Hello, I'm Barry sample. I'll be talking with you in this session about expanded panel drug testing going beyond the so called night of five. First, I'd like to start with the disclosure. I'm currently I'm self employed I retired recently after 40 plus years and drug testing industry and I'm now working as a consultant with a variety of laboratories and IED companies. Let's get started. Many of you have likely heard of the National Survey on Drug Use and Health. It's an annual survey of non institutionalized people within the United States that are 12 years of age or older. And it's a report of self reported illicit and the way the US Department of Health and Human Services or HHS defines illicit for the purposes of the survey is either illegal use or use of prescription drugs, without a valid prescription. And so besides assessing illicit drug use that also includes the use of alcohol and tobacco. This data provides information across the United States. Drug use but also substance use disorder treatment reasons for not receiving substance use treatment mental health issues and co occurring substance use disorders and mental health issues, and involves a survey of approximately 68,000 people annually. Very, very powerful and interesting survey and if you've not looked at it before I would certainly encourage you to look at it and download it. The most recent survey from the 2019 data which was published in September of this year, found that in looking at past month illicit drug use that there are 35.8 million people, or approximately 13% of the US population that admit admitted. What they would call current or past month drug use illicit drug use. Most of that illicit drug use was driven by the use of marijuana and opioid and opioids, specifically in the case of marijuana 30, an estimate of 31.6 million people age 12 years and older had used marijuana in the past month prescription pain relievers have been at 2.8 million cocaine prescription tranquilizers or sedatives hallucinogens all add or close to 2 million prescription stimulants 1.6 million methamphetamine 1.2 inhalants point eight and heroin itself at point four three. So this data gives you an idea of the illicit drug use patterns in the United States. Looking at past month use the survey also looks at past year use. So 20.8% of the US population or 57.2 million people admitted past year illicit use. And as you drill down on that 4.3 million of those were adolescents, age 12 to 17. And if you look also at past month binge drinkers. There were 5.8 million people age 12 or older that had reported past month binge drinking, and of those 1.2 million were adolescents. And they're reporting on substance use disorder 7.4% or 24 20.4 million reported substance use disorder in the past year. 1.9 of those 1.1 million were age 12 to 17 4.8 age million aged 18 to 25 and 14.5 million age 26 or older. So moving now to the expanded drug panel. Starting with opiates and we talked about that the opiates and as well as part of the standard panel, but the addition of the prescription opiates like hydrocodone hydromorphone oxycodone oxymorphone is relatively new to federal testing. And there are some additional points we want to call out as we look at opiates here. So opiates as a class refers to any you know any opiate drug, and those that share many of the properties of opiates. The actual opiates naturally occurring opiates are found in the opium poppy or synthesized from from the opium poppy. And those are typically drugs like codeine and morphine semisynthetic opiates refer to those opiates that are synthesized from other naturally occurring opiates and typically they're they're manufactured from the vein. And those drugs, the semisynthetic opiates like hydrocodone hydromorphone oxycodone and oxymorphone could be synthesized de novo pharmaceutical companies find that it's more efficient and more cost effective to actually use the vein, one of the natural occurring opiates as the starting material. So what's the difference between opiates and opioids. So, opiates, all have a similar structure and are derived from the opium poppy. Opioids, however, refer to those compounds that act at the opiate receptor. And I really more correctly should say the opioid receptor in the body. But these substances that interact with the opioid receptor, not all of them necessarily have the classical opiate structure and a good example of that is fentanyl. So fentanyl is classified as an opioid, it's not actually an opiate itself. However, when we talked about heroin and codeine and morphine. So, morphine is metabolite, ultimately of both heroin, as well as codeine. The list of opioids is rather extensive. So, in addition to the opioids that are included in federal testing, and many private sector programs opioids would also include drugs like methadone dihydromorphine tramadol. Now fentanyl now bufine pentazosine, levorphanol, butorphanol, as well as meparidine so there are a wide variety of substances that are opioids that interact with the opioid receptor in the body that some programs may include as part of their workforce drug testing program. So why are employers