Substance and Non Substance Related Addiction Disorders: Diagnosis and Treatment E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Sprache: Englisch
Substance and Non substance Related Addiction Disorders: Diagnosis and Treatment is an accessible handbook with substance and non subsatance addiction disorders. It is divided into three sections which cover 1) general topics, the scientific underpinnings of addiction disorders (neurobiology, addiction neural reward pathways, genetic and psychosocial basis of addiction, drug screening and treatment of cooccuring psychaitric disorders), 2) information about substances commonly used by individuals with addiction (pharmacology, diagnostics and treatment considerations) and 3) current understandings of the diagnosis and treatment of behavioral addictions (such as gambling), respectively.
Key features:
-covers both substance and behavioral addictions
-uses a reader friendly format with a patient education handout style
-includes key learning points listed in each chapter
-includes clinical vignettes which outline brief history, evaluation, diagnostic considerations with successful pharmacological, psychological and social interventions
-includes references in each chapter
The handbook meets the information needs of medical students and professionals (family physicians, nurses, addiction therapists, psychiatry residents, and other health care professionals) interested in the care of patients afflicted with addiction disorders.
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Seitenzahl: 363
Veröffentlichungsjahr: 2017
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Substance and Non Substance
Related Addiction Disorders:
Diagnosis and Treatment
Edited by:
Subhash C. Bhatia
Co-Editors:
Frederick Petty
Teri Gabel
BENTHAM SCIENCE PUBLISHERS LTD.
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FOREWORD
About one person in three has a problem with potentially hazardous drug or alcohol use which often goes unrecognized. Excessive or hazardous use of drugs, including tobacco, and of alcohol, can have very negative biological, psychological and socio-economic consequences from the direct effect of the substances. In social realm addictive behaviors take a toll on relationships with friends and family. Also often harm can occur to the patient by failure to comply with medical or psychosocial treatment for abstinence or unsupervised withdrawal or through drug interactions. Thus, every practitioner should have knowledge regarding diagnosis and treatment of common substance use disorders.
The authors share with the readers wealth of information based on their experience about diagnosis and management of common substances of abuse as well as neurobiological underpinning of these disorders. Each chapter in section II features discussion of diagnosis, and approaches to treatment and highlights cases with approaches to the patient delineated.
The practitioners should find this volume useful, helpful, and interesting in helping to provide optimal health care to his or her patients.
PREFACE
Substance use disorders are amongst the major causes of disease burden around the globe. In a World Drug Report by the United Nations Office on Drug and Crime it is estimated that 210 million individuals have used illicit drugs at least once and that these drugs are related to about 200,000 deaths. The economic burden of substance use disorders in the USA alone from health care costs, lost productivity, crime, incarceration and drug enforcement is estimated to be $524 billion.
Addiction is a brain disease where a person uses a drug compulsively despite negative consequences and drug use in turn causes persistent changes in the brain circuits which perpetuates its use. In predisposed individual’s addiction starts during adolescent years. Fortunately addictions are preventable through public awareness and education and are treatable through contemporary medications, individual, group or family therapy as a well as self-help groups. Biopsychosocial intervention can mitigate life time suffering of the patient, family, and friends. Treatment also improves the quality of their lives. Moreover it can prevent tragic loss of life as well . Extended abstinence predicts long-term recovery. Drug addiction is a chronic disease and its relapse rate is comparable to hypertension, diabetes or asthma.
Recently one notable development has been publication of DSM-5 . Our publication provides information on the diagnosis of the additive disorders consistent with this new version of DSM.
The book is titled Substance and Non Substance Related Addiction Disorders: Diagnosis and Treatment and is divided in to three sections.
