OFFICE BASED URINE DRUG TESTING TOOLKIT for SAFER OPIOID PRESCRIBING Presented By: Dr

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1 OFFICE BASED URINE DRUG TESTING TOOLKIT FOR SAFER OPIOID PRESCRIBING Presented by: Dr. Nancy Fitch + Dr. Megen Brunskill

2 Disclosure Statement:

We have no actual or potential conflicts of interest in relation to this program/presentation.

Dr. Megen Brunskill and Dr. Nancy Fitch

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Our group…

4 What do you think about urine drug screens in opioid prescription settings? • Quiz #1

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5 Prescribing chronic opioids:

Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care Pain (2014) 155: 2575-2582

Doctors and Patients in Pain

Opioids introduce several elements that can potentially lead to deterioration of the doctor-patient relationship • understanding pain • patients feel that physicians don't understand their pain when they don't offer opioid medications and if they have pain they have a "right to pain medications” • understanding opioid medications • opioids - unwanted burden and ineffective solution • fear of causing harm to patients (addiction, overdose, side effects) • paternalistic relationship

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What we did

• Program started in 2014 • We have something that is working • We want to empower others to do the same or similar

National Guidelines 2017

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9 UDS in the 2017 guidelines

• A baseline urine drug screen may be useful for patients currently receiving or being considered for a trial of opioids.

UDS in the 2017 guidelines

• Clinicians may repeat urine drug screening on an annual basis and more frequently if the patient is at elevated risk or in the presence of any aberrant drug- related behaviours.

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11 How well do physicians determine risk of opioid misuse?

•Relying on aberrant behaviour observations detects less than half of patients who are misusing drugs (Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patient receiving long-term opioid therapy. Anesth Analg. 2003;97(4):1097-1102)

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UDS in the 2017 guidelines

• Approximately 30% of urine drug screening will demonstrate aberrant results, largely because of prescribed opioid non-detection and tetrahydrocannabinol.

The use of urine drug screening for safer opioid prescribing in chronic non‐cancer pain patients in rural Northern Ontario Niharika Shahi1 and Dr. Ryan Patchett‐Marble2 1Medical Student, Northern Ontario School of Medicine , Lakehead University, Thunder Bay, ON 2Family Physician, Marathon Family Health Team, Marathon, ON

ABSTRACT MARATHON FAMILY HEALTH TEAM RESULTS RESULTS The prevalence of opioid abuse has reached an epidemic level. 1. Efficacy of random UDS in a primary care setting 2. Comparison of different UDS methods National guidelines recommend safer opioid prescribing practices, • 55/77 patients provided at least one urine sample during the 12- • Chromatography and immunoassay, separately as well as in including consideration of monitoring patients with urine drug month study period. combination, were determined to be more effective at capturing screening (UDS). There is little evidence supporting or refuting the – 44/55 patients provided at least one random urine sample aberrant results as compared to self-report. use of UDS in the context of chronic non-cancer pain (CNCP) (patient notified ≤36 hours of appointment). – 25% of aberrant results detected by chromatography patients. The Marathon Family Health Team (MFHT) has alone. implemented a randomized UDS program, aimed at making the – 11/55 patients provided only scheduled urine sample(s) (patient had >36 hours of notice before appointment). – 28.6% detected by immunoassay alone. prescribing of opioids safer. This research project evaluated the • Of the 3,913 patients at MFHT, 103 are prescribed opioids for – efficacy of randomized UDS to detect and manage opioid misuse chronic pain (>90 days duration), of which 97 are for non-cancer, • Of the total urine drug screens done: 46.4% detected by chromatography and immunoassay. amongst patients with CNCP. Of the 77 patients prescribed opioids non-palliative pain. – 74% were initially selected through a randomization – Only 2/77 patients admitted to any non-prescribed drugs for CNCP and stratified as low-risk, 71.4% completed at least one • Of the CNCP patients, 77 patients were stratified into the low- process. or medications on self-report. UDS during the 12-month study period. Of these, 80% completed at risk program, 7 into the high-risk program, 6 were excluded from – 26% were “non-randomized” or physician-selected. least one random UDS (≤36 hours of notice), and 20% completed Screening Method for Aberrant Results 13 UDS for other reasons by their family physician (poor mobility, UDS Selection Process 14 only scheduled UDS. Overall, 66.4% of the UDS results were 12 or receiving medications under observation in chronic care, etc.), 60 UDS 10 expected, 29.7% unexpected, and 3.9% equivocal. The physicians at 51 8 of and 7 patients should have been enrolled in the low-risk stream 50 8 7 MFHT took action for 58.8% of the aberrant results. By the end of 6 40

