MLSCI 466 Combined Notes 2nd Half PDF

The what, why, and when… Nicholas Sajko, B.Sc, M.D. Emergency Medicine PGY-5 (University of Alberta) Clinical Pharmacology & Toxicology Fellow (University of Calgary) OBJECTIVES • PADIS Overview – What it is, who we are, and how can we help! • Highlights of toxicologic epidemiology in Canada • Exp...

The what, why, and when… Nicholas Sajko, B.Sc, M.D. Emergency Medicine PGY-5 (University of Alberta) Clinical Pharmacology & Toxicology Fellow (University of Calgary) OBJECTIVES • PADIS Overview – What it is, who we are, and how can we help! • Highlights of toxicologic epidemiology in Canada • Explore some common toxicology cases and what goes into their assessment / management • Recognize the limitations of qualitative drug screening • Open Q/A (Time permitting!) Conflict of Interest • No conflicts of interest to disclose! CASE #1 • 30 year old unknown male, acting bizarre outside • T 40C, HR 149, BP 160/110, RR 30, Sats 95% RA • Extreme agitation and aggression with EMS, requiring multiple (limited) security personnel to hold the patient down on arrival. CASE #2 • 25 yo female took a friend’s “down” • On arrival to the ED: • • • • GCS 3 (nonresponsive) Pinpoint pupils Respirations 6 breaths / minute O2 85% on RA The PADIS Team – Who are we? The PADIS Team • PADIS is staffed by specially trained and certified healthcare professionals. INFORMATION SPECIALISTS (Pharmacists & R.N.s with Subspecialty Training) Dr Morgan Riggan Dr Scott Lucyk Dr Mark Yarema Dr Riley Hartmann Dr Eric McGillis Toxicology Fellowship Training • US Medical Toxicology training • 2 year program • Usually after a 3-5 year Emergency Medicine residency • ONLY Medical Toxicology • Canadian Clinical Pharmacology & Toxicology Training (CPT) • 2 year Royal College Fellowship • CaRMS match via the Medicine Subspecialty Match (MSM) • Entry residency programs include: • • • • FRCPC Emergency Medicine Internal Medicine Anesthesia Pediatrics Dr Nick Sajko Dr Jason Elzinga FIRST YEAR FELLOWS SECOND YEAR FELLOWS Dr Jacqui Hiob Dr Alex Hamelin PADIS Elective Residents • Open to any and all interested residents, from any specialty • Bedside Consults (Usually 1-2x / week, during daytime – depending on cases) • Participate in bedside consultation and patient care Information Specialist Training • 4 month orientation • 3 months of Toxicology • 1 month of Medication Advice training • Didactic, Role Play, Quiz writing • Preceptor buddy shifts • Focus on: Assessment, Documentation, Communication, Resource navigation, Pharmacology, Toxico/Pharmacokinetics The PADIS Team – What is our Role? PADIS Roles • Exposure to drugs, chemicals, or toxins via mouth, lungs, skin, eyes (or any other route possible!) • “I’ve done something I don’t usually do” • “Have I taken too much? I’m concerned I may have poisoned myself…” • “How can I prevent poisoning?” • “I am caring for an overdose / poisoned patient and I want to review management.” PADIS Roles • Day-to-day activities: • Patient Care • Telephone and bedside consultation service (Within Calgary) • Education • General public and health care professionals • Research / Collaboration • Acetaminophen, toxic alcohols, antidotes • Surveillance • Tracking trends / outbreaks in poisoning • Prevention PADIS Roles • Toxicovigilance – the active process of identifying and evaluating the toxic risks existing in a community and evaluating the measures taken to reduce or eliminate them PADIS Roles • Risks of public health concern include poisoning outbreaks due to: • Contamination • Emergency of new drugs • Mass chemical exposures / terrorist events • Unusual patterns or trends The PADIS Team – What do we see? The WEIRD and WONDERFUL So… What happens when I do call PADIS? The Telephone Risk Assessment • Where do we start? • What