Section I addresses basic general topics related to scientific underpinnings of addictive disorders including the neurobiology and addiction neural reward pathways, genetics and psychosocial basis of addictions; urine drug screens in diagnosis and management of substance use disorders, co-occurring psychiatric and substance use disorders and pharmacological treatment of comorbid psychiatric disorders and motivational interviewing. Each chapter has key learning points, references, a patient education hand out .Section II provides updated information about individual drug related addictive disorder. Each chapter in addition to key learning points and a patient education handout, describes a case vignette and its discussion related to specific drug, its diagnosis, medical and biopsychosocial interventions. In addition these chapters include neurobiology, epidemiology summary and updated references with resources for more information.Section III presents information about non-substance related addiction disorders, a vignette and its discussion, diagnosis and interdisciplinary treatment strategies. The chapter in this section is primarily devoted to gambling addiction; other non-substance related addictions are also mentioned.This book is by multiple authors with experience in addictions and is designed to meet the clinical practice needs of internists, family physicians, nurse practitioners, physician assistants, addiction therapists, psychiatry and primary care residents, graduate students and other health care professionals interested in the care of patients with substance use and addiction disorders. A concise format for each chapter is used to maintain its user friendliness for quick review.
List of Contributors
Section I: General Topics
Neurobiology and Psycho-Social Basis for Addiction and Related Disorders
Subhash C. Bhatia*Abstract
Addictive disorders are diseases of the brain. Addictions like chronic illness may have remissions and relapses. These are caused by genetic, biological, psychological, social and economic factors. Reward pathways for all substance and non-substance related addictive behavior (gambling, sex and food addiction etc.) are similar and are mediated through nucleus accumbens and associated circuits. Negative preexisting emotional state or due to withdrawal from substance and self-medication to seek relief may perpetuate addictive behavior. Substance or non-substance related addictive behavior-pleasure-reinforcement-reuse paradigm perpetuates addictive behavior. Environmental cues and memories associated with addiction related activities contribute to craving and relapse. Dopamine neurotransmitter plays major role in addictive behaviors. Treatment consideration should factor in all of these biopsychosocial factors.
Key Learning Points
Addictive disorders have complex biopsychosocial underpinnings for both causation and treatment.Dopamine is the crucial neurotransmitter in reward circuits for all substance and non-substance related addictive disorders. Chronic use causes down regulation of dopamine receptors which accounts for tolerance.Ventral tegmental area, nucleus accumbens, prefrontal cortex, hippocampus, amygdala and basal ganglia all contribute to impulsive and compulsive drug use as well as reward and cue driven craving.Psychosocial stressors as epigenetic factor may change the genotype and may increase propensity to addiction.Association of behaviors leading to reward is part of the operant conditioning paradigm and perpetuates drug use.The self-medication hypothesis to treat negative emotional states is reported to be involved with addiction.Adverse childhood experiences such as physical, sexual, emotional abuse, physical or emotional neglect, domestic violence and drug misuse or mental illness in the family, incarceration of a family member and parental separation and divorce may increase the risk of illicit drug use 2 to 4 times. This drug use may be viewed as self-soothing behavior and may persist through life.Neurobiology of Addiction and Reward Pathways
The neurobiology of substance and non-substance addiction and related disorders is complex but follows a common reward pathway. These disorders are chronic relapsing illnesses, a brain disease, characterized by engaging in the compulsive use of substances despite negative consequences. The drug use starts out with liking, which is a non-problematic use, followed by wanting and craving respectively leading to abuse and dependence. The intense craving is mediated by withdrawal effects, or after due to pleasurable effects of drug and/or environmental cues. The motivation to repeatedly re-experiencing pleasurable effects or to avoid aversive effects of drug withdrawal [1, 2]. This compels the individual to seek the drug. The following information provides a simplified summary version using an example of narcotic addiction.
For addictions, self-administration mimics binding of a substance directly to specific endogenous receptors resulting in reinforcing effects. For example in opiate addiction mu receptor activation in addition to causing analgesia, nausea, reduced bowel motility, miosis (constricted pupils), sedation, reduced blood pressure and decreased respiration is also associated with euphoria [3]. Both substance and behavioral addictions are mediated through dopamine (DA) neurotransmission. DA is a primary neurotransmitter in reward pathways. DA is also responsible for emotion, cognition, motivation and euphoria and dysregulation of reward pathways and is considered the cause for addiction [4]. The dopamine neurotransmission is basis for addiction and related disorders through mesocortocolimbic dopamine projections from the ventral tegmental area (VTA) to the nucleus accumbens (NAc) [5].
