June 30, 2025 • 43 mins
Urine drug testing provides critical insights for addiction treatment, helping clinicians understand what substances patients are actually using and how the drug supply is rapidly changing. Matthew Rutledge, founder of MD Labs, shares his expertise on testing methodologies, detection capabilities, and emerging trends in substance use.
• Different drug test types include basic immunoassay cups (similar to pregnancy tests), which detect drug shapes but can have false positives/negatives
• Liquid and Gas chromatography with mass spectrometry provides highly accurate substance identification down to nanogram levels
• Developing tests for novel substances takes 2-4 months, requiring standards and validation across hundreds of specimens
• Poppy seed muffins can genuinely cause positive opiate tests depending on seed source and patient body mass
• Unexpected test results require clinical judgment—some exposures may occur through contamination, intimate contact, or environmental exposure
• Integration of pain and addiction medicine allows better co-management of patients with both conditions
• Emerging threats include nitazine opioids, exotic benzodiazepines, and tianeptine ("gas station heroin")
• Test adulteration methods (vinegar, bleach, dilution) can be detected through validity testing for oxidants, creatinine levels, and specific gravity
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years, I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is on urine drugtesting.
(00:44):
This is an interview withMatthew Rutledge, who runs a lab
testing company called MD Labs.
Quick disclosure I have nofinancial ties to that company
except that we send specimensfrom our office to them.
Matthew and I discuss urinedrug testing in detail in this
episode, from the differenttypes of tests that are done to
(01:05):
common myths about urine drugtests, to how lab companies
develop tests for new substancesin the drug supply.
We covered urine drug testsback in the summer of 2023, but
this episode goes into a lotmore detail about urine drug
tests and I love Matthew'sperspective as someone who runs
a lab.
We had a great conversation andI learned a lot.
(01:26):
Here we go All right.
Well, good morning, so nice toconnect with you again.
Why don't you start by tellingus who you are and what you do?
Speaker 2 (01:37):
Oh, great to see you, dr Grover Casey.
My name is Matthew Rutledge.
I am one of the founders andmanaging partners of MD Labs.
We're a clinical laboratoryserving the United States and we
specialize in toxicology forsubstance use disorder patients,
toxicology for chronic opioidtherapy patients, a lot of
(01:58):
psychiatry, anyone who's taken adangerous drug that needs to be
monitored.
So that's really what we'vebeen doing for now 14 years.
So I know how I got've beendoing for now 14 years.
Speaker 1 (02:05):
So I know how I got into my career.
How did you get into yourcareer?
Speaker 2 (02:10):
Oh, wow, I talk to a lot of teenagers these days.
My kids just went throughcollege about what they want to
be when they grow up.
And your path finds you andmine found me.
I was pre-med, did pretty wellon my scores and tests and
things and went through thepre-med program in college, got
a degree in chemistry, butchanged my career path when I
(02:31):
met a surgical device rep andsaw what he did, came into the
OR and saved the day with hisbox of tools and steel plates
and helping the doctor put awoman's face back together after
a procedure and I was soimpressed by this guy and I was
pretty handy myself that Ipivoted towards that career.
(02:51):
And in that space I was workingwith a lot of interventional
pain physicians and saw this iswhat the late 2000s and early
2010s we were really seeing therise of the opioid epidemic and
the need for clinical labtesting to determine if patients
are taking what they claimthey're taking and keep them
(03:11):
safe, keep the community safe.
And it was an underservedcommunity in the state of Nevada
and I knew a lot of physiciansthere who needed it.
We're sending things all overthe country and talked about my
background.
I got my degree in chemistryran part of my organic chem lab
in college, coupled up with mypartner, dennis, who's the other
founder, his degrees inbusiness and through all those
(03:34):
careers, we ended up starting upa lab, a mom and pop laboratory
, in Nevada.
With the help of some geniusPhDs and having come from the
space of the provider side,being in the operating room with
doctors talking about what theyneed, what they care about we
really built the lab based onwhat our referring providers
needed, not, like a lot of labs,build their philosophy on what
(03:55):
they can do.
So they'll push out 10 pages ofdata because they can, because
this is incredible data, butmaybe you can share.
What do you look for in a labtest and lab results when
they're being sent your way?
Because that's how we built ourcompany and our model.
Speaker 1 (04:13):
So there's so much dogma in medicine and it's
interesting there oftentimes arelab tests that we order that we
don't necessarily know what todo with, because this is what we
always do like oh gosh, thepatient has abdominal pain.
We always get a completemetabolic panel and then
(04:36):
sometimes physicians get reallystuck on what if the number says
one thing and the patientdoesn't feel badly or
differently?
Do we treat the number or do wetreat the patient?
And that's an ongoing debate inmedicine is why do we order
what we order and what do we dowith the results?
And do we treat the number orthe patient?
And I think the answer is youorder what you need to order and
(05:00):
you have to know what you'regoing to do with the results
abnormal or normal and then it'sreally weaving the patient and
the results together when makingyour decisions.
And in our world of addictionmedicine, the drug supply
changes week to week and it'sreally been wow.
This week our patients aretalking about xylosine and three
(05:24):
weeks ago they were talkingabout isotonitazine, which is
one of these opioids no one'sever heard of.
I didn't know there werenitazine opioids, but
isotonitazine is one of them.
So I think for me and mycolleague, the very lovely and
beautiful Dr Reb Close, whohappens to be my spouse.
We are just trying to see whatour patients are getting, simply
(05:45):
because it changes what we dowith their meds.
And it's largely around opioids, because suboxone,
buprenorphine, subutex requiresa period of not taking another
opioid before you start it.
So let's say a person's takinggood old-fashioned heroin
Heroin's gone, but heroin youhad to wait for about 12 hours
(06:10):
before you took your Suboxone orSubutex or Buprenorphine so you
wouldn't go into withdrawal.
And let's say somebody is on adrug and they wait the 12 hours
and then they take that med andthey feel horrible.
Well, it's not heroin and wewant to know what it is, because
if the next patient has thesame experience we can then test
them, see a pattern and thencounsel our patients going
(06:30):
forward.
Or another example is one of DrClose's patients was on some
weird benzo called bromazolamthat no one's ever heard of, and
he started developing psychosis, he was hallucinating.
And then she had another onewho had that same experience.
And again, once we recognizethe pattern we can counsel our
patients and then inform thecommunity around us.
So very long answer to say we'dlove to know what our patients
(06:55):
are getting, so we can linktheir symptoms to what they test
positive for and thenunderstand to be able to counsel
our patients going forward andthen make decisions based on
what they're on.
Like if somebody's onisotonitazine and it turns out
it doesn't interact well withsuboxone or subutex or
buprenorphine, we do thingsdifferently.
Hopefully that makes sense.
Speaker 2 (07:16):
It absolutely does and it speaks to the vigilance
of your practice and theengagement with the community.
So many of the illicit drugsthat we see, or things off-label
, are very much regionalizedParts of the country where this
drug is a problem, parts of thecountry where that drug is a
problem, and understandingwhat's a problem in your area
and what your patients are doingand what the local drug dealers
(07:38):
got in stock in recent monthsis a huge part of solving the
issue, making the patients awareof the risks they're putting
themselves out and helping themget off the specific medications
, because each medication hasits own peculiarities to it.
Speaker 1 (07:51):
So I think you and I had talked yesterday about level
setting for everyone, thedifferent types of drug tests,
how they work, their pros andcons.
So I'm going to try to be funnyhere.
Let's pretend I'm you incollege, I'm a pre-med and you
need to explain to me when I goto Rite Aid and buy the little
cup drug test, what type of testis that, how does it work and
(08:12):
does it have false, positivesand negatives?
Speaker 2 (08:15):
This I explain a lot.
It is a hit at dinner partiesbecause there are so many
nuances to drug testingcomplications.
So you mentioned the cup thatyou can get at a drugstore.
That cup has little test stripsin it that are very similar in
their activity to a pregnancytest.
They're typically an enzymereaction where if a type of drug
(08:36):
that the enzyme is sensitive to, if it's presented with that,
it will cause a color change.
So these enzymes can besensitive to heat and to age and
to those things.
So if it's been on the shelf atCVS or in the trunk of a hot
car or frozen it may affect howit works.
You might get false positives.
You're also going to get falsepositives and false negatives if
(09:01):
it's a similar drug to what thepaper is sensitive to.
Paper's not that smart, thatenzyme's not that smart.
So a good example ismethamphetamine, the most
commonly abused drug in thiscountry per the DEA.
There is a real similar sistermolecule in Vick's nasal spray.
That's non-euphoric, doesn'tget you high, but it is a
(09:22):
different version ofmethamphetamine.
It will trick that cup intothinking that you are taking
crystal meth and it turns outabout one out of every 25
patients that test positive atour laboratory is actually on
Vicks nasal spray because it isso common.
So the cups aren't very smartand they're prone to errors.
They're prone to missing drugs.
They're prone to being anunguided missile, as they say.
(09:45):
But they're readily available,they give you results in 10
minutes and they can be veryhelpful to a lot of practices.
If you want to write aprescription today and check, at
least cover your bases forchecking the patient.
They're a great, cheap way toget lab testing done in office.
Speaker 1 (09:59):
Yeah, the way I explain them to my patients and
I believe this is called animmunoassay test is it's
essentially looking at shape,right?
