Download September 2016 - Allina Health

September 2016
HCMC Toxicology Transition: Additional information and
Frequently Asked Questions
Many clinicians have asked for more information about the Urine Drug
Compliance Analysis (LAB8742) switch to HCMC on September 6.
“How will the new drug screen results appear?”
You will see a list of results that includes:
1. Immunoassay (pos/neg) results for 14 drugs or drug classes.
In conjunction with mass spectrometry, immunoassay adds
sensitivity for detecting common drugs of abuse. The specific
drugs responsible for any positives are shown under “mass
spectrometry”.
2. Urine pH and creatinine: markers
of specimen quality and integrity.
3. Mass spectrometry: Double-click
to see the specific drugs and
metabolites detected by definitive
mass separation. Mass
spectrometry is the standard
method used to detect nearly all
illicit, prescription, and over-thecounter drugs.
Sample mass spectrometry results
“An earlier announcement showed a screenshot with a positive result for
‘Opiates’ which is not useful for compliance monitoring. I need to see the
specific drugs and metabolites.”
The “positive” and “negative” tests are immunoassay results. The specific drugs and
metabolites responsible for any “positives” are shown in the mass spectrometry result.
“I understand that results will no longer be reported as ‘Expected’ or
‘Unexpected’ based on the patients medication list. How will I correlate
complex test results with the patient’s medication list?”
As shown in the attached examples, HCMC’s reporting of metabolites is quite
straightforward and includes the parent drug name: for example “trazadone
metabolite”; or “norbuprenorphine”. For drugs that metabolize into other drugs, such
as codeine to morphine and amitriptyline to nortriptyline, HCMC consultants are
available 24/7 to assist with results correlation by paging (612) 315-9901.
“Urine test results are negative for a drug that I prescribed to my patient. I
believe my patient is taking the drug as prescribed. Is there another
explanation?”
Drug testing is concentration dependent, so it is possible that the prescribed drug was
present in the specimen but below the positive cutoff. Please page the HCMC hotline,
(612) 315-9901 for consultation and possible follow-up testing in these cases.
“How do I interpret a report that shows (1) only the parent drug with no
metabolite; or, (2) only metabolite and not the parent drug? Does this
mean non-compliance?”
This scenario can occur with compliant patients and is most commonly seen with
opioid drugs. The “missing” parent drug or metabolite may be present but below the
positive threshold in compliant patients who are ultra-slow or ultra-fast metabolizers or
if they are taking other drugs metabolized by the same enzymes, which could slow
metabolism of the parent drug or divert metabolism through a minor pathway. Please
page the HCMC hotline for clinical consultation. Follow-up may include quantitative
blood testing.
For questions, comments, or suggestions about this newsletter or other laboratory issues,
please contact Lauren Anthony, MD, Medical Director of Allina Health Laboratory,
(612) 863-0409 or [email protected]
2
“I understand we will no longer see quantitative urine drug results. Won’t
this have a negative clinical impact?”
No, in fact, national guidelines recommend against quantitative urine drug testing:
“Quantitative definitive [mass spectrometry] urine testing is not more useful at
detecting outcomes in pain management patients compared to qualitative definitive
urine testing. Furthermore, quantitative definitive urine testing should not be used to
evaluate dosage of administered drug or adherence to prescribed dosage regimen.
Strength of recommendations: A; Quality of evidence: II”
National Laboratory Medicine Practice Guideline: Using Clinical Laboratory Tests to
Monitor Drug Therapy in Pain Management Patients, July 2016.
“Is there a resource to show how long a drug should be detectable in a
urine?”
Drug testing is highly standardized and detection windows are the same across
laboratories. Reference tables can be found on national laboratory and medical
websites, see attached pages for a list posted on Mayo’s website.
For questions or help with drug analysis results interpretation,
HCMC encourages you contact a clinical toxicology consultant
available 24/7 by paging (612) 315-9901.
For questions, comments, or suggestions about this newsletter or other laboratory issues,
please contact Lauren Anthony, MD, Medical Director of Allina Health Laboratory,
(612) 863-0409 or [email protected]
3
Example1 :
HCMC Compliance Drug Analysis Results
Example 2
Note that mass spec results correlate with the “POS” results
and metabolites include the parent drug name. Oxymorphone
and Noroxycodone are metabolites of oxycodone.
Example 3
If present, “methamphetamine” would be listed here, but only
amphetamine was found on mass spec. Results correlate with
“POS” results and metabolites are listed by parent drug name.
Drugs of Abuse: Approximate Detection Times - Mayo Medical Laboratories
Page 1 of 2
Web:
MayoMedicalLaboratories.com
E-mail:
[email protected]
Telephone: 800-533-1710
International: +1 855-379-3115
Values are valid only on day of printing.
Approximate Detection Times
All Specific Drug Groups
Last Updated November 2015
LOQ (ng/mL)
Amphetamine-Type Stimulants
Amphetamine
Methamphetamine
3,4-Methylenedioxyamphetamine (MDA)
3,4-Methylenedioxymethamphetamine (MDMA)
Phentermine
Ephedrine/pseudoephedrine
Barbiturates
Long-Acting
Phenobarbital
Intermediate-Acting
Butalbital
Amobarbital
Short-Acting
Pentobarbital
Secobarbital
Benzodiazepines
Long-Acting
Diazepam
Nordiazepam
Intermediate-Acting
Alprazolam
Lorazepam
Oxazepam
Temazepam
Chlordiazepoxide
Clonazepam
Flunitrazepam
Short-Acting
Triazolam
Flurazepam
Buprenorphine
Buprenorphine
Norbuprenorphine
Detection time* up to
25
25
25
25
25
25
3 days
3 days
2 days
2 days
100
15 days
100
100
7 days
3 days
100
100
3 days
3 days
5 days
10 days
100
100
5 days
100
100
100
100
100
100
50
2 days
100
100
0.5
0.5
http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html
7 days
7 days
8/31/2016
Drugs of Abuse: Approximate Detection Times - Mayo Medical Laboratories
Cocaine & Metabolite
Cocaine
Benzoylecgonine
Fentanyl
Fentanyl
Norfentanyl
Ketamine
Ketamine
Norketamine
Lysergic Acid Diethylamide (LSD)
LSD
2-Oxo-3-hydroxy-LSD
Marijuana/Cannabis (THC-COOH)
Single Use
Moderate Use (4 times per week)
Heavy Use (daily)
Chronic Heavy Use
Methadone
Methadone
EDDP (methadone metabolite)
Opiates
6-MAM
Morphine
Codeine
Hydrocodone
Hydromorphone
Oxycodone
Oxymorphone
Phencyclidine
Phencyclidine
Page 2 of 2
50
50
<1 day
5 days
0.2
1.0
3 days
3 days
25
25
2 days
2 days
0.5
5
<1 day
5 days
3
3 days
5 days
10 days
30 days
100
100
7 days
7 days
5
100
100
100
100
100
100
1 day
3 days
3 days
3 days
3 days
3 days
3 days
25
8 days
*These are approximate detection times for the drug or metabolites in urine. The actual detection time depends on dose, frequency of use, and
individual metabolism.
Note: These tests do not differentiate between dextro (+) amphetamine (dexamphetamine) and racemic mixtures
of dextro (+) and levo (-) isomers that are present in “street” amphetamine. These tests do not differentiate
between ephedrine and pseudoephedrine.
http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html
8/31/2016