By: Patricia Simpson, BS, MBA, HSM, HSM, MT
In today’s world those that “distribute” illegal drugs are constantly challenging those of us that that provide testing for drugs found in bodily fluids. One of the newest drugs, Gravel, is a combination of methamphetamine, crack cocaine and bath salts. All of which can be detected using today’s technology. Labs today need to be advanced enough to detect multiple synthetic drugs such as Bath Salts, Spice and Kratom. In recent times, these synthetic drugs have become popular especially due to their psychoactive properties and ability to evade detection via drug urinalysis testing systems.
We then have the distribution of “legal” drugs; drugs which are prescribed by physicians for pain relief (opiates) and anti–anxiety meds such as benzodiazepines. Many that become physically dependent on these “legal” prescription drugs will, at some point along the way, lose the ability to meet their need for the drugs on which they now have become dependent. Those working in the substance abuse and mental health fields have seen an increase in heroin and synthetic drug use. In the past, testing labs have had to test the population for prescription painkillers, benzodiazepines, heroin and alcohol, but today we also have to test for a variety of synthetic drugs. Laboratory reports with quantitative results are a tremendous clinical tool for medical staff and therapists. They can help clinical staff to evaluate if the form of treatment is working and if the person is remaining abstinent.
Substance abuse is not limited to teenagers and college students it effects ages 12 and older. From 1998 to 2008 admissions for pain pill abuse increased from 18,300 to 105,680. Studies have shown an increase in heroin use after 4 or 5 years of use and abuse of Non-Medical Pain Relievers (NMPR). The percentage of heroin use has increased 500% due to the misuse of NMPR’s. Increases in price of street OxyContin® sent many users towards Heroin which is cheaper and easier to obtain.
Heroin use from 2002 to 2011 went from 117,000 to 620,000. Since both NMPR’s and heroin act on the same receptors in the brain, studies have shown a direct link between past NMPR use and the introduction and continued use of Heroin. At New Beginnings Recovery Center (NBRC), we see this on a daily basis. Where many recovery patients have had a past of surgeries, injuries or pain and have been prescribed pain relievers a history of heroin use after the NMPR is frequently noted.
Drug testing is an important tool used by those in the treatment field. In clinical situations drug testing can aid in clinical and psychiatric analysis or detoxification of drugs or alcohol in addition to adding a high degree of accountability with the client. The priority is making sure that patients are taking their prescribed medications as prescribed and avoiding illegal and synthetic drugs.
Laboratory testing is the top of the line defense against these “new” drugs. Some labs now have available the ability to screen for drugs using instruments that are semi-quantitative and confirm those drugs using an instrument that will give us the exact drug and the quantity of it. Using both these defense mechanisms is important for the following reasons:
- Quantification aids our medical staff when diagnosing, monitoring treatment progress of those in the in detoxification level of care.
- It allows psychiatric and medical staff to make informed decisions when prescribing therapeutic medications.
The collection procedure consists of individual urinalysis collection that gives the medical staff an idea of drugs in the patient’s system. This can be a highly useful tool for monitoring patients enrolled in a detoxification program. This screening reinforces the cup results and also gives clinical staff a quantitative analysis.
Of all possible specimens available, urine is the easiest to tamper with or adulterate. By this we mean that either a patient has brought an outside negative urine sample or bought a substance that will interfere with or adulterate the testing of the specimen. Several preventative steps can be taken by lab staff to aid in detection of these practices. By making sure personal affects remain outside of the bathroom, and adding a bluing or coloring agent in the toilet water, you can decrease the chances of adulteration. At collection sites, the water should be turned off to the sink located in the bathroom where specimens are taken. In many cases a laboratory can test for creatinine, pH and specific gravity. These tests will let staff know if the urine is dilute or if a foreign substance has been added. An invalid test may not necessarily mean the test has been adulterated. It may, perhaps, indicate of the presence of dehydration, over hydration, other prescription medications or an illness that may alter the validity of the test.
There are 4 common adulterants which can be bought over the counter:
- Gluteraldehyde known as “Clean X” interferes with immunoassay tests (screening results), has a very sweet smell.
- Sodium or Potassium nitrite known as “Klear” or “Whizzies” will mask the detection of THC-COOH.
- Pyridinium Chlorochromate “Urine Luck” can mask THC and many other drugs.
- Peroxide/Peroxidase also known as “Stealth” effects the detection of THC-COOH and others. By running certain tests and confirmations the laboratory can detect and report the presence/absence of a drug or report adulteration of the submitted specimen. Using anything that changes the result of the drug testing defeats the purpose of an individual’s recovery (SAMH p. 53, TAP 32).