So if something is shaped likemorphine, that little chemical
reaction will occur and it'lllight up as a positive right or
similar.
Like you were saying, aroundamphetamines, if it's shaped
(10:22):
like an amphetamine it will comeup as positive.
And it turns out there's anantidepressant called selegiline
which is structurally verysimilar to an amphetamine and
one of my patients wasincarcerated when he was on
selegiline and his point of careurine cup immunoassay test was
positive for amphetaminesbecause of his selegiline.
I'm a former ER doc.
(10:42):
We love to keep things simple.
The way I think of these testsis it's about shape and that we
try to use the little chemicalassay in the paper to recognize
the shape of the drug.
Speaker 2 (10:51):
We're trying to test, for it's an enzyme with an
antigen.
They're bound together.
The drug comes in, displacesthe enzyme.
That free enzyme causes a colorchange, got it?
So with the test strip cups youcan see it with your eyes.
The next step up in complexityis to have a machine do the
analysis for you.
It's a lot more sensitive, alot more reliable, calibrated.
So that's enzyme immunoassay isa lab analyzer technique that
(11:14):
we use that is more reliable,can test for a broader number of
things, gets calibrated everysingle day.
So you know that it's moreaccurate and reliable.
But the next step up incomplexity is to go to gas
chromatography or liquidchromatography, which is the
high complexity, extremelyreliable technique that most
laboratories employ.
Speaker 1 (11:35):
So again, dumb former ER doc question gas and liquid
are different.
Last time I checked my collegephysics courses.
What is the difference betweengas chromatography and liquid
chromatography?
Speaker 2 (11:48):
It is the state at which the specimen is entered
into the machine.
If you're using all thespecimens that we see typically
come in as liquid blood, urine,saliva, a gas chromatography you
have to vaporize that substanceto get it to travel through the
machine.
The chromatography chromatogramchromo meaning light.
(12:09):
It's like a prism thatseparates light into all of its
colors.
This separates all thecompounds in that specimen into
their components and they comeout of the back end of this
chromatography system separately.
So you concentrate them andseparate them.
To identify all of thecompounds that are in the
specimen and that's the same forgas or liquid chromatography
(12:30):
you then run them through a massspectrometer that measures the
molecular weights of thedifferent compounds.
So if you know the retentiontime they call it how long it
took to go through that column,because some drugs are fast,
some drugs are slow we know whothey are and then you measure
the molecular weight.
You have two factors that canbe used to identify the unknown
(12:51):
compound Interesting.
Speaker 1 (12:53):
So let me make sure again.
Simple ER doc brain.
I got to simplify this.
So for me as a doctor, theimmunoassay is the one I can do
in the office and if there's anunexpected result, I'd want to
send it for the confirmatorytest, which is the
chromatography.
Mass spectrometry and theliquid or gas chromatography is
the process of separating what'sin the specimen into its
(13:15):
individual compounds, and thenthe mass spectrometry is
basically where you analyze themolecular weight of each of
those compounds to identify whatit is.
Speaker 2 (13:25):
Gas chromatography and liquid chromatography are
similar theories behind both.
Liquid is just easier to do.
It can be done more quickly,more comprehensive, with less
sample prep.
It's hard to get blood tovaporize.
It's much easier to keep it asliquid form Well hard in a lab
under controlled conditionswithout destroying the
components of it.
Speaker 1 (13:43):
Harden a lab under control conditions without
destroying the components of it.
So how do you actually create atest for a novel substance?
So I'm actually asking yourcompany and, just so everybody
knows, you don't pay me to doanything.
I don't own anything with MDLabs.
You guys provide service to usand so that's how we connected.
But I've asked you, I want alab assay for isotenidazine,
(14:04):
which is this weird opioid thatwe're hearing about.
What's the actual process likethere?
Speaker 2 (14:09):
chains need to develop a test that will get the
job done.
So if the job is finding, let'ssay, isonitizine in a specimen,
(14:35):
we need to create that method.
It's called a lab-developedtest.
If there's not a commerciallyavailable test on the market, we
need to make one and show thatit works.
In this particular situation,we would need to find a standard
somewhere, find high and lowcontrol calibrators for this
target compound.
Someone's got to be making itsomewhere, order it in, and then
we have to demonstrate that wecan reliably and accurately
(14:57):
detect this drug in hundreds ofspecimens over several days on
several pieces of machinery.
So we go through it's calledthe validation process and
that's how you develop a newtest and if it works and it's
reliable, you'd test it oninpatient specimens and it's
your lab developed test only tobe used in your laboratory.
Speaker 1 (15:17):
So I'm going to try to be funny here with how I ask
my question.
So you must need a drug dealer,because you're basically
analyzing controlled substancesand illicit substances.
Like who's your dealer?
Speaker 2 (15:33):
Ceruleant is a big drug dealer in the United States
who's Ceruleant?
Sorry?
And they're a laboratory thatcreates these.
Now they don't send them to usin any snortable or usable form.
They're all denatured inmethanol.
So the lab staff, the risk ofabuse is very, very low.
But yeah, we buy a lot of drugs.
Speaker 1 (15:56):
Interesting.
So isotonitazine, since I keepfixating on that, one is again.
It's this novel opioid that noone's ever heard of from this
class of opioids callednitazines, and I've tried to
research it and I can't findmuch, except there are loads of
pharmaceutical companies in Asiathat are willing to ship it to
me.
So for a novel substance likethis, are you engaging these
(16:19):
pharmaceutical companiesoverseas?
Speaker 2 (16:22):
We are indirectly Cerulean orders a lot of their
stuff overseas from China andEurope based on these tariffs
that we're getting charged.
So in that process we need tobe made aware of this target
drug out there that's being used.
Xylazine was one of the recentfive, six years that we're all
made aware of and there's a needto test for it.
(16:43):
There's an issue there.
It's going to be a problem forour patients that we're all made
aware of and there's a need totest for it.
There's an issue there.
You know it's gonna be aproblem for our patients that
we're seeing.
So we are made aware.
We order in some specimens, somesample stock.
We create our ownconcentrations of known
specimens and run them and if wecan develop a method and bring
it to market, it's usually a twoto four month process depending
(17:04):
on how complicated that drug isto detect.
We also run metabolites of alot of these compounds.
Why is it important to checkfor a metabolite of a drug?
Well, a lot of times we want tomake sure it's passed through
the patient's body.
If it's a prescription drug, alot of patients will pill shave
the pure mother compound into acup so they can go sell the
(17:28):
mother product, so being able tosee that it went through their
body is vital.
And for things like oxycodoneand morphine and heroin and the
benzos, we check for metabolitesof all those to avoid pill
shaving.
Speaker 1 (17:42):
So let's just again simple ER doc brain needs to
understand this.
So the idea is is that you wantto test for the native compound
, the substance and also themetabolite, to show that the
person's taking it rather thanthey're just putting a little
bit of their pill in the cup.
So for cocaine, which isobviously not prescribed, the
(18:04):
metabolite is benzoylcogonine.
So on your test, which I lookedat this week, my patient tested
positive for cocaine andbenzoylcogonine.
Or in the case of buprenorphine, I prescribed them
buprenorphine and the metaboliteis nor-buprenorphine, so the
patient would test positive forboth of them.
Speaker 2 (18:23):
Yeah, it's important to have that information for a
clinical patient.
So with developing an assay, wedevelop it not just for the
parent drug but for themetabolite when we can, and
report those both reliably.
Speaker 1 (18:41):
So I am pulling up a saved photo on my phone which is
adulterants used to preventdetection of drugs in urine
samples.
So ammonia, bleach, powderedurine, urinate vinegar, visine,
eyedrops these are all thingsthat people can put in urine
drug tests.
Do those affect both theimmunoassay and the liquid
chromatography mass spectrometry?
Speaker 2 (19:00):
They most certainly can.
It's important.
We've seen it all in our 14years and millions of specimens.
If you open up the cup and itsmells like vinegar, it's highly
likely that they added vinegarand the technicians make a note
of that.
If you see white powderfloating in specimens, if you
open up the cup and it smellslike vinegar, it's highly likely
that they added vinegar and thetechnicians make a note of that
.
If you see white powderfloating in the cup, or soap
bubbles or it's blue blue can befrom a patient taking certain
(19:22):
medications, but it also can betoilet water that they've
scooped out of the tank of thetoilet.
So we use a lot of non not veryscientific indicators to detect
adulteration and things.
We also run validity testing onthe specimen.
We check for oxidants, like yousaid, because they can cloud
the machine.
We check for dilution.
(19:43):
Your body secretes creatinineat known levels and if that
level's out of the normal range,it's highly indicative that the
patient has watered thespecimen down.
We counteract that by detectingthe creatinine and then
normalizing the specimenconcentrations.
To tell the doctor, let's say,we detected 10 nanograms per mil
(20:05):
of this target, which normallywould be under the presumptive
cutoff, but we normalized itbecause it was watered down and,
doctor, this patient's actuallyat this concentration here.
So there are lots of ways tocombat that.
Specific gravity of the urineis also detected, or the saliva,
so the lab has a lot offail-safes in place.
Some labs are using DNAtechnology to get a known
(20:28):
specimen of DNA from the patientand then check the urines over
time to make sure that they'vegot some of that same patient's
DNA.
