Random Urine Testing Research Articles

Comparison of self-reported substance use with biological testing among treatment-seeking patients with opioid use disorder

BackgroundSeveral factors may influence the validity of self-report. In this study, we aimed to assess the validity of self-reported drug use compared to urine testing among treatment-seeking patients with opioid use disorder (OUD). MethodsThis cross-sectional study recruited 293 patients with OUD, referred to the Iranian National Center for Addiction Studies (INCAS) clinic, from November 2015 to June 2017. The study compared self-reported opioid use in the past 72 h with the results of urinalysis, using immunoassay technique. We estimated sensitivity, negative predictive value, percent agreement, positive percent agreement, and Cohen's kappa statistics for those with OUD. ResultsThe sensitivity of self-reported opioid use was 85.9%. Percent agreement, positive percent agreement, and Cohen's Kappa statistics between self-reported opioid use and urine testing for morphine in the first month were 88.5%, 78.1%, and 77.0, respectively. Multilevel logistic regression showed that longer treatment duration (OR = 1.21, 95%CI: 1.07–1.37, p-value = 0.002) was significantly associated with the agreement of self-reported opioid use with urine testing. ConclusionSelf-report can be used as a reliable method for monitoring treatment adherence combined with random urine tests.

Relationship of spot urine oxalate to creatinine ratio and 24 hours urinary oxalate excretion in patients with urolithiasis

BackgroundThe evaluation of 24 h urinary oxalate excretion is the gold standard for diagnosing hyperoxaluria in patients with recurrent urolithiasis. However, 24 h urine sample collection is cumbersome. Therefore we aim to see if oxalate to creatinine ratio in random urine sample can be used as an alternative. Materials and methodsA cross-sectional study was conducted at Section of Chemical Pathology, Department of Pathology and Laboratory Medicine Aga Khan University Karachi from 1st February to December 31, 2019. A total of 62 adult patients, 18–60 years of age with history of kidney stones presenting to the clinical laboratory for 24 h urine oxalate estimation were invited to participate in the study after informed consent. Clinical details were recorded on a structured questionnaire and patients were guided to submit 24 h urine and a random spot urine sample. Urinary oxalate was measured on Micro lab 300 using a kit based on oxalate oxidase principle by Trinity Biotech plc, Wicklow, Ireland following standard operating procedures. Urinary creatinine was measured on ADVIA 1800 by Siemens, US using kinetic Jaffe reaction according to the manufacturer's instructions. The data was analyzed on SPSS. ResultsIn a period of ten months, a total of 62 subjects were recruited; mean age was 32.4 ± 2.6 years. Males were 49 (79.0%) and females were 13 (20.9%). Correlation was found to be (r = 0.289) by Spearman correlation (p value < 0.005). Taking 24 h urinary oxalate as gold standard the sensitivity, specificity, positive predictive value and negative predictive value of spot oxalate to creatinine ratio was 83.3%, 17.8%, 9.8% and 90.9% respectively. ConclusionThe random spot urine test cannot replace the 24 h urinary oxalate estimation in patients with urolithiasis.

Serum Cadmium Level Is Positively Associated with Unruptured Intracranial Aneurysm Incidence.

BackgroundCadmium is a toxic element in cigarette smoke associated with ischemic vascular disease. Its association with cerebral aneurysm is unknown.MethodsWe retrospectively analyzed the medical records of patients with headache who underwent imaging studies between March 2014 and August 2016. An unruptured intracranial aneurysm (UIA) was confirmed by brain magnetic resonance angiography or computed tomography angiography. A control group included age- and sex-matched patients without an UIA. Whole blood and random urine tests were used for detection of cadmium and arsenic levels, respectively. Student t-test was used to compare subject characteristics, mean cadmium and arsenic levels between groups, and differences between groups with small (<4-mm) and large (≥4-mm) UIAs. Multivariate regression analysis was used to identify risk factors for aneurysm incidence.ResultsOf 238 patients, 25 had an UIA. Those with an UIA had more pack-years of smoking (19.5±3.8 vs. 12.5±6.8, P=0.044) and higher mean serum cadmium levels (1.77±0.19 vs. 0.87±0.21 µg/L, P=0.027). Arsenic levels showed no difference between groups. (67.4±23.5 vs. 62.2±18.3 µg/L, P=0.458). There were no significantly different demographic, clinical, or laboratory characteristics between small and large aneurysm groups. According to multivariate analysis, smoking (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.06–2.33; P=0.047) and serum cadmium >2.0 mcg/L (OR, 1.39; 95% CI, 1.15–1.84; P=0.043) were associated with aneurysm incidence.ConclusionUIA incidence was associated with pack-years of smoking and serum cadmium level, but aneurysm size was not associated with serum cadmium level.

