Barbituates

Rx Names: Phenobarbital, Mephobarbital, Donnatal, Bellaspas…
Street names: barbs, downers, and tranqs

Act as sedative–hypnotic agents. Affects simple motor performance and can impair performance on complex psychomotor and cognitive tasks. Has adverse withdrawal effects noted by anxiety, nervousness, tremor, weakness, insomnia, anorexia and weight loss.

Therapeutic Uses:
Often used with salicylates for pain and headaches with anxiety. Phenobarbital and Mephobarbital are used for seizures. Used with other drugs in GI disorders such as Donnatal and Bellaspas. Also used with Theophylline in pulmonary bronchial conditions.

Illicit Uses:
Abuse was prevalent in the 1960’s and since replaced by abuse with benzodiazepines. Shorter acting Barbituates such as pentobarbital, secobarb and amobarb are the one used for illicit needs which are very infrequent now.

Metabolism:
Long acting ones like Phenobarbital can take 2-3 weeks to be fully excreted, while shorter- acting ones in 2-4 days.

Urinalysis Diagnosis:
The lab cut–off level is 200 ng/ml by GC/MS lab analysis. Commonly found in urine from using borrowed medication.

Benzodiazepines

Rx Names: Valium, Xanax, Restoril, Ativan, Dalmane…
Street names: downers, and tranqs

Commonly confirmed in urine with a physician’s Rx.

Therapeutic Uses:
These are the most widely prescribed drugs in the world. Diazepam (Valium) and Alprazolam (Xanax) is the most common prescribed. Temazepam (Restoril) and Lorazepam (Ativan) and Flurazepam (Dalmane) commonly used for insomnia. Rx’s used for anxiety-induced depression, stress, panic disorders, muscle spasm, alcohol withdrawal and seizures. Caution in resolving addiction cases and those involved in potentially hazardous activities.

Illicit Uses:
Usually mixed with other drugs such as opiates, cocaine or amphetamine. Overdoses can cause coma, seizures and respiratory depression. Chronic use leads to addiction. Withdrawal symptoms are tremors, seizures, severe anxiety.

Metabolism, Excretion & Urinalysis:
Utilized orally or intravenously. Metabolized in the liver to produce many metabolites. As such can cross react with other medications to give a positive on immunoassays, however, specific drug is identified by GC/MS analysis, with 100 ng/ml being the cut-ff in GC/MS analysis. Excretion can be greatly delayed, presenting in urine 2-3 weeks after drug is stopped.
Foreign drugs may be sold in health food stores and contain diazepam (Black Pearls, Cow’s Head, etc.) and will give positive urine test for diazepam.

Alcohol

Rx Names: Ethyl Alcohol
Street names: spirit, liquor, drink, booze, alky, hard stuff, the sauce, the bottle, juice, hooch

Alcohol Abuse:
This is when people consume large amounts of alcohol and will behave as true alcohols in acting as drunks, being confused, loss of stability, normal speech and passing out. However, unlike alcoholic addicts, they can voluntary stop alcohol consumption without the severe withdrawal effects of the alcoholic.
However:

1. Recurrent use leads to inability to fulfill major obligations at work, school or home.
2. At great risk in performing physically hazardous such as driving or operating complex machinery.
3. Results in legal problems with disorderly conduct, DUI, etc.
4. Severe consequences of loss of job, family, home, physical injuries from fights, etc.
5. The aforementioned effects of alcohol abuse still do not meet the criteria for alcohol dependency.