Speaker 1 (20:34):
So just want to again make sure I get this right.
I was under the impression thatthese adulterants only messed
with the immunoassay cup tests,but you're saying they can mess
with the confirmatorychromatography mass spectrometry
test too.
Speaker 2 (20:49):
Well, each adulterant has a different impact.
Speaker 1 (20:52):
That's true, okay.
Speaker 2 (20:53):
So they all have different impacts on things.
If someone adds bleach to theirspecimen, is it going to remove
all of the fentanyl?
No, we're very sensitive tofentanyl testing, but dilution
could take it down to a levelthat's below our reliable cutoff
.
So that's why we need to detect.
We use four lab tests to detectadulteration, as well as visual
and experienced scientistslooking at specimens.
Speaker 1 (21:16):
So another silly question here.
So my patients teach me so muchabout the illicit drug industry
.
One of my patients will tell melike what their dealer's
selling, and a lot of mypatients in recovery will tell
me how they used to cheat ontheir urine drug tests.
Speaker 2 (21:44):
A lot of my patients in recovery will tell me how
they used to cheat on theirurine drug tests.
Do you have an advisory boardof people in recovery or pain
patients that tell you what theydid when they were using or
what their tricks of the tradewere to pass urine drug tests
base?
But we have experts that webring in.
We've got law enforcementexperts that we work with.
We have a lot of addictionrecovery facilities are run by
recovering people.
We talk to patients as much aswe can and visit and speak with
actual patients.
So we are constantly solicitingthat advice and expertise.
(22:08):
There's a lot of this publishedin literature.
The DEA puts out advisories.
The NIFLIS group talks aboutwhat drugs are currently out
there, how people are avoidingthem, how people are trying to
fake drug tests.
It's the constant battle.
Drug addiction is very powerfuland it really puts people into
a space of doing whatever theycan to survive.
(22:29):
It's that level of effort thatgoes into this sometimes.
Speaker 1 (22:34):
Yeah, so you and I had talked about doing a little
bit of myth, busting aroundurine drug tests.
So let's take a myth that Ithink I know the answer to, but
I'm very curious as to what theexpert here says.
Talk to me about poppy seeds inurine drug tests.
Speaker 2 (22:50):
Talk to me about poppy seeds and urine drug tests
.
Poppy seeds and urine drugtests.
This myth that if you eat apoppy seed muffin in the morning
you might test positive foropiates later on in the day is
not a myth.
There are certain strains outthere of poppy seed that do
contain opiates in them.
We've run a lot of tests hereat the lab and it depends on
(23:13):
where the manufacturer, wherethe bakery, gets their poppy
seeds, because the ones that areon the shelf at the grocery
store have no opium in them fromwhat we can tell.
But my favorite muffin they'vegot plenty of opium in their
poppy seed muffins because wehad the lab staff treated them
all the muffins and bagels andthen took urines later in the
day and a lot of them testedpositive, especially the lighter
(23:34):
weight, smaller people that hada lot more per body mass index
intake of the poppy seeds.
But yeah, it happens, so be.
When your patients say this,there's a chance that they're
not lying.
There's a chance that they'retelling the truth.
Speaker 1 (23:47):
Okay, so that one was confirmed.
So the next one is I'm onlypositive for cannabis because my
buddy was smoking and I wasnext to him.
So the reason I bring this upis my understanding is the cup
test, the immunoassay.
You need more drug in yoursystem to test positive, and
(24:08):
with the confirmatory testing,the chromatography spectrometry,
it's so much more sensitivethat you can detect nanogram per
deciliter levels.
So my assumption has been that,yeah, your confirmatory testing
is sensitive enough that thisone's plausible.
Speaker 2 (24:25):
But you tell me the typical concentration cutoff for
an amino acid might be 500nanograms per mil or even 1,000
on the bottom end.
Below that it just isn'tsensitive enough to pick it up,
whereas chromatography can getdown to 20 nanograms per mil 5
nanograms per mil for sometargets.
We can do 2 nanograms per milfor fentanyl Extremely low
(24:46):
concentrations.
That being said, the secondhandmarijuana smoke myth it's
indeterminate.
I cannot confirm or deny.
I do know that we have tried alot of in-lab reproducible
studies of going to concerts,going to friends' houses, going
to things and giving urine thenext day.
(25:07):
I myself went to a Wu-Tang Clanconcert a few years back at the
Conger Pavilion in a thick,thick cloud of cannabis smoke,
along with a friend of mineneither of us smoke and gave
urine for the next two days.
It was clean.
So I can't tell for sure, but Ithink that one that secondhand
smoke one might be busted.
Speaker 1 (25:27):
I'll share a personal anecdote, since you shared one.
We love to snowboard, my wife,my daughter and I and we go up
to South Lake Tahoe and ourpreferred resort is Heavenly and
.
Heavenly has a gondola and therewas a fire I think it was in
the 90s where someone threw acigarette out of the gondola and
(25:49):
it lit part of the mountain onfire.
And there's actually a run atHeavenly called the Burn where
you can snowboard the burn scarand as a result, they have made
the gondola basicallyimpenetrable so nobody can throw
a cigarette out.
So I don't know, six, sevenyears ago we go to go down the
mountain for the day and go homeand the gondola doors open and
(26:10):
we walk in and we areimmediately aware that someone
hotboxed the gondola on the rideup and it's an 11 minute ride.
So they were smoking cannabisin this enclosed, very small,
probably the size of a car cabinspace for 11 minutes and we
tried to quickly get out of thegondola and the doors of, of
course, closed and I do not usecannabis and man, I was sick as
(26:35):
a dog the rest of the day.
My poor daughter was actingweird and my wife and I were
joking like I think we wouldhave tested positive on your
drug test afterwards.
We actually didn't go test, butI think what I would say is it
probably is dependent on howclose you are to the source,
would say, is it probably isdependent on how close you are
(26:56):
to the source, how big theairspace around you is and the
duration of exposure.
So I would argue in a largeconcert hall there's probably
enough air that it diluted.
But I would be very curious.
Let's say somebody went on along car ride with someone who
was smoking, with the windowsrolled up.
There's probably enoughexposure there that a person
could test positive.
So I'm going to say that themyth is plausible but not
(27:17):
confirmed.
So you guys do very sensitivetesting.
I've had patients test positiveat the three nanograms per
milliliter level and it's reallyhard to know what to do with
because it would be a negativeon an immuno assay.
And usually what I tell them?
Because they'll say let's saythey test positive for cocaine.
(27:37):
I'll tell them I totally hearyou that you don't use cocaine
but you were exposed to it.
And I hear all sorts of storiesin addiction medicine.
You and I've talked about thataddiction is a very devastating
disease and people are dishonestwhen they're trying to conceal
their addiction.
But this is a story one of mypatients told me.
So he goes on a date, meets anew girl, they kiss, nothing
(28:03):
happens.
The relationship goes nowhere.
And then the next week he waspositive for cocaine.
So he was a pain patient and hewas on pain meds and when his
urine drug test came up abnormal, the pain folks appropriately
said whoa, whoa, whoa, you're ona controlled substance.
You got to go see addictionmedicine and essentially what I
was able to get from him is thathe was able to learn that this
(28:25):
particular woman did have acocaine addiction and,
interestingly, when he kissedher his mouth went numb.
And if you think about it, weactually use cocaine in ear,
nose and throat surgeriesbecause it's a local anesthetic
and it's a vasoconstrictor, soit tightens up the blood vessels
.
And they actually used to sell150 years ago cocaine lozenges
(28:48):
for dental pain.
And his level of his cocainetest was like five my patients
who use cocaine it'll be like athousand.
So I actually believed him andhe had severed the relationship
and all of his subsequent testshave been negative.
So have you heard of a caselike that or something like an
(29:09):
exposure like that?
Speaker 2 (29:11):
Quite frequently, quite frequently, and it sounds
very plausible to me, given thecircumstances I remember reading
about.
The first use of anesthetic wasa cocanization of a dog.
They put a I think it was anepidural catheter with cocaine
in a dog and his hind legs wentcompletely numb.
We use Novocaine, bupivacaine.
These canes are all sort of inthe same family.
What do we do in thosesituations?
(29:32):
So first the lab is going totell the referring provider what
they found in the specimen,right, and I think that's a
fundamental baselineacknowledgement that we all need
to understand.
It was in the specimen.
Now, it might not have beenthat patient's urine, it might
have been contaminated, it mighthave been switched with another
(29:54):
patient and the patient mighthave seriously, unwittingly
consumed this, like this patientof yours did.
But we don't know how to treatthe patient.
All we can do is tell you it'sthere, right and in the amount
that it's there, and confirmthat, yes, it's absolutely there
.
In fact we freeze some of theurine or saliva for 45 days so
that if you're going to see thatpatient for a follow-up visit
and they can test their results,we can pull it out of the
(30:15):
freezer and run it again.
So we want to make really surethat we've got the right
specimen and the right results.
The things I hear all the time.
I don't hear cocaine that often.
Although we tested a woman whocame up positive for cocaine and
she came up positive forcocaine twice, even when she
knew she was being tested shetested positive for cocaine
again.
Turns out she was drinking atea, some South American,
(30:36):
brazilian rainforest tea thatshe claims had cocaine in it.
She stopped taking the tea.
Her results went negative.
So that certainly is plausible.
That's possible no-transcript.
