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滥用药物(DOA)试验

Author
Robert J Hoffman, MD
Section Editor
Stephen J Traub, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
李涛, 副教授

引言

出于本专题的目的，“滥用药物(drug of abuse, DOA)”定义为娱乐性滥用的药物、化学品或植物产品。尽管在临床环境下DOA是常规试验，但许多评估此种筛查的研究未能证明临床益处，大部分毒理学家建议仅在有明确指征时才进行此类试验[1-3]。

DOA筛查试验提供的结果表面上很简单，通常报告为给定药物阴性或阳性，这种结果的表面简单性可误导临床医生认为DOA试验简单且结果易于解释。实际上，DOA试验非常复杂，而且正确的结果解读需要专业知识。关于DOA试验的几项研究显示，许多常规安排DOA试验的临床医生并不了解适当的检测技术、可检出哪些药物，及如何正确解释阳性结果和阴性结果[4-6]。DOA筛查结果的正确解读取决于临床背景。临床医生必须考虑实施的试验类型、成瘾物质使用或暴露的怀疑水平(即验前概率)、进行试验的目的、以及假阳性结果和假阴性结果的可能性。

本专题将总结临床环境中，尤其是急诊和急性治疗情况下DOA试验涉及的重要概念和问题。本专题不准备指导工作场所或大部分法医DOA试验，也不论述非临床DOA试验的相关问题。中毒患者的治疗、治疗药物监测，以及应用血清药物浓度诊断或辅助特定药物毒性的治疗见其他专题。 (参见“成人药物中毒的一般处理方法”和“不明原因物质过量重症成人的初始处理”和“Approach to the child with occult toxic exposure”)

一项基本的DOA筛查包括什么？

美国各地一致采用5种药物的基本DOA筛查：

●苯丙胺(参见“急性苯丙胺和人工合成卡西酮(“浴盐”)中毒”和“甲基苯丙胺中毒”)

                                  

