Friday, February 22, 2019

#4: POCs: Screening vs Confirmation


I received a very appropriate text the other day from a sharp employee with questions regarding a patient’s result.  It read, “Our POC (Point of Care) in house reflected suboxone as present, then the lab shows no suboxone. So I’m curious.”  Pulling up the report, the patient’s screen was positive for Buprenorphine, Opiates and Benzodiazapines.  The confirmation was positive for tramadol and O-des-methyltramadol only.  So what happened?....Times up!  First, the confirmation tells us the patient is taking Tramadol, which was not listed as prescribed.  The presence of tramadol commonly produces a false positive screening test for Buprenorphine.  Secondly, the statement that “the in house reflected Suboxone as present” is not accurate.  The only thing present in house was Buprenorphine, which is one of the active ingredients in Suboxone.  The other active ingredient is Naloxone.  Without both being present the only thing that can be stated as fact is the patient tested positive for Buprenorphine on the screen.  Finally, what caused the false positive, in house, for the Benzodiazapine?  Since no other drugs were listed as prescribed other than Suboxone, I have no clue, however the confirmation done in the lab proved there were no Benzodiazapines present in the urine.  Once again this is a classic example of why you must order confirmation testing done and should NEVER rely solely on the drug screening test to confront a patient!!

You will notice in the above paragraph I put the words screen and confirmation in bold black.  Of course there is always a method to my madness.  There is a major difference between a drug screen test and a confirmation or definitive test.  Yet even scholars use the words drug screen too liberally.  A drug screen refers to an Enzyme Linked Immunoassay (EIA) test.  This is what a panel cup test is, or some of you perform EIA screening on an Immunoassay Analyzer in your clinic.  These two testing methods are screens and unfortunately there is a significant problem with “cross-reactivity” in EIA testing.  To put it simply, leaving out the complex chemistry, there are a lot of false positives and false negatives with an EIA test.  Confirmation or definitive testing is performed in our lab on a LC/MS/MS.  This test actually separates and analyzes the different molecules in a drug sample to give you the definitive drugs and metabolites present in the urine sample.  The accuracy of confirmation testing on an LC/MS/MS is undeniable.  Let’s all start being more specific when referring to drug testing.  Do you mean drug screening or drug confirmation?

On a side note, for those of you in the Substance Use Disorder (SUD) treatment world, I recommend you see the movie, “Beautiful Boy.”  It is well done and shows the side of stimulant addiction which is on the rise.  If you are not familiar with methamphetamine use, this film explores that well.  If you know someone with SUD, encourage, support and love them.  There is always hope.  Thanks to all of you for your business.

Lance Benedict
President/CEO Industry Lab Diagnostic Partner
02/22/2019

Friday, February 8, 2019

#3: Overdose Death Rates



 In August of 2018 the National Institute on Drug Abuse (NIDA) published a report on overdose death rates.  At that time, although the count for 2017 was not finalized, NIDA estimated over 72,000 people within the US died of drug overdose.  That is a rate of 197 deaths per day or 8 per hour.  Approximately 29,406 of those deaths involved a synthetic opioid (primarily Fentanyl) overdose.  15,958 of these deaths directly involved Heroin.  The number of deaths involving Cocaine was approximately 14,556.    While all of us are familiar with the dangers of the aforementioned drugs, there are still approximately 12,000 of the 72,000 deaths remaining.  Care to venture a guess as to what drugs are involved with the remaining 12,000 deaths?

 Y’all (do you like that bit of Nashville, TN?) are just too smart.  Benzodiazepine is the correct answer.  Most providers I know do not write prescriptions for Heroin, Fentanyl or Cocaine.  The over the top fear of the Opioid Epidemic (a subject for another time) has many providers decreasing their script writing for opioids and increasing the amount of scripts for anti-anxiety medications in an attempt to assist their patients.  Drugs such as Xanax (Alprazolam), Ativan(Lorazepam), Klonopin(7-Aminoclonazepam) and Valium(Diazepam) are being prescribed for patients with pain.  It is my deeply held believe that most providers have their patients’ best interest in mind and do all they are able to for their patients, within the restrictive environment our government has created.   My purpose of this blog is not to debate the appropriateness or efficacy of any providers scripting practices. I do, however, write these to help educate you in order for you to test your patients appropriately. 

Based solely on the above statistics it is easy to understand after an initial baseline test for all patients, why providers test medium to high risk patients for the opioids, illicits and Benzodiazepines at a minimum.  I have not even discussed the abuse of amphetamines, muscle relaxants and anti-convulsants such as Gabapentin that we see in the lab.  Under testing patients is a result of fear mongering by insurances.  I am not advocating over testing, however I am encouraging appropriate testing and providers making a diagnostic or therapeutic decision for their patient based on the results reported.  Do you really think insurance companies read the statistics in the first paragraph and give a hoot?  After thirty years in the health care business I am here to tell you they do not!!  I will never tell a provider how to practice medicine or tell them what to test, however it is the labs job to assist and educate any provider who requests such help.  We are here to do that.  Wow, almost went off on the insurance companies!

Thank you for your business.

Lance Benedict
President/CEO Industry Lab Diagnostic Partners
02/08/2019

#44: Drug Testing is Another Tool in the Provider's Toolbox

  We have all heard the phrase, “The flavor of the moment” which can be roughly translated into one of my favorites, “People buy what is fam...