Alcohol Dependence:
A maladaptive pattern of alcohol use, leading to clinically impairment or distress, as manifested by three or more occurring at any time in the same 12 months period:

1. Tolerance, as defined by either of the following:
   1. A need for markedly increased amounts of alcohol to achieve intoxication or the desired effect.
   2. Markedly diminished effect with continued use of the same amount of alcohol
2. Withdrawal, as manifested by either of the following:
   1. The characteristic withdrawal syndrome several hours to a few days following cessation (two or more of the following): autonomic hyperactivity (e.g., sweating or pulse rate > 100), increased hand tremor, insomnia, nausea or vomiting, transient visual, tactile or auditory hallucinations or illusions, psychomotor agitation, anxiety or grand mal seizures.
   2. Alcohol or other substances are taken to relieve or avoid withdrawal symptoms.
3. Alcohol is taken in larger amounts or over a longer period than was intended.
4. There is a persistent desire or unsuccessful efforts to cut down or control drinking.
5. A deal of time is spent to obtain alcohol, drink alcohol, or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of drinking alcohol.
7. Alcohol use is continued despite knowledge of having persistent or recurrent physical or psychological problem that is likely to have been caused or exaggerated by alcohol.

Specify if:
With physiologic dependence: evidence of tolerance or withdrawal (i.e., either item 1 or item 2 is present)
Without physiologic dependence: no evidence of tolerance or withdrawal (i.e., neither item 1 nor item 2 is present)

"CAGE" Questionnaire:

1. Have you ever felt you ought to cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Note: This questionnaire is commonly utilized by primary care physicians, taking only a minute to complete, to possibly aid them in their differential diagnosis of Alcohol Abuse vs. Alcohol Dependence. Commonly, an employee is referred to a SAP, an addiction specialist counselor to establish a definite diagnosis with treatment recommends.

Alcohol Metabolism and Excretion
Alcohol with oral ingestion occurs as the alcohol is absorbed from the intestine and is fully absorbed into the blood 30-60 minutes after ingestion. Food in the stomach will delay the time of full absorption, but not the extent of alcohol absorption. Blood alcohol level falls as alcohol starts being excreted in the urine. The heavier a person is the greater amount of alcohol they must be consumed to reach a higher level in the body. The proportion of body weight in men that is water is 55-65% and 45-55% in women. Alcohol mainly is distributed to water containing tissues. Once absorbed, alcohol is 90% metabolized to acetaldehyde then to CO2 and water. The rest is excreted in the breath, urine, sweat and breast milk. Average person eliminates 0.015-0.018 g/dl/hr equivalent to one drink per hour.
Ethanol glucuronide (EtG) is a metabolite of ethanol. In can be detected in urine, blood, hair and perhaps other specimens, and its presence is proof of ethanol consumption. The detection window for EtG is 3-4 days, while that for ethanol is several hours. EtG is useful for monitoring treatment and post rehabilitation programs but is inappropriate in workplace programs in which off-duty alcohol use is allowed. EtG is water soluble, thus its concentration in the hair is removed with washing the hair. A positive hair EtG test confirms alcohol use but a negative is of no value in excluding it.

Laboratory Analysis

Blood:
Blood alcohol concentration is the most direct measure for assessing the possible effects of ethanol on the brain. Alcohol concentration in blood is in either milligrams or grams per 100 ml of blood, written as "mg/dl" or "g/dl." Blood alcohol levels are determined by gas chromatography of a diluted blood or plasma specimen or by the analysis of the "headspace" vapor existing above the specimen. Labs tend to test plasma rather than whole blood, being easier to analyze, and thus probably more accurate. Ratio of plasma (or serum) to blood alcohol levels is between 1.15 and 1.2. Testimony based on either whole blood or breath specimens, with the latter, breath BAC level is converted to the blood concentration level using the ratio of 1:2100.

Urine:
Urine levels may be correlated with corresponding blood alcohol levels, but there are certain caveats. Urine alcohol concentration is related to the average BAC during the time the urine was produced, which can extend for several hours before collection. Therefore alcohol concentration in a random urine specimen may not reflect the donor’s current BAC, therefore urine testing cannot be used to indicate whether the person was impaired or intoxicated at the time the specimen was collected. A two step urine collection may be more closely related to the current BAC level existing in the 30 minute time interval that existed in the second urine specimen. The two step urine collection technique is when the donor completely empties their bladder. They then submit a 2nd urine specimen by voiding again 30 minutes after the initial specimen was voided and it is this specimen that is analyzed for alcohol content.

