Addiction Medicine Made Easy | Fighting back against addiction

A Deep Dive into Urine Drug Testing

• Casey Grover, MD, FACEP, FASAM

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Urine drug testing provides critical insights for addiction treatment, helping clinicians understand what substances patients are actually using and how the drug supply is rapidly changing. Matthew Rutledge, founder of MD Labs, shares his expertise on testing methodologies, detection capabilities, and emerging trends in substance use.

• Different drug test types include basic immunoassay cups (similar to pregnancy tests), which detect drug shapes but can have false positives/negatives
• Liquid and Gas chromatography with mass spectrometry provides highly accurate substance identification down to nanogram levels
• Developing tests for novel substances takes 2-4 months, requiring standards and validation across hundreds of specimens
• Poppy seed muffins can genuinely cause positive opiate tests depending on seed source and patient body mass
• Unexpected test results require clinical judgment—some exposures may occur through contamination, intimate contact, or environmental exposure
• Integration of pain and addiction medicine allows better co-management of patients with both conditions
• Emerging threats include nitazine opioids, exotic benzodiazepines, and tianeptine ("gas station heroin")
• Test adulteration methods (vinegar, bleach, dilution) can be detected through validity testing for oxidants, creatinine levels, and specific gravity

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years, I worked in the emergency department, seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started.

Speaker 1:

Today's episode is on urine drug testing. This is an interview with Matthew Rutledge, who runs a lab testing company called MD Labs. Quick disclosure I have no financial ties to that company except that we send specimens from our office to them. Matthew and I discuss urine drug testing in detail in this episode, from the different types of tests that are done to common myths about urine drug tests, to how lab companies develop tests for new substances in the drug supply. We covered urine drug tests back in the summer of 2023, but this episode goes into a lot more detail about urine drug tests and I love Matthew's perspective as someone who runs a lab. We had a great conversation and I learned a lot. Here we go All right. Well, good morning, so nice to connect with you again. Why don't you start by telling us who you are and what you do?

Speaker 2:

Oh, great to see you, dr Grover Casey. My name is Matthew Rutledge. I am one of the founders and managing partners of MD Labs. We're a clinical laboratory serving the United States and we specialize in toxicology for substance use disorder patients, toxicology for chronic opioid therapy patients, a lot of psychiatry, anyone who's taken a dangerous drug that needs to be monitored. So that's really what we've been doing for now 14 years. So I know how I got've been doing for now 14 years.

Speaker 1:

So I know how I got into my career. How did you get into your career?

Speaker 2:

Oh, wow, I talk to a lot of teenagers these days. My kids just went through college about what they want to be when they grow up. And your path finds you and mine found me. I was pre-med, did pretty well on my scores and tests and things and went through the pre-med program in college, got a degree in chemistry, but changed my career path when I met a surgical device rep and saw what he did, came into the OR and saved the day with his box of tools and steel plates and helping the doctor put a woman's face back together after a procedure and I was so impressed by this guy and I was pretty handy myself that I pivoted towards that career.

Speaker 2:

And in that space I was working with a lot of interventional pain physicians and saw this is what the late 2000s and early 2010s we were really seeing the rise of the opioid epidemic and the need for clinical lab testing to determine if patients are taking what they claim they're taking and keep them safe, keep the community safe. And it was an underserved community in the state of Nevada and I knew a lot of physicians there who needed it. We're sending things all over the country and talked about my background. I got my degree in chemistry ran part of my organic chem lab in college, coupled up with my partner, dennis, who's the other founder, his degrees in business and through all those careers, we ended up starting up a lab, a mom and pop laboratory, in Nevada.

Speaker 2:

With the help of some genius PhDs and having come from the space of the provider side, being in the operating room with doctors talking about what they need, what they care about we really built the lab based on what our referring providers needed, not, like a lot of labs, build their philosophy on what they can do. So they'll push out 10 pages of data because they can, because this is incredible data, but maybe you can share. What do you look for in a lab test and lab results when they're being sent your way? Because that's how we built our company and our model.