is the patient’s current clinical status • HPI – what did they take, intent etc. • Physical Exam • Initial Investigations • Toxin specifics… • What was the ingestion? • How much was ingested? • What was the time of the ingestion? Was it staggered or all at once? • Any coingestants? • Access to other medications? • Any self-decontamination events? • Pill counts? How much was patient prescribed and when? • How has their clinical picture changed over time? http://www.litfl.com The Toxicologic Exam • HEENT • Pupils? – reactive, mydriatic, miotic • Rhinorrhea, secretions? • Temperature? • SKIN • Flushed? Dry? Diaphoretic? Discolored? • CNS • • • • • GI Rigidity? Spasticity? Clonus / hyper-reflexia? Altered mentation / delirium? Cerebellar signs? • N/V/D? • Abdominal pain? Bowel sounds? • CVS • Evidence of pulmonary edema / injury? • FULL SET OF VITALS • • • • • • • Temp Glucose HR BP RR O2 sats GCS • Also: What has the trend been? The Toxicologic Workup • What is included in a “Tox Panel” • • • • • • • CBC +diff • What about urine tox screens? Electrolytes + Extended lytes • Rarely helpful in the acute management Creatinine, Urea, eGFR of tox patients VBG/ABG w/ Co-oximetry, lactate* ASA, EtOH, Acetaminophen serum levels Serum osmols LFTs + Transaminases • ECG (What are we looking for here?) – QRS, QTc • +/- CXR The Toxicologic Workup: Urine Screens • Urine drugs of abuse screen = QUALITATIVE testing for: • • • • • • • • • Amphetamines Barbiturates Benzodiazepines Cocaine Cannabinoids Opiates Oxycodone Methadone Etc. The Toxicologic Workup: Urine Screens The Toxicologic Workup: Urine Screens The Toxicologic Workup: Urine Screens Is there a drug present in the patient? v. Is the patient’s signs and symptoms cause by the drug? The ABCs of Toxicology • A: • Airway protection • Secretions? • B: • Breathing • Tachypnea or Bradypnea? • C: • BP, HR, perfusion • Flushed? Dry? Diaphoretic? The ABCs of Toxicology • D - Decontamination? • Is this an overdose or a patient in which we can initiate decontamination? • What factors do we need to consider? • E – Enhanced Elimination? • Is this an overdose where we can ENHANCE the elimination of the compound? • F – FIND AND ANTIDOTE / Initiate specific therapies • Dependent on the ingestion and a BROAD topic Definitions • Decontamination • Process of preventing systemic absorption into the body • Ex: SDAC, Syrup of Ipecac, gastric lavage, WBI • Enhanced Elimination • Process of speeding up metabolism and elimination of an already absorbed substance; can be ex-vivo or in-vivo methods • Ex: Hemodialysis, MDAC, urinary alkalinization, intra-lipid (IV fat emulsion) Back to the patients… CASE #1 • 30 year old unknown male, acting bizarre outside • T 40C, HR 149, BP 160/110, RR 30, Sats 95% RA • Extreme agitation and aggression with EMS, requiring multiple (limited) security personnel to hold the patient down on arrival. CASE #1: The “Hot & Bothered” DDX • What is our DDX for the HIGH TEMP and AGITATED patient • Think both TOX and non-TOX • BONUS: What is the difference between “Fever” and “Hyperthermia” • TOX Sympathomimetics Anticholinergics Serotonergic  Serotonin Syndrome Antipsychotics  Neuroleptic Malignant Syndrome ETC Uncouplers (ASA, DNP) Drugs that predispose to poor environmental responses • Malignant Hyperthermia • • • • • • • INFECTIOUS • STRUCTURAL • ENDO / METABOLIC • ENVIRONMENTAL Central Effects Agitation Increased Temperature ANS SYMPATHETIC STOP “Fight or flight” Mydriasis Slowed GI / Decreased Secretions PARASYMPATHETIC STOP “Rest and digest” EYES Miosis SALIVARY Increased GI / Secretions Bradycardia, Heart Block Tachycardia / Vasoconstriction CVS Dilated Airways LUNGS Constricted Airways SKIN *Our sweat glands are sympathetically driven* Diaphoresis / pale skin / Temp up N/A CASE #1: The “H & B” Management • Sedation is needed  Rigidity and hyperactivity kill! • Benzos, Benzos, Benzos, Benzos • Consider intubation and paralysis • What should be do about the elevated Temp? • Tylenol? NO CASE #1: Hyperthermia KILLS • Hyperthermia KILLS – we need to aggressively cool these patients • Chemical sedation as before will help • Other cooling methods? Body bag + Ice/water Fanning and Misting Exposure Cooled (4C) IV fluids Cool packs to the axilla, groin, neck (major blood vessel highways) Further sedation and PARALYSIS • When do we stop cooling… What are our targets? • <39 Celsius within 20-30 minutes • True EMERGENCY CASE #2 • 25 yo female took a friend’s “down” • On arrival to the ED: • • • • GCS 3 (nonresponsive) Pinpoint pupils Respirations 6 breaths / minute O2 85% on RA CASE #2: Opioids • Common opioids / opioid-like medications • • • • • • • • • Morphine Codeine Fentanyl Dilaudid Oxycontin Heroin Methadone Tramadol Dextromethorphan • Illicit Opioids contain numerous adulterants… • • • • Sulfonylureas Baking soda Xylazine Etc. CASE #2: Opioids • CNS • Drowsy, somnolent • Pupils • Pinpoint (miosis) • CVS • Bradycardia • Hypotension • Respiratory • Bradypnea, hypopnea • Hypoxia (Decreased O2) • Hypercarbia (Increased CO2) CASE #2: Opioids CASE #2: Opioids • Kratom • Tropical evergreen native to SE asia • Ingestion can produce both stimulant and opioid effects – has been touted as a treatment for opioid withdrawal; NO evidence supporting this. • However, not currently illegal; easy to obtain • 27,338 opioid overdose deaths; 152 of which tested positive for Kratom – post-mortem analysis indicates 91 of the 152 cases where Kratom was the responsible agent. CASE #2: Opioids Management • ANTIDOTE: Naloxone OBJECTIVES • PADIS Overview – What it is, who we are, and how can we help! • Highlights of toxicologic epidemiology in Canada • Explore some common toxicology cases and what goes into their assessment / management • Recognize the limitations of qualitative drug screening • Open Q/A (Time permitting!) QUESTIONS? [email protected] Drug Testing in the Workplace David W. Kinniburgh, PhD, FCACB Director, Alberta Centre for Toxicology [email protected] 1 About Me • Director of the ACFT at U of C • Laboratory Med & Pathology, U of A. Physiology & Pharmacology, U of C. • Clinical Chemistry/Clinical Toxicology/ Environmental Tox/ Forensic Tox • Started the employment drug testing program at Dynacare labs and was the National Director. 2 About Me • Inspector for College of American Pathologists, and the ACFT is an accredited CAP FDT lab 3 Learning Objectives • Overview of Employment Related Drug Testing • Broad understanding of topic • Historical, moral, legal, scientific and technical issues • Role of toxicologist and others involved • Emphasize quality and accuracy 4 Topics of Discussion • • • • • Background Pharmacokinetic considerations Legal Considerations Analytical considerations Interpretation of results 5 Class Survey • Do you think there is a drug problem in Canada? • Do you think drugs are used in the workplace? • Are you opposed to employment related drug testing? • Do you have concerns about the accuracy of employment related drug testing? 6 Drug Testing in the Workplace • Regulated: Mandatory for certain workers. Strict rules. List of drugs. Accredited labs. SAMHSA. HHS. DOT. MRO. • Non-regulated: Not mandatory. No rules. Any drugs. Not accredited. MRO not required. • Urine, oral fluid or breath, and hair. • Forensic testing and Clinical testing 7 History of Drug Testing • • • • • • • • • • • • • 1970’s: 1980’s: 1982: 1985: 1990: 1996: 1997: 1998: 2001: 2004: 2007: 2008: 2009: • 2010: • • • • 2013: 2014: 2015: 2017: US employment testing US regulated testing Canadian employment testing Proposed Canadian policy; Proposed H&W guidelines DND