Random urine testing for carcinoid tumours in paediatric subjects using a LC-MSMS method with age specific normalised reference intervals

Introduction: In clinical practice, tests for urine catecholamine metabolite, 5-hydroxyindole-3-acetic acid (5-HIAA) is often used for diagnosis of carcinoid tumours of the stomach, colon and lung.1,2 Paediatric reference intervals have been traditionally based on timed urine collections. However, there is difficulty in collecting timed urine samples in infants and children.

Witnessed versus Unwitnessed Random Urine Tests in the Treatment of Opioid Dependence

Clinics licensed to provide pharmacotherapy for opiate dependence disorder are required to perform random urine drug screen (RUDS) tests. The results provide the empirical basis of individual treatment and programmatic effectiveness, and public health policy. Patients consent to witnessed testing but most tests are unwitnessed. The purpose of the present study was to compare treatment effectiveness estimates derived from witnessed versus unwitnessed urine samples. We adopted a policy requiring visually witnessed urine drug screens (WUDS) and studied its impact (a single group, pretest-posttest design) on the RUDS test results in 115 male veterans enrolled in the St. Louis VA Opioid Treatment Program. The percentage of opioid-positive urine samples increased significantly following implementation of WUDS (25% vs. 41%, χ(2) = 66.5, p < .001). Results of this preliminary study suggest that random testing alone does not ensure the integrity of UDS testing. Outcome calculations based on random unwitnessed tests may overestimate the effectiveness of opioid dependence disorder treatment.

A Random Urine Test Can Identify Patients at Risk of Mesalamine Non-Adherence: A Prospective Study

Mesalamine non-adherence is common among patients with ulcerative colitis (UC), and can be difficult to identify in practice. We sought to determine whether a random urine test for salicylates could be used as a marker of 5-aminosalicylic acid (5-ASA) ingestion and identify patients at risk of non-adherence. Our aim is to determine whether measurement of salicylates in a random urine sample correlates with 5-ASA levels, and predicts an individual's risk of mesalamine non-adherence. Prospective observational study. Urinary salicylates (by colorimetry) and 5-ASA (by liquid chromatography and tandem-mass spectrometry) were measured in a random urine sample at baseline in patients and controls. Mesalamine adherence was quantified by patient self-reports at enrollment and pharmacy refills of mesalamine over 6 months. A total of 93 patients with UC taking mesalamine maintenance therapy were prospectively enrolled from the clinic. Random urine salicylate levels (by colorimetry) were highly correlated with urine 5-ASA metabolite levels (by mass spectrometry; R2=0.9). A random urine salicylate level above 15 mg/dl distinguished patients who had recently taken mesalamine from controls (area under the curve value 0.9, sensitivity 95%, specificity 77%). A significant proportion of patients (27%) who self-identified as "high adherers" by an adherence questionnaire (Morisky Medication Adherence Scale-8) had random levels of urine salicylate below this threshold. These patients were at higher risk of objectively measured non-adherence to mesalamine over the subsequent 6 months (RR: 2.7, 95% CI: 1.1-7.0). A random urine salicylate level measured in the clinic can identify patients who have not recently taken mesalamine, and who are at higher risk of longitudinal non-adherence. This test could be used to screen patients who may warrant interventions to improve adherence and prevent disease relapse.

