Urine Drug Screening Tests Research Articles

B-300 Fentanyl and Xylazine Positivity Patterns at a Northeast U.S. Children’s Hospital

Abstract Background In the U.S., fentanyl mixed with xylazine has been designated as an emerging health threat. Information on whether xylazine is present with fentanyl poisoning could help better navigate the management of children exposed to fentanyl mixed with xylazine. The detection of xylazine can be a marker used to differentiate medical vs non-medical fentanyl exposure. We aimed to explore the trends in positivity rates of fentanyl and/or xylazine at an urban pediatric tertiary care hospital. Methods We conducted a retrospective analysis from October 2021 - January 2024 of fentanyl positive urine drug screen (UDS) results by immunoassay performed in-house, and the reflex confirmatory testing by liquid chromatography-tandem mass spectrometry (LC-MS/MS), performed by an external laboratory. When available, xylazine detection results by gas chromatography mass spectrometry (GC-MS) were also included in the analysis. A chart review of fentanyl positive UDS cases was conducted to determine if fentanyl was medically administered prior to the UDS. We evaluated the positivity rate of fentanyl, the co-detection of xylazine, and the positivity patterns based on age, sex, and collection department. Results Fentanyl positive tests encompassed 3.4% (227/6632) of all UDS performed at our institution and 11.0% (227/2058) of all positive UDS tests, with medical fentanyl administration prior to UDS documented in 76.2% (173/227) of cases. 217/227 samples had confirmatory testing with 96.8% (210/217) confirmed by LC-MS/MS. The median age of fentanyl positives was 7 years (41.9% ≤ 3 years old) and 57.3% were male. Fentanyl-only positive UDS were seen in 33.0% (75/227) of all fentanyl positives and 45.6% (108/227) were also positive for benzodiazepines. 68.7% (156/227) were collected in the intensive care units, and 19.8% (45/227) were from the emergency department. 46.7% (106/227) of fentanyl positive cases had concurrent GC-MS results available. Xylazine was detected in 13.2% (14/106) of these cases, with 13 cases reported as unintentional exposure on patients' chart, and 12 cases having a fentanyl-only positive UDS. The median age of xylazine positives was 2 years (71.4% ≤ 3 years old, age ranged from 19 days to 14 years) and 78.6% were male. 7/14 fentanyl mixed with xylazine cases were collected in the emergency department and 7/14 were collected in intensive care. 2/14 of the xylazine positive cases had medical fentanyl administration prior to UDS. Conclusions Detection and management of fentanyl poisoning, especially when mixed with xylazine, remains a challenge in children. Presence of xylazine is a distinct marker of exposure to non-medical fentanyl. Continued surveillance of these cases could shed light on patterns that could aid further the management of affected children and contribute to harm reduction efforts.

The more you test, the more you find: Expansion of routine urine drug screening facilitated through an embedded palliative care clinic in thoracic oncology.

