Opiates

Rx Names: Morphine, Codeine, Heroin
 

Rx Use:
Opiates derived from opium that is extracted from seeds of Opium plant and contains morphine and codeine. Opioids are compounds having opioid pharmacologic activity which include synthetic opiates in addition to opiate alkaloids. Opioids do not contain nor or they metabolized to codeine, morphine or 6–AM. Term Narcotics refers to addictive drugs (e.g., opiates and Opioids) that reduce pain and induce sleep. Federally regulated testing only involves opiates, which are morphine, codeine and the heroin metabolite 6–AM. Non federal regulated testing are for Opioids such as fentanyl, hydrocodone, hydromorphone, methadone, oxycodone and propoxyphene, which are missed in the Federal 5 drug panel. Thus a negative 5 drug panel does not imply the donor is not consuming opioid type drugs.

Codeine, Morphine and 6–Acetylmorphine::

Morphine is the most abundant opiate in poppy seeds and is provided by Rx. Codeine occurs naturally in poppy seed and can be synthesized from morphine and is available by Rx.

Heroin (diacetylmorphine) is a semi synthetic opiate obtained by reacting morphine with acetic acid. There is no legitimate use for Heroin.

Opiates rapidly induce feeling of euphoria high with physical and mental relaxation. Higher does are required to maintain the same extent of the high which then induces significance dependence from its addicting qualities. Mental confusion, loss of mental alertness and coordination with inability to operate machinery or driving safely. Pin point pupils (miosis) slurring of speed and signs of intoxication are physical findings in large dosage.

Addiction is strong and withdrawal symptoms severe so medical management required stopping these drugs and removing addiction.

Therapeutic Uses::

Codeine is used as an analgesic (i.e. Tylenol #3) and cough suppressant. Codeine in syrup for cough can be sold without an Rx of codeine not more than 2mg/ml. Codeine tab sold in Canada OTC.

Morphine is used to relieve moderate to severe pain by oral tablets, I.M. or IV within hospital environment. Tincture Opium sold in US OCT in low dosage for diarrhea.

Illicit Use:
Heroin is the major target of workplace drug testing because of its strong abuse from addiction. Rx Opiates and Opioids are frequently abused by health care professionals. Fentanyl is drug of choice for anesthesiologists. Hydrocodone (Vicoden) commonly abused by pharmacists and dentists. IV morphine and meperidine commonly abused by nurses. Oxy–cotin is a long acting pain killer is abused nation–wide. Tablets crushed to snort the drug to get immediate and prolonged high. Lethal when multiple tablets are chewed together.

Metabolism & Excretion of Opiates

Heroin and 6-AM: Heroin (diacetylmorphine) is deacetylated to 6-acetylmorphine (6-AM) in the body. After a single dose of Heroin, it may be detected in the urine for 2-8 hours at concentration of 10 to 250 ng/ml. Its absence does not rule out use of heroin. Positive heroin is obtained when the Morphine concentration exceeds 2000 ng/ml and total codeine to total morphine ratio is less than 0.125. 6 AM is stable refrigerated up to 10 days and frozen up to 2 years. All morphine levels of 2000 ng/ml should be checked for existence of Heroin in screening for 6-AM. The existence of 10 ng/ml or higher of 6-AM in the urine confirms the consumption of Heroin, however non regulated labs will not run the 6-AM screening for Heroin routinely as they require its specific testing from their clients request on each morphine level above 2000 ng/ml. Most companies referring specimens to labs are not informed on this lab requirement, thus their pre-employment drug screening may miss potential employees on heroin and not realize it. The MRO physician utilized by ELSSI has confirmed that all their elevated morphine drug levels are also screened with 6-AM testing in maintaining ELSSI’s high quality standards. The MRO has also included routine screening for the opioid hydrocodone (Vicodin) at no extra cost. As Morphine collections are not aggressively evaluated less than 5,000 ng/ml, confirming the existence of 6-AM is essential in confirming addiction to Heroin, rather than finding a positive level of MS @ 5-10,000 ng/dl, which does not confirm opiate addiction exists as a positive 6-AM for heroin does.

Codeine: rapidly metabolized in the body to morphine and norcodeine in the form of a conjugate. Initially, codeine level is higher than morphine with morphine level later surpassing the codeine level. Codeine and morphine excretion can last up to 4 days with only morphine being detected at 3–4 days.