Hypercalciuria, hyperoxaluria, and hypocitraturia screening from random urine samples in patients with calcium lithiasis

Calcium lithiasis is the most frequently diagnosed renal lithiasis and is associated with a high percentage of patients with metabolic disorders, such as hypercalciuria, hypocitraturia, and hyperoxaluria. The present study included 50 patients with recurrent calcium lithiasis. We conducted a random urine test during nocturnal fasting and a 24-h urine test, and examined calcium, oxalate, and citrate. A study of the linear correlation between the metabolites was performed, and the receiver operator characteristic (ROC) curves were analyzed in the random urine samples to determine the cutoff values for hypercalciuria (excretion greater than 200 mg), hyperoxaluria (excretion greater than 40 mg), and hypocitraturia (excretion less than 320 mg) in the 24-h urine. Linear relationships were observed between the calcium levels in the random and 24-h urine samples (R = 0.717, p = 0.0001), the oxalate levels in the random and 24-h urine samples (R = 0.838, p = 0.0001), and the citrate levels in the random and 24-h urine samples (R = 0.799, p = 0.0001). After obtaining the ROC curves, we observed that more than 10.15 mg/dl of random calcium and more than 16.45 mg/l of random oxalate were indicative of hypercalciuria and hyperoxaluria, respectively, in the 24-h urine. In addition, we found that the presence of less than 183 mg/l of random citrate was indicative of the presence of hypocitraturia in the 24-h urine. Using the proposed values, screening for hypercalciuria, hyperoxaluria, and hypocitraturia can be performed with a random urine sample during fasting with an overall sensitivity greater than 86%.

Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice.

Anesthesiologists with opioid use disorders are at high risk for relapse. In 2005, the impaired professionals monitoring program of the State of Florida implemented a policy whereby anesthesiologists referred for opiate use disorders were contractually obligated to take naltrexone for 2 years. Naltrexone ingestion was witnessed and verified via random urine drugs screens or administered via intramuscular injection. Charts were reviewed for the 11 anesthesiologists who underwent mandated pharmacotherapy with naltrexone, and 11 anesthesiologists who began monitoring immediately before implementation of this policy. Eight of 11 anesthesiologists who did not take naltrexone experienced a relapse on opiates. Only 1 of 11 anesthesiologists experienced a relapse on opiates after taking naltrexone, whereas another relapsed on an inhalant (nitrous oxide). It is noteworthy that 5 of the 11 anesthesiologists who took naltrexone had relapsed before naltrexone treatment, and 7 of the 11 anesthesiologists who did not take naltrexone experienced multiple documented relapses. Only 1 of the 11 anesthesiologists who did not take naltrexone successfully returned to the practice of anesthesiology. This individual suffered primarily from alcohol dependence, and suspected opiate abuse was never verified. Others who attempted return to anesthesiology (n = 7) suffered a relapse. In comparison, 9 of the 11 anesthesiologists who took naltrexone have returned to the practice of anesthesiology without a relapse (as verified by continued random urine and hair testing). Mandatory naltrexone treatment may provide anesthesiologists with an additional safeguard to successfully return to work.

The Global Diversion of Pharmaceutical Drugs

To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals. The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986-2006, Australia 1996-2008 and the United States and France from the mid-1990s. Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements--including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines. Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels.

