Who is helping our Youth Say No??

Parents should be drug testing their kids to help them say no!  Think about it!  People in general will be more hesitant to use drugs if they know there is a urine drug test that will be performed!

PARENTS TEST YOU KIDS TODAY, TOMORROW  AND WHEN YOU THINK IT IS A GOOD IDEA!  IT GIVES KIDS A WAY TO SAY NO!

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Suboxone Side Effects

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Suboxone Rehab Treatment Center

Many people are curious about Suboxone and similar treatment methods. Suboxone is used for safe and comfortable detoxification from opiates (prescription pain medications). Subutex and Suboxone treat opiate addiction by preventing symptoms of withdrawal from heroin and other opiates.

Subutex (buprenorphine hydrochloride) and Suboxone Tablets (buprenorphine hydrochloride and naloxone hydrochloride) are approved for the treatment of opiate dependence.

Dr. A.R. Mohammad, the founder of Inspire Malibu, is considered to be one of the leading authorities on opiate detox and withdrawal and was the first doctor in the state of California, to be licensed to use Suboxone.

What is “Managed Maintenance”?

Managed Maintenance is a proven success program that restores health, life and hope to those unique individuals who, because of either systemic or acquired medical conditions, have become completely dependent on opiates.

Patients with ten to fifteen year addiction histories with medical conditions such as Hepatitis C, HIV, heart problems, and/or psychiatric complications are considered special cases.  These are not the norm, but not being a “normal addict” is no reason to be denied effective life saving, health restoring treatment.

Without Managed Maintenance, 80% of these extreme cases immediately fall right back into dangerous addiction.

The FDA approved Suboxone as a proper and effective way to replace dangerous and illegal substances. Suboxone, used in detox, keeps patients from experiencing life threatening, debilitating withdrawal, and allows them to remain physically stable.

What is Suboxone?

SUBOXONE is a prescription medicine that is used to treat adults who are addicted (dependent) on opioid drugs (prescription or illegal), as part of a complete treatment program that also includes counseling and behavioral therapy.

SUBOXONE is a controlled substance (CIII) because it contains Buprenorphine, which can be a target for people who abuse prescription medicines or street drugs.

SUBOXONE should always be kept in a safe place to protect it from theft. It should never be given to anyone other than who it is prescribed, as it may be harmful or fatal if not used properly. Selling or giving away Suboxone is against the law. Suboxone is not for occasional or “as needed” use.

What are the Ingredients in SUBOXONE?

Active 

Ingredients: Buprenorphine and Naloxone.

Suboxone is only available by prescription, and administered by a physician.  Suboxone comes in tablet form, and easily dissolves under the tongue. It is a “partial opiate.”

Partial Opiates are similar to full opiates such as Heroin, Vicodin, or Methadone.  Suboxone gives the brain what it desires without the dangers associated with full opiated drugs.

An easy way to understand the use of Suboxone in Managed Maintenance is to think of training wheels on a bicycle. Training wheels provide physical balance while promoting personal assurance and confidence during the learning process. In time, the rider balances perfectly, independently.

What’s the right time to stop the Suboxone?

For the extreme opiate dependent patient, the managed use of Suboxone makes it possible for them to acquire the life skills and personal balance to ride “the bike of life” without crashing. It is rewarding and wonderful to see the transformation of opiate addicts into healthy, happy, stable individuals free from cravings, illegal drugs, and life threatening behavior.

How long a medication should be administered is best determined by the treating physician in consultation with the individual patient. Whether or not a patient should continue taking medication for their condition and what medication would be most effective is determined in a case by case basis by a physician.

As patients internalize and integrate the therapeutic tools given them, the patients recognize the “right time” to taper off the use of Suboxone until it is completely discontinued.

Opiate Dependence Treatment

Currently there are not enough addiction treatment centers to help all patients seeking opiate dependence treatments. Methadone can only be dispensed in a limited number of clinics that specialize in addiction treatment.

Subutex and Suboxone are the first narcotic drugs available under the Drug Abuse Treatment Act (DATA) of 2000. The treatment of opiate dependence can now be prescribed in a doctor’s office. This change will provide more patients the opportunity to access treatment.

The newly approved medication, Zubsolv is a prescription opiod maintenance drug similar to Suboxoneto help reduce the opioid cravings that often distract people in recovery from working through their addiction.

Physical dependence is not the same as drug addiction. SUBOXONE contains an opioid that can cause physical dependence. Patients should not stop taking SUBOXONE without first speaking with their doctor. They may feel sick from the uncomfortable signs of withdrawal symptoms because the body has become used to the medication.

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Suboxone Side Effects

A physician should do tests before a patient begins taking Suboxone as well as while using the prescribed drug.

