Opioid Abuse Workup

  • Author: Adrian Preda, MD; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Feb 29, 2012
 

Laboratory Studies

Abuse and dependence

  • Urine drug screen
  • Detection of drugs in sweat and hair is a recent addition to drug abuse detection technology. However, it is not used widely.

Withdrawal

  • Electrolytes
  • CBC count
  • Urine drug screen is rarely useful.

Intoxication

  • Comprehensive urine drug testing is performed when the drug abuse habit of the patient is unknown but suspected. Some labs use the inexpensive thin-layer chromatography (TLC) procedure. This test has low sensitivity for commonly used drugs. TLC cannot detect fentanyl.
  • Enzyme immunoassay and radioimmunoassay are more sensitive than TLC, but they are less specific because molecules with similar functional groups cross-react with antibodies. These are relatively inexpensive tests.
  • Gas-liquid chromatography (GLC) and gas chromatography-mass spectrometry (GC-MS) are very sensitive and specific tests, but they are time consuming, labor intensive, and expensive.
  • In drug abuse detection, knowing the half-life of the drug, the biotransformation of the drug, and the excretion route of the drug are important.
  • Screening and confirmation cut-off concentration for heroin, methadone, morphine, and codeine is 300 ng/mL and are detected in urine within 1-4 days.
  • False-negative results occur more easily than false positives, simply because once a test is screened negative, it is not tested further. The federal government requires that the results of the drug testing programs go directly to medical review offices to prevent improper interpretation of drug testing data.
  • Blood alcohol levels also may be tested.

Addiction

In case of historical or clinical evidence of IV drug abuse, perform the following:

  • LFT
  • Rapid plasma reagent (RPR)
  • Hepatitis viral testing
  • HIV testing
  • Blood cultures (in appropriate clinical setting)
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Imaging Studies

For addiction, in case of historical or clinical evidence of IV drug abuse, perform an x-ray of the lungs (eg, history of injecting drugs contaminated with microcrystalline talc) to search for evidence of pulmonary fibrosis.

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Other Tests

Naloxone challenge test: This test is performed to assess physical dependence. As an intramuscular injection or IV, 0.2-0.8 mg of naloxone is administered.

  • A positive test is indicative of physical dependence and consists of typical withdrawal symptoms and signs. These symptoms and signs usually last for 30-60 minutes.
  • This test is found to be very helpful before starting opiate antagonists for maintenance therapy. Starting opioid antagonists, such as naltrexone, soon after detoxification may cause withdrawal symptoms and discourage patients from further treatment.
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Contributor Information and Disclosures
Author

Adrian Preda, MD  Health Sciences Associate Professor of Psychiatry and Human Behavior, University of California Irvine School of Medicine

Adrian Preda, MD is a member of the following medical societies: International Congress of Schizophrenia Research, Schizophrenia International Research Society, and Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Barry I Liskow, MD  Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Ziaur Rehman, MD, Suzan Khoromi, MD, James E Douglas, MD, Steven A Adelman, MD, and William J Meehan, MD, PhD to the development and writing of this article.

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Schematic diagram of the brain-reward circuitry of the mammalian (laboratory rat) brain with sites at which various abusable substances appear to act to enhance brain-reward and, thus, to induce drug-taking behavior and possibly drug craving. Courtesy William & Wilkins Substance Abuse by Eliot L Gardner.KEY - Nucleus accumbens (Acc), ventral tegmental area (VTA), amygdala (AMYG), locus ceruleus (LC), dopaminergic mesolimbic system (DA), ventral pallidum (VP), noradrenergic fibers (NF), enkephalinergic outflow (ENK), frontal cortex (FCX), GABAergic inhibitory fiber system (GABA), dynorphinergic outflow (DYN),component of reward circuitry preferentially activated by electrical intracranial self-stimulation (ICSS).
 
 
 
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