Acute positive reinforcement, euphoria or the “high” is through the effect of DA and local opioid peptides through the common reward pathways i.e. VTA to nucleus accumbens (NAc) - amygdala reward system (5). Repeated replication of this positive reinforcement forms the basis of addiction.
Chronic substance use leads to neuroadaptation through decreased VTA mesolimbic and NAc DA neurotransmission [6]. Repeated use and excessive production of dopamine leads to down regulation of dopamine receptor sites. To experience the same level of euphoria again, an individual needs higher amounts. This forms the basis for tolerance. Also, stress results in increased production of corticotrophin releasing factor (CRF). This activates the hypothalamic-pituitary-adrenal axis (HPA) and other stress system like the amygdala [7]. This forms the basis for negative emotional states like dysphoria and anxiety. Individuals use substances to deal with these negative emotional states which promote addictive process. CRF adaptation may also explain role of stress and emotional states in craving for drug use (6).
Dysfunction of ventro-medial prefrontal cortex circuitry is the cause for impulsivity expressed as a sense of urgency, lack of evaluative and rational decision making processes [8]. This contributes to impulsive drug use.
Environmental cue-induced craving is mediated through hippocampus and basolateral amygdala [6].
The compulsive drug-seeking behavior is hypothesized to be driven by ventral striatal-ventral pallidum-thalamic-cortical loops [7]. Drug seeking behavior despite harmful consequences may point towards impairment of executive functions.
Treatment directed at craving, stress modulation, promotion of resilience in dealing with stress and impulse control through cognitive behavior therapy is a valuable intervention for all substance and non-substance related addictive behaviors.
Psychosocial Factors
Genetic factors and heritability account for 40-60% of the risk for addictive disorders. Environmental factors may contribute to the change in brain circuits during development which may further contribute to susceptibility of individuals to drug use. Animal studies have shown that stress can contribute to changes in genotype [9].
The self- medication hypothesis postulates that some individuals abuse substances to deal with intolerable emotional states of mind [10]. For example patients with depression may prefer stimulants to relieve symptoms or patients with anxiety may prefer alcohol, a self-directed therapy for anxiety. Patients crave to reuse a drug to seek relief from these dysphoric emotional states.
Drug seeking and drug intake behavior and its association with euphoria, reinforcement and reward are components of operant conditioning which plays a part in addiction
Socio-economic factors like poverty and their impact on social development have a strong association with addiction [11]. These factors also contribute to stress and self-medication is probably one way to seek relief from it. It is also postulated that “drugs are more likely to be a consequence of poverty and crime” [12].
Lastly, social factors such as peer pressure and the easy availability of a drug in a community play a role in addiction and related disorders.
Adverse Childhood Experiences (ACE)
Children who experience physical, sexual, emotional abuse, physical or emotional neglect, domestic violence and drug misuse or mental illness in the family, incarceration of a family member and parental separation and divorce experience chronic stressful events which has negative impact on multiple biopsychosocial functional domains. These childhood disruptions cause neurodevelopment disruptions, depression, interpersonal and family dysfunction, cognitive impairment, early engagement in high risk behaviors, smoking, consuming alcohol, abusing prescription and illicit drugs, engaging in risky sexual behaviors during teen age years as well as afflicted with disease disability and premature mortality [13]. Substance use is often a coping mechanism to deal with emotional pain. Substance use related effects are dose-response i.e. proportionate to degree and severity of adversity. Each adverse experiences increases the risk of early initiation of illicit drug use. There is 2-4 times risk of initiation in to early illicit drug use. Addictive behaviors often start with early initiation of alcohol [14], early smoking initiation [15] and prescription drug use [16]. These addictive behaviors may continue in to adulthood and even may persist through lifetime [17, 18]. Dose related effects of adverse childhood events may also include lifetime depressive episodes [19] and risk of suicide attempts, sleep disturbances [20], high risk sexual behaviors and teen pregnancy [21]. Depression and sleep disturbances may further compound substance use. Surveillance and data acquisition about ACE, increasing awareness with state and county, developing programs, policies and processes for early intervention and prevention planning are valuable.