Morphine: extensively metabolized in passage through the liver. Plasma peak levels of morphine occur one hour after oral ingestion and five minutes after intravenous injection. About 10% excreted in the urine as morphine and the remainder as morphine-3-glucuronide. Morphine does not metabolize to codeine, therefore ingestion of pure morphine cannot account for codeine in the urine. As poppy seeds contain morphine and codeine, consumption will provide positive urine test for morphine and codeine about 300 ng/ml. The highest level of morphine from poppy seed consumption has been 11,571 ng/ml and 4,861 respectively. Poppy seeds can also cause positive salvia morphine test up to one hour after poppy seed consumption.

Laboratory Analysis

Screening immunoassays for opiates are subject to many cross-reactions with other drugs, resulting in false positives. This necessitates the lab to utilize GC/MS testing in confirming a positive test for the specific drug in question. Remember, the semi-synthetic opioids: hydrocodone, oxycodone and hydromorphone are not elicited with standard immunoassay screening tests. A specific opioids drug panel must be utilized if these opioids are to be detected. Do not expect the 5 or 10 drug testing panel to confirm the existence of these opioids in urine drug testing: oxycodone=percocet; hydrocodone=vicodin and oxy-cotin all require the specific opioids drug testing panel.

Urine
In 1998, HHS revised the mandatory guidelines to increase the screening and confirmatory cut-off levels of opiates from 300 ng/ml to 2000 ng/ml with 6-AM analysis in morphine levels above 2000 ng/ml levels. Remember, non regulated labs do not routinely test for 6-AM, as they commonly require their referring clients to specifically request the 6-AM test be done on the elevated morphine specimens. As they are not required to do 6-AM testing on non regulated specimens, they may or may not elect to request their client for an additional charge on each 6-AM test as requested on non-DOT specimens.

Hair
Hair analysis analyses focus on codeine, morphine and heroin. Analysis for opioids is more limited. Advantage is hair will reveal addiction as it provides up to a 3 month history of drug use but will not reveal acute drug use like urine. Hair is positive only after 10 days of frequent drug use and not for the occasional drug user. It is more expensive and slower to report than urine. Its greatest value is for detection of chronic drug users with addiction.

Oral Fluids
Morphine and codeine GC/MS cut-off level is 40 ng/ml. Heroin as 6-AM, appears in oral fluid (salvia) minutes after heroin ingestion at a higher peak level than found in plasma. Poppy seed ingestion can result in morphine concentration greater than 40 ng/ml in oral fluid, up to one hour after ingestion of poppy seed bagels.

Sweat
Use of heroin reveals small amounts of 6-AM and morphine. Questionable value for heroin diagnosis.

Interpreting Results

6–AM Positive Result: is specific in confirming heroin usage.
6–AM Negative Result: If positive for morphine and negative for 6-AM, may be result of poppy seed ingestion unless the morphine/codeine level is at or above 15,000 ng/dl, or if donor admits to illegal consumption or if the donor’s physical examination reveals signs of opium addiction. An M/C ratio less than 2 and a codeine concentration >300 ng/ml, is inconsistent with poppy seed ingestion. Therefore, a donor with a negative 6-AM, with M/C concentration less than 15,000 ng/ml and the donor’s physical examination is negative for opiate use; the positive urine test will be reported as being negative by the MRO, assuming also that the donor denies illicit MS use.

Even if the morphine level is up to 14,000 ng/dl. Although medical exams are poor in confirming opiate addiction, however, should donor refuses a medical exam at his cost by the MRO, the donor is informed his urine drug test will be reported as being positive. Rx and non-Rx medications (Paregoric) can produce a positive morphine level up to 10,000 ng/ml.

Hydrocodone (Hycodan, Vicodin, Lortab, and Lorcet):
Is a semi synthetic opiate that provides significant pain relief. As an opioid, it will not be detected in the common 5 or 10 drug screen panel unless it is specially added as with Elssi drug testing. Metabolite in urine as hydrocodone, then to hydromorphone and codeine. Use of codeine can cause small amounts hydrocodone in urine.

Propoxyphene (Darvon, Darvocet):

Description:
Synthetic opioid for mild to low moderate pain. Potentially fatal when taken in large amounts with alcohol consumption. Pulmonary edema, cardio toxicity, convulsions and hallucinations.

Metabolism and Excretion:
Oral ingestion is standard and its therapeutic effect lasts 2-4 hours. Can be positive in urine up to one week after stopped.

Interpreting Results:
Positive urine test commonly confirmed by an Rx for it or else they borrowed someone else’s prescription.

See also other drug categories

• Stimulants
• Hallucinogens
• Depressants/Sedatives/Hypnotics