urine drug screening - amazon s3 · pdf fileexpert guidance statement 6: urine drug screening...

Urine Drug Screening (UDS)

Dr. Erica L. Weinberg

December 2017

Copyright © 2017 by Sea Courses Inc.

All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any

form or by any means – graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without

prior written permission of Sea Courses Inc. except where permitted by law.

Sea Courses is not responsible for any speaker or participant’s statements, materials, acts or

omissions.

Conflict of Interest Disclosure

Presenter/Faculty: Dr. Erica L. Weinberg

Relationships with Commercial Interests:

Grants/research support: none

Speaker bureau/honoraria: Sea Courses

Consulting fees: none

Other: none

Potential for Conflict of Interest

• I have been Medical Inspector (MI)/Independent Opinion (IO) Provider at the

College of Physicians and Surgeons of Ontario (CPSO, ‘College’) –

frequently regarding opioid prescribing practices

• I have been a member of the National Faculty at the Michael G. Degroote

National Pain Centre since 2012

• I am one of the many authors on the Canadian Pain Society’s revised

consensus statement on the pharmacological management of chronic

neuropathic pain

Mitigating Potential Bias

• Information presented or recommendations made are

evidence/guideline/consensus-based

• I have completed the CPFC Mainpro+/Cert+ Declaration of Conflict of

Interest form evidencing compliance with Mainpro+/Cert+ requirements, a

requisite for this program to be given accredited status

• I will be discussing “off-label” uses of medications

The Guideline - Risk Mitigation

A baseline UDS may be useful for patients currently receiving

or being considered for a trial of opioids.

Clinicians may repeat UDS on an annual basis and more frequently if the patient is at elevated risk or

in the presence of any ADRBs.

When ordering a UDS, clinicians should ask patients about all medications/drugs recently

taken, and be aware of local resources to assist them in assessing for potential false

positive and false negative results.

Expert Guidance Statement 6: Urine Drug Screening

Available at http://nationalpaincentre.mcmaster.ca/guidelines.html

How Often Do You Think a UDS Should be Done?

How Often Do You Think a UDS Should be Done?

http://www.rxfiles.ca/rxfiles/uploads/documents/Urine-Drug-Screening-UDS-QandA.pdf

Should You Do Random UDS?

What about collecting UDS at every visit,

but not necessarily testing every time?

UDS – Why Bother

• To improve patient care and communication

• To help verify self-report of medication history

• To encourage or reinforce healthy behavioural change, sometimes as a

requirement of continued treatment

• Everyone has a role to play in safe medication use


Learning Objectives

After this session, participants will be able to:

• Develop a plan for urine drug screening (UDS)/urine drug testing (UDT) in

the office/clinic

• Interpret UDS results with more confidence

• Manage unexpected UDS results more effectively

Things to Know Before you Start

• You are not a police officer

• UDS is an imperfect tool, yet it can assist you in managing your patients

• The UDS test available to us is not performed up to forensic standards

• You must document your interpretation of the results and your subsequent

plan for action

• You must have standard operating procedures for UDS

Have Standard Operating Procedures

• Inform the patient of the routine nature of the test

– Is it part of your Opioid Treatment Agreement?

• Take a careful history of medication/drug use for the past week

– Consider asking, “What should I expect to see in the results?”

• Collect the urine sample in the your office/clinic, if possible

– Be consistent on what a patient can/cannot take into the washroom with them• E.g. Bulky clothing, bags …

https://www.cpsbc.ca/files/pdf/M-WS-101H-2014-09-13-P06-UDT.pdf


• Ensure proper labelling

• What is the urine temperature – ensure it is checked within a few minutes

– Does the urine sample feel ‘body temperature’

– Have a protocol in place if it feels ‘cold’



If you are doing Point of Care (POC) Testing:

• Ensure you have read the instructions thoroughly

• Consider occasionally verifying your POC UDS results with a laboratory immune

assay (IA) UDS

If you are Delegating the Act of POC Testing:

• Be aware of your College’s equivalent of a “Delegation of Controlled Acts Policy”

and ensure that your staff are adequately trained

– E.g. evaluation of the delegate, quality assurance, supervision of the delegation, ongoing

monitoring and evaluation …

Know the Limits

of the Test You Are

Ordering/Performing

Types of UDS

Point of Care (POC)

Laboratory

Enzyme Immunoassay (EIA)

Immunoassay (IA)

Gas Chromatography/Mass Spectrometry

(GC/MS)