concerned about opioids? Why are they testing for them in their workforce? Well, as I'm sure you're well aware, opioids have a number of cognitive and psychomotor functions. They're impairing, they're potent CNS depressants. And, you know, because of those effects, they pose a substantial risk to people in safety sensitive jobs may be difficult for employees to safely carry out their safety sensitive duties. If they are taking opioids or under the influence of opioids. And in addition, the illicit use of opioid drugs has been associated with theft, as well as distribution of the opioids, you know within the workforce. So the, you know, how do we test for the opioids in our workforce testing. So let's talk a little bit about the mandatory guidelines. Traditionally have required an immunoassay for the initial or screening test, some type of mass spectrometric chromatographic confirmation procedures such as GCMS or LCMS MS, and since late 2017. The EDS guidelines have also permitted alternative testing technologies for the testing of not just opioids but but all drugs, along with the utilization of LC GC technology coupled with a mass spectrometer. In the federal program we test for codeine, morphine, the heroin specific metabolite 6-acetylmorphine, and since January of 2018 in the DOT program, the prescription opiates hydrocodone, hydromorphone, oxycodone, and oxymorphone. As we look at data that Quest Diagnostics publishes on an annual basis, looking at the positivity rates for the various opioids. And this is for general US workforce testing, it's not for the federally mandated safety sensitive workforce as you can see with data going back prior to 2018. Semi-synthetic opiates such as hydrocodone, hydromorphone, oxycodone, oxymorphone has a much higher positivity rate than codeine and in data not shown on this slide. We've been reporting, you know, prior to 2012-2013 year over year increases in the positivity rates for those drugs. We've been seeing some declining positivity rates for those semi-synthetic opiates. So while this doesn't necessarily indicate that there is you know, more broadly in society, less use of these prescription opiates. It certainly would suggest that at least among those subject to drug testing, there is a decreased utilization. There's a decreased use of these drugs. Similar data looking at the federally mandated safety sensitive workforce prior to 2018, only codeine and morphine were included. And while with the implementation of this testing, the positivity rates were high, certainly saw a marked decline in positivity rates for those prescription opiates in 2019. So let's do a little review of drug testing technology. As you recall, as we described, most of the initial testing is done using some type of enzyme immunoassay or EIA. Confirmation testing is performed using a chromatographic mass spectrometric method such as GC-MS or LC-MS-MS. So if we look at not just the standard immunoassays, you know, there's the EIA or enzyme immunoassay based assays which would include other technologies such as ELISA as well as Cedia, but there's RIA that's been used historically, not so much today, which is radio immunoassay, the fluorescence polarization immunoassay, FPIA, but there's also instant testing devices, point of collection test, POCT, test cups and strips that in your practices outside of the federal program, you may also run across or have some experience with. So in clinical laboratories, and I'm saying clinical to differentiate it from workforce drug testing laboratories, there may be some alternate approaches that are also used so they could follow the same model that we follow for federally regulated drug testing, which is screening by immunoassay and then confirm that positive by GC-MS or LC-MS-MS. In some laboratories, they may only analyze by LC-MS-MS. They may only perform a single test, not that two tiered testing that we've been talking about because for clinical testing, there's other information that the physician has that will help them evaluate the results from that laboratory. And oftentimes this testing on the clinical side is a part of some sort of drug monitoring or prescription drug monitoring pain management program where the physician is trying to assess whether the individual is being compliant with their treatment regimen or is either using other drugs that that prescribing physician is not aware of or may also be using the more commonly identified illicit drugs like cocaine or marijuana. Sometimes they may also simultaneously analyze using an immunoassay as well as confirmatory technology. So as we look at these expanded drugs, there may be some things that are missed using that traditional approach with immunoassay reflexing to a confirmatory protocol. So there are relative to what's used in clinical drug monitoring programs, generally higher cutoffs, which can lead to longer detection windows. They may not react well with certain of the drugs within members of the class prior to the introduction of a hydromorphone, hydrocodone specific immunoassay. Many of those may have been missed. Certain of the benzodiazepines may have been missed, may