Drug Screens

I think there is a general misconception in the public that all drugs can be detected by a basic blood or urine drug screen. This is not true.

First, when is a drug screen done?

There are several instances where we would likely run a drug screen. Here are a few.

1. You are having suicidal ideation. Suicidal ideation means you are having thoughts/feelings of hurting yourself and either you have presented or someone has brought you to the ED. This is fairly standard to see what might be in your system. What also will be added will be an acetaminophen (Tylenol) and salicylate (Aspirin) level. These are blood levels.

2. You are acting crazy. Meaning– you’re hearing and seeing things that aren’t there. There are gait disturbances, a decreased level of consciousness. Perhaps even seizure activity. A common set-up for this scenario is a child or teen that begins to act funny at school. Here, there is a concern for ingestion and it will be best to sort out what we might be working with.

3. An actual ingestion in any age group. The history will be looked at very closely but if it is— toddler got into grandma’s medicine cabinet (this happens more often than you would think) and the youngster just flat out began to go through boxes/bottles swallowing everything in sight– he will get a urine drug screen.

A urine drug screen can be an effective screening tool. But it definitely does not rule out all substances. That is the most important thing to know.

So– the following drugs are on a basic drug screen. It may also be called a “drugs of abuse” of panel. Something along those lines.

1. Amphetamines— interesting thing about this is some ADHD drugs contain amphetamines so kiddos on these will show positive. If they are on an ADHD med in this drug class– it doesn’t mean that they are not also abusing other types of amphetamines.

2. Barbiturates: The Truth Serum Drugs (Amytal Sodium, Phenobarbital and Luminal). But, do these drugs really act as truth serum? Interesting article here: http://www.damninteresting.com/the-truth-about-truth-serum/

3. Benzodiazepines: Drugs like Valium, Versed and Ativan are in this drug class.

4. THC: Tetrahydrocannabinol. Cannabis. The active ingredient in marijuana.

5. Cocaine

6. Opiates: Stuff of the opium poppy seed plant. Morphine, Fentanyl, Vicodin, Lortab, Codeine

7. PCP

Notice what is not on the basic drug screen? Alcohol… we would have to test separately for this.

Is this what you thought was on a drug screen?

Ten Myths of Drug Addiction 2/2

Today, we’re concluding Dr. Rita Hancock’s guest post on the ten myths of drug addiction. Today, we’re finishing the last five. These posts have been a wealth of information. Thanks, Rita.

Myth #6:
Most addicts have a “favorite” class of drugs to abuse. Crank addicts don’t necessarily like barbiturates b/c crank addicts like uppers. They might like cocaine, though, b/c that’s also an upper.

Myth #7:

If you’re going to use the term “narcotics,” make sure you know what the term means. Not all habit-forming drugs are “narcotics.” Narcotics are only one specific type of drugs, even though the term “narcotics” is mistakenly used to describe all varieties of illicit drugs. E.g. a “narcotics” police officer actually investigates abuse of non-narcotic drugs, as well. Drugs that are potentially addictive but are non-narcotic include, amphetamines, cocaine, marijuana, hallucinogens, barbiturates, benzodiazepines, etc.

Myth #8:

Naloxone is a medicine used as a antidote for narcotic overdoses. But it does NOT treat overdoses of ALL (e.g. NON-narcotic) controlled substances. On TV shows, I’ve seen it given for barbiturate overdoses, and that’s utterly wrong. It’s used ONLY to reverse narcotic overdoses (with examples of narcotics being morphine, codeine, hydrocodone, oxycodone, methadone, etc.). Moreover, the effects of naloxone don’t last very long. If the overdose is on a long-acting narcotic like methadone, you’re going to have to repeat the naloxone dose after only a short time (like minutes). You might have to give the patient many doses of the naloxone before they’re “safe.”

Myth #9:

Flumazenil is a medicine used as an antidote for benzodiazepine withdrawals (e.g. Valium, Librium, Xanax, etc). In the same way that naloxone is specific for narcotic OD’s, flumazenil is specific for benzodiazepine withdrawals. Again, some benzo’s are longer-acting than others. If your character overdoses on a long-acting benzo, like Librium, he or she may need several doses of Flumazenil in the E.R. 

