interpretation of urine drug testing results for pain … · 2019. 3. 31. · structured method for...
TRANSCRIPT
![Page 1: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/1.jpg)
Interpretation Of Urine
Drug Testing Results For
Pain Management
Alec Saitman, PhD, DABCC (CC, TC)
Director of Special Chemistry and Toxicology
Providence Regional Laboratories
![Page 2: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/2.jpg)
The Intent Of The Session
Provide an introductory overview of structured drug
interpretation
Didactic lecture
Discuss typical and atypical case examples
And how to interpret them
Panel member discussion in real time
![Page 3: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/3.jpg)
Requirements Before Any
Drug Interpretation
Technical knowledge of drug screening methodologies
If applicable
Screening cutoffs
Known interferences
Technical knowledge of confirmation methodologies
What parent drugs and metabolites are tested
Whether drugs are hydrolyzed or not prior to testing
![Page 4: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/4.jpg)
Requirements Before Any
Drug Interpretation
All chromatographic data is:
Thoroughly reviewed by trained staff
Free of any chromatographic interferents
An updated medication list is available
Knowledge of prescribed medications
Parent drugs contained within them
At what dose
At what frequency
![Page 5: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/5.jpg)
Requirements Before Any
Drug Interpretation
Ability to interpret use of illicit/non-prescribed drugs
Heroin
Methamphetamine/Amphetamine
Cocaine
Barbiturates
THC
PCP
Kratom
Pain management populations at high risk for illicit drug abuse
Drug testing for illicit use is typical
![Page 6: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/6.jpg)
Requirements Before Any
Drug Interpretation
Thorough understanding of metabolism patterns of
drugs tested
Drug
Drug
Metabolite
Metabolite
![Page 7: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/7.jpg)
Structured Method For Proper
Drug Testing Interpretation
Step 1
Identify all expected results
Using medication list
Knowledge of parent drugs and metabolites tested
Example: Mr. Smith prescribed methadone only
Possible expected results are
Methadone and EDDP (metabolite)
Methadone EDDP
![Page 8: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/8.jpg)
Structured Method For Proper
Drug Testing Interpretation
Step 2
Identify all observed results
Using final confirmation data for particular drug collection
Example: Mr. Smith is positive for
Methadone
EDDP
Oxycodone
Noroxycodone
Oxymorphone
![Page 9: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/9.jpg)
Structured Method For Proper
Drug Testing Interpretation
Step 3
Identify whether the patient is
Compliant with medications prescribed
Not Compliant with medication prescribed.
Example: “Mr. Smith is not compliant with medications
prescribed.”
![Page 10: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/10.jpg)
Structured Method For Proper
Drug Testing Interpretation
Step 4
Provide explanation/interpretation of decision
Explain any and all discrepancies observed for this testing
Note all parent drugs and metabolites which should have existed but
do not
Note all parent drugs and metabolites which should not have existed
but do
Be concise
Recommend using templates to maintain consistency
![Page 11: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/11.jpg)
Structured Method For Proper
Drug Testing Interpretation
Example: “Mr. Smith was found to be positive for methadone and
its metabolite EDDP indicating the use of a drug containing
methadone. Mr. Smith was also found to be positive for oxycodone
along with its metabolites noroxycodone and oxymorphone. This
pattern indicates the use of a drug containing oxycodone.
Although the presence of methadone and EDDP is expected, the
presence of oxycodone and its metabolites is inconsistent with
the medications prescribed”
![Page 12: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/12.jpg)
Many Times, Unexpected Drug
Results Exist That Can
Complicate Interpretation
What are these circumstances?