not, the introduction of immunoassays for buprenorphine is relatively new. And there are a number of other pain management drugs that simply aren't detected using immunoassay. So some of the limitations of immunoassay for this broader testing is a limited menu. There may be less specificity and also less sensitivity or no sensitivity for certain drugs. In the benzodiazepine class, some of the classic examples of that might be clonazepam or lorazepam. There's no quantification with immunoassay. It's a qualitative test only. If those assays are only detecting parent drug and not the relevant metabolite, good example perhaps being methadone or buprenorphine, an individual who's been prescribed that drug may not actually be taking it. They may be diverting it. And prior to their compliance urine drug test, they may scrape, it's known as pill scraping, a small portion of that drug into their urine specimen and the privacy of the restroom. And if a laboratory is only screening for the parent compound and not for the metabolite, they may not be able to detect that lack of compliance with the program. All of this potentially leads to the potential for false negatives and false positives. And as I mentioned just a bit ago, the lower the cutoff, the longer the detection window. So for monitoring programs, sometimes having a lower cutoff is advantageous. An example in the federal program is when SAMHSA lowered the cutoff for cocaine and amphetamines, essentially cutting it in half. The positivity for cocaine increased 33% simply by changing the screening cutoff from 300 to 150 with a similar, not exactly the same, but with a similar decrease in the confirmation cutoff. Amphetamine positivity increased 26% when that cutoff was changed to 1,000 to 500 nanograms per ml. So some strong data that lowering the cutoff clearly can increase the detection window and detectability of drugs. In another study conducted by Allure, which is now Abbott Laboratories a number of years ago, where they looked at 90,000 specimens and compared confirmatory test results to those using an instant test device POCT and EIA, 35% of the cocaine metabolite positives would have been missed, or 1,104. 34% of the methamphetamines positives had concentrations below the POCT and EIA cutoffs and they would have missed 254 specimens. There would have been a significant number of specimens that would have missed the 6-AM, the heroin-specific metabolite, as compared to POCT. For one strong reason is that POCT tests don't have a test for 6-acetylmorphine for that heroin-specific metabolite. So all of those would have been missed. And, you know, if in total there would have been a miss of nearly 2.6% positive specimens if only POCT was performed. So what are the opioids that are commonly tested for in clinical or employer-expanded panels? Well, obviously the prescription opiates, the semi-synthetic prescription opiates, but also methadone, fentanyl, loperidine, but add buprenorphine really to that list these days as well. So the test results from an MRO perspective for these prescription drugs really should follow typical MRO guidelines. Evaluate the test results, determine if the donor has an alternative medical explanation, and evaluate it as you would for the other opiates. You'll also be hearing about safety concern letters. And one of the things that you need to think about is employers potentially considering a fitness for duty evaluation, particularly if the employee who tests positive is in a safety-sensitive position. And that's true even though tolerance may develop with chronic use of opioids. So moving now from opioids to some of the hallucinogens, MDMA, MDA, MDEA, the methylenedioxy family of drugs, if you recall, only MDMA and MDA are now included in the federal panel. You can see their structure here and see how closely related they are structurally. They're essentially the methylenedioxy analogs of amphetamine and methamphetamine and ethyl amphetamine. So MDMA is a hallucinogen. It's a derivative of methamphetamine, which was first synthesized in 1914. MDA actually predated it slightly. It's a derivative of methamphetamine. Both are stimulants, although MDMA has greater hallucinogenic potential than MDA. And as with all of the amphetamines, the amphetamine analog is a metabolite of the methamphetamine analog. So if somebody takes MDMA, one would expect to find MDA in their urine specimen as well. And while MDEA is also a hallucinogen and is related chemically, it is not widely used or abused, or at least here in the United States at this point in time. So a little bit of history as we look at MDMA. It was patented by Merck in 1914. And it was originally intended to be used as an appetite suppressant, but it also induced psychomotor agitation. It's commonly associated with a party drug and dancing and rave parties. It's been called an empathy drug. The most profound effects appear to be the experience of intense emotions and perception of experiencing the emotion of others, empathic type of feelings. The use of MDMA and LSD became at least well-known by the so-called deadhead followers of Grateful Dead concerts while they