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Lab Manual for Moffitt-Long and Mount Zion

Lab Manual for SFGH

Internal Resources

DRUGS OF ABUSE SCREEN, URINE

Item Value
Available Stat? Yes
Test code DAU
Performed by? Chemistry
Sendout? no
Price range $$$$
In House Availability Routine or STAT: 7 days/week, 24 hours/day

See also Drug Screen Urine, Comprehensive and tests for single drugs/drug classes (e.g. opiates).
Principle Competitive, homogeneous immunoassays [CEDIA(TM) /DRI(TM) - Microgenics].

Qualitative testing for the drugs/drug classes listed at the cutoff concentrations shown. For most drugs, single abuse doses can be detected for up to 2 days - longer in some cases.
Interpretation DRUGS INCLUDED:

1. AMPHETAMINES: Screening CUTOFF: 1000 ng/mL.

All positive results are referred automatically for confirmation testing and identification of the specific agent using LC-MS/MS. Drugs detected include: amphetamine, methamphetamine, methylene dioxymethamphetamine (MDMA) and metabolite (MDA). At SFGH, 90 % of positive screens for amphetamines are confirmed. Further testing for esoteric/designer amines is available if clinically indicated. The presence of these compounds in a sample could result in a positive screen and a negative confirmation. Please page the Chemistry/Toxicology Fellow on call at 719-5166 for consultation.

This assay has low to moderate cross-reactivity towards other amines. Some pharmaceutical drugs, such as bupropion, trazadone and sildenafil can cause a positive screen at high concentrations. This assay will cross-react with a subset of designer drugs (ie: bath salts), but not all of them. Substituted amphetamines (ie: 4-fluoroamphetamine and para-methoxyamphetamine) and piperazines (benzylpiperazine and chlorophenylpiperazine) show moderate to significant cross-reactivity. Other stimulants, such as ephedrine, pseudoephedrine, phenylpropanolamine, methylphenidate and phenylephrine, do not cross-react with this assay at physiologically relevant concentrations.

2. BARBITURATES: Screening CUTOFF: 200 ng/mL.

This is not included in DAU panels ordered from the Emergency Department. Order as an individual test if clinically indicated. Positive results are not confirmed. If identification of the specific agent (butalbital, penta-, pheno-, or secobarbital) using GC/MS is clinically indicated, order on the requisition or page the Chemistry/Toxicology Fellow on call at 719-5166. At SFGH, 98 % of positive screens for barbiturates are confirmed.

3. BENZODIAZEPINES and metabolites: CUTOFF 200 ng/mL.

Positive results are not confirmed. Drugs detected include: alprazolam (Xanax) and metabolites, clonazepam (Klonopin, Rivotril) and metabolites, diazepam (Valium) and metabolites nordiazepam and oxazepam, flurazepam (Dalmane) and metabolites, lorazepam and metabolite (Ativan), nitrazepam (Mogadon), oxazepam (Serax), temazepam (Restoril), and triazolam (Halcion).

This assay, unlike most other benzodiazepine immunoassays, will detect certain benzodiazepines that are excreted primarily as glucuronide metabolites (e.g., lorazepam excreted as lorazepam glucuronide).

4. COCAINE METABOLITE (benzoylecgonine): CUTOFF 300 ng/mL.

Positive results are not confirmed because this assay has very high specificity (> 99 % confirmed). Cocaine and cocaethylene have 54 % and 57 % cross-reactivity, respectively.

5. HEROIN METABOLITE (6-MAM): Screening CUTOFF 10 ng/mL (only for ED DAU)

6-monoacetylmorphine (6-acetylmorphine, 6-MAM) is a heroin specific metabolite that can be detected in urine for 12-24 hours after heroin use. A positive 6-MAM test indicates recent heroin use. Positive results are not confirmed. This test is only included in the DAU panels ordered from the Emergency Department. This assay can be ordered as an individual test from all other locations if clinically indicated.

6. METHADONE METABOLITE (2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine [EDDP]): CUTOFF: 100 ng/mL.

Positive results are not confirmed because this assay has very high specificity (>99% confirmed). If clinically indicated order the GCMS confirmation test on the requisition, or page the Chemistry/Toxicology Fellow on call at 719-5166.

7. OPIATES: Screening CUTOFF 300 ng/mL.

Positive results are confirmed by GC-MS for most locations; exceptions are the Emergency Department and most inpatient locations. Drugs detected are codeine, morphine, hydrocodone, and hydromorphone. Extremely high oxycodone concentrations may cause a positive opiate screen. Note that morphine is the principal metabolite of codeine and of heroin. Hydrocodone has been proposed as a trace metabolite of codeine (see Reference 2). Hydromorphone is a metabolite of hydrocodone, and has been proposed as a trace metabolite of morphine (see Reference 3).

