1
|
Broussard LA, Carr J, Hurst J. Consumption of seasoning containing poppy seeds can cause codeine positive urine drug test results for pain management monitoring. J Anal Toxicol 2024; 48:523-525. [PMID: 38937868 DOI: 10.1093/jat/bkae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/12/2024] [Accepted: 06/26/2024] [Indexed: 06/29/2024] Open
Affiliation(s)
- Larry A Broussard
- Department of Clinical Laboratory Sciences, LSUHSC, New Orleans, LA 70112, United States
| | - Jeanne Carr
- Clinical Laboratory Consultant, Hattiesburg, MS 39402, United States
| | - Jeffrey Hurst
- Encore Health Group, Spectrum Pain Clinics, Nashville, TN 37217, United States
| |
Collapse
|
2
|
Jiang S, Zhao J, Yan H, Xiang P, Shen M. Analysis of 15 anti-obesity drugs in urine using thermal-assisted paper spray mass spectrometry. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2023; 15:4434-4441. [PMID: 37606058 DOI: 10.1039/d3ay00559c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Anti-obesity drugs, used to suppress appetite and reduce fat absorption, have been circulated and traded illegally worldwide. The traditional methods of liquid chromatography tandem mass spectrometry (LC-MS/MS) and gas chromatography-mass spectrometry (GC-MS) for analyzing these drugs in in vivo samples require complex sample pretreatment and time-consuming procedures. To address this issue, a thermal-assisted paper spray mass spectrometry (PS-MS) method was developed in this study to analyze anti-obesity drugs in raw urine. By incorporating a heat source and optimizing the spray solvent and paper substrate, this technique demonstrates reduced matrix effect and higher sensitivity compared to traditional PS-MS methodology for direct analysis of anti-obesity drugs in urine samples. A temperature range of 100-200 °C can be set for screening anti-obesity drugs in urine samples, with the flexibility to adjust the temperature according to the specific drug being analyzed. The limits of detection (LODs) for these 15 anti-obesity drugs in urine ranged between 1 and 500 ng mL-1. Furthermore, the thermal-assisted PS-MS method exhibited good linearities (R2, 0.9903-0.9997) within the range from 10-100 to 1000 ng mL-1 for the direct quantitation of anti-obesity drugs in urine samples with an internal standard. Therefore, the thermal-assisted PS-MS technique may provide a novel approach for the direct analysis of drugs in complex samples.
Collapse
Affiliation(s)
- Shijia Jiang
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai, 200063, China.
- Criminal Justice College, East China University of Political Science and Law, Shanghai, 200042, China
| | - Junbo Zhao
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai, 200063, China.
| | - Hui Yan
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai, 200063, China.
| | - Ping Xiang
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai, 200063, China.
| | - Min Shen
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai, 200063, China.
| |
Collapse
|
3
|
Noguez JH, Koch CD. Bridging the gap: The critical role of laboratory developed tests in clinical toxicology. J Mass Spectrom Adv Clin Lab 2023; 28:70-74. [PMID: 36872953 PMCID: PMC9982682 DOI: 10.1016/j.jmsacl.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
•Toxicology testing provides valuable information for patient management.•Current in vitro diagnostics (IVDs) are unable to meet all clinical needs.•Lab-developed tests (LDTs) in toxicology can be used to close clinical care gaps.•LDTs in clinical toxicology are almost exclusively mass spectrometry-based methods.
Collapse
Affiliation(s)
- Jaime H Noguez
- Department of Pathology, Case Western Reserve University, Cleveland, OH, USA.,Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher D Koch
- Department of Pathology, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.,Sanford Laboratories, Sanford Health, Sioux Falls, SD, USA
| |
Collapse
|
4
|
Rydberg M, Dowling S, Manicke NE. Automated and High-Throughput Urine Drug Screening Using Paper Spray Mass Spectrometry. J Anal Toxicol 2023; 47:147-153. [PMID: 35866550 DOI: 10.1093/jat/bkac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/30/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
Paper spray mass spectrometry (PS-MS) has been shown to be a rapid, simple and inexpensive alternative to traditional forensic drug screening methods. It can address the limitations of both immunoassays and chromatography-based techniques due to its non-reliance on sample preparation and its ability to rapidly screen for a wide array of compounds. In this study, an automated PS-MS system was employed to semi-quantitatively screen for 40 commonly abused drugs and metabolites in urine after a 15-min glucuronidase reaction. The target compounds included common prescription opioids, fentanyl and norfentanyl, stimulants including methamphetamine and cocaine, benzodiazepines and antidepressants. The enzyme, buffer and internal standard solution were combined in one spiking solution to minimize sample handling. Analysis was carried out using a commercially available automated paper spray system coupled to a triple quadrupole mass spectrometer. This method may prove useful for clinical and forensic toxicology laboratories as it allows for automated screening of complex samples for drugs without extraction, separation and sample cleanup.
Collapse
Affiliation(s)
- Magnus Rydberg
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, 402 N Blackford St Indianapolis, IN 46202, USA
| | - Sarah Dowling
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, 402 N Blackford St Indianapolis, IN 46202, USA
| | - Nicholas E Manicke
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, 402 N Blackford St Indianapolis, IN 46202, USA
| |
Collapse
|
5
|
Pablo A, Laha TJ, Breit N, Hoffman NG, Hoofnagle AN, Baird GS, Mathias PC. A web application to support the coordination of reflexive, interpretative toxicology testing. J Pathol Inform 2023; 14:100303. [PMID: 36941960 PMCID: PMC10024164 DOI: 10.1016/j.jpi.2023.100303] [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: 12/21/2022] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023] Open
Abstract
Background Reflexive laboratory testing workflows can improve the assessment of patients receiving pain medications chronically, but complex workflows requiring pathologist input and interpretation may not be well-supported by traditional laboratory information systems. In this work, we describe the development of a web application that improves the efficiency of pathologists and laboratory staff in delivering actionable toxicology results. Method Before designing the application, we set out to understand the entire workflow including the laboratory workflow and pathologist review. Additionally, we gathered requirements and specifications from stakeholders. Finally, to assess the performance of the implementation of the application, we surveyed stakeholders and documented the approximate amount of time that is required in each step of the workflow. Results A web-based application was chosen for the ease of access for users. Relevant clinical data was routinely received and displayed in the application. The workflows in the laboratory and during the interpretation process served as the basis of the user interface. With the addition of auto-filing software, the return on investment was significant. The laboratory saved the equivalent of one full-time employee in time by automating file management and result entry. Discussion Implementation of a purpose-built application to support reflex and interpretation workflows in a clinical pathology practice has led to a significant improvement in laboratory efficiency. Custom- and purpose-built applications can help reduce staff burnout, reduce transcription errors, and allow staff to focus on more critical issues around quality.
