Identified Substance Abuse Research Articles

Integrating Evidence-Based Screening, Brief Intervention, and Referral to Treatment Into a Family Nurse Practitioner Program.

Substance use disorder (SUD)-and more specifically opioid use disorder-is a national epidemic. With the increasing amounts of people suffering from SUD, all healthcare professionals should be educated to identify substance abuse, provide a brief intervention, and refer patients for treatment when indicated. The purpose of this project is to integrate the SBIRT into the curriculum of a graduate-level family nurse practitioner (FNP) program in southeastern Pennsylvania and to determine if educating FNP students on the SBIRT process increases their knowledge of SUDs and their treatment and increases their motivation to work with patients with SUD. The measurements used were as follows: shortened Alcohol and Alcohol Problems Perception Questionnaire (S-AAPPQ), shortened Drug and Drug Problems Perception Questionnaire (S-DDPPQ), a 10-question knowledge test, and demographic data. All subscales of the S-DDPPQ, the S-AAPPQ, and the knowledge test showed a statistically significant change from the pretest score means and to posttest means. This evidence-based practice project supports the integration of SBIRT education into FNP programs to increase their ability to identify and treat individuals with SUDs.

Two-center analysis of cannabis on venous thromboembolism risk after traumatic injury: A matched analysis

BackgroundConflicting evidence exists evaluating associations between cannabis (THC) and post-traumatic DVT. MethodsRetrospective analysis (2014–2023) of patients ≥15yrs from two Level I trauma centers with robust VTE surveillance and prophylaxis protocols. Multivariable hierarchical regression assessed the association between THC and DVT risk. THC ​+ ​patients were direct matched to other drug use categories on VTE risk markers and hospital length of stay. ResultsOf 7365 patients, 3719 were drug-, 575 were THC ​+ ​only, 2583 were other drug+, and 488 were TCH+/other drug+. DVT rates by exposure group did not differ. TCH ​+ ​only patients had higher GCS scores, shorter hospital length of stay, and the lowest pelvic fracture and mortality rates. A total of 458 drug-, 453 other drug+, and 232 THC+/other drug ​+ ​patients were matched to 458, 453, and 232 THC ​+ ​only patients. There were no differences in DVT event rates in any paired sub-cohort set. Additionally, iteratively adjusted paired models did not show an association between THC and DVT. ConclusionsTHC does not appear to be associated with increased DVT risk in patients with strict trauma chemoprophylaxis. Toxicology testing is useful for identifying substance abuse intervention opportunities, but not for DVT risk stratification in THC ​+ ​patients.

RADII FOR CERTAIN CLASS DEFINED BY DIFFERENTIAL OPERATOR

The aim of the study was to identify substance abuse among medical students of the College of Medicine, University of Lagos, Nigeria, and correlate it with their urine samples. Methods: A cross-sectional study was conducted among 150 undergraduate students of the College of Medicine University of Lagos, Nigeria. Ethical approval was obtained for the study and informed consent obtained from the participants before the commencement of the study. Data on the knowledge and prevalence of drug addiction were collected from the undergraduate students using a validated self-developed questionnaire while standard sample bottles were used to collect the students’ urine samples. Data collected were summarized using descriptive statistics. Chi-square was used to establish an association between the variables. Results: Sixty-three (42.2%) male and 87 (57.8%) female medical students participated in this study out of which 99 (65.9%) had good knowledge of drug addiction, 21 (15.6%) admitted that they have taken drugs not prescribed by a physician while 33(24.4%) claimed to have previously done drug test. The prevalence of drug abuse among the students was 15.6%. The age with the highest rate of drug abuse was 11–18 years. Tramadol was the most abused drug by the students while the most preferred route of drug abuse was oral route 20 (14.8%). Conclusion: There was a low prevalence of substance abuse among the medical students. BIOEASYTM immunoassay Multi-Drug Test Card was effective in screening the student’s urine. There is an urgent need for interventions like health education and training to be established in our higher institutions.

Lapse and Relapse Rates in Narcotics Anonymous versus Methadone Maintenance Treatment: A 12-Month Prospective Study.

