Search

Background: Drug overdose-related deaths continue to increase globally. Testing demands have likewise increased, prompting healthcare facilities to adopt a range of methods, from simple point-of-care immunoassays to comprehensive chromatographic and mass spectrometry-based techniques. Each of these testing methods has trade-offs related to cost, performance, speed, and convenience, requiring healthcare facilities to carefully determine the best options to meet their clinical needs. Unfortunately, current testing practices may result in unnecessary costs and certain methods, such as immunoassays, have significant limitations that affect their clinical utility. As such, the goal of this review is to frame the current state of drug testing and related cost-effectiveness and patient centered approaches to address this evolving public health challenge., Content: This review discusses the current state of substance use mortality/morbidity, the economic impact of substance use disorders, provides an overview of testing methods and their relative cost-benefit, solutions to improve test utilization and cost-effectiveness, and finally, future threats and new opportunities that can improve the clinical utility of these tests., Summary: The cost-effectiveness of drugs of abuse testing revolves around proper test utilization, including understanding what test is being ordered, its limitations, understanding results, and ordering testing when it can provide actionable information. Fundamental principles of test utilization such as education, clinical informatics, and optimizing test panels remain essential. Future threats in this space include new compounds and regulatory changes. However, novel solutions such as new noninvasive sample types, automation, and artificial intelligence can play a significant role in improving overall test utilization practices., (© Association for Diagnostics & Laboratory Medicine 2025. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Competing Interests: Conflicts of Interest: See Disclosures at the end of the article.

Background: The opioid crisis has had a substantial financial impact on the health care system in the United States. This study evaluates how health plans have been affected financially and shows how a laboratory benefit management (LBM) program can be used to address related drug testing in an outpatient setting., Methods: Monthly claims data from private health plans were collected from June 1, 2016 to February 29, 2020. The total number of claims (units) for definitive and presumptive drug testing were calculated and the number of paid claims recorded. Claims distribution by laboratory type and medical code billed, the paid rate and compound annual growth rate, and the test distribution and paid rate of rendering providers who had submitted a minimum of 1000 claims were determined., Results: In total, 2,004,230 drug testing claims were submitted. After the LBM program was implemented, the percentage of paid claims for definitive drug testing (Healthcare Common Procedure Coding System code G0483) decreased and the paid rate for the low-cost tests (HCPCS code G0480) in physician office and independent laboratory settings increased. The compound annual growth rate for G0483 claims submitted indicated a 70.5% and 31.9% decrease in payments to physician offices and independent laboratories, respectively, for the period ending February 2020., Conclusions: An LBM program can positively address policy enforcement while reducing unnecessarily complex tests and limiting potential fraud, waste, and abuse by directing testing toward laboratories amenable to cost-efficient contractual savings. Moreover, for definitive drug testing, the enforcement of the use of Healthcare Common Procedure Coding System codes and a move toward more cost-efficient tests (G0480), when clinically applicable, supported by clinical practice guidelines, or evidence-based medicine, is an approach to providing medical benefits while maintaining health costs., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Selective androgen receptor modulators (SARMs) are a group of anabolic enhancer drugs posing threats to the integrity of animal sports and the safety of animal-derived foods. The current research describes for the first time the development of a semi-quantitative assay for the monitoring of SARM family compounds in blood and establishes the relative stability of these analytes under various storage conditions prior to analysis. The presented screening method validation was performed in line with current EU legislation for the inspection of livestock and produce of animal origin, with detection capability (CCβ) values determined at 0.5 ng/mL (Ly2452473), 1 ng/mL (AC-262536 and PF-06260414), 2 ng/mL (bicalutamide, GLPG0492, LGD-2226, ostarine, S-1, S-6, and S-23), and 5 ng/mL (andarine, BMS-564929, LGD-4033, RAD140, and S-9), respectively. The applicability of the developed assay was demonstrated through the analysis of blood samples from racehorses and cattle. The developed method presents a high-throughput cost-effective tool for the routine screening for a range of SARM compounds in sport and livestock animals., (© 2020 The Authors. Drug Testing and Analysis published by John Wiley & Sons Ltd.)

Erythropoietins (EPOs) are substances listed in S2 of the World Anti-Doping Agency (WADA) Prohibited List and are used commonly by athletes to increase endurance performance. According to the current WADA Technical Documents, sarcosyl-polyacrylamide gel electrophoresis (SAR-PAGE) followed by western blotting to differentiate erythropoietins based on their molecular weights is the only method that can be used for both screening and confirmation of all types of erythropoietins. The efficiency of immunopurification and protein transfer is crucial for ensuring the selectivity and sensitivity of erythropoietin detection. Several comparisons and optimization of the SAR-PAGE tests were conducted in this study. We optimized the first blotting conditions and then compared different immunopurification methods based on their selectivity, repeatability, and sensitivity for both urine and blood analysis. Additionally, rapid procedures for both urine and blood analysis were established and compared. The two-step procedure at 1.0 mA/cm 2 for 60 min followed by 1.56 mA/cm 2 for 20 min increased the blotting efficiency compared with the commonly used constant current approach. Comparison of immunopurification revealed no significant difference in selectivity and sensitivity between the different methods. For other factors, such as operation complexity, time and cost, a StemCell® purification kit followed by single blotting and magnetic beads followed by double blotting are recommended for urine screening and confirmation, respectively. While magnetic beads and a MAIIA® kit followed by double blotting are recommended for both screening and confirmation of blood samples, respectively. To ensure high sensitivity and selectivity, double blotting is recommended for a rapid procedure for both urine and blood analysis., (© 2019 John Wiley & Sons, Ltd.)