but were missed. UDS

Number 4 of

the study period, UDS led directly to concrete management steps in 30 2 • 10% of all low-risk patients are randomly selected per month, 0 15/77 patients (19.5%). Of the 77 patients, 4 were escalated to an 18 16 20 Chromatography Alone Immunoassay Alone Chromatography & Number 12 through a computerized program, to complete UDS. Immunoassay addiction program, 2 were tapered or discontinued from opioids, 10 3 and 9 were escalated to a higher-risk monitoring system directly as 1 RESEARCH OBJECTIVES 0  A combination of immunoassay and chromatography was a result of UDS. The results of this study show that in the primary Randomized Non‐Randomized determined to be the best UDS test method as compared to care setting, UDS can be effective for detecting and managing The general objective of this study is to: Expected Unexpected Equivocal either of these tests used individually. Self-report was not a misuse amongst low-risk CNCP patients being prescribed opioids. • Analyze whether random UDS, done by primary care providers • Of the total urine drug screens done: helpful tool in detecting aberrant drug use in this in rural communities, is effective in detecting and managing – 76.2% were unscheduled (≤36 hours of notice). population. misuse amongst patients being prescribed opioids for CNCP. BACKGROUND – 23.8% were scheduled (>36 hours of notice). The specific objectives of this study are to: 3. Physician action The rate at which CNCP patients are being prescribed opioids 1. Analyze the efficacy of random UDS in a primary care setting. UDS Results 1–3 Equivocal Physician Action for Aberrant Results continues to increase. Addictions and prescription drug overdoses 4% 4 2. Compare different methods of UDS. Warning have become a global epidemic. According to a recent report from 18% Harvard Medical School in the United States, opioid misuse and the 3. Determine whether UDS results directly led to physician action Unexpected in managing opioid misuse. Tapered dose number of opioid-related deaths is now comparable to deaths 30% 3% No action 5 caused by smoking. The Public Health Agency of Canada METHODOLOGY 41% reported that about 2,500 Canadians (865 from Ontario) died from Expected 66% Suboxone or opioid overdoses in 2016.5,6 This number is much higher as The project was approved by the Lakehead University Research methadone for addiction compared to the 728 opioid-related deaths in 2015 reported by Ethics Board, as per Tri Council Policy Statement, as it involves 12% Ontario Public Health data.6 collecting data from human participants. No direct patient consent was required as the project involves collecting secondary data from Increased monitoring • Previous studies suggest that ~30% of UDS results will be 26% patient chart reviews. Patient data collected from the MFHT EMR aberrant, most of them due to cannabis and non-detection of was stored in password protected electronic files. The data collected prescribed substances.9 • Physicians took action for 58.8% of the aberrant results. from patient chart reviews was analyzed using the SPSS software. • Cannabis in the urine was not considered an unexpected result in  Of the 77 patients in the program at the beginning of the PATIENT DEMOGRAPHICS this study. If it were considered unexpected, then the number of study, 15 patients had UDS results that directly led to either aberrant results would increase significantly. escalation to an addiction program (4), tapering or Gender Ethnicity • Therefore, this study suggests higher rates of aberrant UDS discontinuing of opioid medication (2), or being escalated to a http://www.ahchealthenews.com/2016/05/06/naloxone- 50 Female reverses-opioid-overdose-saves-lives/ 26 40 results in rural Northern Ontario compared to previously higher-risk monitoring system (9). 34% 12 Patients 30 14 published numbers in other populations. of Historically, higher rates of drug abuse have been seen in rural and 20 28 remote communities of Northern Ontario as compared to the rest of Male 10 23 CONCLUSIONS

51 Number Aberrant Results by Gender Aberrant Results by Age Group the province.7 Several screening tools have been developed to detect 0 66% Caucasian Indigenous 25 23 30 24 The general objective of this study was to analyze the extent to 25 opioid misuse and diversion. National guidelines for prescribing Male Female 20 20