Objective: The present study aimed to compare lapse and relapse-free survival between patients treated in Narcotics Anonymous (NA) groups and Methadone Maintenance Treatment (MMT) centers and to determine the relationship between social support scale and treatment outcome. Method: This study was a prospective, 12-month cohort study using the random sampling method to select 100 newcomer patients treated by the NA Association as well as 100 patients in MMT centers. The data were collected using a demographic questionnaire and Social Support Appraisals (SSA) scale at the onset of the study along with follow-up phone calls every other week. Results: All participants were male, aged between 18 and 65 with a mean (SD) age of 38.98 (± 10.85) years. Prevalence of relapse in 12 months was 60.5%. The lapses in the MMT group and relapses in the NA group were significantly higher (P < 0.001). The younger patients with lower levels of education are at greater risk of lapse/relapse. The mean score of SSA was significantly higher in the MMT group than the NA group in all subscales, including friends, family, and the others' support (P < 0.001). The mean scores of SSA subscales for the participants without relapse in the NA group was significantly higher in comparison to the MMT group. Conclusion: Detection of factors related to drug abuse relapse/lapse may help addiction therapists to identify drug abuse patients with lapse/relapse and to develop treatment and policy guidelines to prevent relapse in addiction recovery.

A Geographic Perspective on Opioid Misuse: Substance Abuse Treatment Deserts in Southwestern Ohio

Background: The opioid crisis is one of the most pressing public health issues facing Ohio, with an impact uneven-ly distributed across the state. This work examined geographical barriers to substance abuse treatment in southwestern Ohio through examining geographical areas with limited access to substance abuse treatment services and identifying substance abuse treatment deserts. Methods: The study domain included the 13 counties in the Ohio Mental Health and Addiction Service's Cincinnati region. Publicly available substance use disorders treatment data were collected from government agency resources, pharmaceutical websites, and web searches. Substance abuse treatment deserts were defined as areas in the 13-county study area that were not within a 15-minute drive from a treatment center. Results: We found large portions of the study region that were considered a substance abuse treatment desert for methadone and naltrexone/buprenorphine clinics, behavioral health treatment centers, and both medicated assisted treatment (MAT) and behavioral health treatment combined. Out of the 2 017 337 total persons living in the 13-county study area, 17% (n = 342 872) live in a desert for all MAT and behavioral treatment. Similarly, 19.7% (n = 396 581) live in a desert for naltrexone/buprenorphine treatment, 60.9% (n = 1 227 560) live in a desert for methadone treatment, and 19.7% (n = 396 581) live in a desert for behavioral health treatment. Conclusion: We successfully defined substance abuse treatment deserts in southwestern Ohio, which will be useful for future research to determine its association with opioid-related health outcomes. This resource is publicly available online (https://doi.org/10.5281/zenodo.4011051).

Buprenorphine exposures in adolescents and adults: a 10-year experience of a French Poison Control Center.

Buprenorphine has been used in pain and opioid addiction management for nearly 25years. Compared to methadone, buprenorphine is thought to exhibit less side effects and respiratory depression in case of accidental or suicidal overdose. The aim was to describe the characteristics of exposures reported to a French Poison Control Center (PCC). We conducted a retrospective study including all buprenorphine exposures for which advice of our PCC was required between 2009 and 2018. After data extraction from the electronic medical files and anonymous transfer to an Access base, a statistical descriptive analysis was performed focusing on adolescents over 10years old and adults. One hundred and ninety-nine cases were analyzed. The major circumstances of exposure were suicide attempts and overdoses in patients with previously identified substance abuse. Buprenorphine exposures have been reduced by 50% between 2009 and 2018. Coingestions, often with benzodiazepines or antidepressants, were almost systematic and 79% of all the series exhibited at least one symptom. Among the symptomatic cases, neurological effects were the most frequent (83%) and respiratory symptoms occurred in 13%. No deaths were registered. Severity did not exceed PSS1 in 80% of all the cases. Treatment was mainly symptomatic even though naloxone was required in at least 5% of the symptomatic cases. Within 24h after exposure, 120 patients were discharged from the emergency department. Despite loss to follow-up, our results suggest that buprenorphine is relatively safe.

Managing Addiction: Guidelines for Patients With Cancer.

Addiction in patients with cancer is not well described. Patients with substance use disorders (SUDs) and cancer experience worse outcomes; however, no guidelines exist for identifying and successfully managing these issues in oncology. With the goal to improve patient safety and outcomes, an interprofessional work group at a major academic cancer hospital initiated a trial screening process for identifying substance abuse issues in an oncology population. Simultaneously, guidelines for patients with cancer and SUDs were created.