Background: The technical advantages of direct-to-definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) urine testing for monitoring patient compliance in pain management are well known. However, the design and implementation of LC-MS/MS methods are more controversial, including factors such as determining appropriate cutoffs, specimen processing (e.g., specimen hydrolysis), reporting of qualitative and/or quantitative results, and test menu., Objectives: The objective of the research was to compare the clinical performance of our previous urine pain toxicology panel, a combination of immunoassay (IA) screens and LC-MS/MS, to our current pain toxicology panel, which features direct-to-definitive LC-MS/MS for 34 drugs and metabolites., Study Design: Six months of results from our previous pain toxicology panel were compared to 5.5 months of results from our current pain toxicology panel, enabling us to make conclusions regarding clinical performance., Setting: The research took place at Brigham and Women's Hospital in Boston, MA., Methods: The percentage of false positive IA results was evaluated for our previous pain toxicology panel. The positivity rates for each drug and/or metabolite were calculated for both the previous and current panels, including rates of detection of both prescribed and illicit drugs. The turnaround time (TAT), direct and send-out costs associated with each approach, as well as projected cost savings were also determined., Results: False positive rates with IA ranged from 0% to 29%; the highest false positive rate was seen for 6-acetylmorphine (6-AM). The elimination of IA, addition of metabolites, and/or lowering of cutoffs increased the detection rate of 6-AM, benzoylecgonine (cocaine metabolite), fentanyl, morphine, and oxycodone. The ability to differentiate compliance from simulated compliance improved after eliminating specimen hydrolysis. The TAT improved significantly and projected yearly cost savings with the current panel was $95,003 (USD). In our opinion, qualitative results appeared sufficient to assess compliance in the majority of cases., Limitations: Our study was performed in a single academic center in a specific geographic region; therefore, our results may not be generalizable to other types of centers or regions., Conclusion: Direct-to-definitive LC-MS/MS testing has several clinical benefits, including reduction of false positive results, improved assessment of patient compliance, decreased TAT, and increased detection of drug use and abuse. Cost savings were also realized using this approach., Key Words: Direct-to-definitive, LC-MS/MS, immunoassay, sensitivity, cost, pain management, turnaround time, patient compliance.

In the last few years an increasing number of new psychoactive substances (NPS), with different chemical structures (of which 37% are stimulants), have been released into the illicit drug market. Their detection and identification in biological samples is hence of great concern. The aim of this work was to develop a high-throughput and rapid method for the determination of different classes of stimulants (amphetamine-type stimulants, cathinones, phenethylamines and ketamine analogues) from blood and urine samples using GC-MS. The proposed method allows the almost simultaneous derivatization and extraction of analytes from biological samples in a very short time, by using hexyl chloroformate as derivatization agent. The extraction of analytes was performed by Dispersive Liquid Liquid Microextraction (DLLME), a very rapid, cheap and efficient extraction technique that employs microliter amounts of organic solvents. The chromatographic method allowed for the separation of 26 stimulants including positional isomers (3-MMC and 4-MMC). The method was validated on urine and blood samples with the ability to detect and quantify all analytes with satisfactory limits of detection (LODs) ranging between 1 and 10ng/mL, limits of quantification (LOQs) between 2 and 50ng/mL, selectivity and linearity (5-1000ng/mL). The method was then applied to real samples from forensic cases, demonstrating its suitability for the screening of a wide number of stimulants in biological specimens., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous-aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy.

Background: Many users believe that synthetic cannabinoids offer a safe and legal means of getting high. However, spikes in emergency department visits have been associated with use of synthetic cannabinoids. The purpose of the current study was to document emergency department visits from three large hospitals in one metropolitan area over a two month period., Method: This was a retrospective chart review examining 218 patients presenting to three inner city emergency departments between March and April 2014. Data collected included demographic information, information regarding ED diagnosis and treatment, signs and symptoms, ancillary testing, ED disposition, and cost of the medical treatment., Results: The majority of patients (75.7%) were discharged after ED workup, but 12.4% were admitted for medical treatment and 11.5% were admitted for psychiatric treatment. Ten patients (4.6%) were admitted to the ICU. Symptoms experienced most frequently include: hypertension, tachycardia, agitation, drowsiness, nausea, and confusion. Cluster analysis revealed four symptom clusters of individuals presenting after using synthetic cannabinoids: 1) confusion, hostility, agitation, 2) nausea, vomiting, abdominal pain, 3) drowsiness, and 4) the absence of these symptoms., Conclusion: This study has three important findings. First, significant ED resources are being used to treat individuals presenting due to effects of synthetic cannabis. Second, synthetic cannabis is not a benign substance. Third, while the hostile and agitated user is generally presented in the media, this study finds significant heterogeneity in presentation. Further research is needed to fully understand the implications of synthetic cannabinoid use., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A study was previously conducted and published describing the magnitude of the under-reporting of drugs in driving under the influence (DUI) cases by using a blood drug screen (BDS) case management protocol and to determine whether not reporting those drugs would have a meaningful impact on the DUI cases. A follow-up study presented herein was conducted to generate a larger dataset for evaluation and to compare the results to the original study. For this follow-up study of 576 cases, the laboratory BDS protocol was modified so that a BDS was performed for all felony cases and all misdemeanor cases with a BAC < 0.15 g/dL, regardless of the officer's request. A cost analysis estimate was also conducted using purchasing and statistical data for calendar year 2014. It was estimated that on average a BDS had a materials cost 30 times greater than a BAC and required over six times as much analyst time. To perform a BDS on every case as has been recommended, the estimated analysis materials cost and analyst time were 218 and 193% of the old protocol, respectively. The results of this follow-up study futher support the insufficiency of presenting drug positivity as a justification for completing drug analysis on every DUI case. For the vast majority of cases with a BAC > 0.08 g/dL, the drugs detected are not significant for supporting a DUI and do not warrant the substantial increase in analysis cost and time required., (© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

