Hello, and welcome to today's PCSS-MAT Training, Lab Testing in Assessment of Substance Use Disorders. My name is Kevin Sevarino, I'm an Associate Clinical Professor with the Yale University School of Medicine, and as well president-elect for the American Academy of Addiction Psychiatry. My disclosures for today. I have no financial relationships with any ACCME defined commercial interest relevant to the content of this presentation. The content of the sub-activity will not include today any off-label recommendations for use of medications. Our target audience. The overarching goal of PCSS-MAT is to make available the most effective medication-assisted treatment to serve our patients in a variety of settings, including primary care, psychiatric care, and pain management settings. Our objectives for today in this presentation are that at the conclusion of this discussion, participants should be able to first, discuss clinical issues and performing urine drug testing, which we'll refer to here on in as UDT. Describe the basic types of UDT and when they should be used. Third, define the metabolism of opioids and benzodiazepines in order to interpret UDT results, and finally, describe other non-urine laboratory testing used as part of substance use disorder evaluations. Our outline pretty much breaks down the same way. We're going to be talking today about the purpose and use of UDT, the types of urine drug testing, the interpreteration of UDT, forensic issues in UDT, and then again, other lab testing. First, let's talk about a case vignette which will make this more interesting. In the following, we will meet Bill, a patient you maintain on buprenorphine/naloxone. He provides the urine drug screening positive for opiates and buprenorphine. We'll discuss how to interpret this result, as well as other aspects of the case moving forward. So first, let's talk about the purpose and use of urine drug testing. I would like to point out first, the very key resource that was released in 2017 is called The Appropriate Use of Drug Testing in Clinical Addiction Medicine, released by the American Society of Addiction Medicine, ASAM. It's an excellent summary of this topic. I'd urge all of you to get a copy of that to have it by your side, because it can go into some more detail than we can in our 45 or so minutes here today. So the goals of urine drug testing, the main thing I want to emphasize that it's not meant to be punitive. It's really meant to improve patient care and safety. It can facilitate the doctor-patient communication, because you and the patient both know you have the same information about what might have been consumed. It can provide objective information. It can confirm the use of prescribed medication, so it's being used for adherence testing, and then it can confirm the lack of use of non-prescribed medications or illicit drugs. In the legal forum, it can be used as a condition of parole and probation, it can be used in custody and parental issues, and it can be used in workplace testing. What do we study when we do urine drug testing? The choice of matrix. Urine is by far the most widely used. It's typical window of detection is hours to days, with some exceptions that I'll point out such as cannabinoids. The advantages, it's a very mature technology. Many labs are doing it. It's low cost. It's fairly easy to collect and you can perform point-of-care testing that is right in your office. The disadvantages are that, there are many ways to tamper with the sample before it reaches you. There's substitution, dilution, they may take a substance and adulterate the sample called in vivo, adulteration, or they may add something after the fact. If you need to do a confirmation, which we'll discuss on it, with gas-chromatography and in mass spec, that becomes more expensive. There is a debate in the field about whether the collection of the urine should be observed or unobserved. Many in the field would feel that they pretty much always have to be observed to be valid, but then there are others that say that that violate patient rights and privacy, and that in fact what you should do is only observe them when you have cause. Of course, there are issues of those that had been exposed to trauma in the past where observing the urine might be more difficult or even traumatic for the patient. There are ways which we'll discuss, to get around the idea that somebody can adulterate the urine. You can normalize the results to creatinine in the urine, to its temperature, to a specific gravity. You can look at its pH, you can look at levels of IgG, and there are even special testing for adulterant such as bleach. There are other choices of matrix, however, which are being developed. Of course in the field for police work, breath would be a very good detection method. Things are more rapidly metabolized usually, and some will be about a minute to hours detection. This is most widely used as a point-of-care test for ethanol. It's used as expanding, but there are volume effects and contaminant effects. The next most common matrix that is