Urine screening for Drug Abuse

What sample is needed for Drug abuse?

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 is detectable within one hour of use.

What are the advantages of Urine testing?

1. It is easy to get a urine sample, and this is not an invasive procedure.
2. Some drug concentrations are higher 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 easier and cheaper.

How will you get the sample from a drug abuser?

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.
5. The patient will leave all his belongings outside the toilet.
6. Someone should be in the toilet while the patient is giving the sample, or he can wait just outside the door to listen to any abnormal sound.
7. Check the urine volume (30 to 40 mL) and any abnormal color.
8. The sample will be in sight of the technician/doctor and the patient all the time.
9. The date and time are noted.

What are the critical alerts on the patient?

1. Keep an eye that there is no tampering, like substitution, adulteration, or urine dilution.
2. Avoid all unauthorized persons handling the specimen.
3. The urine collection may be witnessed or unwitnessed.

What are the precautions for Drug abuse?

1. Urine will detect heroin for 1 to 2 hours, a maximum of up to 2 to 5 hours after use.
   1. The minimum concentration should be 2000 ng/mL.
2. Check for urine dilution by measuring creatinine, pH, and specific gravity.
3. 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.

What are the indications for drug abuse?

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.
4. To diagnose drug-induced signs and symptoms and differentiate from the trauma, infectious process, or metabolic disorder.
5. To diagnose psychosis or drug abuse.
6. It is used in prisoners to detect drug abuse.
7. It is advised in the workplace for public safety.
8. In routine, the 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.
   12. Phencyclidine

How will you perform drug abuse testing?

1. Urine is the best sample for drug abuse, and the following tests are advised:
   1. Screening tests. These are simple, inexpensive, and rapid.
   2. Confirmatory tests. These are laborious and expensive.

How would you classify the drug abuse?

1. CNS stimulants:
   1. It produces euphoria, depresses the appetite, and increases heart and respiration rates.
   2. These are cocaine and its derivatives, amphetamines, and methamphetamines.
2. CNS depressant:
   1. These will lower heart rates and respiratory rates and reduce pain.
   2. These drugs are narcotics, sedatives, hypnotics, and tranquilizers.
3. Psychoactive:
   1. These are also hallucinogenic drugs, cannabinoids, and phencyclidine.
4. Antidepressant:
   1. These drugs include lithium, tricyclic depressant, etc.

What is the prevalence of drug abuse?

Opiates

What are the several opiates used for addiction?

What do you know about Opiates?

1. These are the substances with analgesia, sedation, and anesthesia.
2. There is a high potential for addiction.
3. Chronic use leads to tolerance for 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 was 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.
7. Some of these are:
   1. Heroin.
   2. Morphine.
   3. Oxycodone (Oxycontin).
   4. Hydromorphone (Dilaudid).
   5. Fentanyl (Duragesic).

8. Acetylcholine, an impurity of heroin synthesis, has been suggested as an interesting biomarker of illicit heroin use.
9. Codeine and heroin are metabolized to morphine, which is then excreted in the urine.

Heroin

How will you define Heroin?

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

2. 6-Acetylmorphine and morphine are pharmacologically very active substances.

How will you detect morphine in the urine?

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

Cocaine

How will you define cocaine?

1. These are alkaloid salts, which can be taken by injection, insufflation, or inhaled in vapors.
2. The half-life of cocaine is 0.5 to 1 hour. Because of the short half-life, repeated doses are given.

What is the mechanism of Cocaine action?

1. This is an effective local anesthetic with few adverse effects in a therapeutic dose.
2. This potent CNS stimulator leads to excitement and euphoria.

What are the complications of Cocaine?

• Acute toxicity is associated with hypertension, seizures, arrhythmias, and myocardial infarction.

How will Cocaine be excreted?

1. The hepatic product of cocaine is benzoylecgonine, which is excreted in the urine.
2. The presence of this metabolite in urine is a sensitive and specific indicator of cocaine intake.
3. After a single intake, this can be detected in the urine for up to 3 days.
4. It can be detected in chronic cases up to 20 days in the urine after the last use.

What is the duration of some of the drugs appearing in the urine?

What are the Signs and Symptoms of Opiates?

1. 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.
2. Signs 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.
3. Morphine overdose (intoxication) leads to :
   1. Coma.
   2. Miosis.
   3. Respiratory depression.

What are the withdrawal Symptoms of opiates?

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

How will you diagnose opiates?

1. Commercial kits are available.
2. Gas chromatography. This is one of the accepted methods.
3. Latex Agglutination Inhibition.
4. Thin Layer Chromatography.
5. Radioimmunoassay (RIA).
6. High-Performance Liquid Chromatography (HPLC).
7. Mass Spectrophotometry (GC/MS).
   1. Radioimmunoassay (RIA) is rapid and cheap.
   2. Morphine and Codeine are found after heroin use.
8. A single urine test is enough to diagnose various drugs like cocaine, opiates, barbiturates, amphetamines, methadone, oxycodone, benzodiazepines, cannabinoids, methadone, and tricyclic antidepressants.