Patients which systematic randomized UDS, in a primary care setting, can 15 opioids for CNCP recommend considering UDS as one risk Patients of 15

of 8 Age Groups 10 7 10 6 help detect and manage opioid misuse amongst CNCP patients in mitigation strategy. However, it is unknown to what extent UDS, in 3 5 1 45 5 3 Number rural and remote communities of Northern Ontario. This study had 1 0 a primary care setting, can help detect and guide management of Number 40 0 26‐40 years 41‐55 years 56‐70 years 71 years and some limitations as it had a small data set and no control population Male Female above opioid misuse. 10 Pain Diagnosis 35 Other 9% Unexpected Equivocal Unexpected Equivocal to compare statistical significance of the results. The UDS program Fibromyalgia 30 Neuropathic 8% analyzed in this study requires minimal resources and could be Patients Pain of 25 3% Aberrant Results by Ethnicity replicated by other primary care teams. 13 20 25 23 Number 20 15 32 Musculoskeletal

Patients 15

Overall, this study suggests that randomized UDS in primary care 10 Pain of 15 80% 10 7 can lead to safer prescribing of opioids through identification of at- 5 3 2 2 5 1 0 2 2 Number risk patients and subsequent escalation to addictions programs, or http://www.cbc.ca/news/canada/toronto/harm-reduction- https://beta.theglobeandmail.com/news/national/ontario- 0 26‐40 years 41‐55 years 56‐70 years 71 years and workers-open-letter-emergency-opioid-crisis-overdose-deaths- invests-222-million-to-combat-opioid- Caucasian Indigenous above tighter monitoring and prescribing practices. 1.4264783 crisis/article36113584/ Unexpected Equivocal Male Female 1Griggs C, Weiner S, Feldman J. Prescription Drug Monitoring Programs: Examining Limitations and Future Approaches. West J ACKNOWLEDGMENTS Emerg Med. 2015 Jan 1;16(1):67–70. • The randomization program was effective in picking up aberrant

Average Morphine Equivalent Dose 2Gugelmann HM, Perrone J. Can Prescription Drug Monitoring Programs Help Limit Opioid Abuse? JAMA. 2011 Nov 23 [cited (unexpected and equivocal) results: 2017 Aug 31];306(20). Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2011.1712. 120 1. Northern Ontario School of Medicine, Lakehead University, (MEQ) 3 Kuehn BM. Opioid Prescriptions Soar. JAMA. 2007 Jan 17;297(3):249. 100 – 61.8% of the aberrant results were detected through the 4Okie S. A Flood of Opioids, a Rising Tide of Deaths. N Engl J Med. 2010 Nov 18;363(21):1981–5. Thunder Bay, ON Dose 80 5Chapin D. How to treat chronic pain without turning to opioids. The Globe and Mail. 2017 Jul 4 [cited 2017 Aug 31]; Available random selection process. from: https://beta.theglobeandmail.com/life/health-and-fitness/health/how-to-treat-chronic-pain-without-turning-to- 60 2. Marathon Family Health Team, Marathon, ON opioids/article35545093/?ref=http://www.theglobeandmail.com&. (mg/day)

Equivalent 40 – 70.6% were detected through a short-notice appointment. 6Howlett K, Giovannetti J. Ontario invests $222-million to combat opioid crisis. The Globe and Mail. 2017 Aug 29 [cited 2017 Aug 3. Addiction and Chronic Pain Committee, Marathon Family 31]; Available from: https://beta.theglobeandmail.com/news/national/ontario-invests-222-million-to-combat-opioid- 20 crisis/article36113584/?ref=http://www.theglobeandmail.com&. 51.9 37.7 26.3 74.7 41.5  These results show that the random selection process for UDS Health Team, Marathon, ON 7 0 Canadian Centre on Substance Abuse. Prescription opioids. 2016 [cited 2017 Aug 31]. Available from: Morphine Fibromyalgia Musculoskeletal Neuropathic Pain Other Average http://www.deslibris.ca/ID/248516. Pain is an effective method for detecting aberrant results in a 9Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE, et al. Chronic Opioid Therapy Urine Drug Testing in Primary 8 Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. Pain Diagnosis Care: Prevalence and Predictors of Aberrant Results. J Gen Intern Med. 2014 Dec;29(12):1663–71. Can Med Assoc J. 2017 May 8;189(18):E659–66. primary care setting.

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Results From Our Clinic

• 77 patients enrolled into the “low risk stream” • 55/77 provided a random urine drug screen (71%) • 30% were unexpected results • Previous studies state that 30% is expected to be aberrant results but they included THC – we excluded THC so our results were higher than expected

Caution from the guidelines

• Prescribers may implement risk mitigation strategies with the aim of reducing harm. However, there is also concern that prescribers adopting potentially ineffective risk mitigation strategies may become less vigilant about possible opioid- related harms, and more willing to prescribe opioids for chronic non- cancer pain.