used is blood testing. The window of detection area is usually minutes to hours. It's obviously more invasive, but usually used in emergency rooms or for forensic testing, and it is more costly. Another matrix is oral fluid mainly saliva. Here the window of detection can really vary, it's minutes to days. It's very unobtrusive, it's easy to observe, and it's easy to collect, but there's usually poor sensitivity here. There are higher cutoffs to get specificity again, for urine and especially for marijuana, and it can be prone to contamination by foodstuffs, drinks, etc. Sweat is another matrix. Its windows of detection is hours to weeks. It is more resistant to cheating. It's collected over time with a patch, but the patch may fall off and it's only prospective. In other words, you're collecting from the point you apply the patch forward. Then hair and nails has the longest window of detection, because hair and nails grow the slowest. There, it's weeks to months. It's difficult to adulterate because basically you snip hair off or the nail. It's directly observed but the sensitivity is poor for marijuana, and then believe it or not, there's hair bias. The darker the hair, the higher the cutoff need to be, and there may be treatment such as Lamisil which can affect the results. Practical issues for urine drug testing, especially those that plan on doing them in their office. First question you need to ask, are you going to send the specimen off to another laboratory, or you may work in a hospital where there was automatically a lab set up, or are you going to do this point-of-care testing in your office? Then the next big question which is empathized in the ASAM guidelines, is whether the testing is random versus scheduled? So many clinics, for example, a buprenorphine clinic is the last one, will have a set time where somebody comes in and gets their buprenorphine. Therefore by definition, a collection at that time would be scheduled, and the difficulty maybe that somebody could then time their use of the substance so that during the window that their collection is made, they come up with no unexpected results. Random scheduling is much preferred, but it's harder to manage in your clinic or your office. Again, the issue of whether these are observed or non-observed collections. Finally, what I'll talk about at the end of this presentation is the importance when it's considered a forensically or legally valid measurement to maintain what's called a chain of custody of the sample. How do we discuss urine drug testing with our patients? With a new patient where you're initiating treatment, it's usually can be part of your treatment agreement. I'll usually say this is our routine practice. We do this almost as a universal precaution and it's a patient safety issue. For me to prescribe a medication to you, I need to know what else you might be using. It's also important to realize you're actually doing it to follow whether treatment's working. Because in the patient's best interest, if somebody is not able to achieve the result you'd want usually that's sobriety, then you need to change the treatment plan for that patient. It is increasingly becoming consistent with standards of care. If a patient's been in treatment for awhile and now you're instituting urine drug testing, you're going to get the question, "Why now?" This was always fine before where we didn't do it. You might cite more current guidelines or guidance such as in the ASAM criteria, they really recommend that this be done, and let them know that it's going to be applied universally across the board for all patients and not just some. If the patient says, "But I'm not a drug addict," and this is often the case in pain clinics, again, it's important to say that this is routine testing. It's not singling anyone out, but it's meant, A, to determine the adequacy of the treatment and B, to make sure that it's safe to continue prescribing whatever you're prescribing. If the patient says, "I refuse," I often due would say, "I can't prescribe certain medications if I'm unable to routinely safely monitor you." It's then good to go back and emphasize that you're not using this to judge the patient or to punish the patient, but to treat. If you're treating addiction, to treat that as a disease, and to be able to understand its cause. As I said you can test the validity of collected urine samples. There are even cups that are made now with a strip along the side which will measure the pH, measure the temperature, and then there are some crude ways of doing it. If the sample fills cold in your hand, you might question the validity of that sample. If you shake it and there's no foaming at all, then you also question whether there's much protein in there at all. Most labs we'll actually look at pH and they'll look at level of creatinine usually created in 20 mg/dL is considered a normal clearance into the urine, though there can be some variation with that. If a patient needs to drink a great deal of water to try to give you a sample, the sample is going to come up more dilute and