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WI CAN Educational SeriesOctober 16, 2020

Hillary W. Petska, MD, MPH

Child Advocacy and Protection Services

Children’s Wisconsin

• There is no national consensus on when or how to perform pediatric drug testing.

• Each test has advantages and limitations.

• An understanding of these limitations is important in preventing misinterpretation.

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• At risk of physical or emotional harm

• D/t drug use, possession, manufacturing, cultivation, or distribution

• Risk identification

• Injury surveillance

• Additional info/history

• Opportunity to improve life course trajectory

Test Characteristic Definition

Rapid Short turn-around time

Specific Limited cross-reaction with other drugs

Sensitive Detection at low concentrations of the drug in the specimen

Reliable One lab will derive the same result as another

Easy Technically uncomplicated

Inexpensive Cost:benefit ratio

Woolf 1995

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• Layers of hair

• Types of hair• Vellus

• Intermediate

• Terminal

• Phases of growth• Anagen (1 cm/mo)

• Catagen

• Telogen

Curtis 2008, Farst 2011, Kintz 2017

• 1858 – Report published on arsenic in hair• 1977 – 1st modern use of hair drug testing• 1987 – NIDA considering hair as test

matrix for federal drug testing program• 1995 – Society of Hair Testing formed• 1998 – SAMHSA work group recommends

including hair as a test matrix• 2009 – FBI suspends hair testing in non-

criminal cases

SAMHSA 2013

• Workplace

• Criminal cases• Drug-facilitated crimes

• Detox clinics

• Sports

• Traffic court

• DEC and child custody• Neonates – hair sampled at or shortly after birth

• Passive exposure in the home

• Accidental ingestion or deliberate administration

Klein 2000, Kintz 2017

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• Window of detection = 90+ days

• Easy, non-invasive sample collection

• Decreased risk of adulteration

• Can be directly observed

• Easily stored/transported

Klein 2000, Levy 2014

• Sample size = 60-120 strands

• Location = vertex posterior scalp

• Orientation should be preserved (label which is closest to scalp)

Kintz 2017

1. Decontamination

2. Preparation

3. Incubation

4. Extraction

5. Analysis

Kintz 2017

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• Finer, more porous hair

• Less available

• Anagen : catagen and growth rate vary

Kintz 2014, 2017, Wang 2015

• Higher respiratory rate• Increased risk of environmental

exposure• Developmental stage• Less data• Variable pharmacokinetics and

toxicity

Kintz 2014, 2015, 2017, Wang 2015

• Washing• Caveat: Incorporation from the environment

• Cut-offs• Caveat: not evidence-based

• “Environmental exposure will only generate a positive for the parent drug.”• Caveat: EXCEPT IF:

• The exposure was from the sweat/sebum of a drug user

• The drug contains a metabolite

Curtis 2008, Cuypers 2018, Kintz 2017

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• Washing• Caveat: Incorporation from the environment

• Cut-offs• Caveat: not evidence-based

• “Environmental exposure will only generate a positive for the parent drug.”• Caveat: EXCEPT IF:

• The exposure was from the sweat/sebum of a drug user

• The drug contains a metabolite

Cuypers 2018, Kintz 2017

• SoHT cut-offs could

not differentiate systemic v. environmental exposure

• Washing• Caveat: Incorporation from the environment

• Cut-offs• Caveat: not evidence-based

• “Environmental exposure will only generate a positive for the parent drug.”• Caveat: EXCEPT IF:

• The exposure was from the sweat/sebum of a drug user

• The drug contains a metabolite

Curtis 2008, Cuypers 2018, Kintz 2017

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• Systemic exposure• Better assessment

of health risk

• Environmental exposure• Testing is being

used to ID families in need of services

Kintz 2014, Farst 2011

• Variable hair growth rate and phase of growth

• Incorporation via sweat/sebum or external contamination

• Change in hair structure due to cosmetic treatment

• Incorporation via decontamination

Cuypers 2018, Kintz 2017

• Substance not on the test panel

• Substance at levels too low to be detected

• Missed window of detection

• Substance not incorporated into hair

Kintz 2017

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• Contact with drug smoke or the actual drug

• Contact with sweat/sebum of a drug user

• Accidental/ intentional ingestion of the drug

• In utero exposure

• Intentional administration

• Close contact

• Smoke inhalation

Moosmann 2015, Kintz 2017

• Repeated exposure

• Contamination

Kintz 2017

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• Farst 2011 – children living in meth homes can still test positive regardless of hair color

Lewis 1997, Curtis 2008, Cuypers 2018

% Tested

% +

Black 57 57

Bi-racial 8 66.6

Hispanic 3 100

White 32 0

Previous exposure

Provides no additional information Positive = child still being exposed OR still

positive from initial exposure

Negative = child not re-exposed OR child re-exposed but missed window of detection

Should not be relied on for safety decisions

SAMHSA 2010

• Confirmatory testing

• Lab standards

• Education

• No evidence of an impact on preventing future maltreatment

SAMHSA 2010, Farst 2011, Kintz 2017

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• Use of drug tests and the results should only be one component in the identification of child safety, risk, strengths, protective capacities, and needs of families.