![Page 13: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/13.jpg)
1. Pharmaceutical Impurities
2. Metabolism Abnormalities
3. Diversion Tactics
4. Drug Detection Windows
5. False Negative Drug Screening
6. False Positive Drug Screening
![Page 14: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/14.jpg)
Pharmaceutical Impurities
May Be Present
Commercial Active
Pharmaceutical
Ingredient (API)
Process
Impurities
Allowable
Limit (%)
Typical
Observed (%)
Morphine Codeine 0.5 0.01-0.05
Codeine Morphine 0.15 0.01-0.1
Hydrocodone Codeine 0.15 0-0.1
HydromorphoneMorphine
Hydrocodone
0.15
0.1
0-0.025
0-0.025
Oxycodone Hydrocodone 1 0.02-0.12
OxymorphoneHydrocodone
Oxycodone
0.15
0.5
0.03-0.1
0.05-0.4
![Page 15: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/15.jpg)
Pharmaceutical Impurities
May Be Present
Very common when main drug is found in high
concentrations (>5,000 ng/mL)
Allowable pharmaceutical limits can guide interpreters
as to whether there is an impurity or co-use
![Page 16: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/16.jpg)
Pharmaceutical Impurities
May Be Present
Example: Sample contained 7,983 ng/mL Oxycodone
But also contained 23 ng/mL Hydrocodone
0.29% < 1.0 % allowable impurity limit
Likely pharmaceutical impurity and not co-use
![Page 17: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/17.jpg)
Pharmaceutical Impurities
May Be Present
Example: Sample contained 8,247 ng/mL Oxycodone
But also contained 169 ng/mL hydrocodone
2.0 % >1.0% allowable impurity limit
Likely co-use and not pharmaceutical impurity
![Page 18: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/18.jpg)
1. Pharmaceutical Impurities
2. Metabolism Abnormalities
3. Diversion Tactics
4. Drug Detection Windows
5. False Negative Drug Screening
6. False Positive Drug Screening
![Page 19: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/19.jpg)
Impact On CYP450 Deficiencies
And Co-Use Of Drug Inhibitors.
Up to 80% of drugs are metabolized by CYP enzymes
Drug
Drug
Metabolite
Metabolite
CYPCYP
CYP
![Page 20: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/20.jpg)
Impact On CYP450 Deficiencies
And Co-Use Of Drug Inhibitors.
CYP2C19
8%
CYP1A2
11%
CYP2C8/9
16%CYP2D6
19%
CYP3A4/5
36%
CYP2E1
4%
CYP2B6
3% CYP2A6
3%
![Page 21: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/21.jpg)
Impact On CYP450 Deficiencies
And Co-Use Of Drug Inhibitors.
Germline Variants
Slow Metabolizers
Intermediate Metabolizers
Rapid Metabolizers (Normal Metabolizers)
Ultra-rapid Metabolizers
Inhibitors and Inducers
Co-use of pharmaceutical drugs
Consumption of Food-Based Biologicals
Ex. Grapefruit Juice can inhibit CYP3A4 metabolism
Drug Metabolite
![Page 22: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/22.jpg)
Impact On CYP450 Deficiencies
And Co-Use Of Drug Inhibitors.
CYP2D6CYP3A4
Hydrocodone
1,549 ng/mL
Norhydrocodone
1,939 ng/mL
Hydromorphone
34 ng/mL
![Page 23: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/23.jpg)
Impact On CYP450 Deficiencies
And Co-Use Of Drug Inhibitors.
CYP2D6CYP3A4
Hydrocodone
1,549 ng/mL
Norhydrocodone
1,939 ng/mL
Hydromorphone
<10 ng/mL
![Page 24: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/24.jpg)
Impact On CYP450 Deficiencies
And Co-Use Of Drug Inhibitors.
CYP2D6CYP3A4
* In my lab, 38% of patients with both hydrocodone and
norhydrocodone >500 ng/mL did not have a hydromorphone
>10 ng/mL.
HydrocodoneNorhydrocodone Hydromorphone
![Page 25: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/25.jpg)
1. Pharmaceutical Impurities
2. Metabolism Abnormalities
3. Diversion Tactics
4. Drug Detection Windows
5. False Negative Drug Screening
6. False Positive Drug Screening
![Page 26: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/26.jpg)
Diversion Tactics And What To
Look For
Diversion is not taking a prescribed drug when one
should be
Selling drugs
Hoarding drugs
Forgetting to take drugs
Masking diversion by adding drug directly to urine
![Page 27: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/27.jpg)
Diversion Tactics And What To
Look For
Example 1
Oxycodone 2,934 ng/mL
Noroxycodone 3,145 ng/mL
Oxymorphone 157 ng/mL
Example 2
Oxycodone 6,800 ng/mL
Noroxycodone <10 ng/mL
Oxymorphone <10 ng/mL
How do we know this is not a error or inhibition in metabolism?