The Impact of Substance Abuse on Heart Failure Hospitalizations

BackgroundThe burden of substance abuse among patients with heart failure and its association with subsequent emergency department visits and hospital admissions are poorly characterized. MethodsWe evaluated the medical records of patients with a diagnosis of heart failure treated at the University of California–San Diego from 2005 to 2016. We identified substance abuse via diagnosis codes or urine drug screens. We used Poisson regression to evaluate the incidence rate ratios (IRR) of substance abuse for emergency department visits or hospitalizations with a primary diagnosis of heart failure, adjusted for age, sex, race, medical insurance status, and medical diagnoses. ResultsWe identified 11,268 patients with heart failure and 15,909 hospital encounters for heart failure over 49,712 person-years of follow-up. Substance abuse was diagnosed in 15.2% of patients. Disorders such as methamphetamine abuse (prevalence 5.2%, IRR 1.96, 95% confidence interval [CI] 1.85-2.07), opioid use and abuse (8.2%, IRR 1.54, 95% CI 1.47-1.61), and alcohol abuse (4.5%, IRR 1.51, 95% CI 1.42-1.60) were associated with a greater number of hospital encounters for heart failure, with associations that were comparable to diagnoses such as atrial fibrillation (37%, IRR 1.78, 95% CI 1.73-1.84), ischemic heart disease (24%, IRR 1.67, 95% CI 1.62-1.73), and chronic kidney disease (26%, IRR 1.57, 95% CI 1.51-1.62). ConclusionsAlthough less prevalent than common medical comorbidities in patients with heart failure, substance-abuse disorders are significant sources of morbidity that are independently associated with emergency department visits and hospitalizations for heart failure. Greater recognition and treatment of substance abuse may improve outcomes among patients with heart failure.

Using natural language processing of clinical text to enhance identification of opioid-related overdoses in electronic health records data.

PurposeTo enhance automated methods for accurately identifying opioid‐related overdoses and classifying types of overdose using electronic health record (EHR) databases.MethodsWe developed a natural language processing (NLP) software application to code clinical text documentation of overdose, including identification of intention for self‐harm, substances involved, substance abuse, and error in medication usage. Using datasets balanced with cases of suspected overdose and records of individuals at elevated risk for overdose, we developed and validated the application using Kaiser Permanente Northwest data, then tested portability of the application using Kaiser Permanente Washington data. Datasets were chart‐reviewed to provide a gold standard for comparison and evaluation of the automated method.ResultsThe method performed well in identifying overdose (sensitivity = 0.80, specificity = 0.93), intentional overdose (sensitivity = 0.81, specificity = 0.98), and involvement of opioids (excluding heroin, sensitivity = 0.72, specificity = 0.96) and heroin (sensitivity = 0.84, specificity = 1.0). The method performed poorly at identifying adverse drug reactions and overdose due to patient error and fairly at identifying substance abuse in opioid‐related unintentional overdose (sensitivity = 0.67, specificity = 0.96). Evaluation using validation datasets yielded significant reductions, in specificity and negative predictive values only, for many classifications mentioned above. However, these measures remained above 0.80, thus, performance observed during development was largely maintained during validation. Similar results were obtained when evaluating portability, although there was a significant reduction in sensitivity for unintentional overdose that was attributed to missing text clinical notes in the database.ConclusionsMethods that process text clinical notes show promise for improving accuracy and fidelity at identifying and classifying overdoses according to type using EHR data.

SUBSTANCE ABUSE AND RISK OF HOSPITALIZATION FOR HEART FAILURE

Substance abuse has increased in recent years. The burden of substance abuse among patients with heart failure (HF) is poorly characterized. In this period prevalence study, we identified substance abuse via diagnosis code or urine drug screen among patients with HF treated at the University of

