How To Pee Clean After Taking Opiates
Am Fam Physician. 2010 Mar 1;81(five):635-640.
Article Sections
- Abstruse
- Who Should Be Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Issues for Drug Testing
- References
Urine drug screening can enhance workplace safe, monitor medication compliance, and detect drug abuse. Ordering and interpreting these tests requires an agreement of testing modalities, detection times for specific drugs, and common explanations for simulated-positive and fake-negative results. Employment screening, federal regulations, unusual patient behavior, and risk patterns may prompt urine drug screening. Compliance testing may be necessary for patients taking controlled substances. Standard immunoassay testing is fast, inexpensive, and the preferred initial test for urine drug screening. This method reliably detects morphine, codeine, and heroin; however, it often does not detect other opioids such equally hydrocodone, oxycodone, methadone, fentanyl, buprenorphine, and tramadol. Unexpected positive examination results should be confirmed with gas chromatography/mass spectrometry or high-functioning liquid chromatography. A positive test upshot reflects use of the drug within the previous ane to three days, although marijuana can exist detected in the system for a longer period of time. Careful attention to urine drove methods tin identify some attempts past patients to produce false-negative test results.
Urine drug screening is an role procedure that can enhance workplace prophylactic, monitor patients' medication compliance, and find drug abuse. Considering of the personal, occupational, and legal implications that accompany drug testing, family unit physicians who perform urine drug screenings must exist confident in their ability to translate screening results and respond appropriately to that interpretation. Ordering and interpreting urine drug screenings requires an understanding of the different testing modalities, the detection times for specific drugs, and the common reasons for fake-positive and fake-negative examination results.
SORT: Central RECOMMENDATIONS FOR Practice
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Immunoassay tests are the preferred initial test for urine drug screening. | C | x |
| Positive results from an immunoassay test should be followed by gas chromatography/mass spectrometry or loftier-performance liquid chromatography. | C | 10 |
| An extended opiate console is needed to detect normally used narcotics, including fentanyl (Duragesic), hydrocodone (Hycodan), methadone, oxycodone (Roxicodone, Oxycontin), buprenorphine, and tramadol(Ultram). | C | 10 |
| Advisable collection techniques and tests of specimen integrity can reduce the risk of tampering. | C | fifteen–17 |
Who Should Exist Screened?
- Abstruse
- Who Should Be Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Issues for Drug Testing
- References
Urine drug screening is commonly required as a workplace mandate (e.grand., pre-employment screenings; returning to work after an unexplained absence; industrial accidents where damage, injury, or loss of life may have been caused by negligence or impairment; federal regulations; random testing for continued licensure or employment). Screening may exist required in safety-sensitive occupations, such as the trucking, mass transit, rail, airline, marine, or oil and gas pipeline sectors. Information technology may likewise be required for military or sports participation; for legal or criminal situations (e.g., post-accident testing, parole); or for wellness reasons (e.thousand., rehabilitation testing, pain management, treatment compliance monitoring, determining a crusade of expiry). In addition to mandates and regulations, patient behavior or chance patterns may suggest that urine drug screening is warranted.
At that place are ofttimes no reliable signs of drug abuse, dependency, or addiction; nor are there definitive signs of diversion or trafficking. Relying on observations of aberrant behavior detects less than fifty percent of patients who are misusing drugs.1 Patients who should be screened because of suspicion of drug misuse or dependency are listed in Table i.
Table one.
Behaviors that Raise Suspicion of Drug Misuse or Dependency
| Taking a controlled substance for a long period of time (new patients) |
| Refusing to grant permission to obtain former records or communicate with previous physicians |
| Demonstrating reluctance to undergo a comprehensive history, physical examination, or diagnostic testing (particularly urine drug screening) |
| Requesting a specific drug (often because of the higher resale value of a brand name) |
| Professing multiple allergies to recommended medications |
| Resisting other handling options |
| Other aberrant behavior:
|
Treating chronic hurting in patients with a history of substance abuse can pose a clinical challenge.2,3 Patients, especially young men, with a history of alcohol or drug abuse or criminal convictions are at a college take a chance of opioid misuse. Unfortunately, at that place is no set of predictor variables to routinely identify patients with chronic hurting who are at run a risk of drug misuse or abuse.iv Universal precautions in pain management involve risk stratification, a medication agreement or pain contract, adherence monitoring, and urine drug screening. This will facilitate the appropriate use of opioids for chronic pain management2; mitigate the adverse public health effects of diversion (east.yard., deflection of prescription drugs into the illegal market)v; and help reduce illicit drug use.half dozen
When Should Screening Occur?