We describe the development and validation of a method for the screening and confirmation of a range of chemically diverse synthetic cannabinoid drugs in human whole blood. The method targets the better known arylindole compounds as well as the emerging aminocarbonyl/ carboxamide (NACA) compounds. The approach consists of two separate extraction procedures designed to optimize recovery of each of these two classes, followed by analysis by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The most significant novel compounds added were AB-FUBINACA, ADBICA, 5 F-ADBICA, ADB-PINACA, ADB-FUBINACA, ADB-FUBINACA, 5 F-ADB-PINACA, 5 F-ADB-PINACA, AB-PINACA, AB-CHMINACA, and ADB-CHMINACA. A third procedure is described for the quantitative confirmation of those compounds for which deuterated internal standards permitted quantitative analysis, including JWH-018, JWH-122, JWH-081, JWH-210, AM-2201, XLR-11, and UR-144. The methods were successfully validated according to Scientific Working Group in Forensic Toxicology (SWGTOX) protocol for 34 compounds in common use in the United States in the period of 2014 and 2015, although other substances, unknown at the time may have been introduced to the market over the same time period. The method was determined to be free from carry-over between samples, and no interference was found from other common therapeutic abused or novel psychoactive drugs. The methods were applied to the analysis of 1142 blood samples from forensic investigations, including post-mortem examinations and driving impairment cases. The drugs most frequently detected were AB-CHMINACA (18.6%), ADB-CHMINACA (15%), XLR-11 (5.5%), AB-FUBINACA (4.5%), AB-PINACA (3.9%), and ADB-FUBINACA (2.3%). Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Lysergic acid diethylamide (LSD) is a semi-synthetic hallucinogen that has gained popularity as a recreational drug and has been investigated as an adjunct to psychotherapy. Analysis of LSD represents a major challenge in forensic toxicology due to its instability, low drug concentrations, and short detection windows in biological samples. A new, fast, and sensitive microflow liquid chromatography (MFLC) tandem mass spectrometry method for the validated quantification of LSD, iso-LSD, 2-oxo 3-hydroxy-LSD (oxo-HO-LSD), and N-desmethyl-LSD (nor-LSD) was developed in plasma and applied to a controlled pharmacokinetic (PK) study in humans to test whether LSD metabolites would offer for longer detection windows. Five hundred microlitres of plasma were extracted by solid phase extraction. Analysis was performed on a Sciex Eksigent MFLC system coupled to a Sciex 5500 QTrap. The method was validated according to (inter)-national guidelines. MFLC allowed for separation of the mentioned analytes within 3 minutes and limits of quantification of 0.01 ng/mL. Validation criteria were fulfilled for all analytes. PK data could be calculated for LSD, iso-LSD, and oxo-HO-LSD in all participants. Additionally, hydroxy-LSD (HO-LSD) and HO-LSD glucuronide could be qualitatively detected and PK determined in 11 and 8 subjects, respectively. Nor-LSD was only sporadically detected. Elimination half-lives of iso-LSD (median 12 h) and LSD metabolites (median 9, 7.4, 12, and 11 h for oxo-HO-LSD, HO-LSD, HO-LSD-gluc, and nor-LSD, respectively) exceeded those of LSD (median 4.2 h). However, screening for metabolites to increase detection windows in plasma seems not to be constructive due to their very low concentrations. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

A rapid, simple and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed for the qualitative and quantitative analysis of nine barbiturates (barbital, phenobarbital, pentobarbital, amobarbital, secobarbital, thiopental, butalbital, butabarbital, and hexobarbital) in human whole blood. Barbiturates were extracted from 100 μL of human whole blood samples using a simple liquid-liquid extraction (LLE) procedure, and detected by LC-MS/MS. An UPLC C18 (2.1 mm × 100 mm, 1.7 µm) column was used at 40 °C for the separation and acetonitrile/water system was used as the mobile phase with gradient elution. This method showed excellent accuracy (86-111%) and precision (relative standard deviation <15%). The limits of detection (LODs) were 0.2 ng/mL for barbital and secobarbital and 0.5 ng/mL for the other barbiturates. The linearity ranged from 2 ng/mL to 2000 ng/mL, with r 2  > 0.99 over the range. This method achieved the separation and detection of pentobarbital and amobarbital at the same time in a convenient way. Moreover, it was both simple and sensitive for the determination of nine most commonly used barbiturate drugs, which was meaningful in the field of clinical and forensic toxicology. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

A rapid and direct paper spray ionization/mass spectrometry (PSI/MS) method was developed for quantitative analysis of ephedrine, pseudoephedrine, norpseudoephedrine, and methylephedrine in human urine. This method involves the use of a triangular filter paper and high-resolution mass spectrometry, where the molecular ions of ephedrines were generated by applying high voltage after loading the spray solvent to the paper which urine sample was pre-loaded. Small amounts (2μL) of urine spiked with an internal standard were directly analyzed for ephedrines. The PSI/MS method was validated for linearity, within- and between-run precision, accuracy, and limit of detection. The results showed good linearity (R(2)≥0.9928) and acceptable precision and accuracy. Furthermore, the accuracy of the method was assessed by analyzing a blind urine sample from World Anti-Doping Agency and comparing the measured concentrations with the nominal concentrations. This test resulted in accuracies ranging from 96.4 to 106.1%, indicating that the PSI/MS method has the potential to be an alternative technique for the fast quantitation of ephedrines in doping control analysis., (Copyright © 2016 Elsevier B.V. All rights reserved.)

We present a UPLC(®)-High Resolution Mass Spectrometric method to simultaneously screen for nineteen benzodiazepines, twelve opiates, cocaine and three metabolites, and three "Z-drug" hypnotic sedatives in both blood and urine specimens. Sample processing consists of a high-speed, high-temperature enzymatic hydrolysis for urine samples followed by a rapid supported liquid extraction (SLE). The combination of ultra-high resolution chromatography with high resolution mass spectrometry allows all 38 analytes to be uniquely detected with a ten minute analytical run. Limits of detection for all target analytes are 3ng/mL or better, with only 0.3mL of specimen used for analysis. The combination of low sample volume with fast processing and analysis makes this method a suitable replacement for immunoassay screening of the targeted drug classes, while providing far superior specificity and better limits of detection than can routinely be obtained by immunoassay., (Published by Elsevier B.V.)