IDENTIFYING SUBSTANCE ABUSE AMONG CHILD WELFARE CARETAKERS: AN AMERICAN NATIONAL STUDY

American Child welfare staff has long recognized that substance abuse is common in families they serve. The unanswered questions are how well do child welfare social workers identify substance abuse in caretakers; and, what client and agency variables complicate this assessment? Chaos theory has much to offer social work in dealing with the uncertainty and complexity that characterize families who experience child abuse, neglect, and substance abuse. This exploratory study analyzed the National Study of Protective, Preventive and Reunification Services Delivered to Children and Their Families dataset. This dataset was a national sample of 2,109 opened child welfare cases (National Data Archive on Child Abuse and Neglect). Caretakers included birth mothers and fathers, stepparents, extended family members; such as aunts, uncles, and grandparents, and adoptive parents. Analysis explored the frequency of abuse and neglect substantiation, mental health problems and substance abuse problems identified by caseworkers. Three multivariate logistic regression models were developed to predict whether independent variables were associated with; the dichotomous dependent variable was identified caretaker substance abuse. Twenty-nine percent of caretakers were identified as substance abusers. This study found child welfare cases with identified substance abuse were significantly more chaotic than other families. Identified caretakers’ problems were twice that of non-identified caretakers. Substance abusing cases are opened more than twice the number of years and have twice as many caseworkers. This study found that neglect cases are fifty percent less likely to be identified and abandonment are more than ninety percent less likely to be identified.

Sensitive and simple determination of zwitterionic morphine in human urine based on liquid-liquid micro-extraction coupled with surface-enhanced Raman spectroscopy

Morphine, a kind of illicit drugs, is also one of the main heroin metabolites. In consideration of a noninvasive way to monitor and identify drug abuse during forensic cases, the urine samples are usually detected. Here, colloidal gold nanorods (Au NRs) were introduced to act as active substrate, because of the strong optical extinction and spectral tunability of the longitudinal surface plasmon resonance (SPR). Thus, well surface-enhanced Raman spectra of morphine even at low concentrations could be obtained by portable Raman spectrometer. For the complex matrix environment of urine, liquid-liquid micro-extraction (LLME), a simple and inexpensive pretreatment, was employed to avoid the interferences. And then, the coupled surface-enhanced Raman spectroscopy (SERS) can give full play to the advantages of high sensitivity and unique spectroscopic fingerprint. According to the zwitterionic structure and physicochemical parameters of morphine molecules, the pH value of urine sample was adjusted to about 9 by buffer solution (KOH/NaB4O7) and the mixture of chloroform and isopropyl alcohol (V/V=9:1) was chosen as extractant. Moreover, such pretreatment was proved to be appropriate for separation and concentration of morphine from urine. The developed LLME-SERS method could provide a detection limit less than 1 ppm in the human urine environment and the whole process of detection just needed take 5–6 min. What's more, the results of urine samples from heroin users exhibited application value of the proposed technique. The excellent performance makes it promising to become a rapid, reliable, and on-spot analyzer, especially for public safety and healthcare.

389 Stigma as a barrier to recovery

Purpose of studySequim, WA has an opioid-related death rate over 50% higher than the state. The 2017 Clallam County Community Health Assessment identified substance abuse as its highest health concern. There is no methadone therapy in the county and local chemical dependency counsellors favour absti

Mental health screening instrument domain scores as predictors of recidivism in juvenile probation and drug court populations

ABSTRACTFor juvenile offenders with an identified substance abuse history, the need for early intervention and screening is increasingly critical. This study investigated the use of MAYSI-2 and POSIT standardized screening measures to better understand if the domains measured by these tools could predict recidivism in a juvenile drug court (JDC) population. Findings indicated that none of the domain scores analyzed were predictive of recidivism scores in neither the juvenile probation, nor drug court adolescents. These outcomes suggest that for the juvenile population, these screening tools may be effective measures of potential mental health risks, but poor measures of recidivism.

Misprescribing controlled substances: An evaluation of a professional development program

