Urine Drug Screening: What Pediatric Clinicians Need to Know to Optimize Patient Care

INSTRUCTIONSTo obtain continuing education credit:1.Read the article carefully.2.Read each question and determine correct answer.3.Visit PedsCESM, ce.napnap.org , to complete online Posttest evaluation.4.You must receive 70% responses certificate.5.Tests will be accepted until August 31, 2022. OBJECTIVES1.State differences of most common urine drug screening testing modalities: immunoassay gas chromatography/mass spectrometry.2.Describe causes false-positive false-negative results detection window specific medications.3.Identify caveats when interpreting result.Posttest QuestionsContact hours: 0.5Passing score: 70%This activity is administered by National Association Pediatric Nurse Practitioners (NAPNAP) as an Agency providing credit. Individuals who this program earn a or higher score on awarded 0.5 contact hour, which Pharmacology CE/0.5 Controlled Substances CE.Earn FREE CE Contact Hours OnlineContact for are NAPNAP Members. Non-Members charged fee $10 hours through PedsCESM. Payment can made credit card PedsCESM.1.To take hours, please go PedsCESM at .2.In Course Catalog, search name article.3.If you already have account with log in using your username password. If member, first-time user nonmember, click “New Customer? Click Here.”4.Once successfully passed completed evaluation form, able print out certificate immediately. To 1.State result. Questions Passing This CE. Earn Online Urine (UDS) laboratory test frequently used screen drugs abuse, monitor medication compliance, evaluate suspected intoxication overdose, office-based pain contracts (Kale, 2019Kale N. tests: Ordering Interpreting Results.American Family Physician. 2019; 99: 33-39PubMed Google Scholar; Standridge, Adams Zotos, 2010Standridge J.B. S.M. Zotos A.P. screening: A valuable office procedure.American 2010; 81: 635-640PubMed Scholar). In children adolescents, UDS may prevent substance use, use intoxication, part abuse treatment (Levy et al., 2014Levy S. Siqueira L.M. Ammerman S.D. Gonzalez P.K. Ryan S.A. Smith V.C. Committee Substance AbuseTesting adolescents.Pediatrics. 2014; 133: e1798-e1807Crossref PubMed Scopus (35) When tool make clinical decisions about high-risk medications, it important understand between modalities, results, medications. There two commonly types available: spectrometry (GC-MS; Kale, Immunoassays initial modality because they simple easy automate, provide rapid results. qualitative that identifies presence substances above set threshold antibody complex binds drug, metabolite, class compounds (Jarvis 2017Jarvis M. Williams J. Hurford Lindsay D. Lincoln P Giles L. Safarian T. Appropriate addiction medicine.Journal Addiction Medicine. 2017; 11: 163-173Crossref (31) allow point care typically their low cost, convenience. Because poor specificity risk positive should considered presumptive followed GC-MS confirmation laboratory-based separates medications basis polarity detect (Standridge, Although more costly time-consuming, provides sensitivity Schwebach Ball, 2013Schwebach A. Ball Minimizing false-positives false-negatives optimize patient care.2016https://www.uspharmacist.com/article/urine-drug-screening-minimizing-false-positives-and-false-negatives-to-optimize-patient-careGoogle requires cutoff values met positive. Results lower than established reported negative, but does not necessarily mean was present. Therefore, negative result indicates concentration cutoff. evaluating UDS, also consider time ingestion detection. After used, takes approximately 2 hr become detectable factor crucial patients present acutely ill after recent ingestion. would still indicated interpreted cautiously. The amount detected produce window, clinicians both characteristics. Drug characteristics affect include half-life, metabolites, interactions, dosing interval, versus high dose, chronic occasional last Patient-specific factors body mass, pH urine, concentration, renal liver impairment (Moeller, Lee Kissack, 2008Moeller K.E. K.C. Kissack J.C. Practical guide clinicians.Mayo Clinic Proceedings. 