194 Background: Consensus guidelines strongly recommend urine drug screening (UDS) for all patients receiving opioids for cancer pain management. However, implementation of UDS in oncology clinics is underreported. The primary aim of this study was to evaluate incidence of unexpected UDS results among patients with lung cancer after implementation of confirmatory UDS in a thoracic oncology clinic. Methods: This is a single-institution retrospective study of UDS results among patients diagnosed with any stage thoracic malignancy before and after expansion of chromatography-based UDS facilitated by a palliative care provider embedded in a thoracic medical oncology clinic. Patients were included if their first UDS was collected during the year prior to (pre-intervention) or during the 12 months after (post-intervention) opening of the embedded Thoracic Onco-Palliative Clinic on September 5, 2018. In the pre-intervention period, UDS was routinely ordered for only patients referred to a standalone palliative care clinic. This 2-step UDS includes immunoassay and chromatography-based testing followed by interpretation of results by a specialty-trained palliative care clinical pharmacist. In the post-intervention period, UDS was expanded to include any patient seen by Thoracic Medical Oncology regardless of palliative care referral status. A Kaplan-Meier curve and log-rank test were used to compare time to first unexpected UDS between cohorts. Results: More patients had UDS testing in the post-intervention (n = 182) versus pre-intervention (n = 61) period. A higher volume and proportion of patients had unexpected UDS results in the post-cohort (25/182; 13.7%) compared to pre-cohort (6/61; 9.8%), although this difference was not statistically significant (p = 0.43). The number of UDS tests per patient was significantly higher (p < 0.01) in the post-cohort (mean (SD): 2.4 (2.7)) vs. pre-cohort (1.5 (1.3)). A larger proportion of pre-cohort patients completed only one UDS during the study period (pre: 73.8% (45/61); post: 53.3% (97/182); p < 0.01). In the post-cohort, 58 (31.9%) patients completed UDS ordered by oncology team prior to palliative care referral compared to 0 patients in the pre-cohort; 29 (21.4%) patients completed UDS without receiving outpatient palliative care compared to 0 patients in the pre-cohort. Kaplan-Meier curves for the pre- and post-cohorts were similar during the first 6 months of drug screening (p = 0.7) and diverged after 6 months, with a higher probability of detecting an unexplained UDS in the post cohort at 24 months (Pre: 15.0%; Post: 40.0%). Conclusions: Implementation of confirmatory UDS in a thoracic oncology clinic facilitates closer monitoring for nonprescribed substance use during opioid management and continued detection of unexpected UDS results up to 24 months.

Rapid Metabolism of Monthly Extended-Release Buprenorphine Formulation: A Case Report

Background: Medication-assisted treatment constitutes the gold standard management for patients with opioid use disorder. Many factors can alter the response to medications, including genetic variations. In this case report, we discuss the presentation of a patient maintained on subcutaneous extended-release buprenorphine formulation who repeatedly presented objective and subjective signs of opioid withdrawal when he was switched from weekly to monthly formulation. We particularly highlight the role of metabolic pharmacogenes in this presentation. Case Presentation: Mr. Y, a 31-year-old single man, presented to our rehabilitation center seeking assistance for his polysubstance dependence, mainly opioid use disorder. As part of his multidisciplinary treatment plan, he was started on weekly extended-release buprenorphine. After maintenance for several months, he was transitioned to the monthly equivalent formulation. Since the transition, he began to develop severe withdrawal symptoms 1-2 weeks before his next due injection. This was paralleled by a noted decrease in buprenorphine level on his urine drug screening test. As soon as the patient was placed back on the weekly formulation, his symptoms resolved. Conclusion: This is a novel case highlighting the potential role of pharmacogenomics in clinical presentation and response to medications. Switching patients from weekly to monthly extendedrelease buprenorphine formulation might make rapid or ultra-rapid metabolizers at risk of earlyonset withdrawal symptoms. =In such a case, earlier provision of the injection or switching to another formulation or medication can be considered.

False positive ecstasy (MDMA) urine drug screening test results due to bupropion use: A case report

This case report is about a false positive ecstasy (MDMA) result in the urine substance abuse screening analysis of a person using the antidepressant drugs bupropion and sertraline with a therapeutic indication. Urine drug and stimulant screening analysis of a 25-year-old male patient who is history of bupropion (300 mg/day) and sertraline (100 mg/day) use, followed in the Amatem polyclinic due to the probation law, was performed with Syva® Emit® II Plus kits and immunoassay method. In order to confirm the ecstasy test, which was positive in the screening analysis, the substance analysis was repeated on the same sample with the gas chromatography sequential mass spectrometry (GC-MS) method and ecstasy was not detected in the confirmation analysis. At the same time, the presence of bupropion and sertraline patient declared to use, was confirmed with the LC-MS-Iontrap device. In conclusion, with this case example, we wanted to highlight the potential interaction of bupropion with the Syva® Emit® II Plus urine ecstasy screening tests, which could lead to false positive results. When positive ecstasy values are detected in the urine samples analyzed with the immunoassay method in patients using bupropion, the final decision should be made after a confirmatory analysis.