ABSTRACTBackground: Controlled prescription drug (CPD) abuse has reached epidemic proportions in the United States. Most physicians attending a 3-day continuing medical education (CME) professional development program (PDP) lack training in identifying risk and in managing patients who misuse CPDs. To address this issue, the authors conducted an evaluation of a PDP that trains physicians on proper prescribing, identifying substance abuse, utilizing screening, brief intervention, and referral to treatment (SBIRT), and implementing motivational interviewing (MI). Methods: The authors conducted a program evaluation to assess the efficacy and impact of the PDP on physicians' knowledge and prescribing behaviors. Results: Participants (N = 174) were typically middle-aged (average age of 53 years), male (89%), and physicians (82%) and other health care professionals (18%). Many physicians practice in solo primary care settings (46%). Course evaluations were completed by n = 155 (89%) participants who rated the course and presenters highly (mean 4.8/5 respectively). Physicians' knowledge scores on pre/post assessments increased significantly: pretest (M = 58.7, SD = 13.12) and posttest (M = 78.28, SD = 9.83) (t(173) = 20.06, P ≤ .0001, 95% confidence interval, CI: [−21.51, −17.65]). Almost half of the participants, n = 83/174 (48%), completed the follow-up survey, and 93% agreed/strongly agreed (A/SA) they made professional practice changes. Of participants practicing with an active DEA (Drug Enforcement Administration) registration (n = 57), most agreed/strongly agreed they implemented changes to align their practices with current guidelines (89%), used CPD more appropriately (87%), implemented office policies on prescribing (81%), identified and referred more substance abuse patients to treatment (80%), shared new information/experience from course with other 25 health professionals (93%), and felt the course positively impacted their behaviors personally and professionally (90% and 96%, respectively). Conclusions: This is the first known study evaluating a PDP in this population. Results demonstrated participant satisfaction and improvement in prescribers' knowledge and self-reported prescribing behaviors. However, further study is needed to assess actual clinical practice changes, direct impact on patient outcomes, and rates of recidivism.

Reducing Medical Errors: Using Observed Standardized Clinical Examinations to Assess Fellows' Performance in System-Based Practice Milestones

Medical training has increasingly focused on standardization to improve communication and reduce medical errors. In gastroenterology training programs, the need for clear interpersonal communication is heightened by the high acuity of patients and the frequent use of a home call system. We sought to assess important yet largely unevaluated skill sets based on system-based practice milestones outlined by Accreditation Council for Graduate Medical Education requirements using an Observed Standardized Clinical Examination (OSCE). We created the following cases: recognizing and counseling an impaired colleague, overnight hand-off, a percutaneous endoscopic gastrostomy placement discussion, and feedback on a progress note with a medical student. Fellows from 3 institutions in New York City participated. Behavioral anchored checklists were completed by trained standardized patients (SPs). Fellows received verbal feedback from a faculty observer after each case and completed a questionnaire evaluating their experience after the OSCE. We had 9 fellows participate. Discrepancies were identified between the fellows’ perceived performance in their self-assessments and SP evaluations. In the percutaneous endoscopic gastrostomy case, only 11% of fellows engaged the family member in shared decision making and no fellows assessed the SP’s basic understanding of risks. Conversely, 86% of the fellows believed they were well prepared for the case and 78% believed they did well achieving the case objectives. None of the fellows fully assessed depression, suicidal ideation, or alcohol use in the impaired colleague case. Only 33% screened for depression and collaborated on identifying next steps. Eighty-six percent of these fellows believed that they would be able to identify substance abuse and depression in a colleague before the OSCE, and 100% agreed after the OSCE. In the hand-off case, 55% of fellows fully explained hospital course; 44% collaborated to identify next steps in the plan. Only 44% of the fellows were rated as completely professional during the encounter. In the note feedback encounter, 44% of fellows asked effective questions to engage the learner. The SP rated 22% of the fellows as very effective at giving feedback, and 100% of fellows reported feeling comfortable giving feedback before the OSCE. Our results highlight the discrepancies between perceived performance of fellows and their actual success in achieving milestones in system-based practices. Fellows were more successful in meeting objectives in the more familiar scenarios, that is, in giving handoff and in giving feedback on note writing, although there was still much room for improvement. In less-familiar scenarios, the fellows did not perform as well. Training programs should consider using OSCEs or other educational programs geared toward system-based practice milestones to improve their fellows' performance in a secure setting before they encounter such scenarios with real patients or colleagues.

Psycho-social factors associated with relapse to drug addiction in Bangladesh

Background: Relapse to drug use after successful treatment and rehabilitation is a common problem globally. This study aimed to identify the psychological and social factors associated with relapse of drug addiction in Bangladesh.Methods: We conducted a cross-sectional study among 60 individuals (30 relapsed and 30 non-relapsed cases) with a history of drug addiction in four drug treatment and detoxification center in Bangladesh from May to December 2010. Data were collected from all the participants using a pre-tested, semi-structured questionnaire. A 4-point Likert format was used for scoring the questionnaire. Logistic regression models were performed to identify factors associated with relapse to drug addiction.Results: All participants were male, aged between 18 and 41 years with mean (SD) age of 27.63 (4.23) years. The “negative emotion” factor had strong contribution on relapse, while “peer pressure,” “self-efficacy,” and “lack of assertiveness” contributed to relapse moderately. The “parental discord” and “relation with parents” factors showed no relationship with relapse. The thought/belief, feeling/emotion, and behavior/action patterns related to relapse were identified, and the covert or very internal affairs of relapse components were revealed.Conclusion: Psychological factors were associated with an increased likelihood of relapse than social factors. These findings may help clinicians identify substance abuse patients likely to relapse and develop treatment and policy guidelines for prevention of relapse to drug addiction in Bangladesh.

