Urine drug testing it s not always crystal clear

Transcription

1 Urine drug testing it s not always crystal clear Kirk Moberg, MD, PhD, FASAM Executive Medical Director, UnityPoint Health Illinois Institute for Addiction Recovery Clinical Professor of Internal Medicine and Psychiatry University of Illinois College of Medicine 15 th Annual Midwest Conference on Problem Gambling and Substance Abuse Kansas City, MO June 21, 2018

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3 Unfortunately Drug tests are often misterpreted

4 Drug Tests do not detect Impairment Diversion Physiologic Dependence Addiction

5 Guidelines and Tips

6 Pearl #1 Drug Tests detect Recent Use

7 Pearl #2 You only get what you test for

8 Goals of testing Compounds that should be there Compounds that should not be there

9 Pearl #3 Timing is everything

10 Pearl #4 Know your source

11 Blood Pros Timing Cons Invasive Requires phlebotomist Hurford et al. Appropriate Use of Drug Testing in Clinical Addiction Medicine. American Society of Addiction Medicine

12 Oral fluids Pros Collection easy Difficult to adulterate Detects recent use Cons Oral contamination Saliva production rate variable Narrow window Hurford, et al

13 Sweat Pros Non-invasive Tamper resistant Longer term monitoring Cons Removal risk Contamination Variable sweat production Hurford, et al

14 Hair Pros Long time window Ease of collection Cons Environmental contamination Recent use? Hurford, et al

15 Urine Pros Easy to collect Concentration Cons Adulteration Shy bladder Hurford, et al

16 Pearl #5 Don t jump the gun

17 Urine drug screen

18 Immunoassay screens Label Analyte Antibody

19 Point of care testing Competitive type: positive test will show one line Conjugate: colored particles labelled with target analyte Test line: antibodies to target analyte; unlabelled analyte will bind to test line no color Control line: antibody to compound in matrix Urine flow

20 Confirmation

21 GC/MS or LC/MS

22 Output is quantitative Timing Dose Use Pattern Metabolism Hydration status

23 Pearl #6 Cut-offs Opiates 2000 Morphine 2000 Codeine acetylmorphine 10 6-AM 10 Amphetamines 500 Methamphetamine 250 (with amphetamine 100) Amphetamine, MDMA, MDA, MDEA 250 Phencyclidine 25 PCP 25 Benzoylecognine 150 BE 100 THC 50 THC 15

24 Cut-offs

25 Department of Transportation Opioids Morphine Codeine 6-monoacetyl-morphine Hydrocodone Hydromorphone Oxycodone Oxymorphone Cocaine Marijuana Phencyclidine Amphetamines Amphetamine Methamphetamine MDA MDMA MDEA

26 Heroin Codeine Morphine

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28 Thevis et al. Urinary Concentrations of Morphine and Codeine after Consumption of Poppy Seeds. J Anal Toxicol. 2003;27:53-56.

29 Morphine and Codeine

30 Stimulants

31 Cocaine

32 Other caines I just went to the dentist!

33 Amphetamines

34 3,4 methylenedioxyamphetamine (MDA) amphetamine 3,4 methylenedioxymethamphetamine (MDMA) methamphetamine 3,4 methylenedioxyethylamphetamine (MDEA) -phenylethylamines 3,4 methylenedioxyphenyl-2-butanamine (MBDB)

35 Amphetamine Testing Metabolism methamphetamine amphetamine

36 Amphetamine Testing Chirality

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39 Methylenedioxymethamphetamine MDMA

40 Synthetic cathinones

41 Cannabis 11 hydroxy THC 9 carboxy-11-nor THC

42 Issues Dronabinol Creatinine Correction Passive inhalation Hemp oil Legal status Synthetic cannabinoids

43 Dronabinol (Marinol )

44 Creatinine Correction 9 carboxy THC level at entry 193 ng/ml 9 carboxy THC level one week later 234 ng/ml

45 Creatinine Correction Urine Creatinine at entry 193 mg/dl Urine Creatinine one week later 288 mg/dl

46 The correction Cannabis at entry x normalized Cr/Cr at entry = normalized cannabis 193 x 100/193 = 100 Cannabis one week later x normalized Cr/Cr one wk later = normalized cannabis 234 x 100/288 = 81

47 Legal status

48 Passive inhalation 6 smokers 6 non-smokers Smoking session duration = 1 hour Cone et al. Non-smoker Exposure to Secondhand Cannabis Smoke. I. Urine Screening and Confirmation Results. J Anal Toxicol. 2015;39(1):1-12.