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Literature review current through: 2017-06 . | This topic last updated: 2017-02-23.
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References
Top
  1. Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol (Phila) 2009; 47:286.
  2. Montague RE, Grace RF, Lewis JH, Shenfield GM. Urine drug screens in overdose patients do not contribute to immediate clinical management. Ther Drug Monit 2001; 23:47.
  3. Belson MG, Simon HK, Sullivan K, Geller RJ. The utility of toxicologic analysis in children with suspected ingestions. Pediatr Emerg Care 1999; 15:383.
  4. Durback LF, Scharman EJ, Brown BS. Emergency physicians perceptions of drug screens at their own hospitals. Vet Hum Toxicol 1998; 40:234.
  5. Reisfield GM, Webb FJ, Bertholf RL, et al. Family physicians' proficiency in urine drug test interpretation. J Opioid Manag 2007; 3:333.
  6. Starrels JL, Fox AD, Kunins HV, Cunningham CO. They don't know what they don't know: internal medicine residents' knowledge and confidence in urine drug test interpretation for patients with chronic pain. J Gen Intern Med 2012; 27:1521.
  7. Federal Register, Vol 59, June 9, 1994, (59 CFR 29908). http://www.gpo.gov/fdsys/pkg/FR-1994-06-09/html/94-13940.htm (Accessed on February 13, 2014).
  8. Melanson SE, Baskin L, Magnani B, et al. Interpretation and utility of drug of abuse immunoassays: lessons from laboratory drug testing surveys. Arch Pathol Lab Med 2010; 134:735.
  9. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance. Pain Physician 2012; 15:S67.
  10. Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician 2011; 14:123.
  11. Jamison RN, Ross EL, Michna E, et al. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain 2010; 150:390.
  12. Michna E, Jamison RN, Pham LD, et al. Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings. Clin J Pain 2007; 23:173.
  13. Manchikanti L, Manchukonda R, Pampati V, et al. Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? Pain Physician 2006; 9:123.
  14. Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003; 97:1097.
  15. Perrone J, De Roos F, Jayaraman S, Hollander JE. Drug screening versus history in detection of substance use in ED psychiatric patients. Am J Emerg Med 2001; 19:49.
  16. Skelton H, Dann LM, Ong RT, et al. Drug screening of patients who deliberately harm themselves admitted to the emergency department. Ther Drug Monit 1998; 20:98.
  17. Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatr Emerg Care 2013; 29:903.
  18. Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv 2000; 51:474.
  19. Fortu JM, Kim IK, Cooper A, et al. Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care 2009; 25:387.
  20. Broderick KB, Lerner EB, McCourt JD, et al. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med 2002; 9:88.
  21. Couto JE, Romney MC, Leider HL, et al. High rates of inappropriate drug use in the chronic pain population. Popul Health Manag 2009; 12:185.
  22. Cone EJ, Caplan YH, Black DL, et al. Urine drug testing of chronic pain patients: licit and illicit drug patterns. J Anal Toxicol 2008; 32:530.
  23. Drummer OH, Kourtis I, Beyer J, et al. The prevalence of drugs in injured drivers. Forensic Sci Int 2012; 215:14.
  24. Figl M, Pelinka LE, Weninger P, et al. Urine toxicology screening in Austrian trauma patients: a prospective study. Arch Orthop Trauma Surg 2010; 130:883.
  25. Davey J, Leal N, Freeman J. Screening for drugs in oral fluid: illicit drug use and drug driving in a sample of Queensland motorists. Drug Alcohol Rev 2007; 26:301.
  26. Walsh JM, Flegel R, Cangianelli LA, et al. Epidemiology of alcohol and other drug use among motor vehicle crash victims admitted to a trauma center. Traffic Inj Prev 2004; 5:254.
  27. Macdonald S, Anglin-Bodrug K, Mann RE, et al. Injury risk associated with cannabis and cocaine use. Drug Alcohol Depend 2003; 72:99.
  28. Levy RS, Hebert CK, Munn BG, Barrack RL. Drug and alcohol use in orthopedic trauma patients: a prospective study. J Orthop Trauma 1996; 10:21.
  29. Orsay EM, Doan-Wiggins L, Lewis R, et al. The impaired driver: hospital and police detection of alcohol and other drugs of abuse in motor vehicle crashes. Ann Emerg Med 1994; 24:51.
  30. Loiselle JM, Baker MD, Templeton JM Jr, et al. Substance abuse in adolescent trauma. Ann Emerg Med 1993; 22:1530.
  31. Clark RF, Harchelroad F. Toxicology screening of the trauma patient: a changing profile. Ann Emerg Med 1991; 20:151.
  32. Heinemann AW, Schnoll S, Brandt M, et al. Toxicology screening in acute spinal cord injury. Alcohol Clin Exp Res 1988; 12:815.