In recent years, many new psychoactive substances (NPS) from several drug classes have appeared on the drug market. These substances, also known as 'legal highs', belong to different chemical classes. Despite the increasing number of NPS, there are few comprehensive screening methods for their detection in biological specimens. In this context, the purpose of this study was to develop a fast and simple liquid chromatography-tandem mass spectrometry (LC-MS/MS) screening procedure for NPS in blood. The elaborated method allows the simultaneous screening of 143 compounds from different groups (number of compounds): cathinones (36), phenethylamines (26), tryptamines (18), piperazines (9), piperidines (2), synthetic cannabinoids (34), arylalkylamines (7), arylcyclohexylamines (3), aminoindanes (2), and other drugs (6). Blood samples (0.2 mL) were precipitated with acetonitrile (0.6 mL). The separation was achieved with gradient mobile phase of 0.1% formic acid in acetonitrile and 0.1% formic acid in water in 14 min. Detection of all compounds was based on multiple reaction monitoring (MRM) transitions. The total number of transitions monitored in dynamic mode was 432. The whole procedure was rapid and simple. The limits of detection (LODs) estimated for 104 compounds were in the range 0.01-3.09 ng/mL. The extraction recoveries determined for 32 compounds were from 1.8 to 133%. The procedure was successfully applied to the analysis of forensic blood samples in routine casework. The developed method should have wide applicability for rapid screening of new drugs of abuse in forensic or clinical samples. The procedure can be easily expanded for more substances. Copyright © 2015 John Wiley & Sons, Ltd., (Copyright © 2015 John Wiley & Sons, Ltd.)

The concentration of 11-nor-9-carboxy-Δ(9)-tetrahydrocannabinol (THCCOOH) in whole blood is used as a parameter for assessing the consumption behavior of cannabis consumers. The blood level of THCCOOH-glucuronide might provide additional information about the frequency of cannabis use. To verify this assumption, a column-switching liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the rapid and direct quantification of free and glucuronidated THCCOOH in human whole blood was newly developed. The method comprised protein precipitation, followed by injection of the processed sample onto a trapping column and subsequent gradient elution to an analytical column for separation and detection. The total LC run time was 4.5 min. Detection of the analytes was accomplished by electrospray ionization in positive ion mode and selected reaction monitoring using a triple-stage quadrupole mass spectrometer. The method was fully validated by evaluating the following parameters: linearity, lower limit of quantification, accuracy and imprecision, selectivity, extraction efficiency, matrix effect, carry-over, dilution integrity, analyte stability, and re-injection reproducibility. All acceptance criteria were analyzed and the predefined criteria met. Linearity ranged from 5.0 to 500 μg/L for both analytes. The method was successfully applied to whole blood samples from a large collective of cannabis consumers, demonstrating its applicability in the forensic field.

Drug screening is an essential component of clinical toxicology laboratory service. Some laboratories use only automated chemistry analyzers for limited screening of drugs of abuse and few other drugs. Other laboratories use a combination of various techniques such as immunoassays, colorimetric tests, and mass spectrometry to provide more detailed comprehensive drug screening. Mass spectrometry, gas or liquid, can screen for hundreds of drugs and is often considered the gold standard for comprehensive drug screening. We describe an efficient and rapid gas chromatography/mass spectrometry (GC/MS) method for comprehensive drug screening in urine which utilizes a liquid-liquid extraction, sample concentration, and analysis by GC/MS.

The author argues that drug testing of U.S. high school students for performance-enhancing substance misuse is invasive, expensive, and the low number of positive test results do not justify the costs, especially in financially strapped school districts where this money would be better spent on injury prevention for athletes and the education of all students.

The anti-doping system, under the guidance of WADA, costs at least $228 million per year, mostly to cover the cost of performing about 270,000 doping tests. However, "testing has not proven to be particularly effective in detecting dopers/cheats" (WADA). It is suggested, competitions of doping-endangered disciplines be redesigned. Sports with numerous doping cases should be temporarily excluded from the Olympic program and not be televised. Pecuniary fines should be higher and collection guaranteed by a deferred compensation model. Sports with multiple doping offenses should bear most of the anti-doping costs. Finally, appropriate tenders should guarantee fees of anti-doping laboratories develop more competitively.

Dimethylamylamine (DMAA) is a sympathomimetic amine found in weight-loss/workout supplements or used as an appetite suppressant. DMAA is a stimulant that is banned by the World Anti-Doping Agency (WADA). Adverse health effects as well as fatalities have been implicated with its use. Direct analysis in real time mass spectrometry (DART-MS) is an ambient ionization method that was employed to rapidly identify the presence of DMAA in various samples without any extraction or preparations whatsoever. DMAA was first identified in supplements, sampled directly in their solid forms. Furthermore, DMAA was detected directly in urine over 48 h as a means of indicating recent abuse of the substance. DART-MS analysis is instantaneous, and coupled with the high mass accuracy associated with the time-of-flight mass analyzer, results in unequivocal identification of the presence of DMAA. These features demonstrate DART-MS as an attractive potential alternative screening method for the presence of drugs and medications or for toxicological investigations., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objective: Study tested whether cocaine dependent patients using cocaine or alcohol at intake or in the first few weeks of intensive outpatient treatment would benefit more from extended continuing care than patients abstinent during this period. The effect of incentives for continuing care attendance was also examined., Method: Participants (N = 321) were randomized to treatment as usual (TAU), TAU and telephone monitoring and counseling (TMC), or TAU and TMC plus incentives (TMC+). The primary outcomes were (a) abstinence from all drugs and heavy alcohol use and (b) cocaine urine toxicology. Follow-ups were at 3, 6, 9, 12, 18, and 24 months., Results: Cocaine and alcohol use at intake or early in treatment predicted worse outcomes on both measures (ps ≤ .0002). Significant effects favoring TMC over TAU on the abstinence composite were obtained in participants who used cocaine (odds ratio [OR] = 1.95 [1.02, 3.73]) or alcohol (OR = 2.47 [1.28, 4.78]) at intake or early in treatment. A significant effect favoring TMC+ over TAU on cocaine urine toxicology was obtained in those using cocaine during that period (OR = 0.55 [0.31, 0.95]). Conversely, there were no treatment effects in participants abstinent at baseline and no overall treatment main effects. Incentives almost doubled the number of continuing care sessions received but did not further improve outcomes., Conclusion: An adaptive approach for cocaine dependence in which extended continuing care is provided only to patients who are using cocaine or alcohol at intake or early in treatment improves outcomes in this group while reducing burden and costs in lower risk patients.