testing; SCC accreditation US DOT testing regulations applied to Canada Canadian labs accredited through SCC Canadian Labs accredited directly by SAMHSA Canadian legal challenges Alberta announces possible legislation Hair testing available by mail in Canada Oral fluid testing common in the US Oral fluid testing becoming common in Canada Revisions to US regulated testing (May1, 2010) Oral fluid and hair testing common in Canada Alberta appeal court upholds ruling against random US proposes OF testing for regulated testing Marijuana to be legalized. Implication on testing? • • • • 2018: 2018: 2019: 2020: Alberta Court of Appeal rules against random testing. Marijuana legalized in Canada. Oral fluid testing acceptable for SAMHSA testing. US proposes hair testing for regulated testing 8 Arguments for Drug Screening • • • • • • • Job safety Absenteeism Quality/quantity of production Increased health costs Increased liability costs Unlawful activity Government regulations 9 Arguments Against Screening • • • • • • • • Opposition to US enforcement and US rules Union opposition Legal concerns and complications Does not measure performance Opponents question extent of problem Opponents prefer education Opponents question accuracy What employees do off the worksite is not the employer’s concern • Marijuana and cocaine are safe drugs • Marijuana is a legal drug in many places 10 Arguments for Drug Screening • August 2013 to November 2017, Suncor said it has had over 1,100 alcoholand drug-related security incidents. • 73 incidents of employees testing positive for controlled substances. • 39 occasions where workers tested positive for drugs or alcohol following workplace safety incidents. 11 Industries Using Screening • • • • • Transportation Petroleum Mining Pulp and paper Other industrial operations with transportation • Financial, commercial, security, sports, service, etc... 12 Types of Testing • • • • • • Pre-Employment Random Reasonable Suspicion/Cause Post Accident Return to Duty Follow-Up 13 Pharmacokinetic Considerations • Absorption, Distribution, Metabolism, Elimination • Urine variables • Limitations: Dose, Time, Effect 14 Workplace Drug Screen DOT Mandatory Tests • Amphetamines (Amp, Meth, MDA MDMA) • Cannabinoids • Cocaine Metabolite • Opiods (Cod, Mor, Oxycod, OxyMor, Hydcod, Hydmor, 6AM) • Phencyclidine (PCP) • Ethanol Included in NonRegulated Testing • • • • • • • Benzodiazepines Barbiturates Methadone Methaqualone Propoxyphene LSD Other drugs 15 Elimination Times for Drugs • • • • • • Amphetamines Cannabinoids Cocaine metabolite Opioids Phencyclidine Ethanol 1 - 2 days 1 - 30 days 12 - 48 hours 1 - 3 days 1 - 30 days up to 14 hours 16 Elimination Times for Drugs • • • • • Barbiturates Benzodiazepines Methadone Methaqualone Propoxyphene 1 day - 3 weeks 1 day - 6 weeks 1 - 3 days 1 - 7 days 1 - 3 days 17 PCP - Phencyclidine AKA Appearance Angel dust, peace pills, hogs, elephant tranquilizer, super joint, rocket fuel Crystal, powder, liquid or tablet Class Hallucinogen Dose Injested, smoked, injected, snorted Effect Unpredictable and variable. Rapid thought and action. Euphoria to depression. Hallucinations, irrational and violent behavior. Increased sensory perception. NOTE: Rarely seen in Western Canada Extremely dangerous drug 18 Amphetamines AKA Appearance Speed, Bennies, Black Beauties, CoPilots, Dexies, Meth Crystal, Uppers, ICE Varied pills, powders or solutions Class CNS stimulant Dose Ingested, injected, snorted or smoked Effects Euphoria, mood elevation, increased alertness and energy. Increased heart rate and blood pressure, tremor anxiety and sweating. “Rush” and “Crash” Note: Strength and contamination unpredictable. Designer drugs difficult to test for and can be very toxic. Hyperirritability, restlessness, bizarre behavior, weight loss, paranoia Chest pain, dizziness, tremors, convulsions, hallucinations, psycosis, brain damage and cardiac arrest. 