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Drug Tests

Are your urines being observed?  There is a chain of  custody  that  cannot  be broken with any specimen. Do you know what the chain of  custody  is  and  has your clinic been following one?  ------    Are  you  aware  that  some  medications purchased over-the-counter may cause your urine to test positive for opiates ? Are you aware that prescription medications prescribed by your physician can test positive for cocaine?  Do you know that some of the products advertized for sale to help you pass your drug test can be detected now?  Are you aware of what consequences you will suffer if you are caught using them?  There are other questions, too.  My intention is to lay at rest the confusion surrounding some of the questions that have surfaced lately. 

Let's start at what our State Methadone Treatment Guidelines say along with CSAT Guidelines For The Accreditation of Opioid Treatment Programs.

CSAT Guidelines For The Accreditation of Opioid Treatment Programs

IX. D. Testing For Drug Use 

Click here: http://www.dpt.samhsa.gov/guidelines.pdf

Programs collect all urine or other toxicological specimens  in a therapeutic context that suggests trust and respect and minimizes falsification.  Reliance on direct observation, video camera monitoring, one-way mirrors, although necessary for some patients, is either necessary nor appropriate for all patients.  Temperature testing is minimally intrusive and highly effective in identifying "counterfeit" or altered urine specimens.

Georgia State Regulations 290 - 12.16 Drug-Screen Tests

290-9-12-.16 Drug-Screen Tests.  The program shall develop and implement written policies and procedures for random drug-screen tests.  These policies and procedures will be for the purposes of assessing the patient abuse of drugs and making decisions about the patient’s treatment. These policies and procedures must include the following provisions:

   (a) Clinically appropriate drug-screen tests done in accordance with current and accepted standards of medical practice must be conducted initially upon admission and on a random basis bi-weekly for new patients during the first 30 days of treatment and at least monthly thereafter.  However, patients on a monthly schedule who fail the drug-screen tests will be returned to a bi-weekly schedule for at least two weeks or longer if clinically indicated;

   (b) Each sample collected must be screened for opiates, methadone, amphetamines, cocaine, benzodiazepines, THC, and other drugs as indicated by individual patient use patterns or that are heavily used in the locale of the patient; and

   (c) Programs shall develop and enforce policies for the proper collection and handling of drug-screen test samples to ensure that samples collected from patients are properly handled, are actually collected from the patient being tested, and are unadulterated.  Such policies may include random direct observation, which shall be conducted professionally, ethically, and in a manner that respects patients�?privacy.
Authority O.C.G.A. Sec. 26-5-2 et seq.

I believe the above guideline answers our first question as to whether our urines can be observed.  It is necessary for some patients is not necessary nor appropriate for all patients.  To clear up any confusion -- yes they can observe -- if they are suspicious and feel as if they have reason -- they are in their rights to observe.  As they so stated --temperature testing is minimally intrusive and highly effective  in identifying "counterfeit" or altered urine specimens.

TIP 1
Chapter 6
Federal Methadone Treatment Guidelines

Currently regulations promulgating  by FDA and NIDA (21 CFR 291) requires an admission analysis and eight random urine specimens for the presence of methadone  and drugs of abuse during the first year of treatment .  In subsequent years, at least quarterly urinalysis are required except for those patients who receive a 6-day supply of take home medication; those patients must have their urine taken and screened at least monthly. The Federal regulation requires that urine specimens be "collected in a manner that minimizes falsification." 

21 CFR §291.505(d)(2) and that each urine be tested or analyzed for opiates, methadone, amphetamines, cocaine and barbiturates, as well as any drug(s) that     have been determined by the program to be abused in that particular locality.

These are minimal standards for urinalysis, States may develop methadone maintenance treatment standards and regulations that can exceed Federal requirements; programs must adhere to stringent regulation, whether Federal or State. 

In the matter of urine survelliance, some states require more frequent testing than does the Federal government.