Background: The cost of opiate substitution is usually considered lower in cost when methadone is used, as compared to that of buprenorphine, however the overall cost effectiveness of substitution programmes comparing the two drugs remains largely unknown., Methods: We evaluated the treatment cost and effectiveness of methadone and buprenorphine when used in an opiate substitution programme in Norfolk, UK. All programme costs, estimated from the perspective of the drug treatment clinic, were collected on 361 opiate-dependent participants over a six-month period. Total costs comprised medication (methadone or buprenorphine) costs, pharmacy supervision and dispensing costs, and drug service clinic costs. Effectiveness was measured in terms of (1) each programmes ability to retain participants in the programme for six months, and (2) the ability of the programme to accomplish complete abstinence from illicit opiate consumption., Results: Overall, mean medication-only costs of methadone were lower than that of buprenorphine, however, pharmacy and clinic costs were lower for the buprenorphine programme. The covariate-adjusted mean total cost of the two programmes was not significantly different. Mean six-month retention rates were higher on the methadone programme, therefore, the methadone programme "dominates" the buprenorphine programme as it was slightly more effective for the same cost. Conversely, when ability to stop taking illicit opiates concomitant with opiate substitution medication was considered, the buprenorphine programme was more effective with an additional cost of £903 per individual who stopped illicit opiate use., Conclusions: The provision of buprenorphine should be considered an appropriate treatment if cessation of illicit opiate use, concomitant with programme retention is considered an important outcome., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

A simple LC-MS/MS method was developed and validated for quantitatively analyzing six classes of 26 abused drugs and metabolites in human urine: (1) illicit drugs; (2) opiates; (3) synthetic opioids; (4) sedative; (5) stimulants; and (6) γ-aminobutyric acid analogs. All urine samples were diluted with a mixture of isotope-labeled internal standards, hydrolyzed with β-glucuronidase and directly injected in a gradient chromatographic run. The mobile phase was composed of 0.1% formic acid in water and 0.1% of formic acid in methanol. A 4.9 min run time using the multiplexing driver and ultra-biphenyl column (50 × 2.1 mm, 5 µm, RESTEK) allowed all drugs to have sufficient resolution in a short elute time. The overlapping liquid chromatography runs and scheduled multiple reaction monitoring acquisition method resulted in a higher overall throughput for the system. The result was linear over the studied range (2-16,000 ng/mL) for all compounds with correlation coefficients r(2) ≥ 0.995. The intra-day and inter-day precisions and accuracies were within 15% and recovery was between 83 and 115% for all analytes. Freeze-thaw stability for three cycles and long-term stability (57 days, -20°C) were established for all analytes. The cross-validation between College of American Pathologists and in-house was validated (0.06% ≤ bias ≤ 12.3%). The applicability of the method was examined by analyzing urine samples from chronic pain patients (n = 610)., (Copyright © 2013 John Wiley & Sons, Ltd.)

Stanozolol is one of the most frequently detected anabolic steroids in doping control samples. This compound is metabolized to a large extent and its metabolites can be detected in urine much longer than the parent compound. The main stanozolol metabolites are excreted in urine as glucuronide conjugates and 3'-hydroxy-stanozolol glucuronide (3STANG) is one of the most important in human urine. Therefore enzymatic hydrolysis is usually applied prior to extraction. In this article a method for the sensitive detection of intact 3'-hydroxy-stanozolol glucuronide, by liquid chromatography tandem mass spectrometry, is described. The method takes advantage of an easy and fast sample preparation based on a single solid-phase extraction avoiding enzymatic hydrolysis or derivatization. It allows to detect stanozolol abuse in human urine at 25pgmL(-1). The method was validated according to Eurachem guidelines. The matrix effect, expressed as ion enhancement was +14%. The extraction recovery of the method was 93%. The limit of detection (LOD), whereby all WADA-criteria in chromatography and mass spectrometry are fulfilled, was determined at 50pgmL(-1). Application of the method to an excretion study revealed that the 3'-hydroxy-stanozolol glucuronide could be confirmed for 10 days after oral administration of 2mg of stanozolol, prolonging detection times compared to other metabolites and methodologies by almost 50%., (Copyright © 2013 Elsevier B.V. All rights reserved.)

The continuous appearance of novel psychoactive substances (NPS) in legal high products presents a challenge for the routine analytical laboratory. A rapid screening method for NPS analysis using fast gas chromatography mass spectrometry (fast GC-MS) is presented. Twenty-three analytes, including 5-iodo-2-aminoindane (5-IAI), 1-(thiophen-2-yl)-2-methylaminopropane (MPA), 1-benzylpiperazine (BZP), 4-methylmethcathinone (mephedrone), 5,6-methylenedioxy-2-aminoindane (MDAI) and methoxetamine (MXE) were separated within 4 min. The method was used to analyze 35 Internet and head shop purchased 'legal high' products with the successful identification of their active ingredients. As previously observed, legal high products do not always contain their stated ingredients. Of the group of products purchased as 5-IAI not one contained 5-IAI with several containing mixtures of substances either already controlled in the UK or under consideration by the Advisory Council on Misuse of Drugs (ACMD). The low bleed and high inertness of the chromatography column used ensured clean high quality mass spectrometry data which when combined with the short run time resulted in an efficient tool for NPS screening, even when standards were unavailable. Electron impact and chemical ionization mass spectra used in combination for the identification of unknown NPS are presented., (Copyright © 2013 John Wiley & Sons, Ltd.)

