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Hair Analysis for Detection of Psychotropic Drug Use–Reply–I
LETTERS TO THE EDITOR
worthy of consideration as they attempt to appraise and diagnose a patient’s condition correctly. Analysis of hair or nail scrapings can provide useful information that in some circumstances is unattainable by any other method. Some difficulties exist with keratin tissue testing. Relatively few laboratories are capable of performing competent analysis. Both the protocol for accurate testing and the preparation of the sample are complex. Thus, the test is more expensive than a conventional urine screen, for example, although not prohibitively so compared with many other diagnostic procedures and tests. In addition, the testing procedure is labor-intensive and requires considerable time—several days are necessary even in optimal circumstances. Nonetheless, I can imagine many clinical circumstances in which the information provided by hair analysis could prove useful and thus should be considered. Thomas Mieczkowski, PhD University of South Florida Tampa 1. Lineberry TW, Bostwick JM. Methamphetamine abuse: a perfect storm of complications. Mayo Clin Proc. 2006;81:77-84. 2. Viala A, Deturmeny E, Aubert C, et al. Determination of chloroquine and monodesethylchloroquine in hair. J Forensic Sci. 1983;28:922-928. 3. Sramek JJ, Baumgartner WA, Tallos JA, et al. Hair analysis for detection of phencyclidine in newly admitted psychiatric patients. Am J Psychiatry. 1985;142:950-953. 4. UematSu T, Sato R, Suzuki K, Yamaguchi S, Nakashima M. Human scalp hair as evidence of individual dosage history of haloperidol: method and retrospective study. Eur J Clin Pharmacol. 1989;37:239-244. 5. Kintz P, Mangin P. Hair analysis for detection of beta-blockers in hypertensive patients. Eur J Clin Pharmacol. 1992;42:351-352. 6. Runne U, Ochsendorf FR, Schmidt K, Raudonat HW. Sequential concentration of chloroquine in human hair correlates with ingested dose and duration of therapy. Acta Derm Venereol. 1992;72:355-357. 7. Brewer C. Hair analysis as a tool for monitoring and managing patients on methadone maintenance: a discussion. Forensic Sci Int. 1993;63:277-283. 8. Williams J. Sectional hair analysis as a potential index of therapeutic compliance in an epileptic population. In: deZeeuw RA, et al eds. Proc Intl Conf & Wkshp for Hair Analysis in Forensic Toxicology. Abu Dhabi, UAE; 1995:443-466. 9. Williams J. The assessment of therapeutic compliance based on the analysis of drug concentrations in hair. In: Mieczkowski T, ed. Drug Testing Technology: Assessment of Field Applications. Washington, DC: CRC Press; 1999:1-32. 10. Mieczkowski T, Tsatsakis AM, Psillakis T. The concentration of three anti-seizure medications in hair: the effects of hair color, controlling for dose and age. BMC Clin Pharmacol. 2001;1:2. 11. Ishiyama I, Nagai T, Toshida S. Detection of basic drugs (methamphetamine, antidepressants, and nicotine, from human hair. J Forensic Sci. 1983; 28:380-385. 12. Suzuki O, Hattori H, Asano M. Detection of methamphetamine and amphetamine in a single human hair by gas chromatography/chemical ionization mass spectrometry. J Forensic Sci. 1984;29:611-617. 13. Suzuki 0, Hattori H, Asano M. Nails as useful materials for detection of methamphetamine or amphetamine abuse. Forensic Sci Int. 1984;24:9-16. 14. Nagai T, Sato M, Nagai T, Kamiyama S, Miura Y. A new analytical method for stereoisomers of methamphetamine and amphetamine and its application to forensic toxicology. Clin Biochem. 1989;22:439-442. 15. Suzuki S, Inoue T, Hori H, Inayama S. Analysis of methamphetamine in hair, nail, sweat, and saliva by mass fragmentography. J Anal Toxicol. 1989; 13:176-178. 16. Callahan C, Grant TM, Phipps P, et al. Measurement of gestational cocaine exposure: sensitivity of infants’ hair, meconium, and urine [published correction appears in J Pediatr. 1992;121:156]. J Pediatr. 1992;120:763-768. 17. Graham K, Koren G, Klein J, Schneiderman J, Greenwald M. Determination of gestational cocaine exposure by hair analysis. JAMA. 1989;262:3328-3330. 18. Koren G, Klein J, McMartin K. Diagnosing intrauterine exposure to cocaine by hair testing: six years of clinical use. Ther Drug Monit 1998;20:478-480. 19. Martz R, Donnelly B, Fetterolf D, Lasswell L, Hime GW, Hearn WL. The use of hair analysis to document a cocaine overdose following a sustained survival period before death. J Anal Toxicol. 1991;15:279-281.
Mayo Clin Proc.