Should Urine Drug Screen be Done Universally or Selectively in Palliative Care Patients on Opioids?

Urine drug screen (UDS) is a useful test conducted in patients receiving opioids for chronic pain to aid in validating patient adherence to opioid treatment and to detect any nonmedical opioid use (NMOU). One controversial topic regarding its use in palliative care is whether to conduct the test universally and randomly in all patients who are receiving opioids for chronic pain irrespective of their level of risk for NMOU, or to conduct the test selectively in only those with a high risk for engaging in NMOU behaviors. In this "Controversies in Palliative Care" article, 3 expert clinicians independently answer this question. Specifically, each expert provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. They all agreed that UDS has some utility in routine palliative care practice but acknowledged the insufficient existing evidence supporting its efficacy. They also underscored the need to improve clinician proficiency in UDS interpretation to enhance its utility. Two experts endorsed random UDS in all patients receiving opioids regardless of their risk profile while the other expert recommended targeted UDS until there is more clinical evidence to support universal, random testing. Use of more methodologically robust study designs in UDS research, examination of the cost-effectiveness of UDS tests, development of innovative programs to manage NMOU behaviors, and investigation of the impact of improved clinician proficiency in UDS interpretation on clinical outcomes, were important areas of future research that the experts identified.

SAT474 A Case Report Of Moyamoya Disease Associated With Uncontrolled Graves' Disease

Abstract Disclosure: Z. Tan: None. E. Briggie: None. M. Correia: None. Background: Moyamoya disease is an uncommon cerebrovascular disease that is featured by narrowing of large intracranial arteries and the development of prominent small-vessel collaterals. The etiology of Moyamoya disease is unknown, but it can be associated with multiple conditions including atherosclerosis, sickle cell disease, and Protein S deficiency. It is rarely associated with uncontrolled Graves’ disease. Clinical Case: A 37-year-old female with a history of Graves’ disease and type 1 diabetes presented with sudden onset of slurred speech and right-sided weakness. A CTA of the head and neck showed a small hypodensity in the left basal ganglia without corresponding perfusion deficit and narrowed left internal carotid arteries without focal stenosis. In addition, a brain MRI showed patchy infarcts in the left middle cerebral artery territory. A cervical and cerebral angiogram showed multiple areas of stenosis which was concerning for Moyamoya disease. She ultimately underwent balloon angioplasty of the left internal carotid artery with improvement in perfusion. During the workup for secondary causes of Moyamoya disease, her TSH was < 0.01 µIU/mL (0.270-4.20 µIU/mL), with elevated T4 at 3.84 ng/dl (0.80-1.80 ng/dl) and elevated TSI at 15.5 IU/L (< 0.54 IU/L). Importantly, she was diagnosed with Graves’ disease 2 years before admission, and this condition has never been well controlled due to poor compliance with methimazole. A TSH measured 5 months before admission was also undetectable with elevated T4 at 2.8 ng/dl. Her other workups for Moyamoya disease were negative including HIV antigen/antibody, syphilis IgG antibody, Lyme disease IgG & IgM antibodies, hepatitis panel antibodies, ANA, ANCA, free protein S, dsDNA antibody, factor 5 Leiden mutation, vascular endothelial growth factor-D and urine drug screening test. She started methimazole 20 mg daily and was discharged to acute rehabilitation. After rehabilitation, her Graves’ disease is slowly improving with most recent TSH < 0.008 µIU/mL and free T4 at 2.39 ng/dl. She is almost back to her baseline with significant improvement in speech and strength. Conclusion: Uncontrolled Graves’ disease should be considered in the differential diagnosis of Moyamoya disease in young subjects who present with stroke-like symptoms. Reference: Ischemic Stroke and Intraventricular Hemorrhage in Moyamoya Syndrome Associated With Graves' Disease: A Case Report. Neurologist 2022 Presentation Date: Saturday, June 17, 2023

Prevalence of Substance Abuse Among Trauma Patients in Rural West Virginia.

