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A trio of scientific sessions at the 2020 AACC Annual Scientific Meeting & Clinical Lab Expo tackles the opioids epidemic, providing the latest news on diagnostic tools, forensic toxicology, and trends in abuse of fentanyl and other substances. Clinical labs play a critical role in identifying opioid use, “informing physicians to help guide treatment options, and ensuring abstinence through compliance and drug treatment testing efforts,” said Frederick Strathmann, PhD, MBA, DABCC, senior vice president of operations at NMS Labs and one of the session presenters.

More than Opioids: New Trends in Adolescent and Young Adult Substance Abuse Testing (32229), a scientific session on December 14, will describe the clinical needs and testing approaches for toxicologic assessment in adolescents and young adults as well as the common challenges and solutions for community and specialty hospital laboratories. Sara Love, PhD, DABCC, of Hennepin Healthcare, will offer an analytical toxicologist’s perspective on common drug testing in adolescents and young adults. Attendees will hear a clinical toxicologist’s point of view from Ann Arens, MD, of Hennepin County Medical Center. Sarah Wheeler, PhD, of the University of Pittsburgh Medical Center, offers a clinical chemist’s views on common laboratory questions in drug testing in adolescents and young adults.

Adolescents and young adults in need of toxicology testing often have taken things readily available at home, such as household items, over-the-counter medications, or family prescriptions, Wheeler told CLN Stat. “Because of this, we frequently don’t have a rapid screening test for what they might have taken,” she said. Sending out for more comprehensive testing can take days. Tests for commonly ingested toxic compounds such as salicylate or ethanol are optimized for adults, not adolescents, which can also create problems in screening.

“Lastly, there can be problems distinguishing intentional ingestion, household exposure, and child abuse,” Wheeler continued. Involving child services adds a layer of complexity to testing in this age group.

According to Love, key challenges for toxicology testing in children and adolescents arise from:

  • Physiological differences between adolescents and adults, making drug testing suboptimal in the former.
  • Decision-making differences that highlight the impact of social media.
  • Intentional use versus household passive accidental exposure.

With children as with adults, fast turnaround times on commonly ingested substances like acetaminophen are important, and communication around possible limitations of screening tests will help physicians interpret these results, said Wheeler. “Having an established laboratory for sendout of less common compounds can aid clinicians in identifying new trends and understanding outcomes,” she said. “Most importantly, regular communication between the lab and toxicology physicians will ensure that when there’s a problem, both teams know who to call to resolve it quickly.”

Labs should identify any testing gaps and proactively build mechanisms to bridge them, said Love. Relationships on a local level—both inside and outside an institution—also matter. “Get to know your colleagues in public health, crime labs, and poison centers. Information exchange and collaboration can be critical when a toxic outbreak happens,” she recommended.

Arens elaborated on the importance of collaborative work among stakeholders. “We are often faced with patients who present with confusing signs and symptoms and unclear histories. Often our laboratory studies can provide vital pieces of the puzzle to solve a confusing clinical picture,” she said, adding that this makes collaboration all the more invaluable.

By understanding current trends in substances of abuse, attendees will better identify common challenges and limitations of toxicology testing in children. “More than anything, I hope both laboratorians and clinicians will feel empowered and inspired to improve communication between the lab and clinical toxicology within their institution to improve testing in this age group,” said Wheeler.

The session takes place from 2–4:30 p.m. Central Time and is worth 2 ACCENT credit hours.

Two days later, the topic turns to Fentanyl and Fentanyl Analogs: From Overdose to Outbreaks to Laboratory Detection (34103). Presenter Kara Lynch, PhD, DABCC, FAACC, an associate professor of laboratory medicine at the University of California, San Francisco, plans to review lab diagnostic tools that identify synthetic opioids. “I will focus on analytical techniques that can be used to monitor fentanyl and fentanyl analogs in clinical laboratories and their advantages and disadvantages,” said Lynch. She’ll also discuss the public health role of clinical laboratories in the opioids epidemic, and present clinical cases highlighting the dangers of fentanyl analogs and synthetic opioids.

Sarah Riley, PhD, DABCC, FACB, associate professor of pathology at Saint Louis University, follows up with interactive case studies on overdoses and regional outbreaks. She’ll discuss the history of the opioid epidemic, review how opioids are classified, and talk about some classes of drugs that are emerging threats. “I’ll close by presenting some postmortem toxicology cases involving opioids,” Riley told CLN Stat.

This is one of the biggest challenges clinical labs face, the presenters said in a joint statement. “Some ways that labs can keep track of trends include using published or online resources, forming collaborative networks with forensic toxicology and crime labs, and doing untargeted surveillance work,” they indicated. Three good published sources for drug trend data are:

  • The Center for Forensic Science Research and Education’s novel psychoactive substances (NPS) discovery website.
  • The United Nations’ Office on Drugs and Crime.
  • The Drug Enforcement Administration’s Emerging Threat Reports.

Quadrupole time-of-flight high resolution mass spectrometry is a great technique for surveillance, according to Lynch and Riley. “Labs should consider using this technique to retrospectively interrogate drug screen samples for emerging trends in their area,” they suggested.

Attendees of this session should come away with an appreciation of the challenges labs face in keeping up with the opioid crisis—and armed with some approaches to mitigating those challenges. Join in on December 16 from 11 a.m.–12:30 p.m. and earn 1.5 ACCENT credit hours.

Another session on December 16, Avoiding the Bleeding Edge of the Opioid Epidemic: A Tale of Using Seized Drugs, DUID, and Postmortem Cases to Keep the Laboratory at the Front-Line (34221), looks at expectations and skills laboratory professionals need to stay at the forefront of the opioid epidemic. Donna Papsun, MS, D-ABFT-FT, a forensic toxicologist with NMS Labs, will address surveilling novel psychoactive substances (NPS) and tracking and responding to emerging trends. Alex Krotulski, PhD, a research scientist at the Center for Forensic Science Research and Education, follows up with a talk on leveraging private and public partnerships to enhance chemical identification of NPS in seized drug and toxicological casework for optimal test development. Strathmann will present on the right test at the right time: making the data accessible and testing actionable.

This session is unique “in that it brings a lot more of the forensic experience to the opioid epidemic efforts than what may normally be discussed at the AACC Annual Scientific Meeting,” Strathmann told CLN Stat. He expects that attendees take pride in the impact labs have made in stopping the opioid epidemic and expects they will “recognize aspects of their daily work in what we present,” he said. “At the same time, I want the attendees to recognize the seriousness of what we are being asked to do as a community and to not enter into this effort lightly.”

Many forensic labs conduct testing on seized drugs. “Part of our session will talk about efforts on that front, as well as data analytics to share those findings,” said Strathmann. He and his colleagues will also share various strategies on visualizing and sharing data to leverage the capabilities of numerous laboratories.

Strathmann is excited to see how his own team’s collective efforts align with AACC’s 2019 position statement on the role of laboratories in stopping the opioid epidemic. “The statement lays out the various areas that laboratories are needed, from test utilization to new methods, surveillance, partnerships, and communication. I believe attendees will see the impact that AACC’s position statements can have on influencing how resources are directed and the course that large-scale initiatives can take.”

When it comes to the workflows and technologies labs need to design testing for novel psychoactive substances, “one size definitely does not fit all,” Strathmann continued. 

This session runs from 2–4:30 p.m. and is worth 2.5 ACCENT credit hours.