Urine Drug Screen For Cocaine Research Articles

Estimating the impact of stimulant use on initiation of buprenorphine and extended-release naltrexone in two clinical trials and real-world populations

BackgroundCo-use of stimulants and opioids is rapidly increasing. Randomized clinical trials (RCTs) have established the efficacy of medications for opioid use disorder (MOUD), but stimulant use may decrease the likelihood of initiating MOUD treatment. Furthermore, trial participants may not represent “real-world” populations who would benefit from treatment.MethodsWe conducted a two-stage analysis. First, associations between stimulant use (time-varying urine drug screens for cocaine, methamphetamine, or amphetamines) and initiation of buprenorphine or extended-release naltrexone (XR-NTX) were estimated across two RCTs (CTN-0051 X:BOT and CTN-0067 CHOICES) using adjusted Cox regression models. Second, results were generalized to three target populations who would benefit from MOUD: Housed adults identifying the need for OUD treatment, as characterized by the National Survey on Drug Use and Health (NSDUH); adults entering OUD treatment, as characterized by Treatment Episodes Dataset (TEDS); and adults living in rural regions of the U.S. with high rates of injection drug use, as characterized by the Rural Opioids Initiative (ROI). Generalizability analyses adjusted for differences in demographic characteristics, substance use, housing status, and depression between RCT and target populations using inverse probability of selection weighting.ResultsAnalyses included 673 clinical trial participants, 139 NSDUH respondents (weighted to represent 661,650 people), 71,751 TEDS treatment episodes, and 1,933 ROI participants. The majority were aged 30–49 years, male, and non-Hispanic White. In RCTs, stimulant use reduced the likelihood of MOUD initiation by 32% (adjusted HR [aHR] = 0.68, 95% CI 0.49–0.94, p = 0.019). Stimulant use associations were slightly attenuated and non-significant among housed adults needing treatment (25% reduction, aHR = 0.75, 0.48–1.18, p = 0.215) and adults entering OUD treatment (28% reduction, aHR = 0.72, 0.51–1.01, p = 0.061). The association was more pronounced, but still non-significant among rural people injecting drugs (39% reduction, aHR = 0.61, 0.35–1.06, p = 0.081). Stimulant use had a larger negative impact on XR-NTX initiation compared to buprenorphine, especially in the rural population (76% reduction, aHR = 0.24, 0.08–0.69, p = 0.008).ConclusionsStimulant use is a barrier to buprenorphine or XR-NTX initiation in clinical trials and real-world populations that would benefit from OUD treatment. Interventions to address stimulant use among patients with OUD are urgently needed, especially among rural people injecting drugs, who already suffer from limited access to MOUD.

Safety of upper endoscopy in patients with active cocaine use.

BACKGROUNDCocaine is a synthetic alkaloid initially viewed as a useful local anesthetic, but which eventually fell out of favor given its high addiction potential. Its predominantly sympathetic effects raise concern for cardiovascular, respiratory, and central nervous system complications in patients undergoing procedures. Peri-procedural cocaine use, often detected via a positive urine toxicology test, has been mostly addressed in the surgical and obstetrical literature. However, there are no clear guidelines on how to effectively risk stratify patients found to be positive for cocaine in the pre-operative setting, often leading to costly procedure cancellations. Within the field of gastroenterology, there is no current data available regarding safety of performing esophagogastroduodenoscopy (EGD) in patients with recent cocaine use. AIMTo compare the prevalence of EGD related complications between active (≤ 5 d) and remote (> 5 d) users of cocaine.METHODSIn total, 48 patients who underwent an EGD at John H. Stroger, Jr. Hospital of Cook County from October 2016 to October 2018 were found to have a positive urine drug screen for cocaine (23 recent and 25 remote). Descriptive statistics were compiled for patient demographics. Statistical tests used to analyze patient characteristics, procedure details, and preprocedural adverse events included t-test, chi-square, Wilcoxon rank sum, and Fisher exact test.RESULTSOverall, 20 periprocedural events were recorded with no statistically significant difference in distribution between the two groups (12 active vs 8 remote, P = 0.09). Pre- and post-procedure hemodynamics demonstrated only a statistically, but not clinically significant drop in systolic blood pressure and increase in heart rate in the active user group, as well as drop in diastolic blood pressure and oxygen saturation in the remote group (P < 0.05). There were no significant differences in overall hemodynamics between both groups.CONCLUSIONOur study found no significant difference in the rate of periprocedural adverse events during EGD in patients with recent vs remote use of cocaine. Interestingly, there were significantly more patients (30%) with active use of cocaine that required general anesthesia as compared to remote users (0%).