Protein Z and protein Z-dependent protease inhibitor and renal tubules

Dear Sirs, Protein Z (PZ) is a vitamin K-dependent, plasma protein that serves as a cofactor for the inhibition of factor Xa by protein Z-dependent protease inhibitor (ZPI) in the presence of calcium ions and phospholipids. ZPI is a member of the serpin superfamily of proteinase inhibitors and not only inhibits factor Xa in a PZ-dependent fashion, but also inhibits factor XIa in the absence of cofactors. Both PZ and ZPI are thought to be produced predominantly by the liver (1). To assess other potential sources of PZ besides the liver, tissue northern analysis was performed and showed substantial PZ mRNA expression (~1.4 kb) in the kidney (▶Fig. 1A). Subsequent immunohistochemistry studies using two monoclonal anti-PZ antibodies (Mab 2048, Mab 2306.BF12.2) (2) demonstrated PZ staining in the renal distal and collecting tubules based on tubular morphology and location in paraffin and frozen sections of the renal cortex (not shown) and the renal medulla (Fig. 1C). ZPI was also detected in kidney tubules by immunohistochemical analysis using two monoclonal antibodies (Mab 4242.2, Mab 4336.1E5) (3) in the same location as PZ (Fig. 1D). As Northern analysis has shown little if any ZPI expression in the kidney, compared to that in the liver (4), it is conceivable that the ZPI detected by immunohistochemistry was produced elsewhere and then bound to tubular PZ (2). Notably, PZ and ZPI immune-reactivity was not seen in glomeruli or other renal vascular structures. PZ and ZPI expression was also detected in the liver by immunohistochemistry, but not in lung, heart, spleen, or vasculature (not shown). Figure 1 PZ and ZPI in human kidney tubules Madin-Darby canine kidney cells (MDCK, CCL34, ATCC, Manassas, VA, USA) are derived from canine distal tubule cells, have retained a polarised phenotype, and have been used extensively to examine the sorting of proteins and other molecules. Studies of MDCK cells stably expressing recombinant human PZ, ZPI and both PZ and ZPI cultured on Transwell filter units (0.4 μm, Fisher Scientific, Pittsburgh, PA, USA) (5) demonstrated that these proteins were secreted apically, i.e. toward the tubular lumen (not shown). Random urine testing of six laboratory personnel showed the presence of PZ (61.3 ± 9.3 ng/ml; 2.4 ± 0.4% of the plasma level), but no ZPI by monoclonal sandwich immunoassays (2, 3). Western blotting using rabbit polyclonal antibodies of concentrated (YM 10, Millipore, Billerica, MA, USA) urine specimens demonstrated apparent full-length PZ (62,000 molecular weight [MW]), with little evidence of proteolytic degradation and a trace of ZPI reactivity at 72,000 and 50,000 MW. These results suggest that at least some of the PZ expressed by tubular cells is secreted into the urine, whereas the bulk of ZPI is either not secreted into the urine or is degraded to forms of low molecular weight. Glomerular filtration appears less likely as a source of urinary PZ, since PZ and ZPI circulate as a relatively high-molecular-weight complex in plasma (2). Prothrombin, factor XI and prekallikrein are also produced by kidney tubules (6–10) and the F1 fragment of prothrombin (PTF1) and PZ (11, 12) have been detected in kidney stones. Northern analysis of mouse tissues demonstrates kidney expression of PZ (not shown) and mouse urine (n=5) contains PZ at 1.9 ± 0.6% the PZ level of mouse plasma. Therefore the mouse will likely provide an appropriate model to investigate the physiologic relevance of urinary PZ.

Random Urine Drug Testing

To the Editor: Although the desired outcome for Fitzsimons et al.1 was to “reduce the incidence of addiction,” their surrogate marker of success was a reduction in the number of positive urine tests. Care must be taken not to assume that the cost-benefit of random urine testing in a population in which 100% abuse (drug treatment monitoring program) translates to a population in which 1% are substance abusers (anesthesia residency) and justify this assumption with preliminary data.2 The validity of their surrogate marker depends on the compliance of the tested population and the integrity of the urine sample. Both are in question. Only 150 random samples were collected over 4 yr, less than half required by protocol. Their steps to protect the privacy, dignity, and work ethic of the 99% of residents unlikely to be substance abusers created easy opportunities for the remaining 1% to either opt out of testing or provide an invalid specimen. The 36-h response window allows the individual substance abuser time to acquire a urine sample not his/her own or add a urine adulterant or to water load. Write in “pass drug test” on Google to secure overnight delivery of a clean urine specimen or the latest generation of adulterants.3,4 Devices may be purchased to subvert even witnessed collection (“Whizzinator” and “Butt Wedge”).3 In 2004, the Substance Abuse and Mental Health Services Administration published adulterant testing guidelines.5 The Department of Transportation now makes specimen validity testing mandatory.6 Hair sampling, frequently positive in known substance abusers with negative urine tests, bypasses privacy concerns, but is more expensive than urine testing.7 Saliva testing is undergoing validation.8 Successful monitoring programs combine both random testing and behavioral monitoring.9 But approximately 20% of individuals with known drug dependence escape detection based on behavioral monitoring alone.10 Experienced opioid users may self-inject drugs at work with a sufficient dose to prevent withdrawal symptoms but not impair performance and thereby escape detection. The average age of onset for substance abuse is 20 yr.11 Thus, residents whose addiction becomes manifest during residency have gone undetected in medical school and during residency recruitment. Margaret F. Brock, MD Raymond C. Roy, MD, PhD Department of Anesthesiology Wake Forest University School of Medicine Medical Center Boulevard Winston-Salem, North Carolina [email protected]

