why and when to use oral fluid testing - podbean · intro and welcome . 3 confidential—for...

Why and when to use Oral Fluid TestingPresented by:

Les Edinboro, PhD

Jeff Gudin, MD

2 Confidential—For Internal Use Only

Intro and welcome


What is oral fluid?

Oral fluid (OF) is composed of saliva, mixed with buccal and mucosal transudates, cellular debris, bacteria and residue of ingested products

Oral fluid can also be referred to as saliva testing although not technically correct

Oral fluid is not the same as a buccal swab

This technique is for collection of cells for DNA analysis


How does oral fluid drug detection times compare1?

Detection times are driven by the cutoffs employed

To effectively compare urine or blood to oral fluid, appropriate cutoffs must be employed

To ensure detection of target drugs in a relevant window, Quest Diagnostics uses lower oral fluid cutoffs than those employed in areas such as workplace drug testing


Can we make direct comparison between oral fluid and blood?

Drug Average oral fluid:blood concentration ratio2

Alcohol (ethanol) 1.07

Barbiturates 0.3

Buprenorphine 1.0

Codeine (basic) 4.0

Methamphetamine (basic) 2.0

MDMA (basic) 7.0

Cocaine (basic) 3.0

Diazepam (acidic) 0.02

Methadone (basic) 1.6

Morphine (basic) 0.8

Δ9-Tetrahydrocannabinol (neutral) 1.2


Deeper dive on why not to compare oral fluid versus blood2

During sublingual administration of buprenorphine, the drug will diffuse into the oral

tissues

After the initial spike in oral fluid buprenorphine levels, there will be a drop in

concentration

Then the oral fluid buprenorphine levels will rise again as drug is released from the

tissue depot

Therefore, interpretation of oral fluid buprenorphine levels are dependent on the time of

collection, which will have no relevance to what concentrations may be determined

in blood


What are the benefits of using oral fluid testing?

Client needs for choice or alternative sample

Patient-related conditions

Patient not able to provide urine

Patient not ambulatory

Patient refuses to provide urine

Patient not cooperative

Practice-related reasons

Observed collection needed

High-risk patient population

Substance use disorder treatment population

Backup for urine collection

Dislike of urine collection in office


Oral fluid drug testing offering

Unlike urine, parent drugs are detected in OF

Metabolites are removed to urine and not available for diffusion into blood

Benzodiazepine metabolites

THCCOOH

Ritalinic acid

Notable exceptions:

Norbuprenorphine

Meprobamate

Benzoylecgonine



Menu

Presumptive with reflex to quant definitive

Tandem mass spectrometry methodology

Panel 1

Includes 12 drug classes

Up to 43 compounds reported

Individually orderable

3 additional drugs

No medMATCH® interpretation

Performing Labs

Chantilly, Virginia

Pittsburgh, Pennsylvania

Drug Class – Presumptive with

Reflex to Definitive Tests

Alcohol Metabolite Methadone

Amphetamines Methylphenidate

Barbiturates Naltrexone

Benzodiazepines Nicotine

Cocaine Opioids

Marijuana Phencyclidine

MDMA Zolpidem

Meprobamate



Panel 1 Reportable Drugs/Analytes

Amphetamines Amphetamine Methamphetamine

Barbiturates Amobarbital Butalbital Pentobarbital Phenobarbital Secobarbital

Benzodiazepines Alprazolam Chlordiazepoxide Clonazepam Diazepam

Flunitrazepam Flurazepam Lorazepam Midazolam

Nordiazepam Oxazepam Temazepam Triazolam

Cocaine Benzoylecgonine

Cocaine

Marijuana THC

MDMA MDMA

Meprobamate Carisoprodol Meprobamate



Panel 1 Reportable Drugs/Analytes

Methadone EDDP Methadone

Nicotine Cotinine

Opioids Buprenorphine Codeine Dihydrocodeine Fentanyl Heroin

Hydrocodone Hydromorphone Meperidine Morphine

Naloxone Norbuprenorphine Noroxycodone Norhydrocodone Oxycodone

Oxymorphone Propoxyphene Tapentadol Tramadol

Phencyclidine Phencyclidine

Zolpidem Zolpidem



Additional Reportable Drugs/Analytes

Alcohol Metabolite Ethyl Sulfate (EtS)

Methylphenidate Methylphenidate

Naltrexone Betahydroxynaltrexone Naltrexone


Simple collection procedure

Oral fluid collection method

Indicator window turns blue when

adequate sample volume collected

(1 mL)