The screening test which provides a semi-quantitative result is an immunoassay test. This test involves an antibody-antigen reaction. Thresholds (Cut-offs) are established according to state, federal or instrument detection standards. Drug concentrations above these established thresholds are considered “Positive” for each particular drug. Below threshold would be reported as a “Negative”.
Confirmation testing looks for the molecule for a particular analyte (drug) using mathematical ratio equations which identify and quantitate that particular analyte (drug). Confirmation testing is a more specific type of testing for each specific drug which looks for the identified molecules and provides quantitative results. This is helpful when there is a need to evaluate the amount of substances in the patient’s system and how to evaluate plans for future treatment.
There are reasons why a lab may want to confirm “Positive” drug screens. Many drugs have similar molecular structures which may lead to false Positive results. Amphetamine is a perfect example. Many over the counter medications such as diet pills or cold medications will produce a positive amphetamine screen but will not be positive upon confirmation. Screening for drugs helps detect “Negative” results but it does not always detect synthetic or therapeutic drugs such as Krokodil (a Heroin-like synthetic), Spice (synthetic Marijuana), Bath Salts or even the psychiatric drug Gabapentin.
As stated earlier, confirmations are done using human urine specimens. Since drug metabolites stay in the body longer, and urine contains the majority of drug metabolites, running confirmations on urine is the least invasive and the most reliable way to know beyond a shadow of doubt that a particular result is positive or negative. Cross-reactivity happens among many drug classes such as Amphetamines, Benzodiazepines and even Phencyclidine (PCP). Confirmations distinguish between these substances. For example a patient using “Unisom” with doxylamine may screen positive for Phencyclidine creating a false “positive” result. The report run through confirmation will state “Negative”. The importance of confirming a drug screen test can mean the difference between a “true” relapse and a false positive. Recidivism is a normal part of the recovery process. By reporting a “positive” result the clinical staff can decide whether the patient requires a higher level of care or if an alteration to the treatment plan is indicated.
Privacy considerations need to be understood. The Laboratory can only report results to the medical staff or therapists. HIPAA privacy regulations must be maintained at all times. Specimens are collected, labeled with a barcode label and brought to the laboratory for processing. The laboratory tests for specimen validity, screening and finally confirmation. All results are reviewed and reported should by a Board Certified Technologist. The results are compared between screening result and confirmation. Confirmations are reviewed for drug and/or metabolite, time it is identified and chromatogram peak. These are also reviewed by a qualified Board Certified Technologist.
Quality treatment providers should strive for quality and accuracy by providing medical staff with both screening and confirmation results. This will assist staff in identifying clients / patients that abuse drugs and thus make sure that prescribed medications are being taken responsibly.
Kronstrand, Robert, Roman, Markus, Anderson, Mikael and Eklund, Arne. “Toxicological Findings of Synthetic Cannabinoids in Recreational Users”- Journal of Analytical Toxicology, Vol. 37, No. 8, p. 534 – 541.
McDaniel, Glen, MS, MBA, MT, CLS, CLDIR. “Drugs of Abuse Testing: Old and New” – Advance for Administrators of the Laboratory, Vol. 23, No. 1, p. 24 – 27.
Pradip K. Muhuri, Joseph, C. G. Frocter, Christine Davis. SAMHSA CBHSQ – “Data Review. Associations of Non-Medical Pain Reliever Use and Initiation of Heroin Use in the US”
SAMHSA, Clinical Drug Testing in Primary Care. Technical Assistance Publication
Series, TAP 32. www.samhsa.gov –Treatment Episode Data Set. The TEDS Report – “Characteristics of Substance Abuse Treatment Admissions Reporting Primary Abuse of Prescription Pain Relievers: 1998 and 2008″
Patricia Simpson, BS, MBA, HSM, MT is the Laboratory Director at New Beginnings Recovery Center in Palm Beach Gardens, Florida. Born in Buenos Aires, Argentina, Patty’s family came to this country in 1963. She was the first woman in her family to graduate from University. She graduated from C.W.Post University, with a Medical Biology degree. After that she moved to Florida, and has extensive laboratory experience ranging from hospital laboratory work to reference laboratories. The bulk of Patty’s experience is in forensic toxicology, managing a State of Florida drug free program and working as the responsible person for the federal SAMHSA drug free workplace program. Three years ago she graduated from Keiser University with an MBA in International Business and a Masters in Health Service Administration. Patty has 2 beautiful daughters.
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