2008; 83: 66-76Abstract Full Text PDF (343) Table 1 lists routinely screened UDS. Department Health Human Services has standardized workplace; however, institutions practice. Clinicians confirm institution's before interpretation results.TABLE 1Window urineSubstanceTimeAmphetamines2–3 daysBenzodiazepines Short-acting3–5 days Long-acting30 daysCocaine2–4 daysMarijuana Single-use2 Moderate (3 times/week)2 weeks Daily use/Long-term heavy use4–6 weeksOpioids Buprenorphine11 Codeine1–2 Fentanyl2–3 Heroin1–2 Hydromorphone1–2 Methadone3–4 Morphine3 Oxycodone1–3 Tramadol2–4 daysNote. Levy Open table new tab Note. American Society Medicine (ASAM) Academy Pediatrics (AAP) recommend routine absence suspicion Neither group supports home parents misinterpretation limited evidence reduces adolescent ASAM AAP adolescents emergent care, assessment behavioral mental health symptoms, programs, deterrent juvenile probation system useful identify potential toxins altered status. recommends obtaining if there concern accidental intentional ingestion, unexplained seizures, syncope, arrhythmias, toxidromes those known history trauma, disorders, declining academic performance population benefit from early High-risk having ongoing (by parent clinician) clinicians, particularly presents fatigue, moodiness, school failure Screening necessary honest history, though added value. child denies shows concerning signs/symptoms performed. Accurate lead adverse consequences, such criminal charges, loss job, trust professionals, discontinuation contracts. mistrust tension parents. decrease likelihood inaccurate interpretation, professionals performing these tests familiar (Table 2) signs adulteration. Before providers list all prescription, over-the-counter, herbal fully assess (Schwebach Scholar).TABLE 2Medications causing immunoassayMedicationsAmphetamine/MethamphetamineBenzodiazepinesCannabinoidMethadoneOpioidsOver-the-counter products BrompheniramineX DextromethorphanX DiphenhydramineX DoxylamineXX IbuprofenX NaproxenX PantoprazoleX PseudoephedrineX RanitidineX Vicks nasal inhalerXAntidepressants/antipsychotics BupropionX ChlorpromazineXX DesipramineX DoxepinX FluoxetineX QuetiapineX SertralineX TrazodoneXOther agents EfavirenzXX EphedrineX FluoroquinolonesX LabetalolX MetforminX MethylphenidateX PromethazineX QuinolonesX SelegilineX VerapamilXNote. Brahm 2010Brahm N.C. Yeager L.L. Fox M.D. Farmer Palmer T.A. Commonly prescribed screens.American Journal Health-System Pharmacy. 67: 1344-1350Crossref (91) Scholar); Moeller, Atayee Lee, 2017Moeller R.S. Clinical What need know screens.Mayo 92: 774-796Abstract (65) Adulterating, substituting, diluting done avoid It critical samples’ color, appearance, pH, gravity Patients intentionally adulterate adding vinegar, soap, bleach, drain cleaner, eye drops, salt, ammonia, containing peroxide Changes gravity, appearance prompt further investigation adulteration drink excessive amounts water (2–4 quarts) attempt dilute concentrations Normal specimens range pale yellow clear collected morning concentrated temperature ranges 32°C 38°C samples promptly measured recorded collection substitution. normally 4.5 8 throughout day. Specimen < 3 > 11, 1.002 1.020 Medications similar chemical structures cross-reactivity immunoassays, resulting occurrence influenced being used. cause require frequent carefully weighed against efficacy, effect profile alternative addition, “pill dipping” shaving.” diverts save small “dip” “shave” into leading test. issue problematic compound tested making unable differentiate compliance. excreted suspected. False-negative occur below quantity ingested, performed, Another within immunoassay. Metabolites benzodiazepines opioids. same do follow metabolic pathway immunoassay, rates Amphetamine immunoassays amphetamines, amphetamine isomers, methamphetamine, other amine-containing amphetamines return amphetamine, dexamphetamine, lisdexamfetamine use. Methylphenidate cross-react so (Breindahl Hindersson, 2012Breindahl Hindersson P. distinguished drug-of-abuse testing.Journal Analytical Toxicology. 