Ethanol can be found in a urine specimen in a person that did not consume alcohol as in:

1. The urine contains glucose, i.e., the donor is a diabetic.
2. The urine is contaminated with certain microorganisms, such as Candida albicans.
3. The urine has been stored at room temperature without a preservative for one day or more prior to analysis. (This is usually the case for urine specimens shipped to a laboratory.)

Note: Whenever urine is tested for alcohol for workplace purposes, it should also be tested for glucose. If positive for glucose the urine alcohol concentration may not accurately correlate with the blood alcohol concentration.

Saliva:
Analysis of alcohol in oral fluid (saliva) is performed on site with a specific collection kit. The Q.E.D. saliva Alcohol Test device (Orasure technologies, Inc, Bethlehem, PA, USA) is the most common kit used in USA. A cotton stick (Q-tip product) is wet by saliva and forms a color change via a reaction with alcohol dehydrogenase when the same approximate cut-off level is obtained by BAC testing. This kit has a quality control device, so that it has been granted a waived status under the Clinical Lab Improvements Amendments in the USA.

Hair:
Alcohol is commonly undectable in hair.

Breath:
Represents the most effective and accurate specimen being utilized for accurate Alcohol testing and represents the only method that legally establishes existence of impairment in a tested individual.

Interpreting Results:

Blood alcohol concentrations can be correlated with intoxication. Breath alcohol levels deter mined by BAC are as accurate as blood levels as the BAC result can be correlated with blood concentration. Although clinical signs of intoxication are reduced in individuals who have alcohol tolerance, the alcohol effect t of their clinical impairment is not.
 

Blood Alcohol Concentration (G/100ml)	Stage of Alcohol influence / Intoxication	Anticipated Clinical Symptoms
0.01-0.05	sub clinical	Behavior nearly normal by ordinary observation. Slight changes detectable by special tests. Computation speed diminished.
0.03-0.12	euphoria	Mild euphoria, sociability, talkativeness, increased self-confidence. Decreased inhibition. Diminution of attention, judgment, and control. Mild sensory-motor impairment. Slowed information processing. Loss of efficiency in fine-motor performance tests.
0.09-0.25	excitement	Emotional instability; loss of critical judgment. Impairment of perception, memory and comprehension. Decreased sensory response; increased reaction time. Reduced visual acuity, peripheral vision and glare recovery. Sensory-motor incoordination; impaired balance. Drowsiness.
0.18-0.30	confusion	Disorientation, mental confusion; dizziness. Exaggerated emotional states (e.g., fear, rage, sorrow). Disturbances of vision (e.g., diploipia) and of perception of color, form, motion, dimensions, increased pain threshold. Increased muscular incoordination, staggering gait, slurred speech. Apathy, lethargy.
0.25-0.40	stupor	General inertia; approaching loss of motor functions. Marked muscular incoordination; inability to stand or walk. Vomiting; Incontinence of urine and feces. Impaired consciousness; sleep or stupor.
0.35-0.50	coma	Complete unconsciousness; coma; anesthesia. Depressed or abolished reflexes. Subnormal temperature. Incontinence of urine and feces. Impaired consciousness; sleep or stupor.
0.45+	death	Death from respiratory arrest.

 
The U.S. Federal DOT program has set 0.02 BAC in breath as an action level for temporary removal from safety-sensitive job tasks (i.e.: driving, operating machinery, etc). Employee with a BAC of 0.02-0.039 is temporarily removed from work for 24 hours. Employee’s having a BAC 0.04 is like a positive drug test. Employee is removed from work and only returns after successful completion of the return to work duty process. Companies and police may determine what level of BAC determines "impairment" subject to an "illegal level" to be remov3ed from work or charged with a DUI if driving. BAC level of 0.08 indicates the individual is too intoxicated to drive or work with most citing a lower level of 0.04=impairment.

See also other drug categories

• Stimulants
• Hallucinogens
• Narcotics/Analgesics/Opiates