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Emerging Issues in Drug Testing. Greg Skipper, MD Director, Professional Health Services Promises Treatment Centers Los Angeles, CA gskipper@promises.com 310-633-4595. Drug Testing is Effective and Underutilized.

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Emerging issues in drug testing

Emerging Issues in Drug Testing

Greg Skipper, MD

Director, Professional Health Services

Promises Treatment Centers

Los Angeles, CA

gskipper@promises.com

310-633-4595


Drug testing is effective and underutilized
Drug Testing is Effective and Underutilized

  • When testing is frequent, random and tied to immediate moderate consequences drug use is deterred.



Difficult cases
Difficult Cases

  • Patient prescribed hydrocodone

    • Urine test negative for opioids

    • Urine test positive for hydromorphone only?

    • Oxymorphone?

    • Codeine?



Difficult cases2
Difficult Cases

  • Patient prescribed oxycodone

    • Urine test negative for opioids

    • Urine test positive for hydrocodone

    • Oxymorphone?

    • Codeine?


Emerging issues in drug testing

Anomalous observations of hydrocodone in patients on oxycodone.

West R et al, Clin Chim Acta. 2010 Aug 27.

BACKGROUND: Oxycodone preparations are known to have small amounts of hydrocodone as an impurity estimated to be <0.1%. We established the concentration of unexpected hydrocodone in patients taking oxycodone.

METHODS: 30,000 pain patients

CONCLUSIONS: When oxycodone is >100,000ng/ml, hydrocodone should be <1500ng/ml. When oxycodone is <100,000ng/ml then hydrocodone should be <500ng/ml. Values greater than these indicate non-prescribedhydrocodone use. Clinicians and laboratories testing urine for drugs should be aware of the possibility of low concentrations of hydrocodone in the urine of patients taking high doses of oxycodone.


Difficult cases3
Difficult Cases on oxycodone.

  • Patient prescribed Valium

    • Urine test positive for oxazepam only

    • Temazepam


Difficult cases4
Difficult Cases on oxycodone.

  • Patient on xanax (alprazolam) or

  • Klonopin (Clonzaepam)

    • Urine test negative for benzo’s?


Sensitivity vs specificity
Sensitivity vs Specificity on oxycodone.

  • Are they always mutually exclusive?

  • Highly sensitive

    • More prone to false positive?

  • Highly specific

    • More prone to false negative?


Screening vs confirmation tests
Screening vs Confirmation Tests on oxycodone.

  • Screening

    • Immunoassays, ELISA, EMIT, DRI, Dipstick

    • Tend to be highly sensitive

    • Not so specific

  • Confirmation

    • GC/MS, LC/MS, LC/MS/MS

    • Highly specific

    • Not so sensitive (because of restricted panel)


Matrices
Matrices on oxycodone.


Mro function
MRO function on oxycodone.

  • Is there a cause for positive other than illicit use?

    • Legitimate prescription

    • False positive – at least two types


Legitimate use
Legitimate Use? on oxycodone.

  • Coca tea?

  • Cocaine positive from sex?

  • ENT procedure?

  • Hemp oil? Hemp cereal? Hemp cosmetics? Hemp granola bars? Hemp lip balm?

  • Sprained ankle and was given heroin while visiting Great Britain?

  • THC? Ever legal in US?

    • Passive inhalation

  • Poppy seeds


Poppy seeds
Poppy Seeds on oxycodone.

  • Over 1,000 species of poppy seeds

  • Used in cooking

    • Baking

    • Salad dressings

    • Curry sauces

  • Morphine level >1,000, >2,000, >5,000, >15,000 ????

  • Urine concentration can be a clue


Accidental exposure
Accidental Exposure on oxycodone.

  • Marijuana brownie

  • Someone else’s medication

  • Took pill and didn’t know what it was

  • Drank punch and didn’t know it had alcohol in it

  • Vacuuming up someone else’s cocaine and turned vacuum clearner on reverse and blew it into the air


Crossreactivity
Crossreactivity on oxycodone.


Positive amphetamine due to l isomer
Positive Amphetamine due to l-isomer on oxycodone.

  • Vics inhaler, selegiline, EMSAM patch

    • D & L Isomer test

      • >80% l-amphetamine consistent w/

  • Pseudoephedrine converted to amphetamine inside the GC/MS machine

    • Retest


Dilutes
Dilutes on oxycodone.

  • Creatinine <20mg/dl and sp gr <1.003

    • Creatinine <20 but >10 mg/dl can be from innocent excess water

    • Creatinine <10mg/dl but >5mg/dl not likely innocent

    • Creatinine <5mg/dl probably substitution

    • Creatinine <2mg/dl definitely substituted


What to do
What to do? on oxycodone.

  • Creatinine <20 but >10 mg/dl can be from innocent excess water

    • Warn, observed, obtain hair/nails or saliva test

  • Creatinine <10mg/dl but >5mg/dl not likely innocent

    • Hair/nail, saliva, observed, evaluation

  • Creatinine <5mg/dl probably substitution

    • Assume substitution, verify observed, retest sample


Emerging technologies
Emerging Technologies on oxycodone.

  • Quick Test Kits

  • Better confirmation tests: LC/MS/MS

  • More extensive testing panels

  • Increased Use of Flex Testing

  • Improved testing for ethanol (EtG, EtS, etc)

  • Devices: TAD, SCRAM, Soberlink


Emerging issues in drug testing

Hair on oxycodone.