Speaker 1 (31:21):
And then one question .
So I tell the patients in theoffice we do not do forensic
collections, like I don't watchyou pee, we don't do a chain of
evidence.
But I do my best in sayingpatient go in, I will take it
out of the container that youput it in myself.
But yes, a person couldabsolutely switch a specimen and
(31:43):
sometimes people will say thatis not my test and I say, ok, we
will retest you.
But I do have one question.
We've talked about the factthat these point-of-care cup
tests, the immunoassay, it's allabout shape.
So you can't have falsepositives and negatives In the
confirmatory testing, thechromatography, mass
spectrometry.
Does that technology ever havefalse positives?
(32:04):
And negatives.
Speaker 2 (32:08):
Never, but almost, is the key word in there.
It is extremely rare, but onecase that comes to mind is the
fentanyl acid that we purchaseis highly volatile and it gets
too old.
They'll degrade to regularfentanyl.
So we had an incident severalyears ago where everyone that
(32:28):
day was positive for fentanyl invery small amounts and we shut
down the machine that came upwith this result it hopscotch to
a new machine.
It was a real problem forseveral days till we troubleshot
it and talked to themanufacturers and found that out
.
So in that situation, althoughextremely rare, it's because
this one reagent wasn't storedat the right temperature for a
(32:50):
period of time.
It does happen and if youbelieve this patient, they've
got a clean record up until now.
You know their circumstances.
Retest them, retest them with anew lab, retest them in a
different fashion to justconfirm those findings, because
I would say LC-MS is 99.99%accurate.
(33:10):
I really would.
These incidents are very rare.
They're usually from amalfunction that something like
that would happen.
But in this situation we savedthe frozen retain, we retested
it for all these patients andgot the correct results out
within a matter of days.
Speaker 1 (33:25):
Yeah.
And then just to clarify LCMS isthe acronym for liquid
chromatography, massspectrometry.
We love our acronyms inmedicine.
Yeah, so what we actually do inthe office.
So let's say a person's a painpatient and you and I both know,
with opioids specifically,there's a pure opioid addiction.
There's pure pain and thenthere's a spectrum in between.
(33:47):
Or a pain patient has pain anda different addiction, like pain
and addiction, to say cocaine.
So let's say a patient comes in, they've got chronic back pain,
they've had three backsurgeries, they get put on, say,
methadone for pain, and if theyhave an abnormal test, like
they're positive for fentanyl orthey're positive for cocaine,
our practice's policy is toadvise the patient and retest
(34:12):
them and if they are stillpositive they come to addiction
medicine and then we spend thetime with the patient to figure
out what's going on.
And sometimes it's you knowit's.
Yeah, my roommate is usingfentanyl and there's drug
paraphernalia all over myapartment.
I had one of those and when hemoved out his urine drug test
turned clean.
Oh, I shouldn't use that.
I'm so sorry.
His drug test did not show anabnormal result.
(34:35):
There's a lot of stigma aroundurine drug testing.
I slipped.
I do not like the terms cleanand dirty, because that confers
judgment.
It is an abnormal test is whenthere's an unexpected result.
But yes, so coming back to mystory, this patient was on
methadone, kept testing positivefor fentanyl, told me the
roommate was really deep inaddiction.
(34:55):
I of course, offered to see theroommate.
No-transcript.
Speaker 2 (35:02):
Yeah, and that's rare but it is possible.
We don't make decisions here atthe lab on how to treat
patients, but it's a widespectrum of positions on in that
sort of situation.
Some have a black and whitepolicy, others go with their gut
, others are very lenient.
I see the whole spectrum, havesuch a great background of
(35:29):
training and you see patients inthe chronic pain space
anecdotally and you see a lot ofpatients in the substance space
and you see how they movetogether and go back and forth
and can you have a pain patientthat's also has a substance use
problem?
Speaker 1 (35:36):
yeah, absolutely, it's very common and it it
really puts you in a in a greatposition to to help these
patients yeah, the the painfolks were really grateful when
we joined the practice because,I mean, essentially their
options prior were we'll giveyou a warning, you've tested
abnormal again and basically youwere just going to be weaned
off your pain meds and sorry.
(35:58):
And so the way I describe thisto the patients is pain medicine
in 2025 has a really shortleash.
The years of scrutiny becauseof the opiate problem in America
.
Pain medicine is by the book.
Like the California MedicalBoard has exact guidelines.
Addiction medicine's different.
You come to see the addictiondoctor because you have a
(36:20):
problem and just the rules are alittle bit different.
Now, granted, I can't givesomeone hydrocodone who's
actively addicted to fentanyl.
I would put them on a differentthing, like Suboxone, or send
them to a methadone clinic.
But it's nice that the paindoctors can continue to focus on
the pain and then know that thepatient's other issues are
(36:41):
being managed, and we have a lotof patients that we co-manage
and sometimes addiction medicinemanages the meds and pain
medicine will only offerprocedures because the addiction
is too high risk, or sometimesit's.
We think this is probably anunexpected test result or the
patient totally owned it andwants to get counseling.
(37:01):
They really want to focus ontheir pain.
I think of one gentleman in ourpractice who is a lovely human
being horrible pain and acocaine addiction and he is
working so hard on his cocaineaddiction.
He slipped up once in sixmonths.
He's really trying, and so painmedicine says great, you're
trying, you're doing great,you're seeing addiction medicine
, we'll keep you on your painmeds.
And I actually think thatthere's a lot of value in having
(37:26):
pain and addiction in the samepractice.
Speaker 2 (37:33):
I only know my own clinical experience, but it's
been a really good fit In mypersonal philosophy.
I see lots of differentpractice styles and everyone
cancel lab work because thepatient had tested positive for
(37:53):
an illicit substance.
The patient was retested thatday and subsequently committed
suicide that night and ourfindings although we're doing
our job we're trying to getpatients safe led to the
provider making that decision tocease their pain medications or
cease their treatment or retest, and they knew they'd test
positive again and facerepercussions.
And those are heartbreaking,heartbreaking calls to get that.
(38:15):
This patient has given up hopeand had they been in a really
good treatment program for theother side of their pain, to
help with the psychological andaddictive issues, maybe their
outcomes would have beendifferent.
So I love what you're doing.
Speaker 1 (38:29):
Yeah, thank you.
So we're about at time, but I'mreally interested to hear what
you're working on at MD Labs asnext steps, new projects, what's
on your to-do list?
Speaker 2 (38:40):
What's on our to-do list In the drug testing world?
We are working on compoundsthat seem to be popping up all
over the country for differentburn providers in California,
xylazine, it's, as you mentioned, some of these exotic
benzodiazepines, some of theseexotic fentanyls, these exotic
nitazines that are analogs ofthe parent drugs.
(39:00):
In Texas there is a gas stationheroin that has Ah.
Taneptine?
Yeah, it's a French tricyclicantidepressant.
It's not only French.
They invented it years andyears ago and it's really not
regulated in the US.
Right now.
It's being sold for pain andfor antidepressant.
It's irritable bowel syndrome.
It's a real problem.
There are some deaths relatedto tyaneptine currently, so
(39:24):
we're developing an assay forthat, as well as its metabolite.
Can my office have that?
The test, the tyaneptine, thetyaneptine the drug or the test.
We don't want the drug, butwe'll take the test.
It's interesting you have notheard of it in California yet,
but it doesn't mean it won't behere quickly.
(39:44):
But yeah, it should becommercially available next 30
to 45 days.
Speaker 1 (39:46):
So I think this comes back to another part of how
your ability to generate testsfor new substances helps us.
We don't know if tyaneptine'shere, because we can't test for
it.
Speaker 2 (40:01):
It theoretically would trigger a tricyclic
antidepressant enzymeimmunoassay.
It's a sister molecule and itwould just be an unknown TCA.
But yeah, without the actualtarget compound, the LC-MS is
not looking for everything underthe sun.
It's looking for specifictargets.
So it has to know what to lookfor and yeah, that's a weakness
(40:22):
of that methodology is, if it'snot looking for it, it won't
find it.
Speaker 1 (40:26):
Yeah.
So I'm just going to ask andmaybe you're not the right
person to ask at MD Labs, but Iwould love, when you have
tyaneptine available, to be ableto test for it in our practice
In some ways, because thetesting that you offer us is so
much more sophisticated thananything else anyone's doing in
our region.
We are the canary in the coalmine, so the hospitals only run
(40:47):
the immunoassay tests.
So if you go up to the ER, youjust get a yes, no and it's only
the basic seven substances.
I think it's amphetamines,cannabis, alcohol,
benzodiazepines, opioids,barbiturates and, I think, PCP,
and that's it.
And that's one of the reasonsour patients say I'm going to
(41:07):
use isotonidazine because no onecan test for it and then I can
fake out my drug program.
So again, another utility towhat you do is you help us to
see what's the very tip of thespear coming into our community.
Speaker 2 (41:19):
Yeah, these patients can get very creative and some
have science backgrounds andknow what you're looking for.
So it is important to stay onthe cutting edge of this
technology, so we're doing ourbest to keep up.
The DEA informs us a year ortwo or three after a drug is
found.
They're not really asup-to-date as we'd like, so it's
a lot of word of mouth.
Labs talk to each other aboutwhat's going on in certain
(41:39):
regions, and hearing fromproviders like you who are so
close to the community, that'show labs know what to do and
what you need.
