Alcohol. Ethanol Highlands Parkway, Suite 100 Smyrna, GA 30082

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1 Alcohol The alcohol of interest is ethanol. Ethanol has a sedative effect in the brain. Ethanol intoxication symptoms include blurred vision, slurred speech, poor coordination and difficulty thinking depending on the levels. Ethanol is primarily metabolized into acetaldehyde by alcohol dehydrogenase. Upon the accumulation of acetaldehyde, aldehyde dehydrogenase metabolizes the acetaldehyde into acetic acid. Acetic acid is then transformed to acetyl-coa that is used in the Kreb s cycle (the energy producing cycle in the cell). To a much lesser extent, an enzyme known as UGT transforms ethanol to ethylglucuronide (EtG) and an enzyme known as SULT transforms ethanol to ethylsulfate (EtS). Ethanol consumption has been found to cause dependence and tolerance can be rapidly acquired. EIA screening is not available for the metabolites of ethanol at Castle Medical. chromatography to separate substances in the sample using a mixture of solvents and mass spectrometry fragmentation pattern for further identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that indicates the type and amount of the drug present in the sample. Ethanol detection is achieved mainly through the metabolites EtG and EtS. The presence of EtG and EtS is a good indication of exposure to ethanol. List of Alcohol of Interest Ethanol (ethylglucuronide and ethylsulfate). Urine Ethanol

2 Anticonvulsants The class of anticonvulsants refers to the group of substances that treat epileptic seizures. While anticonvulsants exist as a separate class, it is common to see overlap with drugs between this class and other classes as a result it contains substances that are structurally very different. It is common to see anticonvulsants used to treat neuropathic pain. The potency and acquired dependence on the drug varies from drug to drug in this class. : EIA screening is not available for the anticonvulsants of interest at Castle Medical. : identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Most anticonvulsants undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. Gabapentin is not metabolized and consequently only the parent drug is reported. Similarly, Pregabalin undergoes negligible metabolism and only the parent drug is reported. List of Anticonvulsants of Interest Gabapentin, Pregabalin. Gabapentin

3 Antidepressants The class of antidepressants refers to the group of substances that treat a range of psychological disorders including depression, OCD, sleeping disorder, manic-depressive disorder, etc. Antidepressants can be divided further into subclasses to include: tricyclic antidepressants (TCA s), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). Although the chemical structure may vary across subclasses, they all correct for an imbalance in neurotransmitters in the brain primarily by inhibiting the reuptake. TCA s such amitriptyline and MAOIs such as isoniazid were the earliest antidepressants to be used for treatment. The class then grew to include SSRIs such as sertraline and SNRIs such as venlafaxine that are commonly referred to as the second generation antidepressants. SNRIs are sometime classified as third generation antidepressants. Cyclobenzaprine, while structurally similar to tricyclic antidepressants, is a muscle relaxer. It is not prescribed for depression or other psychological disorders. The potency and acquired dependence on the drug varies from drug to drug in this class. : The screening is performed using an immunoassay-based technique. The technique uses class-specific antibodies and utilizes absorbance for detection. The antibodies have varying cross-reactivity with different antidepressants. The immunoassay method at Castle Medical targets TCA s. Other Over-the-Counter (OTC) medications and/or substances may also cross-react. : identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Antidepressants undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. sure to a substance. Amitriptyline List of Antidepressants of Interest Amitriptyline, nortriptyline, imipramine, desipramine, sertraline, cyclobenzaprine.

4 Barbiturates The class of barbiturates refers to the group of substances that are typically used as hypnotics and/or anticonvulsants by depressing the nervous system. Barbiturates can be very short-, short, intermediate, and long-acting. The onset of action mirrors the duration of action of barbiturates. Very short-acting barbiturates have a rapid onset and a very short duration of action. Long-acting barbiturates have a delayed onset of action and a long duration that could potentially last for days. The potency and acquired dependence on the drug varies from drug to drug in this class. The screening is performed using an immunoassay-based technique. The technique uses class-specific antibodies and utilizes absorbance for detection. The antibodies have varying cross-reactivity across all barbiturates. The immunoassay method at Castle Medical targets the barbiturate class collectively. Other Over-the-Counter (OTC) medications and/or substances may also cross-react. chromatography to separate substances in the sample using a mixture of solvents and mass spectrometry fragmentation pattern for further identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that indicates the type and amount of the drug present in the sample. Barbiturates undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. List of Barbiturates of Interest Butalbital, phenobarbital. Butalbital

