Drug Testing: An Overview. Presented by Burlington Labs. Michael Casarico, Jon Meredith and Jessica Benjamin

Transcription

1 Drug Testing: An Overview Presented by Burlington Labs Michael Casarico, Jon Meredith and Jessica Benjamin

2 When is Drug Testing Most Effective? When it is random When it is observed When it is used to support recovery

3 Why use drug testing? An excellent assessment tool that, along with other indicators, can be used to support a DSM diagnosis. Can help verify that information the client is giving is accurate. Results can give you information indicating whether the client is following their treatment plan. Can support your client in an abstinence based treatment plan. (Makes it easier for the client to say no, if they know they are going to be tested.)

4 How Can Testing be Used? What testing can do: It can tell you if a client has had exposure to a substance What testing cannot do: It cannot tell you how much a person used

5 What are the common types of Oral Fluid Testing drug testing? Hair Testing Blood Analysis Urinalysis

6 Benefits of Oral Fluid Testing Collection methods: Easy to observe, noninvasive, no special accommodations needed Typically detects parent drug only, better correlation with impairment Originally thought to be especially effective for roadside testing

7 Limitations of Oral Fluid Testing Only beneficial for detecting recent exposure (short detection time) Drugs may reduce salivation affecting sample volume Drug concentrations frequently lower than concentrations in urine Passive drool technique can be uncomfortable Small sample volume, fewer testing options False-negatives due to poor adsorption of drugs into devices

8 Benefits of Hair Testing Easy to collect, non-invasive Able to detect long-term drug use May be the only methodology to test postmortem Easy storage and transportation

9 Limitations of Hair Testing $$$ Hair testing costs 2x as much as urinalysis Currently hair testing is not associated with dosage or time of administration Environmental contamination is considered to be significant, unable to differentiate from passive exposure

10 Benefits of Blood Testing Strong correlation to impairment Able to distinguish between abuse and prescribed No issues of dilution Very difficult to adulterate Specimens are refrigerated but stored with preservatives to prevent degradation

11 Limitations of Blood Testing Invasive collection, need a qualifying individual to draw blood; sometimes a subpoena Short detection window Typically only parent drugs are present Cost is expensive

12 Benefits of Urinalysis Long detection window Affordable Accessible Non-invasive collection Most common method of testing Many resources available to help with interpretation of results

13 Limitations of Urinalysis No way to determine extent of impairment Difficult to determine exact time since last use Cross-reactivity of screens Best if collection is observed; same sex collectors needed

14 In summary. Detection Times Collection Procedure Blood Hair Oral Fluids Urine Short, recent exposure only Difficult, phlebotomist needed Longest detection time strands, usually observed Adulteration Very Difficult Difficult if observed Shortest detection time Unpleasant, sample volume issues Unknown Expense $$$ $$$$ $ $$ Storage Usefulness Stored with preservatives Parent drugs, strong correlation to impairment Depends on drug Observed is best, restrooms needed Detectable Easy Refrigeration Refrigeration Not associated with dose or administration time Parent drugs present only, high hopes for roadside tests Very useful, especially with abstinence programs

15 Urine The most common matrix to use with clinical drug testing Many types of urine drug testing: Thin Layer Chromatography; qualitative, pregnancy tests Immunoassay; enzyme-based, semiquantitative results GC/MS and LC/MS/MS; separation of drugs based on physical properties for identification and quantification

16 Cross Reactivity Cross Reactivity occurs when a substance similar in structure mimics the drug of interest and causes a positive result The result is commonly termed falsepositive because the drug of interest is not causing the positive result This is one of the limitations of drug screening with enzyme-based testing

17 Urinalysis methodologies Instant Cups Immunoassays Confirmatory Turnaround Time Immediate 1-3 Days 3-7 Days Expense $ $$ $$$ Cutoffs Variable with test Sensitive Lowest cutoffs Results Qualitative Semi-Quantitative Quantitative Cross Reactivity Very High Dependent on analyte Use Immediate decisions, therapeutic intervention Additional clinical tool; helpful in assessing abstinence Non-existent Clinical and forensic uses

18 What is urine? Urine is a waste substance secreted by the kidneys which contain various products and water. Certain parameters specific to Urine including temperature, ph, creatinine and specific gravity Normal temperature reading: F ph: 3-11 Creatinine: >20 mg/dl, Specific Gravity:

19 Masking Test Results Three ways to attempt masking Dilution Method of reducing the concentration of the drug(s) of abuse (flush kits) Substitution Swapping urine (prosthetic devices) Adulterating Adding a substance to the urine to disrupt the instrumentation or degrade the drug(s) of abuse (bleach)

20 Example Report

21 Specimen Validity Testing Validity Result General Oxidants >200 ug/ml Temperature > 100 F Temperature < 100 F ph outside of range Creatinine < 20 mg/dl Creatinine < 20 md/dl, SG < Specific Gravity > Possible Explanation Possible adulteration (bleach) Substitution Possible Dilution Possible adulteration or substitution Possible dilution Dilution Concentrated urine

22 New Jersey admissions aged 12 and older, by primary substance of abuse: Source: Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS). Data received through

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24 Heroin Detection 6-AM is detectable in urine about 12 hours after use. The presence of 6-AM and morphine in urine is indicative of heroin use. The absence of 6-AM from urine does not mean heroin was not used, but perhaps enough time has elapsed that all of the heroin was metabolized into morphine.

