Substance Clarit y in Toxicolog y | v.10 i.1
What is Kratom? Abuse and legal status
v.10 i.1 2 Opioid Testing in Hair and Nail Specimens 4 What is Kratom?
Opioid Testing in Hair and Nail Specimens By: Michelle Lach, MSIMC
The opioid epidemic is an evolving crisis in drug addiction targeting both prescription and illicit opiates. According to the National Institute on Drug Abuse, every day more than 115 people in the United States die after overdosing on opioids. Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them. Between 8 and 12 percent develop an opioid use disorder and an estimated 4 to 6 percent who misuse prescription opioids transition to heroin.1 The complexity of the opioid epidemic from a detection standpoint is trying to figure out what drugs are being abused. We are working diligently to provide advancements and
fingernail–and they (2) trap drug and drug metabolites within layers of keratin making adulteration more difficult. When testing hair or nail for opioids it’s beneficial to understand the fundamental breakdown of some of the more highly abused substances and how they relate to the metabolites that are detected. For simplicity, we will focus only on the drugs and metabolites that are relevant to the hair and nail panels available at USDTL, seen in the Hair/Nail Drug Panels graphic. It is important to note that the interpretation of drug testing results may be determined by
W hen it co mes to d ete c t i on of proble m at ic beh av ior s on e of t he m o st a dvan ce d way s to d ete c t su b stan ces of abu se is to test a kerat in i z e d sp e ci me n , l i ke h air or n ail. education in the field of forensic drug testing to help make these complexities a little more clear. When it comes to detection of problematic behaviors one of the most advanced ways to detect substances of abuse is to test a keratinized specimen, like hair or nail. Both specimens are advantageous when detecting risky using behavior because they (1) have a long window of detection–up to 3 months for hair, up to 3-6 months for
a Medical Review Officer (MRO). A Medical Review Officer is “a licensed physician (MD or DO) who has knowledge of substance abuse disorders and has appropriate medical training to interpret and evaluate an individual’s positive test result together with his or her medical history and any other relevant biomedical information”.2 This is an incredibly important aspect of drug testing. A laboratory test can detect substances, but a MRO may be used to interpret what that detection means. (cont. on pg. 6)
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Hair and Nail Panels
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WHAT IS KRATOM? Originally published in: DRUGS OF ABUSE | A DEA Resource Guide: 2017 EDITION
Kratom is a tropical tree native to Southeast What does it do to your body? Asia. Consumption of its leaves produces both Kratomâ€™s effects on the body include nausea, stimulant effects (in low doses) and sedative itching, sweating, dry mouth, constipation, effects (in high doses), and can lead to psychotic increased urination, tachycardia, vomiting, symptoms, and psychological and physiological dependence. Several cases of psychosis resulting from use of kratom have been The psychoactive ingredient reported, where individuals addicted to kratom exhibited psychotic is found in the leaves from symptoms, including hallucinations, delusion, and confusion. the kratom tree. These leaves are subsequently crushed and then smoked, brewed with tea, or placed into drowsiness, and loss of appetite. Users of gel capsules. Kratom has a long history of use kratom have also experienced anorexia, weight in Southeast Asia, where it is commonly known loss, insomnia, hepatotoxicity, seizure, and as thang, kakuam, thom, ketum, and biak. In hallucinations. the U.S., the abuse of kratom has increased markedly in recent years. What is its legal status? Kratom is not controlled under the Federal How is it abused? Controlled Substances Act; however, there Mostly abused by oral ingestion in the form of may be some state regulations or prohibitions a tablet, capsule, or extract. Kratom leaves may against the possession and use of kratom. also be dried or powdered and ingested as a tea, The FDA has not approved Kratom for any or the kratom leaf may be chewed. medical use. In addition, DEA has listed kratom as a Drug and Chemical of Concern.
What are the effects?