Collapse
Key Words
- AMR, analytical measurement range
- AWS, Amazon Web Services
- CSV, Comma-separated values
- Custom web application
- GC-MS, gas chromatography-mass spectrometry
- LC-MS/MS, Liquid chromatography-tandem mass spectrometry
- LIS, laboratory information system
- Laboratory workflows
- MLS, medical laboratory scientist
- Mass spectrometry
- Python
- QC, Quality control
- Quality control
- RRT, Relative retention time
- S/N, Signal to noise ratio
- S3, Simple storage service
- TSV, tab-separated values
- UDT, urine drug testing
- UW Medicine, Department of Laboratory Medicine and Pathology at University of Washington Medicine
- XML, Extensible markup language
- mg, milligram
Collapse
Affiliation(s)
- Abed Pablo
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Thomas J. Laha
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Nathan Breit
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Noah G. Hoffman
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Andrew N. Hoofnagle
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Geoffrey S. Baird
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Patrick C. Mathias
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, WA, USA
- Corresponding author at: University of Washington, 1959 NE Pacific St, Box 357110, Seattle, WA 98195-7110, USA
| |
Collapse
|
6
|
Feng S, Strickland E, Enders J, Roslawski M, McIntire T, McIntire G. Ritalinic acid in urine: Impact of age and dose. Pract Lab Med 2021; 27:e00258. [PMID: 34754895 PMCID: PMC8561308 DOI: 10.1016/j.plabm.2021.e00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022] Open
Abstract
Objectives The objective of this work was to study the results of urine drug testing for ritalinic acid (RA), the major urinary metabolite of methylphenidate (MP) (e.g., Ritalin®). The impact of age from 4 to 65 years old and older on median levels of RA was investigated as well as potential variations in pH, specific gravity and creatinine content of the patient urine samples. Design and Methods Samples from patients who were 1) prescribed MP and found to be positive for RA, 2) prescribed MP but found to be negative for RA and 3) not prescribed MP but tested positive for RA were examined by liquid chromatography – mass spectrometry/mass spectrometry (LC-MS/MS) for RA concentration. The levels of RA were examined for median and average levels and further normalized and transformed to reveal a near gaussian distribution. Results Over 20,000 samples from patients who were prescribed MP were examined for this work. Analysis of these data for a subset of patients prescribed MP and testing positive for RA revealed statistically different median values of RA for school age patients of 6 years old through 17 years old from adult patients 18 through 64 years old. Another 6751 samples were positive for RA without a prescription but were not included in the overall assessment of these data. Conclusions While not clear as to the reason, these data indicate that school age children under the age of 18 have much higher levels of RA than adult patients. These results can be used to estimate “normal” levels of RA in these chronically dosed populations.
Collapse
Affiliation(s)
- Sheng Feng
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Erin Strickland
- Ameritox, LLC, 486 Gallimore Dairy Rd, Greensboro, NC, 27409, USA
| | - Jeffery Enders
- Molecular Education, Technology and Research Innovation Center (METRIC), Department of Biological Sciences, North Carolina State University, Raleigh, NC, 27695, USA
| | | | | | | |
Collapse
|
7
|
Smith MD, Emerick T, Brancolini S, Alter B. Clearing up the Confusion: What to Do with Ethanol and Ethanol Metabolites in Urine Drug Screens. PAIN MEDICINE 2021; 22:2401-2413. [PMID: 33595647 DOI: 10.1093/pm/pnab068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael D Smith
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Trent Emerick
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Brancolini
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benedict Alter
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
8
|
Abou El Hassan M, Colantonio D, Likhodii S, Nassar BA. The analytical performance of six urine drug screens on cobas 6000 and ARCHITECT i2000 compared to LC-MS/MS gold standard. Clin Biochem 2021; 93:99-103. [PMID: 33844982 DOI: 10.1016/j.clinbiochem.2021.04.003] [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: 11/22/2020] [Revised: 02/16/2021] [Accepted: 04/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Immunoassays provide a rapid tool for the screening of drugs-of-abuse (DOA). However, results are presumptive and confirmatory testing is warranted. To reduce associated cost and delay, laboratories should employ assays with high positive and negative predictive values (PPVs and NPVs). Here, we compared the results of urine drug screens on cobas 6000 (cobas) and ARCHITECTi2000 (ARCHITECT) platforms for six drugs against LC-MS/MS to assess the analytical performance of these assays. METHODS Eighty nine residual urine specimens, which tested positive for amphetamine, THC-COOH, benzoylecgonine, EDDP, opiates and/or oxycodone during routine drug testing, were stored frozen until later confirmation by LC-MS/MS. Immunoassays were performed on cobas and ARCHITECT using a split sample. A third aliquot from these samples was tested by LC-MS/MS to assess the percentage of false positive, false negative, true positive and true negative results and calculate the PPVs and NPVs for each immunoassay. RESULTS The PPVs of THC-COOH and EDDP assays were 100% on both platforms. Suboptimal PPVs were achieved for oxycodone (cobas, 57.1% vs ARCHITECT, 66.7%), amphetamine (77.8 vs. 100%), opiates (80.0 vs. 84.6%) and benzoylecgonine (88.9 vs. 84.2%) assays. The NPV was 100% for cobas and ARCHITECT oxycodone assays. Lower NPVs were achieved for THC-COOH (cobas, 28.6% vs ARCHITECT, 25.0%), EDDP (72.7% for both assays), benzoylecgonine (74.4% vs 73.8%), amphetamine (83.3% vs 82.8%) and opiates (100% vs 85.3%). CONCLUSION Overall, cobas and ARCHITECT urine drug screens have comparable analytical performance. Confirmatory testing is warranted for positive test results especially for oxycodone, amphetamine, opiates and cocaine. Negative drug screen results must be interpreted with caution especially for THC-COOH, EDDP, benzoylecgonine, amphetamine and opiates.