  33. Ricci G, Majori S, Mantovani W, et al. Prevalence of alcohol and drugs in urine of patients involved in road accidents. J Prev Med Hyg 2008; 49:89.
  34. Soderstrom CA, Dailey JT, Kerns TJ. Alcohol and other drugs: an assessment of testing and clinical practices in U.S. trauma centers. J Trauma 1994; 36:68.
  35. Bast RP, Helmer SD, Henson SR, et al. Limited utility of routine drug screening in trauma patients. South Med J 2000; 93:397.
  36. Langdorf MI, Rudkin SE, Dellota K, et al. Decision rule and utility of routine urine toxicology screening of trauma patients. Eur J Emerg Med 2002; 9:115.
  37. Brett AS. Implications of discordance between clinical impression and toxicology analysis in drug overdose. Arch Intern Med 1988; 148:437.
  38. Hayek SN, Wibbenmeyer LA, Kealey LD, et al. The efficacy of hair and urine toxicology screening on the detection of child abuse by burning. J Burn Care Res 2009; 30:587.
  39. ElSohly MA, Salamone SJ. Prevalence of drugs used in cases of alleged sexual assault. J Anal Toxicol 1999; 23:141.
  40. Annas GJ. Testing poor pregnant women for cocaine--physicians as police investigators. N Engl J Med 2001; 344:1729.
  41. American Academy of Pediatrics. Committee on Substance Abuse. American Academy of Pediatrics. Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention and management of substance abuse. Pediatrics 1998; 101:125.
  42. Foley EM. Drug screening and criminal prosecution of pregnant women. J Obstet Gynecol Neonatal Nurs 2002; 31:133.
  43. Teitelbaum J, Rosenbaum S, Goplerud E. State laws permitting intoxication exclusions in insurance contracts: implications for public health policy and practice. Public Health Rep 2004; 119:585.
  44. Kon AA, Pretzlaff RK, Marcin JP. The association of race and ethnicity with rates of drug and alcohol testing among US trauma patients. Health Policy 2004; 69:159.
  45. Marcin JP, Pretzlaff RK, Whittaker HL, Kon AA. Evaluation of race and ethnicity on alcohol and drug testing of adolescents admitted with trauma. Acad Emerg Med 2003; 10:1253.
  46. Gallardo E, Queiroz JA. The role of alternative specimens in toxicological analysis. Biomed Chromatogr 2008; 22:795.
  47. Walsh JM. New technology and new initiatives in U.S. workplace testing. Forensic Sci Int 2008; 174:120.
  48. Moody DE, Fang WB, Andrenyak DM, et al. A comparative evaluation of the instant-view 5-panel test card with OnTrak TesTcup Pro 5: comparison with gas chromatography-mass spectrometry. J Anal Toxicol 2006; 30:50.
  49. Peace MR, Poklis JL, Tarnai LD, Poklis A. An evaluation of the OnTrak Testcup-er on-site urine drug-testing device for drugs commonly encountered from emergency departments. J Anal Toxicol 2002; 26:500.
  50. Crouch DJ, Hersch RK, Cook RF, et al. A field evaluation of five on-site drug-testing devices. J Anal Toxicol 2002; 26:493.
  51. Lin CN, Nelson GJ, McMillin GA. Evaluation of the NexScreen and DrugCheck Waive RT urine drug detection cups. J Anal Toxicol 2013; 37:30.
  52. Biermann T, Schwarze B, Zedler B, Betz P. On-site testing of illicit drugs: the use of the drug-testing device "Toxiquick". Forensic Sci Int 2004; 143:21.
  53. Walsh JM, Flegel R, Crouch DJ, et al. An evaluation of rapid point-of-collection oral fluid drug-testing devices. J Anal Toxicol 2003; 27:429.
  54. Attema-de Jonge ME, Peeters SY, Franssen EJ. Performance of three point-of-care urinalysis test devices for drugs of abuse and therapeutic drugs applied in the emergency department. J Emerg Med 2012; 42:682.
  55. George S, Braithwaite RA. Use of on-site testing for drugs of abuse. Clin Chem 2002; 48:1639.
  56. Taylor EH, Oertli EH, Wolfgang JW, Mueller E. Accuracy of five on-site immunoassay drugs-of-abuse testing devices. J Anal Toxicol 1999; 23:119.
  57. Bush DM. The U.S. Mandatory Guidelines for Federal Workplace Drug Testing Programs: current status and future considerations. Forensic Sci Int 2008; 174:111.
  58. Brookoff D, Cook CS, Williams C, Mann CS. Testing reckless drivers for cocaine and marijuana. N Engl J Med 1994; 331:518.
  59. Boroda A, Akhter R. Hallucinations in a child: a case demonstrating the pitfalls of urine dipstick drug testing. J Forensic Leg Med 2008; 15:198.
  60. Rogers SC, Pruitt CW, Crouch DJ, Caravati EM. Rapid urine drug screens: diphenhydramine and methadone cross-reactivity. Pediatr Emerg Care 2010; 26:665.
  61. Baker JE, Jenkins AJ. Screening for cocaine metabolite fails to detect an intoxication. Am J Forensic Med Pathol 2008; 29:141.
  62. Cone EJ, Sampson-Cone AH, Darwin WD, et al. Urine testing for cocaine abuse: metabolic and excretion patterns following different routes of administration and methods for detection of false-negative results. J Anal Toxicol 2003; 27:386.