Risk factors associated with continued heroin use during methadone maintenance treatment in Guizhou province, China

To investigate the proportion of methadone maintenance treatment (MMT) clients continuing to use heroin and to explore its associated risk factors. All 1003 heroin addictive patients were recruited from eight MMT clinics in Guizhou province and followed up for 14 months. During the 14 months, each MMT client received random urine tests. MMT clinics, gender, marital status, employment, ethnicity, religion, previous drug using method, having a history being in detoxification program, age, methadone dosage, education level and length of drug use were treated as potential predicting variables into the GEE model. The average age of the 1003 clients was (33.3 +/- 6.1) years old, the average length of drug use was (8.0 +/- 4.0) years, and the average daily methadone dosage was (38.0 +/- 16.6) mg. Among the 1003 clients, 26.0% were female drug users, 15.5% were divorced and 35.8% had a full time job. The rate of positive urine samples was approximately 30% for the first 10 months of follow-up, after which the positive rate decreased. The model found that different MMT clinics, the average daily methadone dosage (RR = 0.98, P = 0.003), treatment duration (RR = 0.95, P = 0.029) and years of education (RR = 0.94, P = 0.014) were associated with patients positive urine test. Continued heroin use was common in MMT clinics in Guizhou province; increasing the dosage of methadone and the duration in the treatment program might decrease the continued use of heroin among clients in MMT clinics.

Random Drug Testing to Reduce the Incidence of Addiction in Anesthesia Residents: Preliminary Results from One Program

Substance abuse occurs in approximately 1%-2% of anesthesia residents and nearly 80% of programs have had one or more resident (s) with such a problem. Education and control efforts have failed to reduce the frequency of substance abuse. Anesthesia providers have a professional obligation to be drug-free for the well being of their patients. We have instituted a program of preplacement and random urine testing of residents in anesthesiology in an attempt to decrease the incidence of substance abuse. We demonstrate that such a program is feasible, despite logistic and cultural obstacles. Larger multi-institutional studies will be required to determine whether instituting a program of random urine testing decreases the incidence of substance abuse in anesthesiology residents.

The increased risk of urinary stone disease in betel quid chewers

The chewing of betel quid is a common practice in many countries of the world, particularly in Southeast Asia. The quid consists of a preparation of areca nut, betel leaf and calcium hydroxide "lime" paste ("chuna"). For the first time, we present a study that links its use to urinary stone disease. Eight patients (seven male and one female) who presented to our Stone Unit with recurrent urinary stones were included in the study. All were from the Indian subcontinent and were found to regularly chew betel. The patients underwent metabolic screening including blood, random urine and 24-h urine tests, quantitative chemical analysis of their calculi (where possible) and each completed a 7-day Diet Diary on his/her free, home diet. The study demonstrated a high incidence of hypercalciuria, a tendency to pass an alkaline urine and low urinary citrate excretion among the patients. Together these urinary risk factors increase the probability of developing both calcium phosphate-containing and calcium oxalate-containing stones. In support of this hypothesis, the patients were found to form stones consisting mainly of calcium phosphate but mixed with calcium oxalate. It is concluded that the use of calcium hydroxide "chuna" in the betel quid is the major contributor to the cause of urinary stones in its users. Moreover, the development of urinary lithiasis in such patients may be a precursor to milk-alkali syndrome in those individuals whose chewing habit is more extensive than in the patients in this study and who do not seek to decrease their habit over the long term.