19 Opioids AKA Appearance Codeine, Morphine, Oxycodone, Oxymorphone, Hydrocodone, Hydromorphone, Heroin, Dust, Horse, Junk, H, Smack White/Brown Powder, Tablets, Tonics Class Narcotic Analgesic, CNS depressants Dose Injected, sniffed, smoked, ingested Effects Skin flushing “rush”, euphoria “nod”, diminished sensory perception, lethergy and confusion. NOTE: Strength and contamination unpredictable and can be lethal. Many OTC meds contain codeine. Fentanyls not detected. Prescriptions are a problem. Respiratory depression can lead to death. Physical dependence can develop quickly. Withdrawl includes nausea, diarrhea, insomnia, sweating, muscle spasms, chills, tremors, vomiting and weakness. IV users risk AIDS and hepatitis. 20 Cannabinoids AKA Appearance Dope, Grass, Weed, Smoke, Pot, Hash, Reefer, Joint, Mary Jane, etc. Green/brown dried leaf, light to dark colored, resin/past or oil. Class Psychoactive substance (possible use as appetite stimulant, anti-nausea, epilepsy, neuromuscular). Dose Smoked or ingested Effects Euphoria, passivity, relaxation, drowsiness, increased auditory and visual perceptions, disinhibition and sensory distortion. Note: Possible link to psychiatric disorders, dependence and carcinogen. Synthetics are toxic. Impaired short-term memory, diminished learning ability, attention lapses, disorientation, depersonalization, paranoia, delirium, hyperemesis syndrome, and hallucinations. Most abused illegal drug (until legalized!). Blood shot eyes and increased heart rate are common. Alcohol amplifies effects. No cross reaction with synthetics in conventional cannabinoid assays. Cannabidiol vs. THC. 21 Cocaine AKA Coke, Nose Candy, Snow, Toot, Blow, Crack Appearance White crystalline powder or transparent crystals Class CNS Stimulant, Local Anaesthetic, Vasoconstrictor Dose Injected, smoked, absorbed via mucus membranes Effects Sweating, rapid shallow breathing, increased heart rate and blood pressure, elevated temperature, and euphoria. NOTE: Strong psychological dependence, can be mixed with other drugs, can produce sudden death May induce tremors, twitching, chest pain, nausea, seizures, respiratory depression, cardiac arrhythmias and death. Other effects include weight loss, constipation, impotence, difficulty urinating, nasal septal necrosis and lung damage 22 Alcohol AKA Ethanol, ethyl alcohol Class CNS depressant Effect Drowsiness, dizziness, flushing, slurred speech, staggering, double vision, stupor and loss of consciousness. Overdose may lead to respiratory failure. Note: Most abused drug. Increases toxic effects of other drugs. Withdrawal symptoms include headache, stiff muscles, nausea, weakness, tremors and vomiting, convulsions, hallucinations and rarely death. 23 Drug Testing in the Workplace Day 2 David W. Kinniburgh, PhD, FCACB Director, Alberta Centre for Toxicology [email protected] 24 Topics of Discussion • Legal Considerations – Examples of legal challenges in Canada – Understand Canadian law with respect to Drug Testing in the Workplace • Analytical considerations 25 Legal Challenges - Entrop Case • Operator, Sarnia Imperial Oil refinery • Disclosure, discipline, follow-up testing • Claimed discrimination against alcoholic in remission (1992) • Ontario Board of Inquiry (1995, 1996), Ontario General Division Court (1998), Ontario Court of Appeal (2000) 26 Legal Challenges - Entrop Case (cont.) • Board of Inquiry: Ruled against random drug testing • General Division Court: Upheld ruling 27 Legal Challenges - Entrop Case (cont.) • Appeal Court Ruled: -Board had no jurisdiction to rule on drug testing -Random alcohol testing for safety sensitive employees is a BFOR -Sanctions for positives