49 Cone et al Session 1 5.3% THC without ventilation Session % THC without ventilation Session % THC with ventilation

50 Hemp oil and hemp seed Leizer et al. The Composition of Hemp Seed Oil and its Potential as an Important Source of Nutrition. J Nutraceuticals, Function and Medical Foods. 2000;2(4):35-52.

51 Sedatives Issues in Testing Long half-lives and active metabolites

52 Benzodiazepine Metabolism Nordiazepam = hours

53 Alcohol testing

54 Biomarkers

55 Ethyl glucuronide (EtG) Ethyl sulfate (EtS)

56 Ethyl alcohol metabolism

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58 Cut-offs EtG 500 ng/ml EtS 100 ng/ml

59 What about hand sanitizers?

60 EtG Helander et al. Postcollection Synthesis of Ethyl Glucuronide by Bacteria in Urine may Cause False Identification of Alcohol Consumption. Clin Chem. 2007;53:

61 EtG EtG Helander et al. Postcollection Synthesis of Ethyl Glucuronide by Bacteria in Urine may Cause False Identification of Alcohol Consumption. Clin Chem. 2007;53:

62 Case: Henry He is a 39 year old man with history of chronic pain to the right hip s/p MVA in He has had a THR that became infected and required 2 revisions. He reports pain management with OxyContin 40mg BID down from 80 and occasional diazepam. On addiction interview, he says I was in the service. I have never used drugs!

63 Case: Henry, UDT

64 Case: Henry, UDT He states, Your lab screwed up. It s not my urine. I ll do another test right now.

65 Case: Henry, UDT

66 Metabolism of Opioids Codeine Morphine 6-MAM* Heroin t ½ =25-30 min t ½ =3-5 min Hydrocodone Hydromorphone Oxycodone Oxymorphone *6-MAM=6-monoacetylmorphine

67 OK, doc. I did use cocaine twice. Once on Jan 1 and once on Feb 1. No other times.

68 What is going on? What do you recommend?

69 Opiate Screen A. Fentanyl B. Morphine C. Naltrexone D. Codeine E. Methadone F. Buprenorphine G. Hydrocodone H. Meperidine I. Oxycodone J. 6-monoacetyl-morphine K. Propoxyphene L. Tramadol

70 Opiate Screen A. Fentanyl B. Morphine C. Naltrexone D. Codeine E. Methadone F. Buprenorphine G. Hydrocodone H. Meperidine I. Oxycodone J. 6-monoacetyl-morphine K. Propoxyphene L. Tramadol Milone. Laboratory Testing for Prescription Opioids. J Med Toxicol. 2012;8:

71 Drug Test Results 6-monoacetyl-morphine and morphine present

72 Drug Test Results 6-monoacetyl-morphine and morphine present Heroin

73 Drug Test Results Morphine and Quinine present

74 Drug Test Results Morphine and Quinine present

75 Drug Test Results

76 Drug Test Results Oxycodone and Hydrocodone

77 Drug Test Results Oxycodone and Hydrocodone

78 Drug Test Results Hydrocodone and Hydromorphone

79 Drug Test Results Hydrocodone and Hydromorphone Hydrocodone Hydromorphone

80 Drug Test Results Hydrocodone and Hydromorphone Hydrocodone Hydromorphone Oxycodone Oxymorphone

81 Drug Test Results Buprenorphine Present

82 Drug Test Results Buprenorphine Present Norbuprenorphine Absent

83 Drug Test Results Buprenorphine Present Norbuprenorphine Absent

84 Drug Test Results Benzoylecgonine Present Explanation Received in Emergency Department

85 Drug Test Results Benzoylecgonine Present Explanation Received in Emergency Department The American Academy of Otolaryngology-Head and Neck Surgery considers cocaine to be a valuable anesthetic and vasoconstricting agent when used as part of the treatment of a patient by a physician. No other single drug combines the anesthetic and vasoconstricting properties of cocaine. Position Statement Medical Use of Cocaine

86 Drug Screen Results Methamphetamine Present in a Patient Treated for Depression

87 Drug Screen Results Methamphetamine Present in a Patient Treated for Depression

88 Drug Screen Results Methamphetamine Present in a Patient Treated for Parkinson s Disease

89 Drug Screen Results Methamphetamine Present in a Patient Treated for Parkinson s Disease

90 True or False Synthetic cannabinoids will test positive for cannabis on the screen but not the confirmation

91 True or False Synthetic cannabinoids will test positive for cannabis on the screen but not the confirmation

92 True or False It is impossible to test for synthetic cannabinoids at this time

93 True or False It is impossible to test for synthetic cannabinoids at this time

94 What assists in the drug test interpretation of urine in which cannabis and ethyl glucoronide are present?

95 What assists in the drug test interpretation of urine in which cannabis and ethyl glucoronide are present?

96 American Society of Addiction Medicine

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