- Abstract
- Who Should Exist Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Issues for Drug Testing
- References
There are several situations when performing urine drug screening may exist appropriate. For example, writing a new prescription for a controlled substance would require evaluating the patient for a history of corruption or addiction, and may include screening. A history of substance misuse does not preclude opioid analgesia; however, patients in recovery may crave purlieus setting, clear delineation of the rules, and participation in an active recovery plan. Urine drug screening is also useful before increasing patients' dosages of analgesics or referring patients to a pain or addiction specialist.
A negative urine drug screening outcome does not exclude occasional or even daily drug employ. Because infrequent drug use is difficult to notice regardless of testing frequency, the benefits of frequent drug testing are greatest in patients who engage in moderate drug apply.7 Random urine screening in patients taking opioids for pain direction may reveal abnormal findings, including absenteeism of the opioid, presence of additional nonprescribed substances, detection of illicit substances, and adulterated urine samples.8
Testing Methods
- Abstruse
- Who Should Exist Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Bug for Drug Testing
- References
Before the screening, physicians should obtain a history of patients' prescription, over-the-counter, and herbal medication utilize. This may raise suspicion of drug abuse or dependency.
There are two primary types of urine drug screening: immunoassay testing and chromatography (i.e., gas chromatography/mass spectrometry [GC/MS] or loftier-performance liquid chromatography). Improper procedures may increase the risk of laboratory or on-site testing errors.9 To correctly interpret test results, physicians must sympathise the differences between the tests and the differences betwixt laboratories and on-site testing. On-site instant drug testing is condign more widely used because of its convenience and toll efficiency. The accuracy of on-site tests depends on the manufacturer, but some testing kits are extremely accurate, like to the GC/MS laboratory tests.
Immunoassay tests employ antibodies to observe the presence of drugs. These tests can be processed rapidly, are inexpensive, and are the preferred initial test for screening.x The about ordinarily ordered drug screens are for cocaine metabolites, amphetamines, phencyclidine, marijuana metabolites, and opiate metabolites. The U.S. Department of Transportation requires testing for these five substances when conducting urine drug screenings for transportation employees. The accurateness of immunoassay testing varies, with a loftier predictive value for marijuana and cocaine, and a lower predictive value for opiates and amphetamines.10 A number of unremarkably prescribed medications tin can crusade positive immunoassay tests (Table 210–13).
Tabular array 2.
Drugs that May Crusade Imitation-Positive Results in Immunoassay Testing
| Test drug or drug category | Drugs that may cause imitation-positive results | Duration of detectability |
|---|---|---|
| Amphetamines | Amantadine (Symmetrel), bupropion (Wellbutrin), chlorpromazine, desipramine (Norpramin), fluoxetine (Prozac), Fifty-methamphetamine (in nasal decongestants*), labetalol (Normodyne), methylphenidate (Ritalin), phentermine, phenylephrine, phenylpropanolamine, promethazine (Phenergan), pseudoephedrine, ranitidine (Zantac), thioridazine, trazodone (Desyrel) | 2 to 3 days |
| Benzodiazepines | Oxaprozin (Daypro), sertraline (Zoloft) | Iii days for short-acting agents (e.grand., lorazepam [Ativan]) |
| Up to 30 days for long-acting agents (e.1000., diazepam [Valium]) | ||
| Cocaine | Topical anesthetics containing cocaine | Two to 3 days with occasional utilize |
| Upward to viii days with heavy use | ||
| Opiates | Dextromethorphan, diphenhydramine (Benadryl), fluoroquinolones†, poppy seeds, quinine, rifampin, verapamil‡ | One to 3 days |
| Phencyclidine | Dextromethorphan, diphenhydramine, ibuprofen, imipramine (Tofranil), ketamine (Ketalar), meperidine (Demerol), thioridazine, tramadol (Ultram), venlafaxine (Effexor) | Seven to 14 days |
| Tetrahydrocannabinol | Dronabinol (Marinol), nonsteroidal anti-inflammatory drugs§, proton pump inhibitors (pantoprazole [Protonix]) | Three days with single use |
| Five to seven days with apply effectually iv times per week | ||
| ten to 15 days with daily employ | ||