should be tailored to individual circumstances 28 Legal Challenges - Entrop Case (cont.) • Appeal Court Opined: -Post-incident, post-reinstatement and safety sensitive certification testing may be OK -Pre-employment and random testing not acceptable 29 Legal Challenges - Entrop Case (cont.) • • • • • Initial vs. final ruling Ruling vs. opinion Individual case fact important Jurisdiction and precedent Addiction is a health impairment thus a handicap • Workers are protected from discrimination 30 Legal Challenges - T.D. Bank Case • Canadian Civil Liberties Association filed complaint under Canadian Human Rights • Claimed testing deprived handicapped persons of employment • Canadian Human Rights Tribunal (1994) Federal Court Trial Division (1996) Federal Court of Appeal (1998) 31 Legal Challenges - T.D. Bank Case (cont.) • Not a traditional safety-sensitive environment • Testing does not reflect ability to perform job 32 Legal Challenges - Trimac Case • Union challenged pre-employment and random testing for drivers working in Canada only (1998) • Claimed testing was invasion of privacy • Ruled pre-employment testing beyond jurisdiction of arbitrator • Ruled random testing not justified vs. individual privacy 33 Legal Challenges - Other Cases • Upheld pre-employment testing: Milazzo 2005, Chiasson 2007. • Denied pre-employment testing: Luka 2008, Bantrel 2009. • Alberta Human Rights Commission 2009: The Commission does not have jurisdiction to tell an employer when or whether they can require a drug or alcohol test. The Commission’s focus is on the treatment of employees who are disabled through drug or alcohol dependency. • 2018: Alberta Court of Appeal rules against Suncor random testing. 34 Legal Considerations • Drug testing is not illegal in Canada • Testing safety-sensitive workers is accepted • Random testing not accepted • Accident/Incident testing is accepted • Pre-employment testing allowed • Pre-access testing more accepted term • Sanctions should be case specific 35 Legal Considerations • Alcohol testing is a measure of impairment • Drug testing not a measure of impairment • Focus of Canadian court appears to be on ability to perform job and individual rights • Focus is on alcohol/drug impairment vs. presence • Focus is not on risk of impairment • Focus is not on company liability due to major accident • Policy and legal prudence are paramount 36 Legal Considerations • Court testimony in support of the testing and interpretation of drug testing results is an important part of a toxicologist’s job for this type of testing (forensic testing). • Training/preparation for being an expert witness is strongly recommended. 37 Analytical Considerations • Sample collection • Drug testing procedure • Non-laboratory based testing 38 Sample Collection • • • • • Collection supplies Chain of custody Collection protocol Donor drug history Specimen adulteration 39 Collection Supplies • • • • • • Specimen containers Temperature strip Evidence tape Chain of custody form Tamper evident bag Instructions 40 Collection Protocol • • • • • • • Identification of donor Explanation of procedure Identification of specimen Split sample specimen collection Completion of chain of custody form Sealing of specimen Transportation to laboratory 41 Collection Supplies 42 Collection Supplies 43 Collection Supplies 44 Collection Supplies 45 Collection Supplies 46 Collection Supplies 47 Collection Supplies 48 Collection Supplies 49 Collection Supplies 50 Elements of Chain of Custody • • • • • Identification of specimen Acknowledgment of testing Identification of collector Security of specimen Individual(s) performing testing The result for that specimen is from that individual and has not been tampered with 51 Drug Testing Procedure • • • • • Specimen log-in Chain of custody