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Utility of Oral Fluid in Compliance Monitoring of Opioid Medications.

Conermann T, et al.

Journal: Pain Physician. 2014; 17:63-70. 15 references. 
Reprint: Till Conermann, M.D., West Penn Allegheny Health System, Anesthesiology and Pain Medicine, 5124 Liberty Avenue, Pittsburgh, PA 15212.
Email: tconerma@wpahs.org 
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.

Editor's Note:
Drug testing has become almost synonomous with urine collection and attempts to deceive have led, on occasion, to evasive techniques such as the wizinator, an artificial reservoir for a clean urine. This article details oral fluid collection and its promise.

Class: Drug testing

In pain management, urinalysis drug testing is often used to monitor patient compliance and is considered the gold standard for testing for the presence or absence of certain drugs. It has good specificity, sensitivity, ease of administration, cost and longer windows of detection than serum. As a test matrix, oral fluid (OF) has several advantages compared to urine since OF collections are typically observed, special facilities are not required and OF is difficult to adulterate. Therefore, for monitoring drug use and compliance in pain management as well as other testing areas, OF has be advocated as an alternative to urine.In this study, 153 paired OF and urine specimens were collected from June 2011 to February 2012 from patients who routinely donated urine on a random basis for compliance testing at a single pain management program in an urban setting. Although both sets of samples were tested for a wide range of medications, the data presented in this study are representative of analgesic opioids and benzodiazepine drug classes only. Of the 153 paired specimens tested, 88.8% (136) were positive for one or more treatment drugs in one matrix, or in both matrices. Confirmation of the positives was done with LC/MS/MS testing. Of the 132 positives pairs, 76.6% (101 pairs) showed exact drug class matches, 15.9% (21 pairs) had at least one drug class positive in both matrices, giving an overall agreement of 92.4%. Only one matrix was positive in 10 pairs: two were OF positive and urine negative; eight were OF negative and urine positive. Over all, in positive urine results, 191 positives averaged 1.4 drugs per specimen; 176 positives were detected using OF with an average of 1.3 drugs per specimen.Historically, urine has been the specimen of choice for drug analysis largely based on urine’s windows of detection being up to three to four days for most opioids and being practical for detecting recent use from metabolites in the urine. Disadvantages of urine drug testing include inability to detect very recent use, since it takes at least six to eight hours for oral medications to start to show up; difficulty collecting specimens from anuric or oliguric patients; and collection is commonly not observed in the clinic due to desire for patient privacy, which may allow for tampering. In a urine positive patient where OF was negative for opioids, it is likely attributable to no recent use within one day and lack of a detectable saliva level, but the urine would be expected to be positive for opioid metabolites if taken within the last three to four days. The route of administration and delivery also play a significant role in the window of detection for OF verses urine testing. OF matrix levels do approximate blood levels of opioid and benzodiazepine medications and may more accurately identify recent intake as seen in blood and saliva before being detectable in urine. Although the OF window of detection is earlier for most agents tested, the window of detection for nearly all opioids is shorter when compared to urine which may be a concern with intermittent dosing or low-level dosing regimens.

Important Points:

Urine drug analysis with validity testing remains the gold standard for compliance monitoring in pain patients. In this study over 90% of the paired samples were positive for at least one drugclass in paired urine and OF specimens. Over 75% of the paired samples showed exact drug class matches. This study project confirmed OF as a reasonable alternative matrix for the detection of prescription medications and its value as a specimen for monitoring patient compliance.

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