Collapse
Affiliation(s)
- Mohamed Abou El Hassan
- Clinical Chemistry Division, Provincial Laboratory Services, Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada; Department of Pathology, Dalhousie University, Halifax, NS, Canada.
| | - David Colantonio
- Department of Pediatric Laboratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Sergei Likhodii
- Department of Laboratory Medicine, Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Bassam A Nassar
- Department of Pathology, Dalhousie University, Halifax, NS, Canada; Department of Pathology and Laboratory Medicine, Nova Scotia Health Authority (NSHA), Halifax, NS, Canada
| |
Collapse
|
9
|
Chakravarthy K, Goel A, Jeha GM, Kaye AD, Christo PJ. Review of the Current State of Urine Drug Testing in Chronic Pain: Still Effective as a Clinical Tool and Curbing Abuse, or an Arcane Test? Curr Pain Headache Rep 2021; 25:12. [PMID: 33598816 DOI: 10.1007/s11916-020-00918-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Therapeutic use, misuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain remain a major concern for physicians, the government, payers, and patients. The challenge remains finding effective diagnostic tools that can be clinically validated to eliminate or substantially reduce the abuse of controlled prescription drugs, while still assuring the proper treatment of those patients in pain. Urine drug testing still remains an important means of adherence monitoring, but questions arise as to its relevance and effectiveness. This review examines the role of UDT, determines its utility in current clinical practice, and investigates its relevance in current chronic pain management. RECENT FINDINGS A review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literature was searched from year 2000 to present examining the relevance and role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. There are only a limited number of reviews and investigations on UDT, despite the fact that clinicians who prescribe controlled medications for chronic states commonly are expected to utilize UDT. Therefore, despite highly prevalent use, there is a limited publication base from which to draw in this present study. Regardless of experience or training background, physicians and healthcare providers can much more adequately assess opioid therapy with the aid of UDT, which often requires confirmatory testing by a laboratory for clinical and therapeutic prescribing decisions. It has become a strongly recommended aspect of pain care with controlled substances locally, regionally, and nationally. Incorporating UDT for all patients in whom chronic opioid therapy is undertaken is consistent with state and national guidelines and best practice strategies. Practice standards vary as to the frequency of UDT locally, regionally, and nationally, however.
Collapse
Affiliation(s)
- Krishnan Chakravarthy
- VA San Diego Healthcare System, UC San Diego School of Medicine, La Jolla, CA, USA. .,Department of Anesthesiology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | - Aneesh Goel
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD, 21205, USA
| | - George M Jeha
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alan David Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA.,Departments of Anesthesiology and Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD, 21205, USA.
| |
Collapse
|
10
|
McMillin GA, Johnson-Davis KL, Kelly BN, Scott B, Yang YK. Impact of the Opioid Epidemic on Drug Testing. Ther Drug Monit 2021; 43:14-24. [PMID: 33230043 DOI: 10.1097/ftd.0000000000000841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a description of how the opioid epidemic has impacted drug testing. METHODS Four major service areas of drug testing were considered, including emergency response, routine clinical care, routine forensics, and death investigations. RESULTS Several factors that the opioid epidemic has impacted in drug testing are discussed, including specimens, breadth of compounds recommended for testing, time to result required for specific applications, analytical approaches, interpretive support requirements, and examples of published practice guidelines. CONCLUSIONS Both clinical and forensic laboratories have adapted practices and developed new testing approaches to respond to the opioid epidemic. Such changes are likely to continue evolving in parallel with changes in both prescription and nonprescription opioid availability and use patterns, as well as emerging populations that are affected by the "waves" of the opioid epidemic.
Collapse
Affiliation(s)
| | | | - Brian N Kelly
- Department of Pathology, University of Utah and ARUP Laboratories; and
| | | | - Yifei K Yang
- Department of Pathology, University of Utah and ARUP Laboratories; and
| |
Collapse
|
11
|
Masood MA, Veenstra TD. LC-MS-sMRM method development and validation of different classes of pain panel drugs and analysis of clinical urine samples. Basic Clin Pharmacol Toxicol 2020; 127:533-550. [PMID: 33135384 DOI: 10.1111/bcpt.13519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/14/2017] [Indexed: 11/26/2022]
Abstract
Urine drug testing (UDT) is an important analytical/bio-analytical technique that has inevitably become an integral and vital part of a testing programme for diagnostic purposes. This manuscript presents a tailor-made LC-MS/MS quantitative assay method development and validation for a custom group of 33 pain panel drugs and their metabolites belonging to different classes (opiates, opioids, benzodiazepines, illicit, amphetamines, etc.) that are prescribed in pain management and depressant therapies. The LC-MS/MS method incorporates two experiments to enhance the sensitivity of the assay and has a run time of about 7 minutes with no prior purification of the samples required and a flow rate of 0.7 mL/min. The method also includes the second-stage metabolites for some drugs that belong to different classes but have first-stage similar metabolic pathways that will enable to correctly identify the right drug or to flag the drug that might be due to specimen tampering. Some real case examples and difficulties in peak picking were provided with some of the analytes in subject samples. Finally, the method was deliberated with some randomly selected de-identified clinical subject samples, and the data evaluated from "direct dilute and shoot analysis" and after "glucuronide hydrolysis" were compared. This method is now used to run routinely more than 100 clinical subject samples on a daily basis.