verification pH and creatinine (or s.g.) check Preliminary testing by immunoassay (IITF) Verify ALL positives by GC/MS, LC/MS, or GC (ethanol) (Alternate confirmation methods) 52 Immunoassay Test • • • • • • Preliminary test only Antigen - Antibody test Rapid test results Easily automated for high volume Tests for drug family Possible cross reaction • IITF as of May 1/10 53 GC/MS • • • • • Confirmation test Extraction of drug Clean up / Concentration / Derivatization Chromatography Detection 54 Cut-Off Concentrations (ug/L) • • • • • • • • • Amphetamines MDA Cannabinoids Cocaine Metabolite Opiates/Opioids Oxy/Hydro opioids 6-AM Phencyclidine Ethanol 500 / 250 500 / 250 50 / 15 150 / 100 2000 / 2000 200/100 (100/100) 10 / 10 25 / 25 200 / 200 (400 / 400) ug/mL 55 Cut-Off Concentrations (ug/L) • • • • • Barbiturates Benzodiazepines Methadone Methaqualone Propoxyphene 300 300 300 300 300 56 Alternate Confirmation Methods • • • • • • LC/MS LC/MS/MS LC/TOF GC/MS/MS GC/TOF Other 57 Alternate Confirmation Methods • GC/MS – Traditional, accepted method – Large spectral data base – SAMHSA slow to change • GC/MS/MS, LC/MS, LC/MS/MS, ToF, etc – Increased sensitivity – Increased spectrum of drugs – Increased efficiencies (sample preparation, multi-drug analysis) – Improvements in data analysis 58 Drug Testing in the Workplace Day 3 David W. Kinniburgh, PhD, FCACB Director, Alberta Centre for Toxicology [email protected] 59 Topics of Discussion • Analytical considerations – Specimen Adulteration – Specimen Types – Non Laboratory Testing – Medical Review Officer – Breath Alcohol Testing • Interpretation of results 60 Adulteration of Specimen • Any attempt to alter the sample so as to invalidate the testing. • • • • • Internal dilution External dilution Substitution Contamination Tampering 61 Specimen Adulteration ADULTERANT Bleach Detergent/Soap Glutaraldehyde Golden Seal Klear (Nitrite) Urine Luck Lye (Drano) Salt Vinegar Visine AFFECT Emit Emit Emit Emit GC/MS GC/MS Emit Emit Emit Emit DETECTION Odor, pH, Cl Visual, pH Emit, UA, GC/MS Visual, Cre, SG IS, UA, Colorometric IS, UA, AS, pH, Color pH Visual, SG, Cl Odor, pH SG 62 Specimen Adulteration Testing • • • • • • • Collection site protocol Sample Temperature Creatinine/SG pH Oxidizing adulterants Odor/Color/Particulates/ Screening or Confirmation interference 63 Specimen Adulteration Myths • • • • • • WD40 Varnish on glass Oral bleach Oral bleach / vinegar Mega-vitamins Face north and close left eye 64 Specimen Types SAMPLE ADVANTAGE/DISADVANTAGE Blood Low concentration - related to effect – short retention Invasive to collect – requires expertise Ample experience with blood Urine High concentration - not easily related to effect Large amount of sample - Relatively easy to obtain Sample adulteration is a problem Extensive experience with urine Acceptable SAMHSA sample type 65 Specimen Types SAMPLE ADVANTAGE/DISADVANTAGE Hair Low concentration - not related to effect Long retention time for drug Somewhat invasive to collect Limited opportunity for adulteration Reasonable experience with hair Oral Fluid Low concentration Small amount of sample – easy to obtain Limited opportunity for adulteration Reasonable experience and history with oral fluid Acceptable SAMHSA sample type 66 Specimen Types SAMPLE ADVANTAGE/DISADVANTAGE Sweat Low concentration - not related to effect Longer window of detection Limited opportunity for adulteration Limited experience with sweat Breath Used only for ethanol testing Comparable to blood ethanol Extensive experience with breath Acceptable SAMHSA sample type Performance No sample required May be a measure of real time impairment May be biased to some individuals Limited experience 67 Non-Laboratory Based Testing (POCT) • Pro: – Cost – Rapid and on-site testing – Internal control