Synthetic and some semi-synthetic opioids/opiates cannot be ruled out by opiate assays, and "false negative" results are likely. Oxycodone has poor cross-reactivity in the opiate assay. A separate screening test specifically for oxycodone is performed at SFGH. Drugs that are not detected at all by the opiate assay include: Buprenorphine, fentanyl, meperidine, methadone, propoxyphene, and tramadol. Page the Chemistry/Toxicology Fellow on call at 719-5166 to discuss testing for synthetic opiates. At SFGH, 97 % of opiate positive screens are confirmed.

See the Opiate Metabolism Chart for a diagram of opiate metabolism and interpretation of confirmation results.

8. OXYCODONE: Screening CUTOFF 100 ng/mL

Drugs detected include oxycodone and oxymorphone [Numorphan], an oxycodone metabolite. Positive results are not confirmed. If clinically indicated order the LC/MSMS confirmation test on the requisition, or page the Chemistry/Toxicology Fellow on call at 719-5166. At SFGH, 96 % of positive screens for oxycodone are confirmed.

INTERPRETATION:

Please note that toxicology testing at SFGH is performed for clinical use only. In particular - unconfirmed or presumptive results cannot be equated with drug use for a forensic or judicial (parole, custody, employment, denial of insurance) purpose.


DETECTION PERIODS FOR DRUGS OF ABUSE:

Drug of Abuse: Drug Detection Period
(Approximate Guidelines)
Amphetamines 2 – 4 days
Barbiturates 1 – 3 days (Phenobarbitol, 2 weeks)
Benzodiazepines Up to two weeks
Cocaine Metabolite 2 – 3 days
Heroin Metabolite (6-MAM) 12 – 24 hours
Methadone metabolite (EDDP) 2 – 4 days
Methadone 2 – 4 days
Opiates 2 – 3 days
Oxycodone 1 – 3 days
Phencyclidine (PCP) 3 – 8 days


SCREENING FALSE POSITIVES and CONFIRMATION FALSE NEGATIVES

Some positive screening results will subsequently be reported as "Negative" with the confirmatory test (screening false positives). Rarely encountered drugs such as new designer amphetamines or opiates available in other countries may cause a true positive screening test but will not be detected with existing confirmation protocols (confirmation false negatives). Confirmation can be requested on the requisition form or performed as an "add on" test by special request if the specimen is available. Consult the Clinical Chemistry/Toxicology Fellow (call the Clinical Laboratory Information Section, x68590 to contact the fellow on call Monday – Friday, 9 am – 5 pm) if you have questions about confirmation testing.

Container type sterile, screw-capped container, without preservative
Amount to Collect 20 mL
Sample type Urine
Min. Volume 15 mL
Normal range No drugs detected
Synonyms Toxicology;
Turn around times Screening results are reported within 1 to 8 hours(STAT/ Routine).

Results are reported as "Negative", "Positive, Unconfirmed" or "Preliminary Positive - Confirmation will be performed." Confirmation results will be reported as a separate test(s) when they are completed (1-4 days).
Additional information For rapid assessment of the presence of drugs of abuse. Not indicated for forensic testing purposes.

Please note that toxicology testing at SFGH is performed for clinical use only. In particular - unconfirmed or presumptive results cannot be equated with drug use for a forensic or judicial (parole, custody, employment, denial of insurance) purpose.
References 1. Microgenics Amphetamine/Ecstasy 10006576-0 2003-1; Barbiturate 98-692-5 2002-09; Benzodiazepines 10006458-0 2002-11; Cocaine metabolite 10006475-0 2002-09; Methadone 10006542-0 2003-01; Methadone metabolite 10002371-2 2001-02; Opiates 98-695-3 2001-07; Phencyclidine 0141-1 2003-4; Ethanol 0318-1 August 2000. Microgenics Corporation, Fremont, CA.

2. Oyler, JM, Cone, EJ, Hoseph, RE Jr., Huestis, MA. Identification of Hydrocodone in Human Urine Following Controlled Codeine Administration. J Anal Toxicol. 2000 Oct; 24(7): 530-5

3. Cone, EJ, Heit, HA, Yale, HC, Gourlay, D. Evidence of Morphine Metabolism to Hydromorphone in Pain Patients Chronically Treated with Morphine. J Anal Toxicol. 2006 Jan/Feb 30(1):1-6.

4. Cook, JD; Strauss, KA; Caplan, YH; LoDico, CP; Bush, DM. Urin pH: The effects of time and temperature after collection. J Anal Chem, 2007; 31:486-496.
Last Updated 10/20/2012 9:33:48 AM
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