Conflict of Interest
The author confirms that he has no conflict of interest to declare for this publication.
Acknowledgements
Declared none.
References
[1]Wikler A. Recent progress in research on the neurophysiologic basis of morphine addiction. Am J Psychiatry 1948; 105(5): 329-38. [http://dx.doi.org/10.1176/ajp.105.5.329] [PMID: 18890902][2]Koob GF, Stinus L, Le Moal M, Bloom FE. Opponent process theory of motivation: neurobiological evidence from studies of opiate dependence. Neurosci Biobehav Rev 1989; 13(2-3): 135-40. [http://dx.doi.org/10.1016/S0149-7634(89)80022-3] [PMID: 2682399][3]http://en.wikipedia.org/wiki/Mu_Opiod_receptor 2010.[4]Koob G, Kreek MJ. Stress, dysregulation of drug reward pathways, and the transition to drug dependence. Am J Psychiatry 2007; 164(8): 1149-59. [http://dx.doi.org/10.1176/appi.ajp.2007.05030503] [PMID: 17671276][5]Koob GF, Sanna PP, Bloom FE. Neuroscience of addiction. Neuron 1998; 21(3): 467-76. [http://dx.doi.org/10.1016/S0896-6273(00)80557-7] [PMID: 9768834][6]Koob GF, Simon EJ. The Neurobiology of addiction: where we have been and where we are going. J Drug Issues 2009; 39(1): 115-32. [http://dx.doi.org/10.1177/002204260903900110] [PMID: 20622969][7]Sarnyai Z, Shaham Y, Heinrichs SC. The role of corticotropin-releasing factor in drug addiction. Pharmacol Rev 2001; 53(2): 209-43. [PMID: 11356984][8]Brewer JA, Potenza MN. The neurobiology and genetics of impulse control disorders: relationships to drug addictions. Biochem Pharmacol 2008; 75(1): 63-75. [http://dx.doi.org/10.1016/j.bcp.2007.06.043] [PMID: 17719013][9]Kendler KS, Neale MC, Heath AC, Kessler RC, Eaves LJ. A twin-family study of alcoholism in women. Am J Psychiatry 1994; 151(5): 707-15. [http://dx.doi.org/10.1176/ajp.151.5.707] [PMID: 8166312][10]Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry 1985; 142(11): 1259-64. [http://dx.doi.org/10.1176/ajp.142.11.1259] [PMID: 3904487][11]Galea S, Nandi A, Vlahov D. The social epidemiology of substance use. Epidemiol Rev 2004; 26: 36-52. [http://dx.doi.org/10.1093/epirev/mxh007] [PMID: 15234946][12]Hart C. High Price: A neuroscientist’s journey of self-discovery that challenges everything you know about drugs and society. HarperCollins 2013.[13]http://en.wikipedia.org/wiki/Mu_Opiod_receptor[14]Dube SR, Miller JW, Brown DN. Adverse childhood experiences and association with ever using alcohol and early initiating alcohol use during adolescents. J Adolesc Health 2006; 38(444): 1-10. [PMID: 16387241][15]Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA 1999; 282(17): 1652-8. [http://dx.doi.org/10.1001/jama.282.17.1652] [PMID: 10553792][16]Anda RF, Brown DW, Felitti VJ, Dube SR, Giles WH. Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients. BMC Public Health 2008; 8: 198. [http://dx.doi.org/10.1186/1471-2458-8-198] [PMID: 18533034][17]Dube SR, Anda RF, Felitti VJ, Edwards VJ, Croft JB. Adverse childhood experiences and personal alcohol abuse as an adult. Addict Behav 2002; 27(5): 713-25. [http://dx.doi.org/10.1016/S0306-4603(01)00204-0] [PMID: 12201379][18]Ford ES, Anda RF, Edwards VJ, et al. Adverse childhood experiences and smoking status in five states. Prev Med 2011; 53(3): 188-93. [http://dx.doi.org/10.1016/j.ypmed.2011.06.015] [PMID: 21726575][19]Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorder in adulthood. J Affect Disord 2008; 84: 217-25.[20]Chapman DP, Wheaton AG, Anda RF, et al. Adverse childhood experiences and sleep disturbances in adults. Sleep Med 2011; 12(8): 773-9. [http://dx.doi.org/10.1016/j.sleep.2011.03.013] [PMID: 21704556][21]Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics 2004; 113(2): 320-7. [http://dx.doi.org/10.1542/peds.113.2.320] [PMID: 14754944]Urine Drug Screening (UDS) in the Management of Substance Use Disorders
Teri Gabel*Abstract
