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

2. Drugs of Abuse

3. The Drugs Wheel
Training

4. 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

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

6. 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

7. 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”

8. Liquid Chromatography - Tandem Mass Spectrometer Detector

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

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

12. 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: ” in boxes of 100.

13. 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

15. 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

17. What is in oral fluid? SMD clients
116 samples
Morphine % Codeine %
6MAM % DHC %
Methadone % Cocaine %
Diazepam % Nordiazepam 55%
Buprenorphine 17% Gabapentin %
Amphetamine 3% MDMA %
Tramadol % Metamphetamine 0%

18. 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

19. What next?
Pregabalin?
Ethylphenidate?
Oxycodone?
THC?