were attempting to achieve some sort of spiritual state, valuing beauty, generosity, and love. Widely used in the early 80s by partygoers, and recommended by some psychotherapists. Became regulated by the DEA as a Schedule I drug in 1985 along with other psychedelic and hallucinogenic drugs. Popular in the 90s as a club drug, whereas used at nightclubs and dance parties that were known as raves. And while there was a recent resurgent, at least among teens, based on self-reported use in 2008 and 2009. Again, it's not widely used or abused in the United States. It seems to be more with a certain demographic, especially more so with young people than generally people that are in the workforce. MDMA, usually taken orally, doses of 100 to 150 milligrams. It does provide an initial amphetamine-like rush over the course of about 20 to 40 minutes. Not only does it cause serotonin release, it also blocks the reuptake, leading to its pharmacological effects. Has a peak effect that's been referred to as world-relatedness, three to four hours after use. But some of the other subjective effects would include altered time perception, increased ability to interact with others, decreased defensiveness and aggression, increased awareness of emotion, and decreased obsessiveness, relentlessness, and impassivity. So how long do the effects last for MDA? Usually about 10 to 12 hours with pronounced day after sluggishness. And in the case of MDMA, four to six hours with slightly gentler effects and less day after fatigue after using MDMA versus MDA. So some of the after effects of MDMA can last 24 hours or more. There can be the loss of pleasure feeling and heterodymia. Some of the side effects, and some of them are quite classical, include the trismus bruxism. If you recall, I said it was developed originally as an appetite suppressant, so anorexia. But because of some of these side effects, the use of suckers or lollipops or pacifiers is also commonly associated with the use of MDMA to help counteract some of the jaw clenching that may occur. At high doses, some of the adverse effects include suspicion, paranoia, increased heart rate, psychosis, and violence. And long-term chronic use can include memory loss, confusion, sleep dysfunction, and aggravation of pre-existing medical conditions. So analytically, while MDMA may cross-react with many of the amphetamine class immunoassays, you can see, at least historically, looking at some of the reagents that were used originally, not what's being used today because of the 80% cross-reactivity requirement that we talked about earlier, some products like the Roche Online had exquisite cross-reactivity, but others, like the original formulation of the Siemens EMIT2+, had very low cross-reactivity. So you can see here why cross-reactivity can be so important. So today, there are specific immunoassays manufactured by all of the major immunoassay manufacturers that are specific for MDMA and MDMA. So certainly mandated for all federal testing, the extent to which non-regulated employers include it is quite variable. There are many employers where they have both regulated and non-regulated employees that will continue to test for MDMA and MDA for consistency in their testing program, irrespective of the job role. Although, outside of those employers that have federally mandated testing, probably a smaller percentage of them also include testing for MDMA and MDA. Okay. Moving now to the benzodiazepines. Benzodiazepines are regulated by the DEA as a Schedule IV substance because they have limited abuse potential. They are excluded from the HHS mandatory guidelines and DOT regulations because they're not considered to be illegal drugs. If you recall, those guidelines focus on Schedule I and Schedule II drugs. So while there may be some prescription drugs that fall into Schedule I and Schedule II, they're not considered to be illegal in the same sense. So federal regulations do not include the testing for benzodiazepines, but many private sector employers may include these drugs, these expanded panel drugs, particularly where they may have safety-sensitive employees and they want to have a better picture of drugs that may be impairing. So as a class, benzodiazepines have four therapeutic actions. They may be used as angiolytics. One of the classical examples there would be chlorodiazepoxide and alprazolam, sedative hypnotic, such as triazolam, anti-convulsants, clonazepam is very well known for its anti-convulsant and uses an anti-convulsant, as well as muscle relaxants, for example, diazepam. They have very different pharmacological parameters. So diazepam, chlorodiazepoxide have relatively long half-lives, you know, between the two ranging between 16 and 37 hours. Alprazolam, much shorter half-life. Triazolam, you know, very short half-life. Very wide range in doses, as well as typical plasma concentrations. They are extensively metabolized, and we'll touch more on that in just a second as we look at the various metabolites, but you can see already, looking at diazepam and chlorodiazepoxide, that there are some metabolites in common between those two substances. So the newer