Myth #10:

There’s a drug called buprenorphine (an orally absorbable narcotic) that’s mixed with naloxone (a narcotic antidote) to form a new type of drug called Subutex (aka Suboxone). It’s novel and interesting b/c it can’t be abused easily and it’s often used to help addicts come off the drugs more safely. It gives the desired therapeutic effect only when you let it dissolve on the tongue. In contrast, if you try to abuse it by swallowing it or by altering it (by crushing, dissolving, etc.), the naloxone takes effect, overriding the narcotic portion, and causes you to go into withdrawals. Doctors have to apply for special licenses to administer Subutex, and they’re limited to having only a small number of patients on it at any given time for the purposes of detox.
Dr. Rita Hancock, a full-time physician and author of Christian health books, writes about how emotional and spiritual factors contribute to physical disease through the mind-body-Spirit connection. According to Dr. Rita, “Once these underlying barriers fall away in the healing light of God’s truth, patients automatically feel less physical pain, experience fewer stress-induced symptoms, lose weight, and shed addictive behaviors more easily.” Dr. Rita is the author of The Eden Diet (Zondervan, 2008) and an as-yet untitled release with Charisma House, pending January 2013. She resides in Oklahoma City with husband Ed, and two wonderful children, Lindsey and Cory.

Ten Myths About Drug Addiction 1/2

Dr. Rita Hancock, a specialist in pain management, is stopping by Redwood’s Medical Edge to discuss the Top Ten Myths about drug addiction. Today, we’re covering the first five. On Friday, we’ll finish off with the last five.

Welcome, Rita!

Myth #1:

If you claim a character in your story is “addicted,” make sure you know the accurate definition of the word. People confuse the terms “physiological tolerance” (meaning your body gets used to the medicine and, over time, you can need more and more medicine to get the same amount of pain relief), “physiological dependence” (meaning if you don’t take the medicine you go through physical withdrawals), and “psychological dependence” (THIS means “addicted,” i.e. you’re dependent on the medicine to cope with stress, anxiety, etc).

The first two are normal physical phenomena that happen in ALL patients who take heavy doses of narcotics, but only the last one is abnormal/pathological. Thus, if you claim your character is addicted, his or her behavior should show at least a few pathological psychological features (bad relationships, inability to hold a job, stealing to pay for fixes, lying to doctors for drugs, etc.).

Myth #2:

You don’t become physiologically tolerant and/or physically dependent on ALL drugs. Thus, you don’t necessarily go through withdrawals when you come off certain controlled substances (e.g. hallucinogens like marijuana and PCP don’t cause withdrawals). And not all withdrawal symptoms are the same. They depend on the drug in question. E.g. withdrawals symptoms and overdose treatment for alcohol/benzodiazepines/ barbiturates are similar. However, the symptoms of stimulant withdrawal and overdose will be totally different. The point is the writer needs to research the specific overdose and/or withdrawal symptoms for the individual drug his or her character is hooked on.

Myth #3:

Only SOME people are susceptible to addiction to controlled substances (don’t make the mistake of thinking that ALL people who take controlled substances eventually become addicted). People susceptible to addiction tend to exhibit addictive tendencies early on (teenage or young adult addictions to smoking, alcohol, etc). In general, young people are more susceptible to developing addiction because their coping skills aren’t yet developed and they can learn to rely on drugs for dealing with the underlying anxiety that leads them into addiction.

Myth #4:

I see many elderly people with severe, painful joint pathology who don’t want to take narcotics b/c they’re afraid of getting addicted. But if they’ve taken narcotics periodically during their lives for e.g. root canals, fractures, etc, and have never had a problem getting off the drugs, they’re at lower risk for addiction. As noted above, though, they will (especially if they’re on large doses) eventually become physically dependent).

