1/18/2019

WI CAN Educational Series

Hillary W. Petska, MD, MPH Child Advocacy and Protection Services Children’s Hospital of Wisconsin

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There are no relevant financial relationships related to this presentation/ program.

There is no sponsorship/commercial support of this presentation/program.

The content being presented will be fair, well-balanced, and evidence-based.

Learners who wish to receive Continuing Education Credit (CME/CLE/CE) must complete and turn in evaluations to successfully complete this program.

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• Drug exposure negatively affects infants and children.

• Drug testing should be considered in cases of suspected child maltreatment.

• Drug testing has many limitations that complicate interpretation.

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• >500,000 kids/yr exposed to drugs • >50,000 kids/yr treated in ED for drug exposures • 400,000 infants/yr exposed prenatally: • Illegal drugs: 4.4% • Alcohol: 10.8% • Cigarette: 16.3%

Bond 2012, Behnke 2013 4

• 8.7 million children with a parent with a substance use disorder • >270,000 children placed in foster care in 2016 • Infant born every 25 minutes with opioid withdrawal

www.aap.org/OpioidFactsheet s 5

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• Direct • Exposure to the substance • Exposure to hazards in the home • Indirect • Poor supervision, neglect • Interpersonal violence

Farst 2012, CWIG 2014 7

• Physical/mental impairments • ↓ response to child’s needs • Difficulty controlling emotions • ↓ parent-child attachment • Spending money on alcohol/drugs instead of food/necessities • Spending time seeking out, manufacturing, or using alcohol/drugs • Incarceration • Estrangement from family/social supports

CWIG 2014 8

• Caregiver with substance abuse disorder = ACE • Mental health issues = ACE • Child neglect and abuse = ACE • Domestic violence = ACE • Chaotic living environment (incarceration, unemployment, housing instability)

CWIG 2014 9

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• Adverse Childhood Experiences Study: • Obesity, drug/alcohol abuse, smoking, depression, suicide, teen pregnancy, incarceration • Diabetes, hypertension, heart disease, liver disease, cancer, stroke

Felitti 1998 10

• What is a drug? • Illegal (amphetamine, cannabinoid, cocaine, opiates, PCP, benzodiazepines) • Prescription • OTC • How are drugs detected? • Signs and symptoms • History (self-report) • Lab testing

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 Symptoms  Known/ suspected  Altered mental exposures status  Witnessed  Unexplained ingestion irritability  Suicide attempt  Unexplained seizures  Drug-endangered environment  Syncope/ arrhythmias  Toxidromes

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 Sympathomimetic (meth, amphetamines, cocaine, opiate withdrawal, PCP)  Hyperthermia (increased body temperature), tachycardia (increased heart rate), hypertension (increased blood pressure), mydriasis (dilation of the pupil), warm/moist skin, agitation  Cholinergic (organophosphates, betel nut, VX, soman, sarin)  SLUDGE (Salivation, Lacrimation, Urinary incontinence, Diarrhea/Diaphoresis, GI upset/hyperactive bowel, Emesis)  Anticholinergic (antihistamines, atropine, phenothiazines, TCA)  Hyperthermia, tachycardia, hypertension, hot/red/dry skin, mydriasis or unreactive pupils, urinary retention, absent bowel sounds  Opioids (codeine, dextromethorphan, heroin)  Miosis (constriction of the pupil), respiratory depression, sedation

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 1/3 – 2/3 of families involved with CPS have AODA issues

Parental Child AODA Maltreatment

CWIG 2014 14

• Hayek 2009 • 30% of pediatric patients with burn injuries due to child maltreatment also exposed to illicit drugs • Yin 2010 • 160 cases/year of “malicious” pharmaceutical exposure in children <7 y/o reported to US poison centers • Oral 2011 • 15% of allegedly maltreated children exposed to illicit drugs

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• Before 2013: Screening based on risk factors • 2013 – present: Screening of all young, physically abused children • 2 urine drug screening panels available • ER drug panel • Comprehensive drug panel - RECOMMENDED

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ER Drug Screen Urine Drug Investigation

Substances Detected 6 >140

Threshold Workplace (high) <

Amount of Urine 1 – 5 ml 1 – 6 ml

Time to Result <2 hours 3-5 days

Confirmation No Yes

Methodology Immunoassay GC-MS or LC-tandem MS

Sensitivity and Specificity Low High

Charge $900 $361

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• Children ages 2 weeks < 5 years • Evaluated for PA by Child Advocacy between 2013-2017

• Three groups: • High concern for abuse • Intermediate concern for abuse • Low concern for abuse

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• Most common occult exposure = cocaine • Rosenberg – 460 children 1-60 months presenting to urban ED for routine complaints – 5.4% had cocaine metabolite in urine • Shannon – 1,120 children’s hospital patients with urine or blood specimens – 4.6% had cocaine or metabolite and 1.3% had ethanol, benzo or narcotic and cocaine • Lustbader – Using very sensitive testing, found 36.3% of infants presenting to ED for routine concerns were positive for cocaine

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• Most common exposures: • Caffeine • Formula fed and not Rx, concerning for administration • May cause poor sleep, irritability, seizures • Cotinine • Likely d/t secondhand smoke • Causes multiple short- and long-term health risks

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• Not all children were tested • May have missed some drugs • Unable to determine source/intent • Did not examine outcomes or cost-benefit

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• Breath • Blood • Saliva • Sweat • Meconium • Hair • Urine

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• Detects alcohol or drug use within 2-12 hours • Correlated with level of impairment • Invasive, sample collection by trained personnel

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• Detects drug exposure during the 2nd and 3rd trimester • Cannot be used to determine timing or amount (self-report) • Negative result ≠ drug-free pregnancy

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• Advantages: • Longer window of detection • First 3 cm = 90 days • Non-invasive • Decreased risk of tampering • Collection can be observed • Easily stored/transported

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• Disadvantages: • Not useful clinically d/t long window of detection • Interpretation = Challenging • Positive: • Contact with drug smoke or the actual drug • Contact with sweat/sebum of a drug user • Accidental/intentional ingestion of the drug • Cannot differentiate who, where, when, why, or how /how much • Negative ≠ no exposure • Results may be affected by hair structure, growth rate, melanin content, hygiene, cosmetic treatment • May be misused in child protection cases

Cuypers 2018, Kintz 2017 27

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• Myth: Hair drug testing proves a child was exposed to meth in their home. • The child could have been exposed to: • Another environment in which meth was used/manufactured • A caregiver that used meth • In utero (< 1 yo) • The strongest evidence of exposure is meth in their home. • What if hair is negative?

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• Myth: Hair drug testing can determine whether a drug was ingested or just in the environment. • Washing – drug incorporation from the environment • “Cut-offs” = anecdotal, not evidence-based • “Environmental exposure will only generate a positive for the parent drug.” EXCEPT IF: • The exposure was from the sweat/sebum of a drug user • The drug contains a metabolite

Cuypers 2018, Kintz 2017 29

• Standardized • Indicates systemic exposure • Less invasive and longer window of detection than blood • Most commonly used specimen in primary care

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 Qualitative  Quantitative  Presence of drug  Amount of drug  What’s there?  How much?

Green, yellow, and purple birds 3 green, 2 yellow, 2 purple birds

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ER Drug Screen Urine Drug Investigation

Substances Detected 6 >140

Threshold Workplace (high) <

Amount of Urine 1 – 5 ml 1 – 6 ml

Time to Result <2 hours 3-5 days

Confirmation No Yes

Methodology Immunoassay GC-MS or LC-tandem MS

Sensitivity and Specificity Low High

Charge $900 $361

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• False + • False – • Test is positive for • Test is negative a drug that is not for a drug that is present actually present • ER Drug Screen – structural cross- reactivity

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• Negative ≠ no exposure • Substance not on the test panel • Substance at levels too low to be detected • Missed window of detection

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• Must be interpreted in context of history • Cannot differentiate appropriate use v. misuse or intent • Young children more likely to be positive

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• Positive • Large exposure days ago

50 ng/mL cocaine OR

• Small exposure hours ago

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Previous exposure  Provides no additional information  Positive = child still being exposed OR still positive from initial exposure  Negative = child not re-exposed OR child re-exposed but missed window of detection  Should not be relied on for safety decisions

SAMHSA 2010 37

 Environmental  Neglect  Illicit drug exposure during pregnancy or breastfeeding  Supervisory neglect  Drug-endangered environment  Momentary lapse of supervision  Breastmilk  In utero

Farst 2012 38

Environmental  “Studies on room air concentrations of marijuana and cocaine indicate that low levels of passive exposure do not result in positive urine drug tests.”  “Room air concentration required to detect drug exposure in the urine is high and results in noxious effects.”

Farst 2012 39

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 Environmental  Neglect  Momentary lapse of supervision  Breastmilk  Contraindicated for women with ongoing drug/alcohol use  Not contraindicated for women in methadone-maintenance programs  Physician guidance – LactMed (http://toxnet.nlm.nih.gov)  In utero

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 Active exposure  Unintentional ingestion, inhalation, dermal absorption  Intentional administration

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• Drugs are bad for kids.

• Not all drug tests are created equal.

• Know your test (or a medical professional who does)!

• Test results must be interpreted in the context of history.

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AAP Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 127(6):1182-9; 2011. Behnke M, Smith M, Committee on Substance Abuse, Committee on Fetus and Newborn. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics .131(3):e1009-24; 2013. Bond RG, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J Pediatr. 160(2):265-70; 2012. Boroda A, Gray W. Hair analysis for drugs in child abuse. J R Soc Med. 98(7):318-9; 2005. Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 37(5):389-396; 2009. Center for Substance Abuse Treatment. Drug Testing in Child Welfare: Practice and Policy Considerations. HHS Pub. No. (SMA) 10-4556 Rockville, MD: Substance Abuse and Mental Health Services Administration, 2010. Child Welfare Information Gateway. Parental Substance Use and the Child Welfare System. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau; 2014. Cuypers E, Flanagan RJ. The interpretation of hair analysis for drugs and drug metabolites. Clin Toxicol (Phila). 56(2):90-100; 2018.

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Dolan K, Rouen D, Kimber J. An overview of the use of urine, hair, sweat and saliva to detect drug use. Drug Alcohol Rev. 23(2):213-7; 2004. Farst K, Reading Meyer JA, Mac Bird T, James L, Robbins JM. Hair drug testing of children suspected of exposure to the manufacture of methamphetamine. J Forensic Leg Med. 18(3):110-4; 2011. Farst K, BB Bolden. Substance-exposed infants and children: forensic approach. Clin Pediatr Emerg Med. 13(3): 221-8; 2012. Felitti VJ, RF Anda, D Nordenberg, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 14(4):245-58; 1998. Hayek SN, Wibbenmeyer LA, Kealey LD, et al. The efficacy of hair and urine toxicology screening on the detection of child abuse by burning. J Burn Care Res. 30(4):587-92; 2009. Hoffman RJ. Testing for drugs of abuse (DOA). In: UpToDate, Traub SJ (Ed). (Accessed on March 3, 2017). Kellogg ND, AAP Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 119(6):1232-41; 2007. Kintz P. Hair analysis in forensic toxicology: an updated review with a special focus on pitfalls. Curr Pharm Des. 23(36):5480-6; 2017.

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Kintz P, Ameline A, Eibel A, et al. Interpretation of cannabis findings in the hair of very young children: mission impossible. Curr Pharm Biotechnol. 18(10):791-5; 2017. Klein J, Karaskov T, Koren G. Clinical applications of hair testing for drugs of abuse – the Canadian experience. Forensic Sci Int. 107(1-3):281-8; 2000. Levy S, Siqueira LM, Committee on Substance Abuse, et al. Testing for drugs of abuse in children and adolescents. Pediatrics. 133(6):e1798-1807; 2014. Lewis D, Moore C, Morrissey P, Leikin J. Determination of drug exposure using hair: application to child protective cases. Forensic Sci Int. 84(1-3):123-8; 1997. Lustbader AS, Mayes LC, McGee BA, Jatlow P, Roberts WL. Incidence of passive exposure to crack/cocaine and clinical findings in infants seen in an outpatient service. Pediatrics. 102(1):e5; 1998. Oral R, Bayman L, Assad A, et al. Illicit Drug Exposure in Patients Evaluated for Alleged Child Abuse and Neglect. Pediatr Emer Care. 27(6):490-5; 2011. Petska HW, Porada K, Nugent M, Simpson P, Sheets LK. Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention. Child Abuse Negl. 88:412-419; 2019. Rosenberg NM, Meert KL, Knazik SR, Yee H, Kauffman RE. Occult cocaine exposure in children. Am J Dis Child. 145(12):1430–2; 1991.

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Shannon M, Lacouture PG, Roa J, Woolf A. Cocaine exposure among children seen at a pediatric hospital. Pediatrics. 83(3):337–41; 1989. Stauffer SL, Wood SM, Krasowski MD. Diagnostic yield of hair and urine toxicology testing in potential child abuse cases. J Forensic Leg Med. 33:61-7; 2015. Wang X, Drummer OH. Review: interpretation of drug presence in the hair of children. Forensic Sci Int. 257:458-72; 2015. Wells K. Substance abuse and child maltreatment. Pediatr Clin North Am. 56(2):345-62; 2009. Wennig R. Potential problems with the interpretation of hair analysis results. Forensic Sci Int. 107(1-3):5-12; 2000. Yin S. Malicious use of pharmaceuticals in children. J Pediatr. 157(5):832-6; 2010.

Thank you to Dr. Lynn Sheets for additional slide content.

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