The implications of this testing are widespread, with reputations and careers always at stake (Coffman and Fernandez 1991).  Therefore the techniques employed in obtaining urine specimens and the accuracy and validity of testing methods are crit-ical (Schwartz et al.1991).  Usually, sophisticated and expensive laboratory method-ologies such as radio-immunoassay (RIA) and gas chromatography/mass spectrometry (GCMS) are employed when the test result will be used to decide employment, partic-ipation in a major league competition, or the ability to practice law or medicine.

The initial test result is generally validated by a second confirmatory testing using a different, more sensitive test procedure.  These methods allow the laboratory to verify positive or negative findings with specificity. In most cases, urine is obtained under direct observation and a chain of custody of the specimen is maintained to ensure that the tested specimen can be traced to the person to whom it belongs, that the results are quantitatively and qualitatively accurate, and that the results will stand up in a court of law. 

It is critical to distinguish between these methods and those commonly used in methadone maintenance programs.  Generally, methadone maintenance treatment programs employ collection and laboratory methods that provide routine urine screening, while the sophisticated collection and methodology described above are more aptly characterized as testing.  The distinction between screening and testing is important in examining urinalysis in methadone maintenance treatment.

In most well-run MMTP's, urine is collected on a frequent and routine basis although not necessarily under direct observation.  Rather, these urine specimens are obtained randomly from patients who must provide them upon request.  Most clinics assign a staff member the responsibility of greeting the patient and determining if a urine specimen is required upon that visit, prior to the patient's receiving his or her medica-tion.  The patient is sent to the bathroom to provide the specimen in a labeled container. Some programs monitor the bathroom to ensure that only one patient uses it at a time and that the patient does not bring packages or parcels into the bathroom.

The person collecting the urine specimen checks the container to determine whether it is a " fresh"  urine.  The specimen that is collected should be felt for warmth (freshly voided specimens are always body temperature, approximately 37°C). Some clinics use a thermometer strip; others use a collection device with a thermometer strip included. 

Many treatment programs collect specimens under direct observation, while others use one-way mirrors and even video-tape to ensure reliable sample collection. In most cases, direct observation need not be employed in collecting urine specimens unless chain of custody is a main concern.  If direct observation is used, it should be done ethically with respect for patient privacy and should be handled profes- sionally in a manner that does not damage the patient-clinic relationship.

Whichever method is used, specimens should be collected in a manner that minimizes falsification.  Appropriate precautions for handling urine specimens (for example, the person collecting the specimen should always wear gloves) should always be taken. The package is then sent to the program laboratory for screening.

Most MMTP's, because of the volume and cost of urine surveillance, use thin-layer chromatography (TLC) or enzyme immunoassay (EIA) laboratory testing methods in conducting required urine screening.   

TLC is one of the oldest methods and is still utilized as a practical technique for a comprehensive drug screening.  A screen based on TLC technique scan detect amphetamines, benzodiazepines, barbiturates, methadone, propoxyphene, tricyclic antidepressants and nicotine.  The most frequently used EIA method in this country is the EMIT system, which allows for short analysis time, can be automated for large-scale samples, and can be used on-site by small programs.(Hawks 1986; Manno 1986).

These efficient low-cost screening methods each have benefits and limitations, EIA provides a testing threshold that allows detection of extremely small quantities of abused substances but does not have the specificity to determine which drug in a class is present (Daistha and Tadrus 1975); Saxon et al. 1990).  For example, this method can detect the presence of opiates but cannot distinguish between morphine  (the metabolite of heroin excreted in urine), codeine, and other opiates, including poppy seeds commonly used in baked goods.   

Yes, using EIA , it can detect extremely positive small quantities of abused substances but does not have the specificity to determine which drug in a class is present.

TLC can make the distinctions but can also produce false negative reports because it requires relatively larger amounts of abused drugs to be detected in the urine.

However, neither the TLC nor the EIA method can be referred to as urine testing because an isolated result, with or without confirmatory testing cannot be presented in a court of law and certified as accurate.  These are urine screens, which in the context of regular, routine, and random surveillance, can yield a patient profile to be used in treatment planning, counseling, casework, and determining the adequacy of the patient's methadone dosage, particularly as patterns emerge during treatment. 