Urine drug screens can add accountability to a patient’s recovery plan. An upfront discussion of the role of the urine drug screen in treatment is important for a solid provider client therapeutic relationship. Substance use disorders are relapsing and remitting disorders. The goal of treatment is to extend the duration of sobriety until it is life-long, a lifestyle. The role of the urine drug screen in a treatment program should be therapeutic not penalizing. Understanding what a drug screen can and can not do in providing information is important. Using a consistent screen and appropriately certified laboratory is a must. This chapter covers the types of drug screens, the substances identified in a standard urine dug screen and provides guidance on when other substances may need to be requested during screening. Some substances such as “bath salts” are not identified in current urine drug screens. In clinical situations it will be important to confirm any positive results found on a urine drug screen. Common agents and medications that cause false positive or negative results are identified in the chapter. Proper process for obtaining and handling the urine sample including proper chain of custody are presented.
Key Learning Points
Most urine drug screens test for 5 common agents i.e. amphetamines, cocaine, PCP, Opiates (codeine and morphine), marijuana. Other substances to be tested must be added to the test request.Urine drug screens do not identify certain substances like “Bath Salts”.Urine drug screen positive results must be confirmed before their use in any clinical decision making.Certain medications can interfere with the results of a urine drug screen.For legal reasons chain of custody of obtained samples must be maintained.Urine samples must be evaluated for pH, temperature, specific gravity and adulteration.Know the issues regarding the urine drug screen performed at your facility – what is tested for routinely, what false positives may occur with the process utilized.Clinical Vignette
Charles works in a high stress job with a large company that has a random drug screening program. His most recent urine drug screen was positive for phencyclidine (PCP). Charles is in danger of being fired from his job. Looking at his medical record, Charles is being treated for high blood pressure, high cholesterol and anxiety. His medications are simvastatin, venlafaxine, propranolol and a multiple vitamin.
Diagnostic Consideration
In this patient a drug screen may have value for clinical management acutely and for follow up. A legal issue may also surface if this patient is actually fired. Charles is being treated with venlafaxine which can yield a false positive for PCP with some immunoassay urine screens. The confirmation test should verify the false positive. Based on that Charles would be in no danger of losing his job.
Reasons for Obtaining an UDS
Medical: UDS may be beneficial when the patient is presenting with unusual symptoms or acting in a strange fashion. In instances of emergency presentation for overdose, seizure, or other situations a UDS can be of immense importance.Legal: UDS may be required for employment, probation or other legal issues.Therapeutic: UDS can assist in the clarification of a diagnosis as part of the work up of a differential diagnosis. Once diagnosed with a substance use disorder the use of urine drug screens can be useful in monitoring compliance with treatment and sobriety.It is important to consider the reason for UDS and its usefulness as in the vignette above. It is interesting to note at times UDS adds a piece of the puzzle not a diagnostic conclusion [1].
Depending on the substance involved, the results of the UDS may impact treatment both in the acute and follow up phase. This may also provide a tool to help identify reasons for relapse from psychiatric illness or help correlate with triggers for reuse of illicit drugs.
With alcohol use disorders medications such as naltrexone and acamprosate may be continued in light of a confirmed positive urine drug screen for ethanol. Alcohol is not included in a routine UDS and must be requested in addition to the baseline urine drug screen. Should the UDS show positive for other substances, treatment may need to be adjusted to address the clinical needs of the patient.
When used with a narcotic treatment contract and contingency management the results of a confirmed positive or negative result for the opioid/opiate adds value to assist with sobriety from drugs. A positive UDS for another substance of abuse may result in termination of the narcotic agent depending on the contract. UDS for opioids are relatively unreliable, many do not test for the desired agent and like alcohol it is important to request they test for the specific agent being prescribed [4-6].
