Drug testing

Nyssa Peake

Meconium testing
What is it.
Meconium is the earliest stools of an infant. Unlike later feces, meconium is composed of materials ingested during the time the infant spends in the uterus making it very usefull in detecting illicit drug use during pregancy meconium testing origianated from the hospital for sick children in toronto they came up with this idea with the efforts of keeping expectant mothers from hiding there drinking during pregancy this test is very effective in the sence that it doesnt only detect if the mother has been drinking during her pregancy but also shows how much the mother has been drinking during her pregancy they put meconium testing in effect to help in the early detection of fedal alchohol syndrome Meconium, the dark green viscous first stool of a newborn, is a collection of debris consisting of desquamated cells of the alimentary tract and skin, lanugo, fatty material from the vernix caseosa, amniotic fluid, and various intestinal secretions.The disposition of drug in meconium is not well understood. The proposed mechanism is that the fetus excretes drug into bile and amniotic fluid. Drug accumulates in meconium either by direct deposition from bile or through swallowing of amniotic fluid . Meconium appears to form in the second trimester; because it is not excreted, it contains drugs to which the fetus has been exposed. Therefore, the presence of drugs in meconium has been proposed to be indicative of in utero drug exposure in the month or more before birth, a longer historical measure than is possible by urinalysis

Who uses it ?
Motherisk Laboratory for Drug Exposure

What is the purpose of the test? Why is this test done?
The purpose of meconium testing is to detect the use of alcohol and any illict drug use during pregancy
Drug abuse during pregnancy is a major health problem since the associated perinatal complications are high. These include a high incidence of stillbirths, meconium stained fluid, premature rupture of the membranes, maternal hemorrhage and fetal distress. In the newborn infant, mortality and morbidity rates are high. The latter includes a high incidence of asphyxia, prematurity, low birth weight, aspiration pneumonia, congenital malformations, cerebral infarction, drug withdrawal and infection,including AIDS. Similarly, long term sequelae in the infants are not uncommon and include delays in physical growth and mental development, sudden infant death syndrome and learning disabilities.Because of these immediate and long-term problems, infants born to women who have abused drugs during pregnancy should be identified soon after birth so that appropriate intervention and follow up can be instituted. Accurate identification of the drug exposed neonate is important for other reasons such as epidemiologic surveys, to identify women who will need support and or to assess the effectiveness of programs designed to reduce the incidence of drug abuse among pregnant women.

Is the test reliable? What reliability scales are used?
Simple, non-invasive collection of a meconium sample eliminates the need to collect a blood or urine specimen from a newborn Proprietary meconium extraction process and meconium GC/MS analysis provides up to a 20-week gestational detection window from a newborn meconium. Meconium Drug Testing results in 48 hours or less for rapid healthcare treatment and planning for both mother and child. Meconium Drug Testing not only provides evidence of fetal drug exposure but can also provide documentation of fetal alcohol exposure by measuring meconium concentrations of fatty acid ethyl esters, the non oxidative metabolites formed from ethanol and fatty acids. Meconium testing has rapidly become the gold standard for diagnosing fetal alcohol and drug exposure. Available as a 5-,7-,9-, and 12- drug panel.
The analysis of meconium for cocaine and metabolites has proved to be a reliable method for the detection of fetal cocaine exposure. Better sensitivity and a larger gestational window of detection have been demonstrated for meconium testing as compared with neonatal urine testing. Cocaine and cocaine metabolites, including benzoylecgonine, ecgonine methyl ester, cocaethylene, norcocaine, benzoylnorecgonine, and m-hydroxybenzoylecgonine, have been identified in meconium. The origin of these metabolites, whether maternal or fetal, has not been established. This study was conducted to compare the disposition of cocaine and metabolites in meconium from fetuses exposed to cocaine with that of urine from cocaine abusers. Meconium specimens were obtained from six neonates of mothers positive for cocaine use by urinalysis or self-reporting or both during pregnancy. Urine specimens were obtained from 17 adult female and 17 adult male cocaine users enrolled in a treatment program. Specimens were analyzed by gas chromatography-mass spectrometry for cocaine and 12 related analytes. The following analytes were identified and measured in meconium and urine : anhydroecgonine methyl ester ; ecgonine methyl ester ; ecgonine ethyl ester ; cocaine ; cocaethylene ; benzoylecgonine ; norcocaine ; norcocaethylene ; benzoylnorecgonine ; m- and p-hydroxycocaine ; and m- and p-hydroxybenzoylecgonine. In addition, both m- and p-hydroxybenzoylecgonine were found to exhibit approximately equal cross-reactivity with benzoylecgonine in the EMIT and TDx assays. The presence of p-hydroxybenzoylecgonine in meconium suggested that this newly identified metabolite, like m-hydroxybenzoylecgonine, might serve as a valuable marker of fetal cocaine exposure during pregnancy. The presence of cocaine and anhydroecgonine methyl ester in meconium was attributed to transfer across the placenta from the mother. However, the origin of the hydrolytic and oxidative metabolites of cocaine could not be established because they were also identified in urine specimens of adult female cocaine users and could have arisen in meconium from either fetal or maternal metabolism.Some laboratories may find it easier to modify existing urine methodologies to perform at lower thresholds than to develop and confirm a new set of more difficult assays for meconium. It is recommended that laboratories contemplating meconium testing should consider first lowering the threshold of their urine assays before embarking on meconium testing because sensitivity of urine testing at lower urine thresholds has been reported to be comparable with that of meconium testing