Effect of Buprenorphine Dose on Treatment Outcome

The goal of this meta-analysis is to provide evidence based information about proper dosing for buprenorphine maintenance treatment to improve treatment outcome. To be selected for the review and inclusion in the meta-analysis, articles had to be randomized, controlled, or double-blind clinical trials, with buprenorphine as the study drug; the length of buprenorphine maintenance treatment had to be 3 weeks or longer; doses of buprenorphine had to be clearly stated; outcome measures had to include retention rates in buprenorphine treatment; outcome measures had to include illicit opioid use based on analytical determination of drugs of abuse in urine samples as outcome variables; and outcome measures had to include illicit cocaine use based on analytical determination of drugs of abuse in urine samples as outcome variables. Twenty-nine articles were excluded because they did not meet the inclusion criteria. The authors present the results of 21 articles that met inclusion criteria. The higher buprenorphine dose (16–32 mg per day) predicted better retention in treatment compared with the lower dose (less than 16 mg per day) (P = .009, R2 adjusted = 0.40), and the positive urine drug screens for opiates predicted dropping out of treatment (P = .019, R2 Adjusted = 0.40). Retention in treatment predicted less illicit opioid use (P = .033, R2 Adjusted = 0.36), and the positive urine drug screens for cocaine predicted more illicit opioid use (P = .021, R2 Adjusted = 0.36). Strong evidence exists based on 21 randomized clinical trials that the higher buprenorphine dose may improve retention in buprenorphine maintenance treatment.

Effects of Labetalol on Hemodynamic Parameters and Soluble Biomarkers of Inflammation in Acute Coronary Syndrome in Patients With Active Cocaine Use

Cocaine use is associated with increased cardiovascular mortality and can promote acute coronary syndrome (ACS). Use of beta-blockers is controversial in patients who use cocaine, and the safety and efficacy of these medications in ACS in patients actively using cocaine is unknown. We enrolled 90 patients with ACS and positive urine drug screen for cocaine. Patients received standard ACS therapy plus either labetalol (n = 60) or diltiazem (n = 30). Blood pressure and heart rate were measured at baseline and 48 hours. Levels of serum CD40 ligand, interleukin (IL)-6, and choline at baseline and 48 hours were determined. There were no baseline differences in hemodynamics or serum levels of inflammatory markers between the labetalol and diltiazem groups. Both groups experienced a significant and equivalent decrease in BP and HR at 48 hours compared with baseline. At 48 hours of treatment, there were significant decreases of 17% in CD40 ligand (P < .005) and 16% in IL-6 (P < .005) but no change in choline in the diltiazem group. Furthermore, in the labetalol group, there were significant differences of 30% in CD40 ligand (P < .005 time and group comparison), 22% in IL-6 (P < .005 time and group comparison), and 18% in choline (P < .005 time and group comparison). There were no adverse events during hospitalization in any patients who received labetalol. In conclusion, labetalol appears to be safe in cocaine-associated ACS. Furthermore, labetalol provides a beneficial hemodynamic response and, in comparison to diltiazem, potentiates an anti-inflammatory vascular response in this setting.

Cocaine-Induced Chest Pain and β-Blockade: An Inner City Experience

Cocaine is the most common illicit drug used in patients presenting with chest pain to emergency departments. Data on beta-blockers in cocaine-related chest pain syndrome are sparse. We sought out to study the causal and detrimental effects of beta-blockers in cocaine-related chest pain in a large inner city cohort of patients. All patients presenting to a large inner city emergency department with chest pain, with positive urine drug screen for cocaine were included. The group comprised predominantly young (mean age 46.8 +/- 8.2 years), African American (90.6%) males (73.4%). Evidence of myocardial infarction in the form of elevation of troponin-I was noted in 7.3%. Evidence of myonecrosis (MN) was significantly more likely in those who were taking beta-blockers at presentation as compared with those who were not (14% versus 4.4%, P < 0.01). In the absence of prospective controlled data, our observational findings seem to suggest that routine initiation or continuation or of beta-blockers after admission increased the likelihood of developing MN (23.3% versus 10.7%, P < 0.01) during the course of hospitalization. MN as reflected by elevation of cardiac biomarkers is uncommon in patients presenting with cocaine-related chest pain. Preexisting use of beta-blockers seems to render a higher risk of myocardial injury in patients presenting with cocaine-related chest pain. In addition initiation or continuation of beta-blockers during hospitalization should be discouraged.