benzodiazepines, like the triazolam benzodiazepines, generally have shorter half-lives, lower therapeutic dosages, and plasma concentrations. They're chemically significantly different from the more classical and first-generation benzos, and a very different profile of metabolites. So you can think of diazepam, noradiazepam, chlorodiazepoxide, and oxazepam as all being long-acting benzodiazepines. The detection time, and we're really talking about chronic use, not single use, may be weeks or months of detection time in a urine specimen. The short-acting benzos, like alprazolam and triazolam, the so-called triazolo benzodiazepines, detection time may only be a few days. So as we look at the various metabolites, and most of these benzodiazepines are excreted as glucuronide metabolites, which requires the use of beta-glucuronidase in the laboratory to hydrolyze the specimen to improve detectability, and would also generally be a requirement for the confirmatory testing. But oxazepam and temazepam, well, oxazepam is a drug into itself, but as you can see here, temazepam and chlorodiazepoxide also have oxazepam as a metabolite. There are specific metabolites for lorazepam and fluoroazepam. Diazepam also has temazepam, noradazepam and oxazepam as a metabolite. We've called historically the metabolite cascade for these first-generation benzodiazepines. And as you can see, the newer ones, like alprazolam, triazolam, midazolam, have specific metabolites, so that while the metabolic pathway produces a similar, but it's not identical metabolite for those various benzos. And again, you can see more of the other benzodiazepines that may be found. So analytically, you know, why does this matter? Most of the immunoassays are calibrated with oxazepam and noradazepam. Sometimes they use another really synthetic, not a prescribed benzodiazepine, in order to enhance cross-reactivity. But, you know, while oxazepam and noradazepam are effective in detecting a number of other benzodiazepines, they may not do as good a job of detecting all of the other newer ones. And at least historically, most of the confirmatory tests, minimally, are detecting and reporting on oxazepam, noradazepam, temazepam, and the alpha-hydroxy alprazolam, less commonly on diazepam itself. Although given the metabolic cascade following the use of diazepam, that's probably not much of an analytical or detection problem for people that are ordering tests for benzodiazepines. Point-of-collection tests do not have that same type of broad-spectrum cross-reactivity. So, those tests, rarely if ever, would trigger a positive, would be presumptively positive for the presence of clonazepam metabolite. Lorazepam, lorazepam glucuronide, doesn't trigger a positive. Remember, I said these benzos are generally excreted as glucuronide metabolite. Oxazepam glucuronide does not cross-react appreciably with those point-of-collection tests for benzodiazepines. So, to the extent that you or your practices are using any POCT tests, be aware that they may miss a large number of benzodiazepines. So, even for the immunoassays, I'm really talking laboratory-based immunoassays, that detect these wider variety of benzos that may cross-react with that immunoassay. Generally, unless LC-MS technology is being used by the confirming laboratory, if they may not detect these other benzodiazepines, some of these newer benzodiazepines. And this really is a reiteration of what we had just talked about. So, it's important to understand as you're either ordering or interpreting these results to, you know, be aware of which benzodiazepines the immunoassay can actually detect, as well as which specific analytes the laboratory is including as a part of their confirmation panel. Generally, for most workforce drug testing, a cutoff of 200 or 300 nanograms per ml is used, but for clinical testing, much lower cutoffs may also be used. And because of the commonality of some of the metabolites, it's very difficult to work backwards and determine exactly which drug was administered. So, while the laboratory analysis, when performed using confirmatory technology such as LC-MS or GC-MS, will definitively identify the metabolite, it's hard to work backwards to determine what drug may have actually been administered. As part of your MRO practice, one of the things that you should be aware of, probably a little less common today, but it still has potential, is adulterated products that illicitly contain prescription benzodiazepines. So, there's an example here of MRO inquiries that had no history of benzodiazepine intake, but the donors had admitted to the use of some herbal products such as cow's head pills, miracle herb pills, potent sex pills. And after analysis of those pills, it was found that some of those products actually contained diazepam. So, it was unlabeled, wasn't part of the labeling, obviously would be controlled substance if they had labeled it. So, with a number of these products, particularly over the internet, it can be a situation of buyer beware. And we'll look at some of the other products in addition to the non-steroidal anti-inflammatory drugs that are sometimes