Collapse
Affiliation(s)
- M Athar Masood
- Laboratory of Proteomics and Analytical Technologies, Advanced Technology Program, SAIC-Frederick, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Timothy D Veenstra
- Laboratory of Proteomics and Analytical Technologies, Advanced Technology Program, SAIC-Frederick, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| |
Collapse
|
12
|
Yang YK, Johnson-Davis KL, Kelly BN, McMillin GA. Demand for Interpretation of a Urine Drug Testing Panel Reflects the Changing Landscape of Clinical Needs; Opportunities for the Laboratory to Provide Added Clinical Value. J Appl Lab Med 2020; 5:858-868. [PMID: 32875314 DOI: 10.1093/jalm/jfaa119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/01/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND The direct detection of drugs and metabolites in urine using a targeted panel offers sensitive and specific detection in comparison to the traditional approach to urine drug testing (screen with reflex of samples with positive results to confirmation testing). The purpose of this study was to evaluate changes in clinical demand for the laboratory to provide interpretation of patient adherence and abstinence, based on reconciling laboratory results and individual patient medication information provided by the clinician. The shifts in toxicology testing likely reflect the inherent complexity of the data and associated interpretation. METHODS Retrospective testing results associated with a targeted urine drug panel and its related interpretation were collected from our laboratory. We examined the associated testing volume and positivity rates of each reported analyte over 5 consecutive years (2015-2019). Requests from clinicians for consultation regarding this test and use of interpretive comments for the most recent year (2019), as well as access to publicly available educational resources over two years (2018-2019) were collected. RESULTS The changes in test ordering patterns demonstrate shifting of clinical demands for toxicology testing, by increased adoption of a targeted panel for which laboratory-based interpretation is provided. Positivity rates reflect national shifts in controlled substance prescriptions. Several consultative services were accessed by clinicians suggesting interest and need. CONCLUSION The value of clinical urine drug testing is improved by providing laboratory-based result interpretation and consultative services.
Collapse
Affiliation(s)
- Yifei K Yang
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, UT
| | | | - Brian N Kelly
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, UT
| | - Gwendolyn A McMillin
- Department of Pathology and ARUP Laboratories, University of Utah, Salt Lake City, UT
| |
Collapse
|
13
|
Hamidi S. Recent Progresses in Sensitive Determination of Drugs of Abuse by Capillary Electrophoresis. CURR ANAL CHEM 2020. [DOI: 10.2174/1573411015666190115153531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Today, “drugs of abuse” pose serious social problems such as many crimes,
medical treatment costs, and economic repercussions. Several worldwide clinical laboratories use analytical
separation methods to analyze their patient samples for drugs and poisons. In this way, they
provide qualitative and quantitative data on the substances in various biological matrices (e.g., urine,
plasma or serum, saliva, and breath).
Methods:
An extensive review of the published articles indicates that the use of Capillary Electrophoresis
(CE) coupled with sensitivity enhancing methods is a very attractive area of interest in the
assay of drugs of abuse.
Results:
This review was prepared to have a comprehensive study on applications of sensitivity enhancing
methods on the determination of drugs of abuse especially from 2007 to present. The sample
preconcentration approaches almost address all methods from online preconcentration (both electrophoretic
and chromatographic-based methods) to offline preconcentration. Furthermore, detection
system modification and capillary column fabrications were investigated in order to increase the detection
sensitivity of complex samples in CE.
Conclusion:
The present review summarizes the most recent developments in the detection of drugs
of abuse using CE. Although CE still has a limitation in sensitive detection, several publications in
recent years have proposed valuable methods to overcome this problem.
Collapse
Affiliation(s)
- Samin Hamidi
- Pharmaceutical Analysis Research Center and Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
14
|
Chua I, Petrides AK, Schiff GD, Ransohoff JR, Kantartjis M, Streid J, Demetriou CA, Melanson SEF. Provider Misinterpretation, Documentation, and Follow-Up of Definitive Urine Drug Testing Results. J Gen Intern Med 2020; 35:283-290. [PMID: 31713040 PMCID: PMC6957646 DOI: 10.1007/s11606-019-05514-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/13/2019] [Accepted: 10/02/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Urine drug testing (UDT) is an essential tool to monitor opioid misuse among patients on chronic opioid therapy. Inaccurate interpretation of UDT can have deleterious consequences. Providers' ability to accurately interpret and document UDT, particularly definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) results, has not been widely studied. OBJECTIVE To examine whether providers correctly interpret, document, and communicate LC-MS/MS UDT results. DESIGN This is a retrospective chart review of 160 UDT results (80 aberrant; 80 non-aberrant) between August 2017 and February 2018 from 5 ambulatory clinics (3 primary care, 1 oncology, 1 pain management). Aberrant results were classified into one or more of the following categories: illicit drug use, simulated compliance, not taking prescribed medication, and taking a medication not prescribed. Accurate result interpretation was defined as concordance between the provider's documented interpretation and an expert laboratory toxicologist's interpretation. Outcome measures were concordance between provider and laboratory interpretation of UDT results, documentation of UDT results, results acknowledgement in the electronic health record, communication of results to the patient, and rate of prescription refills. KEY RESULTS Aberrant results were most frequently due to illicit drug use. Overall, only 88 of the 160 (55%) had any documented provider interpretations of which 25/88 (28%) were discordant with the laboratory toxicologist's interpretation. Thirty-six of the 160 (23%) documented communication of the results to the patient. Communicating results was more likely to be documented if the results were aberrant compared with non-aberrant (33/80 [41%] vs. 3/80 [4%], p < 0.001). In all cases where provider interpretations were discordant with the laboratory interpretation, prescriptions were refilled. CONCLUSIONS Erroneous provider interpretation of UDT results, infrequent documentation of interpretation, lack of communication of results to patients, and prescription refills despite inaccurate interpretations are common. Expert assistance with urine toxicology interpretations may be needed to improve provider accuracy when interpreting toxicology results.