5 Bath Salts Bath Salts refers to the group of substances that produce a stimulatory effect on the nervous system. The chemical structure is very similar to amphetamine with modification at certain points in the structure. They are a variation of the substance Cathinone, a major constituent of the shrub Catha edulis (khat) and as a result sometimes referred to as Designer Cathinones. They are primarily abused for their stimulatory effects however some also produce hallucinogenic effects. Bath Salts are not used to treat any ailment and as a result have no accepted medical use. They are typically sold as a powder marketed as not for human consumption and have no connection with salts used in bathtubs. The potency and acquired dependence on the drug varies from drug to drug in this class. CROSS-REACTIVITY NEEDS TO BE TESTED. PLEASE PROVIDE INPUT IF IT REACTS WITH AMPHETAMINE ON OLYMPUS. chromatography to separate substances in the sample using a mixture of solvents and mass spectrometry fragmentation pattern for further identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that indicates the type and amount of the drug present in the sample. Bath Salts undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. List of Bath Salts of Interest 3,4-methylenedioxypyrovalerone (MDPV), mephedrone, methylone, α-pyrrolidinopentiophenone (α-pvp). Urine, Blood Cathinone

6 Benzodiazepines The class of benzodiazepines refers to the group of substances that decrease the excitability of neurons in the brain. As a result, they are primarily used as anticonvulsants, anti-anxiety, muscle relaxants, and to treat insomnia. Benzodiazepines can be short-, intermediate-, and long-acting. Short-acting benzodiazepine, such as midazolam, are typically used to treat insomnia because of their sedative-hypnotic effect. Long-acting benzodiazepines, such as diazepam, are typically used to treat anxiety. The potency and acquired dependence on the drug varies from drug to drug in this class. : The screening is performed using an immunoassay-based technique. The technique uses class-specific antibodies and utilizes absorbance for detection. The antibodies have varying cross-reactivity with different benzodiazepines for the method used at Castle Medical. Other Over-the-Counter (OTC) medications and/or substances may also cross-react for example sertraline (Zoloft), an antidepressant. : identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Benzodiazepines undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. List of Benzodiazepines of Interest Alprazolam, clonazepam, diazepam, nordiazepam, oxazepam, temazepam, lorazepam, midazolam, triazolam, flunitrazepam, flurazepam, chlordiazepoxide. Diazepam

7 Cannabinoids The class of cannabinoids refers to the group of substances that bind to certain receptors in the brain that represses the release of neurotransmitters. Their mechanism of action results in some mood and perceptual alterations. Cannabinoids have been commonly prescribed to treat anorexia, decrease nausea and vomiting associated with chemotherapy, and to treat glaucoma. The most prevalent cannabinoid is 9-tetrahydrocannabinol (THC), a main constituent in cannabis. Synthetic variations of THC have been formulated in an attempt to circumvent the illegalization of THC and provide safer alternatives even though it is well understood that they are not safer alternatives. The formulations have been modified with chemical additives and plant material to provide psychoactive effects similar to marijuana. The formulations are commonly referred to as K2/Spice and typically marketed as incense that is not for human consumption. The potency and acquired dependence on the drug varies from drug to drug in this class. The screening is performed using an immunoassay-based technique. The technique uses class-specific antibodies and utilizes absorbance for detection. The antibodies have varying cross-reactivity across all cannabinoid derivatives. The immunoassay method at Castle Medical targets the cannabinoid structure with varying interactions with Over-the-Counter (OTC) medications and/or substances. identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Cannabinoids undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. THC List of Cannabinoids of Interest Cannabinoid panel: THC (and the metabolite 11-nor-9-Carboxy-THC (THCA)). K2/Spice panel: AM 1248, AM 2201 OH Pentyl metabolite, JWH-018 (and the metabolites JWH-018 OH Pentyl and JWH Pentanoic Acid), JWH-073 (and the JWH-073 Butonic Acid and JWH-073 OH Butyl), JWH-250 OH Pentyl metabolite, XLR-11, UR-144.

8 Dissociatives The class of dissociative hallucinogens refers to the group of substances that typically produce a feeling of detachment from the body and the surrounding primarily through sensory deprivation and often induces hallucinations. The dissociation can also produce an analgesic effect. Two common dissociatives include Ketamine and Phencyclidine (PCP). The potency and acquired dependence on the drug varies from drug to drug in this class. EIA screening is not available for PCP at Castle Medical. identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Most dissociatives undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. List of Dissociatives of Interest PCP. Phencyclidine

9 Nicotine Nicotine is a constituent of tobacco plants and consequently cigarettes along with Anabasine. It produces a sensation of relaxation and euphoria upon exposure. It is considered highly habit-forming and rapidly causes addiction. Nicotine treatments such as nicotine patches have been developed to help quit cigarette smoking. EIA screening is not available for nicotine and its metabolites at Castle Medical. chromatography to separate substances in the sample using a mixture of solvents and mass spectrometry fragmentation pattern for further identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that indicates the type and amount of the drug present in the sample. Nicotine undergoes metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body to form Continine along with other metabolites. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. There are no known metabolites for Anabasine. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. List of Nicotine of Interest Nicotine, Cotinine, Anabasine. Urine Nicotine