POC UDS

Advantages

• Portable

• Immediate results

• Urine collected & tested

at clinician’s office/clinic

• Concurrently tests for

multiple drug classes

• Very responsive for

morphine and codeine

Disadvantages

• Cost of POC test kit/dipstick

• Less sensitive and specific than laboratory test

• Will NOT identify specific drugs or metabolites,

except for some exception

• Subjective nature of the qualitative assay

• Drug concentration in urine and assay’s

concentration cut-offs will affect detection

• More definitive testing may be required to

identify a specific drug or metabolite


Laboratory IA UDS

Advantages

• Rapid turnaround time

• Less expensive than

GC/MS

• Detects drugs for a longer

time than GC/MS

– e.g. (5-7days vs. 1-2 days)

• Concurrently tests for

multiple drug classes

• Very responsive for

morphine and codeine

Disadvantages

• Does not, usually, differentiate between

various opioids

• Often misses synthetic and semisynthetic

opioids

• Cross reactivity: will show false positives

with poppy seeds, quinolone antibiotics …

• Drug concentration in urine and assay’s

concentration cut-offs will affect detection

• More definitive testing may be required to

identify a specific drug or metabolite


Some Limitations to UDS by IA/EIA

• Cocaine is highly specific as the antibody reacts only to cocaine and its

principle metabolite

• Amphetamine/methamphetamine are highly cross reactive and detects other

sympathomimetic amines e.g. ephedrine and pseudoephedrine

• Opiate testing does not distinguish between morphine, heroin and codeine

• Opiate testing does not always detect semi-synthetics e.g. hydromorphone

• Oxycodone, methadone and buprenorphine need their own specific antibody


Patients who are on fentanyl ONLY and show positive for opiates using standard

IA/EIA test are using other opioids which react with the standard IA/EIA testing

Opioids in CanadaNatural

(extracted from opium)

Semi-synthetic(derived from opium extracts)

Synthetic(man made)

Buprenorphine Fentanyl

Codeine Hydrocodone Loperamide

Morphine Hydromorphone Meperidine

Oxycodone Methadone

Tapentadol

Diamorphine (Heroin) Tramadol

Speak to your laboratory if you are not

sure what opioids their IA UDS

is directed towards

Laboratory GC/MS* UDS

Advantages

• More accurate for semi-

synthetic and synthetic opioids

• Identifies specific drugs

• Differentiates: codeine,

fentanyl, heroin, hydrocodone,

hydromorphone, morphine,

oxycodone …

• Doesn’t react to poppy seeds

• May also detect non-opioid

medications

Disadvantages

• More expensive

• Takes longer to get results

• Requires caution in interpretation

– e.g. codeine metabolized to morphine

*


Some Limitations to UDS

• QUALITATIVE only

• CANNOT determine the amount and frequency of use, time of last use, route

of administration or the source of the drug

• Adherence

– Presence of a prescribed drug CANNOT distinguish whether the patient has been

taking the drug AS DIRECTED

• ‘Window’ of test detection varies for different drugs

• ‘Cut-off concentration’

– Important when interpreting a report of “no drug present”


UDS – Benzodiazepines (BNZ)

• Not all BNZ are equally detected

• Both IA and GC/MS have significant challenges in detection and clinical

interpretation

• In general, EIA/IA for BNZ:

– Is based on the diazepam antibody

– Shows reliably positive test for diazepam and alprazolam

– Does not usually detect clonazepam or lorazepam


Possible Results of a UDS

What you expect IS present

What you expect ISN’T present

What you DIDN’T expect IS present

What To Do if You Find an

Unexpected UDS Result

General Approach to an Inconsistent UDS

• Take a careful Hx of medication/drug use in the past week and discuss

openly with the patient … WITHOUT being accusatory

– Remember there is the potential for false positive and false negative results

• Be aware of resources to assist you in assessing for potential false positive and false

negative results

– Give the patient an opportunity to address the report

• Check with the lab re potential error

– What kind of urine test was done?

General Approach to an Inconsistent UDS

• Interpret results in the context of the patient’s clinical presentation and

assessments

• Possibly ask the lab to re-run the sample with GC/MS if response still unclear

• Unexpected result does NOT necessarily diagnose:

– Abuse or addiction

– Physical dependence

– Diversion


Interpreting Unexpected UDS Results


Some Patients …

• May tamper with urine samples to hide aberrant behaviours by:

– Adding adulterants

– Diluting the sample

– Substituting another individuals sample for their own

– Ingesting excessive water or diuretics prior to giving a sample

• ValidationTests

– Performed to improve the reliability of urine sample results

– The laboratory may point out if a validation test seems “off”