found in these products in just a second. Another product is known as black pearls, which are black, pearl-sized black or brown pills. They have a slight pungent aroma. The ingredients list 20 to 30 herbs, but what they don't list, and what's been found in some of the analysis in various countries such as England, Holland, Japan, Canada, and Australia, is that they may contain, I'm not saying contains all of these, but they've been found to contain acetaminophen, benzodiazepines, dexamethasone, non-steroidal anti-inflammatories, a diuretic, hydrochlorothiazide, endomethazine, steroids. So, over the counter products, particularly, I shouldn't say over the counter, but products that are obtained over the internet, users need to be very, very careful of, particularly if they're not coming from legitimate sources. Moving now to the last group, the barbiturates. There are a variety of barbiturates, a a basic backbone, but with different substitutions on that compound. So, you know, some of them would include amobarbital, butalbitol, pentobarb, phenobarb, cecobarb, and thiopental. Different DEA scheduling, very different pharmacological parameters. They're generally classified as short-acting, intermediate-acting, long-acting. There's also ultra-short-acting, like thiopental, also sometimes referred to as truth serum, going back historically. And very different plasma half-lives as well for these various benzodiazepines. So, they're used as angiolytics or muscle relaxants, analgesics, most commonly butalbitol, which may be formulated with salicylates or aspirin and caffeine, such as furanol, or with acetaminophen and caffeine in the trade name furoset. It can also be used as an anticonvulsant, and phenobarb would be the one of the more common ones that's used. So, detection times, we're looking primarily and primarily detected as parent compound. For long-acting barbiturate, like phenobarb, can be detected for several weeks after chronic use. The intermediate-acting for a shorter period of time, 48 to 96 hours, and the short and ultra-short-acting, maybe as little as a day or less. So, the immunoassays, whether it be a laboratory-based immunoassay or one of the point of collection tests, usually designed to or targeted against cecobarbital at either a 200 or 300 nanogram per mL cutoff. They have good cross-reactivity with the other barbiturates. And the confirmation, so it's a small molecule, which means there are a limited number of diagnostic ions for laboratories that are used for identification purposes. And while most confirmatory panels today would include amobarb, butalbitol, pentobarb, phenobarb, cecobarbital, and rarely butabarbital, generally, the majority of positives that laboratories find are for butalbitol and phenobarbital, and the positivity in workforce drug testing is relatively low. Majority of those laboratory-positive results ultimately are verified negative, because there's a valid prescription on file. And the diminished return of the positive test results, you know, may not justify the cost of the test, particularly in a deterrence program. If you're dealing with safety-sensitive employees, then it may make sense, but it doesn't necessarily make sense if it's simply a deterrence program, given the fact that the majority of those specimens are verified negative after MRO review. So, as we look at results of the drug testing work, of drug tests, excuse me, workforce drug testing results, for these wider variety or expanded panels, as you can see from this data, again, this is Quest Diagnostics Drug Testing Index data, through 2019, benzodiazepines are the most commonly detected and reported analyte within this group of substances, although we've certainly been seeing year-over-year declines in the positivity rates. Barbiturates have been holding relatively steady, but are detected at a much lower rate. Methadone has been holding relatively constant, and propoxyphene, which, even though it's been off the market for a number of years now, and used to have relatively high positivity rates going back into the early 2000s, is essentially non-detectable today. So, as you can see from this data, and some of the data that we've discussed earlier, the drugs that are detected in testing panels represents a changing landscape in terms of what drugs may be used and abused. For example, in the case of fentanyl, fentanyl represents a changing landscape in terms of what drugs may be used and abused. For example, and we haven't shown that positivity data here, but with the explosion of the synthetic substances, marijuana use may move to the so-called K2 or spice products. What we call more generically in laboratory testing, synthetic cannabinoids. The use of methamphetamine or other stimulants may have moved to bath salts, what we would refer to as synthetic cathinones. Prescription opioid abuse is clearly much higher than heroin, particularly as detected in urine drug testing. All of this makes it challenging for law enforcement, toxicologists, MROs, and policy makers. Thank you very much.

drug testing

opioids

benzodiazepines

workplace safety

substance use

immunoassays

GC-MS

fentanyl