that sometimes can be a clinical issue. So what's important to understand about levels of urine drug testing? First level, there's a screening level which is mainly based on immunologics, mainly an enzyme-mediated immunoassay. There's an antigen that is in the urine, it may be say a metabolite of cocaine or it may actually be the opiate molecule and antibody then reacts to that and then that's amplified by a second antibody or fluorescent agent or something else, amplifying the signal. So anywhere where there can be immunologic cross reaction, you can get what's called a false positive and anywhere there would be something that would interfere with the antibody-antigen interaction such as the gross change in pH, you might get a false negative. So there are usually a dipsticks, which you put in and then you see whether a band either disappears or turns black or various other colors. If there are unexpected findings than that, we'll go into this in more detail, then you need to do confirmatory testing, because the antibody is prone to cross reactions. So confirmatory testing, is first using gas chromatography, which may fractionate things largely on the basis of charge plus mass and then mass spectrometry which bombards the various fractions of the gas chromatograph and gives you a defined molecular fingerprint. So this is absolutely specific for what substance is in the sample and there, there's no false positive or false negative, there's only interpretations of levels. The requirements for in-office urine drug testing, practical point is that you must obtain what's called a certificate of waiver through the US Department of Health and Human Services website and you can go online to look for that. That's called a CLIA waiver. Why that is important is because CLIA is the Clinical Laboratory Improvement Amendments is a legal definition of what a test is both accurate and that the people administering it are qualified to do that. So if you get a CLIA waiver that says that your office is qualified to perform whatever tests you want to. Most of the tests we have can be what's called a CLIA waiver test. These are tests that are demonstrated by the manufacturer to be accurate and low risk even when administered and used by untrained personnel, usually the ones that are approved for home use. So if you have that, then a CLIA waiver clearly covers you. But even if you have an in-office fluorometer or other reader of urine drug tests, you can get a CLIA waiver to allow to use that. The CMS will allow billing for a single test per patient encounter, not the number of tests and I've been with the VA so actually I'm not familiar with the actual coding, but a usual code is G0477 for each unit. There is some controversy in people overusing the test multiple times, we'll talk a bit more about the appropriate frequency in the testing in a bit. The other important thing to remember about urine drug-testing is it's part of somebody's protected health information and specifically, specially protected health information that involves ones possible diagnosis of a substance use disorder. So the Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehab Act of 1970, and then later on, the act of 1972 established the Code of Federal Regulations 42, Title 2 for special protections for those with alcohol use disorders, substance use disorders, HIV, and sickle-cell anemia. That information that would reveal people have those is specially protected and requires a release of information that's specifically a state of that information is to be released. These guidelines were revised or this code was guideline revised in January 13th, 2017, to be more specific about that you'd not only have to specify what's being released, but specifically to who it's being released and for how long. It also actually made it a little easier to allow release of this information to entities that are performing research so that it would not preclude the ability to do research. They said the revision is meant to improve the dissemination of data for research, or better protecting privacy. So that's important to know that if somebody calls you and wants to know their urine drug testing, make sure you have the appropriate release of information for that. So in Summary, in our first part of urine drug testing, urine is by far the most widely used matrix. The decisions in urine drug testing include whether you're going to use point-of-care testing or whether you're going to send it out, whether the collection is observed or random, and that whether you are going to maintain a formal chain of custody. Remember UDT results are protected by CFR42, Part 2, according to revision. It's important to discuss UDT with the patient as not only a constructive part of his care, but as a universal precaution and that UDT has two steps; a screening step and a confirmation step. So what are the types and interpretation of urine drug testing? Is our second part. So as I said, the screening part of urine drug testing is my immunoassay and they run these various types; EMIT, CODI, fluorescence-polarized