• i.e. read the report

Validation Tests

Normal Characteristics of a Urine Specimen

Temperature 32-38o C

pH 4.5 – 8.0

Urine Creatinine >20 mg/dL

Specific Gravity >1.003

Known Agents to Cause Interference in UDS Results

Case 1*: Spinal Stenosis

• 73 y.o. female

• 2 “failed” back surgeries in past (1999, 2006)

• Intolerant to NSAIDs/COXIB

• No personal and no family history of drug/alcohol use issues

• No personal history of mental health issues

*Case 1 courtesy of Dr. Joel Bordman


• Taking acetaminophen 650 mg qid on a regular basis

• Previously (>1 year) reported constipation with acetaminophen 300

mg/codeine 30 mg/caffeine 15 mg

• Still reporting significantly decreased QoL over last 6 months, despite

maximizing physical and psychological modalities

• You are considering a trial of oxycodone IR 5 mg prn




• Previously (>1 year) reported constipation with aceta/codeine 30 mg/caffeine




Would you consider a UDS as part of your

work up for a trial of opioid therapy?








UDS (IA) = + opiates, BNZ








Now what do you do?

UDS (IA) = + opiates, BNZ



• Take a careful history of medication/drug use in the

past week and discuss openly with the patient

• Try not to be accusatory

• The patient explains that she occasionally takes her

sister’s diazepam 5 mg pills

• She also has been using left-over aceta /codeine/caffeine tabs

on a fairly regular basis


Post-Operative Opioid Prescriptions

Prescription opioids often go unused after surgery, with few patients

planning to dispose of the unused pills

Researchers analyzed data from six studies that examined the oversupply of prescription opioids

after seven types of surgical procedures (e.g., obstetric, thoracic, urologic). Overall, roughly 800

adults received an opioid prescription after surgery. Among the findings:

• Some 67% to 92% of patients across the studies reported unused opioids.

• Up to 21% did not fill their opioid prescription, and up to 14% filled the prescription but did not

take any of the pills — most often because of adequate pain control.

• Three-quarters of patients stored their opioids in unlocked areas.

• Just 4–30% of patients intended to dispose of their unused pills.

• The researchers caution, "The combination of unused opioids, poor storage practices, and

lack of disposal sets the stage for the diversion of opioids for nonmedical use."

Bicket et al, JAMA Surg. Published online August 2, 2017. doi:10.1001/jamasurg.2017.0831

Sale of Non-Prescription Codeine Products

• Number of countries have already banned the sale of codeine products without

a prescription

– Belgium, Czech Republic, Finland, France, Greece, Iceland, India, Italy, Norway, Russia

and Sweden

– Manitoba = Feb 1, 2016

• Australia announced a ban on OTC sale of products beginning February 2018

• Health Canada announced a move to ban non-prescription (low dose) codeine

products

– Canadians had until November 8 to comment on Health Canada’s proposed regulations

OTC = over the counter; http://www.cbc.ca/news/politics/codeine-opiate-prescription-health-canada-juurlink-pharmacists-ban-sales-1.4284013


• A confirmatory UDS by GC/MS is positive for:

– Oxazepam

– Temazepam

– Diazepam

– Nordiazepam

– Codeine

– Morphine

Can you explain this?


Codeine

metabolizes

to morphine

Diazepam

metabolizes to

nordiazepam,

temazepam and

oxazepam


• A confirmatory UDS by GC/MS is positive for:

– Oxazepam

– Temazepam

– Diazepam

– Nordiazepam

– Codeine

– Morphine

What would your approach

be now?


“Well, yeah, laughter IS the best medicine –

But Xanax is a very close second.”


• Explore the reasons for BNZ use

• Consider non-BNZ treatments for symptoms

• Repeat UDS (3-4 wks) to ensure BNZ negative

• Educate re acceptable acetaminophen intake

WHY?



Drug Urine Detection Time Frame

Methadone 4 - 5 days

Opiates 2 - 3 days

Cocaine/metabolites 2 - 4 days

Benzodiazepines 1 - 42 days

THC single use 2 - 3 days

THC habitual use Up to 12 weeks

Methamphetamine 3 - 5 days

Alcohol 6 - 24 hours

Case 2: Back Pain

• 40 y.o. male; previous lt knee injury; smokes cigarettes and MJ

• 2 month Hx of severe back pain

– CT: L4-5 herniation with encroachment

– MRI: as above with mass effect

• Tried acetaminophen, NSAIDs, PT, chiro with minimal effect

Case 2: Back Pain

• You are now considering a trial of aceta/codeine 30 mg/caffeine

• You elect to order a UDS

– Your office UDS protocol is that your administrative assistant collects and labels

the urine sample and arranges for it to be sent to the lab

• Which type of UDS do you order?