Testing


Nail testing
Nail Testing on oxycodone.

  • Good alternative to hair testing

  • Similar repository window

  • Less prone to adulteration from chemicals

  • Thicker than hair


Saliva testing
Saliva Testing on oxycodone.

  • DHHS - 5 DRUGS, ALCOHOL

  • SIMILAR TO PLASMA

  • INCREASINGLY USED

    (ie dilute urines)


Sweat testing
Sweat Testing on oxycodone.

  • DHHS - 5 DRUGS

  • PAROLE/PROBATION

  • Less invasive than hair testing


New alcohol monitoring technologies

New on oxycodone.Alcohol Monitoring Technologies


In the beginning
In the beginning… on oxycodone.

Blood alcohol

Breath alcohol

Urine alcohol

Limitations when used for alcohol monitoring

GGT, MCV

Carbohydrate Deficient Transferrin


Current technologies
Current Technologies on oxycodone.

Random field breathalyzer

Multiple daily ID home breathalyzer

Transcutaneous alcohol monitoring

New markers

EtG – EtS – PEth

Urine – Hair/Nails – Saliva – Blood


Frequent random breathalyzer
Frequent / Random Breathalyzer on oxycodone.

24/7 Program in South Dakota

Random testing field programs

BAT Mobile


24 7 south dakota
24/7 South Dakota on oxycodone.

House bill 1072

Rules:

Type, frequency, time, location, fees ($1 for each breath test), consequences

Usually twice a day on site in local police dept

Results - 2007

1,021 participants, 165,456 tests, 359 no shows = 99.8% show rate

Of 165,456 tests 534 failed tests


24 7 south dakota1
24/7 South Dakota on oxycodone.

Of 165,456 tests 534 failed tests

Rate of improvement for individuals - good


Positive id home breathalyzers
Positive ID Home Breathalyzers on oxycodone.

New home breathalyzer technologies

MEMS 3000

Smart Start In-Hom

Mobile Breath


Mobilebreath
MobileBreath® on oxycodone.


Soberlink
Soberlink on oxycodone.

Smart Phone Compatible and Required:Requires Android OS 2.2 or higher, or Blackberry OS 5.0 or higher (device must be Bluetooth enabled). Apple iPhone compatibility coming soon.

Photo Identification:Guarantee's the identity of the user. Facial recognition coming soon.

Fuel Cell Sensor:Provides highly accurate and reliable results.

DIMENSIONS:

Product Height: 4.75" (121mm)

Product Width: 1.5" (38mm)

Product Depth: 2.875" (73mm)

WEIGHT:

Product Weight: 6oz (190g)

WARRANTY:

1 Year Limited Warranty


Soberlink1
Soberlink on oxycodone.


Transcutaneous monitors
Transcutaneous Monitors on oxycodone.

SCRAM

TAD


Intermittent transcutaneous alcohol monitoring
Intermittent Transcutaneous Alcohol Monitoring on oxycodone.

www.alcoholmonitoring.com – to locate provider


Unique alcohol metabolites
Unique Alcohol Metabolites on oxycodone.

Ethylglucuronide (EtG)

Urine

Hair/Nails

Saliva


Urine etg and ets
Urine EtG (and EtS) on oxycodone.

1-4 days possible duration

Normalization important

(100/uCreat) x uEtG = Normalized EtG

Important to warn about things to avoid

Foods, mouthwash, handgel, etc.etc.

May be important to have participant sugar fast (4-6 hours) before submitting sample

Juices, fruits, etc contain small amounts etoh


Alcohol metabolites
Alcohol Metabolites on oxycodone.

Phosphatidyl Ethanol (PEth)

Blood

A group of phospholipids formed by alcohol on cell membranes - phospholipase D

Positive only after significant alcohol exposure (approx 7 drinks over a week)

Stays positive (>20ng/ml) for 2-3 weeks

Level correlates well with amount of alcohol consumed


Alcohol metabolites1
Alcohol Metabolites on oxycodone.

Phosphatidyl Ethanol (PEth)


Combination strategies
Combination Strategies on oxycodone.

Using PEth to confirm drinking following positive EtG/EtS when drinking denied

Study: 18 positive EtGs


Settings strategies
Settings / Strategies on oxycodone.

Normalize values to creatinine of 100md/dl (labs should automatically make this calculation)

Have participants sign consent regarding their responsibility to avoid alcohol

Re-advise to avoid all alcohol (including ripe fruits, juices, anything containing sugar) on day of test.


Hope probation
HOPE Probation on oxycodone.

  • HOPE probationers have the most serious felony drug and crime problems and are identified as likely to violate their conditions of community supervision

  • HOPE utilizes intensive random drug testing for up to 6 years

  • Responds to detected violations of probation (drug use, missed probation meetings, etc.) with clear, swift, short-term sanctions


Randomized control trial of hope vs standard probation
Randomized Control Trial of HOPE on oxycodone.vs. Standard Probation

  • In one-year period, HOPE probationers were:

    • 55% less likely to be arrested for a new crime

    • 72% less likely to use drugs

    • 61% less likely to skip appointments with their supervisory officer

    • 53% less likely to have their probation revoked

  • HOPE probationers were sentenced to, on average, 48% fewer days of incarceration than the control group


Hope drug test results
HOPE Drug Test Results on oxycodone.