Collapse
Affiliation(s)
- Isaac Chua
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Athena K Petrides
- Harvard Medical School, Boston, MA, USA
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
| | - Gordon D Schiff
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jaime R Ransohoff
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michalis Kantartjis
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jocelyn Streid
- Harvard Medical School, Boston, MA, USA
- Harvard Kennedy School, Boston, MA, USA
| | - Christiana A Demetriou
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
- The Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Stacy E F Melanson
- Harvard Medical School, Boston, MA, USA.
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|
15
|
Acuña JP. RIESGO DE ADICCIÓN A ANALGÉSICOS OPIOIDES EN EL TRATAMIENTO DE DOLOR CRÓNICO NO ONCOLÓGICO. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
16
|
Barthwell AG, Allgaier J, Egli K. Definitive urine drug testing in office-based opioid treatment: a literature review. Crit Rev Toxicol 2019; 48:829-852. [DOI: 10.1080/10408444.2018.1553935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
17
|
Feldhammer M, Saitman A, Nguyen L, Milstid B. Dilution of Urine Followed by Adulteration in an Attempt to Deceive the Laboratory. J Anal Toxicol 2019; 43:e7-e9. [PMID: 30192938 DOI: 10.1093/jat/bky059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 11/14/2022] Open
Abstract
Adulteration of samples submitted for toxicological analyses can present unique challenges to non-forensic clinical laboratories. With the number of overdose-related deaths expected to surpass 60,000 in 2018, it is incumbent on all members of the healthcare team to be active participants in curbing opioid dependence and identifying prescription drug misuse and diversion. Recently published guidelines have sought to provide guidance to laboratories overseeing prescription drug-monitoring programs. We present a case of sample adulteration in an attempt to conceal prescription non-compliance. The patient possessed only an active prescription for hydrocodone but on initial antibody-based screening the sample tested positive for benzodiazepines and oxycodone in addition to opiates. Active communication between the pain management clinic and the clinical laboratory alerted staff to conduct a more thorough investigation including sample validity testing, analyses of paired serum specimens by liquid chromatography tandem mass spectrometry. Analyses revealed the patient submitted a dilute urine specimen with a crushed hydrocodone pill inside in an attempt to hide prescription non-compliance. Previous screenings had been consistent with the medication list raising the question of whether this was an isolated incident or the patient had simply been more successful in manipulating specimens in the past. This case highlights the need for good communication among all members of the healthcare team and the widespread implementation of specimen validity testing for any laboratory that receives samples from pain clinics.
Collapse
Affiliation(s)
- Matthew Feldhammer
- Department of Pathology and Laboratory Medicine, University of Florida, College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Alec Saitman
- Providence Regional Laboratories, Portland, OR, USA
| | - Ly Nguyen
- Department of Pharmacy, University of Florida Health-Jacksonville, Jacksonville, FL, USA
| | - Bryan Milstid
- University of Florida Health Jacksonville, Jacksonville, FL, USA
| |
Collapse
|
18
|
Fischer B, Jones W, Varatharajan T, Malta M, Kurdyak P. Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016. Prev Med 2018; 116:112-118. [PMID: 30217407 DOI: 10.1016/j.ypmed.2018.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/24/2018] [Accepted: 09/11/2018] [Indexed: 01/17/2023]
Abstract
Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.
Collapse
Affiliation(s)
- Benedikt Fischer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Medical Science (IMS), University of Toronto, Toronto, Canada; Centre for Criminology & Sociolegal Studies, University of Toronto, Toronto, Canada; Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.
| | - Wayne Jones
- Centre for Applied Research in Mental Health and Addictions, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Thepikaa Varatharajan
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
| | - Monica Malta
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Paul Kurdyak
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Mental Health & Addictions Research Program, Institute for Clinical Evaluative Sciences, Toronto, Canada
| |
Collapse
|
19
|
Zheng YZ, Bunch DR, Lembright K, Wang S. Quantitation of Benzodiazepines and Metabolites in Urine by Liquid Chromatography–Tandem Mass Spectrometry. J Appl Lab Med 2018; 3:397-407. [DOI: 10.1373/jalm.2018.026658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/21/2018] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Benzodiazepines (BZDs) are central nervous system depressants that are prescribed to prevent seizures, manage anxiety, or help sleep. When misused, BZDs can lead to addiction and sometimes cause death. Measurement of BZDs in urine is used to identify their use, especially in pain management settings. LC-MS/MS is preferred for these measurements because of its high sensitivity and specificity. Here, we report an LC-MS/MS assay for measuring 7 BZDs and metabolites in urine.
Methods
Urine sample was incubated at 60 °C for 30 min after addition of internal standards and a β-glucuronidase solution. After centrifugation, the supernatant was diluted with methanol and water before being injected onto a C18 analytical column in an LC-MS/MS system for quantification. The analytical time between injections was 4.35 min. The analytes included 7-aminoclonazepam, α-hydroxyalprazolam, α-hydroxytriazolam, oxazepam, lorazepam, nordiazepam, and temazepam.
Results
The lower limit of quantification ranged from 30 ng/mL to 50 ng/mL with an analytical recovery >80% for all 7 analytes. Total CV was <10% for all analytes (3 concentration levels of 100, 2500, and 5000 ng/mL; n = 30 each). This method had 100% agreement with a GC-MS method offered by an independent laboratory for negative urine samples. For the positive urine samples, this method showed a strong correlation (R > 0.96) with the GC-MS method.
Conclusions
The LC-MS/MS assay allows accurate and precise measurement of 7 BZDs and metabolites in a single analytical run with a short analytical run time and broad measuring ranges.