| More than 30 days with long-term, heavy employ |
The federal regime sets threshold levels for these tests. Urine specimens with drug concentrations below the threshold are reported as negative. In clinical use, ordering tests without a threshold tin can increase the detection of drug compliance or corruption only may produce more than faux-positive results.eleven
Positive results from an immunoassay exam should be followed by confirmatory testing using GC/MS or loftier-functioning liquid chromatography. These tests are more expensive and time consuming, but are more accurate than immunoassay tests.10 In these tests, the molecules are separated by the gas chromatograph and analyzed by the mass spectrometer. Each molecule is broken down into ionized fragments and identified by its mass-to-charge ratio. The accuracy of this method makes GC/MS the forensic criterion standard.
Applying Test Results
- Abstract
- Who Should Be Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Bug for Drug Testing
- References
Because false-positive and faux-negative test results are possible (Table 210–13), physicians should choose a test console based on the substances they are seeking to detect. The routine opiate test is designed to detect morphine metabolites. An expanded opiate panel is needed to discover other unremarkably used narcotics, including fentanyl (Duragesic), hydrocodone (Hycodan), methadone, oxycodone (Roxicodone, Oxycontin), buprenorphine, and tramadol (Ultram).ten Unexpected results should exist confirmed and discussed with the patient. Except for marijuana, which tin be detected for weeks after heavy use, positive results reflect use of the drug within the previous ane to three days. A test that is positive for morphine may be from morphine, codeine, or heroin use considering of drug metabolism (morphine is a metabolite of heroin and codeine). Heroin employ tin can exist confirmed by the presence of the metabolite 6-monoacetylmorphine, merely the window for detection is only a few hours after heroin apply. Casual passive exposure to marijuana smoke is unlikely to give a positive test result.ten
Hydrocodone is metabolized to hydromorphone in the liver; therefore, a patient taking hydrocodone every bit prescribed may test positive for hydromorphone.14 Similarly, the morphine metabolite in codeine may exist the only drug detectable two or 3 days after ingestion.
The concern for imitation-negative results is virtually astute when testing for adherence to a prescribed therapeutic regimen. Adherence tin can be masked by dilute urine, time since ingestion, quantity ingested, or the laboratory'south established threshold limits. Discussing adherence with the patient is helpful, just testing for a item medication may be necessary to resolve bug of diverting the prescribed medication. Negative results in a dilute urine specimen make interpretation problematic. The director or toxicologist of the reference laboratory can serve as a valuable resources if questions ascend.
Preventing and Detecting Specimen Tampering
- Abstract
- Who Should Exist Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Problems for Drug Testing
- References
The concentration of a drug in urine depends on several factors, including time since use, corporeality and frequency of use, fluid intake, torso fat pct, and metabolic factors. In that location are many ways for patients to circumvent testing. These include adding adulterants to urine at the time of testing, urine dilution through excessive water ingestion, consumption of substances that interfere with testing, and substitution of a clean urine sample. Appropriate collection techniques and tests of specimen integrity can reduce the risk of tampering.15–17
Several chemicals can be added to a urine sample to interfere with urine drug testing. Household chemicals, including over-the-counter center drops containing tetrahydrozo-line; bleach; vinegar; lather; ammonia; drain cleaner; and table salt, tin can produce a false-negative examination. A variety of commercial products that are available online may also be used. These include glutaraldehyde, sodium or potassium nitrite, pyridinium chlorochro-mate, and peroxide/peroxidase. Some substances are detectable considering of changes they produce in the appearance, specific gravity, or pH of the urine.10
Dilution of the urine through excessive water consumption or diuretics tin can decrease the urine drug concentration and brand a negative test issue more likely. Therefore, excessively dilute samples should be rejected.