immunoassay. The bottom line is that they're all based on antibody-antigen interaction. They're widely available and cost-effective and they're very well understood, but they are prone to cross reactions and false positives, as well in some cases false negatives. So common false positive. I think it's most important to realize that there's local variation in what these are. So always read the package inserts if your doing point-of-care testing for the list of common cross reactants they're aware of. Otherwise you can call your lab and find out what they have more commonly seen as cross reactants and more inclusive list they have down here referenced by molar for Mayo Clinic proceedings. So for amphetamines are by far the one with the most common false positives, commonly bupropion, desipramine, pseudoephedrine, ranitidine, and trazodone can trigger false positives. For benzodiazepines Zoloft is not uncommon, sertraline. Cannabinoids, they can be some of the anti-HIV drugs, NSAIDs, and PPIs. Cocaine is pretty uncommon because it's actually a measurement of benzoylecgonine, which is metabolite of cocaine and so very rare to get a false positive. For EtGs, some of the initial screens we'll see will be triggered by isopropyl alcohol, rubbing alcohol, mouthwashes can actually have real ethanol in them as can NyQuil. Opioids; dextromethorphan, diphenhydramine, rifampin, poppy seed, which we'll talk about in quinine, and in PCP again, dextromethorphan, diphenhydramine, tramadol, venlafaxine, imipramine, and ketamine. Urine testing for ethanol exposure is becoming more widespread over the last five years, up until then people were using breathalyzers only and the problem with breathalyzer testing is it's really got a window mainly of hours. So somebody could have consumed the night before and you'll miss it. With a cutoff of about 100 ng/ml looking for ethyl glucuronide, which is a metabolite for alcohol, and then ethyl sulfate, a more specific metabolite, the window is three to five days post use. We won't talk about blood testing today, which can also look at something called PEth, which has a window of two to three weeks. That testing is very sensitive, but it's not very quantitative, in other words, it's very dependent on how much was drunk and when was drunk. So if you have two beers three hours before the testing, you may get a very high result, whereas if you had an entire bottle of vodka three days before, you may get a little result. The positives as I said can come from any source, real source of alcohol such as cooking wine, hair products, mouthwashes, and hand sanitizers. So it's important to be aware of those. When the result of a drug test, your initial drug screen is either one, contested, two, guiding a change in clinical decision-making or three, done for forensic purposes. Then you've got to take that first immunoassay screening and confirm it with gas chromatography mass spec or sometimes straight liquid chromatography mass spec, and we'll talk about those in a bit. The cutoffs are a bit different for the two. You can see here what we used to call the Federal or SAMHSA 5, the initial things usually involved in the screening for THC, for BEG, for cocaine, opiates, PCP, and amphetamines. This cutoffs they've been modified because what you want to do is you want to have the best sensitivity, that is, pick up the most real true positives and the best specificity and that is eliminate false positives. So actually the opiate cutoff has been usually reduced in most labs to 300. So what is it we detect? Well, the natural opioids, the OPS, include codeine and morphing. These are well detected by standard opioid screens. The next level of only partial detection are the semi-synthetic opiates, hydrocodone and hydromorphone, which are modified from the synthetics, they're less well detected and usually require that you order a special test for them. Mandatory guidelines for federal workplace drug-testing last year made them part of a standard screen for federal workplace testing. Semi-synthetic opioid, that's a very common oxycodone and its metabolite turns out not to be well detected, and so most screens now include them as a separate test. But at high level, something like oxycodone will trip the standard opiate screen. Then finally, the full synthetics, methadone, buprenorphine, fentanyl, meperidine are not detected by a regular opioid screen and they'll require separate tests. Many places now automatically include methadone and fentanyl in their screens. It's important to understand opioid metabolism to interpret a urine drug tests for opioids. So for example, so heroine goes through 6-MAM, 6-monoacetylmorphine to morphine. If you see 6-MAM in your GC mass spec confirmation, that's pathognomonic that subject has been exposed to heroin. Codeine also breaks down to hydrocodone , but also morphine. Morphine is the longest acting intermediate in this breakdown. So many times in your confirmatory testing of an opiate positive urine, you will see morphine only. That means they could have been exposed to heroin, they