10,11 The conversion of codeine into its active opiate morphine is dependent on the activity of cytochrome P450 2D6 (CYP2D6). Individual genetic polymorphisms, with a population frequently as high as 10%, also come into play with opioid use. Individual variability in response and toxicity 8 Although all ages are affected, the increase in use of nonmedical analgesics is most prominent in teenagers and young adults, suggesting that the problem will continue to increase. In 2008, for the first time, deaths attributable to drugs (about half being opioid-related) equaled the number of traffic fatalities in the United States. 7 Death rates vary greatly among states, with those that have higher nonmedical use also having both higher substance abuse treatment admission rates and death rates. Recently, the ready availability of high dosage products and circumventable, controlled-release mechanisms has resulted in a significant increase in accidental fatal overdoses. The traditional “street dealer” is a source only 16% of the time. Indeed, most of the non-prescribed use is accessed by being given (70%) or taking (22%) another person’s prescribed medication. It has often been said that although there is not a drug dealer on every corner of rural and suburban America, there is usually a pharmacy. 5 The Monitoring the Future study (an annual telephone-based survey of more than 45,000 eighth, tenth, and twelfth graders in 400 private and public secondary schools throughout the U.S.) indicates that 8% to 10% of adolescents are using prescription opioids without a valid medical reason or prescription. While Americans comprise less than 5% of the world’s population, they account for more than 80% of the prescription opioid use worldwide, and more than 99% of the hydrocodone (e.g., Vicodin) use. Some statistics regarding opioid use in the U.S. 4 These efforts have had unintended consequences, as it is now clear that over-prescription and inappropriate prescription of narcotics is a growing problem. 1-3 Pain scales became the norm, and they have become a Joint Commission on Accreditation of Healthcare Organizations standard. This was particularly true in the assessment of abdominal pain.ĭuring the 1990s the recognition of the problem of undertreatment of patients with acutely painful conditions led the American Pain Society, the Veterans Administration, and others to promulgate pain as the “fifth vital sign” in an effort to increase physician attention to undertreated pain. Emergency Department physicians, surgeons, and others often withheld pain medication for fear of obscuring a progressive condition or interfering with clinical assessment. History is rife with examples of early promotion of a “new, non-addicting pain reliever” which was promoted to avoid the complications of the previous pain reliever (which had once been heralded the same way). These drugs have been considered both a panacea for the ills and injuries of life and a path to self-destruction due to the rapid onset of tolerance and the potential for addiction. The opiates, along with their semi-synthetic opioid derivatives (heroin, hydrocodone, hydromorphone, nalbuphine, oxycodone, oxymorphone) and the increasing number of completely synthetic opioids (propoxyphene, levorphanol, meperidine, diphenoxylate, butorphanol, methadone, fentanyl derivatives, tramadol, buprenorphine, tapentadol) have a long and checkered history in medicine. The presence of any of those would not be a result of the donor taking hydrocodone.The naturally occurring opiates (morphine, codeine, and thebaine) can be extracted from the opium poppy, Papaver somniferum, along with a number of other alkaloid compounds. We than should never see codeine, morphine or 6-Acetylmorphine.

The solid arrows in the metabolic pathways indicate major metabolites and the dashed lines minor metabolites.īased on the chart below, if someone is taking hydrocodone (prescribed or not) we would expect to see hydrocodone present and possibly, dihydrocoeine, norhydrocodone or hydromorphone. 6-Acetylmorphine will than continue to break down into morphine and down the rest of the metabolic pathway from there. 6-Acetylmorphine is what the lab is testing for to confirm heroin use.

For example, heroin (top right) within minutes will break down toĦ-Acetylmorphine.

This is a helpful reference to illustrate how the laboratory utilizes mass spectrometry results to identify specific analytes in a specimen. The following flow-chart shows the different metabolic pathways of both OPI and OXY. Opiates ( represented in blue) have a completely separate metabolic pathway to OXY ( represented in orange). Illustrating The Separate Metabolic Pathways Of OPI And OXY

Opioid cross reactivity