Interpretation of Drug Testing Results in Medication-Assisted … · 2019-02-05 · Interpretation...
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Interpretation of Drug Testing Results in Medication-Assisted Treatment ©NCDC, April 2018 The following presentation may not be copied in whole or in part without the written permission of the author of the National Drug Court Institute. Written permission will generally be given upon request. Developed by: Paul L. Cary M.S. National Center for DWI Courts
Transcript of Interpretation of Drug Testing Results in Medication-Assisted … · 2019-02-05 · Interpretation...
Interpretation of Drug Testing Results in
Medication-Assisted Treatment
©NCDC, April 2018The following presentation may not be copied in whole or in part without the written permission of the author of the National Drug Court Institute.
Written permission will generally be given upon request.
Developed by: Paul L. Cary M.S.
National Center for DWI Courts
WHAT DOES THIS DRUG TEST RESULT MEAN?
Does the use of MAT drugs in
an effort to promote recovery
complicate the interpretation of
drug testing results?
TYPES OF DRUG TESTS
On-site devices (“instant”, “rapid”, POCT – “point of care testing”)
Dozens and dozens of individual products
Lab-based/Court-based immunoassay screening instruments
Lab-based confirmationGC/MS
LC/MS/MS
NOT ALL DRUG TESTS ARE CREATE EQUAL
Selectivity of a drug testChemical properties of the test that determine the degree to which drugs will react to (bind) to that test
Test A – Opiates (300 ng/mL cutoff)Urine sample that contains oxycodone at 500 ng/mL will test positive
Test B – Opiates (300 ng/mL cutoff)Urine sample that contains oxycodone at 500 ng/mL will test negative
Test A for Opiates – has a greater affinity for oxycodone than Test B
TWO-STEP TESTING APPROACH
Screening Test(Usually immunoassay tests) Designed to
separate negative samples from samples
that are “presumptively positive”
Confirmation Test(GC/MS, LC/MS) Follow-up procedure
designed to validate positive test results
Why can’t you adjudicate based on the screening
test results? FALSE POSITIVES
DRUG TESTS AND CROSS REACTIVITY
Screening tests can and do react to “non-target compounds”
• Amphetamines
• Benzodiazepines
Obtain list of interfering compounds from lab or on-site
vendor
Study results have demonstrated accuracy rates for initial
screening tests as low as 70%
Confirm positive results – BEST PRACTICE!
TYPICAL CUTOFF LEVELS
Amphetamines * 500 ng/mL 250 ng/mL
Benzodiazepines 300 ng/mL variable
Cannabinoids * 20/50 ng/mL 15 ng/mL
Cocaine (crack)* 150 ng/mL 100 ng/mL
Opiates (heroin) * 300/2000 ng/mL variable
Phencyclidine (PCP) * 25 ng/mL 25 ng/mL
Alcohol 20 mg/dL 10 mg/dL
SAMHSA (formerly NIDA) drugs
Screening Confirmation
WHAT IS A CUTOFF LEVEL?
Cutoffs are not designed to frustrate treatment professionals or court practitioners
A drug concentration, administratively established for a drug test that allows the test to distinguish between negative and positive sample - Threshold
Cutoffs provide important safeguardsScientific purposes (detection accuracy)Legal protections (evidentiary admissibility)
Measured in ng/ml = ppb
CUTOFFS AND FALSE POSITIVES
As you lower the cutoff level of a drug test
You increase the potential for false positive test results
How Do “Screening” Drug Tests
Work?
DRUG TESTS AND CROSS REACTIVITY
Drug Test Drug
Same principle applies to how drugs produce a response in the brain.
DRUG TESTS AND CROSS REACTIVITY
opiates fit = positive test
methadone doesn’t fit = negative test
Immunoassay screening tests
opiates antibody
DRUG TESTS AND CROSS REACTIVITY
morphine 100%
codeine 200%
heroin 80%
hydrocodone 75%
hydromorphone 45%
oxycodone 20%
DRUG TESTS AND CROSS REACTIVITY
(300 ng/mL opiate cutoff test)
150 ng/mL codeine
1500 ng/mL oxycodone
+
+
If oxycodone is a major substance of abuse in your
jurisdiction, you should consider a separate drug test for oxycodone as part of your
initial screening analysis.
NEGATIVE OR NONE DETECTED RESULTS
Client is remaining abstinent or not using a
drug that can be detected by the test.
Other possible explanations
Client not using enough drug
Client’s drug use is too infrequent
Collection too long after drug use episode
Sample has been tampered
Test being used not sensitive enough
Client using drug not on testing list
NEGATIVE OR NONE DETECTED RESULTS
Indicates that no drugs or breakdown products (metabolites), tested for, were detected in the sample tested
No such thing as “zero” tolerance or “drug free”
Negative does not mean NO drugs present
NEGATIVE = NONE DETECTED INTERPRETATION
NO need to second-guess every negativeresult
Not suggesting withholding positive reinforcement and rewards for positive behaviors
Drug testing is a monitoring tool
Assess none detected drug testing results in the context of your client’s overall program compliance (or non-compliance) and their life’s skills success (or lack thereof)
POSITIVE TEST RESULT INTERPRETATION
Indicates that drug(s) or breakdown products (metabolites), tested for, were detected in the sample tested
Drug presence is above the cutoff level
Greatest confidence achieved with confirmation
Result
Interpretation
for MAT Drugs
MEDICATION-ASSISTED TREATMENT
Medication-Assisted Treatment (MAT) is a
form of pharmacotherapy and refers to any
treatment for a substance use disorder that
includes a pharmacologic intervention as part
of a comprehensive substance abuse
treatment plan with an ultimate goal of
participant recovery with full social function.