At low doses, kratom produces stimulant effects with users reporting increased alertness, physical energy, and talkativeness. At high doses, users experience sedative effects. Kratom consumption can lead to addiction. Several cases of psychosis resulting from use of kratom have been reported, where individuals addicted to kratom exhibited psychotic symptoms, including hallucinations, delusion, and confusion.
Morphine, Codeine, and Heroin Morphine is available as a pharmaceutical opioid, and is also produced when the body metabolizes codeine or heroin. Codeine is metabolized directly to morphine. Heroin is metabolized to 6-Monoacetylmorphine (6-MAM) and then metabolized to morphine. The metabolite 6-MAM is unique because it is created only when heroin is metabolized.3 Being able to detect a heroin-specific metabolite such as 6-MAM is a very useful tool when trying to differentiate between morphine, codeine, or heroin ingestion, both intentional or unintentional.
Hydrocodone, Hydromorphone, and Norhydrocodone Hydrocodone (e.g., Norco®, Vicodin®) is metabolized to hydromorphone and norhydrocodone. While hydromorphone is a metabolite of hydrocodone, it is also available as a pharmaceutical opioid (e.g., Dilaudid®, Exalgo®). Norhydrocodone is not available as a pharmaceutical opioid and its presence implies ingestion, both intentional or unintentional
Oxycodone, Oxymorphone, and Noroxycodone Oxycodone (e.g., OxyContin®) is metabolized to oxymorphone and noroxycodone. While oxymorphone is a metabolite of oxycodone, it is also available as a pharmaceutical opioid (e.g., Opana®). Noroxycodone is not available as a pharmaceutical opioid and its presence implies ingestion, both intentional or unintentional.
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Incorporation of Drugs / Metabolites There are multiple routes in which drugs or drug metabolites can become incorporated into hair or nail. 1. Environmental Exposure: If someone is handling drugs or around someone smoking drugs, the drugs or drug metabolites get on the hair and nail and work their way into the pores, binding to the keratinized protein. 2. Sweat/Oil: Sweat and oil containing drugs or drug metabolites bathe the hair shaft or nail plate and work their way into the pores, binding to the keratinized protein. 3. Blood Supply: Blood supply deposits drugs or drug metabolites into the hair root, the germinal matrix of the nail, and the nail bed. Environmental exposure to substances can be detected immediately in hair and nail specimens. However, when drugs are ingested, they can be detected as early as 1-7 days after the last ingestion in hair, and 1-2 weeks after the last ingestion in nail. Due to normal hygiene habits (showering/bathing/washing) and exposure to the elements, degradation of drugs or drug metabolites can occur. References: 1) National Institute on Drug Abuse. (2018, March 06). Opioid Overdose Crisis. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis. 2) Journal of Occupational and Environmental Medicine: (January 2003 - Volume 45 - Issue 1 - p 102-103) Qualifications of Medical Review Officers (MROs) in Regulated and Nonregulated Drug Testing. Departments: ACOEM Consenus Opinion Statement 3) Von Euler M, (2003 Oct;25(5):645-8). Interpretation of the presence of 6-monoacetylmorphine in the absence of morphine-3-glucuronide in urine samples: evidence of heroin abuse. Therapeutic Drug Monitoring. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/14508389
Michelle Lach, Editor-in-Chief of Substance/NeoTox and Marketing Manager at USDTL, has over 10 years of experience working in the drug and alcohol abuse and testing industry helping bring a better understanding of advanced drug testing services to the public, so the right tests and the best results can be utilized.
Substance volume 10 issue 1
Managing & Design Editor
Michelle Lach, MSIMC
Kelly Crost, MS
Science Advisory Board
Douglas Lewis, D.Sc. Joseph Jones, Ph.D., NRCC-TC Adam Negrusz, Ph.D., F-ABFT
Substance is a news magazine of adult and adolescent toxicology science, data, and news. It is our mission to distill the technical world of toxicology, drug testing, and addiction science into plain words. If you have suggestions for topics you would like to know more about or are interested in contributing to our publication, let us know at email@example.com.
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