Speaker 1:

So there's so much dogma in medicine and it's interesting there oftentimes are lab tests that we order that we don't necessarily know what to do with, because this is what we always do like oh gosh, the patient has abdominal pain. We always get a complete metabolic panel and then sometimes physicians get really stuck on what if the number says one thing and the patient doesn't feel badly or differently? Do we treat the number or do we treat the patient? And that's an ongoing debate in medicine is why do we order what we order and what do we do with the results? And do we treat the number or the patient? And I think the answer is you order what you need to order and you have to know what you're going to do with the results abnormal or normal and then it's really weaving the patient and the results together when making your decisions.

Speaker 1:

And in our world of addiction medicine, the drug supply changes week to week and it's really been wow. This week our patients are talking about xylosine and three weeks ago they were talking about isotonitazine, which is one of these opioids no one's ever heard of. I didn't know there were nitazine opioids, but isotonitazine is one of them. So I think for me and my colleague, the very lovely and beautiful Dr Reb Close, who happens to be my spouse. We are just trying to see what our patients are getting, simply because it changes what we do with their meds. And it's largely around opioids, because suboxone, buprenorphine, subutex requires a period of not taking another opioid before you start it. So let's say a person's taking good old-fashioned heroin Heroin's gone, but heroin you had to wait for about 12 hours before you took your Suboxone or Subutex or Buprenorphine so you wouldn't go into withdrawal.

Speaker 1:

And let's say somebody is on a drug and they wait the 12 hours and then they take that med and they feel horrible. Well, it's not heroin and we want to know what it is, because if the next patient has the same experience we can then test them, see a pattern and then counsel our patients going forward. Or another example is one of Dr Close's patients was on some weird benzo called bromazolam that no one's ever heard of, and he started developing psychosis, he was hallucinating. And then she had another one who had that same experience. And again, once we recognize the pattern we can counsel our patients and then inform the community around us. So very long answer to say we'd love to know what our patients are getting, so we can link their symptoms to what they test positive for and then understand to be able to counsel our patients going forward and then make decisions based on what they're on. Like if somebody's on isotonitazine and it turns out it doesn't interact well with suboxone or subutex or buprenorphine, we do things differently. Hopefully that makes sense.

Speaker 2:

It absolutely does and it speaks to the vigilance of your practice and the engagement with the community. So many of the illicit drugs that we see, or things off-label, are very much regionalized Parts of the country where this drug is a problem, parts of the country where that drug is a problem, and understanding what's a problem in your area and what your patients are doing and what the local drug dealers got in stock in recent months is a huge part of solving the issue, making the patients aware of the risks they're putting themselves out and helping them get off the specific medications, because each medication has its own peculiarities to it.

Speaker 1:

So I think you and I had talked yesterday about level setting for everyone, the different types of drug tests, how they work, their pros and cons. So I'm going to try to be funny here. Let's pretend I'm you in college, I'm a pre-med and you need to explain to me when I go to Rite Aid and buy the little cup drug test, what type of test is that, how does it work and does it have false, positives and negatives?

Speaker 2:

This I explain a lot. It is a hit at dinner parties because there are so many nuances to drug testing complications. So you mentioned the cup that you can get at a drugstore. That cup has little test strips in it that are very similar in their activity to a pregnancy test. They're typically an enzyme reaction where if a type of drug that the enzyme is sensitive to, if it's presented with that, it will cause a color change. So these enzymes can be sensitive to heat and to age and to those things. So if it's been on the shelf at CVS or in the trunk of a hot car or frozen it may affect how it works.

Speaker 2:

You might get false positives. You're also going to get false positives and false negatives if it's a similar drug to what the paper is sensitive to. Paper's not that smart, that enzyme's not that smart. So a good example is methamphetamine, the most commonly abused drug in this country per the DEA. There is a real similar sister molecule in Vick's nasal spray. That's non-euphoric, doesn't get you high, but it is a different version of methamphetamine. It will trick that cup into thinking that you are taking crystal meth and it turns out about one out of every 25 patients that test positive at our laboratory is actually on Vicks nasal spray because it is so common. So the cups aren't very smart and they're prone to errors. They're prone to missing drugs. They're prone to being an unguided missile, as they say. But they're readily available, they give you results in 10 minutes and they can be very helpful to a lot of practices. If you want to write a prescription today and check, at least cover your bases for checking the patient. They're a great, cheap way to get lab testing done in office.