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Results from Our Clinic

• 58% of the unexpected results led to action by the prescribing physician • escalation up the opioid ladder (43%) • transition to addiction treatment (12%) • taper and discontinuation of opioids (3%)

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UDS in the 2017 guidelines

• Formal study of urine drug screening for risk mitigation was limited to only one abstract report of a large retrospective cohort study that found no difference in rates of opioid overdose for those who did or did not receive baseline urine drug screening

• More studies are needed!!

HARMS Program

• For more information about implementing a program like this please visit www.harmsprogram.ca • High Yield Approach to Risk Mitigation and Safety

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Back to the Guidelines…

• When ordering a urine drug screen: • clinicians should ask patients about all medications/drugs recently taken

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Start-IT

• Electronic tool for patient self-report and interpretation of urine drug screen results • Allows for automatic entry of results into EMR

• For more information, check out www.harmsprogram.ca

Back to the Guidelines… • When ordering a urine drug screen: • clinicians should ask patients about all medications/drugs recently taken • be aware of local resources to assist them in assessing for potential false positive and false negative results

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Back to the Guidelines…

• When ordering a urine drug screen: • clinicians should ask patients about all medications/drugs recently taken • be aware of local resources to assist them in assessing for potential false positive and false negative results • Consider the different options of urine drug screening and select the one that fits your practice best

Let’s Practice Some UDS Interpretation

• Quiz 2

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29 Urine Drug Tests (UDT)

Urine Drug Tests (UDT)

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31 UDS Kits

Multiple options for clinic point of care tests We choose $4 5-item kits: (Hospital chooses $12 12-item kits.) • EDDP (methadone metabolite) • Morphine-based Opioids • Oxycodone • Benzo • Cocaine --you can get amphetamines, PCP, THC, etc --you can get a separate fentanyl or buprenorphine dipstick for $1

32 Urine Drug Test – opioids

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33 Immunoassay (IA)

Advantages Disadvantages

 fast (done in office)  non-specific  sensitive  MOP (morphine-based  cheap (~$3-12 each, opioids) does not detect however not covered by synthetic opioids such as OHIP) fentanyl  the “BZO” doesn’t pick up clonazepam

34 Chromatography

Advantages Disadvantages

 specific (few false  Expensive (covered by positives) the province though)  tests dozens of different  Slow drugs automatically  If you want certain drugs (like mushrooms), then you have to specifically ask for them  Need to write ‘no lower limit ritalinic acid’ for methylphenidate

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Disadvantages of LC/MS

• The screen only picks up drugs they are looking for:  immunoassay will be positive for a new drug in a class but LC/MS has to be designed for the specific chemical;  we depend on Gamma Dynacare to monitor street uses and adapt test.

• While false positives do not happen at a chemical level with LC/MS, due to the requirement for technician entry, tech error is unfortunately a possible source of false positives

36 Advantages of IA + LC/MS “the double method”

• Urine is dipped in the clinic setting in front of the patient to minimize patients claiming error (‘that wasn’t my sample’) • This same urine sample is bagged and labeled in front of the patient and sent to the lab for provincially- covered LC/MS analysis (‘broad spectrum tox screen”) • Unexpected results are then compared/reinforced by 2 results on the same urine • Minimizes risks of physicians acting on false positive or false negative results

Disadvantages of the double method: • Cost • delay for LC/MS report

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38 Costs & Ordering

• Boxes of 100 kits

• Provincial supplier, arrive by mail

• Zero cost to us through cost recovery via local employers

 clinic agrees to be the local facilitator for employer- required UDS at a cost per test to employers

 All income from this service goes to UDS kit purchases; it is not a revenue generator

• UDT appt banks -- two 3h banks of appts each week have sufficed for our clinic (includes our suboxone program) – + funding for new staff !

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Let’s do some practice

• The following are real examples…notice how helpful having BOTH IA and LC/MS reports is... • Also pay attention to how the patient self-report helps with interpretation of results

• Call out your synthesis that the UDT is ”expected” or “unexpected” once we reach the LC/MS of each example

Example #1 (1 of 2)

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Example #1 (1 of 2)

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Example #1 (2 of 2)

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Example #2 (1 of 2)

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Example #2 (1 of 2)

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Example #2 (2 of 2)

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Example #3 (1 of 2)

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Example #3 (1 of 2)

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Example #3 (2 of 2)

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58 Urine Drug Screens (UDS)

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Example #4 (1 of 2)

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Example #4 (1 of 2)

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Example #4 (2 of 2)

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65 How do you add an opioid prescribing program to your practice?