Speaker 1 (41:47):
So I have to say I am going to say thank you, because
I am a smarter human beingafter talking to you, and I will
be smarter with my patientsnext week in the office when I
explain urine drug testing tothem.
Speaker 2 (41:59):
I'm very happy to come out and be of service and
share the lab's perspective andwhat we can do with the whole
world, especially all theproviders that listen to your
show.
So thank you for letting me behere.
Speaker 1 (42:07):
Absolutely.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
(42:30):
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
(42:51):
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
Bye.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years, I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is on urine drugtesting.
(00:44):
This is an interview withMatthew Rutledge, who runs a lab
testing company called MD Labs.
Quick disclosure I have nofinancial ties to that company
except that we send specimensfrom our office to them.
Matthew and I discuss urinedrug testing in detail in this
episode, from the differenttypes of tests that are done to
(01:05):
common myths about urine drugtests, to how lab companies
develop tests for new substancesin the drug supply.
We covered urine drug testsback in the summer of 2023, but
this episode goes into a lotmore detail about urine drug
tests and I love Matthew'sperspective as someone who runs
a lab.
We had a great conversation andI learned a lot.
(01:26):
Here we go All right.
Well, good morning, so nice toconnect with you again.
Why don't you start by tellingus who you are and what you do?
Speaker 2 (01:37):
Oh, great to see you, dr Grover Casey.
My name is Matthew Rutledge.
I am one of the founders andmanaging partners of MD Labs.
We're a clinical laboratoryserving the United States and we
specialize in toxicology forsubstance use disorder patients,
toxicology for chronic opioidtherapy patients, a lot of
(01:58):
psychiatry, anyone who's taken adangerous drug that needs to be
monitored.
So that's really what we'vebeen doing for now 14 years.
So I know how I got've beendoing for now 14 years.
Speaker 1 (02:05):
So I know how I got into my career.
How did you get into yourcareer?
Speaker 2 (02:10):
Oh, wow, I talk to a lot of teenagers these days.
My kids just went throughcollege about what they want to
be when they grow up.
And your path finds you andmine found me.
I was pre-med, did pretty wellon my scores and tests and
things and went through thepre-med program in college, got
a degree in chemistry, butchanged my career path when I
(02:31):
met a surgical device rep andsaw what he did, came into the
OR and saved the day with hisbox of tools and steel plates
and helping the doctor put awoman's face back together after
a procedure and I was soimpressed by this guy and I was
pretty handy myself that Ipivoted towards that career.
(02:51):
And in that space I was workingwith a lot of interventional
pain physicians and saw this iswhat the late 2000s and early
2010s we were really seeing therise of the opioid epidemic and
the need for clinical labtesting to determine if patients
are taking what they claimthey're taking and keep them
(03:11):
safe, keep the community safe.
And it was an underservedcommunity in the state of Nevada
and I knew a lot of physiciansthere who needed it.
We're sending things all overthe country and talked about my
background.
I got my degree in chemistryran part of my organic chem lab
in college, coupled up with mypartner, dennis, who's the other
founder, his degrees inbusiness and through all those
(03:34):
careers, we ended up starting upa lab, a mom and pop laboratory
, in Nevada.
With the help of some geniusPhDs and having come from the
space of the provider side,being in the operating room with
doctors talking about what theyneed, what they care about we
really built the lab based onwhat our referring providers
needed, not, like a lot of labs,build their philosophy on what
(03:55):
they can do.
So they'll push out 10 pages ofdata because they can, because
this is incredible data, butmaybe you can share.
What do you look for in a labtest and lab results when
they're being sent your way?
Because that's how we built ourcompany and our model.
Speaker 1 (04:13):
So there's so much dogma in medicine and it's
interesting there oftentimes arelab tests that we order that we
don't necessarily know what todo with, because this is what we
always do like oh gosh, thepatient has abdominal pain.
We always get a completemetabolic panel and then
(04:36):
sometimes physicians get reallystuck on what if the number says
one thing and the patientdoesn't feel badly or
differently?
Do we treat the number or do wetreat the patient?
And that's an ongoing debate inmedicine is why do we order
what we order and what do we dowith the results?
And do we treat the number orthe patient?
And I think the answer is youorder what you need to order and
(05:00):
you have to know what you'regoing to do with the results
abnormal or normal and then it'sreally weaving the patient and
the results together when makingyour decisions.
And in our world of addictionmedicine, the drug supply
changes week to week and it'sreally been wow.
This week our patients aretalking about xylosine and three
(05:24):
weeks ago they were talkingabout isotonitazine, which is
one of these opioids no one'sever heard of.
I didn't know there werenitazine opioids, but
isotonitazine is one of them.
So I think for me and mycolleague, the very lovely and
beautiful Dr Reb Close, whohappens to be my spouse.
We are just trying to see whatour patients are getting, simply
(05:45):
because it changes what we dowith their meds.
And it's largely around opioids, because suboxone,
buprenorphine, subutex requiresa period of not taking another
opioid before you start it.
So let's say a person's takinggood old-fashioned heroin
Heroin's gone, but heroin youhad to wait for about 12 hours
(06:10):
before you took your Suboxone orSubutex or Buprenorphine so you
wouldn't go into withdrawal.
And let's say somebody is on adrug and they wait the 12 hours
and then they take that med andthey feel horrible.
Well, it's not heroin and wewant to know what it is, because
if the next patient has thesame experience we can then test
them, see a pattern and thencounsel our patients going
(06:30):
forward.
Or another example is one of DrClose's patients was on some
weird benzo called bromazolamthat no one's ever heard of, and
he started developing psychosis, he was hallucinating.
And then she had another onewho had that same experience.
And again, once we recognizethe pattern we can counsel our
patients and then inform thecommunity around us.
So very long answer to say we'dlove to know what our patients
(06:55):
are getting, so we can linktheir symptoms to what they test
positive for and thenunderstand to be able to counsel
our patients going forward andthen make decisions based on
what they're on.
Like if somebody's onisotonitazine and it turns out
it doesn't interact well withsuboxone or subutex or
buprenorphine, we do thingsdifferently.
Hopefully that makes sense.
Speaker 2 (07:16):
It absolutely does and it speaks to the vigilance
of your practice and theengagement with the community.
So many of the illicit drugsthat we see, or things off-label
, are very much regionalizedParts of the country where this
drug is a problem, parts of thecountry where that drug is a
problem, and understandingwhat's a problem in your area
and what your patients are doingand what the local drug dealers
(07:38):
got in stock in recent monthsis a huge part of solving the
issue, making the patients awareof the risks they're putting
themselves out and helping themget off the specific medications
, because each medication hasits own peculiarities to it.
Speaker 1 (07:51):
So I think you and I had talked yesterday about level
setting for everyone, thedifferent types of drug tests,
how they work, their pros andcons.
So I'm going to try to be funnyhere.
Let's pretend I'm you incollege, I'm a pre-med and you
need to explain to me when I goto Rite Aid and buy the little
cup drug test, what type of testis that, how does it work and
(08:12):
does it have false, positivesand negatives?
Speaker 2 (08:15):
This I explain a lot.
It is a hit at dinner partiesbecause there are so many
nuances to drug testingcomplications.
So you mentioned the cup thatyou can get at a drugstore.
That cup has little test stripsin it that are very similar in
their activity to a pregnancytest.
They're typically an enzymereaction where if a type of drug
(08:36):
that the enzyme is sensitive to, if it's presented with that,
it will cause a color change.
So these enzymes can besensitive to heat and to age and
to those things.
So if it's been on the shelf atCVS or in the trunk of a hot
car or frozen it may affect howit works.
You might get false positives.
You're also going to get falsepositives and false negatives if
(09:01):
it's a similar drug to what thepaper is sensitive to.
Paper's not that smart, thatenzyme's not that smart.
So a good example ismethamphetamine, the most
commonly abused drug in thiscountry per the DEA.
There is a real similar sistermolecule in Vick's nasal spray.
That's non-euphoric, doesn'tget you high, but it is a
(09:22):
different version ofmethamphetamine.
It will trick that cup intothinking that you are taking
crystal meth and it turns outabout one out of every 25
patients that test positive atour laboratory is actually on
Vicks nasal spray because it isso common.
So the cups aren't very smartand they're prone to errors.
They're prone to missing drugs.
They're prone to being anunguided missile, as they say.
(09:45):
But they're readily available,they give you results in 10
minutes and they can be veryhelpful to a lot of practices.
If you want to write aprescription today and check, at
least cover your bases forchecking the patient.
They're a great, cheap way toget lab testing done in office.
Speaker 1 (09:59):
Yeah, the way I explain them to my patients and
I believe this is called animmunoassay test is it's
essentially looking at shape,right?
So if something is shaped likemorphine, that little chemical
reaction will occur and it'lllight up as a positive right or
similar.
Like you were saying, aroundamphetamines, if it's shaped
(10:22):
like an amphetamine it will comeup as positive.
And it turns out there's anantidepressant called selegiline
which is structurally verysimilar to an amphetamine and
one of my patients wasincarcerated when he was on
selegiline and his point of careurine cup immunoassay test was
positive for amphetaminesbecause of his selegiline.
I'm a former ER doc.
(10:42):
We love to keep things simple.