Speaker 1:

Yeah, the way I explain them to my patients and I believe this is called an immunoassay test is it's essentially looking at shape, right? So if something is shaped like morphine, that little chemical reaction will occur and it'll light up as a positive right or similar. Like you were saying, around amphetamines, if it's shaped like an amphetamine it will come up as positive. And it turns out there's an antidepressant called selegiline which is structurally very similar to an amphetamine and one of my patients was incarcerated when he was on selegiline and his point of care urine cup immunoassay test was positive for amphetamines because of his selegiline. I'm a former ER doc. We love to keep things simple. The way I think of these tests is it's about shape and that we try to use the little chemical assay in the paper to recognize the shape of the drug.

Speaker 2:

We're trying to test, for it's an enzyme with an antigen. They're bound together. The drug comes in, displaces the enzyme. That free enzyme causes a color change, got it? So with the test strip cups you can see it with your eyes. The next step up in complexity is to have a machine do the analysis for you. It's a lot more sensitive, a lot more reliable, calibrated. So that's enzyme immunoassay is a lab analyzer technique that we use that is more reliable, can test for a broader number of things, gets calibrated every single day. So you know that it's more accurate and reliable. But the next step up in complexity is to go to gas chromatography or liquid chromatography, which is the high complexity, extremely reliable technique that most laboratories employ.

Speaker 1:

So again, dumb former ER doc question gas and liquid are different. Last time I checked my college physics courses. What is the difference between gas chromatography and liquid chromatography?

Speaker 2:

It is the state at which the specimen is entered into the machine. If you're using all the specimens that we see typically come in as liquid blood, urine, saliva, a gas chromatography you have to vaporize that substance to get it to travel through the machine. The chromatography chromatogram chromo meaning light. It's like a prism that separates light into all of its colors. This separates all the compounds in that specimen into their components and they come out of the back end of this chromatography system separately. So you concentrate them and separate them. To identify all of the compounds that are in the specimen and that's the same for gas or liquid chromatography you then run them through a mass spectrometer that measures the molecular weights of the different compounds. So if you know the retention time they call it how long it took to go through that column, because some drugs are fast, some drugs are slow we know who they are and then you measure the molecular weight. You have two factors that can be used to identify the unknown compound Interesting.

Speaker 1:

So let me make sure again. Simple ER doc brain. I got to simplify this. So for me as a doctor, the immunoassay is the one I can do in the office and if there's an unexpected result, I'd want to send it for the confirmatory test, which is the chromatography. Mass spectrometry and the liquid or gas chromatography is the process of separating what's in the specimen into its individual compounds, and then the mass spectrometry is basically where you analyze the molecular weight of each of those compounds to identify what it is.

Speaker 2:

Gas chromatography and liquid chromatography are similar theories behind both. Liquid is just easier to do. It can be done more quickly, more comprehensive, with less sample prep. It's hard to get blood to vaporize. It's much easier to keep it as liquid form Well hard in a lab under controlled conditions without destroying the components of it.

Speaker 1:

Harden a lab under control conditions without destroying the components of it. So how do you actually create a test for a novel substance? So I'm actually asking your company and, just so everybody knows, you don't pay me to do anything. I don't own anything with MD Labs. You guys provide service to us and so that's how we connected. But I've asked you, I want a lab assay for isotenidazine, which is this weird opioid that we're hearing about. What's the actual process like there?

Speaker 2:

chains need to develop a test that will get the job done. So if the job is finding, let's say, isonitizine in a specimen, we need to create that method. It's called a lab-developed test. If there's not a commercially available test on the market, we need to make one and show that it works. In this particular situation, we would need to find a standard somewhere, find high and low control calibrators for this target compound. Someone's got to be making it somewhere, order it in, and then we have to demonstrate that we can reliably and accurately detect this drug in hundreds of specimens over several days on several pieces of machinery. So we go through it's called the validation process and that's how you develop a new test and if it works and it's reliable, you'd test it on inpatient specimens and it's your lab developed test only to be used in your laboratory.

Speaker 1:

So I'm going to try to be funny here with how I ask my question. So you must need a drug dealer, because you're basically analyzing controlled substances and illicit substances. Like who's your dealer?