![Page 28: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/28.jpg)
Diversion Tactics And What To
Look For
Example 1
Oxycodone 2,934 ng/mL
Noroxycodone 3,145 ng/mL
Oxymorphone 157 ng/mL
Example 2
Oxycodone 6,800 ng/mL
Noroxycodone <10 ng/mL
Oxymorphone <10 ng/mL
Look at past drug results. Did they have typical drug metabolism patterns?
![Page 29: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/29.jpg)
Diversion Tactics And What To
Look For
Example 1
Buprenorphine 835 ng/mL
Norbuprenorphine 674 ng/mL
Naloxone <100 ng/mL
Is this diversion?
Example 2
Buprenorphine 2,835 ng/mL
Norbuprenorphine 16 ng/mL
Naloxone 3601 ng/mL
Is this diversion?
![Page 30: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/30.jpg)
1. Pharmaceutical Impurities
2. Metabolism Abnormalities
3. Diversion Tactics
4. Drug Detection Windows
5. False Negative Drug Screening
6. False Positive Drug Screening
![Page 31: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/31.jpg)
Detection Windows
Detection windows
“My patient claims they took XX tablets of XX drug XX days
ago but the sample is screened and/or confirmed
negative. Is that possible?”
“My patient claims they haven’t used XX drug of since XX
days ago but the sample is screened and/or confirmed
positive. Is that possible?”
Drug Metabolite(s)Detection Window
(Days)
HydrocodoneNorhydrocodone
Hydromorphone1-4
Hydromorphone N/A 1-4
CodeineMorphine
Hydrocodone1-4
Morphine Hydromophone 1-4
OxycodoneNoroxycodone
Oxymorphone1-4
Oxymorphone N/A 1-4
Buprenorphine Norbuprenorphine 1-6
Fentanyl Norfentanyl 1-4
Methadone EDDP 1-5
![Page 32: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/32.jpg)
Detection Windows
Know your common detection windows for the drugs you
analyze
Know that detection windows have many variables
Use caution with providing strong-worded interpretation
on detection windows
Ex. “Based on the presence of the metabolite for
oxycodone, the patient has likely ingested a drug
containing oxycodone in the last 1-4 days”
![Page 33: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/33.jpg)
1. Pharmaceutical Impurities
2. Metabolism Abnormalities
3. Diversion Tactics
4. Drug Detection Windows
5. False Negative Drug Screening
6. False Positive Drug Screening
![Page 34: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/34.jpg)
False Negative Drug
Screening May Have Occurred
Many drug screening algorithms only reflex presumptive
positive results
False negative results common for particular
benzodiazepines prescribed
Clonazepam and sometimes Lorazepam
![Page 35: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/35.jpg)
Why Do Some Screens Not
Pick Up Benzodiazepines?
Oxazepam Clonazepam 7-amino
clonazepam
Many screening
antibodies are
raised against
![Page 36: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/36.jpg)
Why Do Some Screens Not
Pick Up Benzodiazepines?
Oxazepam Clonazepam 7-amino
clonazepam
This prescribed
benzodiazepine
extensively
metabolizes to
![Page 37: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/37.jpg)
Why Do Some Screens Not
Pick Up Benzodiazepines?
Oxazepam Clonazepam 7-amino
clonazepam
This metabolite which is
structurally too dissimilar
to oxazepam to be
detected reliably
![Page 38: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/38.jpg)
1. Pharmaceutical Impurities
2. Metabolism Abnormalities
3. Diversion Tactics
4. Drug Detection Windows
5. False Negative Drug Screening
6. False Positive Drug Screening
![Page 39: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/39.jpg)
False Positive Drug Screening
May Have Occurred
“My patient screened positive for methamphetamine
but confirmed negative. What caused the false
positive?”