• Do you prescribe the aceta/codeine/caffeine on this visit?

Case 2: Back Pain

• Two (2) UDS (both GG/MS) arrive from the lab 1 week later

• You find no additional information from your administrative assistant and she

cannot remember any particulars

o 1st UDS positive for:

✓ BNZ, opiates, oxycodone, GBP and cotinine

o 2nd UDS positive for:

✓ THC, cotinine

What

might this

mean?

Result

Case 3: Crush Injury to Hand

• 35 y.o. man

• Crush injury to right hand 2008 (surgery followed by infection …)

• On high dose oxycodone for years

• 1st UDS = October 2015

– UDS (IA) = opiates


• 35 y.o. man

• Crush injury to right hand 2008 (surgery followed by infection …)

• On high dose oxycodone for years

• 1st UDS = October 2015

– UDS (IA) = opiates

– UDS laboratory report clearly states that oxycodone is not determined by their assay


• 2011 note from ER: “suspected narcotic abuse”

• 2013 call from pharmacist re ‘polypharmacy; “away for work”

• 2014 polypharmacy; left pills in another city …

• 2015 BPI – 100% pain relief

• MD did not in, even with above

▪ Only after got a from ‘reliable’ source

Case 4: The Wandering Oxycodone

• 67 y.o. woman, long standing patient

• DM II, chronic pain, stress/anxiety

• On CR oxycodone for decades

June visit

– UDS (GC/MS) ordered Rx: CR OC 40 mg iii 5x/d + alprazolam bid

– 5 days later UDS report: alprazolam, lorazepam, lidocaine, diphenhydramine

Checked with pharmacy; pt 4 days late filling prescription

Checked with pharmacy; pt 4 days late filling prescription

http://www.prescribechangeallegany.org/assets/samhsa-toolkit_community.pdf

Case 4: The Wandering Oxycodone

• 67 y.o. woman

• DM II, chronic pain, stress/anxiety; long standing pt

• On CR oxycodone for decades

June visit

– UDS (GC/MS) ordered Rx: CR OC 40 mg iii 5x/d + alprazolam bid

– 5 days later UDS report: alprazolam, lorazepam, lidocaine, diphenhydramine

July visit

– UDS (GC/MS) ordered Rx: as above

– 6 days later UDS report: morphine, alprazolam, lorazepam, gabapentin,

diphenhydramine

Case 5: the Report?

• 25 y.o. woman; currently on hydromorphone (CR + IR) plus gabapentin

March

• UDS (IA) = opiates

Case 5: the Report?

• 25 y.o. woman; currently on hydromorphone (CR + IR) plus gabapentin

March

• UDS (IA) = opiates

“creatinine concentration and specific gravity are not consistent

with expected ranges for a normal urine”

May• UDS (GC/MS) = + morphine, codeine, hydromorphone, norhydrocodone,

diphenhydramine, pseudo/ephedrine, cotinine, lorazepam

http://mytopcare.org/prescribers/about-urine-drug-tests/

http://mytopcare.org/wp-content/uploads/2013/06/Screen-Shot-2013-07-22-at-3.32.32-PM.png

Pearls - UDS

• 2017 Guideline found only low/very low quality of evidence regarding

strategies to reduce the adverse impact of opioid prescribing

• Expert Guidance Statement 6: UDS ‘may be useful’

• Have a Standard Operating Procedure for UDS in your office/clinic

• Different UDS (POC, laboratory IA, laboratory GC/MS) have different

advantages, disadvantages and limitations

Pearls - UDS

• Always compare the UDS result to the actual patient chart/drugs prescribed

- Are the prescribed drugs/metabolites present?

- Are any prescribed drugs absent?

- Are there any unexpected drugs present?

- Read any comments listed by the laboratory

• If you encounter an inconsistent/unexpected UDS, your first action should be:

To take a careful history of medication/drug use in the past week and discuss

openly with the patient – without being accusatory

• Each type of inconsistent UDS result has a differential diagnosis and actions

for the clinician to take – documentation is key

Don’t rely on

your memory

Resources on UDS

• Ron Joe, College of BC: Urine Drug Testing

– https://www.cpsbc.ca/files/pdf/M-WS-101H-2014-09-13-P06-UDT.pdf

• Rxfiles

– http://www.rxfiles.ca/rxfiles/uploads/documents/Urine-Drug-Screening-

UDS-QandA.pdf

urine drug screening - amazon s3 · pdf fileexpert guidance statement 6: urine drug screening...

Documents