VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Table B-4. Interpreting Urine Toxicology Screening [189-191,196] Non-opioids Opioids or “Opiates”- Natural (From Opium) Drug or Class Expected Results Considerations Alcohol Alcohol • Testing for ethanol metabolites, ethyl glucuronide or ethyl sulfate, can identify alcohol up to 80 hr after consumption Amphetamines Benzodiazepines Immunoassay – Amphetamines, methamphetamines or MDMA Confirmatory – Amphetamines, methamphetamines or MDMA Immunoassay – Unconjugated oxazepam or its metabolites Confirmatory – Alprazolam, diazepam, clonazepam, lorazepam, etc. Barbiturates Immunoassay – Barbiturates • N/A Cocaine metabolites Immunoassay – Cocaine or benzoylecognine Codeine (Tylenol #2,3/4) Morphine (Avinza, Embeda, MS Contin, Kadian) Heroin Opiates Immunoassay – Positive Confirmatory – Codeine, possibly morphine & hydrocodone Opiates Immunoassay – Positive Confirmatory – Morphine, possibly hydromorphone Opiates Immunoassay – Positive Confirmatory – Heroin (6- MAM), morphine, possibly codeine • Immunoassay tests are highly crossreactive; therefore confirmatory testing is required and can identify which amphetamine is present • Immunoassays for benzodiazepines have a 28% overall false negative rate • Confirmatory testing is needed when use is expected or suspected (alprazolam, clonazepam and lorazepam often not detected by immunoassay) • Cocaine’s primary metabolite, benzyolyecgonine, has low crossreactivity with other substances and is highly predictive of cocaine use • A positive result should be interpreted as recent exposure to cocaine • Immunoassays for “opiates” are responsive to morphine and codeine but do not distinguish which • Codeine is metabolized to morphine and small quantities of hydrocodone • Immunoassays for “opiates” are responsive to morphine and codeine but do not distinguish which • Morphine (
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Opioids- Semisynthetic (Derived from Opium) Opioids – Synthetic (Man-made) Drug or Class Expected Results Considerations Hydrocodone (Lorcet, Lortab, Norco, Vicodin) Hydromorphone (Dilaudid, Exalgo) Oxycodone (Roxicet, OxyCotonin) Oxymorphone (Opana) Buprenorphine Fentanyl Meperidine (Demerol) Methadone (Methadose) Opiates Immunoassay – Positive Confirmatory – Hydrocodone, possibly hydromorphone Opiates Immunoassay –May be positive Confirmatory – Hydromorphone Opiates Immunoassay – May be positive Oxycodone Immunoassay – Positive Confirmatory – Oxycodone possibly oxymorphone Oxycodone Immunoassay – Positive Confirmatory – Oxymorphone Immunoassay – Buprenorphine LCMS, GCMS – Buprenorphione, norbuprenorphine GCMS – Fentanyl, norfentanyl GCMS – Normeperidine, possibly meperidne Methadone Immunoassay – Positive GCMS – Methadone, EDDP • “Opiates” immunoassay may detect semisynthetic opioids • hydrocodone >hydromorphone >oxycodone • Negative result does not exclude use and confirmatory testing (GCMS) is required • Hydrocodone is metabolized in small amounts to hydromorphone, both may be found in urine • Oxycodone is metabolized to oxymorphone, both may be found in urine • Hydromorphone and oxymorphone use does not result in positive screens for hydrocodone and oxycodone, respectively • Current “opiates” immunoassays do not detect synthetic opioids • Confirmatory testing (gas chromatography-mass spectrometry is needed) 1 1 Confirmatory testing: Gas chromatography-mass spectrometry or liquid chromatography-mass spectrometry Note: Each facility may have its own order sets and lab policies and procedures. Contact your lab for additional details. Abbreviations: 6-MAM: 6-monoacetylmorpine; EDDP: 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine; GCMS: gas chromatography-mass spectrometry; LCMS: liquid chromatography-mass spectrometry; MDMA: 3,4- methylenedioxy-methamphetamine Figure B-1. Opioid Metabolic Pathways [190-193] Codeine Morphine 6-MAM Heroin
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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