New high-resolution urine drug testing profile
Eye on Innovation
For the millions of individuals worldwide struggling with substance use disorders, recognizing
the problem as a medical condition with serious health consequences is an exceedingly important initial step toward seeking help. That acknowledgement, however, is just part of the oftentimes difficult process required for patients to start down the path to recovery.
“When care providers suspect substance abuse, it is really essential that they have a means to detect and document the problem,” says Terry Schneekloth, M.D., chair of the Department of Psychiatry and Psychology at Mayo Clinic’s Arizona campus. “One of the major challenges of treating alcohol and substance use disorders is that few people acknowledge having a problem, and most patients don’t speak openly about their substance use to their health care providers.”
Terry Schneekloth, M.D.
Laboratory urine drug testing plays a key role in distinguishing which substances individuals are using so they can begin appropriate therapy. However, the large and oftentimes arbitrary drug testing panels currently offered by some laboratories do little to increase understanding of a patient’s substance use disorder, says Paul Jannetto, Ph.D., co-director of the Clinical and Forensic Toxicology Laboratory at Mayo Clinic.
“This type of testing is often inappropriate and can be very costly to the patient and health care system,” Dr. Jannetto says. “The goal is not to identify every drug technically possible, but to perform medically necessary testing for those drugs that are most likely to impact clinical outcomes.”
Mayo Clinic Laboratories has developed a new, data-driven urine drug testing (UDT) profile to equip physicians with necessary information while ensuring proper testing utilization.
Paul Jannetto, Ph.D.
Geared toward managing patients with addiction to common substances, such as prescription opioids, alcohol, marijuana, and nicotine, the new Addiction Medicine Monitoring Profile (Mayo ID ADMPU) aligns with the American Society of Addiction Medicine’s consensus statement on the appropriate use of drug testing in clinical addiction medicine.
While the media tends to sensationalize certain types of drugs, such as designer or club drugs, these classes of substances are not widely used in most community settings, explains Loralie Langman, Ph.D., co-director of the Clinical and Forensic Toxicology Laboratory.
“Our testing focuses on drugs that are highly prevalent,” Dr. Langman says. “We don’t perform testing on esoteric drugs that are not commonly used or abused.”
Loralie Langman, Ph.D.
Utilizing high-resolution, accurate mass spectrometry, ADMPU offers enhanced sensitivity and specificity to identify parent drugs and metabolites from 22 drug classes. The profile includes targeted testing for 33 opioids, 27 benzodiazepines, and 10 stimulants and PCP, as well as immunoassay testing for barbiturates, cocaine, marijuana, and ethyl glucuronide, which reflex to confirmatory testing. In addition, testing for nicotine and its metabolites is included.
“These targeted screens have lower detection limits, so offer improved sensitivity,” Dr. Jannetto says. “The targeted screening also improves test utilization without compromising turnaround times, since they significantly reduce the need for additional confirmatory testing required with traditional immunoassay screens.”
ADMPU, which joins CSMEU and CSMPU in Mayo Clinic Laboratories’ portfolio of comprehensive, substance monitoring profiles, also includes specimen validity testing and adulterant testing to ascertain specimen integrity prior to analysis.
Determining whether patients are actively misusing substances, including alcohol and tobacco, or if attempts have been made to mask the use, is one of the greatest challenges of effective drug testing.
“Adulterants for masking substances in urine screens are widely available in drugstores or over the internet,” Dr. Schneekloth says. “You really need the most accurate lab test for detection of the substance and its confirmation, and that is something available at Mayo Clinic. Once we identify the substances of active abuse, then we can monitor for any evidence of relapse over the course of treatment.”
The comprehensive nature of ADMPU gives it greater efficacy as a tool to detect and monitor treatment for polysubstance abuse.
“When I came out of my addictive disorders fellowship nearly 30 years ago at Mayo Clinic Rochester, we were primarily treating alcoholics,” Dr. Schneekloth says. “Patients were less likely to have multiple, co-occurring substance use problems. In 30 years, that’s changed — there are far fewer individuals reporting only alcohol use, which has changed the recovery world. Most people who attend AA also have a cannabis smoking history and many have experimented with a number of other drugs.”
“Cross-addiction” is when people develop problems with multiple substances, explains Dr. Schneekloth. Whether alcohol, heroin, cannabis, or other chemicals, the substances stimulate the same neural pathways in the brain that result in a pleasurable experience and foster repeated use, eventually leading to compulsive or addictive use. Awareness of all the drugs a patient has used is crucial to achieving successful treatment outcomes.
“When people come into addiction treatment, we don't know what they're on, and we're often very surprised to find out that they've told us about the alcohol, but they haven’t mentioned the other things. Sometimes they do not recall what they’ve used when intoxicated,” Dr. Schneekloth says.
For patients who require substance abuse monitoring as part of a medical intervention for disease management, transparency about their substance use is essential for successful medical outcomes.
“A physician may be most concerned about testing for alcohol if the patient has liver disease and might not check whether the patient just gave up alcohol but transitioned to cannabis or another substance,” Dr. Schneekloth explains. “This may keep their addiction going and put them at greater risk of eventually going back to the primary substance.
“Unless all active substance use problems are under treatment, the team would not be moving forward in helping the patient with the problem. It’s critical then that the treatment team has the best technology and the highest accuracy in testing to monitor people. And that's something that we do.”
To provide clinicians with the highest level of detail about test results, each of Mayo Clinic Laboratories’ comprehensive substance monitoring profiles includes interpretative results reporting.
“This simplifies the challenges associated with interpreting this type of testing, from complex metabolic pathways to identification of potential pharmaceutical impurities found in these controlled substances,” Dr. Langman says.
From a provider’s point of view, inclusion of this type of detailed reporting inspires confidence in the accuracy of the test results.
Not only does Mayo Clinic Laboratories’ testing identify the presence of interfering compounds and metabolic breakdowns, it also determines thresholds of alcohol exposure that are highly specific for ingestion as opposed to trace exposures, like mouthwash or hand sanitizers. It also identifies active marijuana use as opposed to trace exposures and distinguishes the drug’s slow clearance after previous high-dose use.
“There are so many things in the environment that can cause less-sensitive tests — immunoassay, for instance — to register something that in fact is not there. This really speaks to the importance of an extremely high level of laboratory precision offered through the Mayo laboratory,” Dr. Schneekloth says.
The clarity enabled by ADMPU provides an accountability for patients on which change can be measured.
“Whether people are trying to modify their diet or get out for a daily walk, we need accountability for change, and there’s no place more critical for accountability than when people are trying to manage an addiction,” Dr. Schneekloth says. “One of the major factors in helping people get off substances is detecting them and rapidly helping them develop an effective treatment plan. Accessible and accurate urine testing gives them that level of accountability and also the capacity to demonstrate that they are staying clean.”
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