Quick and easy to use in office, IOP or

PSC

Takes approximately 5 minutes

No citric or salty taste

A Simple Collection Process


Describe collection procedure

Demonstration of oral fluid collection system


Oral fluid collection issues

Observations Indicator not turning blue after 15 minutes - office

instructing patients to just put the swab on their cheek or tongue

Incorrect office instructions

Telling people with dry mouths to go drink some water to wet their mouth

This will dilute the sample

Allowing people to pop out a piece of candy or gum and then put the swab in

This adulterates the sample

Spilling the fluid in the vial and not replacing it with a new one

This will increase the quant results dramatically

Breaking off the pad too high up on the indicator

The swab then absorbs all the fluid in the vial and there is none left to test

Jamming the pad into the bottom of the vial

The fluid is unable to be pipetted out for testing


Oral fluid collection instructions

Use this instruction sheet to train your clients

Practice sample collection prior to demonstrating to client

Learnings:

The person trained may pass the job onto someone else

without proper training

Hectic pace of some offices may need special attention to

collections despite ease of collection


Oral fluid drug testing brochure

Alternative sample type

Advantages and disadvantages

Menu and cutoff values

Value proposition

Key Information


Oral fluid interpretation issues

Like urine, do not try to interpret the absolute values of the analytes

Relative amounts of parent/metabolite combinations may be useful in understanding time of last use prior

to collection

Be aware of potential environmental exposure leading to presumption of drug use

Cocaine

Fentanyl

Heroin


Oral fluid reporting is slightly different

Presumptive with reflex definitive

Below cutoff—reported as negative

At or above cutoff—reported with numerical value

No medMATCH interpretation


Oral fluid summary

Oral fluid drug testing is offered as an alternative sample type, not a replacement for urine drug testing

Knowing your patient needs will help you to choose the right product

Key messages

Provides choice

Alternative sample type when necessary

Simple collection process

Avoid over-interpretation of the results


Summary: Quest Diagnostics

The abuse and misuse of prescription drugs remains epidemic in the US

Quest serves 1 in 3 adult Americans and half the physicians and hospitals in the United States

Quest Diagnostics has the world's largest database of clinical lab results; our diagnostic insights help improve healthcare management

A properly implemented drug testing program is an important step in tackling drug misuse and abuse

By performing more than 10 million drug tests annually, Quest Diagnostics has the experience to help you implement a successful PDM program—one that helps protect your practice, safeguards your patients, and keeps your community safe

Rx Tox Line available to help clinicians with test ordering or result interpretation

1.877.40.RXTOX (1.877.407.9869)

Visit QuestDrugTesting.com or subscribe through your favorite podcast venue


Appendix


Oral fluid panel and components

Test codes

93975 Drug Toxicology Monitoring 1, with Confirmation, Oral Fluid

Panel components can be ordered individually

93977 Drug Toxicology Amphetamines, with confirmation, Oral Fluid 93983 Drug Toxicology Meprobamate, with confirmation, Oral Fluid

93978 Drug Toxicology Barbiturates, with confirmation, Oral Fluid 93984 Drug Toxicology Methadone, with confirmation, Oral Fluid

93979 Drug Toxicology Benzodiazepines, with confirmation, Oral Fluid 93986 Drug Toxicology Nicotine, with confirmation, Oral Fluid

93980 Drug Toxicology Cocaine, with confirmation, Oral Fluid 93987 Drug Toxicology Opioids, with confirmation, Oral Fluid

93981 Drug Toxicology Marijuana, with confirmation, Oral Fluid 93988 Drug Toxicology PCP, with confirmation, Oral Fluid

93982 Drug Toxicology MDMA, with confirmation, Oral Fluid 93990 Drug Toxicology Zolpidem, with confirmation, Oral Fluid


Test codes

Additional Oral Fluid Drug Tests

93976 Drug Toxicology Alcohol Metabolite, with confirmation, Oral Fluid

93974 Drug Toxicology Methylphenidate, with confirmation, Oral Fluid

93985 Drug Toxicology Naltrexone, with confirmation, Oral Fluid

Additional tests


References

1. Caplan, YA, Cone, EJ (2009), Laboratory Testing in Pain Management: Approaches & Issues, www.samhsa.gov

2. Drummer OH. Drug testing in oral fluid. Clin Biochem Rev. 2006;27(3):147–159.

http://www.samhsa.gov/

why and when to use oral fluid testing - podbean · intro and welcome . 3 confidential—for...

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