25 Marijuana Areas affected in the brain

26 THC Delta-9-Tetrahydrocannabinol (THC) is the psychoactive part of the drug THC is metabolized into 11-OH-THC and then to 11-COOH. Urinalysis detects the final metabolite, 11- COOH. THC and cannabinoids are lipophilic and adhere to adipose tissue (fatty tissue). This contributes to long detection times.

27 THC detection times in urine Single use up to 3 days Moderate use up to 4 days Heavy use up to 10 days Chronic use up to days Excellent tool to accurately assess Client s usage pattern

28 THC Normalization Values The hydration level of the donor at the time of collection greatly influences the results of any drug Over time, the levels may not appear to be trending down, as expected Important to normalize the results to account for this fluctuation in hydration.

29 Scenario One: Did Joe Relapse? Date 1/1/13 1/4/13 1/7/13 1/10/13 1/17/13 THC (ng/ml) Creatinine (mg/dl)

30 Yes. Joe can t fool you! Date 1/1/13 1/4/13 1/7/13 1/10/13 1/17/13 THC (ng/ml) Creatinine (mg/dl ) Normalization (ng/mg) (125/100) * 100 = 125 (100/95) * 100 = 105 (75/100) * 100 = 75 (70/95) * 100 = 73 (55/25) * 100 = 220

31 Scenario Two: Did Jane Relapse? Date 1/1/13 1/4/13 1/7/13 1/10/13 1/17/13 THC (ng/ml) Negative Negative 90 Creatinine (mg/dl)

32 Question the report Date 1/1/13 1/4/13 1/7/13 1/10/13 1/17/13 THC (ng/ml) Negative Negative 90 Creatinine (mg/dl) First Question to always ask when dealing with a negative result. What is the cutoff???? Date 1/1/13 1/4/13 1/7/13 1/10/13 1/17/13 THC (ng/ml) LESS THAN 50 Creatinine (mg/dl) LESS THAN

33 No. Jane did not use again. Date 1/1/13 1/4/13 1/7/13 1/10/13 1/17/13 THC (ng/ml) Creatinine (mg/dl ) Normalization (ng/mg)

34 Alcohol Ethanol detectable in urine for up to 12 hours after last drink. Metabolism is dependent on amount consumed. Ethanol is metabolized in the liver into two compounds: Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS). EtG is detectable in urine for up to 80 hours. First direct biomarker indicating ethanol exposure

35 EtG Benefits Able to detect alcohol exposure up to 3 days after use Extremely sensitive, only one drink needed to elicit a positive result Excellent in monitoring abstinence and identification of early relapse Burlington Labs offers free EtG testing with every panel

36 EtG Limitations Sensitive to extraneous alcohol exposure (including hand sanitizers and cooking wine) Some medications contain EtG (NyQuil) Difficult to interpret results (extraneous exposure vs. consumption, light drinking vs. binge) Suggested for Clients to sign a contract understanding extraneous exposure

37 Synthetic Cannabinoids Researcher John Huffman, professor at Clemson University Synthesis of drugs with properties of THC Huffman received phone calls indicating one of his cannabinoids, JWH-018 was showing up on the internet as Spice Gold, Spice Diamond, Purple Haze, K2, Skunk and Smoke. Cannabinoid receptor agonist; structurally dissimilar from THC

38 Detection of Synthetic Cannabinoids Typically High BP as opposed to Low BP Increased anxiety/agitation, nausea and vomiting and psychiatric disturbances Able to be detected by LC/MS/MS Imperative to get a comprehensive test (our referral lab can detect 21 cannabinoids) Currently qualitative methods

39 Designer Stimulants (Bath Salts) MDPV, mephedrone and methylone are the main constituents Synthetic powder is inhaled, ingested or injected Powder produces effects similar to methamphetamine and MDMA Serious side effects: Increased BP, kidney failure, seizures, muscle spasms, loss of bowel control, hallucinations and delusions, aggression, severe paranoia, panic attacks Less serious side effects: chest pains, agitation, insomnia, lack of appetite, anxiety, nosebleeds

40 Detection of Bath Salts Over 100 various bath salt compounds available, toxicologists able to identify no more than 40 (as of Oct 2010) Peak high lasts 3-4 hours Detectable in urine 2-3 days

41 Opioid and Opiate Detection Opiates are derived from the poppy plant (heroin, morphine, codeine and metabolites) Opioids are synthetic opiates like pharmaceuticals or non-narcotic analgesics Many opioids are detected by screens Pharm parties skittling Upcoming questionable abused drugs Lyrica? Gabapentin?

42 Other common questions ADHD medications do they show up positive on amphetamine screen??? Vyvanse? Yes. Concerta? Yes. Adderall? Yes. Ritalin? No. Is there currently a test for inhalants? Yes, but they are typically very expensive If my Clients drink pickle juice will they test negative? Maybe, but it s not because of the pickle juice. Consuming large amounts of any liquid can affect test results by masking the results.

43 Questions?

44 Burlington Labs Resources Michael Casarico, President (802) Jessica Benjamin, Scientist (802) Jon Meredith, Summit Diagnostics (973)