2012; 36: 538-539Crossref (4) Unfortunately, false positives rate cross-reacting linked bupropion, phenothiazines, tricyclic antidepressants, trazodone, pseudoephedrine, ephedrine, ranitidine, ofloxacin (Nomier Al-Huseini, 2004Nomier Al-Huseini H. False-positive TDxFLx amphetamine/methamphetamine II assay ofloxacin.Saudi Pharmaceutical Journal. 2004; 12: 42-46Google Scholar), labetalol dimethylamylamine, widely energy supplement, screens (Vorce, Holler, Cawrse Magluilo, 2011Vorce S.P. Holler J.M. B.M. Magluilo Dimethylamylamine: amphetamines.Journal 2011; 35: 183-187Crossref (36) Structural similarities reason inhaler contains isomer methamphetamine (l-methamphetamine) euphoric effects, Selegiline metabolism produces l-amphetamine l-methamphetamine, contributing Given widespread anxiety sedation, thorough obtained testing. given inability conjugated benzodiazepine metabolites free oxazepam nordiazepam, chlordiazepoxide, temazepam, diazepam, clorazepate Benzodiazepines pathways, lorazepam, clonazepam, alprazolam, rendering them been taking efavirenz sertraline; therefore, confirmatory performed report (Blank 2009Blank Hellstern V. Schuster Hartmann Matthée A.K. Burhenne Mikus G. Efavirenz test.Clinical Infectious Diseases. 2009; 48: 1787-1789Crossref (15) Nasky, Cowan Knittel, 2009Nasky K.M. G.L. Knittel D.R. benzodiazepines: An association sertraline?: two-year retrospective chart analysis.Psychiatry. 6: 36-39PubMed Cannabis, marijuana, refers any cannabis plant Cannabinoids subset chemicals found plant, delta-9- tetrahydrocannabinol (THC) primarily responsible marijuana's psychoactive properties Estimating THC's marijuana complex, route administration, potency frequency one's Chronic users over 30 cessation, whereas single-use only up available practice dronabinol nabilone chemotherapy-induced vomiting anorexia AIDS. Dronabinol synthetic THC, true-positive Nabilone cannabinoid THC. follows different Nonsteroidal anti-inflammatory drugs, pantoprazole, THC Confirmatory nonsteroidal efavirenz. cocaine detects main metabolite cocaine, benzoylecgonine Cross-reactivity rarely exists its relatively nonexistent Cocaine topical anesthetic otolaryngology ophthalmic procedures, reason, accurately interpret opioids, opioid metabolism. Most morphine, codeine, norcodeine; heroin, codeine easily Morphine metabolized 3-morphine-glucuronide 6-morphine-glucuronide Codeine norcodeine, hydrocodone, hydromorphone. Codeine, norcodeine ingestion; hydromorphone hydrocodone Heroin semisynthetic derivative morphine. rapidly 6-monoacetylmorphine (6-MAM), then morphine 6-MAM heroin only, definitive However, 8-hr Oxycodone oxycodone, oxycodone conjugates, oxymorphone, noroxycodone, none Fentanyl lacks usually Methadone, long-acting opioid, unchanged 2-ethylidene-1,5- dimethyl-3,3-diphenylpyrrolidine. uses methadone adulterates pill dipping. ethylidene-1,5- dimethyl-3,3-diphenylpyrrolidine Buprenorphine treat disorders. few clinically significant buprenorphine subject tramadol (Shaikh 2008Shaikh Hull M.J. Bishop K.A. Griggs D.A. Long W.H. Nixon A.L. Flood J.G. Effect three-point-of-care instrument based buprenorphine.Journal 32: 339-343Crossref (18) Quetiapine (Cherwinski, Petti Jekelis, 2007Cherwinski K. Jekelis False methadone-positive treated quetiapine.Journal Child Adolescent Psychiatry. 2007; 46: 435-436Abstract (8) involved informed consent imminent danger, consent. clinician open discussion regarding privacy clarify permission share guardian want shared, respect adolescents’ wishes encourage parent/guardian. scenarios maintain confidentiality, always case. suspects puts legal ethical implications, disclose information refuses screening, refusal documented, referred specialist unexpected, hopes additional information, were panel confirmed matches adolescent's reporting, begin developing plan. plan abstinence, testing, and/or referral center states, without despite no explanation exists, discussed adolescent. Repeat remains abuse. modalities (immunoassay vs. GC-MS), Remember interferences vary discovered annually. ever doubt, possible interference call ask interferences. Send patient's