The way I think of these testsis it's about shape and that we
try to use the little chemicalassay in the paper to recognize
the shape of the drug.
Speaker 2 (10:51):
We're trying to test, for it's an enzyme with an
antigen.
They're bound together.
The drug comes in, displacesthe enzyme.
That free enzyme causes a colorchange, got it?
So with the test strip cups youcan see it with your eyes.
The next step up in complexityis to have a machine do the
analysis for you.
It's a lot more sensitive, alot more reliable, calibrated.
So that's enzyme immunoassay isa lab analyzer technique that
(11:14):
we use that is more reliable,can test for a broader number of
things, gets calibrated everysingle day.
So you know that it's moreaccurate and reliable.
But the next step up incomplexity is to go to gas
chromatography or liquidchromatography, which is the
high complexity, extremelyreliable technique that most
laboratories employ.
Speaker 1 (11:35):
So again, dumb former ER doc question gas and liquid
are different.
Last time I checked my collegephysics courses.
What is the difference betweengas chromatography and liquid
chromatography?
Speaker 2 (11:48):
It is the state at which the specimen is entered
into the machine.
If you're using all thespecimens that we see typically
come in as liquid blood, urine,saliva, a gas chromatography you
have to vaporize that substanceto get it to travel through the
machine.
The chromatography chromatogramchromo meaning light.
(12:09):
It's like a prism thatseparates light into all of its
colors.
This separates all thecompounds in that specimen into
their components and they comeout of the back end of this
chromatography system separately.
So you concentrate them andseparate them.
To identify all of thecompounds that are in the
specimen and that's the same forgas or liquid chromatography
(12:30):
you then run them through a massspectrometer that measures the
molecular weights of thedifferent compounds.
So if you know the retentiontime they call it how long it
took to go through that column,because some drugs are fast,
some drugs are slow we know whothey are and then you measure
the molecular weight.
You have two factors that canbe used to identify the unknown
(12:51):
compound Interesting.
Speaker 1 (12:53):
So let me make sure again.
Simple ER doc brain.
I got to simplify this.
So for me as a doctor, theimmunoassay is the one I can do
in the office and if there's anunexpected result, I'd want to
send it for the confirmatorytest, which is the
chromatography.
Mass spectrometry and theliquid or gas chromatography is
the process of separating what'sin the specimen into its
(13:15):
individual compounds, and thenthe mass spectrometry is
basically where you analyze themolecular weight of each of
those compounds to identify whatit is.
Speaker 2 (13:25):
Gas chromatography and liquid chromatography are
similar theories behind both.
Liquid is just easier to do.
It can be done more quickly,more comprehensive, with less
sample prep.
It's hard to get blood tovaporize.
It's much easier to keep it asliquid form Well hard in a lab
under controlled conditionswithout destroying the
components of it.
Speaker 1 (13:43):
Harden a lab under control conditions without
destroying the components of it.
So how do you actually create atest for a novel substance?
So I'm actually asking yourcompany and, just so everybody
knows, you don't pay me to doanything.
I don't own anything with MDLabs.
You guys provide service to usand so that's how we connected.
But I've asked you, I want alab assay for isotenidazine,
(14:04):
which is this weird opioid thatwe're hearing about.
What's the actual process likethere?
Speaker 2 (14:09):
chains need to develop a test that will get the
job done.
So if the job is finding, let'ssay, isonitizine in a specimen,
(14:35):
we need to create that method.
It's called a lab-developedtest.
If there's not a commerciallyavailable test on the market, we
need to make one and show thatit works.
In this particular situation,we would need to find a standard
somewhere, find high and lowcontrol calibrators for this
target compound.
Someone's got to be making itsomewhere, order it in, and then
we have to demonstrate that wecan reliably and accurately
(14:57):
detect this drug in hundreds ofspecimens over several days on
several pieces of machinery.
So we go through it's calledthe validation process and
that's how you develop a newtest and if it works and it's
reliable, you'd test it oninpatient specimens and it's
your lab developed test only tobe used in your laboratory.
Speaker 1 (15:17):
So I'm going to try to be funny here with how I ask
my question.
So you must need a drug dealer,because you're basically
analyzing controlled substancesand illicit substances.
Like who's your dealer?
Speaker 2 (15:33):
Ceruleant is a big drug dealer in the United States
who's Ceruleant?
Sorry?
And they're a laboratory thatcreates these.
Now they don't send them to usin any snortable or usable form.
They're all denatured inmethanol.
So the lab staff, the risk ofabuse is very, very low.
But yeah, we buy a lot of drugs.
Speaker 1 (15:56):
Interesting.
So isotonitazine, since I keepfixating on that, one is again.
It's this novel opioid that noone's ever heard of from this
class of opioids callednitazines, and I've tried to
research it and I can't findmuch, except there are loads of
pharmaceutical companies in Asiathat are willing to ship it to
me.
So for a novel substance likethis, are you engaging these
(16:19):
pharmaceutical companiesoverseas?
Speaker 2 (16:22):
We are indirectly Cerulean orders a lot of their
stuff overseas from China andEurope based on these tariffs
that we're getting charged.
So in that process we need tobe made aware of this target
drug out there that's being used.
Xylazine was one of the recentfive, six years that we're all
made aware of and there's a needto test for it.
(16:43):
There's an issue there.
It's going to be a problem forour patients that we're all made
aware of and there's a need totest for it.
There's an issue there.
You know it's gonna be aproblem for our patients that
we're seeing.
So we are made aware.
We order in some specimens, somesample stock.
We create our ownconcentrations of known
specimens and run them and if wecan develop a method and bring
it to market, it's usually a twoto four month process depending
(17:04):
on how complicated that drug isto detect.
We also run metabolites of alot of these compounds.
Why is it important to checkfor a metabolite of a drug?
Well, a lot of times we want tomake sure it's passed through
the patient's body.
If it's a prescription drug, alot of patients will pill shave
the pure mother compound into acup so they can go sell the
(17:28):
mother product, so being able tosee that it went through their
body is vital.
And for things like oxycodoneand morphine and heroin and the
benzos, we check for metabolitesof all those to avoid pill
shaving.
Speaker 1 (17:42):
So let's just again simple ER doc brain needs to
understand this.
So the idea is is that you wantto test for the native compound
, the substance and also themetabolite, to show that the
person's taking it rather thanthey're just putting a little
bit of their pill in the cup.
So for cocaine, which isobviously not prescribed, the
(18:04):
metabolite is benzoylcogonine.
So on your test, which I lookedat this week, my patient tested
positive for cocaine andbenzoylcogonine.
Or in the case of buprenorphine, I prescribed them
buprenorphine and the metaboliteis nor-buprenorphine, so the
patient would test positive forboth of them.
Speaker 2 (18:23):
Yeah, it's important to have that information for a
clinical patient.
So with developing an assay, wedevelop it not just for the
parent drug but for themetabolite when we can, and
report those both reliably.
Speaker 1 (18:41):
So I am pulling up a saved photo on my phone which is
adulterants used to preventdetection of drugs in urine
samples.
So ammonia, bleach, powderedurine, urinate vinegar, visine,
eyedrops these are all thingsthat people can put in urine
drug tests.
Do those affect both theimmunoassay and the liquid
chromatography mass spectrometry?
Speaker 2 (19:00):
They most certainly can.
It's important.
We've seen it all in our 14years and millions of specimens.
If you open up the cup and itsmells like vinegar, it's highly
likely that they added vinegarand the technicians make a note
of that.
If you see white powderfloating in specimens, if you
open up the cup and it smellslike vinegar, it's highly likely
that they added vinegar and thetechnicians make a note of that
.
If you see white powderfloating in the cup, or soap
bubbles or it's blue blue can befrom a patient taking certain
(19:22):
medications, but it also can betoilet water that they've
scooped out of the tank of thetoilet.
So we use a lot of non not veryscientific indicators to detect
adulteration and things.
We also run validity testing onthe specimen.
We check for oxidants, like yousaid, because they can cloud
the machine.
We check for dilution.
(19:43):
Your body secretes creatinineat known levels and if that
level's out of the normal range,it's highly indicative that the
patient has watered thespecimen down.
We counteract that by detectingthe creatinine and then
normalizing the specimenconcentrations.
To tell the doctor, let's say,we detected 10 nanograms per mil
(20:05):
of this target, which normallywould be under the presumptive
cutoff, but we normalized itbecause it was watered down and,
doctor, this patient's actuallyat this concentration here.
So there are lots of ways tocombat that.
Specific gravity of the urineis also detected, or the saliva,
so the lab has a lot offail-safes in place.
Some labs are using DNAtechnology to get a known
(20:28):
specimen of DNA from the patientand then check the urines over
time to make sure that they'vegot some of that same patient's
DNA.
Speaker 1 (20:34):
So just want to again make sure I get this right.
I was under the impression thatthese adulterants only messed
with the immunoassay cup tests,but you're saying they can mess
with the confirmatorychromatography mass spectrometry
test too.
Speaker 2 (20:49):
Well, each adulterant has a different impact.
Speaker 1 (20:52):
That's true, okay.
Speaker 2 (20:53):
So they all have different impacts on things.
If someone adds bleach to theirspecimen, is it going to remove
all of the fentanyl?
No, we're very sensitive tofentanyl testing, but dilution
could take it down to a levelthat's below our reliable cutoff
.