Substance abuse poses considerable clinical, economic, and social challenges. West Virginia is hailed as the epicenter of the substance abuse in the United States, the prevalence and pattern of different trauma mechanisms in a rural context or in patients with different forms of substance abuse remain unclear. We performed the following analysis to understand the prevalence of substance abuse in patients with different trauma mechanisms in the rural setting with high substance abuse in the West Virginia. We performed a cross-sectional retrospective analysis of adult trauma patients (motor vehicle, fall, assault, firearm suicide, brawl/rape and machinery) hospitalized in two tertiary care hospitals in West Virginia between 2006 and 2016. We identified all patients who had a urine drug screen (UDS) test and extracted the data related to the substance and trauma. Among 8734 patients screened using UDS, 5940 (68.1%) patients were tested positive for the substance. Opiates, alcohol, benzodiazepines, and cannabis were the four most common substances identified in trauma victims. In all instances, the prescribed drug was less than 20%. Fatal outcome was observed in 366 patients in the sample, with 44% (n=162) testing positive for UDS, 12% (n=45) testing positive for only alcohol, and 15% (n=56) testing positive for both alcohol and UDS. Regarding the trauma mechanism, the motor vehicle accident (MVA) was the most prominent with a clear association of substance abuse with fatal outcome. The most prevalent trauma mechanism was a MVA, with a strong link between drug usage and mortality. Due to the high incidence of positive substance abuse screens, UDS tests may need to be more widely implemented in trauma in the West Virginia region. The findings of this study might help in establishing regional or national policies to reduce acute substance abuse.

It's Not Always Just a Rash

It's Not Always Just a Rash Adam Bossert I looked at the emergency department track board and saw a patient waiting for a provider who was "roomed" in a hallway stretcher with a chief complaint of a rash. I briefly considered his ultimate disposition, "He's probably fine. He can't be that sick if he was triaged as safe for the hallway." I was tired and close to the end of an overnight shift and thought he would be a quick turnaround, likely discharged, since rashes are typically benign. I walked over to his stretcher after a quick chart biopsy that highlighted his mildly increased heart [End Page 24] rate on arrival as well as his history of polysubstance use and homelessness. "Hey doc, I don't feel so good." "I'm sorry to hear that. What's specifically bothering you?" "I am itching all over with these bumps. My skin is red, and I also think I'm withdrawing since I have body aches and chills." The interview continued. I discovered his last heroin use was approximately eight hours prior to arrival. I thought he was an ideal candidate for buprenorphine since he was actively withdrawing. I was recently licensed to prescribe this medication and excited to use my license for the first time. He declined the suggestion, however, preferring methadone instead. Buprenorphine can precipitate withdrawal if not given long enough after opioid use or if an incorrect dose is given; thus, many patients are hesitant to take it. He also stated he was predominantly here for his rash and did not want rehabilitation placement. I ordered our initiation methadone dose as well as a screening COVID-19 test and a urine drug screen test, which are both needed for rehabilitation placement in case he changed his mind. His rash was highly suspicious for scabies. He was covered with red bumps that spared only his face, some in linear distributions, and was actively scratching his arms and legs during the interview. I prefer oral ivermectin over topical permethrin for the homeless population simply for ease of administration, lower cost, and increased compliance. He received ivermectin for his scabies and knew he could return to the emergency department for a repeat dose if he was unable to fill a prescription. What happened next is, in my experience, an all-too-common scenario. The patient told me that the methadone is "doing nothing." I explained he could no longer take buprenorphine since he already received methadone, which only made him more frustrated. Unfortunately, I am restricted with the amount of methadone I can give in the emergency department, largely due to the drug's long half-life, and thus I was unable to give him more, let alone attempt titrating to his tolerance. Opioid withdrawal is not a life-threatening diagnosis; these patients are not typically admitted to the hospital. The management consists of initiating either methadone or buprenorphine, symptomatic treatment and then outpatient referral or rehabilitation placement. I explained the options to him, and he requested to be discharged since he was deferring rehabilitation. He was discharged. I was able to treat his rash but his chronic illness, opioid use disorder, was not controlled. I discharge a patient in opioid withdrawal or who has opioid use disorder almost every day, and I think most emergency medicine physicians would echo that statement. The disposition is not wrong from the perspective of the individual physician, but it feels like the system has failed these patients when I think of the frequency that they return and their baffling risk of overdose. The latter can be reduced by giving patients Narcan, the drug to reverse opioid overdose, upon discharge but this is just placing a bandage over the problem and not all emergency departments can fund this risk-reduction tool. I saw my patient's COVID-19 result return as I wrapped up my shift. It was positive. And, of course, he was in our department's hallway the whole time, only intermittently using his mask. I suddenly realized that while yes, he was withdrawing, he also may have had a symptomatic COVID-19 infection! I quickly reopened his chart, only to...

