Are you seeing the whole picture? ARE YOU SEEING THE WHOLE ...€¦ · LCMS CUT OFF 450 POC CUT...
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© Southwest Labs LLC. Albuquerque, NM. 2017. All rights reserved. Reproduction and/or reuse not authorized. LC-MS/MS POINT OF CARE POC Advantages: -Inexpensive -Instant read POC Disadvantages: -Possible False Positives -Possible False Negatives -Small Testing Panel (6-14 panel) -Unclear Readings- Human Error -Many Untested Medications -Metabolites not Shown Individually Prescription Monitoring Program (PMP) Accumulates Schedule II-V controlled substance prescription and dispensing information into a restricted access online database in order to meet its mission to reduce the diversion of these controlled substances while serving as a valuable tool for legitimate medical practice and patient care. WHAT YOU SEE USING PMP -Shows Prescription History by Patient -State Database with Limited Interstate data sharing WHAT YOU MISS USING PMP: -It is not a National Database (State based) -Inaccuracies from Pharmacy Delays and Errors -Diverted Medications will not be Reported -Medical Cannabis will not be Reported -Methadone Dispensed by OTPs will not be Reported -Buprenorphine Dispensed by OTPs will not be Reported -VA Patient Medications will not be Reported -Illicit Drugs will not be Reported VS CLINICAL SIGNIFICANCE Drug overdose deaths with fentanyl involved have increased 50% over the last 4 years in the US Sedative hypnotic medications can be very dangerous in combination with opioids/benzodiazepines/barbiturates/etc Without testing for the urinary metabolite of buprenorphine, it is dicult to truly monitor medication compliance Prescription stimulants are highly diverted and place practitioners at risk when clinical monitoring is absent or inadequate These dangerous illicit substances have inconsistent and unpredictable eects, and are becoming increasingly abused due to practitioners frequently excluding them from clinical monitoring CNS depressant skeletal muscle relaxants are dangerous in combination with other medications and should be provided with clinical monitoring Psychotherapeutic medications are not taken reliably in some patient populations and can have signicant eects when not taken as prescribed, appropriate clinical monitoring is warranted POINT OF CARE POC LCMS Testing Options Cut Ong/mL Cut O ng/mL THC 50 20 Cocaine 300 50 Amphetamine 100 50 Methamphetamine 500 50 Opiates 300 50 Barbiturates 300 200 Benzodiazepines 300 50 Methadone 300 50 Methadone Metabolite 300 50 Heroin 300 10 Buprenorphine 10 10 Oxycodone 100 50 Ecstasy 500 50 Phencyclidine 25 10 Tricyclic Antidepressants 1000 50 Propoxyphene 300 50 Ethanol 500 150 DRUGS ON SWL LCMS MENU MISSED ENTIRELY BY POC Naloxone Fentanyl Tramadol Tapentadol Zolpidem Zaleplon Pregabalin Duloxetine Norbuprenorphine Ketamine Gabapentin Methylphenidate Phentermine Synthetic Cathinones "Bath Salts" Synthetic Cannabinoids "Spice" Tylenol Cyclobenzaprine Carisoprodol / Meprobamate Fluoxetine Paroxetine Venlafaxine Aripiprazole Clozapine Haloperidol Olanzapine Risperidone Quetiapine Ziprasidone Positive Test Results Missed by POC 10 300 CUT OFF 150 Missed POC Positives Results due to high cut o LCMS CUT OFF 450 POC CUT OFF - + NEGATIVE NEGATIVE + PMP LC-MS/MS POC POC POC 12 Panel False Positives False Negatives POC Accurate Results Inaccuracies LC-MS/MS ARE YOU SEEING THE WHOLE PICTURE?
Transcript of Are you seeing the whole picture? ARE YOU SEEING THE WHOLE ...€¦ · LCMS CUT OFF 450 POC CUT...
© Southwest Labs LLC. Albuquerque, NM. 2017. All rights reserved. Reproduction and/or reuse not authorized.
LC-MS/MS
Accurate Results Inaccuracies
POINT OF CARE
POC Advantages: -Inexpensive -Instant read
POC Disadvantages: -Possible False Positives -Possible False Negatives -Small Testing Panel (6-14 panel) -Unclear Readings- Human Error -Many Untested Medications -Metabolites not Shown Individually
Prescription Monitoring Program (PMP)Accumulates Schedule II-V controlled substance prescription and dispensing information into a restricted access online database in order to meet its mission to reduce the diversion of these controlled substances while serving as a valuable tool forlegitimate medical practice and patient care.
WHAT YOU SEE USING PMP-Shows Prescription History by Patient -State Database with Limited Interstate data sharing
WHAT YOU MISS USING PMP:-It is not a National Database (State based)-Inaccuracies from Pharmacy Delays and Errors-Diverted Medications will not be Reported-Medical Cannabis will not be Reported -Methadone Dispensed by OTPs will not be Reported-Buprenorphine Dispensed by OTPs will not be Reported-VA Patient Medications will not be Reported-Illicit Drugs will not be Reported
Are you seeing the whole picture? When treating your patients...