of testing 68 Non-Laboratory Based Testing (POCT) cont. • Con: – False positives and negatives – No confirmation – Real cost – Unqualified, untrained, unmotivated, distracted operators – Little or no QA/QC – No documentation – Biased testing 69 Non-Laboratory Based Testing (POCT) cont • Con: – Not SAMHSA accepted methods – Difficult to standardize – Legal defensibility is more difficult – No professional review – Success very user dependent – Not “fool proof” 70 Non-Laboratory Based Testing (POCT) cont • “Singapore nightclub uses a urinal-based urine POCT device to screen patrons’ alcohol levels and discourage drunks from driving themselves home” • California University develops temporary tattoo that measures alcohol level. 71 Medical Review Officer (MRO) • • • • • • • Licensed doctor of medicine/osteopathy Knowledge of drug abuse disorders Certified training program (with retraining) Receives all results Contacts all positive donors Determines “reportable” positives Reports results to company 72 Donor Drug History • Prescription medications • Over-the-counter medications – Codeine analgesics and cold medications – Decongestants and antihistamines • Poppy seeds • Health fad preparations • Alcohol consumption 73 Breath Alcohol Testing • • • • • • • Breath test mandatory for DOT (not pre) During, before or just after working EBT or saliva test (DOT approved) Test performed by trained BAT Company may perform own testing Results do not have to go to MRO 0.02 / 0.04 (% or g/100mL) BAC cut-off Note that DUI cut-off is 0.05-0.10 74 Breath Alcohol Testing cont. • Breath confirm by EBT after 15 min. • Saliva confirm by EBT within 30 min. 75 Interpretation of Results • Negative – Drug not present at all – Drug present but less than cut-off – Drug present but masked – Error 76 Interpretation of Results • Positive – Drug present, above cut-off and confirmed – False positive is not a reasonable possibility – Indicates drug use in past hours to days – Not a measure of impairment – Cannot differentiate use from abuse 77 Interpretation of Results • Ethanol – Up to 14 hours after use (in urine) – Urine may not correlate with impairment – Consider history 78 Interpretation of Results • Opioids/Opiates – Over-the-counter codeine – Poppy seeds – Codeine is metabolized to morphine 79 Interpretation of Results • Cocaine – Metabolized to Benzoylecgonine – “Inca tea” positives are very unlikely 80 Interpretation of Results • Cannabinoids – Positive from hours to days after last use – May be intermittent positive and negative – Passive inhalation not possible 81 Snowboarding And Marijuana • • • • Urine THC level 17.8 ng/mL Feb 11/98 Claimed last use April 1997 Claimed passive inhalation Jan 1998 IOC disqualified snow boarder 82 Not Guilty ? • • • • 17.8 is a very low level Cut-off is 50 Marijuana in BC is stronger Anecdotal “evidence” of positives for over 1 year 83 Confidence in Results • SAMHSA accreditation (or other) – Reliable screening method – Confirmation of all positives – Quality assurance program • Chain of custody • Professional review of results 86 Class Survey • Do you feel there is a drug problem in Canada? • Are you opposed to employment drug testing? • Do you have concerns about the accuracy of accredited employment related drug testing programs? 87 Exam Questions • Cover material in lectures and slides • For mandatory or regulated drug testing, such as for commercial trucking companies driving into the US, ethanol testing is not performed on a urine sample. Ethanol testing may be performed on a breath or saliva sample with an approved device. If the initial test is positive it is confirmed by a second test. T or F (1 88 mark) Drug Testing in the Workplace David W. Kinniburgh, PhD, FCACB Director, Alberta Centre for Toxicology [email protected] 89