Speaker 2:

Ceruleant is a big drug dealer in the United States who's Ceruleant? Sorry? And they're a laboratory that creates these. Now they don't send them to us in any snortable or usable form. They're all denatured in methanol. So the lab staff, the risk of abuse is very, very low. But yeah, we buy a lot of drugs.

Speaker 1:

Interesting. So isotonitazine, since I keep fixating on that, one is again. It's this novel opioid that no one's ever heard of from this class of opioids called nitazines, and I've tried to research it and I can't find much, except there are loads of pharmaceutical companies in Asia that are willing to ship it to me. So for a novel substance like this, are you engaging these pharmaceutical companies overseas?

Speaker 2:

We are indirectly Cerulean orders a lot of their stuff overseas from China and Europe based on these tariffs that we're getting charged. So in that process we need to be made aware of this target drug out there that's being used. Xylazine was one of the recent five, six years that we're all made aware of and there's a need to test for it. There's an issue there. It's going to be a problem for our patients that we're all made aware of and there's a need to test for it. There's an issue there. You know it's gonna be a problem for our patients that we're seeing. So we are made aware.

Speaker 2:

We order in some specimens, some sample stock. We create our own concentrations of known specimens and run them and if we can develop a method and bring it to market, it's usually a two to four month process depending on how complicated that drug is to detect. We also run metabolites of a lot of these compounds. Why is it important to check for a metabolite of a drug? Well, a lot of times we want to make sure it's passed through the patient's body. If it's a prescription drug, a lot of patients will pill shave the pure mother compound into a cup so they can go sell the mother product, so being able to see that it went through their body is vital. And for things like oxycodone and morphine and heroin and the benzos, we check for metabolites of all those to avoid pill shaving.

Speaker 1:

So let's just again simple ER doc brain needs to understand this. So the idea is is that you want to test for the native compound, the substance and also the metabolite, to show that the person's taking it rather than they're just putting a little bit of their pill in the cup. So for cocaine, which is obviously not prescribed, the metabolite is benzoylcogonine. So on your test, which I looked at this week, my patient tested positive for cocaine and benzoylcogonine. Or in the case of buprenorphine, I prescribed them buprenorphine and the metabolite is nor-buprenorphine, so the patient would test positive for both of them.

Speaker 2:

Yeah, it's important to have that information for a clinical patient. So with developing an assay, we develop it not just for the parent drug but for the metabolite when we can, and report those both reliably.

Speaker 1:

So I am pulling up a saved photo on my phone which is adulterants used to prevent detection of drugs in urine samples. So ammonia, bleach, powdered urine, urinate vinegar, visine, eyedrops these are all things that people can put in urine drug tests. Do those affect both the immunoassay and the liquid chromatography mass spectrometry?

Speaker 2:

They most certainly can. It's important. We've seen it all in our 14 years and millions of specimens. If you open up the cup and it smells like vinegar, it's highly likely that they added vinegar and the technicians make a note of that. If you see white powder floating in specimens, if you open up the cup and it smells like vinegar, it's highly likely that they added vinegar and the technicians make a note of that. If you see white powder floating in the cup, or soap bubbles or it's blue blue can be from a patient taking certain medications, but it also can be toilet water that they've scooped out of the tank of the toilet.

Speaker 2:

So we use a lot of non not very scientific indicators to detect adulteration and things. We also run validity testing on the specimen. We check for oxidants, like you said, because they can cloud the machine. We check for dilution. Your body secretes creatinine at known levels and if that level's out of the normal range, it's highly indicative that the patient has watered the specimen down. We counteract that by detecting the creatinine and then normalizing the specimen concentrations. To tell the doctor, let's say, we detected 10 nanograms per mil of this target, which normally would be under the presumptive cutoff, but we normalized it because it was watered down and, doctor, this patient's actually at this concentration here. So there are lots of ways to combat that. Specific gravity of the urine is also detected, or the saliva, so the lab has a lot of fail-safes in place. Some labs are using DNA technology to get a known specimen of DNA from the patient and then check the urines over time to make sure that they've got some of that same patient's DNA.

Speaker 1:

So just want to again make sure I get this right. I was under the impression that these adulterants only messed with the immunoassay cup tests, but you're saying they can mess with the confirmatory chromatography mass spectrometry test too.