A rapid and simple gas chromatography-mass spectrometry (GC-MS) method was developed and validated to identify and quantify synthetic cannabinoids in the materials seized during drug trafficking. Accuracy and reproducibility of the method were improved by using deuterated JWH-018 and JWH-073 as internal standards. Validation results of the GC-MS method showed that it was suitable for simultaneous qualitative and quantitative analyses of synthetic cannabinoids, and we analyzed synthetic cannabinoids in seized materials using the validated GC-MS method. As a result of the analysis, ten species of synthetic cannabinoids were identified in dried leaves (n = 40), bulk powders (n = 6), and tablets (n = 14) seized in Korea during 2009-2012, as a single ingredient or as a mixture with other active co-ingredients. JWH-018 and JWH-073 were the most frequently identified compounds in the seized materials. Synthetic cannabinoids in the dried leaves showed broad concentration ranges, which may cause unexpected toxicity to abusers. The bulk powders were considered as raw materials used to prepare legal highs, and they contained single ingredient of JWH-073, JWH-019, or JWH-250 with the purity over 70 %. In contrast, JWH-018 and JWH-073 contents in the tablets were 7.1-13.8 and 3.0-10.2 mg/g, respectively. Relatively low contents in the tablets suggest that the synthetic cannabinoids may have been added to the tablets as supplements to other active co-ingredients.

Background: Road users driving under the influence of psychoactive substances may be at much higher relative risk (RR) in road traffic than the average driver. Legislation banning blood alcohol concentrations above certain threshold levels combined with roadside breath-testing of alcohol have been in lieu for decades in many countries, but new legislation and testing of drivers for drug use have recently been implemented in some countries., Methods: In this article we present a methodology for cost-benefit analysis (CBA) of increased law enforcement of roadside drug screening. This is an analysis of the profitability for society, where costs of control are weighed against the reduction in injuries expected from fewer drugged drivers on the roads. We specify assumptions regarding costs and the effect of the specificity of the drug screening device, and quantify a deterrence effect related to sensitivity of the device yielding the benefit estimates., Results: Three European countries with different current enforcement levels were studied, yielding benefit-cost ratios in the approximate range of 0.5-5 for a tripling of current levels of enforcement, with costs of about 4000 EUR per convicted and in the range of 1.5 and 13 million EUR per prevented fatality., Conclusions: The applied methodology for CBA has involved a simplistic behavioural response to enforcement increase and control efficiency. Although this methodology should be developed further, it is clearly indicated that the cost-efficiency of increased law enforcement of drug driving offences is dependent on the baseline situation of drug-use in traffic and on the current level of enforcement, as well as the RR and prevalence of drugs in road traffic., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The use of illegal drugs generates a wide range of social harms depending on various ways, according to the policy definition of the problem. The challenge is the way to model the impact of illegal drugs use during a long time period considering the factors that affects the process. Based on these models, estimation could be measured and prediction could be achieved. The illegal drugs use might affect the economic and social structure of the public system leading to direct and effective decisions to overcome the problematic. For that reason, calculation of social cost related to the use of illegal could be introduced over time (t) as a proposed social measure to define the variability of social indicator on society. In this work, a theoretical approach for the calculation of social cost of illegal drugs is proposed and models over time are defined.

Background: Overcrowding and prolonged length of stay in emergency departments (ED) are increasing problems in hospitals. Rapid availability of all laboratory results has an impact on clinical decision-making, admissions or discharge decisions and resource utilisation. Increasing number of our urinary drugs of abuse (DOA) screens had a turnaround time (TAT) of up to 33 days after the discharge of the patient., Materials and Methods: Following an audit and a consultation period with clinicians using the service, a policy change was implemented to reduce the use of gas chromatography mass spectroscopy (GCMS): all requests would have a standard immunoassay (IA) test panel undertaken unless specifically they requested GCMS (including medico-legal) analysis., Results: Almost all of the clinicians interviewed had no understanding of the DOA screening or the difference in the information generated between a confirmatory GCMS urine toxicology screen and IA DOA panel. It appeared none of the patients surveyed in the audit would have had a different clinical decision made if a GCMS had not been undertaken. Post change audit showed only 4.3% of drug requests for IA also received a confirmatory GCMS testing. The estimated saving post change implementation was $127,000 (AU $) in test costs alone over a two year period. The TAT of GCMS results was reduced to 3-4 days., Conclusion: A laboratory-led behavioural change in test requesting is possible and sustainable provided the reason is clinically sound and accompanied by consultation and availability of advice by phone when requested on test requesting or interpretation.

Objective: This article summarizes the literature on the implementation costs of alcohol screening and brief intervention (SBI) in medical settings., Method: Electronic databases were searched using SBI- and cost-related terms. Methodological approaches and cost estimates were abstracted from each study and categorized based on the cost methodology. Costs were updated to 2009 U.S. dollars. To determine a summary cost measure, we excluded outliers and computed the median of the remaining cost estimates., Results: Seventeen studies with cost estimates were identified for further study. Costs ranged from $0.51 to $601.50 per screen and from $3.41 to $243.01 per brief intervention (BI). Cost estimates were lower when an activity-based cost methodology was used, in primary care settings, and when the provider was not a doctor. The median summary cost of a screen is approximately $4, and the median summary cost of a BI is approximately $48., Conclusions: Screening cost estimates had more variation than BI cost estimates. Provider type and service delivery time drive the cost variation. Interpretation of cost differences was limited by insufficient reporting of the cost methodology. Cost estimates presented here are similar in size to the Healthcare Common Procedure Coding System and Current Procedural Terminology reimbursement amounts, suggesting that insurance-based service reimbursement may be sufficient to sustain alcohol SBI in practice.

Objectives: To estimate the cost of providing methadone maintenance treatment in Ontario, Canada, from the perspective of the public payer., Methods: We analyzed a database of all patient clinic visits, laboratory tests for urine toxicology screening, and methadone scripts from a group of methadone clinics in Ontario. The database consisted of patient visits and visit information from 1 January 2003 to 31 December 2009. We estimated the cost of providing methadone maintenance treatment as the sum of physician costs, laboratory costs for urine samples (toxicology screens), methadone costs, and pharmacy costs. Pharmacy costs include dispensing fees and markups. All costs are expressed in 2010 Canadian dollars., Results: The database consisted of 9479 unique patients. The average age on the date of the first recorded visit was 34.3, and among the patients 62.3% were male. There were 6,425,937 patient days of treatment and the total cost of all treatment-related services was approximately $99,491,000. The total cost was comprised of physician billing (9.8%), pharmacy costs (39.8%), methadone (3.8%), and performing urine toxicology screens (46.7%). The average cost per day for treatment was $15.48, corresponding to $5651per year if patients were to remain in treatment continuously., Conclusions: The cost of providing methadone maintenance treatment in Ontario is comparable to estimates from the United States and Australia., Scientific Significance: This information is important to policy makers for planning and budgeting purposes and as part of a full cost-benefit or cost-effectiveness analysis of methadone treatment.