Patients taking Suboxone have a higher risk of death and coma if combined with other medications that utilize benzodiazepines. Various side effects such as respiratory problems, sleepiness, dizziness, and problems with coordination have been recorded.

Dependency or abuse can cause liver problems such as yellowish skin or the white part of patient’s eyes turning yellow (symptoms of jaundice), dark-colored urine, or light-colored stools, a decrease in appetite, or nausea with stomach and abdominal pain. Call a doctor immediately if any of these signs are present.

Some patients may experience an allergic reaction and or have a rash, hives, facial swelling, wheezing, or a loss of blood pressure and consciousness.

Symptoms and other signs to watch for can include nausea and vomiting, drug withdrawal syndrome, headaches, increased sweating, numb mouth, constipation, pain in the tongue, disturbances in attention, irregular heart beat or palpitations, insomnia or trouble sleeping, blurry vision, and back pains.

What are the Withdrawal Symptoms from Suboxone?

Withdrawal symptoms can include any of the following:

• increased sweating
• shaking
• an unnatural feeling of hot or cold
• runny nose
• watery eyes
• goose bumps
• vomiting
• diarrhea
• muscle aches combined with a decrease in blood pressure or a dizzy sensation when standing up too quickly from sitting or lying down position

Contact a doctor immediately if any of these symptoms develop.

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Where can I order Urine Drug Testing Devices

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Where can I order an at home urine drug test?

Urine drug testing (UDT) is widely used for testing for opioids and illicit drugs. There are two types of UDT: a screening test and a confirmatory test. The screening test uses an immunoassay to look for the parent drug and/or metabolite. Most UDTs screen for marijuana, cocaine, opiates, PCP, amphetamines, while some also test for benzodiazepines and methadone. The confirmatory urine drug test is done by gas Chromatography/mass spectrometry (GC/MS) or high-performance liquid chromatography (HPLC); this test is highly specific and is typically used when testing for the presence of a specific drug is needed.

How far does it go back?

Urine testing detection periods will vary greatly for drug to drug.  Table below will cover the common drugs and detection time.

Substance Detection Time:
Substance	Detection Period	Substance	Detection Period
Amphetamines	2-5 days	Barbituates (Short-Acting)	2 days
Barbituates (Long-Acting)	3-4 weeks	Benzodiazepines	7-10 days
Cannabinoids (THC, Marijuana)	5-60 days (See Chart Below)	Clenbuterol	4-6 days
Cocaine	1-4 days	Codeine	5-7 days
Euphorics (Ecstasy, Shrooms)	5-7 days	Ketamine (Special K)	5-7 days
LSD - ACID	7-10 days	Methamphetamines	5-7 days
Nicotine (Cigarettes)	4-10 days	Opiates	5-7 days
Peptide hormones	undetectable	Phencyclidine (PCP)	2-4 days
Phenobarbital	10-20 days	Propoxyphene	6 hours to 2 days
Steroids (anabolic oral)	14-28 days	Steroids (anabolic parenterally)	1-3 months

Cannabinoids (THC, Marijuana) Detection Time:
1 time only	5-8 days
2-4x per month	11-18 days
2-4x per week	23-35 days
5-6x per week	33-48 days
Daily	49-63 days

Do medications interfere?

There are some prescriptions that contain the same drugs that are commonly found "on the street". There is no easy way to distinguish between the two forms of the drug. However, the problem is not as big as it would seem. 

There are no prescriptions for PCP or cocaine. It is extremely rare to find cocaine used in a medical setting, although it happens occasionally, usually to control bleeding from the eye or nose. If used, it will be well documented in the person’s medical file. Such use would cause the urine to test positive for cocaine metabolite for a few days.

Heroin is rarely prescribed in the United States, but again would be well documented. Other prescribed opiates may occasionally cause a positive screen, but are sorted out in a confirmation test.

There are some prescription diet pills that contain either amphetamine or methamphetamine, as well as a drug for Parkinson’s Disease that is a form of methamphetamine. Some doctors prescribe amphetamines for ADHD. Ecstasy is included in the amphetamine class of drugs, and is identified at confirmation. 

What if I’m in a room with someone who is using drugs?