In situations where observed voiding is mandated, urinary substitution techniques and devices tin can exist quite sophisticated and difficult to discover. An artificial penis with an electronic, temperature-controlled urine reservoir tin can exist purchased online. Patients may attempt to evade detection by voiding before testing, then refilling their float with clean urine using a catheter.15
Federal testing procedures will grab some, but not all, tampering attempts. Summaries of the most important factors are listed in Tables 3sixteen and 4.xv,17 Excessively dilute, adulterated, or any other rejected urine is reported as positive.
Table 3.
Steps to Reduce Tampering in Urine Drug Screening
| Request removal of whatever unnecessary outer wearable |
| Remove anything in the drove area that could be used to adulterate or substitute a urine specimen |
| Request the display and removal of any items in the patient'south pockets, coat, lid, etc. |
| Require all other personal belongings (e.one thousand., briefcase, purse) to remain with the outer clothing |
| Instruct the patient to wash and dry out his or her hands (preferably with liquid soap) under direct observation and not to launder again until after delivering the specimen |
| Identify a bluing agent in the commode and turn off the water supply to the testing site |
Table 4.
Methods and Criteria for Urine Drug Screening
| Collection methods and criteria | |
| Collection of split samples in sealed tamper-resistant containers | |
| Direct observation of specimen drove (when required) | |
| Sample size of 30 mL or more than | |
| Temperature between ninety°F (32.2°C) and 100°F (37.7°C) | |
| Urine pH of iv.5 to eight.v | |
| Utilize of an canonical concatenation of custody course to track specimen handling | |
| Findings suggestive of adulterated, diluted, or substituted specimens* | |
| General | |
| Temperature < 90°F or > 100°F | |
| Unusual appearance (e.g., bubbly, cloudy, clear, nighttime) | |
| Adulterated | |
| Nitrite concentration >5 00 mg per dL (four.ii mmol per L) | |
| Urine pH < three or ≥ 11 | |
| Diluted | |
| Creatinine concentration ≥ 2.0 mg per dL just < 20 mg per dL (176.8 mmol per L) | |
| Specific gravity > 1.0010 simply < one.0030 | |
| Substituted | |
| Creatinine concentration < ii.0 mg per dL (17.68 mmol per 50) | |
| Specific gravity ≤ one.0010 or ≥ 1.0200 | |
Legal Issues for Drug Testing
- Abstract
- Who Should Be Screened?
- When Should Screening Occur?
- Testing Methods
- Applying Test Results
- Preventing and Detecting Specimen Tampering
- Legal Issues for Drug Testing
- References
Legally mandated drug testing requires the expertise of a Certified Medical Review Officer (CMRO). The CMRO is a md who is responsible for receiving, reviewing, and evaluating results generated past employers' drug testing programs. The CMRO is also responsible for the accuracy and integrity of the drug testing process by determining whether in that location is a legitimate explanation for unexpected test results and protecting the confidentiality of the drug testing information.
When performing non–legally mandated tests, physicians should be familiar with the specific drug screening statutes and regulations in their ain state. State regulations might address concatenation of custody requirements, patient privacy, which specimens may be screened, and how results may be used or shared. Reference laboratories routinely offer medical review officer services and telephone consultation with a laboratory toxicologist. When in doubt, the rules and best practices of the U.S. Section of Transportation provide a legally defensible framework for near jurisdictions.
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REFERENCES
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xi. Luzzi VI, Saunders AN, Koenig JW, et al. Analytic operation of immunoassays for drugs of corruption below established cutoff values. Clin Chem. 2004;50(4):717–722.
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xvi. US Section of Health and Homo Services. Substance Corruption and Mental Health Services Administration Partitioning of Workplace Programs. Urine specimen collection handbook for federal agency workplace drug testing programs. November 2004. http://workplace.samhsa.gov/DrugTesting/Level_1_Pages/HHS%20Urine%20Specimen%20Collection%20Handbook%20(Effective%20November%201,%202004).aspx. Accessed January 7, 2009.
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