A brief history of urine drug testing. Forging a common vocabulary for urine drug testing

Transcription

1 A brief history of urine drug testing Forging a common vocabulary for urine drug testing Gary M. Reisfield, M.D. Assistant Professor and Director Division of Pain and Palliative Medicine Department of Community Health & Family Medicine University of Florida College of Medicine Jacksonville

2 Objectives Describe the history of urine drug testing in methadone maintenance, the military, the regulated and non regulated workplace, and chronic opioid therapy Discuss vocabulary issues pertaining to the opiate/opioid distinction and certain positive and negative test results

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7 1986: EO Federal Drug Free Workplace Drug policy Employee education Supervisor training Employee Assistance Program Urine drug testing

8 1987: Public Law , section 503 Mandatory Guidelines for Workplace Drug Testing Programs Collection procedures Chain of custody Drugs and techniques Laboratory requirements and certification Medical Review Officer

9 The DOT Procedures

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11 Trends in non medical opioid use Source: National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2004

12 Forging a common vocabulary Confirmed results False positive False negative Screened results Opiates None detected

13 Opi what? Opioids Synthetics Semi synthetics Opioids Synthetics Opiates Codeine Morphine Opiates Codeine Morphine Semi synthetics Stoelting RK. Opioid Agonists and Antagonists. In: Pharmacology and Physiology in Anesthetic Practice. Philadelphia: JB Lippincott, 1987:69 Gutstein HB, Akil H. Opioid Analgesics. In: Goodman and Gilman s The PharmacologicBasis of Therapeutics, 11 th ed. New York: McGraw Hill, 2006: 547

14 Positivity Discussing certain positive confirmatory tests

15 What should we call these positive GC/MS results? A confirmed positive morphine result due to poppy seed consumption? False positive (True) positive (True) positive with valid medical explanation Other?

16 What should we call these positive GC/MS results? A confirmed positive for hydrocodone and a small quantity of hydromorphone in a patient who claims adherence with a regimen of only Lortab (hydrocodone/acetaminophen), 10/500, 2 tabs qid? False positive (True) positive (True) positive with valid medical explanation Other?

17 What should we call these positive GC/MS results? A confirmed positive THC A result due to prescription Marinol (dronabinol) administration. False positive (True) positive (True) positive with valid medical explanation Other?

18 Negativity Discussing certain negative tests

19 Negative opiates screen A patient is adherent with Rx oxycodone, 160 mg/d. A urine specimen is subjected to a Roche KIMS opiate IA. The report states, none detected. Product literature indicates 0.6% cross reactivity with oxycodone, i.e. [oxycodone] 46,575 ng/ml = [morphine] 300 ng/ml False negative screen (True) negative screen Negative screen, appropriate

20 Negative methadone GC/MS A patient on methadone maintenance therapy, 30 mg daily (witnessed administration), intermittently screens and confirms negative (at LOD) for methadone. The patient is taking phenobarbital (CYP3A4 inducer) for a seizure disorder. False negative (True) negative Negative, appropriate

21 Discussing screened results Example: Screened positive for opiates (appropriate) and benzodiazepines (inappropriate)

22 Discussing confirmed results Examples: Confirmed positive for hydrocodone (appropriate) Confirmed positive for morphine (appropriate) and oxycodone (inappropriate) Confirmed negative for morphine (inappropriate)

23 End Miscellaneous slides follow

24 Positive results: regulated testing

25 Negative screens: regulated testing

26 Reynolds LA. Historical aspects of drugs of abuse testing in the United States. In: Wong RC, Tse HY, eds. Forensic Science and Medicine: Drugs of Abuse: Body Fluid Testing. Totowa, NJ: Humana Press, 2006