Since it takes multiple uses to test positive, and metabolites are checked when possible, it is pretty much impossible to test positive from passive exposure on a limited basis.
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Clinical Withdrawal Opiate Scale

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Clinical Withdrawal Opiate Scale

Patient's Name:___________________________

Resting Pulse Rate: _____beats/minute
Measured after patient is sitting or lying for one minute
0 pulse rate 80 or below
1 pulse rate 81-100
2 pulse rate 101-120
4 pulse rate greater than 120
_____________________________________________________
Sweating: Over past 1/2 hour not accounted for by room temperature or patient activity
0 no report of chills or flushing
1 subjective report of chills or flushing
2 flushed or observable moistness on face 3 beads of sweat on brow or face
4 sweat streaming off face
_____________________________________________________
Restlessness: Observation during assessment 0 able to sit still
1 reports difficulty sitting still, but is able to do so
3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds
_____________________________________________________
Pupil size:
0 pupils pinned or normal size for room light
1 pupils possibly larger than normal for room light
2 pupils moderately dilated
5 pupils so dilated that only the rim of the iris is visible
_____________________________________________________
Bone or Joint aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored
0 not present
1 mild diffuse discomfort
2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to

Date and Time: / / _______ 0 not present

1. 1  nasal stuffiness or unusually moist eyes
   
2. 2  nose running or tearing
   

4 nose constantly running or tears streaming down
cheeks ____________________________________________________ GI Upset: Over last 1/2 hour
0 no GI symptoms
1 stomach cramps
2 nausea or loose stool
3 vomiting or diarrhea
5 Multiple episodes of diarrhea or vomiting
____________________________________________________ Tremor: Observation of outstretched hands
0 No tremor
1 tremor can be felt, but not observed 2 slight tremor observable
4 gross tremor or muscle twitching
____________________________________________________
Yawning: Observation during assessment 0 no yawning
1 yawning once or twice during assessment
2 yawning three or more times during assessment 4 yawning several times/minute
____________________________________________________
Anxiety or Irritability:
0 none
1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious
4 patient so irritable or anxious that participation in the
assessment is difficult ____________________________________________________ Gooseflesh skin:
0 skin is smooth
3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection
The total score is the sum of all 11 items
(5-12 = mild 13-24 = moderate 25-36 = moderately severe >36=severe withdrawal)

sit still because of discomfort
_____________________________________________________
Runny nose or tearing: Not accounted for by cold symptoms or ____________________________________________________ allergies

Total Score:__________________

Initials of person completing assessment:____________________ Reference: California Society of Addiction Medicine

Clinical Opiate Withdrawal Scale

ADDRESSOGRAPH 


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Philosophy of Urine Drug Testing in Pain Management

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Philosophy of Urine Drug Testing in Pain Management

by Howard A. Heit, MD, FACP, FASAM

& Douglas L. Gourlay, MD, MSc, FRCPC, FASAM

Expert authors received compensation from Janssen Pharmaceuticals, Inc. for their contributions to PrescribeResponsibly.com

Urine drug testing (UDT) is a useful tool in pain management that provides valuable objective information to assist in diagnostic and therapeutic decision making.³⁶ Results of a UDT provide confirmation of the agreed-upon treatment plan (adherence/compliance). They can diagnose relapse or drug misuse as early as possible, and they also can be used to advocate for the patient with third-party interests.³⁷

To assess compliance, the healthcare professional may look for the presence of prescribed medications in the urine as evidence of their use. Finding no presence of the prescribed drug or finding unprescribed or illicit drugs in the urine merits further discussion with the patient. At the same time, it is important to recognize that laboratory error and test insensitivity can result in misleading data. Bingeing by the patient can result in unexpected negative urine reports if the patient runs out of medication prior to urine sample collection. Therefore, these results by themselves cannot be relied upon to prove drug diversion and may be consistent with addiction, pseudoaddiction, or the use of an opioid for nonpain purposes—so called chemical coping.³⁶

The purpose of UDT should be explained to the patient at the initial evaluation. UDT can also enhance the relationship between healthcare professionals and patients by providing documentation of adherence to mutually agreed-upon treatment plans.³⁶

In the pain management setting, the presence of an illicit or unprescribed drug does not necessarily negate the legitimacy of the patient’s pain complaints, but it may suggest a concurrent disorder such as drug abuse or addiction. The patient must be willing to accept assessment and treatment of both disorders to receive adequate outcomes in either. Thus, the diagnosis of a concurrent addictive disorder, when it exists, does nothing to negate a legitimate pain disorder; rather, it complicates it.³⁶

Specimen Choice

Urine has been the preferred biologic specimen for determining the presence or absence of most drugs. This is, in part, due to the increased window of detection of 1 to 3 days for most drugs and/or their metabolites.³⁶ Table 3

Whom to Test and Frequency of Testing

The question of whom to test is made easier by having a uniform practice policy either in a pain or primary practice that would help reduce individual stigma. Any risk of patient profiling based on racial, cultural, or other physical appearances is eliminated. Careful explanation of the purpose of testing normally allays patient concerns.³⁶

Healthcare professionals sometime find the subject of drug testing a difficult one to explore with their patients, especially those who have been in the practice for many years. Often, a healthcare professional's perception is that requesting a urine sample for drug testing may be seen as mistrusting the patient and, consequently, potentially damaging to the healthcare professional-patient relationship. In fact, when approached in a respectful, patient-centered fashion, most patients are more than willing to do their part in managing risk in order to receive the care that they need.

