Opioids Low level positive result in MMT patient, question about lipophilicity and remnant positives

[Pembroke]

I haven’t posted here in quite a while, so while I searched for an answer on this I apologize if I’m just not finding it. I have a clinical question that I cannot find an answer for. I’ve checked not only traditional sources like looking at articles, going through my pharmacology texts, and even asking colleagues and contacting some old professors; I’ve additionally checked google, Erowid, and a few other community-sourced sites with no luck. I remembered that there were quite a number of professionals on this site before, so I thought to give it a go here!

To the matter at hand: I have a patient on methadone maintenance therapy who has been stable and has not testes positive on random urinalysis for over a year. They tested positive this last week, but at a level that the counselor calls a “remnant”. I haven’t seen the secondary spect results yet in full, as the patient contested and so the sample was sent out for more conclusive testing.

The counselor is in support of this reading being the result of the hot weather and the patient’s workout routine, reporting that a level this low likely was diffused from fat breaking down. She has not seen or been reported any signs of relapse in this particular patient. It is worth mentioning that I have had cause to question this particular counselor’s level of professionalism and competence in the past and so am potentially biased, but I find her to be easily manipulated and just not very good at her job. I mention that only because it is a factor in my questioning here.

I have encountered a number of articles which discuss this phenomenon occurring in patients who were heavy users of cannabis in the past, where years later they may test positive for a miniscule amount of THC while in heavy training for a marathon or equally rigorous activity, but I cannot find any sources which definitively state the same is possible for heroin or fentanyl, or any opiate, really. Both opiates and opioids are known to have some level of lipophilicity, which suggests that it is possible, in theory, for the same thing to occur with opiate drugs. That said, saying it is theoretically possible does not provide a level of certainty that is sufficient to call this test an invalid fluke. I am going to have to present this information to this patient’s parole officer and they will be relying on my opinion on the matter to determine if this is a violation of the patients terms, and I am in a pickle. If this is likely a result of the patient breaking down fat, then I do not want to be responsible for their freedom and/or custodial situation being compromised; I equally do not want to risk misspeaking and risking the safety of a child in this person’s custody. I am kind of a prison abolitionist so if it were just that matter I wouldn’t be so conflicted, but the safety of the child is a great concern.

Does anyone know the answer to this? Do you know of studies or articles I could review which are specific to heroin and fentanyl? Or is the best practice in this circumstance to extrapolate the information from what is stated in the articles and studies which teated this hypothesis against false positives in marijuana cessation?

Thank you in advance for reading and pointing me in the correct direction! You are appreciated.

 

[axe battler]

That is a pickle.
When was their last UA?
I would give them the benefit of the doubt this time personally. That said drug addicts do relapse and will lie about it, especially if it means going back to prison.
If they had a one time lapse and were able to stay clean for an upcoming UA to only show minute amounts then the child is unlikely to be in danger.
Can you call for random UA's so they are less likely to slip up?
If this person is telling the truth and ends up incarcerated again it would be horrendously unfair.

 

[Nurse Ratched]

I suppose I would also give the client the benefit of the doubt based on the whole year of clean UA's.

Your bias towards the other counselor may , or may not, be influencing your take on it.

If the UA's are monthly in order to continue getting the MMT, I would wait and see if the next one was dirty.

The threat of returning to Prison might be enough for the client to cease and desist if in fact they did have a slight relapse.

One year of complying with the program has to count for something.

 

[somnilicious]

Fentanyl is highly lipophilic and has been known to throw someone, who is trying to induct on Suboxone into precipitated withdrawal, even more than a week after last use. As for your question regarding trace amounts showing up years later I cannot comment.

 

[BeachBum4u]

I will always feel this way about certain matters. This is in line with the old, I'd rather let some guilty defendants go free than send an innocent one to prison or to death. I believe I'd rather see a few patients get meds maybe where, who knows, something's a shade off than deny suffering pain patients appropriate medication. That's just me!

 

[G_Chem]

If the biggest worry is the patients children’s safety, I think Axe said it well in that a person who’s been clean a year but had a slip that was still able to clean up for a UA mostly... That shows they’re trying in my eyes.

I know you want literature but unfortunately you’ll probably just got a lot of opinions.

-GC

 

[Pembroke]

Thank you everybody!

Having given it thought, I’m going to support the position that, due to the possibility that this is in result of the change in workout regimen, it is likely the same process we see with cannabis in similar situations. I’m still looking for literature in case DOC or my program manager requires it, but in the interim I’m basically going with the position that I am extrapolating the information from the indisputable fact that this is a possible occurrence for drugs within the class and then to go from there. If it continues to occur, I won’t be able to sign off in medical in the future unless and until I can find the correct documentation.

Thank you all for your input. One of the reasons that I wanted to come here is because there are too many forums where the answer was “junkies lie“, and I don’t believe that that’s true or fair a year into a program where someone has been and is clearly trying. I feel like they would be able to be honest with me because I have gone to bat for somebody who had one slip up a year into a program, but if they’ve been burned in the past I can see why they would stand their ground on this one either way. I’m sort of in to think if this is possible with marijuana, why wouldn’t it be possible with street drugs?

 

[Xorkoth]

Good for you for caring and wanting to try to do what's best for everybody involved. Compassion for drug users is more rare than it should be.