  63. Price JW. Dilution of urine drug tests: is it random? J Addict Med 2013; 7:405.
  64. Cone EJ, Lange R, Darwin WD. In vivo adulteration: excess fluid ingestion causes false-negative marijuana and cocaine urine test results. J Anal Toxicol 1998; 22:460.
  65. Chaturvedi AK, Sershon JL, Craft KJ, et al. Effects of fluid load on human urine characteristics related to workplace drug testing. J Anal Toxicol 2013; 37:5.
  66. Tilley MA, Cotant CL. Acute water intoxication during military urine drug screening. Mil Med 2011; 176:451.
  67. Centers for Disease Control and Prevention (CDC). Use of niacin in attempts to defeat urine drug testing--five states, January-September 2006. MMWR Morb Mortal Wkly Rep 2007; 56:365.
  68. Mittal MK, Florin T, Perrone J, et al. Toxicity from the use of niacin to beat urine drug screening. Ann Emerg Med 2007; 50:587.
  69. Uebel RA, Wium CA. Toxicological screening for drugs of abuse in samples adulterated with household chemicals. S Afr Med J 2002; 92:547.
  70. Warner A. Interference of common household chemicals in immunoassay methods for drugs of abuse. Clin Chem 1989; 35:648.
  71. Cody JT, Valtier S, Kuhlman J. Analysis of morphine and codeine in samples adulterated with Stealth. J Anal Toxicol 2001; 25:572.
  72. Venkatratnam A, Lents NH. Zinc reduces the detection of cocaine, methamphetamine, and THC by ELISA urine testing. J Anal Toxicol 2011; 35:333.
  73. Lin CN, Strathmann FG. Elevated urine zinc concentration reduces the detection of methamphetamine, cocaine, THC and opiates in urine by EMIT. J Anal Toxicol 2013; 37:665.
  74. Paul BD, Jacobs A. Spectrophotometric detection of iodide and chromic (III) in urine after oxidation to iodine and chromate (VI). J Anal Toxicol 2005; 29:658.
  75. Larson SJ, Holler JM, Magluilo J Jr, et al. Papain adulteration in 11-nor-Delta9-tetrahydrocannabinol- 9-carboxylic acid-positive urine samples. J Anal Toxicol 2008; 32:438.
  76. Burrows DL, Nicolaides A, Rice PJ, et al. Papain: a novel urine adulterant. J Anal Toxicol 2005; 29:275.
  77. Valtier S, Cody JT. A procedure for the detection of Stealth adulterant in urine samples. Clin Lab Sci 2002; 15:111.
  78. Wu AH, Bristol B, Sexton K, et al. Adulteration of urine by "Urine Luck". Clin Chem 1999; 45:1051.
  79. Paul BD, Jacobs A. Effects of oxidizing adulterants on detection of 11-nor-delta9-THC-9-carboxylic acid in urine. J Anal Toxicol 2002; 26:460.
  80. Welsh KJ, Dierksen JE, Actor JK, Dasgupta A. Novel spot tests for detecting the presence of zinc sulfate in urine, a newly introduced urinary adulterant to invalidate drugs of abuse testing. Am J Clin Pathol 2013; 140:572.
  81. Peace MR, Tarnai LD. Performance evaluation of three on-site adulterant detection devices for urine specimens. J Anal Toxicol 2002; 26:464.
  82. Ferslew KE, Hagardorn AN, Robert TA. Capillary ion electrophoresis of endogenous anions and anionic adulterants in human urine. J Forensic Sci 2001; 46:615.
  83. Cody JT, Valtier S. Effects of Stealth adulterant on immunoassay testing for drugs of abuse. J Anal Toxicol 2001; 25:466.
  84. Wu AH, McKay C, Broussard LA, et al. National academy of clinical biochemistry laboratory medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Clin Chem 2003; 49:357.
  85. Mazor SS, Mycyk MB, Wills BK, et al. Coca tea consumption causes positive urine cocaine assay. Eur J Emerg Med 2006; 13:340.
  86. Altunkaya D, Smith RN. Aberrant radioimmunoassay results for cannabinoids in urine. Forensic Sci Int 1990; 47:195.
  87. Rollins DE, Jennison TA, Jones G. Investigation of interference by nonsteroidal anti-inflammatory drugs in urine tests for abused drugs. Clin Chem 1990; 36:602.
  88. Cotten SW, Duncan DL, Burch EA, et al. Unexpected interference of baby wash products with a cannabinoid (THC) immunoassay. Clin Biochem 2012; 45:605.
  89. Costantino A, Schwartz RH, Kaplan P. Hemp oil ingestion causes positive urine tests for delta 9-tetrahydrocannabinol carboxylic acid. J Anal Toxicol 1997; 21:482.
  90. Huestis MA, Mitchell JM, Cone EJ. Detection times of marijuana metabolites in urine by immunoassay and GC-MS. J Anal Toxicol 1995; 19:443.
  91. Dackis CA, Pottash AL, Annitto W, Gold MS. Persistence of urinary marijuana levels after supervised abstinence. Am J Psychiatry 1982; 139:1196.
  92. Rengarajan A, Mullins ME. How often do false-positive phencyclidine urine screens occur with use of common medications? Clin Toxicol (Phila) 2013; 51:493.
  93. Ly BT, Thornton SL, Buono C, et al. False-positive urine phencyclidine immunoassay screen result caused by interference by tramadol and its metabolites. Ann Emerg Med 2012; 59:545.