Analysis of Hospital Based Urine Drug Screening Tests over 2 Years. Does it Mirror the Actual Prevalence of Drug Abuse!

Effect of drugs often interplays with the diagnosis and treatment of patients presenting to Emergency and critical care services of the hospital. Urine drug screen (UDS) is a qualitative toxicological screening tool which is simple, fast and has a relatively low cost providing a clue in acute care settings. The present study aims to determine the prevalence of drugs of abuse determined by UDS in suspected patients in a hospital set up and compare it to national prevalence study. It is a retrospective study conducted in the Toxicology lab in KIMS Medical College and Hospital, in Odisha over a period of 30 months where urine samples received from the hospital were included. Commonly abused substances were detected by urine drug screen by the help of a commercially available lateral flow assay kit. We received 232 samples in this study period of which 108 (46.5%) tested positive by urine drug screen.The highest positivity among the samples was noted in the age group of 21-30 (33.3%) closely followed by 11-20 (30.6%) with a male preponderance.(32.3%) cases where single drug was found in urine drug screen while 33 (14.2%) of cases had multiple drugs detected in the UDS. Most common substance of abuse was benzodiazepines in 43.2% cases. THC (29.05%) and OPI (14.2%) were the other commonly abused drugs. In poly drug abusers, commonest drug combination consisted of OPI and THC with or without BZO in 36.36 % (12 /33) cases. Thus, in spite of having many limitation of urine drug screen will help in the acute patient care set up particularly for diagnosis of poly drug abuse.

Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study

ObjectiveThe objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT).MethodsData for this retrospective cohort study of 55...

Urine Drug Screening for Isolated Marijuana Use in Labor and Delivery Units.

Isolated marijuana use is frequently used as an indication for urine drug screening in labor and delivery units. We aimed to identify the results of urine drug screening in a labor and delivery unit for isolated marijuana use. This retrospective cohort study reviewed data from patients admitted for delivery at an urban academic center from January 1, 2020, to December 31, 2020. Patients undergoing urine drug screening for isolated marijuana use were more likely to be younger (median age 25 vs 29 years, P <.001), more often Black (adjusted odds ratio [aOR] 2.58, 95% CI 1.94-3.41), and more likely to have public insurance (aOR 1.54, 95% CI 1.21-1.95). A few (5/338, 1.5%) urine drug screening tests performed for isolated marijuana use were positive for substances besides marijuana. Most patients (177/197, 89.8%) with a urine drug screening test result that was positive for marijuana were reported to the state child abuse hotline. The utility of isolated marijuana use as a criterion for urine drug screening thus appears limited in benefit but rife with inequitable potential to harm.

Urine drug screening on labor and delivery

Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units. This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results. This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed. Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider-ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing. Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

Extended-release pharmacotherapy for opioid use disorder (EXPO): protocol for an open-label randomised controlled trial of the effectiveness and cost-effectiveness of injectable buprenorphine versus sublingual tablet buprenorphine and oral liquid methadone

