection varies for different drugs Cut-off concentration Important when interpreting a report of no drug present

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27 UDS Benzodiazepines (BNZ) Not all BNZ are equally detected Both IA and GC/MS have significant challenges in detection and clinical interpretation In general, EIA/IA for BNZ: Is based on the diazepam antibody Shows reliably positive test for diazepam and alprazolam Does not usually detect clonazepam or lorazepam

28 Possible Results of a UDS What you expect IS present What you expect ISN T present What you DIDN T expect IS present

29 What To Do if You Find an Unexpected UDS Result

30 General Approach to an Inconsistent UDS Take a careful Hx of medication/drug use in the past week and discuss openly with the patient WITHOUT being accusatory Remember there is the potential for false positive and false negative results Be aware of resources to assist you in assessing for potential false positive and false negative results Give the patient an opportunity to address the report Check with the lab re potential error What kind of urine test was done?

31 General Approach to an Inconsistent UDS Interpret results in the context of the patient s clinical presentation and assessments Possibly ask the lab to re-run the sample with GC/MS if response still unclear Unexpected result does NOT necessarily diagnose: Abuse or addiction Physical dependence Diversion

32 Interpreting Unexpected UDS Results

33 Interpreting Unexpected UDS Results

34 Some Patients May tamper with urine samples to hide aberrant behaviours by: Adding adulterants Diluting the sample Substituting another individuals sample for their own Ingesting excessive water or diuretics prior to giving a sample ValidationTests Performed to improve the reliability of urine sample results The laboratory may point out if a validation test seems off i.e. read the report

35 Validation Tests Normal Characteristics of a Urine Specimen Temperature o C ph Urine Creatinine >20 mg/dl Specific Gravity >1.003

36 Interpreting Unexpected UDS Results

37 Known Agents to Cause Interference in UDS Results

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40 Case 1 * : Spinal Stenosis 73 y.o. female 2 failed back surgeries in past (1999, 2006) Intolerant to NSAIDs/COXIB No personal and no family history of drug/alcohol use issues No personal history of mental health issues * Case 1 courtesy of Dr. Joel Bordman

41 Case 1 * : Spinal Stenosis Taking acetaminophen 650 mg qid on a regular basis Previously (>1 year) reported constipation with acetaminophen 300 mg/codeine 30 mg/caffeine 15 mg Still reporting significantly decreased QoL over last 6 months, despite maximizing physical and psychological modalities You are considering a trial of oxycodone IR 5 mg prn * Case 1 courtesy of Dr. Joel Bordman

42 Case 1 * : Spinal Stenosis Taking acetaminophen 650 mg qid on a regular basis Previously (>1 year) reported constipation with aceta/codeine 30 mg/caffeine Still reporting Would significantly you consider decreased a QoL UDS over as part last 6 of months, your despite maximizing physical and psychological modalities work up for a trial of opioid therapy? You are considering a trial of oxycodone IR 5 mg prn * Case 1 courtesy of Dr. Joel Bordman

43 Case 1 * : Spinal Stenosis Taking acetaminophen 650 mg qid on a regular basis Previously (>1 year) reported constipation with aceta/codeine 30 mg/caffeine Still reporting significantly decreased QoL over last 6 months, despite maximizing physical UDS and psychological (IA) = + opiates, modalities BNZ You are considering a trial of oxycodone IR 5 mg prn * Case 1 courtesy of Dr. Joel Bordman

44 Case 1 * : Spinal Stenosis Taking acetaminophen 650 mg qid on a regular basis Previously (>1 year) reported constipation with aceta/codeine 30 mg/caffeine Still reporting significantly decreased QoL over last 6 months, despite maximizing physical UDS and psychological (IA) = + opiates, modalities BNZ You are considering a trial of oxycodone IR 5 mg prn Now what do you do? * Case 1 courtesy of Dr. Joel Bordman

45 Case 1 * : Spinal Stenosis Take a careful history of medication/drug use in the past week and discuss openly with the patient Try not to be accusatory The patient explains that she occasionally takes her sister s diazepam 5 mg pills She also has been using left-over aceta /codeine/caffeine tabs on a fairly regular basis * Case 1 courtesy of Dr. Joel Bordman

46 Post-Operative Opioid Prescriptions Prescription opioids often go unused after surgery, with few patients planning to dispose of the unused pills Researchers analyzed data from six studies that examined the oversupply of prescription opioids after seven types of surgical procedures (e.g., obstetric, thoracic, urologic). Overall, roughly 800 adults received an opioid prescription after surgery. Among the findings: Some 67% to 92% of patients across the studies reported unused opioids. Up to 21% did not fill their opioid prescription, and up to 14% filled the prescription but did not take any of the pills most often because of adequate pain control. Three-quarters of patients stored their opioids in unlocked areas. Just 4 30% of patients intended to dispose of their unused pills. The researchers caution, "The combination of unused opioids, poor storage practices, and lack of disposal sets the stage for the diversion of opioids for nonmedical use." Bicket et al, JAMA Surg. Published online August 2, doi: /jamasurg

47 Sale of Non-Prescription Codeine Products Number of countries have already banned the sale of codeine products without a prescription Belgium, Czech Republic, Finland, France, Greece, Iceland, India, Italy, Norway, Russia and Sweden Manitoba = Feb 1, 2016 Australia announced a ban on OTC sale of products beginning February 2018 Health Canada announced a move to ban non-prescription (low dose) codeine products Canadians had until November 8 to comment on Health Canada s proposed regulations OTC = over the counter;

