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Home , Hydrocodone, Hydromorphone, Oxymorphone

METABOLISM DATA FOR COMMON MEDICATIONS

Detection or Time in Drug Screening Classes Urine* to Order Expected Results Consideration or “” – Natural (from ) 1–3 days Opiates Immunoassay + Opiates Immunoassay Immunoassays for “opiates” are responsive for (Tylenol #2/3/4) GC/MS or LC/MS/MS – positive and codeine but do not Opiates GC/MS or LC/MS/ distinguish which is present. MS – codeine, possibly Confirmatory testing is morphine and required to reliably identify drug(s) present. Since Morphine (Avinza, 1–3 days Opiates Immunoassay codeine is metabolized Embeda, MS – positive to morphine and small Contin, Kadian) GC/MS or LC/MS/MS quantities to hydrocodone, – morphine, possibly these drugs may be found in the urine. Also, morphine may metabolize to produce a small amount (<10%) of hydromorphone. Opioids – Semisynthetic (derived from opium Hydrocodone 1–3 days Opiates Immunoassay + GC/ Opiates Immunoassay “Opiates” immunoassays (Lorcet, Lortab, MS or LC/MS/MS Opiates – positive may also detect Norco, Vicodin) semisynthetic opioids GC/MS or LC/MS/MS – depending on their cross- hydrocodone, possibly reactivity pattern. However, hydromorphone a negative result does not Hydromorphone 1–3 days Opiates Immunoassay + GC/ Opiates Immunoassay exclude use of semisynthetic (Dilaudid, Exalgo) MS or LC/MS/MS Opiates –positive opioids. Confirmatory GC/MS or LC/MS/MS testing (GC/MS or LC/ – hydromorphone MS/MS) is required to verify compliance with the 1–3 days Oxycodone Immunoassay Opiates Immunoassay prescribed semisynthetic (Roxicet, + GC/MS or LC/MS/MS –positive (s). OxyContin) Opiates GC/MS or LC/MS/MS Since hydrocodone is – oxycodone possibly metabolized in small amounts to hydromorphone, Oxymorphone 1–3 days Opiates or Oxycodone Opiates or Oxycodone both may be found in (Opana) Immunoassay + GC/MS or Immunoassay – positive the urine. Likewise, LC/MS/MS Opiates GC/MS or LC/MS/MS oxycodone is metabolized – oxymorphone to oxymorphone, so these may both be present in the urine of oxycodone users. However, the reverse is not true. In other words, hydromorphone and oxymorphone use does not result in positive screens for hydrocodone and oxycodone, respectively.

OPIOID PRESCRIBING GUIDELINES May 2016 www.oregonpainguidance.org Detection Drugs or Drug Time in Urine Drug Screening Classes Urine* to Order Expected Results Consideration Opioids – Synthetic (man-made) 1–3 days GC/MS or LC/MS/MS GC/MS or LC/MS/MS – Current “opiates” Fentanyl fentanyl & norfentanyl immunoassays do not Meperidine 1–3 days GC/MS or LC/MS/MS GC/MS or LC/MS/MS – detect synthetic opioids. Thus confirmatory testing (Demerol) Meperidine normeperidine, possibly meperidine (GC/MS or LC/MS/MS) is needed to identify these drugs. If the purpose is to document compliance with treatment, the laboratory can be instructed to remove the cutoff concentration so that the presence of lower concentrations can be identified. 3–7 days Methadone Immunoassay Methadone (Methadose) + GC/MS or LC/MS/MS Immunoassay – positive Methadone GC/MS or LC/MS/MS – methadone & EDDP Propoxyphene 1–3 days Propoxyphene Propoxyphene Immunoassay – positive (Darvon, Immunoassay + GC/MS or LC/MS/ Darvocet) GC/MS or LC/MS/MS MS – propoxyphene & Propoxyphene Others Up to 8 Alcohol Alcohol – see Additional testing for hours Consideration alcohol metabolites, ethyl glucuronide (EtG) or ethyl sulfate. 2–3 days Amphetamines, Amphetamines, Amphetamines or methamphetamines or immunoassays are highly MDMA Immunoassay MDMA Immunoassay cross-reactive so results + GC/MS or LC/MS/MS – see Consideration should be interpreted Amphetamines GC/MS or LC/MS/ cautiously, and may MS – , require consultation with or the lab. They may detect MDMA other sympathomimetic amines, such as ephedrine, pseudoephedrine or selegiline. Confirmatory testing can identify which amphetamine is present. 1–3 days Barbiturates Immunoassay Barbiturates The clearance half-life w/short- Immunoassay – see of intermediate-acting acting; up to Consideration barbiturates averages 30 days w/ 24 hours. It takes about long acting 5 to 7 half-lives to clear 98% of a drug . Thus, the presence of anintermediated-acting indicates exposure within 5–7 days.

OPIOID PRESCRIBING GUIDELINES May 2016 www.oregonpainguidance.org Detection Drugs or Drug Time in Urine Drug Screening Classes Urine* to Order Expected Results Consideration 1–3 days Benzodiazepines Benzodiazepines Immunoassays for w/short- Immunoassay Immunoassay – see benzodiazepines have a 28% acting; up to Consideration GC/MS or overall false negative rate 30 days w/ LC/MS/MS – alprazolam, and vary in cross-reactivity. long acting , clonazepam, Certain benzodiazepines , etc. (clonazepam and alprazolam) have limited detectability by most available immunoassays. Confirmatory testing is needed when use is expected or suspected. or 2–4 days Cocaine Metabolites Cocaine Metabolites Cocaine immunoassays do benzoylecgonine Immunoassay Immunoassay – see not cross-react with other Consideration topical that end in “caine” (e.g. ) and are highly specific for cocaine use. Marijuana 2–4 days; up (THC) Cannabinoids THC may be an indicator of to 30 days Immunoassay Immunoassay – the patient’s risk category. w/chronic see Consideration GC/ Prescribers should have an heavy use MS or office policy, discuss with LC/MS/MS – THC the patients reason for use and adjust monitoring plan accordingly.

*Agency Medical Directors Group, Interagency guideline on Opioid dosing for Chronic Non- , 2010.

OPIOID PRESCRIBING GUIDELINES May 2016 www.oregonpainguidance.org