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In reply: We appreciate the opportunity to respond to Dr Mieczkowski’s suggestions for improving drug screening for methamphetamine. Debate about the usefulness of drug testing is ongoing in many arenas. Specific questions have been raised about the purpose and effectiveness of standard serum and urine drug assays in the emergency department evaluation, diagnosis, and management of substance-abusing patients. Emergency medicine physicians argue appropriately that emergency department management is dictated by the patient’s clinical presentation, and the results of drug screens do not customarily influence emergency department management.1 Psychiatrists counter that the initial evaluation in the emergency department is a window of opportunity to obtain information that could help confront denial or build the necessary legal and clinical case to secure treatment.2 In a prospective study of drug screening vs history for detection of substance abuse in 218 emergency department psychiatric patients, Perrone et al3 found that use of the patient’s history of drug use alone was unreliable. Drug screening alone was similarly flawed. They found that a combination of history and drug testing identified significantly more patients with substance abuse. Dr Mieczkowski’s recommendations for hair testing could potentially resolve many current practice issues. We believe that hair analysis for methamphetamine abuse could be particularly useful because it can detect the drug for longer periods, which could improve the identification of substanceabusing patients. Hair testing also allows assessment by the patient’s primary outpatient or inpatient treatment team. Dr Mieczkowski accurately describes the problems associated with hair analysis (limited availability, time-consuming, and expensive). Nevertheless, we hope the use of such testing will increase, thus enabling easier diagnosis and targeted treatment of substance abuse. Timothy W. Lineberry, MD J. Michael Bostwick, MD Mayo Clinic College of Medicine Rochester, Minn 1. Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9:88-92. 2. Fochtmann LJ. Psychiatric perspectives on medical screening of psychiatric patients [letter]. Acad Emerg Med. 2002;9:963-964. 3. Perrone J, de Roos F, Jayaraman S, Hollander JE. Drug screening versus history in detection of substance use in ED psychiatric patients. Am J Emerg Med. 2001;19:49-51.
CORRECTION Incorrect journal name: In the article by Jabbour et al entitled “Adult Acute Myeloid Leukemia,” published in the February 2006 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2006;81:247260), the name of the journal in reference #159 on page 260 was listed incorrectly. The reference should read, Kantarjian H, O’Brien S, Cortes J, et al. Results of intensive chemotherapy in 998 patients aged 65 years or older with acute myeloid leukemia or high-risk myelodysplastic syndrome-predictive prognostic models for outcome. Cancer. In press.
April 2006;81(4):566-569
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
569
worthy of consideration as they attempt to appraise and diagnose a patient’s condition correctly. Analysis of hair or nail scrapings can provide useful information that in some circumstances is unattainable by any other method. Some difficulties exist with keratin tissue testing. Relatively few laboratories are capable of performing competent analysis. Both the protocol for accurate testing and the preparation of the sample are complex. Thus, the test is more expensive than a conventional urine screen, for example, although not prohibitively so compared with many other diagnostic procedures and tests. In addition, the testing procedure is labor-intensive and requires considerable time—several days are necessary even in optimal circumstances. Nonetheless, I can imagine many clinical circumstances in which the information provided by hair analysis could prove useful and thus should be considered. Thomas Mieczkowski, PhD University of South Florida Tampa 1. Lineberry TW, Bostwick JM. Methamphetamine abuse: a perfect storm of complications. Mayo Clin Proc. 2006;81:77-84. 2. Viala A, Deturmeny E, Aubert C, et al. Determination of chloroquine and monodesethylchloroquine in hair. J Forensic Sci. 1983;28:922-928. 3. Sramek JJ, Baumgartner WA, Tallos JA, et al. Hair analysis for detection of phencyclidine in newly admitted psychiatric patients. Am J Psychiatry. 1985;142:950-953. 4. UematSu T, Sato R, Suzuki K, Yamaguchi S, Nakashima M. Human scalp hair as evidence of individual dosage history of haloperidol: method and retrospective study. Eur J Clin Pharmacol. 1989;37:239-244. 5. Kintz P, Mangin P. Hair analysis for detection of beta-blockers in hypertensive patients. Eur J Clin Pharmacol. 1992;42:351-352. 6. Runne U, Ochsendorf FR, Schmidt K, Raudonat HW. Sequential concentration of chloroquine in human hair correlates with ingested dose and duration of therapy. Acta Derm Venereol. 1992;72:355-357. 7. Brewer C. Hair analysis as a tool for monitoring and managing patients on methadone maintenance: a discussion. Forensic Sci Int. 1993;63:277-283. 