BackgroundSublingual tablet buprenorphine (BUP-SL) and oral liquid methadone (MET) are the daily, standard-of-care (SOC) opioid agonist treatment medications for opioid use disorder (OUD). A sizable proportion of the OUD treatment population is not exposed to sufficient treatment to attain the desired clinical benefit. Two promising therapeutic technologies address this deficit: long-acting injectable buprenorphine and personalised psychosocial interventions (PSI). This study will determine (A) the effectiveness and cost-effectiveness — monthly injectable, extended-release (BUP-XR) in a head-to-head comparison with BUP-SL and MET, and (B) the effectiveness of BUP-XR with adjunctive PSI versus BUP-SL and MET with PSI. Safety, retention, craving, substance use, quality-adjusted life years, social functioning, and subjective recovery from OUD will be also evaluated.MethodsThis is a pragmatic, multi-centre, open-label, parallel-group, superiority RCT, with a qualitative (mixed-methods) evaluation. The study population is adults. The setting is five National Health Service community treatment centres in England and Scotland. At each centre, participants will be randomly allocated (1:1) to BUP-XR or SOC. At the London study co-ordinating centre, there will also be allocation of participants to BUP-XR with PSI or SOC with PSI. With 24 weeks of study treatment, the primary outcome is days of abstinence from non-medical opioids during study weeks 2–24 combined with up to 12 urine drug screen tests for opioids. For 90% power (alpha, 5%; 15% inflation for attrition), 304 participants are needed for the BUP-XR versus SOC comparison. With the same planning parameters, 300 participants are needed for the BUP-XR and PSI versus SOC and PSI comparison. Statistical and health economic analysis plans will be published before data-lock on the Open Science Framework. Findings will be reported in accordance with the Consolidated Standards of Reporting Trials and Consolidated Health Economic Evaluation Reporting Standards.DiscussionThis pragmatic randomised controlled trial is the first evaluation of injectable BUP-XR versus the SOC medications BUP-SL and MET, with personalised PSI. If there is evidence for the superiority of BUP-XR over SOC medication, study findings will have substantial implications for OUD clinical practice and treatment policy in the UK and elsewhere.Trial registrationEU Clinical Trials register 2018-004460-63.

A suicide attempt by intramuscular injection of pentobarbital sodium into rectus abdominis suggested by computed tomography.

Suicide attempts in humans due to injections of the veterinary drug pentobarbital sodium have been rarely reported. Herein, we present a case of a suicide attempt by intramuscular injection of pentobarbital sodium into the rectus abdominis muscle, which was suggested by computed tomography (CT). A 73-year-old man was brought to the emergency department with GCS 3 (E1V1M1) and an incised wound on the right side of the neck. A bottle of Somnopentyl® (pentobarbital sodium, 64.8mg/ml), a 20-ml empty syringe with an 18-mm needle, and no. 10 scalpel were present at the scene. At the emergency department, the patient was intubated and was admitted to the intensive care unit. A urine drug screen test by SIGNIFY® ER was positive for benzodiazepines and barbiturates, and continuous veno-venous hemofiltration (CHF) was initiated. The route of drug administration was initially unknown; however, a CT scan revealed swelling of the left rectus abdominis muscle with a wound suggestive of a needle puncture, and the CT analysis suggested 38.16ml as the maximum dose of pentobarbital sodium. On day 3, the patient's consciousness improved, and he was weaned off CHF and mechanical ventilation. There have been several reports of postmortem CT yielding information on the site of administration of intoxicants, but there have been none for surviving intoxicated patients. This is the first report of the usefulness of CT to identify the site of administration of the causative agent of intoxication while the patient is still alive.

A false positive fentanyl result on urine drug screen in a patient treated with ziprasidone

BackgroundThe objective of this case report is to highlight the possibility of the second-generation antipsychotic ziprasidone causing a false positive result for fentanyl on a urine drug screen (UDS). Case summaryA 70-year-old female was admitted to an inpatient psychiatric unit for treatment of a manic episode of bipolar I disorder. She had no previous history of a substance use disorder (SUD) and had no previous positive results on UDS tests spanning an 8-year period. However, her UDS obtained in the emergency department (ED) was positive for fentanyl. The patient adamantly denied that she had ingested anything other than her prescribed medications. Her outpatient psychiatric provider also endorsed that she had no previous known history of an SUD. It was suspected that the patient’s treatment with ziprasidone prior to admission and in the ED contributed to this positive fentanyl result. Practice implicationsIt has been established that risperidone may cause false positive fentanyl results on UDS. Due to structural similarities, ziprasidone may also cause this same result. As clinicians become more aware of the ubiquity of fentanyl in the illicit drug supply, it is imperative that clinicians also consider limitations of the currently available UDSs.

