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McMillin GA, Morad AW, Boyd JM, Johnson-Davis KL, Metz TD, Smid MC, Krasowski MD. Biological Testing and Interpretation of Laboratory Results Associated with Detecting Newborns with Substance Exposure. Clin Chem 2024; 70:934-947. [PMID: 38549034 DOI: 10.1093/clinchem/hvae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Substance use during pregnancy is common, as is biological testing that is intended to help identify prenatal exposures. However, there is no standardized requirement for biological testing with either maternal or newborn specimens, nor is there standardization related to when testing occurs, how frequently testing occurs, what specimen(s) to test, what substances to test for, or how to perform testing. CONTENT We review common specimen types tested to detect maternal and newborn substance exposure with a focus on urine, meconium, and umbilical cord tissue. We also review common analytical methods used to perform testing, including immunoassay, and mass spectrometry platforms. Considerations regarding the utilization of testing relative to the purpose of testing, the drug analyte(s) of interest, the specific testing employed, and the interpretation of results are emphasized to help guide decisions about clinical utilization of testing. We also highlight specific examples of unexpected results that can be used to guide interpretation and appropriate next steps. SUMMARY There are strengths and limitations associated with all approaches to detecting substance exposure in pregnant persons as well as biological testing to evaluate a newborn with possible substance exposure. Standardization is needed to better inform decisions surrounding evaluation of substance exposures in pregnant people and newborns. If biological sampling is pursued, testing options and results must be reviewed in clinical context, acknowledging that false-positive and -negative results can and do occur.
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Affiliation(s)
- Gwendolyn A McMillin
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Anna W Morad
- Department of Pediatrics, Academic General Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Jessica M Boyd
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Kamisha L Johnson-Davis
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
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de Paula Meirelles G, Pereira E Silva J, Paranhos BAPB, Yonamine M. Development of a dispersive liquid-liquid microextraction method for the evaluation of maternal-fetal exposure to cocaine employing human umbilical cord tissue. J Anal Toxicol 2024; 48:263-272. [PMID: 38551067 DOI: 10.1093/jat/bkae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 06/12/2024] Open
Abstract
Illicit drug use is a serious and complex public health problem, not only due to the severity of the health damage but also to the social implications, such as marginalization and drug trafficking. Currently, cocaine (COC) is among the most abused drugs worldwide with about 22 million users. Drug abuse has also been found in women during the pregnancy period, which has shed light on a new group for epidemiology. The diagnosis of COC use in these cases usually depends largely on the mother's reports, which in several cases omit or deny consumption. Therefore, considering physical-chemical methods of sample preparation and exposure biomarkers, the development of analytic toxicological methods can help to confirm drug use during pregnancy. Thus, the objective of the present work was to develop an analytical method based on dispersive liquid-liquid microextraction for the determination of COC analytes, using umbilical cord tissue as an alternative biological matrix, and detection by gas chromatography coupled to mass spectrometry. Therefore, after optimization, the dispersive liquid-liquid microextraction method was fully validated for quantification of COC, benzoylecgonine, cocaethylene, ecgonine, ecgonine methyl ester and norcocaine. The limits of detection were between 15 and 25 ng/g, the limits of quantification were 30 ng/g for ecgonine and 25 ng/g for the other analytes. Linearity ranged from the limits of quantification to 1,000 ng/g. Coefficients of variation for intra-assay precision were <18.5%, inter-assay was <8.75% and bias was <16.4% for all controls. The developed method was applied in 10 suspected positive samples, based on the mother's report and maternal urine screening and confirmation. COC, benzoylecgonine, ecgonine and ecgonine methyl ester were quantified in four umbilical cords with concentrations that ranged from 39.6 to 420.5 ng/g.