Myth #5:

There’s a difference between pain and suffering. Pain happens when an inciting event causes pain receptors to fire (e.g. a burn, a sprain, a pulled muscle, etc.). However, that physical pain is interpreted by the brain in the context of the person’s emotional state. A highly anxious patient or one with a volatile psych history (history of abuse, etc.) is more likely to experience psychological “suffering” with a low level of pain.
Thus, if the person tries to medicate his or her subjective experience with pain using pain pills, he or she is likely to over-medicate to quell the anxiety. You’re not supposed to treat your anxiety with pain pills. That’s how you become addicted. Many, many chronic pain patients suffer with psych issues, and often those psych issues long pre-dated their chronic pain. Psych issues are a definite risk factor for chronic pain and addiction.



Drug Abuse in America: Part 2/3

Have you been to an ER in the last decade? If so, do you remember being asked about your pain level? The infamous question in the adult realm, “Sir, can you rate your pain on a scale of 0-10… zero being no pain and ten being the worst pain you’ve ever had in your entire life.” Every wonder why this was? Maybe you weren’t even in pain and they still asked you. Do you remember being in the ER perhaps two decades ago where there wasn’t a big push to know what your pain was? Maybe, you weren’t even asked.

What is JCAHO and what might it have to do with the drug abuse problem in the US?

JCAHO is an abbreviation for Joint Commission on Accreditation of Healthcare Organizations.  It is an organization made up of individuals from the private medical sector to develop and maintain standards of quality in medical facilities in the United States.Okay, great Jordyn, how can this possibly relate to the prescription abuse problem in the USA?

Joint Commission comes out with goals for medical care of patients. In the 90’s, one of their thoughts was that pain was not being adequately addressed among healthcare professionals so it became a standard for them to have us ask, evaluate and treat patients’ pain.

This Time magazine piece gives a nice consensus about how well intentioned bureaucracy intrusion can have disastrous effects on how medical care is delivered and ultimately leads to consequences for the patient:

“The U.S.’s opiate jag began, like so many things, with the best of intentions. In the 1990s, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) — the accrediting body for hospitals and other large care facilities — developed new policies to treat pain more proactively, approaching it not just as an unfortunate side effect of illness but as a fifth vital sign, along with temperature, heart rate, respiratory rate and blood pressure. As such, it would have to be routinely assessed and treated as needed. “It was a compassionate change,” says Barber. “Patient-advocacy groups pushed hard for it.” And, she points out, drug companies did too, since more-aggressive treatment of pain meant more more-aggressive prescribing.

But the timing was problematic. The new JCAHO policy went into effect in 2000, which was not only about the time the new opioids were hitting the market but also shortly after the Federal Trade Commission began allowing direct-to-consumer drug advertising. When market, mission and product converge this way, there’s little question what will happen. And before long, patients were not only being offered easy access to drugs but were actually having the medications pushed on them. No tooth extraction was complete without a 30-day prescription for Vicodin. No ambulatory surgery ended without a trip to the hospital pharmacy to pick up some Oxy. Worse, people with chronic pain were getting prescriptions that could be renewed again and again.”
What other government policies do you think are having a negative effect on patients?

Drug Abuse in America: Part 1/3

Dr. Edwards is here for his monthly post and I thought his topic of choice was very timely. He sent me a piece on dealing with chronic pain patients in the ED. This is a problem for every ED… including pediatrics.

In the past two years, I’ve been shocked by the number of chronic pain patients we are seeing in those under the age of 18. If you’re writing an in-depth novel with an ED worker in the center, this is one area of conflict you could explore.

How do we deal with these patients? Is there a component of drug addiction in this patient population? To say no for all cases would not be the truth either.

I think this trend bodes for some introspection on all of us. Here is Dr. Edwards post. On Wednesday and Friday this week I’m going to explore this topic more in depth and why there might be such an explosive prescription drug abuse problem in the US… and believe me… there is.

Desperately Seeking

Frank J. Edwards, MD

I hadn’t been practicing emergency medicine very long when I saw this particular patient, a thin woman in her mid-seventies wearing an old fashioned lace-collared evening gown.

“Doctor, I’ve passed another kidney stone,” she said.

My mind’s eye narrowed.  Was this a narcotic seeker?  Kidney stones are like white-hot ice picks thrust into one’s flank and violently twisted, over and over again.  Marine drill sergeants cry with kidney stones.  But there she sat smiling.  I was young.  Did she take me for an easy mark?