Presentations with reported methamphetamine use to an urban emergency department in Switzerland.

The stimulant methamphetamine (e.g., "crystal meth") is a commonly abused drug in many parts of the world and can cause significant health problems. The present study aims to describe presentations with reported methamphetamine use at an urban emergency department (ED) in Switzerland, to investigate prevalence, patterns and susceptible groups. Retrospective study at the ED of the University Hospital of Bern, Switzerland. Cases from June 2012 to July 2019 were retrieved from the electronic patient database using full-text terms and were categorised into three groups based on patient history: "acute", if patients presented within 72 hours of last reported use, "chronic" in cases of regular use but not within the previous 72 hours, and "past" in cases of discontinued consumption. Cases with a positive methamphetamine urine drug screening test with no further information available were described separately. During the study period, 40 cases were categorised as "acute". Among those, the mean age was 29.5 years (standard deviation [SD] 8.7), 75% (n = 30) were male, and agitation (n = 11, 28%), hypertension (n = 11, 28%), tachycardia (n = 11, 28%), sleep disturbances (n = 10, 25%) and aggression (n = 8, 20%) were the most common symptoms. Most patients (n = 22, 55%) were medically discharged, but 35% (n = 14) were admitted to a psychiatric clinic. Most (n = 33, 82.5%) were polydrug users, with alcohol, cocaine and cannabis being the most frequent co-used substances. The "chronic" group included 37 cases. Those patients were mostly male (n = 26, 70%), with a mean age of 31 years (SD 11.0), and 46% (n = 17) presented because of psychiatric symptoms, such as psychosis, depression or aggression. Of the 45 cases in the "past" group (mean age of 30 years, SD 8.6), 69% (n = 31) were male, and 49% (n = 22) and 24% (n = 11), respectively, had medical and psychiatric symptoms as the reason for admission. Of 61 cases with a positive urine drug screening test as the sole indicator of methamphetamine use, 19 patients reported MDMA use (cross-reactivity with methamphetamine in the urine immunoassay used). In the 42 remaining cases, it was unclear if the positive result was due to unreported methamphetamine use or cross-reactivity. Most patients with reported methamphetamine use were young and male, with signs of sympathomimetic arousal and/or psychiatric symptoms. Although ED visits with reports of methamphetamine use appear to be uncommon, consumption-related health problems can require significant pre- and in-hospital resources.

Mexiletine and False Positive Urine Drug Screen for Amphetamine: A Case Review

Advanced heart failure patients commonly suffer from ventricular arrhythmias which can be managed by antiarrhythmic drugs like mexiletine. These ventricular arrhythmias can be complicated by illicit drug use which alter outcomes and can potentially impact the patient-physician relationship through countertransference. However, mexiletine can lead to false positive urine drug screen testing for amphetamine, and these false-positive urine drug screen test results can affect the decision-making process. Health care providers should be aware of this fact and should either use confirmatory testing or look for confounding compounds in patients who deny using illicit substances and have a positive urine drug screen. Our patient is 64 years old who arrived at the emergency department after experiencing a shock by his intracardiac defibrillator. The patient tested positive for amphetamine on his urine drug screen and was later ruled out by confirmatory quantitative testing.

Drug and alcohol use in Tanzanian road traffic collision drivers.