Testing Strategies

The healthcare professional must know the drugs for which to test, appropriate methods to use, and the expected use of the results obtained.³⁶Immunoassay drug tests are most commonly used. They are designed to classify substances as either present or absent and are generally highly sensitive. In pain management, specific drug identification using more sophisticated identification tests is needed.³⁶ Techniques such as Gas Chromatography/Mass Spectroscopy (GC/MS) and High Performance Liquid Chromatography (HPLC) are used for the identification of a specific drug and/or its metabolites.³⁶

Immunoassay drug tests for natural opiates are very responsive to morphine and codeine, but do not distinguish between the two. UDT by immunoassay also shows a low sensitivity for semisynthetic/synthetic opioids such as oxycodone and fentanyl.³⁶ Even though an immunoassay may be negative for consumed oxycodone, it should be positive on GC/MS if the drug was used within the window of detection. The clinical importance of this fact with UDT cannot be overstated, because compliant patients may have been dismissed from pain management practices secondary to a false-negative immunoassay test when looking specifically for prescribed oxycodone.³⁶Specific drug identification by chromatographic testing (ie, GC/MS) also is necessary to identify which member of the detected class is responsible for the positive screen.³⁶ Drug-specific immunoassays presently on the market and under development will identify semisynthetic/synthetic opioids.³⁷ The healthcare professional should always know the limits of the UDT ordered.³⁷

A routine UDT screening panel suggested for the following drugs/drug classes is listed in Table 4.³⁶

Healthcare professionals also must understand the basic metabolism of commonly prescribed drugs, especially opioids, so they will be able to explain a UDT result that is positive for the prescribed medication and/or its metabolite(s). Figure 1³⁷

Dealing With Unexpected Urine Toxicology Results

UDT in clinical practice must be used to improve patient care. Unfortunately, these test results may come back unexpectedly negative for a prescribed drug or positive for an unprescribed one. The first step in interpreting these results is to contact the lab to ensure that no clerical errors have been made.³⁷ If unexpected results are confirmed, there must be a process in place that should include discussing the unexpected result with the patient.³⁶

Conclusion

UDT is an effective tool in the assessment and ongoing management of patients who will be, or are being, treated chronically with controlled substances. Most importantly, a healthcare professional should have a relationship of mutual honesty and trust with the patient when using UDT in the clinical practice, as well as maintain open communication with the testing laboratory. The use of UDT should be consensual; it is designed to improve patient care and to assist the healthcare professional to advocate on the patient’s behalf.³⁶

TABLE 3: Windows of Detection in Urine Drug Testing³⁶

Drug	Approximate Retention Time
Amphetamines	48 hours
Barbiturates	Short acting (eg, secobarbital): 24 hours Long acting (eg, phenobarbital): 2-3 weeks
Benzodiazepines	3 days, if therapeutic dose is ingested Up to 4-6 weeks after extended dosage (ie, 1 or more years)
Cocaine Metabolite	2-4 days
Ethanol	2-4 hours
Methadone	Approximately 3 days
Opiates	2 days
Propoxyphene	6-48 hours
Cannabinoids	Moderate smoker (4 times/week): 5 days Heavy smoker (smoking daily): 10 days Retention time for chronic smokers may be 20-28 days
Phencyclidine	Approximately 8 days Chronic users: up to 30 days  (mean value = 14 days)

Note: Interpretation of retention time must take into account variability of urine specimens, drug metabolism and half-life, patient's physical condition, fluid intake, and method and frequency of ingestion. These are general guidelines only.

TABLE 4: Suggested Screening Panel³⁶

A routine UDT screening panel should test for the following drugs/drug classes:

• Cocaine
• Amphetamines/Methamphetamine
• Opioids
• Methadone
• Marijuana
• Benzodiazepines

FIGURE 1. Metabolism of Opioids³⁷

Permission use granted by Dr. Howard Heit and Dr. Douglas Gourlay.

References Used in the Section:

• 36Heit HA, Gourlay DL. Urine Drug Testing in Pain Medicine. The Journal of Pain and Symptom Management. 2004; 27(3):260-267.
• 37Gourlay D, Heit H, Caplan Y. Urine Drug Testing in Primary Care: dispelling the myths & designing strategies. Monograph for California Academy of Family Physicians. 2006.

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