could have been exposed to codeine, they could've been exposed actually to morphine, which is not very commonly used anymore. Because poppy seeds can actually be contaminated by opium milk, sometimes it isn't enough. They could have been exposed to poppy seeds, so that's not just an urban legend. But let's say you found hydrocodone and hydromorphone, that usually would be indicative that both morphine and codeine had been ingested or you saw just codeine and hydrocodone, it would mean that they took vicodin and not that they took codeine and as well could've used vicodin. Oxycodone does not go to any of those metabolite, it goes straight to oxymorphone and noroxymorphone, and as well noroxycodone. So let's use an example here of our thinking with this. If we add an enzyme immunoassay that initially showed up as positive for oxycodone and positive for opiates, you then would need to do a confirmatory test to try to determine what opioids that was involved. So if oxycodone is present and in high enough amount, it would trigger opiates, but if not, it could be another substance. So you do your GC mass spec and you find only oxycodone and oxymorphone. What does that mean? If you go back to your little chart here, we've got oxycodone and oxymorphone which is consistent with only oxycodone having been ingested or used by that subject. Benzodiazepine is also important to know their metabolism. Clonazepam and lorazepam are not well detected in my labs. Usually 0.5 mgs BID of clonazepam does not trigger a positive result and confirmatory testing is often needed to identify this specific metabolites for a positive screen or to confirm the absence of metabolites. So for example, if clonazepam comes back negative and you are prescribing that person low-dose of clonazepam, you can do GC mass spec to confirm that there are levels of clonazepam and its metabolite there, but they just don't trip the enzyme immunoassay screen. This is another diagram you may want to post up. You can see that many of the benzodiazepines have simple metabolism, clonazepam to 7-aminoclonazepam, alprazolam to alpha-hydroxyalprazolam and lorazepam to lorazepam glucuronide. But the most complicated one is Valium, diazepam. Diazepam not only can break down to nordazepam, which can then go to oxazepam, but it can go through temazepam. So if somebody is taking diazepam and you do GC mass spec, you may find all three diazepam, temazepam, and oxazepam. So it would be important to, if you were prescribing them Valium not to misinterpret this to mean they were also using other agents. Chlordiazepoxide also goes to oxazepam [inaudible]. Typical detection kinds for detecting somebody's exposure to a substance. You can see that tetrahydrocannabinol, because it is lipophilic, a single use can be still positive to five days or under and that chronic use can be positive for a month or less. Cocaine is usually three days or less. Opiates can really vary depending on whether it's a long-acting opiate or short-acting opiate whether they're exposed to high dose or low dose, six hours to three days is typical. PCP again, can be eight days or less and 30 days for chronic, and amphetamines are fairly short acting, short-lived in urine at minus three days. Then let's look at some of the common opioid and benzos broken down. If for example, the longest acting opioid we have here is methadone, you can see it can be positive out to 11 days. Oxycodone on the other hand, just to three days. Diazepam, as you saw it had the most complicated metabolism or catabolism. That can be positive or up to 21 days, very long acting. That's why it's a bit difficult if somebody uses that for alcohol detox to then follow them to make sure they're not using something else. Lorazepam and alprazolam which are short acting, two and three days. So summary to our second part. Urine drug testing begins with an immunoassay based screening. Always remember that to confirm the result, a GC mass spec confirmation. False positives are most common for amphetamines, least common for cocaine. EtG and EtS testing for alcohol is coming into wider use. I think it has helped us and then to understand the catabolism of especially the opioids and the benzodiazepines helps us to accurately interpret GC mass spec results, the confirmatory stamp. A few words about forensic issues, which only some of you will be involved with, but it is important to understand. The federal government regulates urine drug testing for just a select group of patients, outpatients, people, employees, federal employees, and then public and private sector employees that work in the transportation and pipeline industries. Then finally, all of the drug-testing is regulated by the state. Only about half have specific drug testing statutes. I should also point out that an employer in terms of short-term disability and long-term disability plans or workers comp can also attempt to define requirements for urine drug testing as well. Requirements for a valid forensic collection. So for example, for the federal workforce. You can see this is pretty complicated. You