1. Comparisons Of Different Modalities Michael Casarico LADC
Urine Drug Testing
Comparisons Of Different Modalities
Michael Casarico LADC

2. Creating Opportunity To Embrace Recovery
MAT
LESS CRAVING
NO WITHDRAWAL
STABILITY
NEEDED THERAPIES

3. Presence Of Drug Detected
Abstinence Reinforcements
Drug Free Test Result
Affirmation of progress
Increase in motivation
Empowerment
Restoration of privilege
Self esteem
Deepening commitment
Strengthening of recovery
Presence Of Drug Detected
Adjustment of treatment plan
Increase in motivation
Possible suspension of privilege

4. Abstinence Reinforcements
Random Urine Collection
Prevents Opportunities For Tampering
Observed Urine Collection
Creates High Degree Of Specimen Integrity

5. Point of Care Testing (POCT)

6. ASAM Box 2 p14

7. ASAM Box 2 p14

8. One examination of LC-MS/MS results following immunoassay POC testing in addiction treatment settings found high rates of clinically false negatives, that is, samples tested by POC were reported negative but LC-MS/MS results were positive.31 Twenty-nine percent of opioids other than methadone identified by LC-MS/MS were missed by POC tests; 28% methadone, 43% amphetamines, 35% benzodiazepines, 40% cocaine and 20% marijuana. Additionally, investigators found rates of office-based false positive results including 22% of opioids other than methadone identified as positive on POC but negative on LC-MS/MS, 46% methadone, 21% amphetamines, 61% benzodiazepines, 12% cocaine and 21% marijuana.
ASAM Box 2 p14

9. How POCT Works
Antibody
Drug
Antigen

10. Negative Sample

11. Positive Sample

12. How POCT Works
That reaction (color change, fluourescence, chemiluminescence, etc) can then be “read” by an internal detector in the screening cup to yield a result.
Take home message: negative samples typically have more of a reaction occurring than positive samples.

13. Confirmation Testing

14. Testing in a Lab Advantages Disadvantages Higher Precision
Laboratory Professionals
Drug Quantitation
Specific Drug Used
Confirmation on Sample
Trained Professionals
Turn Around Time

15. Why Use Urine? Urine is by definition concentrated
Urine shows recent exposure.
Is an easy and non-invasive collection (does require same gender collector for observed collections)
Is a relatively safe biological product to handle.
Both drugs and their metabolites can be seen in many cases – extends out the detection window. (blood and Oral Fluids show current use)
Drugs/metabolites often present in higher concentrations than blood or oral fluid (easier to detect)

16. Two stages of Testing: (1) Screening (2) Confirmation Screening:
Sample tracked from start to finish. Minimum of TWO identifiers (must match between the cup and the identifiers on requisition). Minimizes/reduces the chance of sample mix ups.
Two stages of Testing: (1) Screening (2) Confirmation
Screening:
Performed using Immunoassay. Relatively quick.
Sensitive but not always specific. (Identify class vs. specific analyte)
Prone to cross-reactivity.
Confirmation:
Performed using LC-MS/MS and GC-MS/MS.
Sensitive and Specific. Identifies each drug with certainty.
Checks performed at every step of setup & identification to ensure highest quality of sample.
Confirmation testing requires time.

17. Immunoassay Drug Screening
Specialized test that exploits antibody/antigen relationships
Antibodies are a type of protein produced by the immune system in response to foreign substances antigens (unexpected substances). Think of the antibodies as the “warriors” sent out to neutralize the antigens, the “invaders”
Antibodies bind to the antigen responsible for their production

18. Screening Qualitative Results: positive or negative
Is the drug concentration above the cut-off level: yes/no
Cut-off Levels: The cut-off for a test gives a defined drug concentration, typically measured using ng/ml.
Example: cut-off for Opiates is 300 ng/ml
Most labs use the SAMSHA guidelines for cut-off levels
Analyzer: Utilizes EIA (Enzyme Immunoassay) technology
Rapid Turn Around Time: 24 Hours

19. Window of Detection/Test Scheduling
SAMHSA

20. Examples of potential false positives due to cross-reacting compounds for certain immunoassays
UDT 6 p *

21. EIA – Enzyme Immunoassay
All “liquid”
Automated
Somewhat specific
Some assays look for specific drugs
Some assays look for drugs within a certain class
Rapid
Uses large, high sample capacity analyzers
Ability to give a semi-quantitative result

22. Validities
Use at least four “validity” parameters: pH, General Oxidants, Specific Gravity and Creatinine. These tests are performed to test for ADULTERANTS.
If any of these are outside normal parameters, the sample is flagged.
These values can help pinpoint if a sample has been adulterated or tampered with.
Acceptable ranges are listed on every report.