So that's why we need to detect.
We use four lab tests to detectadulteration, as well as visual
and experienced scientistslooking at specimens.
Speaker 1 (21:16):
So another silly question here.
So my patients teach me so muchabout the illicit drug industry
.
One of my patients will tell melike what their dealer's
selling, and a lot of mypatients in recovery will tell
me how they used to cheat ontheir urine drug tests.
Speaker 2 (21:44):
A lot of my patients in recovery will tell me how
they used to cheat on theirurine drug tests.
Do you have an advisory boardof people in recovery or pain
patients that tell you what theydid when they were using or
what their tricks of the tradewere to pass urine drug tests
base?
But we have experts that webring in.
We've got law enforcementexperts that we work with.
We have a lot of addictionrecovery facilities are run by
recovering people.
We talk to patients as much aswe can and visit and speak with
actual patients.
So we are constantly solicitingthat advice and expertise.
(22:08):
There's a lot of this publishedin literature.
The DEA puts out advisories.
The NIFLIS group talks aboutwhat drugs are currently out
there, how people are avoidingthem, how people are trying to
fake drug tests.
It's the constant battle.
Drug addiction is very powerfuland it really puts people into
a space of doing whatever theycan to survive.
(22:29):
It's that level of effort thatgoes into this sometimes.
Speaker 1 (22:34):
Yeah, so you and I had talked about doing a little
bit of myth, busting aroundurine drug tests.
So let's take a myth that Ithink I know the answer to, but
I'm very curious as to what theexpert here says.
Talk to me about poppy seeds inurine drug tests.
Speaker 2 (22:50):
Talk to me about poppy seeds and urine drug tests
.
Poppy seeds and urine drugtests.
This myth that if you eat apoppy seed muffin in the morning
you might test positive foropiates later on in the day is
not a myth.
There are certain strains outthere of poppy seed that do
contain opiates in them.
We've run a lot of tests hereat the lab and it depends on
(23:13):
where the manufacturer, wherethe bakery, gets their poppy
seeds, because the ones that areon the shelf at the grocery
store have no opium in them fromwhat we can tell.
But my favorite muffin they'vegot plenty of opium in their
poppy seed muffins because wehad the lab staff treated them
all the muffins and bagels andthen took urines later in the
day and a lot of them testedpositive, especially the lighter
(23:34):
weight, smaller people that hada lot more per body mass index
intake of the poppy seeds.
But yeah, it happens, so be.
When your patients say this,there's a chance that they're
not lying.
There's a chance that they'retelling the truth.
Speaker 1 (23:47):
Okay, so that one was confirmed.
So the next one is I'm onlypositive for cannabis because my
buddy was smoking and I wasnext to him.
So the reason I bring this upis my understanding is the cup
test, the immunoassay.
You need more drug in yoursystem to test positive, and
(24:08):
with the confirmatory testing,the chromatography spectrometry,
it's so much more sensitivethat you can detect nanogram per
deciliter levels.
So my assumption has been that,yeah, your confirmatory testing
is sensitive enough that thisone's plausible.
Speaker 2 (24:25):
But you tell me the typical concentration cutoff for
an amino acid might be 500nanograms per mil or even 1,000
on the bottom end.
Below that it just isn'tsensitive enough to pick it up,
whereas chromatography can getdown to 20 nanograms per mil 5
nanograms per mil for sometargets.
We can do 2 nanograms per milfor fentanyl Extremely low
(24:46):
concentrations.
That being said, the secondhandmarijuana smoke myth it's
indeterminate.
I cannot confirm or deny.
I do know that we have tried alot of in-lab reproducible
studies of going to concerts,going to friends' houses, going
to things and giving urine thenext day.
(25:07):
I myself went to a Wu-Tang Clanconcert a few years back at the
Conger Pavilion in a thick,thick cloud of cannabis smoke,
along with a friend of mineneither of us smoke and gave
urine for the next two days.
It was clean.
So I can't tell for sure, but Ithink that one that secondhand
smoke one might be busted.
Speaker 1 (25:27):
I'll share a personal anecdote, since you shared one.
We love to snowboard, my wife,my daughter and I and we go up
to South Lake Tahoe and ourpreferred resort is Heavenly and
.
Heavenly has a gondola and therewas a fire I think it was in
the 90s where someone threw acigarette out of the gondola and
(25:49):
it lit part of the mountain onfire.
And there's actually a run atHeavenly called the Burn where
you can snowboard the burn scarand as a result, they have made
the gondola basicallyimpenetrable so nobody can throw
a cigarette out.
So I don't know, six, sevenyears ago we go to go down the
mountain for the day and go homeand the gondola doors open and
(26:10):
we walk in and we areimmediately aware that someone
hotboxed the gondola on the rideup and it's an 11 minute ride.
So they were smoking cannabisin this enclosed, very small,
probably the size of a car cabinspace for 11 minutes and we
tried to quickly get out of thegondola and the doors of, of
course, closed and I do not usecannabis and man, I was sick as
(26:35):
a dog the rest of the day.
My poor daughter was actingweird and my wife and I were
joking like I think we wouldhave tested positive on your
drug test afterwards.
We actually didn't go test, butI think what I would say is it
probably is dependent on howclose you are to the source,
would say, is it probably isdependent on how close you are
(26:56):
to the source, how big theairspace around you is and the
duration of exposure.
So I would argue in a largeconcert hall there's probably
enough air that it diluted.
But I would be very curious.
Let's say somebody went on along car ride with someone who
was smoking, with the windowsrolled up.
There's probably enoughexposure there that a person
could test positive.
So I'm going to say that themyth is plausible but not
(27:17):
confirmed.
So you guys do very sensitivetesting.
I've had patients test positiveat the three nanograms per
milliliter level and it's reallyhard to know what to do with
because it would be a negativeon an immuno assay.
And usually what I tell them?
Because they'll say let's saythey test positive for cocaine.
(27:37):
I'll tell them I totally hearyou that you don't use cocaine
but you were exposed to it.
And I hear all sorts of storiesin addiction medicine.
You and I've talked about thataddiction is a very devastating
disease and people are dishonestwhen they're trying to conceal
their addiction.
But this is a story one of mypatients told me.
So he goes on a date, meets anew girl, they kiss, nothing
(28:03):
happens.
The relationship goes nowhere.
And then the next week he waspositive for cocaine.
So he was a pain patient and hewas on pain meds and when his
urine drug test came up abnormal, the pain folks appropriately
said whoa, whoa, whoa, you're ona controlled substance.
You got to go see addictionmedicine and essentially what I
was able to get from him is thathe was able to learn that this
(28:25):
particular woman did have acocaine addiction and,
interestingly, when he kissedher his mouth went numb.
And if you think about it, weactually use cocaine in ear,
nose and throat surgeriesbecause it's a local anesthetic
and it's a vasoconstrictor, soit tightens up the blood vessels
.
And they actually used to sell150 years ago cocaine lozenges
(28:48):
for dental pain.
And his level of his cocainetest was like five my patients
who use cocaine it'll be like athousand.
So I actually believed him andhe had severed the relationship
and all of his subsequent testshave been negative.
So have you heard of a caselike that or something like an
(29:09):
exposure like that?
Speaker 2 (29:11):
Quite frequently, quite frequently, and it sounds
very plausible to me, given thecircumstances I remember reading
about.
The first use of anesthetic wasa cocanization of a dog.
They put a I think it was anepidural catheter with cocaine
in a dog and his hind legs wentcompletely numb.
We use Novocaine, bupivacaine.
These canes are all sort of inthe same family.
What do we do in thosesituations?
(29:32):
So first the lab is going totell the referring provider what
they found in the specimen,right, and I think that's a
fundamental baselineacknowledgement that we all need
to understand.
It was in the specimen.
Now, it might not have beenthat patient's urine, it might
have been contaminated, it mighthave been switched with another
(29:54):
patient and the patient mighthave seriously, unwittingly
consumed this, like this patientof yours did.
But we don't know how to treatthe patient.
All we can do is tell you it'sthere, right and in the amount
that it's there, and confirmthat, yes, it's absolutely there
.
In fact we freeze some of theurine or saliva for 45 days so
that if you're going to see thatpatient for a follow-up visit
and they can test their results,we can pull it out of the
(30:15):
freezer and run it again.
So we want to make really surethat we've got the right
specimen and the right results.
The things I hear all the time.
I don't hear cocaine that often.
Although we tested a woman whocame up positive for cocaine and
she came up positive forcocaine twice, even when she
knew she was being tested shetested positive for cocaine
again.
Turns out she was drinking atea, some South American,
(30:36):
brazilian rainforest tea thatshe claims had cocaine in it.
She stopped taking the tea.
Her results went negative.
So that certainly is plausible.
That's possible no-transcript.
Speaker 1 (31:21):
And then one question .
So I tell the patients in theoffice we do not do forensic
collections, like I don't watchyou pee, we don't do a chain of
evidence.
But I do my best in sayingpatient go in, I will take it
out of the container that youput it in myself.
But yes, a person couldabsolutely switch a specimen and
(31:43):
sometimes people will say thatis not my test and I say, ok, we
will retest you.
But I do have one question.
We've talked about the factthat these point-of-care cup
tests, the immunoassay, it's allabout shape.
So you can't have falsepositives and negatives In the
confirmatory testing, thechromatography, mass
spectrometry.