need appropriate collection sites that are approved. You need trained collection personnel. You need to inspect the sample immediately after the collection. Then we're going to have what's called a logbook at every step of the way. There are initials or signatures there. The specimen must be collected in view of the testee and the collector at all times and then it's label and the testee needs to confirm the label. You immediately record the field testing, which is mainly temperature and pH. Then finally, you complete the logbook and the testee also signs this. So you can see that most of the time in the clinic we're not following those kind of process. So then, with the chain of custody form, the collector completes the CCF. You must have an approved secure place to store it. You must use colored toilet water to make sure they can't adulterate the sample with it and any handling or transfer the sample. So for example, to somebody that carries it down to the car that's going to transport it to the person that's in the car driving to the person that then handed off to the lab person, all those have to have signed of transfers and the container must be sealed with tape, signed and packaged and approved for transportation with certified lab. So you can see that it's quite important to have an established chain of custody if you're going to do forensically valid collections. Interestingly, many probation officers don't require that from clinical programs. What is a medical review officer? The important thing about these sample is their results must then be reviewed by a medical review officer, an MRO. These are largely established by regulations in 2001. A licensed physician must have clinical experience in substance use disorders, take a training course every three years, and then be certified by the MRO Coordinating Council or the AA MRO. What does he do? If a sample is negative, he signs off that the specimen was in expected parameters, usually temperature and pH, not temperature and creatinine, and that the Custody and Control Form is up to [inaudible]. If it's positive, he a, makes sure that that result was confirmed by confirmatory testing, that the cutoffs were correct in that confirmatory testing. Interestingly, if the sample had been considered invalid, that is the cutoffs are wrong or there were other procedural issues, it is called test canceled. They don't give the results out to whoever is asking for the results. The test is immediately reordered. If the sample is adulterated in the MRO's opinion, the results are not released, but is put down as refusal to test, which could be grounds for termination. If the for example, if somebody is on Adderall and it comes back positive for an amphetamine that is being used under a prescribed conditions, it's not reported as amphetamine positive explained, it's reported as negative, so that you protect the information of the employee. So in summary of this part, the federal government regulate urine drug testing for only certain classes of employees. A chain of custody requirements are very specific and must be followed. An MRO provides the interpretation of results to protect the validity of the results and to protect the testee. Finally, let's talk about other lab testing, and I'm mainly talking about other blood work that you may obtain. In terms of the substance abuse evaluation. You can do this for diagnosis. Remember, a single year in drug test does not necessarily tell you that something's been used chronically or that has been resulting in an adverse medical condition. You may use a pretreatment monitoring. You may use it for detection of physical sequelae, and detection of comorbidity, which as somebody treating substance disorders, we are in a unique position to actually identify comorbidity and try to guide somebody to treatment such as, venting them to stop smoking, or convincing them to get hep C treated, etc. So other lab testing other than urine or urine drug testing is meant to compliment the H&P for chronic alcohol use. You might find macrocytosis, you might find anemia, you might find thrombocytopenia. Biomarkers are not often used, the least specific are GGT, and LFTs, and the classic pattern is SGOT or AST two times greater than SGPT, otherwise known as ALT. More specific is carbohydrate deficient transferase, which unfortunately is not available in any labs. You can check for B12 and folate, magnesium, phosphorus leading times such as PT/PTT because vitamin K may be low, or stool guaiac, and then importantly, elevated bilirubin. If you're not only have a transaminitis, but bilirubins are now elevating, you may be heading for cirrhosis. Elevated bilirubins within normal SGOT and PT maybe see if the liver is burning out, and it can't produce many transaminases anymore. But of course, you're still going to have the bilirubin load and you can examine, analyze in pancreatitis. For people who inject drugs, it's important to look for signs of infection, look for elevated white blood counts. Always screen, and if you can for the sexually blood-borne