Introduction: The use of psychoactive drugs by militaries is not compatible with the analytical skills and self-control required by their jobs. Military physicians take this problem into consideration by organising systematic drugs screening in the French forces. However, for technical reasons, opiates are not concerned by this screening with the agreement of the people concerned. The estimated number of militaries who use an opiate substitute may be an approach of heroin consumption in the French forces. This study describes buprenorphine and methadone reimbursements made during 2007 by the national military healthcare centre to French militaries., Material and Method: Each French soldier is affiliated to a special health insurance. The national military healthcare centre has in its information system, all the data concerning drug reimbursement made to French military personnel. This is a retrospective study of buprenorphine and methadone reimbursements made during 2007 by the military healthcare centre, to militaries from the three sectors of the French forces, and from the gendarmerie and joint forces. Only one reimbursement of one of these two drugs during this period allowed the patient to be included in our study. Daily drug dose and treatment steadiness profile have been calculated according to the criteria of the French monitoring centre for drugs and drug addiction. The criteria of the National guidelines against frauds have been used to identify misuse of these drugs. Doctors' shopping behaviour has also been studied. Finally, the nature of the prescriber and the consumption of other drugs in combination with opiate substitute have been analysed., Results: One hundred and eighty-one military consumers of opiate substitute drugs (167 men and 14 women) participated. This sample included people from the three sectors of the French forces as well as from the gendarmerie and from the joint forces. The average age of the consumers was 26.6 years (20-42 years). The average length of service was 6.1 years (maximum 22 years service). One hundred and fifty-nine militaries had been delivered buprenorphine, 15 had been delivered methadone and seven had been delivered both. The prevalence of opiate substitute drug consumption by the militaries (52 per 100,000) is lower than in general population. According to the criteria of the National Healthcare Insurance, this population is not affected by abuse or fraud behaviour. Doctors' shopping behaviour is unusual. Opiate substitutes are prescribed by general physicians in 88% of issues. Only one prescriber was a military physician. An analysis of reimbursement of some drugs associated with opiate substitute has been made. The sampled military consume more psychoactive drugs (anxiolytics, antidepressants, hypnotics) than the French population under opiate substitution., Conclusion: In our observation, the military physician is almost always excluded the process of substitution. His/her different responsibilities of care, but also in determining the working aptitude, lead to dissimulation behaviour by the militaries. The difficulty for military physicians is to identify such consumption. They have to evaluate the capacity to work through a physical and psychological examination., (Copyright © 2011 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

A fast and sensitive reference method for quantification of Δ(9) -tetrahydrocannabinol (THC) and its main metabolite 11-nor-9-carboxy-Δ(9) -tetrahydrocannabinol (THCCOOH) in oral fluid is described in this study. Samples were collected using an oral specimen collection device, followed by solid-phase extraction and liquid chromatography-tandem mass spectrometry analysis. Chromatographic separation of the analytes was achieved by gradient elution on a reversed-phase column with subsequent detection by electrospray triple quadrupole mass spectrometry in positive ionization multiple reaction monitoring mode. Quantification was performed by means of deuterated analogues of the analytes as internal standards. Total run time of the assay was 12 min. The method allowed sensitive quantification of both analytes at a limit of quantification of 0.2 ng/ml. This sensitivity is essential for analysis of samples collected with the Intercept Oral Fluid Collection device (OraSure) and an assay for simultaneous quantification of THC and THCCOOH in saliva has not yet been described. The calibration curves for THC and THCCOOH were linear in the range between 0.25 and 8 ng/ml (r(2)  > 0.99). Ion suppression effects from endogenous or exogenous interferences were investigated using selected model substances (albumin, ascorbic acid, bilirubin, hemoglobin, breath spray, cigarette, chewing gum, chewing tobacco, candy, tooth whitening, and Tums antacid). These substances were chosen because of the high probability of their presence in the collected samples. None of the 11 endogenous model interferences altered the accuracy of analysis, demonstrating good robustness of the method with respect to interferences in common hygiene products, medicine, tobacco and naturally occurring endogenous substances., (Copyright © 2012 John Wiley & Sons, Ltd.)

Objective: The purpose of this retrospective study was to compare oxycodone concentrations in saliva and whole blood with a view to propose therapeutic concentrations in oral fluid. Oral fluid is an easy specimen to collect with several advantages over urine, including ease of collection and difficulty of adulteration. As oral fluid is a reflection of free drug circulating in the blood, drug concentrations in saliva are more closely related to blood levels than urine concentrations. The number of testing laboratories offering the analysis of prescription pain medications in urine has increased significantly over the last few years, along with the overuse and abuse of pain killing drugs, specifically oxycodone. Hence, the utility of oral fluid analysis in this field was assessed., Design: Paired specimens of blood and oral fluid were retrospectively studied in an attempt to establish a range for oxycodone concentrations in oral fluid reflective of therapeutic intake. Twenty-three paired oral fluid-blood specimens were studied. Oral fluid samples had been collected with the Quantisal™ oral fluid device, stored cold and shipped overnight to the laboratory prior to testing. Blood specimens were collected simultaneously in gray top tubes., Results: From 23 pairs of samples, the median concentration in oral fluid was 524 μg/L and blood was 53 μg/L. The whole blood to plasma ratio for oxycodone was 1.3, so the median plasma concentration was 41 μg/L projecting a saliva to plasma ratio (S:P ratio) of 12. The comparison of oral fluid-blood concentrations allowed the projection of a S:P ratio for oxycodone and the development of a potential therapeutic range for oxycodone in oral fluid., Conclusion: Saliva drug concentrations in pain management are more closely related to blood levels than urine so can be more easily interpreted. These data provide a foundation for interpretative advances; however, further research surrounding other pain medications and controlled studies are necessary.

Random drug testing of people being treated for chronic pain has become more common. Physicians may drug test patients on opioid therapy as a result of concerns over prosecution, drug misuse, addiction, and overdose. However, profit motive has remained unexplored. This article suggests profits also drive physician drug-testing behavior and evidence is offered, including an exploration of Medicare reimbursement incentives and kickbacks for drug testing.

A screening procedure specifically developed for the detection of saccharides and polyalcohols in human urine in the framework of doping control analysis is presented. The proposed method, set-up, and validated to detect the abuse of dextran, hydroxyethyl starch and mannitol as a doping practice in sport, involves only one enzymatic hydrolysis step and the direct injection into a liquid chromatography-tandem mass spectrometry (LC-MS/MS) system. The chromatographic conditions were optimized to allow the efficient separation of compounds with the same molecular weight. Good linearity (R(2) 0.990-0.995) and reproducibility of relative retention times (CV% lower than 1) and of relative abundances of characteristic ion transitions (CV% lower than 10) were obtained. The lower limits of detection and quantification were in the range of 30-100 µg/ml. Since the analytes studied are present also in non-doping products (e.g. in fruit as well as in food products and drugs additives), the developed method was also used to establish a range of reference urinary concentrations: 600 doping control samples and 30 samples from volunteers not using any medication were considered. While the hydrolysis products (isomaltose and maltose hydroxyl-ethylated), used as specific markers for the detection of dextran and hydroxyethyl starch abuse, were not detected in urine; mannitol was present in all urines in a concentration range of 30-1200 µg/ml. Since no criteria of positivity for mannitol has been established yet, the results obtained in this study could be considered, in combination with those of previous researches, as a starting point to fix a threshold value for doping control purpose., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: To review the literature on costs associated with chronic pain therapy and to identify key contributing factors. Also, to assess the potential cost-saving benefits of monitoring pain treatment adherence using urine drug tests (UDTs), emphasizing their use in opioid therapy., Results: Reduced productivity, compensation costs, and treatment of comorbid conditions related to chronic pain contribute to the substantial financial burden of chronic pain management in the United States. The growing use of opioids for chronic pain increases the risk for drug nonadherence and associated drug abuse, potential addiction, and aberrant drug-related behaviors (ADRBs). Treatment of drug abuse increases health care costs; opioid abusers are 25 times more likely to require hospitalization than nonopioid abusers. Early detection of patient nonadherence using UDTs could significantly reduce costs of chronic pain therapy by allowing the physician to identify and treat patients' ADRBs related to controlled substances and drug addiction and abuse problems. Adherence in chronic pain may be determined by point-of-care (POC) tests, and more sensitive laboratory urine tests employing gas chromatography/mass spectrometry with high-performance liquid chromatography tests (LUTs). Cost-benefit studies suggest that the cost of LUTs to optimize adherence may reduce costs associated with nonadherence, such as inpatient clinical care and patient self-release. Current estimates indicate that appropriate use of LUTs could produce decreases up to 14.8-fold in the cost of chronic pain therapy., Conclusions: The cost benefits of UDTs can only be fully realized if physicians know how to define and detect various types of drug abuse, addiction, and diversion. Physicians should be educated on the proper implementation of POC tests and LUTs, and interpretation of adherence data. Early monitoring of drug adherence using POC tests and follow-up LUTs may provide substantial cost savings associated with health care issues incurred in nonadherent chronic pain patients, especially those taking opioid therapy.

Raman spectroscopy can provide rapid, sensitive, non-destructive analysis of a variety of drug types (e.g. amphetamines, alkaloids, designer drugs, and date rape drugs). This review concentrates on developments in the past 15 years. It considers identification and quantification of drugs of abuse in different types of forensic evidence, including bulk street drugs as well as traces found in drinks, on fibres/clothing, in fingerprints, on fingernails, on bank notes, and in body fluids., (Copyright © 2010 John Wiley & Sons, Ltd.)

Unlabelled: Methadone is the main therapeutic option in heroin addiction treatment, but also an abuse substance. Given the analytical focus on the diagnosis of drug abuse and the usefulness of toxicological analysis methods in both overdose and monitoring substitution therapy, this study was aimed at the semi-quantitative determination of methadone by using Thin Layer Chromatography (TLC). By having the advantage of simplicity and rapidity, TLC finds its rightful place among the analysis methods when other relatively costly methods that involve instrumental performance are not available., Materials and Methods: TLC plates (silicagel GF 254 Merck), developing system methanol: strong ammonia 100: 1,5, photometric quantification at 254 nm, using TLC Scanner 3 (Camag)., Results: The results show that methadone can be determined semi-quantitatively in the chromatographic conditions mentioned in the two domains tested (5 - 40 microg and 10 - 80 microg), with the best results obtained in the 5 - 40 microg domain., Conclusions: Semi-quantitative TLC evaluation proposed by us has as main advantages the rapidity, simplicity and relatively low cost compared to other useful methods.

Background: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose., Study Design: A retrospective review of urine drug testing services., Objective: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits., Methods: An audit of services provided during 2007 was conducted using computer software., Outcome Measures: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care., Results: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured., Limitations: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care., Conclusion: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician's toolbox, the physician's ability to accurately diagnose and treat these patients could be impaired.

The Uniform Accident and Sickness Policy Provision Law (UPPL) is a state statute that allows insurance companies in 26 states to deny claims for accidents and injuries incurred by persons under the influence of drugs or alcohol. Serious repercussions can result for patients and health care professionals as states enforce this law. To examine differences within the laws that might facilitate amendments or reduce insurance companies' ability to deny claims, a content analysis was carried out of each state's UPPL law. Results showed no meaningful differences between each state's laws. These results indicate patients and health professionals share similar risk related to the UPPL regardless of state.