Speaker 2:

Well, each adulterant has a different impact.

Speaker 1:

That's true, okay.

Speaker 2:

So they all have different impacts on things. If someone adds bleach to their specimen, is it going to remove all of the fentanyl? No, we're very sensitive to fentanyl testing, but dilution could take it down to a level that's below our reliable cutoff. So that's why we need to detect. We use four lab tests to detect adulteration, as well as visual and experienced scientists looking at specimens.

Speaker 1:

So another silly question here. So my patients teach me so much about the illicit drug industry. One of my patients will tell me like what their dealer's selling, and a lot of my patients in recovery will tell me how they used to cheat on their urine drug tests.

Speaker 2:

A lot of my patients in recovery will tell me how they used to cheat on their urine drug tests. Do you have an advisory board of people in recovery or pain patients that tell you what they did when they were using or what their tricks of the trade were to pass urine drug tests base? But we have experts that we bring in. We've got law enforcement experts that we work with. We have a lot of addiction recovery facilities are run by recovering people. We talk to patients as much as we can and visit and speak with actual patients. So we are constantly soliciting that advice and expertise. There's a lot of this published in literature. The DEA puts out advisories. The NIFLIS group talks about what drugs are currently out there, how people are avoiding them, how people are trying to fake drug tests. It's the constant battle. Drug addiction is very powerful and it really puts people into a space of doing whatever they can to survive. It's that level of effort that goes into this sometimes.

Speaker 1:

Yeah, so you and I had talked about doing a little bit of myth, busting around urine drug tests. So let's take a myth that I think I know the answer to, but I'm very curious as to what the expert here says. Talk to me about poppy seeds in urine drug tests.

Speaker 2:

Talk to me about poppy seeds and urine drug tests. Poppy seeds and urine drug tests. This myth that if you eat a poppy seed muffin in the morning you might test positive for opiates later on in the day is not a myth. There are certain strains out there of poppy seed that do contain opiates in them. We've run a lot of tests here at the lab and it depends on where the manufacturer, where the bakery, gets their poppy seeds, because the ones that are on the shelf at the grocery store have no opium in them from what we can tell. But my favorite muffin they've got plenty of opium in their poppy seed muffins because we had the lab staff treated them all the muffins and bagels and then took urines later in the day and a lot of them tested positive, especially the lighter weight, smaller people that had a lot more per body mass index intake of the poppy seeds. But yeah, it happens, so be. When your patients say this, there's a chance that they're not lying. There's a chance that they're telling the truth.

Speaker 1:

Okay, so that one was confirmed. So the next one is I'm only positive for cannabis because my buddy was smoking and I was next to him. So the reason I bring this up is my understanding is the cup test, the immunoassay. You need more drug in your system to test positive, and with the confirmatory testing, the chromatography spectrometry, it's so much more sensitive that you can detect nanogram per deciliter levels. So my assumption has been that, yeah, your confirmatory testing is sensitive enough that this one's plausible.

Speaker 2:

But you tell me the typical concentration cutoff for an amino acid might be 500 nanograms per mil or even 1,000 on the bottom end. Below that it just isn't sensitive enough to pick it up, whereas chromatography can get down to 20 nanograms per mil 5 nanograms per mil for some targets. We can do 2 nanograms per mil for fentanyl Extremely low concentrations. That being said, the secondhand marijuana smoke myth it's indeterminate. I cannot confirm or deny. I do know that we have tried a lot of in-lab reproducible studies of going to concerts, going to friends' houses, going to things and giving urine the next day. I myself went to a Wu-Tang Clan concert a few years back at the Conger Pavilion in a thick, thick cloud of cannabis smoke, along with a friend of mine neither of us smoke and gave urine for the next two days. It was clean. So I can't tell for sure, but I think that one that secondhand smoke one might be busted.

Speaker 1:

I'll share a personal anecdote, since you shared one. We love to snowboard, my wife, my daughter and I and we go up to South Lake Tahoe and our preferred resort is Heavenly and.

