September 2016 HCMC Toxicology Transition: Additional information and Frequently Asked Questions Many clinicians have asked for more information about the Urine Drug Compliance Analysis (LAB8742) switch to HCMC on September 6. How will the new drug screen results appear? You will see a list of results that includes: 1. Immunoassay (pos/neg) results for 14 drugs or drug classes. In conjunction with mass spectrometry, immunoassay adds sensitivity for detecting common drugs of abuse. The specific drugs responsible for any positives are shown under mass spectrometry. 2. Urine ph and creatinine: markers of specimen quality and integrity. 3. Mass spectrometry: Double-click to see the specific drugs and metabolites detected by definitive mass separation. Mass spectrometry is the standard method used to detect nearly all illicit, prescription, and over-thecounter drugs. Sample mass spectrometry results
An earlier announcement showed a screenshot with a positive result for Opiates which is not useful for compliance monitoring. I need to see the specific drugs and metabolites. The positive and negative tests are immunoassay results. The specific drugs and metabolites responsible for any positives are shown in the mass spectrometry result. I understand that results will no longer be reported as Expected or Unexpected based on the patients medication list. How will I correlate complex test results with the patient s medication list? As shown in the attached examples, HCMC s reporting of metabolites is quite straightforward and includes the parent drug name: for example trazadone metabolite ; or norbuprenorphine. For drugs that metabolize into other drugs, such as codeine to morphine and amitriptyline to nortriptyline, HCMC consultants are available 24/7 to assist with results correlation by paging (612) 315-9901. Urine test results are negative for a drug that I prescribed to my patient. I believe my patient is taking the drug as prescribed. Is there another explanation? Drug testing is concentration dependent, so it is possible that the prescribed drug was present in the specimen but below the positive cutoff. Please page the HCMC hotline, (612) 315-9901 for consultation and possible follow-up testing in these cases. How do I interpret a report that shows (1) only the parent drug with no metabolite; or, (2) only metabolite and not the parent drug? Does this mean non-compliance? This scenario can occur with compliant patients and is most commonly seen with opioid drugs. The missing parent drug or metabolite may be present but below the positive threshold in compliant patients who are ultra-slow or ultra-fast metabolizers or if they are taking other drugs metabolized by the same enzymes, which could slow metabolism of the parent drug or divert metabolism through a minor pathway. Please page the HCMC hotline for clinical consultation. Follow-up may include quantitative blood testing. For questions, comments, or suggestions about this newsletter or other laboratory issues, please contact Lauren Anthony, MD, Medical Director of Allina Health Laboratory, (612) 863-0409 or Lauren.Anthony@allina.com 2
I understand we will no longer see quantitative urine drug results. Won t this have a negative clinical impact? No, in fact, national guidelines recommend against quantitative urine drug testing: Quantitative definitive [mass spectrometry] urine testing is not more useful at detecting outcomes in pain management patients compared to qualitative definitive urine testing. Furthermore, quantitative definitive urine testing should not be used to evaluate dosage of administered drug or adherence to prescribed dosage regimen. Strength of recommendations: A; Quality of evidence: II National Laboratory Medicine Practice Guideline: Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients, July 2016. Is there a resource to show how long a drug should be detectable in a urine? Drug testing is highly standardized and detection windows are the same across laboratories. Reference tables can be found on national laboratory and medical websites, see attached pages for a list posted on Mayo s website. For questions or help with drug analysis results interpretation, HCMC encourages you contact a clinical toxicology consultant available 24/7 by paging (612) 315-9901. For questions, comments, or suggestions about this newsletter or other laboratory issues, please contact Lauren Anthony, MD, Medical Director of Allina Health Laboratory, (612) 863-0409 or Lauren.Anthony@allina.com 3
Example1 : HCMC Compliance Drug Analysis Results
Example 2 Note that mass spec results correlate with the POS results and metabolites include the parent drug name. Oxymorphone and Noroxycodone are metabolites of oxycodone.
Example 3 If present, methamphetamine would be listed here, but only amphetamine was found on mass spec. Results correlate with POS results and metabolites are listed by parent drug name.
Drugs of Abuse: Approximate Detection Times - Mayo Medical Laboratories http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html Page 1 of 2 8/31/2016 Web: MayoMedicalLaboratories.com E-mail: mml@mayo.edu Telephone: 800-533-1710 International: +1 855-379-3115 Values are valid only on day of printing. Approximate Detection Times All Specific Drug Groups Last Updated November 2015 LOQ (ng/ml) Detection time* up to Amphetamine-Type Stimulants Amphetamine 25 3 days Methamphetamine 25 3 days 3,4-Methylenedioxyamphetamine (MDA) 25 2 days 3,4-Methylenedioxymethamphetamine (MDMA) 25 2 days Phentermine 25 Ephedrine/pseudoephedrine 25 5 days Barbiturates Long-Acting Phenobarbital 100 15 days Intermediate-Acting Butalbital 100 7 days Amobarbital 100 3 days Short-Acting Pentobarbital 100 3 days Secobarbital 100 3 days Benzodiazepines Long-Acting 10 days Diazepam 100 Nordiazepam 100 Intermediate-Acting 5 days Alprazolam 100 Lorazepam 100 Oxazepam 100 Temazepam 100 Chlordiazepoxide 100 Clonazepam 100 Flunitrazepam 50 Short-Acting 2 days Triazolam 100 Flurazepam 100 Buprenorphine Buprenorphine 0.5 7 days Norbuprenorphine 0.5 7 days
Drugs of Abuse: Approximate Detection Times - Mayo Medical Laboratories Page 2 of 2 Cocaine & Metabolite Cocaine 50 <1 day Benzoylecgonine 50 5 days Fentanyl Fentanyl 0.2 3 days Norfentanyl 1.0 3 days Ketamine Ketamine 25 2 days Norketamine 25 2 days Lysergic Acid Diethylamide (LSD) LSD 0.5 <1 day 2-Oxo-3-hydroxy-LSD 5 5 days Marijuana/Cannabis (THC-COOH) Single Use 3 3 days Moderate Use (4 times per week) 5 days Heavy Use (daily) 10 days Chronic Heavy Use 30 days Methadone Methadone 100 7 days EDDP (methadone metabolite) 100 7 days Opiates 6-MAM 5 1 day Morphine 100 3 days Codeine 100 3 days Hydrocodone 100 3 days Hydromorphone 100 3 days Oxycodone 100 3 days Oxymorphone 100 3 days Phencyclidine Phencyclidine 25 8 days *These are approximate detection times for the drug or metabolites in urine. The actual detection time depends on dose, frequency of use, and individual metabolism. Note: These tests do not differentiate between dextro (+) amphetamine (dexamphetamine) and racemic mixtures of dextro (+) and levo (-) isomers that are present in street amphetamine. These tests do not differentiate between ephedrine and pseudoephedrine. http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html 8/31/2016