Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Why and when to use Oral Fluid TestingPresented by:
Les Edinboro, PhD
Jeff Gudin, MD
2 Confidential—For Internal Use Only
Intro and welcome
3 Confidential—For Internal Use Only
What is oral fluid?
Oral fluid (OF) is composed of saliva, mixed with buccal and mucosal transudates, cellular debris, bacteria and residue of ingested products
Oral fluid can also be referred to as saliva testing although not technically correct
Oral fluid is not the same as a buccal swab
This technique is for collection of cells for DNA analysis
4 Confidential—For Internal Use Only
How does oral fluid drug detection times compare1?
Detection times are driven by the cutoffs employed
To effectively compare urine or blood to oral fluid, appropriate cutoffs must be employed
To ensure detection of target drugs in a relevant window, Quest Diagnostics uses lower oral fluid cutoffs than those employed in areas such as workplace drug testing
5 Confidential—For Internal Use Only
Can we make direct comparison between oral fluid and blood?
Drug Average oral fluid:blood concentration ratio2
Alcohol (ethanol) 1.07
Barbiturates 0.3
Buprenorphine 1.0
Codeine (basic) 4.0
Methamphetamine (basic) 2.0
MDMA (basic) 7.0
Cocaine (basic) 3.0
Diazepam (acidic) 0.02
Methadone (basic) 1.6
Morphine (basic) 0.8
Δ9-Tetrahydrocannabinol (neutral) 1.2
6 Confidential—For Internal Use Only
Deeper dive on why not to compare oral fluid versus blood2
During sublingual administration of buprenorphine, the drug will diffuse into the oral
tissues
After the initial spike in oral fluid buprenorphine levels, there will be a drop in
concentration
Then the oral fluid buprenorphine levels will rise again as drug is released from the
tissue depot
Therefore, interpretation of oral fluid buprenorphine levels are dependent on the time of
collection, which will have no relevance to what concentrations may be determined
in blood
7 Confidential—For Internal Use Only
What are the benefits of using oral fluid testing?
Client needs for choice or alternative sample
Patient-related conditions
Patient not able to provide urine
Patient not ambulatory
Patient refuses to provide urine
Patient not cooperative
Practice-related reasons
Observed collection needed
High-risk patient population
Substance use disorder treatment population
Backup for urine collection
Dislike of urine collection in office
8 Confidential—For Internal Use Only
Oral fluid drug testing offering
Unlike urine, parent drugs are detected in OF
Metabolites are removed to urine and not available for diffusion into blood
Benzodiazepine metabolites
THCCOOH
Ritalinic acid
Notable exceptions:
Norbuprenorphine
Meprobamate
Benzoylecgonine
9 Confidential—For Internal Use Only
Oral fluid drug testing offering
Menu
Presumptive with reflex to quant definitive
Tandem mass spectrometry methodology
Panel 1
Includes 12 drug classes
Up to 43 compounds reported
Individually orderable
3 additional drugs
No medMATCH® interpretation
Performing Labs
Chantilly, Virginia
Pittsburgh, Pennsylvania
Drug Class – Presumptive with
Reflex to Definitive Tests
Alcohol Metabolite Methadone
Amphetamines Methylphenidate
Barbiturates Naltrexone
Benzodiazepines Nicotine
Cocaine Opioids
Marijuana Phencyclidine
MDMA Zolpidem
Meprobamate
10 Confidential—For Internal Use Only
Oral fluid drug testing offering
Panel 1 Reportable Drugs/Analytes
Amphetamines Amphetamine Methamphetamine
Barbiturates Amobarbital Butalbital Pentobarbital Phenobarbital Secobarbital
Benzodiazepines Alprazolam Chlordiazepoxide Clonazepam Diazepam
Flunitrazepam Flurazepam Lorazepam Midazolam
Nordiazepam Oxazepam Temazepam Triazolam
Cocaine Benzoylecgonine
Cocaine
Marijuana THC
MDMA MDMA
Meprobamate Carisoprodol Meprobamate
11 Confidential—For Internal Use Only
Oral fluid drug testing offering
Panel 1 Reportable Drugs/Analytes
Methadone EDDP Methadone
Nicotine Cotinine
Opioids Buprenorphine Codeine Dihydrocodeine Fentanyl Heroin
Hydrocodone Hydromorphone Meperidine Morphine
Naloxone Norbuprenorphine Noroxycodone Norhydrocodone Oxycodone
Oxymorphone Propoxyphene Tapentadol Tramadol
Phencyclidine Phencyclidine
Zolpidem Zolpidem
12 Confidential—For Internal Use Only
Oral fluid drug testing offering
Additional Reportable Drugs/Analytes
Alcohol Metabolite Ethyl Sulfate (EtS)
Methylphenidate Methylphenidate
Naltrexone Betahydroxynaltrexone Naltrexone
13 Confidential—For Internal Use Only
Simple collection procedure
Oral fluid collection method
Indicator window turns blue when
adequate sample volume collected
(1 mL)
Quick and easy to use in office, IOP or
PSC
Takes approximately 5 minutes
No citric or salty taste
A Simple Collection Process
14 Confidential—For Internal Use Only
Describe collection procedure