• A positive drug test may indicate the need for a safety assessment but does not by itself indicate parental drug use, child maltreatment, or the need for out-of-home care.

• A negative drug test is not enough information to make a decision on reunification.

SAMHSA 2010, Farst 2011, Petska 2019

• Know your test (or a medical professional who does)!

• Test results must be interpreted carefully.

• Boroda A, Gray W. Hair analysis for drugs in child abuse. J R Soc Med. 98(7):318-9; 2005.

• Center for Substance Abuse Treatment. Drug Testing in Child Welfare: Practice and Policy Considerations . HHS Pub. No. (SMA) 10-4556 Rockville, MD: Substance Abuse and Mental Health Services Administration, 2010.

• Curtis J, Greenberg M. Screening for drugs of abuse: hair as an alternative matrix: a review for the medical toxicologist. Clin Toxicol (Phila). 46(1):22-34;2008.

• Cuypers E, Flanagan RJ. The interpretation of hair analysis for drugs and drug metabolites. Clin Toxicol (Phila). 56(2):90-100; 2018.

• Dolan K, Rouen D, Kimber J. An overview of the use of urine, hair, sweat and saliva to detect drug use. Drug Alcohol Rev. 23(2):213-217;2004.

• Farst K, Reading Meyer JA, Mac Bird T, James L, Robbins JM. Hair drug testing of children suspected of exposure to the manufacture of methamphetamine. J Forensic Leg Med. 18(3):110-4; 2011.

• Felitti VJ, RF Anda, D Nordenberg, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 14(4):245-58; 1998.

• Gummin DD, Mowry JB, Spyker DA, et al. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clin Tox (Phila). 2017;55(10):1072-1252.

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• Kintz P. Hair analysis in forensic toxicology: an updated review with a special focus on pitfalls. CurrPharm Des. 23(36):5480-6; 2017.

• Kintz P, Ameline A, Eibel A, et al. Interpretation of cannabis findings in the hair of very young children: mission impossible. CurrPharm Biotechnol. 18(10):791-5; 2017.

• Klein J, Karaskov T, KorenG. Clinical applications of hair testing for drugs of abuse –the Canadian experience. Forensic Sci Int. 107(1-3):281-8; 2000.

• Levy S, Siqueira LM, Committee on Substance Abuse, et al. Testing for drugs of abuse in children and adolescents. Pediatrics . 133(6):e1798-1807; 2014.

• Lewis D, Moore C, Morrissey P, Leikin J. Determination of drug exposure using hair: application to child protective cases. Forensic Sci Int. 84(1-3):123-128;1997.

• Lipari RN, Van Horn SL. The CBHSQ Report: Children living with parents who have a substance use disorder. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; August 24, 2017.

• National Vital Statistics System, Mortality Data. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2018. https://www.cdc.gov/nchs/nvss/deaths.htm. Accessed June 12, 2019.

• Petska HW, Budzak-Garza AE, Graff AH, et al. Advocating for our youngest victims: Wisconsin’s approach to testing drug-endangered children. WMJ. 118(3):109-110;2019.

• Stauffer SL, Wood SM, Krasowski MD. Diagnostic yield of hair and urine toxicology testing in potential child abuse cases. J Forensic Leg Med. 33:61-67;2015.

• United Health Foundation. America’s Health Rankings: Wisconsin Summary 2018. Available at: https://www.americashealthrankings.org/explore/annual/state/WI. Accessed June 12, 2019.

• Wang X, Drummer OH. Review: interpretation of drug presence in the hair of children. Forensic Sci Int. 257:458-472;2015.

• Wisconsin Department of Health Services. Methamphetamine (Meth). Available at: https://www.dhs.wisconsin.gov/meth/index.htm. Updated October 7, 2019. Accessed October 17, 2019.

• Woolf AD, Shannon MW. Clinical toxicology for the pediatrician. PediatrClin North Am. 42(2):317-333;1995.

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