Our activities was contacted through the Pain monitoring Centerregarding a patient who tested positive for cocaine metabolite in urine,but denied abuse. Because this population is receiving prescriptions forcontrolled narcotics because that pain, the physicians need to determine patientcompliance and also rule out abuse the street drugs because that continuedparticipation in the program. For this patient, the laboratory wasconsulted to distinguish whether the urine positivity was attributableto natural medication cross-reactivity or whether the patient wasdeceiving the clinic physicians. The patient was a 47-year-old female with a background of Wegenergranulomatosis and vasculitis. She had undergone substantial surgery,including resection that the frontal and nasal sinus cavity and septum,and was receiving aggressive analgesic management, including opioidanalgesics because that head pain related to her condition. It is the policy ofthe pains Management facility to test every patients on a arbitrarily basis threeto 4 times a year because that medication compliance and to exclude, abuse ofstreet drugs. The patience tested hopeful once before this episode forurine cocaine metabolite. On October 31, 2001, the patient"s urine tested hopeful forcocaine metabolite (qualitative, >300 g/L) through fluorescentpolarization immunoassay (FPIA; Abbott Laboratories), yet she deniedabuse within the past several months. Instead, she claimed passiveexposure to cocaine exhilaration from life in an apartment building where herupstairs neighbor was a "crack" addict. The patient submitteda second urine ~ above November 2, 2001, which was also positive byimmunoassay because that cocaine metabolite (qualitative, >300 g/Lcutoff). In ~ this particular time, the patient shown use of one herbalproduct, mugwort.

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Mugwort (Artemisia vulgaris) is a usual herb used in alternativemedicine. The is also known as typical artemisia, felon herb, St.John"s herb, chrysanthemum weed, and sailor"s tobacco and is aclose loved one of wormwood (Artemisia absinthium L.). Mugwort has a longhistory of folk tradition and use. Anglo-Saxon tribes believed that thearomatic mugwort was one of the nine spiritual herbs offered to the human being bythe god Woden. It was additionally used together a smell additive come beer before theintroduction the hops. Mugwort is taken into consideration a magical herb, with specialproperties to defend road-weary travelers versus exhaustion. TheRomans planted mugwort through roadsides, wherein it would be accessible topassersby to placed in your shoes to relieve aching feet. St. Man theBaptist was claimed to have worn a girdle that mugwort once he set out intothe wilderness. Several of the "magic" in mugwort is in itsreputed capability to induce prophetic and vivid dreams when the herb isplaced close to the bed or under the sleeper"s pillow. Today, mugwortleaf and also stem are provided medicinally as a bitter digestive tonic, uterinestimulant, menstrual regulator, and antirheumatic. Infusions room madewith 1 oz (28 g) of fresh sheet in 1 pint (473 mL) of boiling waterfor 5-10 min. Alcoholic extracts can likewise be ready by steeping thepowdered dried tree for several days in a 50:50 mixture (by volume) ofalcohol come water (1).
The patient"s medical professional contacted our activities questioningthe opportunity of immunoassay cross-reactivity v the herbal productand sent the patient"s mugwort come our activities for analysis. Atea to be brewed native the leaves and analyzed by FPIA ~ cooling toroom temperature. The tea was negative for amphetamine, phencyclidine,barbiturates, benzodiazepines, opiates, and cannabinoids at the standardcutoffs, but tested above linearity (>5000 g/L) for cocainemetabolite. Both the tea and also the patient"s urine (from October 31,2001) were sent to a local reference activities for gaschromatography--mass spectrometry (GC/MS) analysis. While us were wait for confirmation results, we derived mugwortfrom a neighborhood natural foodstuffs store controlled by a certified herbalist.Visual compare of the two mugwort specimens was significantlydifferent (Fig. 1). The patient"s product to be darker, an ext finelycrushed, and coated through a white, granular powder, whereas the mugwortobtained native the herbalist to be lighter in color, contained more wholeleaves and also flowers, and also did no seem to have the same coating the whitepowder. Tea native the mugwort obtained from the herbalist, ready in amanner similar to the of the patient"s mugwort, tested negativein all drug-of-abuse immunoassays, consisting of the assay for cocainemetabolite. The patient developed a 3rd urine, on November 13, 2001,that was likewise positive because that cocaine metabolite (qualitative, >300g/L by FPIA).
outcomes from the GC/MS evaluation confirmed the the patient"surine was positive for cocaine metabolite (qualitative, >150g/L), and also the tea do from the patient"s sample that mugwortwas positive for cocaine (qualitative, cutoff >150 g/L) andcocaine metabolite (qualitative, >150 g/L). The patience wasconfronted through the results and continued to refuse abuse. She did,however, send three succeeding urines that were an unfavorable for cocainemetabolite: ~ above November 28, 2001; December 12, 2001; and also January 8, 2002(qualitative, with the boosted prevalence of different medicine in America,clinicians are confronted with the difficulty of determining even if it is aparticular natural product could be responsible for test positive orwhether the patience is truly positive. Although finish interferenceprofiles have not to be adequately defined for most immunoassays, thewidespread use of herbals would argue versus significantcross-reactivity in routinely supplied immunoassays. This instance alsoemphasizes the need for GC/MS check in part clinical situationswhere abuse is suspected. Only through GC/MS evaluation were us able todefinitively establish that the patient"s mugwort contained actualcocaine. Return there was no definitive proof the the patientactually contaminated the mugwort through cocaine, the sample she producedand asserted to be the resource of her urine positivity was shown tocontain both cocaine and cocaine metabolite. Tea brewed from mugwortobtained native an herbalist did no test positive. This instance was clearlynot an natural cross-reactivity since the visibility of drug wasconfirmed through GC/MS. Someone added the drug to the patient"smugwort; even if it is it to be a friend, family members member, or the patient herselfhas not been established, but it is unlikely that she purchase thisproduct indigenous a legal distributor with cocaine top top it. Clinicians thusshould not underestimate the lengths that patients will require to evadedetection. Recommendation (1.) Hanrahan C. Mugwort. In: Krapp KM, ed. The Gale encyclopediaof alternative medicine. Farmington Hills, MI: Gale Group, 2000. Kelly Hickey, <1> Rania Seliem, <1> James Shields, <1> AlfredMcKee, <2> and also James H. Nichols <1> * <1> department of Pathology and also <2> Pain administration Center, Baystate health System, Springfield, MA01199; * resolve correspondence to this writer at: Clinical Chemistry,Department that Pathology, Baystate clinical Center, 759 Chestnut St.,Springfield, MA 01199; fax 413-794-5893, e-mail james.nichols
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Hickey, Kelly; Seliem, Rania; Shields, James; McKee, Alfred; Nichols, James H.
Clinical Chemistry
Jun 1, 2002
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