Demonstration of oral fluid collection system
15 Confidential—For Internal Use Only
Oral fluid collection issues
Observations Indicator not turning blue after 15 minutes - office
instructing patients to just put the swab on their cheek or tongue
Incorrect office instructions
Telling people with dry mouths to go drink some water to wet their mouth
This will dilute the sample
Allowing people to pop out a piece of candy or gum and then put the swab in
This adulterates the sample
Spilling the fluid in the vial and not replacing it with a new one
This will increase the quant results dramatically
Breaking off the pad too high up on the indicator
The swab then absorbs all the fluid in the vial and there is none left to test
Jamming the pad into the bottom of the vial
The fluid is unable to be pipetted out for testing
16 Confidential—For Internal Use Only
Oral fluid collection instructions
Use this instruction sheet to train your clients
Practice sample collection prior to demonstrating to client
Learnings:
The person trained may pass the job onto someone else
without proper training
Hectic pace of some offices may need special attention to
collections despite ease of collection
17 Confidential—For Internal Use Only
Oral fluid drug testing brochure
Alternative sample type
Advantages and disadvantages
Menu and cutoff values
Value proposition
Key Information
18 Confidential—For Internal Use Only
Oral fluid interpretation issues
Like urine, do not try to interpret the absolute values of the analytes
Relative amounts of parent/metabolite combinations may be useful in understanding time of last use prior
to collection
Be aware of potential environmental exposure leading to presumption of drug use
Cocaine
Fentanyl
Heroin
19 Confidential—For Internal Use Only
Oral fluid reporting is slightly different
Presumptive with reflex definitive
Below cutoff—reported as negative
At or above cutoff—reported with numerical value
No medMATCH interpretation
20 Confidential—For Internal Use Only
Oral fluid summary
Oral fluid drug testing is offered as an alternative sample type, not a replacement for urine drug testing
Knowing your patient needs will help you to choose the right product
Key messages
Provides choice
Alternative sample type when necessary
Simple collection process
Avoid over-interpretation of the results
21 Confidential—For Internal Use Only
Summary: Quest Diagnostics
The abuse and misuse of prescription drugs remains epidemic in the US
Quest serves 1 in 3 adult Americans and half the physicians and hospitals in the United States
Quest Diagnostics has the world's largest database of clinical lab results; our diagnostic insights help improve healthcare management
A properly implemented drug testing program is an important step in tackling drug misuse and abuse
By performing more than 10 million drug tests annually, Quest Diagnostics has the experience to help you implement a successful PDM program—one that helps protect your practice, safeguards your patients, and keeps your community safe
Rx Tox Line available to help clinicians with test ordering or result interpretation
1.877.40.RXTOX (1.877.407.9869)
Visit QuestDrugTesting.com or subscribe through your favorite podcast venue
22 Confidential—For Internal Use Only
Appendix
23 Confidential—For Internal Use Only
Oral fluid panel and components
Test codes
93975 Drug Toxicology Monitoring 1, with Confirmation, Oral Fluid
Panel components can be ordered individually
93977 Drug Toxicology Amphetamines, with confirmation, Oral Fluid 93983 Drug Toxicology Meprobamate, with confirmation, Oral Fluid
93978 Drug Toxicology Barbiturates, with confirmation, Oral Fluid 93984 Drug Toxicology Methadone, with confirmation, Oral Fluid
93979 Drug Toxicology Benzodiazepines, with confirmation, Oral Fluid 93986 Drug Toxicology Nicotine, with confirmation, Oral Fluid
93980 Drug Toxicology Cocaine, with confirmation, Oral Fluid 93987 Drug Toxicology Opioids, with confirmation, Oral Fluid
93981 Drug Toxicology Marijuana, with confirmation, Oral Fluid 93988 Drug Toxicology PCP, with confirmation, Oral Fluid
93982 Drug Toxicology MDMA, with confirmation, Oral Fluid 93990 Drug Toxicology Zolpidem, with confirmation, Oral Fluid
24 Confidential—For Internal Use Only
Test codes
Additional Oral Fluid Drug Tests
93976 Drug Toxicology Alcohol Metabolite, with confirmation, Oral Fluid
93974 Drug Toxicology Methylphenidate, with confirmation, Oral Fluid
93985 Drug Toxicology Naltrexone, with confirmation, Oral Fluid
Additional tests
25 Confidential—For Internal Use Only
References
1. Caplan, YA, Cone, EJ (2009), Laboratory Testing in Pain Management: Approaches & Issues, www.samhsa.gov
2. Drummer OH. Drug testing in oral fluid. Clin Biochem Rev. 2006;27(3):147–159.