48 Case 1 * : Spinal Stenosis A confirmatory UDS by GC/MS is positive for: Oxazepam Temazepam Diazepam Nordiazepam Codeine Morphine Can you explain this? * Case 1 courtesy of Dr. Joel Bordman

49 Codeine metabolizes to morphine

50 Diazepam metabolizes to nordiazepam, temazepam and oxazepam

51 Case 1 * : Spinal Stenosis A confirmatory UDS by GC/MS is positive for: Oxazepam Temazepam Diazepam Nordiazepam Codeine Morphine What would your approach be now? * Case 1 courtesy of Dr. Joel Bordman

52 Well, yeah, laughter IS the best medicine But Xanax is a very close second.

53 Case 1 * : Spinal Stenosis Explore the reasons for BNZ use Consider non-bnz treatments for symptoms Repeat UDS (3-4 wks) to ensure BNZ negative Educate re acceptable acetaminophen intake WHY? * Case 1 courtesy of Dr. Joel Bordman

54 Drug Methadone Opiates Cocaine/metabolites Benzodiazepines THC single use THC habitual use Methamphetamine Alcohol Urine Detection Time Frame 4-5 days 2-3 days 2-4 days 1-42 days 2-3 days Up to 12 weeks 3-5 days 6-24 hours

55 Case 2: Back Pain 40 y.o. male; previous lt knee injury; smokes cigarettes and MJ 2 month Hx of severe back pain CT: L4-5 herniation with encroachment MRI: as above with mass effect Tried acetaminophen, NSAIDs, PT, chiro with minimal effect

56 Case 2: Back Pain You are now considering a trial of aceta/codeine 30 mg/caffeine You elect to order a UDS Your office UDS protocol is that your administrative assistant collects and labels the urine sample and arranges for it to be sent to the lab Which type of UDS do you order? Do you prescribe the aceta/codeine/caffeine on this visit?

57 Case 2: Back Pain Two (2) UDS (both GG/MS) arrive from the lab 1 week later You find no additional information from your administrative assistant and she cannot remember any particulars o o 1 st UDS positive for: BNZ, opiates, oxycodone, GBP and cotinine 2 nd UDS positive for: THC, cotinine What might this mean?

58 Interpreting Unexpected UDS Results

59 Result

60 Case 3: Crush Injury to Hand 35 y.o. man Crush injury to right hand 2008 (surgery followed by infection ) On high dose oxycodone for years 1 st UDS = October 2015 UDS (IA) = opiates

61 Case 3: Crush Injury to Hand 35 y.o. man Crush injury to right hand 2008 (surgery followed by infection ) On high dose oxycodone for years 1 st UDS = October 2015 UDS (IA) = opiates UDS laboratory report clearly states that oxycodone is not determined by their assay

62 Case 3: Crush Injury to Hand 2011 note from ER: suspected narcotic abuse 2013 call from pharmacist re polypharmacy; away for work 2014 polypharmacy; left pills in another city 2015 BPI 100% pain relief MD did not in, even with above Only after got a from reliable source

63 Case 4: The Wandering Oxycodone 67 y.o. woman, long standing patient DM II, chronic pain, stress/anxiety On CR oxycodone for decades June visit UDS (GC/MS) ordered Rx: CR OC 40 mg iii 5x/d + alprazolam bid 5 days later UDS report: alprazolam, lorazepam, lidocaine, diphenhydramine Checked with pharmacy; pt 4 days late filling prescription

64 Checked with pharmacy; pt 4 days late filling prescription

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67 Case 4: The Wandering Oxycodone 67 y.o. woman DM II, chronic pain, stress/anxiety; long standing pt On CR oxycodone for decades June visit UDS (GC/MS) ordered Rx: CR OC 40 mg iii 5x/d + alprazolam bid 5 days later UDS report: alprazolam, lorazepam, lidocaine, diphenhydramine July visit UDS (GC/MS) ordered Rx: as above 6 days later UDS report: morphine, alprazolam, lorazepam, gabapentin, diphenhydramine

68 Case 5: the Report? 25 y.o. woman; currently on hydromorphone (CR + IR) plus gabapentin March UDS (IA) = opiates

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72 Case 5: the Report? 25 y.o. woman; currently on hydromorphone (CR + IR) plus gabapentin March UDS (IA) = opiates creatinine concentration and specific gravity are not consistent with expected ranges for a normal urine May UDS (GC/MS) = + morphine, codeine, hydromorphone, norhydrocodone, diphenhydramine, pseudo/ephedrine, cotinine, lorazepam

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74 Pearls - UDS 2017 Guideline found only low/very low quality of evidence regarding strategies to reduce the adverse impact of opioid prescribing Expert Guidance Statement 6: UDS may be useful Have a Standard Operating Procedure for UDS in your office/clinic Different UDS (POC, laboratory IA, laboratory GC/MS) have different advantages, disadvantages and limitations

75 Pearls - UDS Always compare the UDS result to the actual patient chart/drugs prescribed - Are the prescribed drugs/metabolites present? - Are any prescribed drugs absent? - Are there any unexpected drugs present? - Read any comments listed by the laboratory Don t rely on your memory If you encounter an inconsistent/unexpected UDS, your first action should be: To take a careful history of medication/drug use in the past week and discuss openly with the patient without being accusatory Each type of inconsistent UDS result has a differential diagnosis and actions for the clinician to take documentation is key

76 Resources on UDS Ron Joe, College of BC: Urine Drug Testing Rxfiles UDS-QandA.pdf

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