Does that technology ever havefalse positives?
(32:04):
And negatives.
Speaker 2 (32:08):
Never, but almost, is the key word in there.
It is extremely rare, but onecase that comes to mind is the
fentanyl acid that we purchaseis highly volatile and it gets
too old.
They'll degrade to regularfentanyl.
So we had an incident severalyears ago where everyone that
(32:28):
day was positive for fentanyl invery small amounts and we shut
down the machine that came upwith this result it hopscotch to
a new machine.
It was a real problem forseveral days till we troubleshot
it and talked to themanufacturers and found that out
.
So in that situation, althoughextremely rare, it's because
this one reagent wasn't storedat the right temperature for a
(32:50):
period of time.
It does happen and if youbelieve this patient, they've
got a clean record up until now.
You know their circumstances.
Retest them, retest them with anew lab, retest them in a
different fashion to justconfirm those findings, because
I would say LC-MS is 99.99%accurate.
(33:10):
I really would.
These incidents are very rare.
They're usually from amalfunction that something like
that would happen.
But in this situation we savedthe frozen retain, we retested
it for all these patients andgot the correct results out
within a matter of days.
Speaker 1 (33:25):
Yeah.
And then just to clarify LCMS isthe acronym for liquid
chromatography, massspectrometry.
We love our acronyms inmedicine.
Yeah, so what we actually do inthe office.
So let's say a person's a painpatient and you and I both know,
with opioids specifically,there's a pure opioid addiction.
There's pure pain and thenthere's a spectrum in between.
(33:47):
Or a pain patient has pain anda different addiction, like pain
and addiction, to say cocaine.
So let's say a patient comes in, they've got chronic back pain,
they've had three backsurgeries, they get put on, say,
methadone for pain, and if theyhave an abnormal test, like
they're positive for fentanyl orthey're positive for cocaine,
our practice's policy is toadvise the patient and retest
(34:12):
them and if they are stillpositive they come to addiction
medicine and then we spend thetime with the patient to figure
out what's going on.
And sometimes it's you knowit's.
Yeah, my roommate is usingfentanyl and there's drug
paraphernalia all over myapartment.
I had one of those and when hemoved out his urine drug test
turned clean.
Oh, I shouldn't use that.
I'm so sorry.
His drug test did not show anabnormal result.
(34:35):
There's a lot of stigma aroundurine drug testing.
I slipped.
I do not like the terms cleanand dirty, because that confers
judgment.
It is an abnormal test is whenthere's an unexpected result.
But yes, so coming back to mystory, this patient was on
methadone, kept testing positivefor fentanyl, told me the
roommate was really deep inaddiction.
(34:55):
I of course, offered to see theroommate.
No-transcript.
Speaker 2 (35:02):
Yeah, and that's rare but it is possible.
We don't make decisions here atthe lab on how to treat
patients, but it's a widespectrum of positions on in that
sort of situation.
Some have a black and whitepolicy, others go with their gut
, others are very lenient.
I see the whole spectrum, havesuch a great background of
(35:29):
training and you see patients inthe chronic pain space
anecdotally and you see a lot ofpatients in the substance space
and you see how they movetogether and go back and forth
and can you have a pain patientthat's also has a substance use
problem?
Speaker 1 (35:36):
yeah, absolutely, it's very common and it it
really puts you in a in a greatposition to to help these
patients yeah, the the painfolks were really grateful when
we joined the practice because,I mean, essentially their
options prior were we'll giveyou a warning, you've tested
abnormal again and basically youwere just going to be weaned
off your pain meds and sorry.
(35:58):
And so the way I describe thisto the patients is pain medicine
in 2025 has a really shortleash.
The years of scrutiny becauseof the opiate problem in America
.
Pain medicine is by the book.
Like the California MedicalBoard has exact guidelines.
Addiction medicine's different.
You come to see the addictiondoctor because you have a
(36:20):
problem and just the rules are alittle bit different.
Now, granted, I can't givesomeone hydrocodone who's
actively addicted to fentanyl.
I would put them on a differentthing, like Suboxone, or send
them to a methadone clinic.
But it's nice that the paindoctors can continue to focus on
the pain and then know that thepatient's other issues are
(36:41):
being managed, and we have a lotof patients that we co-manage
and sometimes addiction medicinemanages the meds and pain
medicine will only offerprocedures because the addiction
is too high risk, or sometimesit's.
We think this is probably anunexpected test result or the
patient totally owned it andwants to get counseling.
(37:01):
They really want to focus ontheir pain.
I think of one gentleman in ourpractice who is a lovely human
being horrible pain and acocaine addiction and he is
working so hard on his cocaineaddiction.
He slipped up once in sixmonths.
He's really trying, and so painmedicine says great, you're
trying, you're doing great,you're seeing addiction medicine
, we'll keep you on your painmeds.
And I actually think thatthere's a lot of value in having
(37:26):
pain and addiction in the samepractice.
Speaker 2 (37:33):
I only know my own clinical experience, but it's
been a really good fit In mypersonal philosophy.
I see lots of differentpractice styles and everyone
cancel lab work because thepatient had tested positive for
(37:53):
an illicit substance.
The patient was retested thatday and subsequently committed
suicide that night and ourfindings although we're doing
our job we're trying to getpatients safe led to the
provider making that decision tocease their pain medications or
cease their treatment or retest, and they knew they'd test
positive again and facerepercussions.
And those are heartbreaking,heartbreaking calls to get that.
(38:15):
This patient has given up hopeand had they been in a really
good treatment program for theother side of their pain, to
help with the psychological andaddictive issues, maybe their
outcomes would have beendifferent.
So I love what you're doing.
Speaker 1 (38:29):
Yeah, thank you.
So we're about at time, but I'mreally interested to hear what
you're working on at MD Labs asnext steps, new projects, what's
on your to-do list?
Speaker 2 (38:40):
What's on our to-do list In the drug testing world?
We are working on compoundsthat seem to be popping up all
over the country for differentburn providers in California,
xylazine, it's, as you mentioned, some of these exotic
benzodiazepines, some of theseexotic fentanyls, these exotic
nitazines that are analogs ofthe parent drugs.
(39:00):
In Texas there is a gas stationheroin that has Ah.
Taneptine?
Yeah, it's a French tricyclicantidepressant.
It's not only French.
They invented it years andyears ago and it's really not
regulated in the US.
Right now.
It's being sold for pain andfor antidepressant.
It's irritable bowel syndrome.
It's a real problem.
There are some deaths relatedto tyaneptine currently, so
(39:24):
we're developing an assay forthat, as well as its metabolite.
Can my office have that?
The test, the tyaneptine, thetyaneptine the drug or the test.
We don't want the drug, butwe'll take the test.
It's interesting you have notheard of it in California yet,
but it doesn't mean it won't behere quickly.
(39:44):
But yeah, it should becommercially available next 30
to 45 days.
Speaker 1 (39:46):
So I think this comes back to another part of how
your ability to generate testsfor new substances helps us.
We don't know if tyaneptine'shere, because we can't test for
it.
Speaker 2 (40:01):
It theoretically would trigger a tricyclic
antidepressant enzymeimmunoassay.
It's a sister molecule and itwould just be an unknown TCA.
But yeah, without the actualtarget compound, the LC-MS is
not looking for everything underthe sun.
It's looking for specifictargets.
So it has to know what to lookfor and yeah, that's a weakness
(40:22):
of that methodology is, if it'snot looking for it, it won't
find it.
Speaker 1 (40:26):
Yeah.
So I'm just going to ask andmaybe you're not the right
person to ask at MD Labs, but Iwould love, when you have
tyaneptine available, to be ableto test for it in our practice
In some ways, because thetesting that you offer us is so
much more sophisticated thananything else anyone's doing in
our region.
We are the canary in the coalmine, so the hospitals only run
(40:47):
the immunoassay tests.
So if you go up to the ER, youjust get a yes, no and it's only
the basic seven substances.
I think it's amphetamines,cannabis, alcohol,
benzodiazepines, opioids,barbiturates and, I think, PCP,
and that's it.
And that's one of the reasonsour patients say I'm going to
(41:07):
use isotonidazine because no onecan test for it and then I can
fake out my drug program.
So again, another utility towhat you do is you help us to
see what's the very tip of thespear coming into our community.
Speaker 2 (41:19):
Yeah, these patients can get very creative and some
have science backgrounds andknow what you're looking for.
So it is important to stay onthe cutting edge of this
technology, so we're doing ourbest to keep up.
The DEA informs us a year ortwo or three after a drug is
found.
They're not really asup-to-date as we'd like, so it's
a lot of word of mouth.
Labs talk to each other aboutwhat's going on in certain
(41:39):
regions, and hearing fromproviders like you who are so
close to the community, that'show labs know what to do and
what you need.
Speaker 1 (41:47):
So I have to say I am going to say thank you, because
I am a smarter human beingafter talking to you, and I will
be smarter with my patientsnext week in the office when I
explain urine drug testing tothem.
Speaker 2 (41:59):
I'm very happy to come out and be of service and
share the lab's perspective andwhat we can do with the whole
world, especially all theproviders that listen to your
show.
So thank you for letting me behere.
Speaker 1 (42:07):
Absolutely.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
(42:30):
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
(42:51):
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
Bye.
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