Underestimation of substance abuse in psychiatric patients by conventional hospital screening
Introduction
Psychiatric diagnosis mainly relies on behavioral signs and symptoms. Substance abuse can mimic the clinical presentation of major psychiatric disorders, including schizophrenia and bipolar disorder, and further complicates the management of psychiatric patients. The identification of substance abuse in acutely ill psychiatric patients is of paramount importance. The prevalence of psychiatric disorders in the general population over the age of 18 years is relatively high, and this population is at and even greater risk for substance abuse than those without a psychiatric diagnosis (Regier et al., 1990, Mueser et al., 1995, McCreadie, 2002). Moreover, substance abuse exacerbates psychiatric symptoms, is often associated with treatment resistance and often leads to emergency room visits. First Episode of Psychosis (FEP) patients are twice as likely to be substance abusers in comparison with the general population (Barnett et al., 2007). The lifetime prevalence rate of substance use in patients with FEP has been reported as high as 74% (Lambert et al., 2005), and as low as 23% (National Survey on Drug use and Health, 2012). Data from the National Survey on Drug Use and Health (NSDUH) indicated that 20% of adults described as having “any mental illness” were also diagnosed with a substance abuse problem in 2010, in comparison to 5% diagnosis in adults without a psychiatric diagnosis. Physicians in general and psychiatrists more specifically, regularly have to make decisions concerning the contribution of substance abuse and its clinical presentation at the time of hospital admission. The reliability and accuracy of this information are vital in the proper and safe treatment of the patient. Current trends in substance abuse demonstrate that it is not only the conventional drugs of abuse (cocaine, heroin, cannabis and methamphetamine) that should be of concern to the treating physician, but also prescription medications and new designer drugs. The ingestion of these latter substances can be addictive and may lead to, or contribute to, presentation of the symptoms representing a primary psychotic disorder such as schizophrenia. The widespread increase in polysubstance abuse (McCabe et al., 2006) and these changing trends in drugs abuse require a comprehensive and broad ranging approach to the detection of licit and illicit substances to optimize treatment and rehabilitation. Detailed knowledge of what drugs are being abused is critical because it allows the physician to develop an appropriate treatment plan. Three major approaches have traditionally been used to evaluate what type of drug, if any, the patient is/or has taken, individually standardized questionnaires, information provided by the patients, and finally urine/blood drug screening (American Psychiatric Association publishers, 2005). In this paper drug abuse encompasses all drugs with the exception of alcohol. Urine drug testing more accurately detects the presence of substance use than clinical interviews, patient self-reports and diagnostic questionnaires (McNagny and Parker, 1992, Lindsay et al., 1997). However, this is very much dependent on the quality of the testing. Because some studies have shown that routine drug testing does not affect the disposition or length of stay in a psychiatric emergency facility (Schiller et al., 2000a, Dhossche and Rubenstain, 1996, Breslow et al., 1979), the testing of urine samples for low levels of drugs may be particularly useful. The importance of drug use when treating mental illness is of great significance. In general, urine samples are collected and sent to a hospital laboratory for drug screening. The drugs classes measured vary among hospitals or institutions they typically include; marijuana, amphetamine(s), cocaine (metabolite), opiate(s) and benzodiazepine(s). Some laboratories also include phencyclidine (PCP), propoxyphene, barbiturates and methadone but this is highly variable (Armbruster et al., 1993). The methodology used to analyze these drugs also varies by laboratory, and there is no set standard for the choice of instrumentation or technique to screen for these drugs in hospital laboratories (Armbruster et al., 1993).
The purpose of this present study was to determine the accuracy of clinical toxicology testing for acutely ill patients with a history of drug abuse and/or, psychiatric illness. The abuse of prescription medications and illicit drugs in the psychiatric population was also examined.
Section snippets
Study design
Urine samples from 220 consecutive psychiatric inpatients admitted to either an acute drug and alcohol unit or psychiatric unit via a community hospital emergency department were analyzed for drugs of abuse by a standard hospital Kinetic Interaction of Microparticles in Solution (KIMS). Each sample was then analyzed by a more sensitive Enzyme Linked Immunosorbent Assay (ELISA) and Basic Drugs Screen (BDS) by Gas Chromatography–Mass Spectrometry (GC–MS) by this laboratory. The study group
Materials and method
A Dynex DS2 (Chantilly, VA) fully automated ELISA instrumentation, including photometer; pipetting, incubation, and wash station was used. Data reduction was accomplished using the supplied DSX/DS2 reporting software version: 10/21/2009.