Urine Drug Screens
It is recommended that urine drug screens be performed by a laboratory that is certified by the Department of Health and Human Services (DHHS). This guarantees the use of standardized testing processes and procedures to provide consistent reliable and valid results.(http://workplace.samhsa.gov/ResourceCenter/lablist.htm)
Urine assay allows for the presence or absence of certain drugs to be evaluated with (relatively) good specificity, sensitivity, ease of administration, and reasonable cost.
Types of Urine Drug Tests
Screens: Urine Drug Screens determine the presence or absence of particular substances according to predetermined threshold levels. Screens can be performed in either the office or at a laboratory. Urine drug screens are immunoassays. Immunoassays use antibodies to the substrate that combine with the substance of abuse causing a change (form a line or change color) in the test medium.
The two most common types of immunoassay screens are the Enzyme Multiplied Immunoassay (EMIT) and the Fluorescence Polarized Immunoassay (FPIA).
Office-based drug screens can be performed using one of the in office screening tests on the market. These screens use a urine “dip stick” to identify the presence of classes of substances in the urine. They have a different level of sensitivity compared to laboratory-based screening tests.
Screening tests generally have a higher cutoff and as a result it may be possible for a patient to have used a substance but the level in their urine is under that cut off number leading to a false negative report (Table 1).
Confirmation Screens: A positive urine drug screen requires a confirmation screen. These identify the specific drug present via Gas Chromatography/Mass Spectroscopy (GC/MS) Thin Layer Chromatography (TLC), or High Performance Liquid Chromatography (HPLC). Confirmatory tests are done by an outside laboratory. Positive and negative tests are determined by established cut off levels for substances.
The cutoff amounts in confirmatory tests are much lower and would be able to detect this use if there were doubts about its being positive during the screen [1] (Table 1).
Urine Drug Test as a Follow-up Tool
The timing of UDS should be random and irregular intervals for optimal usefulness. For substance use disorders testing is recommended randomly during the first 1-2 years of sobriety then annually or as clinically indicated.
Urine Sample Collection
Depending on the reason for the type of UDS, collection of the urine sample may be witnessed or un-witnessed. Any suspicious unobserved urine would necessitate the immediate recollection of a witnessed sample. The sample should be obtained in a special urine sample container which has indicators for pH and temperature at a minimum.
Chain of Custody
Securing the sample maintains credibility of the test result. This process is more important when testing is done for reasons of employment or legal issues.
Specific Criteria About Urine Samples: A urine specimen must meet certain criteria to provide a valid result.
Temperature: if collected within 4 minutes, the temperature range of urine should be between 90° and 100° F.Urine pH should be between 4.5 and 8.Creatinine norm is 20 mg/dl or greater. Diluted urine has <20 mg/dl creatinine, while urine with <5 mg/dl of creatinine is extremely dilute and may not be human.Significant variation in these parameters should be regarded with suspicion, and may suggest the need for prompt re-sampling.
Medication Interfering with UDS
Medications can interfere with urine drug screens (Table 2). It is important to check for these interactions when screens are positive. The confirmatory tests will identify a false positive.
Special Considerations
Opiate/Opioid Metabolism
Many UDS can be confounded by the presence of opioid/opiate metabolites (Fig. 1). It is important to be aware of the metabolites of the medication being prescribed. Fentanyl has no metabolites and oxycodone does not metabolize into morphine so it is not detected by a routine UDS [3, 4].
Fig. (1)) Opiate/opioid metabolism.Benzodiazepines
UDS tests for metabolites oxazepam and nordiazepam but not for all specific benzodiazepines. Not all benzodiazepines are associated with these metabolites including alprazolam and lorazepam. Depending on your laboratory you may be able to order a test of the specific agent.
Untested Substances
UDS is not able to detect some substances such as “bath salts”, 3, 4- methylenedioxy-N-methyl amphetamine (MDMA), ketamine and methanol. An alternative test will be needed. Working with the laboratory doing the testing you can order tests for these and other substances of interest.