diseases, as hepatitis B, hepatitis C, and HIV, or uncommon infections. For substance use disorders in general, indices may include signs of malnutrition, sexually transmitted diseases, which are indicative of high risk behaviors. Again, hep B/C and HIV and tuberculosis. So I've given you an ear full. Let's talk about our case vignette. So our patient Bill was maintained on buprenorphine/naloxone, name brand, Suboxone, and provide the urine drug screen positive for opiate and buprenorphine. Is this expected for somebody on buprenorphine/naloxone? I think I have the answers next. So these are the possible answers. What is the correct answer? A. Yes, because buprenorphine is a semi-synthetic opioid? No. UDT should be positive for bup only. C Yes, because naloxone is an opioid derivative. D. Yes, Because buprenorphine will metabolize to opioid, and no, buprenorphine should have metabolized completely to opioids. So I could give you just a minute here to pick your answer. You should have music here. The correct answer is? No. The UDS should be positive for buprenorphine only. Now, why is that? First of all, buprenorphine is not a semi-synthetic opioid, it's a full synthetic opioids and so is not detected in the opioid screening. It would require a special test for buprenorphine, which especially in those in buprenorphine clinic, you should always include that as part of your P&L. Buprenorphine will not metabolize to a full opioid. Naloxone is not an opioid derivative. If we look at our metabolism screen here, I added on the bottom that buprenorphine only goes to norbuprenorphine and does not go up to the opioids, and that the opioids have been detected, of which are codeine, and morphine, and six [inaudible] do not metabolize to or from buprenorphine. Naloxone goes to naloxone-3-glucuronide. So we have it's positive for opioids and for buprenorphine. What do we do next? One, we can ask the patient what happened. B, discharge the patient. C, raise your patient's bup/nal dose. D, begin to taper your patient's bup/nal dose, and E, repeat the lab test. The answer in my opinion and most of my colleagues opinions is, next is do the simple thing. Instead of testing, instead of taking a knee-jerk reaction, ask the patient what has happened. Often the patient will tell you a story that makes testing unnecessary. He may say, "Yes, I had a headache and I decided to take a Percocet for my friend", or, "I've relapse to heroin," and then you don't really need to go further. You can take his word for it. If he says, "I didn't do anything else," then you try to explore a little further and you might repeat the lab test. So in conclusion to that, in this case, your patient says that he relapsed, the result, if you didn't have the patient would support heroin or codaine use. In here I explain why poppy seed sometimes can give you a positive. It's actually poppy seed cake is the highest density of poppy seeds more than poppy seed bagel. You obtain more history to help with the insight motivation and assess cravings. You also check your state prescription monitoring program. What's that? In each state, there is a prescription monitoring program which allows you each time you prescribe a controlled substance to make sure that your patient is not accessing other sources of script such as you could access the PMP and have found that actually he had gotten a script of Percocet from somebody else which would then give you a moderate or a therapeutic discussion. Now, if you're patient says he has relapsed, he's had craving, you probably would consider raising the dose of buprenorphine/naloxone at that time if you're not our Re-Entry Clinic's maximum dose. Even if you are, you want to make sure that your patient has been adherent to it, hadn't exposed themselves to unnecessary triggers, people, places, and things, and unnecessary stress. These are the references that I've included at the bottom of the slide, as well as some good, especially like Number 3, very nice review articles. I want to tell you a bit about the PCSS Mentor program. I want to make you aware of these resources. The PCSS Mentor Program is designed to offer mentoring assistance to those in need of one or more interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from our mentor directory or we're happy to pair you with one. To find out more information, please visit our website, PCSS maps website using the weblink noted on the slide, which is at the bottom there. There is no cost for this. If you have a clinical question, you can ask a colleague, you don't necessarily have to be paired with a mentor. It's a simple and direct way. We also have very nice lister which allows you to, if you join now, allows you to get a lot of support from various colleagues. Finally, this is the lift of the consortium that is involved in the PCSS Program. It really PCSS-MAT and PCSS-O for opioids, include the coalition now covering greater than 1.1 million providers. It allows us really to try to provide training to the broadest number of people involved in dealing with substance use disorders. Thank you.