How will you treat opiates?

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

Amphetamines

How will you define Amphetamines?

1. Amphetamine and methamphetamine are therapeutic drugs used for:
   1. Narcolepsy.
   2. Attention deficit disorder.
   3. Obesity
2. These are stimulants with a high rate of drug abuse.

What is the route of administration of Amphetamines?

1. Amphetamines are readily absorbed from the GIT and widely distributed throughout the body.
2. These are converted into more polar substances in the liver and easily excreted in the urine.
3. These are mostly excreted in 48 hours.
4. Possible routes are:
   1. Oral.
   2. Injections.
   3. Inhalation.
   4. Insufflation.

What is the mechanism of action of Amphetamines?

1. Amphetamines are sympathomimetic amines that stimulate the CNS and produce excitement.
2. It increases the release and blocks the uptake of some of the neurotransmitters.
3. It induces euphoria and alertness and boosts energy.
4. It induces loss of apatite and reduces the sense of fatigue.

What are the complications of Amphetamines?

1. It leads to addiction. One can develop psychological and physiological addiction.
2. It induces irritability, anxiety, and insomnia.
3. It may lead to blurred vision.
4. Increases blood pressure and cardiac palpitation.
5. It increases body temperature.
6. It may lead to anxiety, paranoid behaviors, and psychosis.

Barbiturates

What is the mechanism of action of Barbiturates?

1. These are CNS depressants.
2. These are used as anxiolytic, anticonvulsants, anesthetic, and muscle relaxant drugs.
3. These drugs bind to chloride channel molecules of GABA receptors and induce sedation, mood alteration, and euphoria.
4. The duration of action of these barbiturates is divided into the:
   1. Short-acting.
   2. Ultra-short-acting.
   3. Lonf-acting.
   4. Intermediate-acting.
5. Once absorbed, these are metabolized in the liver.
6. There will be oxidation and glucuronide conjugation.

What is the mode of administration of Barbiturates?

• The most common routes are oral and parenteral.

What are the complications of Barbiturates?

1. There may be drowsiness.
2. Mental impairment.
3. Ataxia.
4. Dysarthria.
5. In case of high doses may lead to coma and cardiovascular and respiratory depression.

Benzodiazepines

What is the mode of action of the Benzodiazepines?

1. It is like barbiturates.

What is the mode of administration of Benzodiazepines?

1. These can be given orally or parenterally.

What are the side effects of Benzodiazepines?

1. These are like barbiturates but are milder.
2. There is physical dependence, and the patient may have withdrawal symptoms like:
3. Agitation.
4. Irritability
5. Insomnia.
6. Muscle tension.
7. Psychosis and seizures.

What is the metabolism of Benzodiazepines?

1. In the liver, benzodiazepine is converted into active and inactive forms.
2. The half-life of the parent drugs is less than that of metabolites.

Cannabinoids

What is the source of Cannabinoids?

• Cannabinoids are found in the hemp plant, from which marijuana is formed.

What is the mechanism of action of cannabinoids?

1. In Marijuana, THC is the psychoactive ingredient that leads to euphoria and relaxation effects, which is the reason for its abuse.
2. It is highly lipophilic and is converted into more than 20 metabolites.
3. Urinary metabolites 11-nor-Δ9-tetrahydrocannabinol⁹-carboxylic acid (THC-COOH) is used to detect in the urine.
4. 70% of the THC is excreted in the feces and urine within 72 hours.
5. In addicts, the half-life may be >10 days.

What is the mode of administration of Cannabinoids?

1. It can be used for inhalation and also can be ingested.
2. THC is nonlethal when it is used alone.

What are the side effects of Cannabinoids?

1. Some of the patients may have side effects like:
   1. Tachycardia.
   2. Respiratory distress.
   3. Behavior and mental abnormalities.
   4. Long-term use leads to tolerance and mild withdrawal symptoms.

Phencyclidine

How will you define Phencyclidine?

1. It is a potent hallucinogenic agent.

What is the mode of action of Phencyclidine?

1. It antagonizes the glutamate receptors and may block dopamine uptake as well.
2. This drug is lipophilic, so it can be stored for a longer period in the brain and adipose tissue.
3. Metabolism occurs in the liver through oxidative hydroxylation and conjugation; it is cleared from the kidneys.

What are the other phencyclidines?

1. Cyclohexamine.
2. Phenylcyclohexylpyrrolidine.
3. Thienylcyclohexylpiperidine.

What is the mode of administration of Phencyclidines?

1. These substances can be taken orally.
2. Intravenously.
3. Smoked in combination with marijuana or tobacco.

What are the side effects of Phencyclidine?

1. Tachycardia.
2. Paranoia.
3. Psychosis.
4. Respiratory depression.
5. There is mydriasis (dilatation of the pupil).

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