An extended opiate panel is needed to detect commonly used narcotics, including fentanyl Duragesic , hydrocodone Hycodan , methadone, oxycodone Roxicodone, Oxycontin , buprenorphine, and tramadol Ultram. Appropriate collection techniques and tests of specimen integrity can reduce the risk of tampering.
Urine drug screening is commonly required as a workplace mandate e. Screening may be required in safety-sensitive occupations, such as the trucking, mass transit, rail, airline, marine, or oil and gas pipeline sectors. It may also be required for military or sports participation; for legal or criminal situations e. In addition to mandates and regulations, patient behavior or risk patterns may suggest that urine drug screening is warranted.
There are often no reliable signs of drug abuse, dependency, or addiction; nor are there definitive signs of diversion or trafficking. Relying on observations of aberrant behavior detects less than 50 percent of patients who are misusing drugs. Refusing to grant permission to obtain old records or communicate with previous physicians.
Demonstrating reluctance to undergo a comprehensive history, physical examination, or diagnostic testing especially urine drug screening. Requesting a specific drug often because of the higher resale value of a brand name. Other aberrant behavior: Issuing threats or displaying anger. Treating chronic pain in patients with a history of substance abuse can pose a clinical challenge.
Unfortunately, there is no set of predictor variables to routinely identify patients with chronic pain who are at risk of drug misuse or abuse. This will facilitate the appropriate use of opioids for chronic pain management 2 ; mitigate the adverse public health effects of diversion e. There are several situations when performing urine drug screening may be appropriate.
For example, writing a new prescription for a controlled substance would require evaluating the patient for a history of abuse or addiction, and may include screening. A history of substance misuse does not preclude opioid analgesia; however, patients in recovery may require boundary setting, clear delineation of the rules, and participation in an active recovery program.
Urine drug screening is also useful before increasing patients' dosages of analgesics or referring patients to a pain or addiction specialist. A negative urine drug screening result does not exclude occasional or even daily drug use. Because infrequent drug use is difficult to detect regardless of testing frequency, the benefits of frequent drug testing are greatest in patients who engage in moderate drug use. Before the screening, physicians should obtain a history of patients' prescription, over-the-counter, and herbal medication use.
This may raise suspicion of drug abuse or dependency. There are two main types of urine drug screening: immunoassay testing and chromatography i. Improper procedures may increase the risk of laboratory or on-site testing errors. On-site instant drug testing is becoming more widely used because of its convenience and cost efficiency.
Immunoassay tests use antibodies to detect the presence of drugs. These tests can be processed rapidly, are inexpensive, and are the preferred initial test for screening.
The U. Department of Transportation requires testing for these five substances when conducting urine drug screenings for transportation employees. The accuracy of immunoassay testing varies, with a high predictive value for marijuana and cocaine, and a lower predictive value for opiates and amphetamines. Dextromethorphan, diphenhydramine, ibuprofen, imipramine Tofranil , ketamine Ketalar , meperidine Demerol , thioridazine, tramadol Ultram , venlafaxine Effexor.
Information from references 10 through The federal government sets threshold levels for these tests. Urine specimens with drug concentrations below the threshold are reported as negative.
In clinical use, ordering tests without a threshold can increase the detection of drug compliance or abuse but may produce more false-positive results.
These tests are more expensive and time consuming, but are more accurate than immunoassay tests. Each molecule is broken down into ionized fragments and identified by its mass-to-charge ratio. Because false-positive and false-negative test results are possible Table 2 10 — 13 , physicians should choose a test panel based on the substances they are seeking to detect. The routine opiate test is designed to detect morphine metabolites. An expanded opiate panel is needed to detect other commonly used narcotics, including fentanyl Duragesic , hydrocodone Hycodan , methadone, oxycodone Roxicodone, Oxycontin , buprenorphine, and tramadol Ultram.
Except for marijuana, which can be detected for weeks after heavy use, positive results reflect use of the drug within the previous one to three days. A test that is positive for morphine may be from morphine, codeine, or heroin use because of drug metabolism morphine is a metabolite of heroin and codeine.
Heroin use can be confirmed by the presence of the metabolite 6-monoacetylmorphine, but the window for detection is only a few hours after heroin use. Casual passive exposure to marijuana smoke is unlikely to give a positive test result. Hydrocodone is metabolized to hydromorphone in the liver; therefore, a patient taking hydrocodone as prescribed may test positive for hydromorphone. The concern for false-negative results is most acute when testing for adherence to a prescribed therapeutic regimen.
Adherence can be masked by dilute urine, time since ingestion, quantity ingested, or the laboratory's established threshold limits. Discussing adherence with the patient is helpful, but testing for a particular medication may be necessary to resolve issues of diverting the prescribed medication.
Negative results in a dilute urine specimen make interpretation problematic. The director or toxicologist of the reference laboratory can serve as a valuable resource if questions arise.
The concentration of a drug in urine depends on several factors, including time since use, amount and frequency of use, fluid intake, body fat percentage, and metabolic factors. There are many ways for patients to circumvent testing.
These include adding adulterants to urine at the time of testing, urine dilution through excessive water ingestion, consumption of substances that interfere with testing, and substitution of a clean urine sample.