What are the procedures used for the test?
Meconium samples are collected from the diaper of the newborn as soon as they have there first bowl movement they are then analyzed for the presence of alcohol and by-products called fatty acid ethyl esters (FAEE). Minimal amounts of FAEE are found in the meconium of neonates who were not exposed to alcohol before birth. Significantly greater amounts of FAEE are found in the meconium of neonates who were exposed to alcohol before birth.
How to submit a sample for testing
Step 1: Collect a minimum of 1 gram of meconium in a urine collection bottle. Keep the sample refrigerated. If the sample is collected on the weekend, keep it refrigerated and send it to us on Monday morning. If it will take more than 48 hours to get to our Lab, freeze the sample at -20°C and ship it on dry ice.
Step 2: Include a letter with the sample that states:
Why alcohol use is suspected
Where to send results
Where to send our invoice
Step 3: Send the sample by courier to Motherisk , The Hospital for Sick Children, Elm Wing, 10th Floor, Room 10142, 555 University Avenue, Toronto, ON M5G 1X8
What are the advantages and the disadvantages of using this test?
Meconium is much more sensitive then new born hair for detection of cacaine and cannabis Possiably because it can detect drugs being used over a period of 4 to 5 months where as a new borns hair can only dectect drugs being used in the third trimester as the new borns hair does not grow until the final trimester of pregancy. Results show that though meconium is more sensitive showing drug use over a 4 to 5 month period of pregancy it is only available for 1 to 2 days where as the new borns hair can be used for up to 3months after birth.
Most docters preferred over urine for drug testing because it is easier to get and has a larger detection window.
Meconium can detect multiple drug use over an extended period of time.
Urine testing can only detect drug use over the last 1-10 days depending on the drug.
Meconium is easier to get a hold of.
What are the controversies of using this test?
Meconium is easier to collect than urine, and the amount collected is usually sufficient for complete analysis, including confirmation.
Meconium testing does have some limitations. Meconium is usually passed by full-term newborns within 24 to 48 h, after which transition from blackish-green color to yellow color indicates beginning of passing of neonatal stool. Infants with low birth weight (1000 g) have been shown to pass their first meconium at a median age of 3 days. Thus, meconium collection can be missed because of delayed passage and also may not be available soon after birth for early detection of illicit drug use testing. In fact, in a large-scale study, only 77.6% of 3879 newborns had meconium available for analysis.
In the clinical laboratory, meconium is an unfamiliar test, being a sticky material that is more difficult to work with than urine. Furthermore, processing of meconium for analysis requires weighing and extraction steps that are not needed for urine. An accurately weighed 0.1 to 1 g of meconium is generally used, and drug analyte has to be extracted from meconium into a medium that is compatible with the initial immunoassays. Extraction has been achieved by acidified water or saline, methanol, or acetonitrile. Improved assay sensitivity can be attained by evaporating the extract solvent either to dryness or a lower volume. A variety of immunoassays has been used for the initial testing of meconium extracts: EIA, RIA, FPIA, and kinetic interaction of microparticles in solution (KIMS)To improve sensitivity, thresholds for the extract should be set as low as possible and certainly lower than the workplace drug-testing thresholds. All urine drugs-of-abuse assays, if they are used with meconium extracts, must be investigated for possible effect of matrix on accuracy, precision, and assay linearity.