![Page 40: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/40.jpg)
False Positive Drug Screening
May Have Occurred
“My patient screened positive for methamphetamine
but confirmed negative. What caused the false
positive?”
Serotonin Norepinephrine
Dopamine
![Page 41: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/41.jpg)
Other Frequently Asked
Questions From Providers
Positive because of passive exposure
“My patient claims they were in an apartment where
others were using cocaine and that is why they are
confirmed positive at 7,305 ng/mL.”
“Is this possible?”
Other Medication causing positive confirmed illicit drug
“My patient claims they took Tylenol 3 (from a friend) and
that is why they are positive for heroin metabolite at 348
ng/mL”
“Is this possible”
![Page 42: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/42.jpg)
Moving Into Case Presentations
All further discussions are based off of real cases
Some data may have been altered for demonstration
purposes
![Page 43: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/43.jpg)
Case Study 1Presented by: Alec Saitman PhD, DABCC (CC, TC)
Director of Toxicology and Special Chemistry
Providence Regional Laboratories, Portland, OR
![Page 44: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/44.jpg)
Case Study 1-Background
Patient and History
35 y/o female
Persistent pain following a MVA 3 years prior
Current Medications
Percocet®
(oxycodone and acetaminophen 5/325 mg 2X daily)
![Page 45: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/45.jpg)
Case Study 1-Results
Screened positive for oxycodone
By IA at 100 ng/mL oxycodone cut-off
Confirmed for
Oxycodone at 738 ng/mL
Noroxycodone at 984 ng/mL
Oxymorphone at 24 ng/mL
![Page 46: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/46.jpg)
Case Study 1-Panel Discussion
Step 1: Identify all expected results
Step 2: Identify all observed results
Step 3: Identify whether the patient is
Compliant with medications prescribed
Not Compliant with medication prescribed.
Step 4: Provide explanation/interpretation of decision
![Page 47: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/47.jpg)
Case 1- Final Interpretation
![Page 48: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/48.jpg)
Case Study 2Presented by: Deborah French Ph.D., DABCC (CC, TC), FAACC
Assistant Director of Chemistry and Director of Mass Spectrometry
at the University of California San Francisco Medical Center
![Page 49: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/49.jpg)
Case Study 2-Background
Patient and History
71 y/o male
Depression
Hypertension
Persistent pain
Current Medications
Norco®
(hydrocodone and acetaminophen 5/325 mg 4 times daily)
Zestril®
(Lisinopril 5 mg daily)
Wellbutrin®
(bupropion 150 mg daily)
![Page 50: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/50.jpg)
Case Study 2-Results
Screened positive for opiates
By IA at 300 ng/mL Opiates cut-off
Confirmed for
Hydrocodone at 76,254 ng/mL
Norhydrocodone at 84,528 ng/mL
Hydromorphone at 5,402 ng/mL
Oxycodone at 68 ng/mL
Noroxycodone at 76 ng/mL
Oxymorphone at < 10 ng/mL
![Page 51: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/51.jpg)
Case Study 2-Panel Discussion
Step 1: Identify all expected results
Step 2: Identify all observed results
Step 3: Identify whether the patient is
Compliant with medications prescribed
Not Compliant with medication prescribed.
Step 4: Provide explanation/interpretation of decision
![Page 52: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/52.jpg)
Case 2- Final Interpretation
![Page 53: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/53.jpg)
Case Study 3Presented by: Deborah French Ph.D., DABCC (CC, TC), FAACC
Assistant Director of Chemistry and Director of Mass Spectrometry
at the University of California San Francisco Medical Center
![Page 54: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/54.jpg)
Case Study 3-Background
Patient and History
46 y/o female
Anxiety
Persistent pain
Current Medications
Norco®
(hydrocodone and acetaminophen 10/325 mg 4 times daily)
Xanax®
(Alprazolam 1 mg daily)
![Page 55: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/55.jpg)
Case Study 3-Results Screened positive for opiates only
By IA at 300 ng/mL opiates cut-off
Confirmed for
Hydrocodone at 70,906 ng/mL
Norhydrocodone at <10 ng/mL
Hydromorphone at <10 ng/mL
Oxycodone at 206 ng/mL
Noroxycodone at <10 ng/mL
Oxymorphone at < 10 ng/mL
Directly analyzed for
Alprazolam at <10 ng/mL
a-hydroxy alprazolam at <10 ng/mL
![Page 56: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/56.jpg)
Case Study 3-Panel Discussion
Step 1: Identify all expected results
Step 2: Identify all observed results
Step 3: Identify whether the patient is
Compliant with medications prescribed
Not Compliant with medication prescribed.
Step 4: Provide explanation/interpretation of decision
![Page 57: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/57.jpg)
Case 3- Final Interpretation
![Page 58: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/58.jpg)
Case Study 4Presented by: Amadeo Pesce Ph.D. DABCC
Professor in the Department of Pathology and Laboratory Medicine, University of California, San Diego, School of Medicine
Laboratory Director Precision Diagnostics LLC, San Diego
![Page 59: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/59.jpg)
Case Study 4-Background
Patient and History
55 y/o male
Depression
Persistent pain
Current Medications
Tylenol 3®
(Tylenol and acetaminophen 15/300 mg 4 times daily)
Prozac®
(Fluoxetine 40 mg daily)
![Page 60: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/60.jpg)
Case Study 4-Results
Screened positive for opiates
By IA at 300 ng/mL opiates cut-off
Confirmed for
Codeine at 2,150 ng/mL
Morphine at <10 ng/mL
Hydrocodone <10 ng/mL
Norhydrocodone at 150 ng/mL
Hydromorphone at <10 ng/mL
![Page 61: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/61.jpg)
Case Study 4-Panel Discussion
Step 1: Identify all expected results
Step 2: Identify all observed results
Step 3: Identify whether the patient is
Compliant with medications prescribed
Not Compliant with medication prescribed.
Step 4: Provide explanation/interpretation of decision
![Page 62: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/62.jpg)
Case 4- Final Interpretation
![Page 63: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/63.jpg)
Case Study 5Presented by: Frederick G. Strathmann, PhD, MBA, DABCC (CC, TC)
Vice President of Quality Assurance, Director of New Technology and
Innovation, and Assistant Laboratory Director, NMS Labs, Horsham, PA
![Page 64: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/64.jpg)
Case Study 5-Background
Patient and History
61 y/o male
Persistent pain
In addiction treatment
Current Medications
Suboxone®
(Buprenorphine and naloxone 4/1 mg daily)
![Page 65: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/65.jpg)
Case Study 5-Results
Screened negative for all drug components
Confirmed for
Buprenorphine at 142 ng/mL
Norbuprenorphine at 186 ng/mL
Buprenorphine glucuronide at 368 ng/mL
Naloxone at <100 ng/mL
Oxycodone at <10 ng/mL
Noroxycodone at <10 ng/mL
Oxymorphone at <10 ng/mL
Noroxymorphone at 65 ng/mL
Previous collections revealed similar patterns
![Page 66: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/66.jpg)
Case Study 5-Panel Discussion
Step 1: Identify all expected results
Step 2: Identify all observed results
Step 3: Identify whether the patient is
Compliant with medications prescribed
Not Compliant with medication prescribed.
Step 4: Provide explanation/interpretation of decision
![Page 67: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/67.jpg)
Nornaloxone = Noroxymorphone!
noroxymorphone | nornaloxone
noroxycodone
oxymorphone
naloxone
oxycodone
![Page 68: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/68.jpg)
Final Interpretation
![Page 69: Interpretation Of Urine Drug Testing Results For Pain … · 2019. 3. 31. · Structured Method For Proper Drug Testing Interpretation Example: “Mr. Smith was found to be positive](https://reader035.vdocuments.us/reader035/viewer/2022071001/5fbe6b24b545327b3e368992/html5/thumbnails/69.jpg)
Questions For The Panel?