Speaker 1:

Heavenly has a gondola and there was a fire I think it was in the 90s where someone threw a cigarette out of the gondola and it lit part of the mountain on fire. And there's actually a run at Heavenly called the Burn where you can snowboard the burn scar and as a result, they have made the gondola basically impenetrable so nobody can throw a cigarette out. So I don't know, six, seven years ago we go to go down the mountain for the day and go home and the gondola doors open and we walk in and we are immediately aware that someone hotboxed the gondola on the ride up and it's an 11 minute ride. So they were smoking cannabis in this enclosed, very small, probably the size of a car cabin space for 11 minutes and we tried to quickly get out of the gondola and the doors of, of course, closed and I do not use cannabis and man, I was sick as a dog the rest of the day. My poor daughter was acting weird and my wife and I were joking like I think we would have tested positive on your drug test afterwards. We actually didn't go test, but I think what I would say is it probably is dependent on how close you are to the source, would say, is it probably is dependent on how close you are to the source, how big the airspace around you is and the duration of exposure. So I would argue in a large concert hall there's probably enough air that it diluted. But I would be very curious. Let's say somebody went on a long car ride with someone who was smoking, with the windows rolled up. There's probably enough exposure there that a person could test positive. So I'm going to say that the myth is plausible but not confirmed. So you guys do very sensitive testing. I've had patients test positive at the three nanograms per milliliter level and it's really hard to know what to do with because it would be a negative on an immuno assay. And usually what I tell them? Because they'll say let's say they test positive for cocaine. I'll tell them I totally hear you that you don't use cocaine but you were exposed to it.

Speaker 1:

And I hear all sorts of stories in addiction medicine. You and I've talked about that addiction is a very devastating disease and people are dishonest when they're trying to conceal their addiction. But this is a story one of my patients told me. So he goes on a date, meets a new girl, they kiss, nothing happens. The relationship goes nowhere. And then the next week he was positive for cocaine. So he was a pain patient and he was on pain meds and when his urine drug test came up abnormal, the pain folks appropriately said whoa, whoa, whoa, you're on a controlled substance.

Speaker 1:

You got to go see addiction medicine and essentially what I was able to get from him is that he was able to learn that this particular woman did have a cocaine addiction and, interestingly, when he kissed her his mouth went numb. And if you think about it, we actually use cocaine in ear, nose and throat surgeries because it's a local anesthetic and it's a vasoconstrictor, so it tightens up the blood vessels. And they actually used to sell 150 years ago cocaine lozenges for dental pain. And his level of his cocaine test was like five my patients who use cocaine it'll be like a thousand. So I actually believed him and he had severed the relationship and all of his subsequent tests have been negative. So have you heard of a case like that or something like an exposure like that?

Speaker 2:

Quite frequently, quite frequently, and it sounds very plausible to me, given the circumstances I remember reading about. The first use of anesthetic was a cocanization of a dog. They put a I think it was an epidural catheter with cocaine in a dog and his hind legs went completely numb. We use Novocaine, bupivacaine. These canes are all sort of in the same family. What do we do in those situations?

Speaker 2:

So first the lab is going to tell the referring provider what they found in the specimen, right, and I think that's a fundamental baseline acknowledgement that we all need to understand. It was in the specimen. Now, it might not have been that patient's urine, it might have been contaminated, it might have been switched with another patient and the patient might have seriously, unwittingly consumed this, like this patient of yours did. But we don't know how to treat the patient. All we can do is tell you it's there, right and in the amount that it's there, and confirm that, yes, it's absolutely there. In fact we freeze some of the urine or saliva for 45 days so that if you're going to see that patient for a follow-up visit and they can test their results, we can pull it out of the freezer and run it again. So we want to make really sure that we've got the right specimen and the right results.

Speaker 2:

The things I hear all the time. I don't hear cocaine that often. Although we tested a woman who came up positive for cocaine and she came up positive for cocaine twice, even when she knew she was being tested she tested positive for cocaine again. Turns out she was drinking a tea, some South American, brazilian rainforest tea that she claims had cocaine in it. She stopped taking the tea. Her results went negative. So that certainly is plausible. That's possible no-transcript.