Most reports in the literature describe the detection of cocaine in meconium, but studies in which meconium was also analyzed for other drugs of abuse demonstrated that cocaine was detected at a much higher rate than marijuana, amphetamines, or opiates Several studies reported that some infants whose urines were negative for cocaine had positive meconium, suggesting that meconium testing is more sensitive than urine testing However, part of the improved detection rate relates to the method of analysis— rather than the type of specimen (urine vs meconium). When more sensitive urine analytical methods and lower cut offs were used, infant urine and meconium analyses yielded equivalent results for identifying newborns who have been exposed to cocaine in utero.
Are there any legal implications of this test and if so, what are they?



What are the ethical issues around this test?
The impact of illegal substance abuse on the developing fetus and newborn infant is devastating. The effects are manifested in increased risk of mortality and morbidity along with associated behavioral and developmental concerns. Thus, an ethical question arises for nursing staff concerning the decision to initiate legal intervention subsequent to or in conjunction with positive toxicology screening. Should newborns be taken from their mother when they test positive for illicit substances?
Perinatal substance abuse can cause a wide range of serious medical complications for an infant, including drug withdrawal, physical and neurological deficits, fetal alcohol syndrome, growth retardation, and cardiovascular abnormalities. One of the most well-known syndromes attributable to substance involvement is fetal alcohol syndrome (FAS). Michaelis (1994) suggests the following characteristics of low birthweight; a pattern of malformation affecting the head, face, heart, and urinary tract; and abnormalities within the brain that lead to various intellectual and behavioral problems early in childhood.
There is no clear cut solution in dealing with these families. Taking the infants from their biological mothers means revictimizing the infants, as vital bonding with that parent is missed. However, leaving the infants with their substance-abusing mothers does not ensure the bonding process, and may serve to reinforce the cycle of addiction and continued psychological, physical, and spiritual harm to the child. There are several possible options or courses of action in response to the problem, however, they range from supportive services to punitive judgmental treatment.
Foster Care
Some would argue that the best course of action in the best interest of the infant in the situation of perinatal drug abuse would be foster care. It makes logical sense: if the baby is not safe, separate the baby from the mother and place him or her in a safer situation. But it is not that simple. The option of foster care usually imposes an additional burden on the child. Children placed in foster homes generally move from home to home, which exacerbates the problems of parent-infant bonding, sense of continuity and stability, and object constancy. DeBettencourt (1990), in a study of 13 children in Los Angeles, California exposed to illicit drugs in utero, found the children had experienced 35 foster homes before the age of 3.
Adoption
For some mothers faced with the realization that they cannot care for their child the way he or she needs and deserves, adoption provides an alternative for care. Adults willing and able to take on the responsibilities of parenting can offer an atmosphere of security and well-being that may have otherwise been lacking.
While adoption is another viable option of intervention, a U.S. Department of Health and Human Services (1990) report states, "few crack babies have been adopted, as the process is generally long, difficult and expensive. The termination of parental rights is often contested and can take 3 years or more. These older children are less likely to be adopted" (p. 1). Another long-standing barrier, according to the report, is the bias against interracial adoptions. Black foster parents and homes for infants with special needs are in short supply. The reason for shortages are services (such as child care and respite care) and agency restriction (DHHS, 1990). Agency policy restrictions include not allowing white families to adopt black children based on cultural differences. Thus, while adoption is one measure of intervention, it possesses many conflicts, challenges, and obstacles for both child and adopting parent.

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