85: Cocaine-Associated Seizures and Incidence of Status Epilepticus

Methods: We performed a retrospective multi-center study of patients with seizures resulting from cocaine use. We identified study subjects at 15 hospitals by record review and conducted a computer-assisted records search to identify patients with seizures for each institution over a fouryear period. We selected subjects from this group on the basis of cocaine use and determined the occurrence of status epilepticus among them. Data were collected on each subject using a standardized data collection form. Results: We evaluated 43 patients in the ED for cocaine-associated seizures. Their age range was 17 to 54, with a mean age was 31 years; 53% were male. Of 43 patients, 42 experienced a single tonic-clonic seizure and one developed status epilepticus. All patients had either a history of cocaine use or positive urine drug screen for cocaine. Conclusion: Despite reported cases of status epilepticus with cocaine-induced seizures, the incidence of this complication was unclear based on prior literature. This study shows that most cocaine-associated seizures are self-limited. [West J Emerg Med. 2010; 11(2):157-160.]

Cocaine is Associated with Intrauterine Fetal Death in Women with Suspected Preterm Labor

The objectives of this study were to determine the rate of recent cocaine use in a metropolitan population of predominantly Hispanic and African-American women with suspected preterm labor and to evaluate the impact of recent cocaine use on intrapartum complications in this population. Urine toxicology screens were prospectively obtained on 102 women with suspected preterm labor. The urine screen did not influence management decisions. Gestational age at delivery, birthweight, and intrapartum complications were compared using Student's t-test, chi-square analysis, or Fisher's exact test. The rate of positive urine drug screens for cocaine was 12.7%. Women with positive toxicology were older (27.8 +/- 5.7 versus 22.1 +/- 4.8 years, p = 0.002) and of higher parity (2 [1 to 7] versus 1 [0 to 7], p = 0.0). Women with positive toxicology were more likely to be black (92.3%) than Hispanic (7.7% [p = 0.0004]). They had more advanced cervical dilation at presentation (3 cm [0 to 6] versus 1 cm [0 to 8], p = 0.008), were more likely to be admitted (85% versus 32%, p < 0.0001), but less likely to receive tocolysis due to advanced dilation or pregnancy complication (36% versus 79%, p = 0.0002). There was no difference in gestational age or birthweight at delivery. There was a significantly higher intrauterine fetal death rate in the cocaine positive group (18.2% versus 0%, p = 0.02). These data suggest that recent cocaine use among women with suspected preterm labor is common in only some segments of an urban population and significantly impacts pregnancy outcome.

Cocaine intoxication presenting as preclampsia and eclampsia

To relate the clinical presentation of acute cocaine intoxication in the third trimester to preeclampsia and eclampsia.Eleven women presented to Long Beach Memorial Women's Hospital and the University of California, Irvine Medical Center with hypertension and clinical symptoms of headache, blurred vision, abdominal pain, or seizures in the third trimester of pregnancy. Each had a positive urine drug screen for cocaine. The laboratory evaluation for preeclampsia included a complete blood count, platelet count, uric acid, aspartate aminotransferase, alanine aminotransferase, creatinine, and urine for protein content.All women had a diastolic blood pressure of at least 90 mmHg, which returned to the normal range 45-90 minutes after admission. Each presented with one or more symptoms associated with preeclampsia, which ultimately improved as the drug wore off. In addition, all laboratory evaluations for preeclampsia were negative.If a patient presents in the third trimester with hypertension and clinical symptoms of preeclampsia that rapidly improve shortly after admission, cocaine intoxication should be considered as the possible source.

Cocaine Poisoning: An Easily Missed Diagnosis in an Infant

We describe an infant with a positive urine drug screen for cocaine. Given the fact that he was bottle fed and 9 months of age, we presume that this drug was intentionally administered to the patient.

TAC topical anesthesia produces positive urine tests for cocaine

The combination of tetracaine, adrenalin, and cocaine (TAC) has become increasingly popular as a topical anesthetic for the suturing of simple skin lacerations. The purpose of this study was to determine the effects of TAC on a urine drug test for cocaine. On the morning after the use of TAC, 14 of 18 patients (78%) studied had positive screening tests for benzoylecgonine (cocaine metabolite) by the enzyme multiplied immunoassay test (EMIT) method. All specimens also were analyzed by gas chromatography and mass spectrometry, the reference standard for analysis of drugs of abuse in urine, and 15 of the specimens (83%) were positive. Four of 18 positive specimens (22%) still had positive EMIT drug screens on the morning of the next day, an average of 36 hours after use of TAC. We recommend that physicians who use TAC solution as a local anesthetic caution their patients that they may fail a urine drug screen for cocaine if they are tested within 36 to 48 hours of the administration of the use of TAC.

Intracranial hemorrhage in a neonate following prenatal cocaine exposure

A term infant who had a positive urine drug screen for cocaine is reported. There was ultrasonographic evidence of an intracranial hemorrhage. A small area of low echogenicity in the left caudothalamic groove documented at 96 hours of age was resolved on repeat ultrasonography at 16 days of age. This neonate was born by repeat cesarean section and growth was appropriate for gestational age. The findings indicate the importance of considering cerebrovascular events in neonates exposed to cocaine in utero.