What we did…

• Use objective tools and strategies • Risk stratification of patients

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67 Opioid Risk Tool

What we did…

• Use objective tools and strategies • Risk stratification of patients • Treatment contracts • Urine drug screening

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What we did…

• Use objective tools and strategies • Risk stratification of patients • Treatment contracts • Urine drug screening • BPI

72 BPI –Brief Pain Inventory

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What we did…

• Use objective tools and strategies • Risk stratification of patients • Treatment contracts • Urine drug screening • BPI • Chronic Pain Flowsheet

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What we did…

• Use objective tools and strategies • Risk stratification of patients • Treatment contracts • Urine drug screening • BPI • Chronic Pain Flowsheet • Opioid Prescribing Ladder

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Our Program

What we did…

• Use objective tools and strategies • Risk stratification of patients • Treatment contracts • Urine drug screening • BPI • Chronic Pain Flowsheet • Opioid Prescribing Ladder • Opioid Prescribing Program

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Our Program

What we did…

While chronic pain is a subjective diagnosis, the use of objective tools during opioid therapy appears to ease much of the stress/burden to the prescriber.

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Lessons learned…

• Patient resistance • Use of a “universal precautions” approach

84 Universal Precautions

Benefits of universal precautions for random urine drug screening in pain management:  facilitate appropriate use of opioid medications (Manubay JM, Comer SD, Sullivan MA. Treatment selection in substance abusers with pain. Adv Pain Manage. 2008;2(2):59-67) mitigate diversion (Ives TJ, Chelminski PR, Hammett- Stabler CA, et al. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46) reduce illicit drug use (Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv. 2000;51(4):474-478) Also Manchikanti 2004, Manchikanti 2006)

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Lessons learned…

• Patient resistance • Use of a “universal precautions” approach • Advertise the program

Lessons learned…

• Patient resistance • Use of a “universal precautions” approach • Advertise the program • Remember the goal is safety not punishment

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Lessons learned…

• Patient resistance • Interpretation Issues • Get to know your local lab • Use metabolism charts • Self report is vital • Remember time is your friend

Lessons learned…

• Patient resistance • Interpretation Issues • Dealing with the Results • Conversations about abnormal results become easier because it is an objective finding • Explain the ladder to the patient and use it to create a plan • Remember it is not meant to be a punishment – the focus is safety

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Our Program

Lessons learned…

• Patient resistance • Interpretation Issues • Dealing with the Results • System Issues • Creation of a master list • Contact issues • Which type of UDT should be used • Record keeping

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91 Questions?

Documents from the MFHT Opioid Prescribing Program (MOPP) Toolkit are available by logging into MI OWL:

http://miowl.org [email protected] [email protected] [email protected]

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93 miowl.org/owls/categories/1

94 MFHT Toolkit

MFHT chronic pain flowsheet MFHT addictions questionnaire MFHT addictions flowsheet MFHT opioid contract MFHT UDS protocol MFHT low literacy opioid contract MFHT UDS patient self report SOPP opioid contract MFHT UDS recording form SOPP low literacy opioid MFHT UDS agreement contract  BPI MOPP patient handout  MOPP/SOPP flowchart MFHT suboxone agreement MFHT chronic pain questionnaire

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HARMS Program

• For more information about implementing a program like this please visit www.harmsprogram.ca

Example #5 (1 of 2)

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Example #5 (1 of 2)

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Example #5 (2 of 2)

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Example #6 (1 of 2)

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Example #6 (1 of 2)

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Example #6 (2 of 2)

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Example #7 (1 of 2)

108

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Example #7 (1 of 2)

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Example #7 (2 of 2)

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Example #8 (1 of 2)

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Example #8 (1 of 2)

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Example #8 (2 of 2)

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MFHT Opioid Prescribing Program

Note to workshop participants: you can make this yours, see the toolkit! Education for patients is key.

What is the MFHT Opioid Prescribing Program?

It is a framework for physicians and nurse practitioners who prescribe opioid medications to patients for chronic non‐cancer pain. The program helps physicians to safely and effectively prescribe these medications to patients.

How does an Opioid Prescribing Program help patient safety?

Having a clinic‐wide program for the use of these medications ensures that all patients have the same quality and care. Specialists in chronic pain call this type of program “universal precautions”. It is much the same as wearing gloves for procedures or washing hands between seeing patients. The focus of this program is on physician practice and not individual patients in order to ensure safety for everyone. Unfortunately, there has been a steady increase in opioid medication overdoses in Ontario and MFHT wants to do our best to utilize these medications in the safest way possible. Studies show that using urine drug screens can prevent opioid medication misuse.

What does this mean for me?

If you receive opioid medications for chronic pain you will be asked to sign an opioid contract which is an agreement between you and your family physician. The contract explains the responsibilities of the physician and the patient in using these medications. You will also complete a risk assessment to explore your risk of developing an addiction to opioid medications. If you score “at risk” for addiction, it does not necessarily mean that you won’t receive a prescription for opioid medications; it just means that your physician will likely create a more structured way of dispensing these medications to keep you safe. Finally, you will be asked to provide urine drug screens. The clinic has a computerized random urine drug screening program. When your name is selected by the computer, you will be called by a staff person and asked to provide a urine sample within 24 hours. If you are unable to come to this appointment your family physician will be notified and will determine the next steps with you. Again, this doesn’t mean that your prescription will be stopped, but it will likely result in a period of time of more frequent urine drug screens. While coming in to provide urine drug screens can be an inconvenience, please remember that ALL patients on these medications are being asked to do this. This is the best and safest practice.

How do I get more information?

Please speak to your family doctor if you are on these medications to learn more about this program.

UDT immunoassay interpretation cheat sheet

SUBSTANCE Length of time False Positive False negative detected possibilities possibilities

2‐30 days Concentrated urine Clonazepam not detectable BZO by immune; dilute urine COC 2‐5 days Concnetrated urine Dilute urine EDDP 1‐4 days Concentrated urine Dilute urine 2‐4 days Poppy seeds, quinolone Synthetic opioids NOT MOP antibx, DM cough product, detectable, eg fentanyl, gravol, concentrated urine oxycodone, suboxone; dilute urine OXY 1‐3 days concentrated urine Dilute urine

Broad Spectrum LC/MS cheat sheet “broad spectrum tox screen”

1. The window for detection of opioid in urine is max 2‐4 days after last use. This varies from opioid to opioid, and from patient to patient.

2. For their broad spectrum urine toxicology screen, Gamma Dynacare commits to updating the Liquid chromatography/tandem mass spectrometry list of substances, based on reports of community use. Tramadol remains pending. Currently, the following substance testing may not be non‐self‐explanatory and are therefore mentioned here:

o 7‐aminoflunitrazepam, 7–aminonitrazepam = Rohypnol or ‘roofies’ o 6‐acetylmorphone = recent heroin use o buprenorphine = suboxone; norbuprenorphine = suboxone metabolite o cocaethylene = cocaine and ETOH use o cotinine = nicotine metabolite o des‐alkyl‐flurazepam = midazolam metabolite o dihydrocodeine = new semi‐synthetic opiate; hydrocodone = Vicodin o EDDP = methadone metabolite o Levamisole = an antihelminth used to adulterate cocaine o mCPP, MDMA = ecstasy o MDPV = bath salts stimulant o MDA, MDEA = psychadelics o Methamphetamine = ADHD med Desoxyn o Naloxone = Narcan o Naltrexone = Revia o Norcocaine, norcodeine, norfentanyl, etc etc = metabolites o Nordiazepam is actually an active metabolite of diazepam, chlordiazepoxide/Librium, and several other less‐used benzos o Ritalinic acid = methylphenidate metabolite o THCA = medication THC eg Marinol 3. Common normal metabolites (see schematic below):

o Morphine is metabolized to hydromorphone o Codeine is metabolized to hydrocodone and morphine, and after several days, morphine may be all that remains in the urine o Hydrocodone is metabolized to hydromorphone o Oxycodone is metabolized to oxymorphone. 4. False positives do not happen at a chemical level with LC/MS/MS. BUT due to the requirement for tech entry, tech error is unfortunately a possible source of false positives.

www.miowl.org ‐‐ Find the toolkit below in this open source medical library. These are Word documents you can amend for your own clinic use. For more information about implementing a clinic‐based opioid prescribing program as part of a prospective study, please visit www.harmsprogram.ca

Use the Risk Ladder to manage UDT results.