Caring for ME Webinar: Urine Drug Screening Speaker: Dr. Jonathan Fellers Tuesday, November 20, PM

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1 Caring for ME Webinar: Urine Drug Screening Speaker: Dr. Jonathan Fellers Tuesday, November 20, PM Audio is available through your computer speakers.

2 Mission Maine Quality Counts is a nonprofit located in Manchester, Maine. We are working to improve the health of all Maine people (and beyond) by transforming the way healthcare is delivered.

3 Priorities QC Brings Together the People Who Give, Get and Pay for Healthcare to Address Shared Priorities: Improve the alignment of healthcare systems to transform health for all Maine people Provide quality improvement assistance to practices Engage consumers in healthcare Promote the integration of physical and behavioral health

4 Connect With Us Join our list mainequalitycounts.org Engage and be social

5 Important Webinar Notes You are in listen-only mode. Please use the Q&A function to ask questions or make comments. Video screen size and location is adjustable. Tomorrow you ll receive an with links to slides and recordings.

6 CME Disclosure: Today s speaker not have any relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. CME will be available for participants who have signed into the live webinar. If there are multiple people at one computer, please type their names and addresses into the chat box for our attendance records. We do not have separate nursing CEUs- but you can get a CME certificate. A CME evaluation survey will be will be sent after the webinar via the day following the webinar. Please complete the survey via Survey Monkey within 2 weeks. NEW CME PROCESS: You will be able to immediately download your CME certificate on the last page of the survey. Please contact Jackie Tiner jtiner@mainequalitycounts.org if you have any questions, or problems downloading the document.

7 Funding Funding for this webinar is provided by: Board of Licensure in Maine

8 Objectives Provide an overview of the purposes of drug testing Describe mechanics behind screening and confirmatory drug testing Understand common sources for falsepositives and false-negative test results 8

9 Today s Speaker Jonathan Carl Fellers, MD Dr. Jonathan Fellers is an addiction psychiatrist in Portland, Maine and is affiliated with Maine Medical Center and Spring Harbor Hospital. He received his Bachelor of Science from the Massachusetts Institute of Technology and his medical degree from Cornell University Medical College. He completed his psychiatry residency at the University of Virginia where he served as Chief Resident. He completed a fellowship in Addiction Psychiatry at the Oregon Health and Science University and a postdoctoral fellowship at the MIRECC Portland VA Health Care System. Dr. Fellers joined MMC s Department of Psychiatry in September 2015 to head up the new Integrated Medication Assisted Therapy Team (IMAT). His work has expanded to include assisting MBH with the implementation of a treatment model across the MaineHealth footprint

10 Urine Drug Screening Maine Quality Counts November 20, 2018 Jonathan C Fellers, MD, FAPA Assistant Professor of Psychiatry, TUSM Medical Director, IMAT Program, MMC/MMP

11 Disclosures Nothing to disclose 11

12 Outline Why test? Specimen integrity Screening tests Confirmatory tests 12

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18 Drug Testing Provides objective evidence of whether a drug was taken within a detection window - Prescribed medication adherence - Unreported substance use Serves a monitoring function that deters illicit drug use Enables clinical intervention for substance use disorders 18

19 Detection Window Drug Single Use Chronic Use Opiates 1 3 days 14 days (i.e. long-acting) Oxycodone 1 3 days Fentanyl < 1 day 3 days Alcohol < 12 hours 5 days (via EtG) Benzodiazepines 1 3 days 21 days (i.e. diazepam) Amphetamines < 3 days Cocaine < 4 days THC < 6 days 30 days Methadone 2 days 11 days

20 Specimen Integrity Addition of adulterants to interfere with test Diluting the specimen Substituting artificial urine Substituting one s own urine from a time when not using Substituting someone else s urine 20

21 Specimen Integrity Chain of custody - Chronological documentation showing the collection, transfer, receipt, analysis, storage, and disposal - Fully defensible and can disprove any allegations of tampering or misconduct Medical Review Officer (MRO) - Independent expert scrutiny of positive results - Prescribed medication exclusion 21

22 Specimen Integrity Tampering mitigation strategies - Removal of items from pockets - Remove unnecessary clothing or items - Secure water access (i.e. blue dye in toilet water) - Consider observation (i.e. listening, visual) 22

23 Specimen Integrity Quality assurance observation - Patient behavior (i.e. accident in bathroom) - Visual (i.e. color, clarity) - Odor (i.e. chemical or malodorous after storage) 23

24 Specimen Integrity Quality assurance testing - Temperature (i.e º F) - ph (i.e. 4 10) - Specific gravity (i.e ) - Creatinine (i.e ) - Nitrates (i.e. none) - Oxidants (i.e. none) 24

25 Specimen Integrity 25

26 Screening Tests Usually the initial assay performed Advantages: - Ability to be performed at point-of-care (POC) - Rapid results - Low cost Disadvantages: - Lower sensitivity/specificity - Binary (positive/negative) results 26