Several chemicals can be added to a urine sample to interfere with urine drug testing. Household chemicals, including over-the-counter eye drops containing tetrahydrozo-line; bleach; vinegar; soap; ammonia; drain cleaner; and table salt, can produce a false-negative test.
A variety of commercial products that are available online may also be used. Some substances are detectable because of changes they produce in the appearance, specific gravity, or pH of the urine.
Dilution of the urine through excessive water consumption or diuretics can decrease the urine drug concentration and make a negative test result more likely. Therefore, excessively dilute samples should be rejected. In situations where observed voiding is mandated, urinary substitution techniques and devices can be quite sophisticated and difficult to detect. An artificial penis with an electronic, temperature-controlled urine reservoir can be purchased online.
Patients may attempt to evade detection by voiding before testing, then refilling their bladder with clean urine using a catheter.
Federal testing procedures will catch some, but not all, tampering attempts. Summaries of the most important factors are listed in Tables 3 16 and 4. Remove anything in the collection area that could be used to adulterate or substitute a urine specimen.
Request the display and removal of any items in the patient's pockets, coat, hat, etc. Require all other personal belongings e. Instruct the patient to wash and dry his or her hands preferably with liquid soap under direct observation and not to wash again until after delivering the specimen. Place a bluing agent in the commode and turn off the water supply to the testing site.
Information from reference Unusual appearance e. Information from references 15 and The CMRO is a physician who is responsible for receiving, reviewing, and evaluating results generated by employers' drug testing programs. The CMRO is also responsible for the accuracy and integrity of the drug testing process by determining whether there is a legitimate explanation for unexpected test results and protecting the confidentiality of the drug testing information.
When performing non—legally mandated tests, physicians should be familiar with the specific drug screening statutes and regulations in their own state.
State regulations might address chain of custody requirements, patient privacy, which specimens may be screened, and how results may be used or shared. Reference laboratories routinely offer medical review officer services and telephone consultation with a laboratory toxicologist.
When in doubt, the rules and best practices of the U. Department of Transportation provide a legally defensible framework for most jurisdictions. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. At the time the manuscript was written, Dr.
Zotos was completing a geriatric medicine fellowship in the Department of Family Medicine at the University of Tennessee College of Medicine—Chattanooga. Address correspondence to John B. Reprints are not available from the authors.
Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. Treatment selection in substance abusers with pain. Adv Pain Manage. Department of Justice. Drug Enforcement Administration. Opioids are often misused, leading to overdoses and death.
In the United States, tens of thousands of people die every year from opioid overdoses. Opioid testing can help prevent or treat addiction before it becomes dangerous. Opioid testing is often used to monitor people who are taking prescription opioids. The test helps ensure you are taking the right amount of medicine.
Opioid testing may also be included as part of an overall drug screening. These screenings test for a variety of drugs, such as marijuana and cocaine , as well as opioids. Drug screenings may be used for:. You may need opioid testing if you are currently taking prescription opioids to treat chronic pain or another medical condition.
The tests can tell if you are taking more medicine than you should, which can be a sign of addiction. You may also be asked to take a drug screening, which includes tests for opioids, as a condition of your employment or as part of a police investigation or court case. Your health care provider may also order opioid testing if you have symptoms of opioid abuse or overdose. Symptoms may start as lifestyle changes, such as:. Most opioid tests require that you give a urine sample. You will be given instructions to provide a "clean catch" sample.
During a clean catch urine test, you will:. In certain instances, a medical technician or other staff member may need to be present while you provide your sample. During a blood test , a health care professional will take a blood sample from a vein in your arm, using a small needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial.
You may feel a little sting when the needle goes in or out. This usually takes less than five minutes. Be sure to tell the testing provider or your health care provider if you are taking any prescription or over-the-counter medicines.
Some of these may cause positive results for opioids. Poppy seeds can also cause a positive opioid result. So you should avoid foods with poppy seeds for up to three days before your test. There are no known risks to having a urine or saliva test.
There is very little risk to having a blood test. You may have slight pain or bruising at the spot where the needle was put in, but most symptoms go away quickly. Although physical risks to testing are very small, a positive result on an opioid test may affect other aspects of your life, including your job or the outcome of a court case.
If your results are negative, it means no opioids were found in your body, or that you are taking the right amount of opioids for your health condition. But if you have symptoms of opioid abuse, your provider will probably order more tests.
If your results are positive, it may mean that there are opioids in your system. If high levels of opioids are found, it may mean you are taking too much of a prescribed medicine or otherwise abusing drugs.
False positives are possible, so your health care provider may order more tests to confirm a positive result. Learn more about laboratory tests, reference ranges, and understanding results.
If your results show unhealthy opioid levels, it's important to get treatment. Opioid addiction can be deadly. If you are being treated for chronic pain, work with your health care provider to find ways to manage pain that don't include opioids.
Treatments for anyone who is abusing opioids may include:. The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health. Opioid Testing. What is opioid testing? Drug dealers sometimes add fentanyl to heroin. This combination of drugs is especially dangerous. Other names: opioid screening, opiate screening, opiate testing. What is it used for? Drug screenings may be used for: Employment.
Legal or forensic purposes. Testing may be part of a criminal or motor vehicle accident investigation.
0コメント