Positive urine results should always be discussed with the patient, and the patient's response should be recorded in the case record.  Some patients will adamantly deny substance use despite the positive result from the laboratory.  Methadone maintenance treatment providers should take adamant denial seriously and not discount the patient as a manipulator or a liar. 

A careful history of any prescribed or over-the-counter drugs used by the patient should be obtained. This history should be discussed with the laboratory pathologist or chemist to determine if these drugs can result in a positive screen or confound the result in any way.  Wherever possible, the positive screen  (if the positive screen is still available) should be retested and confirmed by another method.  If this is not possible, future screens should be ordered with confirmation. 

More accurate testing methods such as RIA or GC/MS can also be used to verify the laboratory report.  Urine can be collected under direct observation and a chain of custody can be maintained to assure the patient that every effort is being made to prevent laboratory error and to respond to the patient's denial.

Another critical issue
 is the reliability of the
 urine screens.  
 (Blanke 1986; Morgan
 1984)  Properly train
 and educate staff
 about the tests and 
 procedures used so 
 their benefits and 
 limitations can be
 understood. 

Programs have argued that frequent screening or use of the results in treatment decisions is not warranted because the results are not reliable.  While it is important to understand the difference between the various methods laboratories use and the limitations of some of the tests, urine screening is basically reliable, particularly if a program monitors for trends and does not act on a single isolated screen.  It is important to understand that accuracy depends on the choice of laboratory; use of proper equipment and me-thodology, quality control, and use of high-quality standards by all evolved in screening.  In all laboratory testing, human errors, confounding results, chain of custody of the sample, and other problems can occur.  Informed decisions by programs can reduce these problems markedly.   

The literature on the accuracy of urine toxicology in MMTP's is sparse; however, several studies have been done to measure the accuracy of the screening techniques generally used.  In the main, the studies report an accuracy level for screening techniques that is at least 70% of that of the RIA or GC/MS, depending on the technique used. On the basis of the vast differences in cost, the techniques used are adequate for methadone maintenance treatment. When results are contested or confusing, confirming tests should be used.  For example, when EIA is used and patients deny any drug use, con-firmation TLC can be useful. These confirmations help offset the limitations ofthe screening techniques, though in general practice, confirmations are not necessary

  

LIST OF PRESCRIPTION AND NONPRESCRIPTION DRUGS THAT COULD AFFECT A DRUG TEST

TOXICOLOGY LAB TECHNICAL BRIEF                                                                      FROM DR. JOSEPH GRAAS, Ph.D.

The following list of drugs that could affect a drug test has been compiled by this office for informational purposes only.  We have assumed that the testing incliudes both an initial immunoassay screening test and a confirmatory gas chromatography/mass spectrometry test including the HHS established testing levels for each drug class.

Note:  If a non-regulated workplace drug testing program uses only an immunoassay screening test, there may be other substances that could cause a presumptive positive response on the immunoassay test.  

Amphetamines (Methamphetamine and Amphetamine)

Prescription medications that contain either d-amphetamine or racemic d, l-amphetamine (i.e. equal amounts of d- and l-amphetamine):
Adderall®
Benzedrine®
Biphetamine®
Dexedrine®
Durophet®
Obetrol®

Prescription medication that contains d-methamphetamine:
Desoyn® (Gradumet®)

Substances known to metabolize to methamphetamine (and amphetamine):
Benzphetamine (Didrex®)
Dimethylamphetamine
Famprofazone
Fencamine
Furfenorex
Selegiline (Deprenyl, Elderpryl®)

Substances known to metabolize to amphetamine:
Amphetaminil
Clobenzorex (Dinintel®, Finedal®)
Ethylamphetamine
Fenethylline (Captagon®)
Fenproporex (Tegisec®)
Mefenorex (Pondinil®)
Mesocarb
Prenylamine

Nonprescription medication that contains l-methamphetamine:
Vicks Inhaler

Note: Although one would expect to see 100% l-methamphetamine following Vicks Inhaler use, there may be a trace amount of d-isomer present because a very slight amount of d-methamphetamine may be present as a contaminant in the Vicks Inhaler.