Communication Commentary: Substance-Related and Addictive Disorders: Substance Use Disorder

Communication Commentary: Substance-Related and Addictive Disorders: Substance Use Disorder

107: A Systematic Review of Primary Substance Abuse Prevention Programs For School-Age Children and Youth

Youth substance abuse has been described as an international public health problem (Tortolero, 2012). In Canada, recent statistics demonstrate concerning trends in youth substance abuse toward increasing usage and a lower age at first use (Health Canada, 2012). Given these trends, recent decades have seen a proliferation in primary substance abuse prevention programs for children and youth focused on preventing the initial onset of alcohol and drug use. However, evidence for the effectiveness of these programs is fragmented, with heterogeneous measures and a variety of mediating factors reported in the literature (Riggs, Black, & Ritt-Olson, 2014). The aim of the current project was to conduct a systematic review that synthesizes evidence in this area by: (i) identifying substance abuse prevention programs available for school-aged children and youth; and (ii) reporting the type and quality of evidence to support the effectiveness of identified programs. We undertook a systematic search process using Cochrane Collaboration (2009) methods. To begin, a research librarian created a search strategy designed to identify studies relevant to the stated objectives. Eight academic databases were searched. All studies that met the following criteria were eligible for the first stage of inclusion: i) published in English; ii) evaluated the effectiveness of a substance abuse prevention program; iii) the program was delivered to school-age children and youth; and iv) the study included a control group. After screening articles using these initial criteria, two researchers independently engaged in a second stage screening process using the following criteria: i) the program was delivered to a general population of children/youth; ii) the program was designed as a primary prevention program; iii) the article described a final evaluation, as opposed to a pilot evaluation; and iv) the program only targeted children. The combined results of these two search strategies yielded over 100 articles that met inclusion criteria. Results indicate a number of primary prevention programs that demonstrate varying levels of evidence to support their effectiveness. This presentation will discuss the key characteristics shared by programs at each evidence level, with the aim of providing practical information for decision-makers, practitioners, and other service providers seeking to select the most appropriate prevention initiatives for their communities. This review has a number of implications for the implementation of primary substance abuse prevention programs. This review also highlights a number of areas in which the quality of research in this field can be strengthened.

Underestimation of substance abuse in psychiatric patients by conventional hospital screening

Psychiatric diagnosis mainly relies on behavioral signs and symptoms. Substance abuse can mimic the clinical presentation of primary psychiatric disorders and can also complicate the management of psychiatric patients. The reliability and accuracy of urine toxicology is a vital tool in the optimal treatment of these patients. Current demographics of substance abuse suggest that in addition to the most conventional drugs of abuse (e.g. cocaine, cannabis) that are of concern to treating physicians, prescription medications and new designer drugs also should be when evaluating patients who present with symptoms of psychosis/drug addiction or altered mental status. MethodsUrine samples from 220 psychiatric inpatients admitted to either an acute drug and alcohol unit or acute psychiatric unit were analyzed for drugs by the standard hospital assay (KIMS) and by a more sensitive ELISA and GC–MS basic drug screening protocol. ResultsThe standard hospital toxicology (KIMS) was inferior to the ELISA and GC–MS methods in terms of both assay sensitivity and in detecting a broader number of drugs. The KIMS tests failed to identify opiates and amphetamine/methamphetamine in 50% of the patients. The KIMS screen did not identify zolpidem, buprenorphine and a number of synthetic drugs of abuse including cathinone and tryptamines. ConclusionIn order to reliably identify substance abuse in patients with altered mental status in inpatient settings, analytical methodologies with adequate assay sensitivity and range to detect the vast majority of commonly abused illicit drugs and prescription medications are required for optimal clinical assessment and treatment.