VS
CLINICAL SIGNIFICANCE
Drug overdose deaths with fentanyl involved have increased 50% over the last 4 years in the US
Sedative hypnotic medications can be very dangerous in combination with opioids/benzodiazepines/barbiturates/etc
Without testing for the urinary metabolite of buprenorphine, it is di!cult to truly monitor medication compliance
Prescription stimulants are highly diverted and place practitioners at risk when clinical monitoring is absent or inadequate
These dangerous illicit substances have inconsistent and unpredictable e"ects, and are becoming increasingly abused due to practitioners frequently excluding them from clinical monitoring
CNS depressant skeletal muscle relaxants are dangerous in combination with other medications and should be provided with clinical monitoring
Psychotherapeutic medications are not taken reliably in some patient populations and can have signi#cant e"ects when not taken as prescribed, appropriate clinical monitoring is warranted
POINT OF CARE POC LCMS
Testing Options Cut O!ng/mL Cut O! ng/mL
THC 50 20 Cocaine 300 50 Amphetamine 100 50 Methamphetamine 500 50 Opiates 300 50 Barbiturates 300 200 Benzodiazepines 300 50 Methadone 300 50 Methadone Metabolite 300 50 Heroin 300 10 Buprenorphine 10 10 Oxycodone 100 50 Ecstasy 500 50 Phencyclidine 25 10 Tricyclic Antidepressants 1000 50 Propoxyphene 300 50 Ethanol 500 150
DRUGS ON SWL LCMS MENU MISSED ENTIRELY BY POC Naloxone Fentanyl Tramadol Tapentadol Zolpidem ZaleplonPregabalin DuloxetineNorbuprenorphine KetamineGabapentin Methylphenidate Phentermine Synthetic Cathinones "Bath Salts" Synthetic Cannabinoids "Spice" Tylenol Cyclobenzaprine Carisoprodol / Meprobamate Fluoxetine Paroxetine Venlafaxine Aripiprazole Clozapine Haloperidol Olanzapine Risperidone Quetiapine Ziprasidone
Positive Test Results Missed by POC
10
300
CUT OFF
150
Missed POC Positives Results due to high cut o" levels
LCMS CUT OFF
450
POC CUT OFF
-+
NEGATIVE NEGATIVE
+
PMP
LC-MS/MS POC
POC
POC 12 panel False Positves False NegaƟvesPOC 12 Panel False Positives False Negatives
POC
Accurate Results Inaccuracies
LC-MS/MS
ARE YOU SEEING THE WHOLE PICTURE?
TEST STRIP DRUG DRUGS TARGETED BY IMMUNOASSAY SUBSTANCES KNOWN TO CAUSE A FALSE POSITIVE
AMA Amphetamine AmphetaminePhenylpropanolamine,Ephedrine,Pseudoephedrine,Rani6dine,Phentermine,Brompheniramine,Bupropion,Trazodone,Chlorpromazine,Promethazine,Dimethylamylamine.
BAR BarbituratesButalbital,Phenobarbital,Secobarbital,AmobarbitalandotherBarbiturates
Ibuprofen,Naproxen
BUP Buprenophine Buprenex,Butrans,Suboxone,Subutex,ZubsolvTramadol,Morphine,Codeine,Metadone,Dihydrocodeine,Hydroxychloroquine,Chloroquine,Plaquenil
BZO BenzodiazepinesOxazepam,Nordiazepam,Temazepam,AlprazolamandotherBenzodiazepinestovaryingdegrees
Oxaprozin,Sertraline
COC Cocaine Cocaine Unknown/Infrequent
MTD Methadone MethadoneVerapamil,Que6apine,Diphenhydramine,Doxylamine,Chlorpromazine
MET MethamphetamineMethamphetamineNote:MethamphetamineisametabolicproductofBenzphetamine,Selegiline&Famprofazone.
Adderall,Phenylpropanolamine,Ephedrine,Pseudoephedrine,Rani6dine,Phentermine,Brompheniramine,Bupropion,Trazodone,Chlorpromazine,Promethazine
MDMAMethylenedioxymethamphetamine
MethylenedioxymethamphetaminePhenylpropanolamine,Ephedrine,Pseudoephedrine,Rani6dine,Phentermine
OPI/MOP Opiates Codeine,Morphine,Hydrocodone,HydromorphoneOxycodone(athighconcentra6ons)andpoppyseeds(whichcontainmorphine),certainquinolone
OXY Oxycodone Oxycodone,Oxymorphone Codeine,Morphine,Hydrocodone,Hydromorphone
PCP Phencyclidine PhencyclidineVenlafaxine,Dextromethorphan,Diphenhydramine,Ibuprofen,Tramadol
TCH TCH Marijuana,Marinol,Dronabinol Prilosec,Protonix,Efavirenz,NSAIDs
TCA TricyclicAnFdepressantsAmitriptyline,Nortriptyline,Imipramine,Desipramine,DoxepinandotherTricyclicstovaryingdegrees
Cyclobenzaprine,Carbamazepine,Diphenhydramine,Que6apine
POC CROSS REACTIVITY CHART
How can you be mislead with POC results?
Point-of-care tests do not provide a complete analysis of drugs in a patient’s system, therefore they can’t be counted on for 100% accuracy and often produce a false positive or false negative result.
I no longer use point-of-care cups because they are unreliable. I received too many false positives and negatives, and I was missing one of the major commonly abused drugs such as Tramadol, Fentanyl, and Soma.
Can you depend on a screen?
Detecting drug classes is an important step of testing. EIA screening is a testing method that produces qualitative results.
Limitations to only using EIA screening*:
•Cannot detect presence of specific compounds. •Cannot provide quantitative concentrations. •Results are affected by other medications or adulterations. •Occurrence of False Positive/False Negative can be as high as 30%.
Benefits of confirmation testing:
•LC-MS/MS technology is set with the industry’s most precise detection levels to ensure the highest sensitivity. •Individual testing options •70+ compounds tested in urine and oral fluid. •Accurate results enable physicians to determine true patient compliance. •Turnaround time: Less than two days.
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