Urine drug screening in a forensic mental health population: frequency and clinical utility in risk management

AimsCo-existing mental illness and substance misuse is highly prevalent within the UK, with approximately 40% of people diagnosed with psychosis having a history of substance misuse. However, in Redbridge we currently do not have access to a dual diagnosis team or integrated care.This audit aims to assess the health and social implications of fragmented care, plus the effectiveness of mental health services in assessing patients with dual diagnosis and referring to specialist misuse teams. We used the NICE guidelines on co-existing severe mental illness and substance misuse [CG120] to help guide our recommendations.MethodWe identified 50 out of 359 patients within our service who were admitted to psychiatric hospital over a one year period (between 01/11/2019- 01/11/2020).We looked at medication compliance, use of the Mental Health Act and accommodation status to compare between those with and without known dual diagnosis. We used frequency and length of admission as indicators of how successfully patients were being managed in the community and the cost to the hospital trust. Urine drug screening and referral to substance misuse services were chosen as markers of whether patients were being appropriately managed on admission.ResultA higher percentage of patients with dual diagnosis were detained under the Mental Health Act compared to those without substance misuse (89% versus 72%). They were more likely to have no fixed abode (28% versus 13%) and be non-compliant with treatment pre-admission (83% versus 56%). Patients with dual diagnosis also had a higher number of hospital admissions, with a greater proportion having 3 admissions that year (11% versus 3%).Only 50% of patients with known dual diagnosis had a urine drug screen performed on admission and just 25% of patients who were currently misusing substances were referred to specialist services by the inpatient team.ConclusionOur audit found that there are overall poorer outcomes for patients with dual diagnosis versus a psychiatric illness only. It is evident that integration of services will improve the care we are able to provide and reduce costs associated with multiple admissions to hospital.We identified three key areas for improvement. Firstly, we advised on the need to improve documentation. Additionally, we recommend ensuring assessment of current drug misuse is done on admission, including performing simple tests such as urine drug screening. Finally, we highlighted the need to improve discussions about substance misuse with patients, within teams and between services, aiming for integrated and holistic care.

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Urine Drug Screening

Diagnostic Innovation ◽

10.2165/00024666-200111000-00004 ◽

2001 ◽

Vol 11 (3) ◽

pp. 18???22

Author(s):

Albert Jekelis

Keyword(s):

Drug Screening ◽

Urine Drug ◽

Urine Drug Screening

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Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing

Journal of Substance Abuse Treatment ◽

10.1016/j.jsat.2006.11.008 ◽

2007 ◽

Vol 33 (1) ◽

pp. 33-42 ◽

Cited By ~ 83

Author(s):

William B. Jaffee ◽

Elisa Trucco ◽

Sharon Levy ◽

Roger D. Weiss

Keyword(s):

Systematic Review ◽

Drug Screening ◽

Urine Drug ◽

Urine Drug Screening

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O30: Comparing the performance of HR-TOFMS and immunoassay for urine drug screening

Toxicologie Analytique et Clinique ◽

10.1016/s2352-0078(14)70038-1 ◽

2014 ◽

Vol 26 (2) ◽

pp. S18

Author(s):

M. Sundström ◽

A. Pelander ◽

I. Ojanperä

Keyword(s):

Drug Screening ◽

Urine Drug ◽

Urine Drug Screening

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Urine Drug Screening in the Era of Designer Benzodiazepines: Comparison of Three Immunoassay Platforms, LC-QTOF-MS, and LC-MS/MS

Journal of Analytical Toxicology ◽

10.1093/jat/bkab108 ◽

2021 ◽

Author(s):

Andrii Puzyrenko ◽

Dan Wang ◽

Randy Schneider ◽

Greg Wallace ◽

Sara Schreiber ◽

...

Keyword(s):

Drug Screening ◽

Forensic Toxicology ◽

Confirmatory Testing ◽

Urine Drug ◽

Screening Assays ◽

Us Fda ◽

Urine Specimens ◽

Abbott Architect ◽

Designer Benzodiazepines ◽

Urine Drug Screening

ABSTRACT This study investigated the presence of designer benzodiazepines in 35 urine specimens obtained from emergency department patients undergoing urine drug screening. All specimens showed apparent false-positive benzodiazepine screening results (i.e., confirmatory testing using a 19-component LC-MS/MS panel showed no prescribed benzodiazepines at detectable levels). The primary aims were to identify the possible presence of designer benzodiazepines, characterize the reactivity of commercially available screening immunoassays with designer benzodiazepines, and evaluate the risk of inappropriately ruling out designer benzodiazepine use when utilizing common urine drug screening and confirmatory tests. Specimens were obtained from emergency departments of a single US Health system. Following clinically ordered drug screening using Abbott ARCHITECT c assays and lab-developed LC-MS/MS confirmatory testing, additional characterization was performed for investigative purposes. Specifically, urine specimens were screened using two additional assays (Roche cobas c502, Siemens Dimension Vista) and LC-QTOF-MS to identify presumptively positive species, including benzodiazepines and non-benzodiazepines. Finally, targeted, qualitative LC-MS/MS was performed to confirm the presence of 12 designer benzodiazepines. Following benzodiazepine detection using the Abbott ARCHITECT, benzodiazepines were subsequently detected in 28/35 and 35/35 urine specimens, respectively, using Siemens and Roche assays. LC-QTOF-MS showed the presumptive presence of at least one non-FDA approved benzodiazepine in 30/35 specimens: flubromazolam (12/35), flualprazolam (11/35), flubromazepam (2/35), clonazolam (4/35), etizolam (9/35), metizolam (5/35), nitrazepam (1/35), and pyrazolam (1/35). Two or three designer benzodiazepines were detected concurrently in 13/35 specimens. Qualitative LC-MS/MS confirmed the presence of at least one designer benzodiazepine or metabolite in 23/35 specimens, with 3 specimens unavailable for confirmatory testing. Urine benzodiazepine screening assays from three manufacturers were cross-reactive with multiple non-US FDA-approved benzodiazepines. Clinical and forensic toxicology laboratories using traditionally designed LC-MS/MS panels may fail to confirm the presence of non-US FDA-approved benzodiazepines detected by screening assays, risking inappropriate interpretation of screening results as false-positives.

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