IntroductionRoad traffic collisions (RTCs) are an important public health problem in low and middle-income countries (LMIC), where 90% of RTC deaths occur. The World Health Organization has suggested strategies to address excess mortality from RTCs including efforts to combat driving after using alcohol or drugs. Data on the impact of drug and alcohol use on RTCs is limited in many low-resource settings including Tanzania. We sought to examine the prevalence of drug and alcohol use in Tanzanian RTC drivers.MethodsThis prospective, observational study was conducted in the emergency centre (EC) of Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. We enrolled adult drivers presenting within 24 h of an RTC. We collected a saliva test of blood alcohol content (BAC) and a urine drug screen (UDS) and administered a validated substance use disorder screening tool, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Patients were excluded from individual analyses if they could not produce saliva or urine or answer questions. Primary outcomes were rates of positive BAC, UDS and self-reported risky alcohol and drug use patterns.ResultsWe screened 5264 trauma patients and enrolled 418, in whom 190 had a BAC, 364 had a UDS, and 410 had a complete ASSIST. 15 of 190 patients (7.9%) had a positive BAC, and 67/361 (18.7%) had a positive UDS for at least one drug. ASSIST scores showed 75/410 (18.3%) patients were at moderate or high risk for alcohol use disorder. Few were at risk for disordered use of other non-tobacco substances.DiscussionIn our population of RTC drivers, positive BAC and UDS tests were rare but many patients were at risk for an alcohol use disorder. Ideal screening for substance use in Tanzanian trauma populations may involve a combination of objective testing and a verbal screening tool.

Urine Drug Screening in the Era of Designer Benzodiazepines: Comparison of Three Immunoassay Platforms, LC-QTOF-MS and LC-MS-MS.

This study investigated the presence of designer benzodiazepines in 35 urine specimens obtained from emergency department patients undergoing urine drug screening. All specimens showed apparent false-positive benzodiazepine screening results (i.e., confirmatory testing using a 19-component liquid chromatography-tandem mass spectrometry (LC-MS-MS) panel showed no prescribed benzodiazepines at detectable levels). The primary aims were to identify the possible presence of designer benzodiazepines, characterize the reactivity of commercially available screening immunoassays with designer benzodiazepines and evaluate the risk of inappropriately ruling out designer benzodiazepine use when utilizing common urine drug screening and confirmatory tests. Specimens were obtained from emergency departments of a single US Health system. Following clinically ordered drug screening using Abbott ARCHITECT c assays and laboratory-developed LC-MS-MS confirmatory testing, additional characterization was performed for investigative purposes. Specifically, urine specimens were screened using two additional assays (Roche cobas c502 and Siemens Dimension Vista) and LC-quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) to identify presumptively positive species, including benzodiazepines and non-benzodiazepines. Finally, targeted, qualitative LC-MS-MS was performed to confirm the presence of 12 designer benzodiazepines. Following benzodiazepine detection using the Abbott ARCHITECT, benzodiazepines were subsequently detected in 28/35 and 35/35 urine specimens using Siemens and Roche assays, respectively. LC-QTOF-MS showed the presumptive presence of at least one non-Food and Drug Administration (FDA)-approved benzodiazepine in 30/35 specimens: flubromazolam (12/35), flualprazolam (11/35), flubromazepam (2/35), clonazolam (4/35), etizolam (9/35), metizolam (5/35), nitrazepam (1/35) and pyrazolam (1/35). Two or three designer benzodiazepines were detected concurrently in 13/35 specimens. Qualitative LC-MS-MS confirmed the presence of at least one designer benzodiazepine or metabolite in 23/35 specimens, with three specimens unavailable for confirmatory testing. Urine benzodiazepine screening assays from three manufacturers were cross-reactive with multiple non-US FDA-approved benzodiazepines. Clinical and forensic toxicology laboratories using traditionally designed LC-MS-MS panels may fail to confirm the presence of non-US FDA-approved benzodiazepines detected by screening assays, risking inappropriate interpretation of screening results as false positives.

Development and implementation of a clinician report to reduce unnecessary urine drug screen testing in the ED: a quality improvement initiative

BackgroundUnnecessary testing is a problem-facing healthcare systems around the world striving to achieve sustainable care. Despite knowing this problem exists, clinicians continue to order tests that do not contribute to...