27 Screening Tests Sensitivity - Immunoassays require a threshold amount of the target - Physiologic levels below this level and can lead to false negatives Specificity - May bind to unintended targets with a similar structure - Sometimes this is a moot point - In other cases, the poor specificity of immunoassays leads to false positives 27

28 Screening Tests Morphine Opiate Antibody Drugs that contain morphine: Morphine Opium Drugs metabolized to morphine: Codeine Heroin 28

29 Screening Tests 6-Monoacetyl Morphine Drugs metabolized to 6-Monoacetyl Morphine: Heroin Opiate Antibody 29

30 Screening Tests Oxycodone Drugs that contain oxycodone: Oxycontin Percocet Opiate Antibody 30

31 Screening Tests Fentanyl Drugs that contain fentanyl: Duragesic Spiked heroin Opiate Antibody 31

32 Screening Tests Test True Positive False Positive Amphetamine Amphetamine Bupropion, Ephedrine, Phentermine, Phenylephrine, Phenylpropanolamine, Promethazine, Pseudoephedrine Benzodiazepines Alprazolam, Clonazepam, Sertraline Diazepam, Lorazepam, Oxazepam, Temazepam, Triazolam Cocaine Benzoylecgonine Amoxicillin Methadone Methadone Diphenhydramine, Verapamil Opiates Oxycodone Heroin, Morphine, Codeine, Hydrocodone, Hydromorphone Oxycodone, Oxymorphone Dextromethorphan, Quinine, Quinolones, Rifampin THC THC Efavirenz, NSAIDs, PPIs 32

33 Confirmatory Tests Necessary to confirm a screening result Advantages: - Practically 100% sensitivity/specificity - Obtain levels - Can identify some drugs and metabolic products that screening tests cannot measure Disadvantages: - Expensive - Takes time to obtain results 33

34 Confirmatory Tests Sensitivity - Can detect targets at a much lower threshold than screening tests - e.g. fentanyl, clonazepam, ethyl glucuronide Specificity - Discriminates between structurally similar drugs - e.g. buprenorphine/norbuprenorphine, opiates, benzodiazepines, amphetamines 34

35 Alcohol and EtG Ethyl glucuronide (EtG) - Fairly specific for alcohol exposure - Can detect up to 5 days after exposure Ethyl sulfate (EtS) - Very specific for alcohol exposure Combination improves sensitivity and specificity Consumption of 30-33oz of beer (4.2 %) can result in EtG concentrations of 22,000-67,000 ng/ml at 3 hours

36 Opioid Metabolism Heroin 6-Monoacetyl Morphine Morphine Opium Codeine 36

37 Opiate Confirmatory Tests Heroin Opium Morphine (MS Contin) Codeine (Tylenol #3) Hydrocodone (Vicodin) Hydromorphone (Dilaudid) Oxycodone (Percocet, Oxycontin) Oxymorphone (Opana) Poppy seeds 6-Monoacetyl Morphine Morphine Codeine Hydrocodone Hydromorphone Oxycodone Oxymorphone 37

38 Benzodiazepine Metabolism Diazepam Temazepam Chlorazepate Nordiazepam Oxazepam Chlordiazepoxide 38

39 Benzodiazepine Confirmatory Tests Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Flurazepam (Dalmane) Lorazepam (Ativan) Oxazepam (Serax) Temazepam (Restoril) Lorazepam Nordiazepam Oxazepam Temazepam Alpha-hydroxyalprazolam 7-aminoclonazepam Hydroxyethyl-flurazepam 39

40 Amphetamine Confirmatory Tests Amphetamine - Amphetamine illicit or prescribed (Adderall, dextroamphetamine) - As a metabolic product of another drug» Methamphetamine illicit or prescribed (Desoxyn, Vicks inhaler)» Benzphetamine, selegiline Methamphetamine - Methamphetamine illicit or prescribed (Desoxyn, Vicks inhaler) - As a metabolic product of another drug» Selegiline MDMA 40

41 Buprenorphine Confirmatory Tests Liver Buprenorphine Pattern of Behavior Consistent adherence Stopped, recently restarted Has not taken in a while Spiked sample with medication Not taking Norbuprenorphine Buprenorphine/Norbuprenorphine Norbuprenorphine > buprenorphine Buprenorphine > norbuprenorphine Norbuprenorphine only Buprenorphine only Neither present 41

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47 Contact Information Amy Belisle, MD, MBA, Senior Medical Director Kayla Cole, Project Manager Jackie Tiner, Administrative Coordinator QC Website: 47

48 Upcoming Webinars! 1. Tuesday, November 27, 2018: 12:00 PM - 1:00 PM EST Registration MICIS: Opioid Use Disorder and Medication Assisted Recovery: Caring for Our Communities: Elisabeth Fowlie Mock 2. Tuesday, December 11, 2018: 12:00 PM - 1:00 PM EST Registration MICIS: Co-Prescribing Benzodiazepines and Opioids: The Black Box of Increased Overdose Risk: Elisabeth Fowlie Mock 3. Thursday, December 20, :00 pm 1:00 PM MICIS; Alternative Treatments to Chronic Pain Registration Speaker: Elisabeth Fowlie Mock

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