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?

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?

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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.

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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/.

   

Medical Question: Carol's Answer

Last post, Carol provided a detailed question for a manuscript in progress about giving Benadryl to a 2y/o boy who some nasty kidnappers have taken. They want the child to be quiet. The child is rescued by the police and taken to the ER. What is treatment in the ER for this fiction scenario? Check last Wednesday’s post for her full question.

Benadryl can be a tricky drug, particularly in the pediatric population. I am a pediatric ER nurse and have seen lots of kids get Benadryl and get too much Benadryl. The issue is this... an appropriate dose may make them sleepy but not knock them out. A child in a high stress situation may not get sleepy because his adrenaline may counteract the effects of the Benadryl. If you give more than the appropriate dose of Benadryl, they can actually begin to have toxic effects and are not very sleepy at all. In fact, they can be more like little Tasmanian devils.

I think a better choice for your fiction scenario might be a sleeping pill or tranquilizer. Something your nefarious characters may have around via prescription. Now, I’m going to defer publishing a drug and appropriate dosing here as you can find that yourself by Googling “tranquilizer dosing in kids/pediatrics” and it will give you several drug names. From those drug names you can Google the drug by typing “(drug) dosing in pediatrics). The pill could be crushed and given in something like a spoon full of pudding. A tranquilizer will have a more predictable effect than Benadryl. I think the EMS response is reasonable considering his vital signs.

In the ER, we're going to assume worst case scenario. If he was kidnapped (I'm assuming he has been given that the cops rescue him), we're going to assume the kidnappers may have given him other bad things. Standard treatment for drug ingestion is to draw blood for salicylic acid (Aspirin) and acetaminophen (Tylenol) levels. Probably baseline labs are in order to check his blood electrolytes.

We'll want his urine for a urine drug screen. This will check for common drugs of abuse and also prove that he was given a tranquilizer if the kidnappers aren't forthright with what they did give him. If we know the child received the drug within 60 minutes of his arrival to the ED, the physician may choose to give activated charcoal, which is a substance given orally to help absorb the drug from the stomach. He'll be placed on a monitor and observed for several hours until the drug wears off and he’s back to his normal baseline.

Hospital admission is unlikely as long as he does well during his ER observation period and we feel he’ll be in safe hands with the mother. We'll take a good look over his skin... checking for unusual bruising that may indicate he'd been abused/injured.

The circumstances of the child's kidnapping are unclear. We would contact the police but it is clear that the police are involved in your scenario. This is a situation where we will also involve social work as well either for support of the mother, over concern for the child if we felt a parent's negligence was a factor in the kidnapping, or family dynamics were concerning… say there’s an acrimonious divorce and the mother states the father was involved in the kidnapping. These factors could increase conflict in your story.

What other factors can increase conflict in Carol’s story?

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Carol Moncado lives with her husband in Southwest Missouri. When she isn’t writing Inspirational Romance or Romantic Suspense, she’s teaching American Government at a community college, hanging out with her four kids, reading, or watching NCIS. You can find her at: http://www.carolmoncado.com/, http://www.carolmoncado.wordpress.com/ , and her newest blog, Pentalk Community Blog, where she serves as editor-in-chief: http://www.pentalkcommunity.blogspot.com/ .

Medical Question: Using Medication to Subdue Kidnapped Child in Manuscript

Carol asks the following question concerning a manuscript in progress:

2yo boy is given a drug [I'm thinking Benadryl but open to suggestions] to keep him quiet for several hours. He's rescued by his mom/cops and put in the ambulance to head for the ER.

When they find him [about 5 hrs after being taken], his pulse is strong but a bit on the slow side and his O2 is fine.  They hurry but no lights/sirens/etc. Does that sound right?

I'm thinking they would take him to the ER for observation and possibly admit to watch him until he's fully out of it.  Is there anything else they would do to counteract it?  Or just let it work its way out of his system as long as everything else looks good?  Start an IV since he's been out/sleeping for so long?  Are there any other concerns?

I don't want any long term affects of the drugs, just something they did to keep him under control.  How long they keep him [ER or admitted] will play a bit of a role in the story. I tried Googling Benadryl and all I got was info about using Benadryl for kids on flights, etc. [and most of that was criticizing, bashing, condemnation depending on the author of that particular post] which isn't quite what I need.

Any thoughts for Carol? How will your thoughts compare to mine? I’ll post my answer Wednesday.