10 Opiates Opioids The class of opiates and opioids refers to the group of substances that produce analgesic effects in the body. Opiates refer to the group of chemicals present naturally in the poppy plant such as morphine and codeine. Opioids refer to the group of chemicals either synthetic or semi-synthetic such as oxycodone and hydrocodone that behave similar to opiates in the body producing similar effects. This class of drugs is typically used for pain treatment. Carisoprodol however has been used primarily as a muscle relaxant. The potency and acquired dependence on the drug varies from drug to drug in this class. : The screening is performed using an immunoassay-based technique. The technique uses class-specific antibodies and utilizes absorbance for detection. The antibodies have varying cross-reactivity with different opiates/opioids. The immunoassay method at Castle Medical targets all opiates. The method also screens selectively for oxycodone with some cross-reactivity towards other opiates. Other Over-the-Counter (OTC) medications and/or substances may also cross-react. : identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Opiates/Opioids undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. Heroin presence is evaluated by detecting the metabolites 6-monoacetylmorphine (6-MAM) and morphine and not the parent drug heroin. Morphine List of Opiates/Opioids of Interest Morphine, codeine, hydrocodone, hydromorphone, dihydrocodeine, naloxone, buprenorphine, norbuprenorphine, oxycodone, oxymorphone, 6-MAM, tramadol, O-desmethyltramadol, tapentadol, Destapentadol, fentanyl, norfentanyl, carisoprodol, meprobamate, methadone, EDDP, meperidine, normeperidine, propoxyphene, norpropoxyphene, dextrorphan, dextromethorphan.

11 Stimulants The class of stimulants refers to the group of substances that produce a stimulatory effect on the nervous system. A common example of a stimulant is amphetamine. Stimulants are typically used to treat disorders such as ADD, ADHD, obesity, and narcolepsy. Many stimulants such as amphetamine and methamphetamine have chiral carbons dividing them into d- and l- stereoisomers of the same drug. The d- isomer is typically more active and is sometime used to refer to illicit use of methamphetamine based on the d/l isomer ratio. Some stimulants may have additional hallucinogenic effects such as MDMA, MDEA, and MDA. The potency and acquired dependence on the drug varies from drug to drug in this class. : The screening is performed using an immunoassay-based technique. The technique uses class-specific antibodies and utilizes absorbance for detection. The antibodies have varying cross-reactivity with different stimulants particularly phenethylamine derivatives. The immunoassay method at Castle Medical targets amphetamine with some cross-reactivity towards phenethylamine derivatives. Other Over-the-Counter (OTC) medications and/or substances may also cross-react. : identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that Stimulants undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. However, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. Amphetamine List of Stimulants of Interest Comprehensive panel Amphetamine, methamphetamine, MDMA (3,4-methylenedioxymethamphetamine), MDA (3,4-methylenedioxyamphetamine), cocaine (and the metabolites benzoylecgonine and cocaethylene), methylphenidate (and the metabolite ritalinic acid). Expanded amphetamine panel: MDEA (3,4-methylenedioxyethylamphetamine), phendimetrazine, ephedrine, phentermine, PPA phenylpropanolamine.

12 Z-Drugs Z-drugs refer to a group of three drugs (zolpidem, zaleplon, and zopiclone/ezopiclone) that are typically used to treat insomnia. They are categorized as nonbenzodiazepine hypnotics. Though their activity in the brain is similar to that of benzodiazepines by targeting benzodiazpine receptors, they are structurally very different from benzodiazepines. The potency and acquired dependence on the drug varies from drug to drug. The decision to prescribe the Z-drugs over benzodiazepines for insomnia is based on the decreased probability of dependence, however long-term use of the Z-drugs can still result in dependence and/or addiction. Tolerance to them is thought to be rapidly acquired. EIA Screening is not available for the Z-drugs of interest at Castle Medical. chromatography to separate substances in the sample using a mixture of solvents and mass spectrometry fragmentation pattern for further identification. The result is obtained from both the chromatography and mass spectrometry to produce a unique identification pattern that indicates the type and amount of the drug present in the sample. Z-drugs undergo metabolism by the family of Cytochrome P450 (CYP) enzymes in the human body. It is common to detect metabolites and to a lesser extent parent drugs in urine specimen. In fact, Z-drugs undergo extensive metabolism to their metabolites. In contrast, it is likely to detect parent drugs and to a lesser extent metabolites in saliva and blood specimens. The presence of parent drugs and/or metabolites in all matrices is a good indication of exposure to a substance. List of Z-Drugs of Interest Zaleplon, zolpidem (and the phenolic metabolite zolpidem-cooh), zopiclone/ezopiclone. Zolpidem