In this study, Neogen® (Lexington, KY, USA) ELISA kits are used. The kit includes; an antibody coated 96 well plate, K-blue substrate, phosphate buffer, conjugate, and acid stop solution. Individual certified stock solution of prazepam, amphetamine,
Analysis protocol
All samples analyzed in-house, received a 12-panel urine drug screen (amphetamines, benzodiazepines, buprenorphine, ketamine, methamphetamine, cocaine, cannabis, opiates, oxycodone, zolpidem, methylphenidate, barbiturates) by ELISA.
Subsequent to the ELISA, an alkaline drug screen by GC–MS (method documented below) was carried out on all specimens to screen for an extensive array of drugs.
Hospital KIMS assay
The authors did not perform this assay, and only the results were supplied with samples. The Hospital KIMS analysis methods were carried out in accordance with the manufacturer's package inserts (Amphetamine, 2012, Cannabis, 2014, Cocaine and 2009, Opiate and 2011, Benzodiazepine, 2014). All urine samples received a 5 panel drug screen via Roche reagents, amphetamine, benzodiazepine, cannabis, cocaine, and opiates. All steps were carried out using the automated Cobas® C50. Roche online reagent
ELISA screening
The ELISA methods were carried out in accordance with the manufacturer's package inserts (Immunalaysis Corp, 2004, Neogen Corp, 2009). All steps were carried out using the automated DS2 instrument. Briefly, urine specimens were prepared by diluting the urine sample with kit supplied phosphate buffer (pH 7); the dilution range is dependent on each assay. Calibrators and controls were treated identically to specimens. To each appropriate well, the diluted urine, calibrator, or control was added;
Basic drug screen (BDS) by GC–MS
GC–MS analysis was performed on an Agilent 7890 GC coupled to a 5975 MS –electron impact mode. The GC was fitted with an Agilent DB-5MS column (15 M × 0.25 mm i.d. × 0.25 μm d.f.) fitted with a dean switch operating in splitless mode with helium as the carrier gas operated in constant pressure of 31.49 psi and an injection volume of 1 μL. The injector and detector temperatures were 280 °C and 300 °C, respectively. The initial oven temperature was held at 100 °C for 0.5 min, and then ramped at
Group demographics
These results presented are a direct comparison between hospital screening KIMS results and the results obtained from ELISA and the BDS using GC–MS analysis. Females comprised of 28% of the population tested with a population average age of 42 yrs (median = 39 with a range from 18 to 79). Patients were admitted due to a variety of psychiatric and drug addiction conditions. Table 2 shows a summary of the major admission diagnostic categories and information provided with the samples.
ELISA and hospital KIMS
The results
Discussion
In summary, the results show that there is a need for more comprehensive screening in this population. The results of the present study, using the ELISA and GC–MS screen clearly reveal deficiencies in the standard hospital KIMS screen in assessing acutely ill psychiatric patients. This is highlighted in the false negatives reported for benzodiazepines, opiates and other drugs not commonly screened for via KIMS or ELISA. The data also shows the need for testing for other drugs such as
Role of funding source
None.
Author contributions
Dr. Reidy who is independent of any commercial funding or sponsor had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Reidy, Junquera.
Analysis and interpretation of data: Reidy and Van Dijck.
Drafting of the manuscript: Reidy and Nemeroff.
Critical revision of the manuscript for important intellectual content: All authors.
Administrative, technical, or material support: Reidy, Steele,
Conflict of interest
Dr. Steele reported that has research support and consulting fees from Beckman-Coulter and Ortho Clinical Diagnostics.
Dr. Nemeroff reported that he had research support from National Institutes of Health, Agency for Healthcare Research and Quality (AHRQ) and has received consulting fees from Xhale, AstraZeneca Pharmaceuticals, PharmaNeuroBoost, CeNeRx BioPharma, NovaDel Pharma, Reevax Pharma, American Psychiatric Publishing, Takeda, SK Pharma, Shire, Roche, Lilly, Allergan. Dr Nemeroff has
Acknowledgments
None.
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