Athletes vs Drug Tests [Archive]

Dr. Joel Nathan

03-22-2009, 09:12 PM

Urine Drug Screens

If you have questions on urine drug tests, ask here or PM me at vo2max.

The standard urine drug screen in a clinical setting is a panel of immunoassays to detect common drugs of abuse. The panel usually includes the five drugs required by federal workplace testing: amphetamines, cocaine, opiates, marijuana, and PCP.

Other drugs that are prevalent in the community can be added to the panel, including benzodiazepines (Valium, Xanax, Klonopin) and barbiturates. Generally, drugs and their metabolites are detectable in urine tests for about 3 days after use. Notable exceptions are THC (from marijuana), methadone and benzodiazepines (Valium, Xanax, etc) stay in the system for weeks after heavy use.

Here’s where some docs need some education (perhaps you can teach them a thing or two): Most immunoassays for opiates are designed to detect heroin and measure codeine, which is a byproduct of heroin and morphine metabolism. However, synthetic opioids such as oxycodone or methadone do not cross-react with most codeine immunoassays, and will produce a negative result. A negative urine drug screen for opioids might falsely lead the physician to believe that the person does not use any opioids.

The same is true for opioids agonist/antagonists: Suboxone (buprenorphine and naloxone combination), Subutex (buprenorphine), Nubain (nalbuphine) and others that are not picked up on routine opiate drug testing. There is a test for buprenorphine that can be done in the office, but few docs have this test available in the office or think of doing it, if they are inexperienced.

Ultram (tramadol) is a unique centrally acting analgesic that feels like an opiate. People can become addicted to it and need detox. This medication is also non-controlled and does not tested on urine tox screens.

False positives (test will be positive for opiates even though they are not being used) occur if someone eats an equivalent of 1-2 teaspoons of poppy seeds. This can be the amount in 2 poppy seed bagels. By the way, just being in the same room with marijuana smokers does not cause your urine drug screen to be positive for THC. Also antihistamines and decongestants do not cause false positives for amphetamines.

This thread does not cover hair follicle or saliva testing and testing for anabolic steroids. These belong in threads by themselves.

Dr. Joel Nathan

03-23-2009, 02:53 PM

I am not a cut and paste poster, but I found this great article that summed the topic up extremely well.

Athletes vs. drug tests: What clinicians should know
By Bradley Anawalt, M.D.

The recent admission by baseball superstar Alex Rodriguez that he used banned drugs earlier in his career is
only one chapter in the ongoing saga of performance-enhancing products in sports, as athletes seek an edge
and regulators try to keep the playing field level with high-tech drug tests.
Athletes looking for a performance boost often use new compounds that have been chemically modulated to have the same effects as existing compounds, but can’t be detected by the usual tests. You can add a methyl
group or otherwise tweak a molecule and get the positive performance-enhancing effects, but it won’t show up on a conventional assay for a conventional compound.

Some athletes will use an adulterated compound that was previously testable and is no longer testable, or they may take diuretics, so they have a massive output of urine that dilutes the concentration of the compound
being tested.

Athletes may use a naturally occurring compound, such as testosterone, for performance enhancement, and they can claim that the high levels are their own. Administrators of drug tests have tried to take this a step
further, arguing that anyone with high levels of testosterone should have equally high levels of epitestosterone.
Testers could test for an appropriate testosterone/epitestosterone ratio, but then the athletes could become clever and start taking epitestosterone, too.

Tests for testosterone have become very sophisticated. Most synthetic testosterone or testosterone derivatives are made from plant sources of testosterone, not animal sources. There is a different ratio of carbon-14 and
carbon-12 in steroid hormones that are made from plant sources compared with animal sources. So testers can measure the carbon-14 to carbon-12 ratio, and if it is more consistent with a plant steroid, they might
suspect that someone is using an exogenous plant steroid. Natural human hormones are consistent with a ratio for an animal steroid.
In the future, the use of mass spectroscopy and liquid chromatography testing may help catch more of the athletes who are abusing anabolic agents.

Using mass spectroscopy and liquid chromatography would allow
testers to identify a substance that is similar to testosterone or other performance-enhancing drugs that raises suspicions, even if the compound isn’t easily identifiable. For the would-be cheating athlete, the next step
might be to use a performance-enhancing compound that is structurally similar to substances that naturally occur in high levels in humans, so there would not be any obvious anomalies on the liquid chromatography or
mass spectroscopy test.

Not only elite athletes, but weekend warriors and high school students may be using these performance- enhancing drugs, especially androgenic steroids, and providers need to know the long-term consequences for
these agents. Not only can they cause liver toxicity and possible heart and prostate disease, they can turn off the male reproductive system and cause short-term and long-term infertility. Much of the time, lab tests from
these patients won’t cross react with conventional testosterone assays because the body’s natural testosterone has been turned off. In fact, the testosterone readings might be low or undetectable, but there is actually too much of the anabolic steroid in the bloodstream.

Physicians are most likely to encounter possible steroid abuse in male patients who complain of a loss of libido, loss of sexual function, or infertility. The clinician should ask men with sexual complaints whether they
have a history of any kind of “supplement” or steroid use, especially if they are very muscular.

Longitudinal studies of young men who have used steroids have not been done, but the little data that we have suggest that the effects can persist for a year, or even longer. There appears to be a dose and duration effect.
For example, a 35-year-old man who used high doses of steroids for several years in young adulthood has a much higher chance of having persistent infertility, with low testosterone production and low sperm count,
compared with a younger man who used lower doses of steroids for a shorter period of time.

Also, clinicians should think about insulin abuse if a muscular man – or woman – presents with hypoglycemia. There have been case reports of body builders abusing insulin that has led to life-threatening hypoglycemia.
Insulin isn’t considered performance-enhancing as far as we know, but it is abused as a potential anabolic agent, particularly by bodybuilders. Very little is known about the long-term effects of giving insulin plus sugar
to a person without diabetes. But if athletes think something like that would be helpful, someone will try it.

When treating a patient who has a history of steroid use, keep in mind that many of them feel depressed, sluggish, and tired when they stop taking steroids and their endogenous testosterone and gonadotropin (FSH
and LH) levels are low. These patients may benefit from a prescription of androgen replacement therapy with initially high dosages and then a gradual tapering off over several months.

Although no one knows exactly how athletes may try to enhance performance in the future, it’s important for clinicians to pay attention to the physiology of their most athletic patients and educate them about the
long-term consequences of manipulating their body chemistry.

Dr. Anawalt is chief of medicine and vice chair of the department of medicine at the University of Washington Medical Center in Seattle.
© Copyright 2009 Elsevier Global Medical News.