“Oh really,” I said.  “Are you looking for some medication, ma’am?”

“Heavens no,” she said.  “I thought you might like to see it.  I have these things all the time.”

“See it?”

Out of her cloth handbag, she fished a chunk of coarse roadbed gravel and plopped it in my hand.  Driving in the hospital entrance that muggy Sunday morning I had noticed a pile of similar stone.

“You can keep it if you like, doctor,” she said.

Since then, I’ve seen hundreds of patients feigning illnesses, but unlike the lady of the road gravel, they definitely want something more than the smidgeon of attention and sympathy she needed.   They may have headaches, back spasms, abdominal cramping or severe pelvic pain, but kidney stones do remain a common theme.  And, unlike her, they come in writhing and wincing.  When asked to give urine, they may prick their fingers and squeeze a drop of blood into the sample so the dipstick comes back positive. 

The typical drug seeker will have a genuine history of a disease characterized by recurrent episodes of agonizing pain.  Along with kidney stones, such conditions include migraine headaches, lumbar disc disease, fibromyalgia, inflammatory intestinal disorders (Crohn’s disease, for example), and pelvic problems such as endometriosis and interstitial cystitis.   Thanks to the powerfully addicting properties of the narcotics used to treat their pain, a handful gradually awaken in the labyrinth of Morpheus, from which escape is very hard.

These patients generate a swirl of negative emotions in healers.   You want to give everyone the benefit of the doubt, but you do not like the sense of being manipulated.  You do not want to reinforce their addiction, but on the other hand, you understand they are suffering.  You just do not really know how much of the suffering is physical pain and how much is . . . whatever.   And, Lord help the healer who pigeonholes a drug seeker and misses something disastrous.  Drug seekers get sick too.

So you examine them carefully and maybe run some tests, and you look for the usual clues.  Drug seekers often frequent many local EDs.  They’ve had multiple work-ups that never reveal anything new.  If you are blessed with the ability to look up records on the Internet (an innovation which can’t come too soon), you may discover they were in the ED at a hospital down the road just last week and neglected to mention it.   They are allergic to all the non-narcotic pain relief options and they know exactly which agent on the menu works best.  They demand the dose IV and require amounts that would kick most opiate virgins into a coma.
I know some healers who pretty much give in and give the drug seeker whatever he or she wants just to sweep them out quickly, and who may even discharge them with substantial prescriptions for more narcotics (a real mistake).  Other healers get angry and point to the door immediately.  Most of us are in the middle somewhere, but it is never a happy situation.  At some level, you feel like a drug dealer.  I assuage my conscience by counseling them on the dangers of secondary addiction, and try referring them to pain centers.  I’ve also stopped calling them drug seekers.  They are chronic pain patients until proven otherwise, which removes some of the tendency to pass judgment.

Regarding the danger of cynicism, not long ago, a doctor going off duty passed me a back-pain case.  His plan was to give this young man a single shot and send him packing in the hope he wouldn’t darken our doorway again.    The patient had admitted to visiting an urgent care center the day before and had furthermore confessed to heroin abuse in the past.

Slam dunk drug seeker, right?   Wait a minute.  How many of them volunteer a history of heroin abuse?  That’s either a pretty dumb drug seeker, or a rare instance of honesty.   I sat down and listened to his story, got a sense of his personality and observed the concern of his girl friend.  Then I re-examined him and ended up ordering a CT.  The next morning he had surgery for a severely herniated lumbar disc. 

Then, there are the true professional patients—few in number and slippery—who ply their ailments to score drugs for the street trade.   One patient I recall from many years ago made a circuit of EDs from Florida to Virginia.  He had a draining bone infection—chronic osteomyelitis of the tibia—from a motorcycle accident.  If he took his antibiotic, the wound would start to heal.  If he stopped taking his antibiotic, the wound would boil and drain pus.  He could literally shut it off and on like a faucet.

It was very hard to argue with such an ugly wound, and he reeled me in like a catfish on Valium.  Until I saw him again a few months later at an ED on the far end of North Carolina.  With a different name.


Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.