Evidence of Morphine Metabolism to Hydromorphone in Pain Patients Chronically Treated with Morphine

Minor metabolic pathways in human subjects have been shown to exist for the conversion of codeine to hydrocodone but have not been reported for the metabolic conversion of morphine to hydromorphone. In this study, urine specimens were collected in an out-patient setting from 13 pain patients who were chronically treated with morphine and other opioids (methadone, oxycodone, and fentanyl). The chronic pain patients were chosen for study because they were treated with high-dose morphine and had no personal or family history of addiction. Results of the initial evaluation and follow up of these patients with random urine tests did not indicate opioid misuse. The specimens were analyzed by GC-MS for the presence of hydromorphone. The reporting limit for hydromorphone was 100 ng/mL. Ten of the 13 morphine-treated patients excreted hydromorphone in minor amounts ranging 120 to 1400 ng/mL. Concurrent morphine concentrations were exceedingly high in these 10 patients and frequently exceeded the upper limit of linearity (> 10,000 ng/mL) of the assay. The ratio of hydromorphone to morphine ranged from 0.015 to 0.024. Morphine concentrations in the three patients in which hydromorphone was not detected tended to be lower than those observed in other patients. For comparison, one additional patient was included in the study, who was prescribed both morphine and hydromorphone. Concentrations of hydromorphone in this patient were in the range of 3400-13,000 ng/mL, while concurrent morphine concentrations were in the range of 3200-6600 ng/mL. These data are highly suggestive that hydromorphone can be produced as a minor metabolite of morphine in humans. Although additional studies in more restricted settings are needed, it is recommended that interpretation of low urinary concentrations of hydromorphone in combination with high concentrations of morphine in morphine-treated pain patients should not be considered as conclusive evidence of hydromorphone misuse.

Random Urine Testing as an Intervention for Drug Addiction

Random Urine Testing as an Intervention for Drug Addiction

Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders.

Physicians recovering from substance-related disorders are usually allowed to return to practice if they agree to remain abstinent from drugs, including alcohol, and to undergo random urine testing. Over 9000 physicians are currently involved in such monitoring programs in the US. To date, it has been difficult to adequately monitor abstinence from alcohol due to the short half-life of alcohol and no other highly specific marker. Ethyl glucuronide (EtG), a direct metabolite of alcohol, offers an extended window for assessment of drinking status (up to 5 days). Our aim was to assess the potential value of EtG testing in abstinence-based monitoring programs. Urine samples were obtained from 100 participants in a physician monitoring program and additional samples were subsequently obtained 'for cause', 'to verify positive urine alcohol, when drinking was denied' and 'in high risk individuals'. All participants had signed contracts agreeing to remain abstinent from mood-altering drugs, including alcohol, and had agreed to random urine testing. EtG was determined using LC/MS-MS in addition to standard testing. The main outcome measure were urine specimens positive for EtG versus those positive based on standard testing for alcohol and other drugs. Among the initial 100 random samples collected, no sample was positive for alcohol using standard testing; however, seven were positive for EtG (0.5-196 mg/l), suggesting recent alcohol use. Subsequent EtG testing was performed clinically during the course of monitoring. Of the 18 tests performed to date, eight of eight tests performed 'for cause' were positive for EtG but negative for all other drugs including urine alcohol. All eight were confirmed positive by self reported drinking by the patient when confronted regarding the positive test result. Of six tests performed to 'confirm a positive urine alcohol' two were positive for EtG and confirmed positive by self reported drinking. For the other four samples, especially as two are from a diabetic, in vitro fermentation of ethanol is discussed. These data suggest that physicians in monitoring programs have a higher rate of unrecognized alcohol use than previously reported. Incorporation of EtG testing into alcohol abstinence monitoring can strengthen these programs.

Reducing Substance Use in Prison: The California Department of Corrections Drug Reduction Strategy Project

Inmate welfare, staff security, public health concerns, and the need for recovery-friendly prison environments have been cited as supporting efforts to control in prison substance use. This article reports on the California Department of Corrections (CDC) Drug Reduction Strategy Project, which involved systematic random urine testing and drug interdiction measures. The two-phase evaluation took place at four CDC institutions, with three serving as test sites and one serving as a standard-procedures comparison site. The results of Phase I, random urine testing of 150 inmates per week from the eligible inmate general population, supported the effectiveness of systematic random urine testing in reducing in-prison substance use, as measured by the number of inmates refusing to test or testing positive for illicit substances. The results of Phase II, which involved continued random urine testing at the three test sites in addition to K-9 drug detection teams at one institution and drug detection equipment at another institution, led to further reductions in substance use, but few drug finds resulted from the additional interdiction measures.

