#2: “Accurate knowledge is power.”

Knowledge is power!  We have all heard this saying.  In the world of drug testing this should be “Accurate knowledge is power.” All of you have patients come in and very convincingly share their “knowledge” of why their test was negative or positive.  Without accurate knowledge, you and even the provider can sometimes be convinced of the patient’s story.  Everyone has access to the internet and the ton of information, both correct and incorrect, that is out there.  Some of your patients spend a LOT of time educating themselves on drug usage and drug testing.  Without accurate knowledge when looking at a drug report, it is easy to begin to question yourself when an “internet taught” patient questions the results. 

Drug metabolism is the chemical alteration of a drug by the body.  Many drugs have a parent compound (analyte) which is chemically altered in the body to form one or more metabolites.  If a patient is prescribed an analyte, such as Hydrocodone, Norhydrocodone (one metabolite of Hydrocodone) should be present if the patient is taking the drug as prescribed.  Norhydrocodone stays in the system the longest and is an excellent indicator of Hydrocodone use.  Hydromorphone (another metabolite of Hydrocodone) may also be present but typically is the first metabolite of Hydrocodone to fall below the cutoff.  Hydromorphone can also be a stand-alone drug called Dilaudid.  Using your accurate knowledge, let’s look at a case.

A patient is prescribed Hydrocodone.  Their confirmation results come back from the lab with Hydrocodone positive, Norhydrocodone negative, and Hydromorphone positive.  This patient is okay, right?  Be careful.  You know that the patient had Hydrocodone in their urine as they should.  However, there is NO Norhydrocodone.  So they either took the Hydrocodone just before their test and it had not metabolized yet, or they crushed the pill in their urine in an attempt to pass the test.  The patient looks you in the face and with all the confidence of a river boat gambler, tells you the presence of Hydromorphone proves they took their Hydrocodone correctly.  Due to your intense studying and accurate knowledge, you know that Hydromorphone can also be Dilaudid, therefore you realize the presence of Hydromorphone without the presence of Norhydrocodone, could mean this patient is taking Dilaudid.  Perhaps this is a patient that should be randomly tested very soon.

Yes this really did happen.  The provider called the lab and I was able to walk him through the exact scenario I just took you through.  The lab is always here to help you with situations like this.  As you gain more accurate knowledge your confidence in your ability to understand results will grow.  As always, thank you for your business.

Lance Benedict
President/CEO Industry Lab Diagnostic Partners
01/25/2019

#1: Importance of the Prescribed Medications List

Recently Faye (ILDP’s executive administrator for those that do not know) received a phone call from an irate patient who claimed the addiction clinic where she attends told her the lab report stated she was positive for Benzodiazepines. Faye was able to calm the patient down enough to transfer her to me.  As I pulled up the requisition form, I noticed the only prescribed drug reported by the clinic was Suboxone. (Suboxone comprises of Buprenorphine, Norbuprenorphine, and Naloxone.)  The test results revealed the patient positive for Buprenorphine and Norbuprenorphine (no Naloxone), as well as Amphetamines.  No Benzodiazapines were present.  I quickly reviewed this patient’s historical documentation and she had never tested positive for Benzodiazapines.  I did notice approximately 9 months ago the patient had positive results for Buprenorphine, Norbubprenorphine and Naloxone.  The other 12 tests since then have been positive only for Buprenorphine and Norbuprenorphine with the most recent also being positive for Amphetamine.  Every requisition from the clinic stated the patient was prescribed Suboxone.  So is this patient not taking Suboxone properly?, Benzodiazapines as the staff had asked? or Amphetamines?  Should they be dismissed from the clinic for not taking drugs prescribed?  As the famous Lee Corso, on Saturday game day says, “Not so fast, my friend!”

After calming the patient down she stated that she had just had a baby.  Ah Ha!  Clue number 1.  She had been pregnant the last 9 months.  Why does this matter, you ask?  The reason is most providers will change a pregnant woman from Suboxone to Subutex so they are not exposed to Naloxone.  Remember, we were only seeing a positive Buprenorphine and Norbuprenorphine for the past 9 months without the Naloxone (Narcan) that should have been there if the patient was taking Suboxone.  The patient confirmed she had been switched to Subutex when she told the provider she was pregnant.  Clue number 2 occurred when the patient told me she had recently been put on Sertraline (Zoloft).  Zoloft is a drug that commonly causes a false positive for Benzodiazapines on a screening analyzer or a cup test.  There is a good chance she was positive on the clinic’s analyzer for Benzodiazapines but negative when confirmed at the lab.  Finally Clue number 3 the patient also told me she was prescribed and taking Adderall.  Thus the positive Amphetamine result.   This patient’s drug results were correct and she is taking her prescribed medications. The Requisition form sent with the patient sample should have indicated SUBUTEX, ADDERALL and ZOLOFT on the prescribed medication list.   

You can see why it is important to make sure the prescribed medications are current whenever a sample is sent and also why clinical decisions should never be made just off of a patient’s screening test. We are always here to help and answer questions.  As always we thank you for your business.

Lance C Benedict
President/CEO Industry Lab Diagnostic Partners
01/11/2019