Drugs of Abuse Service: Urine and oral fluid testing Dr Paul Cawood Toxicology, Clinical Biochemistry, RIE GP-Laboratory Medicine Update Meeting 11th February 2016

Drugs of Abuse

The Drugs Wheel Training

6-MonoAcetyl Morphine 327.4 Morphine 285.3 Codeine 299.4 Heroin (Diacetyl Morphine + Acetyl Codeine) - metabolised too quickly to detect in urine 6-MonoAcetyl Morphine 327.4 Conjugates Morphine 285.3 Codeine 299.4 Hydrocodone 299.4 Dihydrocodeine 301.4 Conjugates

Benzodiazepine metabolism Chlordiazepoxide (librium) T½ 6-28 h Diazepam (valium) T½ 20-70 h Nordiazepam T½ 39-96h Nitrazepam T½ 20-30 h Clonazepam T½ 18-50 h Flunitrazepam T½ 10-40 h Oxazepam* T½ 5-15 h Temazepam* T½ 8-20 h Conjugation 7-Amino metabolites Urinary Excretion Active drug

Urine Drugs of Abuse Move 2 years ago to specific drug analysis by Tandem MS to confirmation standard – Fully ISO accredited Currently 20 drugs: Morphine, codeine, 6MAM, DHC AMP, MDMA, MetAMP Cocaine metabolite EDDP, Methadone Diazepam, Nordiazepam, Temazepam, Oxazepam, Nitrazepam, 7-A-Clonazepam Gabapentin, Tramadol Buprenorphine, Norbuprenorphine

Spiked sample detection in urine Methadone strongly positive with undetected EDDP Diazepam strongly positive with undetected Nordiazepam Buprenorphine strongly positive with undetected nordiazepam Temazepam strongly positive Reported as “methadone strongly positive with undetectable EDDP is inconsistent with recent methadone consumption but is suggestive of methadone being added to (spiked into) the urine sample”

Liquid Chromatography - Tandem Mass Spectrometer Detector

Example of calibration – nordiazepam 7 point calibration curve 5-1000µg/L

Quantitative peak 468.3 > 55.0 Qualifying peak 468.3 > 101.0 Internal Standard 472.2 > 59.1 Drug identification: Retention times match internal standard Peaks are same shape Ratio of quatifying:qualifying match standards

Requesting oral fluid Using Blood Science request form – indicating oral fluid as the sample type GP ICE – Oral fluid drugs of Abuse will be added to Common Tests screen 14th Feb TRAK Collection devices available from Astley Ainslie Stores as a non-stock item “Sarstedt Salivette Blue: 51.1534.500” in boxes of 100.

Chew plug for 1 min Sample volume 50µl Clean analysis v urine Costs for urine and oral fluid are the same Can mix and match urine / Oral fluid as required Advantage of witnessed collection Mouth can be contaminated With prescribed drugs e.g. buprenorphine, diazepam Metabolites are not reliably present

Morphine 20 40 Codeine 6MAM 4 DHC AMP 50 30 Met AMP MDMA Cocaine 10 8 Drug Threshold oral fluid Driving under influence of drugs European Workplace Drug Testing DRUID EWDTS screen EWDTS confirmation RIE Morphine 20 40 Codeine 6MAM 4 DHC AMP 50 30 Met AMP MDMA Cocaine 10 8 BEC Methadone EDDP NA Diazepam 5 1 Nordiazepam Temazepam Oxazepam Nitrazepam Clonazepam Gabapentin Tramadol Buprenorphine Norbuprenorphine

What is in oral fluid? SMD clients 116 samples Morphine 47% Codeine 36% 6MAM 48% DHC 7% Methadone 62% Cocaine 18% Diazepam 59% Nordiazepam 55% Buprenorphine 17% Gabapentin 10% Amphetamine 3% MDMA 1% Tramadol 3% Metamphetamine 0%

Reporting Oral Fluid drugs Report currently has same 5 core tests as urine Opiate group negative – no specific drugs reported Opiate group positive – Morphine, codeine, 6MAM and dihydrocodeine reported as positive/negative Amphetamine; Cocaine; Methadone always reported Benzodiazepine group reported as neg or pos Other drugs only reported when present: MDMA, metamphetamine, gabapentin, tramadol, buprenorphine Appear on TRAK, SCIStore, Clinical Portal and EDT reports. Printed reports have mainly been switched off May drop amphetamine and replace with buprenorphine

What next? Pregabalin? Ethylphenidate? Oxycodone? THC?