Collapse
Affiliation(s)
- Yu Zi Zheng
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH
| | - Dustin R Bunch
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Sihe Wang
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
20
|
Sobolesky PM, Smith BE, Pesce AJ, Fitzgerald RL. Interpretation of Pain Management Testing Results Using Case Examples. J Appl Lab Med 2018; 2:610-621. [PMID: 33636894 DOI: 10.1373/jalm.2017.024786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Because of the increasing volume of opiate-related overdoses, clinical testing of urine for drugs and related compounds in pain management clinics has become increasingly important. Interpreting findings of drugs present in urine specimens requires knowledge of pharmacokinetics, metabolism, drug purity, and cutoff concentrations used to report a positive result. CONTENT This case-based mini-review provides examples of how to interpret immunoassay and quantitative confirmatory urine drug-testing results. Particular emphasis is placed on interpretation of opiate and benzodiazepine results, as these drugs have complicated metabolic profiles. SUMMARY Both determining patient medication compliance and identifying the presence of additional drugs provides important information to the treating physician involved in managing pain. Mass spectrometry-based methods are required to identify specific drugs present and can provide important quantitative data for interpreting opiate medication compliance.
Collapse
Affiliation(s)
- Philip M Sobolesky
- Department of Pathology, Center for Advanced Laboratory Medicine, University of California, San Diego Health Systems, San Diego, CA
| | - Breland E Smith
- Department of Pathology, Center for Advanced Laboratory Medicine, University of California, San Diego Health Systems, San Diego, CA
| | | | - Robert L Fitzgerald
- Department of Pathology, Center for Advanced Laboratory Medicine, University of California, San Diego Health Systems, San Diego, CA
| |
Collapse
|
21
|
Flood JG. Use of Metabolic Ratios of Drugs in Urine for Monitoring Pain Management Patients. J Appl Lab Med 2018; 2:644-647. [PMID: 33636900 DOI: 10.1373/jalm.2017.023804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 11/07/2017] [Indexed: 11/06/2022]
Affiliation(s)
- James G Flood
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
22
|
Eldrige JS, Rho RH, Martin JL, Murphy JB, Hooten WM. Opioids: Clinical Practice, Monitoring, and Medicolegal Considerations. J Appl Lab Med 2018; 2:573-586. [DOI: 10.1373/jalm.2017.024026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/11/2017] [Indexed: 11/06/2022]
Abstract
Abstract
Background
In the past decade, opioid use in the general population of the US has increased dramatically. Concomitantly, opioid-related morbidity and mortality have also risen steeply. The causes of opioid over-prescribing are multifactorial, with pressure from medical agencies, patients, aggressive patient-directed marketing, and use of patient surveys as an evaluation tool to unduly influence medical providers' decision-making. Providers also have significant concerns regarding scrutiny from their medical board and exposure to medicolegal liability.
Content
To provide the basis for best practice recommendations, several aspects of modern opioid prescribing practice require review. The practicing clinician should be aware of: (a) the pervasiveness of current opioid prescribing within the US; (b) the availability and applicability of clinical tools used to assess patient risk; (c) the new guidelines designed to facilitate appropriate and safe medical use of opioids; (d) the incorporation of clinical tools and best documentation practices to reduce medicolegal exposure.
Summary
On completion of this review, the reader should be able to recognize the magnitude of the problem of opioid over-prescribing in the US and identify several patient risk factors for opioid misuse, abuse, and/or diversion. Specifically, better familiarity with the recently published CDC guidelines for opioid prescribing will help ensure the adoption of best-use practices that maximize therapeutic efficacy while attenuating the possibility of harm to patients. A thorough review of the legal principles and risk-mitigation strategies relevant to opioid prescribing will also lessen the clinician's exposure to medicolegal liability.
Collapse
Affiliation(s)
- Jason S Eldrige
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Foundation, Rochester, MN
| | - Richard H Rho
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Foundation, Rochester, MN
| | | | | | - W Michael Hooten
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Foundation, Rochester, MN
| |
Collapse
|
23
|
Jannetto PJ, Bratanow NC, Clark WA, Hamill-Ruth RJ, Hammett-Stabler CA, Huestis MA, Kassed CA, McMillin GA, Melanson SE, Langman LJ. Executive Summary: American Association of Clinical Chemistry Laboratory Medicine Practice Guideline—Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients. ACTA ACUST UNITED AC 2017; 2:489-526. [DOI: 10.1373/jalm.2017.023341] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/12/2017] [Indexed: 11/06/2022]
|
24
|
Abstract
While the evidence for urine drug testing for patients on chronic opioid therapy is weak, the guidelines created by numerous medical societies and state and federal regulatory agencies recommend that it be included as one of the tools used to monitor patients for compliance with chronic opioid therapy. To get the most comprehensive results, clinicians should order both an immunoassay screen and confirmatory urine drug test. The immunoassay screen, which can be performed as an in-office point-of-care test or as a laboratory-based test, is a cheap and convenient study to order. Limitations of an immunoassay screen, however, include having a high threshold of detectability and only providing qualitative information about a select number of drug classes. Because of these restrictions, clinicians should understand that immunoassay screens have high false-positive and false-negative rates. Despite these limitations, though, the results can assist the clinician with making preliminary treatment decisions. In comparison, a confirmatory urine drug test, which can only be performed as a laboratory-based test, has a lower threshold of detectability and provides both qualitative and quantitative information. A urine drug test's greater degree of specificity allows for a relatively low false-negative and false-positive rate in contrast to an immunoassay screen. Like any other diagnostic test, an immunoassay screen and a confirmatory urine drug test both possess limitations. Clinicians must keep this in mind when interpreting an unexpected test result and consult with their laboratory when in doubt about the meaning of the test result to avoid making erroneous decisions that negatively impact both the patient and clinician.