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Affiliation(s)
- Gabriela de Paula Meirelles
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580, 13B, Sao Paulo, SP 05508-000, Brazil
| | - Jefferson Pereira E Silva
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580, 13B, Sao Paulo, SP 05508-000, Brazil
| | - Beatriz Aparecida Passos Bismara Paranhos
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580, 13B, Sao Paulo, SP 05508-000, Brazil
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Brown HM, Roper SM, Dietzen DJ, Crews BO. High-sensitivity neonatal urine drug testing has similar positivity rates to meconium for detecting in utero exposure to methamphetamine and cocaine. J Anal Toxicol 2024; 48:99-103. [PMID: 37952088 DOI: 10.1093/jat/bkad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023] Open
Abstract
Current guidelines recommend universal screening for substance use disorders in obstetric patients, and neonatal drug testing is also frequently performed. Meconium is often the preferred specimen type to detect neonatal drug exposure due to a longer window of detection compared to urine, but most laboratories send out meconium testing to specialized reference laboratories, which can delay results for several days or more. Here, we evaluate a rapid and definitive liquid chromatography-tandem mass spectrometry method for neonatal urine drug testing and compare results obtained using this method to paired meconium drug testing in 1,424 neonates for amphetamines, cocaine, cannabinoids, opiates, oxycodone and phencyclidine. Urine testing showed equivalent sensitivity to current meconium methods for detecting in utero exposure to amphetamines and cocaine.
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Affiliation(s)
- Hannah M Brown
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Stephen M Roper
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Dennis J Dietzen
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Bridgit O Crews
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
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Uljon S. Advances in fentanyl testing. Adv Clin Chem 2023; 116:1-30. [PMID: 37852717 DOI: 10.1016/bs.acc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Fentanyl is a synthetic opioid that was approved by the FDA in the late 1960s. In the decades since, non-prescription use of fentanyl, its analogs, and structurally unrelated novel synthetic opioids (NSO) has become a worsening public health crisis. There is a clear need for accessible testing for these substances in biological specimens and in apprehended drugs. Immunoassays for fentanyl in urine are available but their performance is restricted to facilities that hold moderate complexity laboratory licenses. Immunoassays for other matrices such as oral fluid (OF), blood, and meconium have been developed but are not widely available. Point of care tests (POCT), such as lateral flow immunoassays or fentanyl test strips (FTS), are widely available but not approved by the FDA for clinical use. All immunoassays are vulnerable to false positive and false negative results. Immunoassays may or may not be able to detect fentanyl analogs and NSOs. Mass spectrometry (MS) can accurately and reliably measure fentanyl and its major metabolite norfentanyl in urine and oral fluid. MS is available at reference laboratories and large hospitals. Liquid chromatography paired with tandem mass spectrometry (LC-MS/MS) is the most widely used method and has outstanding specificity and sensitivity for fentanyl and norfentanyl. When compared to immunoassays, MS is more expensive, requires more technical skill, and takes longer to result. Newer mass spectrometry methods can measure fentanyl analogs and NSO. Both mass spectrometry assays and immunoassays [in the form of fentanyl test strips (FTS)] have potential use in harm reduction programs.
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Affiliation(s)
- Sacha Uljon
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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Langman LJ, Rushton AM, Thomas D, Colbourne P, Seiden-Long I, Brun MM, Colantonio D, Jannetto PJ. Drug testing in support of the diagnosis of neonatal abstinence syndrome: The current situation. Clin Biochem 2023; 111:1-10. [PMID: 36379240 DOI: 10.1016/j.clinbiochem.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/21/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Illicit drug use during pregnancy is a concern worldwide, with many international studies describing attempted strategies to mitigate this problem. Drug misuse during pregnancy is associated with significant maternal as well as perinatal complications, which include a high incidence of stillbirths, fetal distress, neonatal abstinence syndrome (NAS) and increased neonatal mortality. Unfortunately, the identification of a drug-exposed mother or neonate is challenging. Maternal disclosure of drug use is often inaccurate, principally due to psychosocial factors including behavioral denial or the fear of the consequences resulting from such admissions. Likewise, many infants who have been exposed to drugs in utero may appear normal at birth and initially show no overt manifestations of drug effects. Thus, the identification of the drug-exposed infant requires a high index of clinical suspicion. Conversely, analytical testing is an objective means of determining drug exposure when it may be necessary to document proof of the infant's exposure to illicit drugs. The review will discuss the different matrices that are most commonly used for testing (e.g., maternal urine, neonatal urine, meconium, and umbilical cord), the strengths and limitations for each matrix, which drugs and metabolites are appropriate for testing, the various testing methods, and the advantages and disadvantages of each method.
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Affiliation(s)
- Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Alysha M Rushton
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Dylan Thomas
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Penny Colbourne
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Isolde Seiden-Long
- Alberta Precision Laboratories and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Miranda M Brun
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - David Colantonio
- Eastern Ontario Regional Laboratory Association and Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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