Speaker 1:

And then one question. So I tell the patients in the office we do not do forensic collections, like I don't watch you pee, we don't do a chain of evidence. But I do my best in saying patient go in, I will take it out of the container that you put it in myself. But yes, a person could absolutely switch a specimen and sometimes people will say that is not my test and I say, ok, we will retest you. But I do have one question. We've talked about the fact that these point-of-care cup tests, the immunoassay, it's all about shape. So you can't have false positives and negatives In the confirmatory testing, the chromatography, mass spectrometry. Does that technology ever have false positives? And negatives.

Speaker 2:

Never, but almost, is the key word in there. It is extremely rare, but one case that comes to mind is the fentanyl acid that we purchase is highly volatile and it gets too old. They'll degrade to regular fentanyl. So we had an incident several years ago where everyone that day was positive for fentanyl in very small amounts and we shut down the machine that came up with this result it hopscotch to a new machine. It was a real problem for several days till we troubleshot it and talked to the manufacturers and found that out. So in that situation, although extremely rare, it's because this one reagent wasn't stored at the right temperature for a period of time.

Speaker 2:

It does happen and if you believe this patient, they've got a clean record up until now. You know their circumstances. Retest them, retest them with a new lab, retest them in a different fashion to just confirm those findings, because I would say LC-MS is 99.99% accurate. I really would. These incidents are very rare. They're usually from a malfunction that something like that would happen. But in this situation we saved the frozen retain, we retested it for all these patients and got the correct results out within a matter of days.

Speaker 1:

Yeah.

Speaker 1:

And then just to clarify LCMS is the acronym for liquid chromatography, mass spectrometry. We love our acronyms in medicine. Yeah, so what we actually do in the office. So let's say a person's a pain patient and you and I both know, with opioids specifically, there's a pure opioid addiction. There's pure pain and then there's a spectrum in between. Or a pain patient has pain and a different addiction, like pain and addiction, to say cocaine. So let's say a patient comes in, they've got chronic back pain, they've had three back surgeries, they get put on, say, methadone for pain, and if they have an abnormal test, like they're positive for fentanyl or they're positive for cocaine, our practice's policy is to advise the patient and retest them and if they are still positive they come to addiction medicine and then we spend the time with the patient to figure out what's going on. And sometimes it's you know it's.

Speaker 1:

Yeah, my roommate is using fentanyl and there's drug paraphernalia all over my apartment. I had one of those and when he moved out his urine drug test turned clean. Oh, I shouldn't use that. I'm so sorry. His drug test did not show an abnormal result. There's a lot of stigma around urine drug testing. I slipped. I do not like the terms clean and dirty, because that confers judgment. It is an abnormal test is when there's an unexpected result. But yes, so coming back to my story, this patient was on methadone, kept testing positive for fentanyl, told me the roommate was really deep in addiction. I of course, offered to see the roommate. No-transcript.

Speaker 2:

Yeah, and that's rare but it is possible. We don't make decisions here at the lab on how to treat patients, but it's a wide spectrum of positions on in that sort of situation. Some have a black and white policy, others go with their gut, others are very lenient. I see the whole spectrum, have such a great background of training and you see patients in the chronic pain space anecdotally and you see a lot of patients in the substance space and you see how they move together and go back and forth and can you have a pain patient that's also has a substance use problem?

Speaker 1:

yeah, absolutely, it's very common and it it really puts you in a in a great position to to help these patients yeah, the the pain folks were really grateful when we joined the practice because, I mean, essentially their options prior were we'll give you a warning, you've tested abnormal again and basically you were just going to be weaned off your pain meds and sorry. And so the way I describe this to the patients is pain medicine in 2025 has a really short leash. The years of scrutiny because of the opiate problem in America. Pain medicine is by the book. Like the California Medical Board has exact guidelines.

Speaker 1:

Addiction medicine's different. You come to see the addiction doctor because you have a problem and just the rules are a little bit different. Now, granted, I can't give someone hydrocodone who's actively addicted to fentanyl. I would put them on a different thing, like Suboxone, or send them to a methadone clinic.

Speaker 1:

But it's nice that the pain doctors can continue to focus on the pain and then know that the patient's other issues are being managed, and we have a lot of patients that we co-manage and sometimes addiction medicine manages the meds and pain medicine will only offer procedures because the addiction is too high risk, or sometimes it's. We think this is probably an unexpected test result or the patient totally owned it and wants to get counseling. They really want to focus on their pain. I think of one gentleman in our practice who is a lovely human being horrible pain and a cocaine addiction and he is working so hard on his cocaine addiction. He slipped up once in six months. He's really trying, and so pain medicine says great, you're trying, you're doing great, you're seeing addiction medicine, we'll keep you on your pain meds. And I actually think that there's a lot of value in having pain and addiction in the same practice.

