There are many variables regarding the analyses of substance abuse testing. Clients will often ask about specifics pertaining to the determination of time, dose and frequency when detecting substance(s) of abuse.

When testing a reservoir matrix- a material or substance which can accumulate and retain drug and alcohol biomarkers (eg., urine, blood, hair, nail, umbilical cord, or meconium, etc.), the reported quantitation of a drug or its metabolite cannot be used to determine when/if a specific substance was used, how much of a substance was used or how often a substance was used. Test results show only if a substance was detected or not detected.

A specimen’s window of detection provides an estimated timeframe for detecting substance(s) of abuse. Based on extensive research studies, the generally accepted windows of detection for specimens used in our testing are as follows:

• Scalp Hair- Up to approximately 3 months prior to collection.
• Fingernail- Up to approximately 3-6 months prior to collection.
• Umbilical Cord- Up to approximately 20 weeks prior to birth.
• Meconium- Up to approximately 20 weeks prior to birth.
• Urine- Up to approximately 2-3 days prior to collection.
• Blood (PEth)-May be up to approximately 2-4 weeks prior to collection.

It is important to know that the interpretation of drug testing results may be determined by a Medical Review Officer (MRO). A Medical Review Officer is a licensed physician (MD or DO) who has knowledge of substance abuse disorders and has the appropriate medical training to interpret and evaluate an individual’s positive test result together with his or her medical history and any other relevant biomedical information.¹This is an incredibly important aspect of drug testing. A laboratory can detect substances, but an MRO may be used to interpret what that detection means.

1. Journal of Occupational and Environmental Medicine: (January 2003-Volume 45-Issue 1-p 102-103) Qualifications of Medical Review Officers (MRO’s) in Regulated and Nonregulated Drug Testing. Departments: ACOEM Consensus Opinion Statement

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According to the Centers for Disease Control and Prevention (CDC), fentanyl-related overdose deaths in the United States have increased by more than 1,000 percent from 2011 through 2016.¹ The increased availability of illicitly manufactured fentanyl has contributed to the prevalence of neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) throughout the United States. There was a greater than five-fold increase in the proportion of babies born with NAS from 2004 to 2014, when an estimated 32,000 infants were born with NAS/NOWS —equivalent to one baby suffering from opioid withdrawal born approximately every 15 minutes.²

In response to an ongoing opioid epidemic, medical professionals and advocates are invested in providing education, resources, testing, and preventative care in efforts to combat one of the most powerful opioids in the world —Fentanyl. This synthetic, opioid is extremely addictive and when used while pregnant can cause devastating outcomes to the fetus including neural tube defects, congenital heart defects, gastroschisis, stillbirth, and pre-term delivery.³

Newborns are often diagnosed with NAS/NOWS as a direct result of a sudden interruption of fetal exposure to prescription and illicit substances that were used or abused by the mother. Diagnosing an infant with NAS/NOWS is often assessed by identifying the following symptoms: tremors, jitteriness, irritability, excessive crying, and diarrhea. These indicators have been determined in the medical field as the standards for identifying a compromised central nervous system. Prenatal use & abuse of fentanyl can increase an infant’s risk for developing NAS/NOWS.

What Makes Fentanyl So Dangerous?

According to the United States Drug Enforcement Administration (DEA), fentanyl is approximately 100 times more potent than morphine and 50 times more potent than heroin.⁴ Its initial development was intended as a licit intravenous anesthetic; however, it has now become a public health threat as pharmaceutical products are subjected to theft, fraudulent prescriptions and illicit or less regulated distribution and manufacturing. The drug is often abused by injecting, snorting / sniffing, oral tablets/pills or removing the gel on fentanyl patches and then injecting or ingesting. The popularity of fentanyl within drug addicted communities derive from the addictive effects the drug produces —relaxation, euphoria, pain relief, and sedation. However, abused fentanyl also produces fatal side effects including: confusion, dizziness, nausea, vomiting, urinary retention, pupillary constriction, and respiratory depression.

Fentanyl’s Long-Term Effects on Fetus

Prenatal substance abuse can lead to long-term, irreversible damage to a developing fetus. In relation to fentanyl, these effects can consist of the following when associated with NAS/NOWS:⁵

• Cognitive and motor development deficiencies
• Infections
• Vision complications
• Sudden Infant Death Syndrome (SIDS)
• Susceptible to future substance abuse

Fentanyl and Toxicology Confirmation

According to the American Academy of Pediatrics, NAS/NOWS is a clinical diagnosis, however toxicological confirmation is necessary to identify the exact type of substance that the mother was using or abusing and to confirm or rule out the use of other licit or illicit substances during pregnancy.⁶

Due to the recent increase of cases regarding pregnant women and fentanyl exposure, it is critical to utilize testing that can help detect the latest drugs of abuse. Through internal research and strategic analysis, our laboratory is combating the growing epidemic of fentanyl use among pregnant women and those of childbearing age, with the development of testing for fentanyl in both umbilical cord tissue and meconium. As the first and only laboratory to offer fentanyl testing utilizing both advanced newborn specimens, our partnerships are provided with the opportunity to proactively and effectively address the alarming rates of prenatal fentanyl use. Both meconium and umbilical cord tissue belong to the baby, therefore maternal consent is not needed to proceed in testing.

Umbilical Cord Tissue

The umbilical cord tissue is available immediately for 100 percent of births and requires only 1 collection by 1 collector. This specimen’s look back provides detection up to approximately 20 weeks prior to birth, the most advanced newborn specimen on the market.

Meconium

Meconium has been recognized for decades as the “gold standard” for the detection of substances. It is the first stool of an infant produced in utero, consisting of epithelial cells, bile, mucous, and is odorless with a very dark, tar-like appearance. Meconium is uniquely developed during gestation with exclusive capabilities of preserving substances exposed prenatally up to approximately 20 weeks prior to birth. The average start of a meconium passage after birth occurs within 24-48 hrs., in most newborns it is generally passed in the first day or so of life.

Turnaround Time

Our methodology and advanced instrumentation contribute to our laboratory’s efficient turnaround time. Generally, the standard turnaround time for reporting negative screening test results is the next business day, with an additional 1-2 business days for specimens that require confirmatory testing. Turnaround time begins from receipt of the valid specimen–accompanied by a properly documented valid order– into the laboratory. Some tests require additional time to process and will fall outside the standard turnaround time window.

As one of the only laboratories in the nation focusing exclusively on substance abuse testing, we are consistently adapting our services to meet the needs of our clients and communities. The validity of newborn toxicology results has never been more imperative. Through our partnership and services, we can customize a flexible comprehensive drug testing program based on your population health needs. Today’s substance abuse landscape is drastically different than it used to be-collaboration is vital in supporting our mission of protecting and enriching lives. 

References

1. Spencer, M.P.H., M., Warner, Ph.D, M., Bastian, B.S., B., Trinidad, M.P.H., M.S., J. and Hedegaard, M.D., M.S.P.H., H. (2019). “National Vital Statistics Reports.” [online] Cdc.gov. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf [Accessed 17 Sep. 2019].
2. Drugabuse.gov. (2019). “Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome.” [online] Available at: https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome [Accessed 17 Sep. 2019].
3. Center for Disease Control and Prevention, U. (n.d.). “Pregnancy and Opioid Pain Medications.” Retrieved from https://www.cdc.gov/drugoverdose/pdf/pregnancy_opioid_pain_factsheet-a.pdf.
4. Department of Education, U. (n.d.). “Drugs of Abuse Guide” (2017)(pp. 40-41) (United States).
5. “Long-Term Outcomes of Infants With Neonatal Abstinence Syndrome.” (n.d.). Retrieved from https://www.seattlechildrens.org/healthcare-professionals/education/continuing-medical-nursing-education/neonatal-nursing-education-briefs/long-term-outcomes-of-infants-with-nas/
6. Kocherlakota, P. (2014, August 01). “Neonatal Abstinence Syndrome.” Retrieved from http://pediatrics.aappublications.org/content/134/2/e547

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What you need to know about meconium collection.

by Michelle Lach, MSIMC

Meconium is the first stool of a newborn infant. It is produced in utero and consists of materials such as epithelial cells, bile, mucous, and more. In most newborns, meconium is generally passed in the first day or so of life, has no odor, and appears as a very dark, tar-like substance. This helps distinguish meconium from the next phase of passage called transitional stool. 

Transitional stool will start to have an odor and present with a more brown, green, or yellow color as the newborn starts digesting milk. When drug testing the meconium of a newborn, it is important to note this difference since only meconium is created during gestation and transitional stool is created after birth. Collection of any stool other than meconium for drug testing purposes may result in a rejected specimen.  

Unlike umbilical cord tissue, drugs are not distributed uniformly throughout the meconium specimen (see Figure 1). Because of this, the collection of the entire mass of meconium is highly encouraged to assure that there will be enough specimen to test, and that the maximum window of drug detection is achieved. It can take multiple passages of meconium before the newborn begins the transitional stool phase. 

We require a minimum of 3 grams of meconium to be able to properly run our tests, so collecting the entire passage of meconium from newborns that have been exposed to substances of abuse is highly critical since they tend to have lower birth weights and create less specimen in the first place. If there is not enough specimen to run the test, the results are reported out as QNS. Quantity Not Sufficient (QNS) is a result of not having a sufficient quantity (volume) of specimen to test for the panels ordered.

What You Need To Know: Testing for Drug Exposure vs. Ingestion

Testing for environmental exposure to illicit drugs is a powerful tool for protecting the welfare of children. Exposure testing is different from typical drug testing, and when properly done, has the potential to reduce the risk of harm to children.

No Metabolite Does NOT Mean No Exposure

Testing labs often apply government workplace testing guidelines to child exposure testing samples. Under workplace guidelines, negative results are reported when drug metabolites are absent in the testing sample, even if the native drug is present.

Child hair and nail samples for exposure testing often do not contain drug metabolites because the child has not ingested illicit substances. Adhering to workplace guidelines can result in false negative reporting for drug exposure, especially when children are involved.

Environmental Exposure

Environmental Exposure testing is most effective in alternative sample types, such as hair and fingernails. For example, hair testing is 3.5x more likely to detect methamphetamine exposure than urine testing. Typical drug testing samples are washed to remove drug biomarkers resulting from exposure. Environmental exposure testing eliminates this step.

 – Click here to download the pdf.

When a child is exposed to illegal substance abuse they often also face other coexisting obstacles to a normal life – neglect, abuse, violence, and other vulnerabilities. Substance abuse is a disease, one that often prevents adults from doing what is in a child’s best interests. Our environmental exposure test for children can help.

Our hair environmental exposure test is the only drug test designed to detect passive exposure to drugs and detect both native drugs and drug metabolites in the hair specimen. Drug metabolites are produced in the body only if drugs have been ingested. Children in drug exposed environments are most often not drug users themselves, so drug metabolites are typically absent in child specimens. However, the hair, like a sponge, can absorb non-metabolized drug (native drug) if it is exposed through things such as touching or being in contact with drugs or drug users.

Standard hair tests with other labs will only report a positive exposure result if drug metabolites are detected, even when the native drug is in the child’s hair specimen. Our hair environmental exposure test reports a positive result if either native drugs or drug metabolites are detected.

A hair exposure test can provide evidence of drugs in a child’s environment for the past 3 months. A positive test result suggests that the child has experienced one or more of the following: passive inhalation of drug smoke, contact with drug smoke, contact with sweat or sebum (skin oil) of a drug user, contact with the actual drug, or accidental or intentional ingestion of illegal drugs.

ChildGuard^®is the only child hair test designed to detect exposure to native drugs and drug metabolites.

Please click here to read the full article by Eric Frazer, Ph. D., and Linda Smith, Ph. D., in our Fall issue of Substance.

One of the most common issues that arises in Juvenile and Family Court is parental substance abuse. Once this allegation has been raised, there is immediate concern about the child’s safety and well-being. In particular, there is often concern about neglect and abuse. For example, will the parent prioritize drug seeking over caring for the child? Will the parent drive under the influence, with the child in the vehicle? Less commonly mentioned in the courtroom, especially in the family courtroom, is potential child exposure to drugs. Unfortunately, this is a significant risk to children, and should be considered and discussed in every case.

One of the challenges family lawyers and courts face is how to properly investigate the substance abuse allegation and determine if it is a valid concern. Gathering and organizing the most relevant information has historically been difficult to do because of a lack of awareness regarding what is most relevant and important. Fortunately, the drug testing lab can bridge that gap of uncertainty, especially when there is an allegation about child exposure.

The objective for any lawyer and the court is to have sufficient information available to rule in, or out, the substance abuse allegations. This information may be presented via admissible evidence, witness testimony, and/or expert testimony. The following pointers may be helpful to legal professionals so that they are able to most effectively present a case on this matter.

Step 1 – Inquiry & Investigation

One of the first steps in evaluating a substance abuse allegation is to ask research informed questions so that the most relevant data can be gathered. Questions should be focused on potential exposure of the children to parental drug possession or use. For example, relevant questions may include:

• Where does the defendant allegedly store the drugs?
• Does the child have easy access to these storage containers and locations?
• Is the child typically present when the drugs are used?
• In what ways may the child have been exposed?
• What steps, if any, did the parent take to protect the child from accidental exposure?

Step 2 – Drug & Alcohol Monitoring

If a parent tests positive on an alcohol or drug test, this may result in a motion, agreement, or court order for ongoing monitoring. However, many questions then arise. For example, how long should the monitoring extend? Should it
include both alcohol and drugs? What type of drug monitoring method should be used (urine/hair/SCRAM/Soberlink, etc.)?