Urine for screening for Drugs, Drugs abuse, Opiates, Cocaine, Marijuana, Amphetamines and other stimulants

Sample

1. One of the samples is urine.
   1. Urine should be taken in the presence of a technician or doctor.
2. Saliva test: This is detectable in saliva within one hour of use.
3. Hair follicle test: This is detectable in hairs in 5 to 7 days.
4. Blood test: This detectable within one hour of use.
5. Urine testing advantages are:
   1. It is easy to get a urine sample, and this is not an invasive procedure.
   2. Some of the drug concentration is more in urine, which may not be detected in the blood.
   3. Drug metabolites are excreted for a longer period of time in the urine, indicating the drug’s past use.
   4. Urine test kits for drugs are more easy and cheap.
6. Procedure to get a urine sample for drug abuse:
   1. The patient should wash their hands and wear gloves.
   2. Add bluing agents in the toilet to avoid adulteration of the urine sample.
   3. Avoid all sources of water in the toilet.
   4. The patient will provide a photo ID.
      1. The patient will leave all his belongings outside the toilet.
      2. Someone should be present in the toilet while the patient is giving the sample, or he can wait just outside of the door to listen to any abnormal sound.
      3. Check the volume of the urine (30 to 40mL) and any abnormal color.
      4. The sample will be all the time in the sight of the technician/doctor and the patient.
      5. The date and time are noted.
   5. Critical alert:
      1. Keep an eye that there is no tampering, like substitution, adulteration, or urine dilution.
      2. Avoid all unauthorized persons to handle the specimen.
      3. The urine collection may be witnessed or unwitnessed.

Precautions

1. Urine will detect heroin 1 to 2 hours, maximum up to 2 to 5 hours after use.
2. The minimum concentration should be 2000 ng/mL.
3. Check for any dilution of the urine by measuring creatinine, pH, and specific gravity.
4. The following agents will give false results:
   1. Sodium chloride.
   2. Dilute urine due to low specific gravity.
   3. Acidic urine due to high pH.
   4. Alkaline urine due to low pH.
   5. Blood in the urine.
   6. Detergents in the container.

Indications

1. To diagnose drug abuse.
2. Indicated in athletes, industrial workers, and professionals.
3. It is used in toxicology to confirm clinical or postmortem diagnosis.
   1. To diagnose drug-induced signs and symptoms and differentiate from the trauma, infectious process, or metabolic disorder.
   2. To diagnose psychosis or drug abuse.
   3. It is used in the prisoners to detect drug abuse.
4. It is advised in the workplace for public safety.
5. In routine following drugs are tested:
   1. Cocaine.
   2. Marijuana.
   3. Opiates (narcotics).
   4. Methadone.
   5. Barbiturates.
   6. Benzodiazepines.
   7. Amphetamines.
   8. Methamphetamines.
   9. Sedatives.
   10. Analgesics.
   11. Sympathomimetics.

Pathophysiology

1. Urine abuse by drugs is done by:
   1. Screening tests. These are simple, inexpensive, and rapid.
   2. Confirmatory tests.
2. Drugs of abuse are classified into:
   1. CNS stimulants produce euphoria, depress the apatite, and increase heart and respiration rates.
      1. These are cocaine and its derivatives, amphetamines, and methamphetamines.
   2. CNS depressant lowers heart rates, respiratory rate and reduces pain.
      1. These drugs are narcotics, sedatives, hypnotics, and tranquilizers.
   3. Psychoactive or hallucinogenic drugs are cannabinoids and phencyclidine.
   4. Antidepressant drugs include lithium, tricyclic depressant, etc.
3. The prevalence of drug abuse is as follows.

Drug abuse	Prevalence %
Alcohol	75 to 80
Marijuana	20 to 26
Cocaine	5 to 13
Benzodiazepine	1 to 5
Barbiturates	0.5 to 5
Opiates	0.1 to 2
Phencyclidine	0.1 to 2
Amphetamines	0.1 to 1
Other stimulants	0.8 to 2
Sedatives and hypnotics	0.6 to 2

There are several opiates used for addiction:

1. Some of these are:
   1. 1. Heroin.
      2. Morphine.
      3. Oxycodone (Oxycontin).
      4. Hydromorphone (Dilaudid).
      5. Fentanyl (Duragesic).
2. Acetylcodeine, an impurity of heroin synthesis, has been suggested as an interesting biomarker of illicit heroin use.
3. Codeine and heroin are metabolized to morphine, which is then excreted in the urine.

4. Heroin metabolism shows that it is not an active compound but becomes active after conversion to 6-Acetylmorphine.

5. 6-Acetylmorphine and morphine are pharmacologically very active substances.

6. So the detection of morphine in urine can result from:
   1. Intake of heroin.
   2. Morphine.
   3. Codeine.
   4. Poppy seeds intake.
7. Heroin may be present until 5 days in urine after the last dose. (Some say 3 to 4 days).