23. Validities (cont’d)
pH = measurement of how acidic or basic the specimen is, if below 3 or above 11, sample is rejected as unsuitable for EIA testing.
General Oxidants – one way of adulterating samples is to add an oxidizing substance into it to break down the offending drug rendering it undetectable.
Specific Gravity – measures the “urine density”; the concentration of all chemical entities within the urine. A good marker for water balance and kidney function.

24. Validities (cont’d)
Creatinine - Breakdown product of creatine phosphate in the muscle, a product of a normal biological function
<20 = “dilute” or overhydrated
>400 = very concentrated
Some agencies call any sample with a Specific Gravity lower than cutoff and a creatinine <20 “dilute,” and therefore considered positive.
In assessing unusual or suspect results, Creatinine and Specific Gravity are closely evaluated.

25. C.O.P.S.
Creatinine
Oxidants (General) pH
Specific Gravity

26. Drug Screening Summary
Drug Screening can be used for many purposes.
Results can indicate that a sample may require closer scrutiny.
Screening is not always specific enough to give detail on exactly what drug is in a person’s system – may just be a drug class – and not all drugs are offered as a screen.
While “generally accurate” there can be other substances that cross react and “trick” the screen into being positive.
To find out for certain what drug and what amount is in a sample, a “confirmatory” or “definitive” test must be performed. Specialized extraction and analysis is performed on the selected sample.

27. Confirmations
The term “drug confirmation” comes from the law enforcement arm of forensic toxicology. “Confirming the presence of an offending substance”
For something to be considered a true confirmation, it must be a second aliquot of the sample and must be determined by an alternative technology.
Screening is performed by EIA – enzyme immunoassay. The portion of the urine specimen used for that is discarded. Another portion is removed from the specimen cup and analyzed by a chromatographic and mass spectrometric (mass spec) technique.

28. Semantics
Confirmation is vernacular for testing and identifying the presence of a specific drug.
Also known as Directed Analysis and Targeted Analysis.
A quantitative confirmation will give you a specific amount of drug in the urine and the exact drug found
A qualitative confirmation will tell you that a drug in is present.
Screening often tells you if a drug class, not a specific compound, is present.

29. How it works… “Confirm all positives”
Sample is received, accessioned and screened.
Screening data is “accepted” into the LIMS system and that triggers the order in the LIMS system for confirmations.
The confirm ordered samples are retrieved and a portion of it is placed into a test tube.
That sample then undergoes a series of sample preparation steps before being placed onto the LCMSMS or GCMS.
The instrument identifies the exact drug by its “retention time” – how long it takes to separate from everything else in the sample and it’s mass spectral identification (chemical fingerprint)
The amount of the drug is determined by the size of the peak displayed.

30. Why Perform Confirmation Testing?
Screening may only detect someone is positive for a class of drugs – may not be able to pinpoint the exact drug.
Screening cutoffs are typically higher than confirm cutoffs.
Screening at best gives a “semi-quantitative” result – a ballpark.
Screening does not “see” all metabolites. Could miss cases of diversion.
Screening kits aren’t always sensitive to all drugs in the class, some drugs no screen exists.
ANYTIME there’s possibility of legal action, a confirmation should be performed.

31. Substance Use Testing for Buprenorphine
Reliable Screening Results – Cutoff is 20 nanograms (ng) per milliliter (ml)
Very low rate of False Positive Reports
Confirmation by LCMS/MS - LOQ is 5 ng/ml for both Buprenorphine and its metabolite Norbuprenorphine

32. Substance Use Testing Complications
Screening does not necessarily test for Buprenorphine and its metabolite, Norbuprenorphine.
It is possible for a donor to add a trace of their medication to their urine sample (“spike”), thus causing a positive screen while not having actually taken the medication.
An LCMS/MS Confirmation of this same sample will report that the metabolite, Norbuprenorphine, is not present at an appropriate level, therefore the sample tested positive on the Screen because of the Parent Drug itself being present in the sample.

35. Importance of reliable testing as a means of motivating a client

36. Further Testing Report Examples
Substance Use Testing for Other Opioids
Further Testing Report Examples

37. Report

38. Report

39. Report

40. Thank You For Your Time And Attention
Questions ~ Comments
Thank You For Your Time And Attention

41. References White Paper ASAM
statements/drug-testing-a-white-paper-by-asam.pdf?sfvrsn=2
Clinical Drug Testing In Primary Care SAMHSA
Primary-Care/SMA
Urine Drug Testing In Clinical Practice: The Art And Science Of Patient Care Edition 6 Center for Independent Health Care Education