Speaker 2:

I only know my own clinical experience, but it's been a really good fit In my personal philosophy. I see lots of different practice styles and everyone cancel lab work because the patient had tested positive for an illicit substance. The patient was retested that day and subsequently committed suicide that night and our findings although we're doing our job we're trying to get patients safe led to the provider making that decision to cease their pain medications or cease their treatment or retest, and they knew they'd test positive again and face repercussions. And those are heartbreaking, heartbreaking calls to get that. This patient has given up hope and had they been in a really good treatment program for the other side of their pain, to help with the psychological and addictive issues, maybe their outcomes would have been different.

Speaker 2:

So I love what you're doing.

Speaker 1:

Yeah, thank you. So we're about at time, but I'm really interested to hear what you're working on at MD Labs as next steps, new projects, what's on your to-do list?

Speaker 2:

What's on our to-do list In the drug testing world? We are working on compounds that seem to be popping up all over the country for different burn providers in California, xylazine, it's, as you mentioned, some of these exotic benzodiazepines, some of these exotic fentanyls, these exotic nitazines that are analogs of the parent drugs. In Texas there is a gas station heroin that has Ah.

Speaker 2:

Taneptine? Yeah, it's a French tricyclic antidepressant. It's not only French. They invented it years and years ago and it's really not regulated in the US. Right now. It's being sold for pain and for antidepressant. It's irritable bowel syndrome. It's a real problem. There are some deaths related to tyaneptine currently, so we're developing an assay for that, as well as its metabolite. Can my office have that? The test, the tyaneptine, the tyaneptine the drug or the test.

Speaker 2:

We don't want the drug, but we'll take the test. It's interesting you have not heard of it in California yet, but it doesn't mean it won't be here quickly. But yeah, it should be commercially available next 30 to 45 days.

Speaker 1:

So I think this comes back to another part of how your ability to generate tests for new substances helps us. We don't know if tyaneptine's here, because we can't test for it.

Speaker 2:

It theoretically would trigger a tricyclic antidepressant enzyme immunoassay. It's a sister molecule and it would just be an unknown TCA. But yeah, without the actual target compound, the LC-MS is not looking for everything under the sun. It's looking for specific targets. So it has to know what to look for and yeah, that's a weakness of that methodology is, if it's not looking for it, it won't find it.

Speaker 1:

Yeah. So I'm just going to ask and maybe you're not the right person to ask at MD Labs, but I would love, when you have tyaneptine available, to be able to test for it in our practice In some ways, because the testing that you offer us is so much more sophisticated than anything else anyone's doing in our region. We are the canary in the coal mine, so the hospitals only run the immunoassay tests. So if you go up to the ER, you just get a yes, no and it's only the basic seven substances. I think it's amphetamines, cannabis, alcohol, benzodiazepines, opioids, barbiturates and, I think, PCP, and that's it. And that's one of the reasons our patients say I'm going to use isotonidazine because no one can test for it and then I can fake out my drug program. So again, another utility to what you do is you help us to see what's the very tip of the spear coming into our community.

Speaker 2:

Yeah, these patients can get very creative and some have science backgrounds and know what you're looking for. So it is important to stay on the cutting edge of this technology, so we're doing our best to keep up. The DEA informs us a year or two or three after a drug is found. They're not really as up-to-date as we'd like, so it's a lot of word of mouth. Labs talk to each other about what's going on in certain regions, and hearing from providers like you who are so close to the community, that's how labs know what to do and what you need.

Speaker 1:

So I have to say I am going to say thank you, because I am a smarter human being after talking to you, and I will be smarter with my patients next week in the office when I explain urine drug testing to them.

Speaker 2:

I'm very happy to come out and be of service and share the lab's perspective and what we can do with the whole world, especially all the providers that listen to your show. So thank you for letting me be here.

Speaker 1:

Absolutely. Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives. Bye.