Amphetamines

1. 1. Amphetamine and methamphetamine are therapeutic drugs used for narcolepsy and attention deficit disorder.
   2. These are stimulants with a high rate of drug abuse.

Opiates

1. 1. These are the substances with analgesia, sedation, and anesthesia.
   2. There is a high potential for addiction.
   3. Chronic use leads to tolerance with physical and psychological dependence.
      1. Acute use with overdose leads to respiratory acidosis with respiratory system depression, myoglobinuria, and possibly increased myocardial infarction indicators.
      2. A very high dose of opiates may lead to death due to cardiopulmonary failure.
      3. Treatment of an overdose of opiates is antagonists like naloxone.
   4. This derived from the opium poppy.
   5. Naturally occurring modified opiates are:
      1. Opium.
      2. Morphine.
      3. Codeine.
      4. Heroin.
      5. Hydromorphone.
      6. Oxycodone.
   6. Chemically synthetic opiates are:
      1. Meperidine.
      2. Methadone.
      3. Propoxyphene.
      4. Pentazocine.
      5. Fentanyl.

Cocaine

1. 1. These are alkaloid salts, which can be taken by injection or insufflation or inhaled in vapors.
      1. The half-life of cocaine is 0.5 to 1 hour. Because of the short half-life, repeated doses are given.
   2. This is an effective local anesthetic with few adverse effects in a therapeutic dose.
   3. This is potent CNS stimulator leads to excitement and euphoria.
   4. Acute toxicity is associated with hypertension, seizures, arrhythmias, and myocardial infarction.
   5. The hepatic product of cocaine is benzoylecgonine, which is excreted in the urine.
      1. The presence of this metabolite in urine is a sensitive and specific indicator of cocaine intake.
      2. This can be detected for up to 3 days in the urine after a single intake.
      3. It can be detected in chronic cases up to 20 days in the urine after the last use.
         Some of the drugs and their duration in the urine:

         Drugs	Screening cut-off value	Duration of detection
         Heroin	2000 ng/mL	1 to 2 hours
         Cocaine	300 mg/dL	2 to 4 days
         Opiates	300 ng/mL	2 to 4 days
         Marijuana	50 ng/mL	30 to 60 days
         Amphetamines	1000 ng/mL	2 to 3 days
         Methadone	300 ng/mL	8 to 60 hours
         Barbiturates	200 ng/mL	up to 30 days
         Benzodiazepines	200 ng/mL	up to 40 days
         Alcohol	20 ng/mL	12 hours
         Tricyclic antidepressant	1000 ng/mL	1 to 3 days
         PCP	25 ng/mL	2 to 3 days
         Methaqualone	300 ng/mL	up to 7 days

Signs and Symptoms of Opiates:

All opiates (Morphine, Codeine, Hydroxymorphine and Oxycodone, hydrocodone, hydrocodone) have the common S/S.

1. Heroin action is very rapid in onset.
2. These have an analgesic effect.
3. Sign and symptoms are:
   1. Sedation.
   2. Pinpoint pupil.
   3. Constipation.
   4. Euphoria
   5.  Respiratory depression.
   6. Orthostatic hypotension.
   7. Decreased intestinal motility leads to constipation.
   8. There are nausea and vomiting.
   9. Bradycardia.
4. Morphine overdose (intoxication) leads to :
   1. Coma.
   2. Miosis.
   3. Respiratory depression.

Withdrawal Symptoms of  opiates are:

1. Dilated pupil.
2. Tachycardia.
3. Lacrimation and rhinorrhea.
4. Irritability and restlessness.
5. Diaphoresis.
   1. These symptoms can be decreased by methadone ( an opiate antagonist). Another used drug is clonidine.

Lab diagnosis of opiates, Various methods available are:

1. Commercial kits are available.
2. Gas chromatography.
3. Latex Agglutination Inhibition.
4. Thin Layer Chromatography.
5. Radioimmunoassay (RIA).
6. High-Performance Liquid Chromatography (HPLC).
7. Mass Spectrophotometry (GC/MS).
8. Radioimmunoassay (RIA) is rapid and cheap.
   1. Morphine and Codeine are found after heroin use.

Treatment

1. Treat intoxication due to opiates with opiates antagonists like Naloxone.
2. Another antagonist is Nalmefene, which is synthetic in origin.

   Normal urine picture:

   Physical features	Chemical features	Microscopic findings
   Color = Pale yellow or amber Appearance = Clear to slightly hazy pH = 4.5 to 8.0 Specific gravity = 1.015 to 1.025	Blood = Negative Glucose = Negative Ketones= Negative Protein = Negative Bilirubin = Negative Urobilinogen = Negative (±) Leucocyte esterase = Negative Nitrite for bacteria = Negative	RBCs = Rare or Negative WBC = Rare or Negative Epithelial cells = Few Cast = Negative (Occasional hyaline) Crystal = Negative (Depends upon the pH of the urine) Bacteria = Negative

    

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