Collapse
|
25
|
Enders JR, Reddy SG, Strickland EC, McIntire GL. Identification of metabolites of brexpiprazole in human urine for use in monitoring patient compliance. CLINICAL MASS SPECTROMETRY 2017. [DOI: 10.1016/j.clinms.2017.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
26
|
Kwong TC, Magnani B, Moore C. Urine and oral fluid drug testing in support of pain management. Crit Rev Clin Lab Sci 2017; 54:433-445. [PMID: 28990451 DOI: 10.1080/10408363.2017.1385053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In recent years, the abuse of opioid drugs has resulted in greater prevalence of addiction, overdose, and deaths attributable to opioid abuse. The epidemic of opioid abuse has prompted professional and government agencies to issue practice guidelines for prescribing opioids to manage chronic pain. An important tool available to providers is the drug test for use in the initial assessment of patients for possible opioid therapy, subsequent monitoring of compliance, and documentation of suspected aberrant drug behaviors. This review discusses the issues that most affect the clinical utility of drug testing in chronic pain management with opioid therapy. It focuses on the two most commonly used specimen matrices in drug testing: urine and oral fluid. The advantages and disadvantages of urine and oral fluid in the entire testing process, from specimen collection and analytical methodologies to result interpretation are reviewed. The analytical sensitivity and specificity limitations of immunoassays used for testing are examined in detail to draw attention to how these shortcomings can affect result interpretation and influence clinical decision-making in pain management. The need for specific identification and quantitative measurement of the drugs and metabolites present to investigate suspected aberrant drug behavior or unexpected positive results is analyzed. Also presented are recent developments in optimization of test menus and testing strategies, such as the modification of the standard screen and reflexed-confirmation testing model by eliminating some of the initial immunoassay-based tests and proceeding directly to definitive testing by mass spectrometry assays.
Collapse
Affiliation(s)
- Tai C Kwong
- a Department of Pathology and Laboratory Medicine , University of Rochester Medical Center , Rochester , NY , USA
| | - Barbarajean Magnani
- b Department of Pathology and Laboratory Medicine , Tufts Medical Center , Boston , MA , USA
| | | |
Collapse
|
27
|
|
28
|
Arthur JA, Edwards T, Lu Z, Reddy S, Hui D, Wu J, Liu D, Williams JL, Bruera E. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer 2016; 122:3732-3739. [PMID: 27509305 DOI: 10.1002/cncr.30240] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/01/2016] [Accepted: 07/01/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. METHODS A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. RESULTS Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%). CONCLUSIONS UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.
Collapse
Affiliation(s)
- Joseph A Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Tonya Edwards
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Zhanni Lu
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Jimin Wu
- Department of Quantitative Sciences, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Janet L Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| |
Collapse
|
29
|
Arthur JA, Haider A, Edwards T, Waletich-Flemming J, Reddy S, Bruera E, Hui D. Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care. J Palliat Med 2016; 19:778-82. [PMID: 27171327 DOI: 10.1089/jpm.2015.0335] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aberrant opioid use is a public health issue, which has not been adequately described in the palliative care literature. With the increasing integration of palliative care into oncologic care, palliative care clinicians are seeing patients earlier in the disease trajectory, and therefore, more outpatients with chronic pain requiring chronic opioid therapy. This may have resulted in a concomitant rise in the number of patients with aberrant opioid use. In this article, we report on two patients with aberrant opioid-related behavior seen at our palliative care clinic. A high suspicion of opioid abuse, misuse, or diversion based on certain behavioral cues necessitated the ordering of a urine drug test (UDT). The tests helped the medical team to confirm an already existing pattern of maladaptive opioid use. In both cases, we provided ample opioid education and implemented effective strategies to address their aberrant opioid use. These cases suggest the need for palliative care clinicians to develop strategies to effectively address this issue in our field of medicine. It also highlights the usefulness of UDT in the outpatient palliative care setting.
Collapse
Affiliation(s)
- Joseph A Arthur
- 1 Department of Palliative Care and Rehabilitation Medicine, University of Texas at MD Anderson Cancer Center , Houston, Texas
| | - Ali Haider
- 1 Department of Palliative Care and Rehabilitation Medicine, University of Texas at MD Anderson Cancer Center , Houston, Texas
| | - Tonya Edwards
- 2 Supportive Care Center, University of Texas at MD Anderson Cancer Center , Houston, Texas
| | | | - Suresh Reddy
- 1 Department of Palliative Care and Rehabilitation Medicine, University of Texas at MD Anderson Cancer Center , Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative Care and Rehabilitation Medicine, University of Texas at MD Anderson Cancer Center , Houston, Texas
| | - David Hui
- 1 Department of Palliative Care and Rehabilitation Medicine, University of Texas at MD Anderson Cancer Center , Houston, Texas
| |
Collapse
|
30
|
Baciu T, Borrull F, Neusüß C, Aguilar C, Calull M. Capillary electrophoresis combined in-line with solid-phase extraction using magnetic particles as new adsorbents for the determination of drugs of abuse in human urine. Electrophoresis 2016; 37:1232-44. [DOI: 10.1002/elps.201500515] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/01/2016] [Accepted: 02/02/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Tatiana Baciu
- Department of Analytical Chemistry and Organic Chemistry; Universitat Rovira i Virgili; Tarragona Spain
| | - Francesc Borrull
- Department of Analytical Chemistry and Organic Chemistry; Universitat Rovira i Virgili; Tarragona Spain
| | | | - Carme Aguilar
- Department of Analytical Chemistry and Organic Chemistry; Universitat Rovira i Virgili; Tarragona Spain
| | - Marta Calull
- Department of Analytical Chemistry and Organic Chemistry; Universitat Rovira i Virgili; Tarragona Spain
| |
Collapse
|
31
|
Lee CT, Vo TT, Cohen AS, Ahmed S, Zhang Y, Mao J, Chen L. Profiles of Urine Drug Test in Clinical Pain Patients vs Pain Research Study Subjects. PAIN MEDICINE 2016; 17:636-43. [PMID: 26398237 DOI: 10.1111/pme.12900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine similarities and differences in urine drug test (UDT) results in clinical pain patients and pain subjects participating in pain research studies. DESIGN An observational study with retrospective chart review and data analysis. METHODS We analyzed 1,874 UDT results obtained from 1) clinical pain patients (Clinical Group; n = 1,529) and 2) pain subjects consented to participate in pain research studies (Research Group; n = 345). Since several medications such as opioids used in pain management are drugs of abuse (DOA) and can result in a positive UDT, we specifically identified those cases of positive UDT due to nonprescribed DOA and designated these cases as positive UDT with DOA (PUD). RESULTS We found that 1) there was a higher rate of PUD in clinical pain patients (41.3%) than in pain research study subjects (14.8%); 2) although subjects in the Research Group were informed ahead of time that UDT will be conducted as a screening test, a substantial number (14.8%) of pain research study subjects still showed PUD; 3) there were different types of DOA between clinical pain patients (cannabinoids as the top DOA) and research study subjects (cocaine as the top DOA); and 4) a common factor associated with PUD was opioid therapy in both Clinical Group and Research Group. CONCLUSION These results support previous findings that PUD is a common finding in clinical pain patients, particularly in those prescribed opioid therapy, and we suggest that UDT be used as routine screening testing in pain research studies.