Glycaemic Control In Diabetics Attending Primary Care Clinics In A Multi-Ethnic Caribbean Country

Objectives: To conduct an audit of glycaemic control in diabetics attending primary care clinics in Trinidad. Methods: Random glucose and urine test strip results at 3 primary care clinics were compared with measurements of glucose and HbA1c at a reference laboratory. Results: There were 207 volunteers: 73 males, 134 females; 57.6±10.9 yrs (mean±sd). Clinic glucose (95%CI=10.4 -12.3 mmol/L) correlated strongly with that of the reference laboratory (r=0.91, p 11.1 mmol/L) in the different clinics was similar; 46% of the diabetics were hyperglycemic and 19% had glucose >16.7 mmol/L. Plasma glucose and urine test strip results correlated positively (r=0.45, p 11.1 mmol/L. The sensitivity and specificity of urine test strips at a plasma glucose of 11.1 mmol/L were: 71% and 62%, respectively. The predictive value was 63% and the diagnostic efficiency was 47%. Mean HbA1c was 8.9% (95%CI=8.2-9.6%); this correlated with glucose (r=0.66, p<0.005) and urine test strip (r=0.50, p<0.005). Conclusions: Optimal glycaemic control of diabetic patients at these primary care facilities is not being achieved. Blood glucose measurement is superior to urine test strip; however, the validity of both these results may be improved by the implementation of routine quality assurance. The work was conducted at the Biochemistry Unit, Department of Preclinical Sciences, Faculty of Medical Sciences, The University of the West Indies. St. Augustine. Trinidad & Tobago. Funding: This study was supported by a grant from PAHO/WHO

A commentary on “Urine testing in methadone maintenance treatment: applications and limitations”

Urine surveillance is an important tool for methadone treatment programs that is typically used to determine whether clients are receiving the proper dosage of methadone and whether they are using any illicit drugs. Results from urinalysis are used to monitor treatment compliance and progress. Many treatment staff see urinalysis as a therapeutic tool that can be used to support the addiction recovery process. Results can be used to help confront unhealthy behaviors, break through denial, and to support clinical progress such that persons receiving treatment are enabled to abstain from heroin and other drug use. In ‘‘Urinalysis as a Clinical Tool’’, Ira Marion (1993) distinguishes urine ‘‘screening’’ from urine ‘‘testing’’ and asserts that screening is more typically the practice employed by methadone treatment programs. Testing is the more rigorous of the two, more expensive, and frequently involves followup tests where test results clarify clinical issues such as diversion or other drug use. Screening is a more limited procedure, but according to Marion, ‘‘in the context of regular, routine, and random surveillance, can yield a patient profile to be used in treatment planning, counseling, casework, and determining the adequacy of the patient’s methadone dosage, particularly as patterns emerge during treatment’’. When considering the applications and limitations of urine surveillance the distinction between testing and screening takes on major significance. There are organizational and resource problems that compromise the potential effectiveness of urine testing within methadone maintenance programs. It is typically the case that methadone treatment staff have caseloads that exceed desired levels, making it difficult to conduct urine surveillance strategies with the frequency and rigor necessary to produce reliable, conclusive data. Treatment staff, then, are likely to be restricted in their ability to do much more than to implement screening at the minimal level required by regulatory agencies. The combination of limited fiscal resources and large caseloads creates an environment where it is difficult to meet even minimum requirements. (In New York State, those minimal requirements involve weekly screenings for the first three months of treatment and once monthly thereafter, unless assessment indicates a need for more frequent screening.) Given the likelihood that a program is screening once a week or less and using a less costly, less sophisticated screen, it may be assumed that urine screens are yielding limited data related to dosage and drug use. However, the screens can provide a valuable snapshot of a client’s performance at a given moment in the treatment process that, along with other clinical data, can be used to help assess that client’s clinical progress. Frequent random urine testing, the use of confirmatory testing, and testing methods that promote the integrity of test results would increase the reliability and thereby the utility of the results as an indicator of treatment compliance and effectiveness. However, given the workforce and resource limitations that impact methadone treatment programs, it is likely that programs will continue to rely on less frequent, less reliable screening protocols. Advocacy is clearly needed for additional resources to enhance the likelihood that testing and screening can be conducted as clinically needed. Even with the serious workforce and resource challenges confronting methadone treatment programs, they can, nonetheless: