specialty toxicology testing: the interface with …...robert a. middleberg, ph.d., dabft, dabcc(tc)...
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Robert A. Middleberg, Ph.D., DABFT, DABCC(TC) NMS Labs Willow Grove, PA
Specialty Toxicology Testing: The Interface with the Clinician and the
Response to Emerging Drugs of Abuse
The laboratory response to the brave new world
• I have no known conflicts of interest • Any mention of a given laboratory is to
reference only • Many pictures are from google images
Our chicken and egg issue
• Laboratories need to develop tests to stay relevant
• Clinicians need tests that are relevant, so …
Should a laboratory develop tests before clinicians need them, or should clinicians tell labs what is needed?
Obvious answer
Both are needed!
Are all toxicology laboratories created equal?
• The basic stuff – Hospitals – Some reference labs
• The basic stuff and more – Specialized reference labs
Are all toxicology laboratories created equal?
Hospital/Basic Specialized
Adavantages TAT STAT Automated Good enough Cost
Number of analytes Agility Instrumentation Specificity Sensitivity Staff/Skill set Flexibility
Disadvantages Number of analytes Not agile Instrumentation Specificity Sensitivity Staff/Skill set Inflexible
TAT STAT Not automated Detailed Cost
The Problem • Laboratories proactively develop tests based
on perceived need – Clinical input – Trends – Research – FDA approvals – Etc.
• In a toxicology laboratory, a typical test costs on average ~$40-60K to develop and takes ~3 months
How is a new test developed?
• Specification – Physico-chemical information – General relevancy – PK data – Proper specimen types – Critical concentrations – Reference comments – Analytical considerations – References – http://toxwiki.wikispaces.com/duloxetine
How is a new test developed?
• R&D – Obtaining reference materials – Analytical egg-heads
• Method Validation – Parameters include,
VALIDATION STUDY NAME Required/ Optional
Chromatography/ Spectrophotometry/
Immunoassay Exogenous/ Endogenous
A. Specimen(s) of Choice Required All Both B. Primary Standard Validation Required All Both C. Standard Curve / Calibration Required All Both D. Linearity Study AMR Required All Both E. Limit of Detection (LOD) Required All Both F. Lower Limit of Quantitation (LLOQ) Required Chromatography Both G. Lower Limit of Quantitation (LLOQ) Required Spectrophotometry Both H. Precision – Within Run Required All Both I. Precision – Between Run Required All Both J. Precision - Total Required All Both K. Accuracy – Bias Estimate Required All Both L. Accuracy – Method Correlation Required All Both M. Interfering Substances Required All Exogenous N. Interfering Substances Required All Endogenous O. Recovery Optional All Both P. Stability Required All Both Q. Maximum Allowable Dilution Required All Both R. Dilution of Samples Required All Both S. Matrix Matching Optional All Both T. Matrix Effect Required All Both U. Carryover Required All Both V. Standard Addition Optional All Both W. Robustness and Ruggedness Required All Both X. Reference Intervals Required All Endogenous Y. Clinical Sensitivity and Specificity Optional All Endogenous Z. Hook Effect Required Immunoassay Both AA. Cross-Reactivity Required Immunoassay Both BB. Uncertainty Required All Both
So, what can go wrong?
• The build it and they will come risk
So, what can go wrong?
• Great intentions, but …
So, what can go wrong?
• I shoulda’ thought of that
So, what can go wrong?
• The regulators – Accrediting bodies – CLIA vs. FDA and LDTs
A laboratory-based toxicologist’s view of specialized tox testing in support of Medical Toxicology
• Will it help with patient treatment – Maybe yes, maybe no – Will results be able to help the Dx or Tx?
A laboratory-based toxicologist’s view of specialized tox testing in support of Medical Toxicology
Clinical Correlate
• Unexplained hypoglycemia – Pathology vs. Toxicology – Toxicological agents of interest
• Insulin • Oral hypoglycemics • Natural products
– Woman comes back from Jamaica – Develops a severe, life-threatening hypoglycemia – No known pathology
Source: Google images
Source: Google images
• Will it help the patient – Maybe yes, maybe no – Will results be able to help the Dx or Tx? – Risk (Cost) vs. Benefit
• Reimbursement/ACOs/Hospital lab-based pressures
A laboratory-based toxicologist’s view of specialized tox testing in support of Medical Toxicology
• Will it help the patient – Maybe yes, maybe no – Will results be able to help the Dx or Tx? – Risk (Cost) vs. Benefit
• Reimbursement/ACOs/Hospital lab-based pressures
• Are there medicolegal implications • Trends • “Gee, I wish I had done that!” • “It’s not what we do!”
• Academic interest
A laboratory-based toxicologist’s view of specialized tox testing in support of Medical Toxicology
So, what should a clinician do?
• Consult with the laboratory toxicologist – It should be a partnership not “who knows
more” or “who has the right …” – Make sure the test will provide the information
you need • The value of case history
– Make it clear the expectations, e.g., TAT – Understand the sample parameters
• Evaluate the cost vs. benefit • Be prepared for the worst
The evolution of specialty toxicology testing
• What allows us to do what we do? • What is the expectation today of such tests? • Where are we going?
The Analytical Part - 1840
Source: Google Images
The progression of analytical tools
• Color/Precipitation – Marsh/Gutzeit for arsenic
• Plating – the Reinsch Test (1842) • Spectrophotometry -1940 (Beckman) • Chromatography
– GC – 1952 (Martin and James) • Spectrometry (mass spec) - ~1900 (Thompson) • Immunoassays – 1960 (Yalow)
• Hyphenated Techniques – GC-MS (1968) – LC-MS (1977) – ICP-MS (1975) – LC-MS/MS, LC-TOF, LC-MSn, GC-MS/MS
• Sample preparation
The progression of analytical tools
What might the future bring?
Emerging drug trends
Why do we need these tools?
December 12, 2012
December 23, 2012
November 9, 2012
April 2013
Designer Drugs, in a nutshell
Synthetic cannabinoids Known on the street as K2 or “fake weed”, these drugs are very real. The newest compounds on the street are chemically different than the first generation compounds. They are potent, impairing and addictive, but their chemistry makes them invisible to older designer drug screens and traditional drug tests.
Bath salts Data becoming available shows “bath salts” are deadly. Of 472 samples recently submitted to one laboratory, 30% confirmed positive for 1 or more analytes in our Expanded Bath Salts & Stimulants Panel. Other next generation compounds, 25I-NBOMe, 25C-NBOMe, 25H-NBOMe, are commonly found in “bath salts” and have been recently linked to deaths in the United States. Although labeled as “not for human consumption,” these substances often come as a powder to be snorted, injected or smoked by users.
K2/Spice
What is K2/Spice? • Synthetic chemicals that look to
the brain like marijuana. • Sprayed onto plant material for
smoking. • Give marijuana-like high • Sold online and in head-shops • Legal grey area
Synthetic Cannabinoids 2010 2011 2012
JWH-018 AM-2201 AM-2201 JWH-073 AM-694 AM-694 JWH-019 JWH-018 JWH-018 JWH-250 JWH-019 JWH-019
JWH-073 JWH-073 JWH-081 JWH-081 JWH-122 JWH-122 JWH-200 JWH-200 JWH-210 JWH-210 JWH-250 JWH-250
RCS-4 RCS-4 RCS-8 RCS-8
JWH-203 JWH-022
JWH-018 Cl-analog UR-144 XLR-11
AM-2233 AM-1248 A-796260
NMS Labs Data
History
• 1960s – Analogues of THC first developed – HU-210, dronabinol, etc.
• 1970s – Pfizer developed CP series of compounds – CP 47,497
• 1990s – John W. Huffman (Clemson University) synthesized a new series of compounds- e.g., naphthoylindoles (JW-015, JW-018, etc); naphthylmethylindoles; naphthoylpyrroles; naphthylmethylindenes; and phenylacetylindoles
• 2000s – Other compounds are synthesized 37
*1988/1990- Cannabinoid receptor identification – CB1 and CB2
• First appeared in Europe approximately 2004 – The Psyche Deli
• First appeared in U.S. around 2008
• Believed to be synthesized in China, India, and other growing economies
• Originally believed to be a blend of herbal products
• Considered here to stay
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History
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A: Jan 2014: New Lenox, IL. $2 million mail order synthetic weed operation gets busted by Feds. Hosey, Joseph.“Feds Charge New Lenox Father & Son with Running $2M Synthetic Pot Biz”New Lenox Patch January 31, 2014.
B: Dec 2013: Denver, CO. Synthetic marijuana is linked to the sickness of 221 people during a month long outbreak in Colorado “Synthetic Marijuana has sickened more than 200 people in Colorado”The Huffington PostDecember 13, 2013.
C: Nov 2013: Waverly, NE. 18 year old smokes synthetic cannabis, goes to sleep and never wakes up., Reece “Nebraska teen’s death brings synthetic marijuana battle to forefront.”Daily NebraskanNovember 15, 2013.
D: Jan 2014: Wasilla, AK. Teenager found dead in his room next to a pipe full of Spice, official cause of death is unknown but spice is suspected culprit. Doogan, Sean. “In the wake of a teen’s unexplained death, answers about Spice are hard to come by”Alaska DispatchJanuary 10, 2014.
E: Feb 2014 Dalton, GA. Officials discover new liquid form of synthetic marijuana during a tobacco store raid. Regan, Tom. “Liquid synthetic pot new drug threat”Action News JaxFebruary 7, 2014.
F: Aug 2013: Asheboro, NC. Police confiscate 3.5 pounds of synthetic weed from three stores valued at $12,000. “3.5 Pounds of Synthetic cannabinoids seized from stores in Asheboro.”WFMY News 2 August 9, 2013.
Cannabinoids Adverse Effects
• Major Effects • Cardiovascular
• Hypertension Tachycardia
• Gastrointestinal • Vomiting
• Neurological • Agitation • Confusion • Hallucinations • Seizures
• Death?
• Other Effects • Headache • Muscle • Numbness • Slurred speech
Syncope • Vomiting • Tremors • Drowsiness
Texas Poison Center Networks
Marijuana/K2 Effects
Red$eyes$/$bloodshot$Burning$of$the$eyes$$
Xerostomia$(dry$mouth)$$Tachycardia$
Changes$in$percep=on/mood$$Balance$and$Coordina=on$
Hallucina=ons$$Seda=on$$
Subjec=ve$thought$disrup=on/loss$of$concentra=on$
Impaired$sense$of$=me$
Self$assessed$impairment$$Arrhythmias$
Seizures/Convulsions$Panic$AFacks$
Paranoia$and$Anxiety$Sickness$
Specific laboratory challenges
• Matrix – Blood vs. Urine
• Both are of value – ED – if under the influence, most likely still detectable in
blood
• Metabolites – what are they?
• Analytical – Immunoassays – Reference materials – Validation
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Delta-9 THC
Eicosanoid
C5H11
Anandamide
JWH-018 Naphthoylindole
CP-47,497 Cyclohexylphenol
AKB - 48 Adamantylcarboxamide indole
PB-22 (QUPIC) 5-F-PB-22
The latest and greatest, until …
Bath Salts
Media Stories—Bath Salts Usage is Growing in Your Backyard
A: Apr 2013: Orlando, FL. 17 year old dies after an overdose on bath salts. “Drug in bath salts caused teen’s overdose death, Dr. G says.” Click Orlando, WKMG Local 6 April 9, 2013.
B: Nov 2013: Anchorage, AK. Matt Scott becomes the first person to die from bath salts in Alaska. Hollander, Zaz. “Alaska case first federal prosecution involving a methylone death” Anchorage Daily NewsNovember 27, 2013.
C: Nov 2013: Springfield, MO. Bath salts user attacks police dog and officer. Herzog, Stephen. “Man on ‘bath salts’ assaulted officer and dog”News Leader November 30, 2013.
D: Dec 2013: Bakersfield, CA. One thousand pounds of bath salts and other synthetic drugs are found in a smoke shop owner’s warehouse along with $2.7 million in cash. Jauregui, Andres.“1000 Pounds of Bath Salts, Other Synthetic Designer Drugs Seized in California“ The Huffington Post 17, 2013.
E: Jan 2014: Luling, LA. A man high on bath salts rapes his ex-girlfriend. Karoliszyn, Henrick.“Luling man convicted of rape, admits to using bath salts during assault” The Times-Picayune 17, 2014.
F: Feb 2014: Sherwood, OR. New LSD-like drug 25I, or N-bomb, caused seizures in Sherwood, deaths around nation. Hammill, Luke. “New LSD-like drug 25I, or N-bomb, caused seizures in Sherwood, deaths around nation” The Oregonian February 3, 2014.
One year ago, DMAA was the culprit with a 33%
positivity rate. Alpha PVP wasn’t even on the charts.
Containing
! Cathinones ! Phenethylamines (Shulgin/Nichols)
! 2C-X ! NBOMe’s
! Pyrovalerones ! Pyrrolidophenones
Synthetic Stimulants Adverse Effects
• Agitation • Insomnia • Mydriasis • Myoclonus • Tachycardia • Hypertension • Chest pain • Paranoia • Delusions/hallucinations • Excited Delirium
• Combative behavior • Hyperthermia • Rhabdomyolysis • Kidney Failure • Seizures • Death
Scope: Hallucinogens & Stimulants
Drug Count DMAA 66 alpha-PVP 62 MDPV 39 Methylone 32 4-MEC 11 Buphedrone 10 Pentylone 8 MBZP 7 DMA 7 Ethylone 7 Butylone 6 3,4 DMMC 5 2C-I 4 1,4 DBZP 3 25I-NBOMe 3
Screen: Basic Extraction EI-GC-MS or LC-TOF
Confirmation: GCMS LC-TOF LC-MS/MS
Analytical Challenges
• Not as severe as synthetic cannabinoids • Blood vs. Urine
– Metabolites? – Reference materials
• Often appear in screens of basic compounds using GC-MS, LC-MS/MS, LC-TOF, if you know what to look for
• Questionable cross-reactivity with amphetamine-based immunoassays
Other emerging (emerged) drugs
• Synthetic opioids – Doxylam (AH-7921) – Krokodil (desomorphine) – Acetylfentanyl – ????
Clinicians role with emerging drugs • Understand the signs and symptoms • Understand that these substances can kill • Ask questions of the patient or friends
– Gather as much information as possible • Collect specimens (blood/urine) – Why?
– It’s the only way to identify trends – It’s the only way to identify new compounds – It’s the only way to accumulate PK data
• Consider being part of studies • Speak to the lab, be part of the solution …