Collapse
Affiliation(s)
- Cheng-ting Lee
- *University of Texas Southwestern Medical Center in Dallas, Texas, USA
| | - Trang T Vo
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail S Cohen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shihab Ahmed
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Zhang
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jianren Mao
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy Chen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
32
|
Ceasar R, Chang J, Zamora K, Hurstak E, Kushel M, Miaskowski C, Knight K. Primary care providers' experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings. Subst Abus 2016; 37:154-60. [PMID: 26682471 PMCID: PMC4823143 DOI: 10.1080/08897077.2015.1132293] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper. METHODS Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology. RESULTS The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use. CONCLUSIONS These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.
Collapse
Affiliation(s)
- Rachel Ceasar
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jamie Chang
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kara Zamora
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
| | - Emily Hurstak
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Margot Kushel
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Christine Miaskowski
- School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Kelly Knight
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
33
|
Baciu T, Botello I, Borrull F, Calull M, Aguilar C. Capillary electrophoresis and related techniques in the determination of drugs of abuse and their metabolites. Trends Analyt Chem 2015. [DOI: 10.1016/j.trac.2015.05.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
34
|
Yuan C, Chen D, Wang S. Drug confirmation by mass spectrometry: Identification criteria and complicating factors. Clin Chim Acta 2014; 438:119-25. [PMID: 25182671 DOI: 10.1016/j.cca.2014.08.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 08/06/2014] [Accepted: 08/19/2014] [Indexed: 11/27/2022]
Abstract
Drug confirmation by mass spectrometry coupled with chromatography is essential to toxicology, doping control, pain management, and workplace drug testing. High confidence in this technology is due to its superior specificity and sensitivity. However, there are challenges associated with drug confirmation, and proper setup and validation of these assays are important in assuring high-quality results. In this article, assay parameters required for drug confirmation are summarized based on recent scientific publications, various established guidelines, and our own practical experience. Factors affecting the result quality and correct results interpretation are critically reviewed. Several emerging technologies and their potential applications are briefly explored.
Collapse
Affiliation(s)
- Chao Yuan
- Department of Clinical Pathology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Derrick Chen
- Department of Clinical Pathology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Sihe Wang
- Department of Clinical Pathology, Cleveland Clinic, Cleveland, OH 44195, USA.
| |
Collapse
|
35
|
McMillin GA, Slawson MH, Marin SJ, Johnson-Davis KL. Demystifying Analytical Approaches for Urine Drug Testing to Evaluate Medication Adherence in Chronic Pain Management. J Pain Palliat Care Pharmacother 2013; 27:322-39. [DOI: 10.3109/15360288.2013.847889] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
36
|
Meltzer EC, Hall WD, Fins JJ. Error and Bias in the Evaluation of Prescription Opioid Misuse: Should the FDA Regulate Clinical Assessment Tools? PAIN MEDICINE 2013; 14:982-7. [DOI: 10.1111/pme.12099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
37
|
Fatal Overdose due to Confusion of an Transdermal Fentanyl Delivery System. Case Rep Crit Care 2013; 2013:154143. [PMID: 24829815 PMCID: PMC4010010 DOI: 10.1155/2013/154143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 03/07/2013] [Indexed: 11/17/2022] Open
Abstract
Background. The use of transdermal fentanyl systems has increased over recent years, especially in patients with chronic pain. Large misuse potential and fatal outcomes have been described. Case Presentation. A 58-year-old patient presenting with clinical signs of opioid poisoning (hypoventilation, bradycardia, hypotension, and miosis) was admitted to our ICU. The first body check revealed a 75 mcg per hour fentanyl patch at the patient's right scapula. Some months ago, patient's aunt died after suffering from an oncological disease. During breaking up of her household, the patches were saved by the patient. Not knowing the risk of this drug, he mistook it as a heat plaster. Investigations. Laboratory test showed an impaired renal function and metabolic acidosis. Urine drug test was negative at admittance and 12 h later. CCT scan presented a global hypoxic brain disease. Treatment and Outcome. The patient was discharged 30 days after admittance in a hemodynamic stable condition but a vegetative state and transferred to a rehabilitation center. Learning Points. With the ongoing increase in fentanyl patch prescriptions for therapeutic reasons, it is likely that misuse cases will become more relevant. Conventional urine drug screening tests are not able to exclude the diagnosis fentanyl intoxication. History taking should include family member's drug prescriptions.
Collapse
|
38
|
Abadie J. How Can the Clinical Picture Guide Appropriate Laboratory Drug Testing in the Treatment of Pain Clinic Patients with Opioid Analgesics? PAIN MEDICINE 2012; 13:857-9. [DOI: 10.1111/j.1526-4637.2012.01421.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
39
|
Schonwald G. What is the Role of Urine Drug Testing (UDT) in the Management of Chronic Non-Cancer Pain with Opioids? PAIN MEDICINE 2012; 13:853-6. [DOI: 10.1111/j.1526-4637.2012.01440.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|