MAT DRUGS
Medications for Alcohol DependenceNaltrexone: (ReVia®, Vivitrol®, Depade ®)
Disulfiram: (Antabuse®)
Acamprosate: (Campral®)
Medications for Opioid DependenceMethadone
Buprenorphine: (Suboxone® and Subutex®)
Naltrexone: (ReVia®, Vivitrol®, Depade ®)
WHAT IS NALTREXONE?
Belongs to a class of drugs known as opiate antagonists
Block the brain’s neurotransmitters
Displaces opiates from their binding site
Diminishes physical effects of opiates
Will naltrexone test positive on an opiate drug test?
Neuron Transmission
synapse
Credit Dennis Wei
Credit Dennis Wei
NEURAL SURFACE MEMBRANE
Ligand could be heroin, morphine, oxycodone or a MAT drug
LIGAND (MAT DRUG) BINDS TO RECEPTOR
MAT Drug (naltrexone)
Opiate Drug
Credit Dennis Wei
Do MAT drugs bind to immunoassay drug tests to produce “false positives”?
opiates fit = positive test
Does naltrexone “fit” and produce a “false positive” result?
Immunoassay screening tests
opiates antibody
Ethanol
SIEMENS EMIT ASSAY CROSS-REACTIVITY DATA
= 1,000,000 ng/mL
Abstract: A clinical evaluation of the naltrexone, a biodegradable sustained-release dosage was carried out in 4 healthy normal males.
Subjects were given an intravenous dose of 10 mg naltrexone and approximately 1 week later a 63-mg dose of naltrexone by subcutaneous administration.
Urine levels for naltrexone were 79-215 ng/mL.
MAT DRUGS
Medications for Alcohol DependenceNaltrexone: False Positive with Opiate Assay – NO!
Disulfiram: (Antabuse®)
Acamprosate: (Campral®)
Medications for Opioid DependenceMethadone
Buprenorphine: (Suboxone® and Subutex®)
Naltrexone: False Positive with Opiate Assay – NO!
OPIATES – RESULTS INTERPRETATION
All opiates are narcotic analgesics
Relieve pain and controlled substances
Not all narcotic analgesics are opiatesMeperidine (Demerol®)
Propoxyphene (Darvon®)
Methadone
Pentazocine (Talwin®)
Fentanyl (Sublimaze®)
Buprenorphine: (Suboxone®)
Naltrexone: (ReVia®, Vivitrol®, Depade ®)
Siemens Negative Reactivity Data
Thermo-Fisher Negative Reactivity Data
= 1,000,000 ng/mL
Siemens Negative Reactivity Data
Thermo-Fisher Negative Reactivity Data
= 100,000 ng/mL
MAT DRUGS
Medications for Alcohol DependenceNaltrexone: False Positive with Opiate Assay – NO!
Disulfiram: (Antabuse®)
Acamprosate: (Campral®)
Medications for Opioid DependenceMethadone: NO! with Opiate Assay
Buprenorphine: NO! with Opiate Assay
Naltrexone: False Positive with Opiate Assay – NO!
MAT DRUGS
Medications for Alcohol DependenceNaltrexone: False Positive with Opiate Assay – NO!
Disulfiram: NO! with drug tests reviewed
Acamprosate: NO! with drug tests reviewed
Medications for Opioid DependenceMethadone: NO! with Opiate Assay
Buprenorphine: NO! with Opiate Assay
Naltrexone: False Positive with Opiate Assay – NO!
CONCLUSIONS
Using standard instrument-based screening immunoassay drugs tests (in-lab or in-court), MAT drugs do not cross-react to produce “false positive” results.
When using on-site testing devices the cross-reactivity toward MAT drugs is largely unstudied. Contact product vendor.
Confirmation testing (GC/MS or LC/MS) resolves all cross-reactivity issues
CONFIRMATION: BEST PRACTICE
Gas Chromatography-mass Spectrometry (GC/MS) or (LC/MS)
Drug molecules separated by physical characteristicsIdentified based on chemical “finger-print”Considered Gold Standard
Refer to NADCP Adult Drug Court Best Practice Standards – Volume II
NO SUBSTITUTE FOR KNOWLEDGE AND EXPERTISE
Unethical to adjudicate based upon misinformation -violation of due process
Develop a relationship with your laboratory
Develop a relationship with your on-site device vendor
Don’t be afraid to “call the company”
Seek expert advice
CONFIRM – positive results!
About this Project
For More Information:
Website: www.ndcrc.org
This project was supported by Grant No. G1299ONDCP02A awarded by the Office of National Drug Control Policy, Executive Office of the President. Points of view or
opinions in this document are those of the authors and do not represent the official position or policies of the Executive office of the President.