8. Williams J. Sectional hair analysis as a potential index of therapeutic compliance in an epileptic population. In: deZeeuw RA, et al eds. Proc Intl Conf & Wkshp for Hair Analysis in Forensic Toxicology. Abu Dhabi, UAE; 1995:443-466. 9. Williams J. The assessment of therapeutic compliance based on the analysis of drug concentrations in hair. In: Mieczkowski T, ed. Drug Testing Technology: Assessment of Field Applications. Washington, DC: CRC Press; 1999:1-32. 10. Mieczkowski T, Tsatsakis AM, Psillakis T. The concentration of three anti-seizure medications in hair: the effects of hair color, controlling for dose and age. BMC Clin Pharmacol. 2001;1:2. 11. Ishiyama I, Nagai T, Toshida S. Detection of basic drugs (methamphetamine, antidepressants, and nicotine, from human hair. J Forensic Sci. 1983; 28:380-385. 12. Suzuki O, Hattori H, Asano M. Detection of methamphetamine and amphetamine in a single human hair by gas chromatography/chemical ionization mass spectrometry. J Forensic Sci. 1984;29:611-617. 13. Suzuki 0, Hattori H, Asano M. Nails as useful materials for detection of methamphetamine or amphetamine abuse. Forensic Sci Int. 1984;24:9-16. 14. Nagai T, Sato M, Nagai T, Kamiyama S, Miura Y. A new analytical method for stereoisomers of methamphetamine and amphetamine and its application to forensic toxicology. Clin Biochem. 1989;22:439-442. 15. Suzuki S, Inoue T, Hori H, Inayama S. Analysis of methamphetamine in hair, nail, sweat, and saliva by mass fragmentography. J Anal Toxicol. 1989; 13:176-178. 16. Callahan C, Grant TM, Phipps P, et al. Measurement of gestational cocaine exposure: sensitivity of infants’ hair, meconium, and urine [published correction appears in J Pediatr. 1992;121:156]. J Pediatr. 1992;120:763-768. 17. Graham K, Koren G, Klein J, Schneiderman J, Greenwald M. Determination of gestational cocaine exposure by hair analysis. JAMA. 1989;262:3328-3330. 18. Koren G, Klein J, McMartin K. Diagnosing intrauterine exposure to cocaine by hair testing: six years of clinical use. Ther Drug Monit 1998;20:478-480. 19. Martz R, Donnelly B, Fetterolf D, Lasswell L, Hime GW, Hearn WL. The use of hair analysis to document a cocaine overdose following a sustained survival period before death. J Anal Toxicol. 1991;15:279-281.
Mayo Clin Proc.
•
In reply: We appreciate the opportunity to respond to Dr Mieczkowski’s suggestions for improving drug screening for methamphetamine. Debate about the usefulness of drug testing is ongoing in many arenas. Specific questions have been raised about the purpose and effectiveness of standard serum and urine drug assays in the emergency department evaluation, diagnosis, and management of substance-abusing patients. Emergency medicine physicians argue appropriately that emergency department management is dictated by the patient’s clinical presentation, and the results of drug screens do not customarily influence emergency department management.1 Psychiatrists counter that the initial evaluation in the emergency department is a window of opportunity to obtain information that could help confront denial or build the necessary legal and clinical case to secure treatment.2 In a prospective study of drug screening vs history for detection of substance abuse in 218 emergency department psychiatric patients, Perrone et al3 found that use of the patient’s history of drug use alone was unreliable. Drug screening alone was similarly flawed. They found that a combination of history and drug testing identified significantly more patients with substance abuse. Dr Mieczkowski’s recommendations for hair testing could potentially resolve many current practice issues. We believe that hair analysis for methamphetamine abuse could be particularly useful because it can detect the drug for longer periods, which could improve the identification of substanceabusing patients. Hair testing also allows assessment by the patient’s primary outpatient or inpatient treatment team. Dr Mieczkowski accurately describes the problems associated with hair analysis (limited availability, time-consuming, and expensive). Nevertheless, we hope the use of such testing will increase, thus enabling easier diagnosis and targeted treatment of substance abuse. Timothy W. Lineberry, MD J. Michael Bostwick, MD Mayo Clinic College of Medicine Rochester, Minn 1. Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9:88-92. 2. Fochtmann LJ. Psychiatric perspectives on medical screening of psychiatric patients [letter]. Acad Emerg Med. 2002;9:963-964. 3. Perrone J, de Roos F, Jayaraman S, Hollander JE. Drug screening versus history in detection of substance use in ED psychiatric patients. Am J Emerg Med. 2001;19:49-51.
CORRECTION Incorrect journal name: In the article by Jabbour et al entitled “Adult Acute Myeloid Leukemia,” published in the February 2006 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2006;81:247260), the name of the journal in reference #159 on page 260 was listed incorrectly. The reference should read, Kantarjian H, O’Brien S, Cortes J, et al. Results of intensive chemotherapy in 998 patients aged 65 years or older with acute myeloid leukemia or high-risk myelodysplastic syndrome-predictive prognostic models for outcome. Cancer. In press.
April 2006;81(4):566-569
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
569