Over-the-counter cold and allergy remedies that contain ephedrine, pseudoephedrine, propylephedrine, phenylephrine, or deoxyephedrine:  Nyquil, Contact, Sudafed, Allerest 12 Hour, A.R.M., Triaminic 12;Ornade, Tavist-D, Dimetapp, Neosynephrine, Actifed, Bayer Select Maximum Strenght Sinus Pain Relief Caplets, Contact Non-Drowsy Formula Sinus Caplets, Maximum Strength, Dristan Cold Caplets, Maximum Strength Sudafed Sinus Tablets, Dristan Cold Tablets, Maximum Strength Sine-Aid Tablets, Maximum Strength Sinus Gelcaps, No Drowsiness Sinarest Tablets, Sinus Excedrin Extra Strength Caplets, Cheracol Sinus, Drixoral Cold and Flu, Efidac/24, Phenergan -D, Robitussin Cold And Flu, Vicks Nyquil, 

Over-the-counter diet aids containing Phenylpropanolamine:  Dexatrim®, Accutrim®  

Over-the-counter Nasal Sprays that contains l-Methamphetamine                         

Vicks Inhaler®, Afrin®

Asthma Medication:  Marax®, Bronkaid Tablet®s, Primatene Tablets®  

Barbiturates

Prescription medications that contain barbiturates:
Phenobarbital:              Pentobarbital:                        Secobarbital:
Acro-Lase Plus®           Nembutal Sodium,                  Seconal Sodium
Antrocol Elixor®           Pentobarbital Sodium,            Secobarbital Sodium Bellergal-S®
Donnatal®
Kenesed®
Luminal®
Mudrane GC®
Quadrinal®
Rexatal®
Solfoton®

Benzodiazepines:

Prescription medications that contain benzodiazepines:

Diazepam:       Valium®         Valrelease®                                            

Oxazepam       Serax®

Clonazepam     Klonopin®      Rivotril®

Triazolam          Halcion®                                      

Flurazepam       Dalmane®  

Lorazepam         Ativan®  

Loprazolam        Dormonocet®    

Chlordiazepoxide   Librium®       Libritab®

Chlordiazepoxide 5mg & Amitriptyline 12.5mg      Limbitrol®

Alprazolam          Xanax®                                                               

This is only a partial list of benzodiazepines. It is impossible to list each and everyone of them. Please ask if you think you are pres-cribed one before you test positive for them. Cocaine Prescription medications that contain cocaine: None More prescription medications that will cause you to test false-positive for cocaine: Amoxicillin Most Antibiotics   Tonic Water                                                  Note: The medical community uses TAC (tetracaine, epinephrine, cocaine) as a topical preparation prior to various surgical procedures and may use cocaine by itself as a topical vasocontrictive anesthetic for various ear, nose, throat, and bronchoscopy procedures. Note: Cocaine is structurally unique and does not resemble any of the other topical analgesics, such Novocaine®, Xylocaine® (lidocaine), benzocaine, etc. Although these compounds have analgesic properties, there is no structural similarity to cocaine or its metabolite (benzoylecgonine). LYSERIC ACID DIETHYLAND Migraine medications::  ergotamine, Ergostat®, Cafergot®, Wigraine®, Imitrex Hydergine®, bromocriptine/Parlodel®, methysergide/Sansert®, lisuride/Dopergin®, Lysergol, benzatropine/Artane®, Triprolidine, amitriptyline/ Elavil®, dicyclomine (Bentyl)® . Antinausea medications that contain promethazine:                          Phenergan®, Promethagan®. Marijuana (THC) Prescription medication that contains delt-9-tetrahydrocannabinol (THC): Dronabinol (Marinol®) Note: Marinol ® may be used for stimulating appetite and preventing weight loss in patients with a confirmed diagnosis of AIDS and treating nausea and vomiting associated with cancer chemotherapy. Additionally, some individuals have been permitted by a court order to use THC for the management of glaucoma. There are no other prescription medications that contain cannabinoids or any other substance that might be identified as or metabolized to THC. Opiates (Heroin, Morphine, Codeine) Prescription medications that contain morphine: Astramoprh PF ® Duramorph® MSIR® MS Contin Tablets® Infumorf Oramorph Rescudose Roxanol Prescription medications that contain codeine: Actifed with Codeine Cough Syrup® Ambenyl Aspirin with Codeine Broncholate CS Capital and Codeine Oral Solution Cheracol Codinal PH® Deconsal Dimetane-DC Cough Syrup ® Emprin with Codeine® Fioricet with Codeine® Fiorinal with Codeine® Isoclor Expectorant Novahistine DH® Novahistine Expectorant® Nucofed Expectorant Par-Glycerol-C (CV) Pediacof® Phenaphen with Codeine® Phenergan with Codeine® Phenergan VC® Poly-Histine Promethazine VC with Codeine Robitussin A-C® Robitussin DAC® Soma with Codeine Triaminic Expectorant with Codeine® Tussi-Organiden Tylenol (acetaminophen) with Codeine® Tylenol with Codeine (#1, 2, 3, or 4) ® Tussar 2® Tussar SF® Note: List is only a representative sample of the prescription medications that contain codeine or morphine. Nonprescription products that contain opium (i.e., morphine): Amogel PG® Diabismul® Donnagel-PG ® Infantol Pink ® Kaodene with Paregoric® Paregoric Nonprescription product that contains codeine: Kaoden with Codeine® Note: The listed nonprescription products are used as antidiarrheals. They are generally availableover-the-counter; however, nonprescription sale is prohibited in some states. Paregoric alone is a Schedule III prescription drug, but in combination with other substances in a Schedule V over-the-counter product. Substance that metabolizes to morphine: Heroin Note: There are a number of synthetic or semisynthetic opiates available including, but not limited to: Hydromorphone (Dilaudid®)                    Oxymorphone (Numorphan®) Hydrocodone Bitartrate& Homatropine Methylbromide        (Hycodan®) Dihyrocodeine (Paracodine®) (Synalgos DC®)   Oxycodone  (Percodan®) Propoxyphene  (Darvon®)                             Methadone      (Dolophine®) Buprenorphine           (Buprenex®)            Hydrocodone      (Vicodin ES®) These drugs do not metabolize to either codeine, morphine, or 6-acetyl-morphine.  When a doctor presents a prescription for a narcotic analgesic, the MRO should verify that it does not contain codeine or morphine and, therefore, cannot metabolize to codeine, morphine, or 6-acetylmorphine. Food item that contains morphine: Poppy seeds Note: Eating normal dietary amounts of poppy  seeds can cause a  urine  speci-men to test positive for morphine and (possibly) codeine. The concentration of morphine can be substantial, with usually very low concentrations or no detect-able codeine. Over-The Counter NSAIDS: Advil®, Nuprin®, Medipren®, Motrin®, Bayer Select Pain Relief Formula®, Excedrin IB Caplets®, Genpril®, Haltran®, Ibuprofen®, Midol 200, Pamprin®, Trendar Cramp Relief Formula®, Cramp End Tablets® Rufin®, Naprosyn®, Aleve®, Ketoprofen®, Orudis KT® Prescription NSAIDS, Anaprox®, Tolectin®, Ifenoprofen®, Fluriprofen®, oxaprozin®, Ansaid®, Clinoril®, Dolobid®, Feldene®, Indocin®, Lodine®, Meclomen®, Motrin®, Nalfon®, Naprosyn ®, Orudis®, Relafen ®, Voltaren® Over-The-Counter allergy preparations, sleep-aids and anti-nausea medications that contain promethazine, Phenergan®, Promethagan® Riboflavin (vitamin B2), Dronabad®, Edecrin ® Phencyclidine (PCP) Prescription medications that contain PCP: None Note: There are no legal medical uses of PCP or any other substances that can be misidentified as PCP. Continued in next post: