Foundation of Addiction Medicine 2019

CNS Disinhibition Regulat
+ ory

Neuro-Developmental
Lag

Pre-Fron
tal

Cortex

Limbi Striat Drug
c al Use

Toxic Stress 201
+

Reward
Deficiency

February 26, 2019

Outline

• Addiction Heritability – essential ingredients?

• Evidence from

✔ Genetic Epidemiology (Family, Twin & Adoption)
✔ Molecular Genetics (Linkage, Association and

Polygenic studies)

✔ Gene vs Environment (rGE, intGxE)
✔ Neurobiological Studies (Electrophysiology,

Imaging studies)

• Take home message

February 26, 2019 202

Take home messages

• Addiction is but an epiphenomenon of various
underlying diathesis that modulate reward, behavioral
control and the anxiety or stress response.

• Family studies -> RR: 4- to 8-fold increased risk of
addiction

• Twin Adoption studies -> h2 = 0.4 to 0.7

• Despite high heritability, only a few genes have been
identified using GWAS -> multiple small-effect genes
(Post GWAS methods are promising)

• Gene:Env correlations and interactions are important

• Endophenotypic markers can aid genomic discovery
through phenotype refinement

February 26, 2019 203

Additional Resources

• Psychiatric Genomics Consortium - Substance Use
Disorder Workgroup (PGC-SUD) (>400K GWAS)

https://pgc-sud.med.wustl.edu/scientific-plan/

• ENIGMA-Addiction: A Data-Pooling of Brain and Genetic
Correlates of Addiction
(>14000 MRI-GWAS)

https://enigma.ini.usc.edu/ongoing/enigma-addiction-w
orking-group/

• The Accelerator program for Discovery in Brain
disorders using Stem cells (ADBS) (Overall 4500 & 1500

https://www.ncbs.res.in/adbs/aboutM-aRdI-ebxso-mper)ogram

• The Consortium on Vulnerability
to Externalizing Disorders and Addictions (c-VEDA)

https://cveda.org/summary/ (Overall >8000
1000 MRI-GWAS)

February 26, 2019 204

Urine testing for substance
abuse for general health care
provider

Mrs. Shravanthi Daphine Anand
Dr. Priyamvada Sharma
Clinical Toxicology Lab

Centre for Addiction Medicine
NIMHANS

205

Educational Objective

• Introduction
• Need for Drug testing
• How to test?
• Types of testing approaches
• Interpretation of results
• Take home message

206

Real Case Scenario:

● Mr A, 32 year male, IT professional. Parents
suspecting that he is using “joints”. On
confronting by mother, he rejected but after
repeated coaxing, he replied that he had used
“joints” two weeks back. But he uses two to
three times a week. Now on wards, he will
stop. Parents are worried as they think that
he is minimizing.

● Very reluctantly he was brought to us.

207

What should I do

join at
Slido.com

#foam

208

Need for Drug Testing -
WHY?

209

Need for Drug Testing - WHY?

Substance use User Treatment needed

Alcohol 14.6% 5.7 Crore with harmful alcohol
Cannabis 2.83% use

72 Lakh need help

Opiates 2.06% 60 Lakh need help
Sedative 1.08% 18 Lakh adults need help

Inhalant 0.70% 4.6 Lakh children need
immediate help

( Survey conducted by NDDTC, AIIMS, New Delhi 2019)

Study showed only 8% of physicians recommend drug testing for treatment (Bhalla et al 2014)
210

Need for drug testing

211

Need for drug testing

212

Need for Drug Testing - WHY?

• There is a need to monitor drug use/abuse, abstinence
and relapse.

Types of Drug Testing :
• Clinical–Monitoring/screening for substance use

concurrent addiction issues and relapse. Therapeutic drug
monitoring.
• Work Place Drug Testing-Indian Railways, Indian Air
force
• Legal reasons-Police, Probation, motor vehicle accident,
forensic.

213

Types of Testing
Approach

214

Testing Approach

(Substance Abuse and Mental Health Administration
(SAMHSA), 2017)

Screening Confirmation test
test
To validate
To separate positive test
negative samples
from samples that results.
are
“presumptively” 215
positive

Current Techniques

Screening:
Immunoassays

(ELISA)

Confirmatory
Chromatography
GC/MS, LC/MS,
HPLC, HP-TLC etc.

216

Drug testing types

Step1: Sample Integrity test : Is it urine or Water or soap mixed etc

samples

2. On spot/ Screening kits 3. Confirmatory test

• Immunoassay procedure • Detection of specific compounds
• Rapid and cost effective • Highly sensitive and specific
• No sophisticated instruments are • Chromatography coupled with Mass

required spectrometry (GCMS or LCMS) are
• Arbitrary cut-off’s considered as one of the Gold standard
technique for analysis.

217

Step1: Sample Integrity test :

Is it urine or Water or soap mixed etc
samples

- Urine specimens range from pale yellow to clear depending on
concentration.

- Urine specimens collected in the early morning are the most
concentrated and often provide the most reliable information

- by shaking if excessive bubble
- pH for normal urine fluctuates throughout the day but usually is

in the range of 4.5 to 9.0
- Specimen contamination should be suspected if the pH level is less

than 3 or greater than 11 or if the specific gravity is less than 1.003
or greater than 1.030

218

Step1: Sample Integrity test :

Is it urine or Water or soap mixed etc
samples

Urine adulteration strips
● Dip the strip in suspected urine.
● Read results with color card

Results:
● Change of pH
● Specific gravity (1.003 - 1.025)
● Creatinine
● Nitrite- oxidizing the major cannabinoid metabolite THC-COOH

219

Easily available in market: Not
compulsory..only when doubt
about the urine!!

220

Step 2: Screening Kit

221

URINE IS A GOOD SPECIMEN OF CHOICE FOR
MOST ANALYTES

● Increased window detection compared to blood
● 1-3 days for most of the drug or their metabolites
● Collection is Non invasive

● Limitation: Sample integrity.

222

Immunoassay

• Antigen Antibody Mediated.
• Qualitative .
• Point of Care (POC) or Laboratory based.
Advantages:
• Sensitive and Inexpensive.
• Requires small volume of sample.
• Can be performed by minimally trained staff.
Disadvantages:
• Qualitative analysis only.
• Subject to cross reactivity.
• Sensitivity and Specificity vary by manufacturer and device.
• Does not reliably detect semi synthetic / synthetic opiates.

223

Basic Principle

Drug conjugate
Drug/metabolite
Antibody (Ab)

224

Immunoassay Screening and Confirmation
cutoff

Multi Drug Screening and Confirmation

Cannabis Morphine Cocaine Benzodiazepines Amphetamines

Detection 5-45 1-2 days 2-3 3-15 1-5 days
Window days days days 300ng/ml

Cut- off 50ng/ml 300ng/ml 300ng/ml 300 ng/ml

225

1. drug testing (Cannabis,
Opioids etc.)

226

On site screening of abused drugs using cassettes

227

Mr A urine was tested and and the
kit is showing like this
Is the Test positive for Cannabis or
NOT? Slido.com #foam

C
T

228

Detection window

Moeller KE, Lee KC, Kissack JC. Urine drug
screening: practical guide for clinicians. InMayo
Clinic Proceedings 2008 Jan 1 (Vol. 83, No. 1, pp.
66-76). Elsevier.

229

On-site Drug Detection:

Intensity of band is NOT quantitative!

230

Choosing an On-Site Testing
Device

● Ease of use
● Appropriate cut-off levels
● customer service (access to expert

advice)
● Request current customer list
● Confirmation required

231

Available in market

232

Multikit

233

2. Alcohol On-Spot
Testing

(Demonstration) &
Confirmation

234

On Spot Breath Alcohol Testing

235

Step 1: Breaking of cover(inside)

Press

236

Step 2: Blowing of Balloon

Blow Hard (30-40 second ) to fill the Balloon

237

Step 3: Release of air

Release air slowly by putting finger on the tip.

238

Step 4: Observe Color Change

Positive
Negative

239

Semi-quantitate results by matching the
color

240

Alcohol - Results Interpretation

● Screening tests specific for ethanol, ethyl alcohol
● Positive results indicate presence alcohol
● Negative results don’t necessarily document

abstinence
● Alcohol detection time = hours
● example - person intoxicated at 11:00 PM, collect

second urine sample of next day (11:00 AM), most
likely test negative for alcohol

241

Alcohol:
Extending the detection window

242

Alcohol Biomarker

243

3. Inhalant spot test

244

Solvent abuse test

In India 4.6 Lakh children needs help for
harmful dependence of inhalants.

245

Solvent abuse test

Result: observe color- pale red to wine red indicates current
exposure

246

Solvent Abuse test

• Color card is displayed with Figure-1,
could successfully calculate the
approximate values without taking
absorbance.

Color card showing approximate concentration with
color
Sharma et al European Journal of Pharmaceutical Research- 2017

247

Step 3 (Optional)
: Confirmation and
Quantification Tests

● To rule out False positive

● FALSE POSITIVES

248

Chromatography

• GC/MS or LC/MS.
• Laboratory based, Drug-Specific.
• Quantitative.
Advantages:
• Quantitative.
• Highly Sensitive and Specific.
• Very few false positive results.
Disadvantages:
• Very expensive and labor intensive.
• Due to the complexity of the instrument, highly
trained operators and technologists are required.

249

Instruments used for
confirmation

Gas Chromatograph Mass Spectrometer Liquid Chromatograph
Mass Spectrometer
250