What is clinical toxicology?

The 21st century has brought clinical toxicology to the forefront of medical testing and safety monitoring. With the increasing development of successful pharmacological therapies, there has also been a rise in safety concerns and monitoring for physicians and patients alike.

Between1983 and 2000, 63 poison centers in the United States reported 2,168,248 cases of poisoning by toxic substances, 1/3 of these cases were unintentional adult poisonings, and 71% of these cases were due to a single substance, 5% from a drug reaction.

Working with a competent, medically driven laboratory, clinical toxicology can improve a clinician’s ability to manage therapy of prescription drugs, including controlled substances, and to assist in the diagnosis of substance misuse or addiction, as well as to guide treatment, and to advocate for patients.

References: Mokhlesi B, Leiken J, Murray P, Corbridge T. Adult Toxicology in Critical Care.Chest [serial online]. February 2003;123(2):577.


Why to test?

Everyone is unique.

Healthcare professionals are typically taught to treat all patients in the same manner. In recent years with new available pharmacogenomic research, it has been shown that this approach may in fact be harmful.Because every individual has a different genetic makeup, the tolerance and response of everyone to virtually all medications is also different. An example of this is the new finding that approximately 9% of Caucasians do not have enough CYP2D6 activity to have any analgesic effects from codeine therapy.

Successful therapy is the fundamental goal.

Because drug responses are only partially but significantly linked to a patient’s genetic makeup, without the consideration ofthis fact, it is easy to either undertreat or over-treat a patient. Presently it is unusual for a physician to know anything about a patient’s genetic makeup.

Unnecessary healthcare costs are skyrocketing.

In 2009, the total cost (direct and indirect) of opioid-related poisonings in the United States was approximately $20.4 billion.

  • Evaluate patients and monitor compliance:
    To ensure adequate therapy and adverse effects, periodic evaluations of
    patients is important.
  • Support assessment and diagnosis:
    The evaluation of disease-related biomarkers strongly support new diagnoses, and help physicians track the progression or regression of disease.
  • Identify use of undisclosed substances:
    Be certain that your patients are not using unreported substances.
  • Diversion discovery:
    Evaluate your patient’s potential illicit drug use or misuse of therapy medication.

References: Benzon H, Kendall M, Avram M, et al. Prescription Patterns of Pain Medicine Physicians. Pain Practice [serial online]. July 2013;13(6):440-450.

Inocencio T, Carroll N, Read E, Holdford D. The Economic Burden of Opioid-Related Poisoning in the United States. Pain Medicine [serial online]. October 2013;14(10):1534-1547.

Whom to test?

With the development of the concept of addressing multiple physiologic causes of chronic pain, many clinicians rely on the use of polypharmacy to address their patients’ needs. Unintentionally, many patients are exposed to multiple drug-drug interactions.

  • New patients already receiving a controlled substance
    Evaluate a new patient’s drug baseline, potential for benefits from therapy, abuse, and new therapy consideration.
  • Patients treated with multidrug pharmacotherapies
    Evaluate possible drug-drug interactions, and potential issues with current or future therapy.
  • Patients resistant to full evaluation
    Be aware of the use of any potential drugs of abuse and other prescription medications, which are not disclosed.
  • Patientsthat request a specific drug
    Some patients with expert knowledge of a specific drug may be engaging in drug-seeking behavior.
  • Patientsthat display aberrant behavior
    Determine if substance use is a differential in your diagnosis.
  • Patients in recovery
    Track patient successful rehabilitation and cessation of a substance of multiple substances, including synthetics.

References: Chianta M, Guevara M. Pharmacogenetics and pain management. MLO: Medical Laboratory Observer [serial online]. February 2014;46(2):9-11.

When to test?

What do most experts say?

When asked, 59% of Pain Medicine Physicians order a random urine drug test for their patients to evaluate compliance, abuse and use of other substances.

  • When meeting a patient for the first time
    Assessing a patient’s baseline is essential when considering
    therapy not just with a controlled substance, but with any pharmaceutical that
    may have potential drug-drug interactions.
  • In the beginning of therapy with a controlled substance
    Determining the metabolism and potential overuse of a drug is essential when first beginning therapy.
  • When making major changes in therapy
    Modifying therapy requires a reassessment of baseline to determine any potential interactions or drug metabolism issues.
  • Supporting a decision to refer
    Competent physician-physician referrals require communication to include the evaluation of drug level status and/or compliance at the time of referral.
  • As a component of treatment agreements
    In many practices, the physician-patient contract should include the potential for random testing, as a condition of therapy.
  • Any observed aberrant behavior
    A competent physician should always observe patient behavior at each visit, and question aberrant behavior as potentially being a result of current therapy or drug misuse.
  • Notification from a third party regarding any aberrant drug-related behavior
    In cases of inter-agency communication of aberrant behavior, a physician should respond appropriately with random testing.

References: Benzon H, Kendall M, Avram M, et al. Prescription Patterns of Pain Medicine Physicians. Pain Practice [serial online]. July 2013;13(6):440-450.

What is pharmacogenomics?

The term pharmacogenomics refers to the ability to identify how genes affect a patient’s response to medication. Genomic differences can influence the efficacy of medication and can be the source of serious drug side-effects and increase the risk of drug-to-drug interactions. It is estimated that adverse drug reactions occur in 10% of hospitalized patients, and account for 100,000 hospital deaths per year in the US. It is estimated that more than 100 drugs contain pharmacogenomics information and by having an evidence-based report of a patient’s genomic drug suitability profile, a clinician can better understand how their specific patients may react to a medication.

References: Johansen Taber K, Dickinson B. Pharmacogenomic knowledge gaps and educational resource needs among physicians in selected specialties. Pharmacogenomics & Personalized Medicine [serial online]. July 2014;7:145-162.

Is it confidential?

ACLS is adherent to Health Insurance Portability and Accountability Act (HIPAA) regulations. We do not store any specimens after processing. Patient DNA, as well as each specimen are securely discarded after the completion of testing. The lab analyzes DNA for the presence of specific markers to medication response only, and cannot provide any other information about patient’s DNA.