Cocaine and Metabolites Confirmation, Meconium
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
Cocaine is an alkaloid found in Erythroxylon coca, which grows principally in the northern South American Andes and to a lesser extent in India, Africa, and Java.(1) Cocaine is a powerfully addictive stimulant drug. Cocaine abuse has a long history and is rooted into the drug culture in the United States,(2) and is 1 of the most common illicit drugs of abuse.(3,4) Cocaine is rapidly metabolized primarily to benzoylecgonine, which is further metabolized to m-hydroxybenzoylecgonine (m-HOBE).(1,5) Cocaine is frequently used with other drugs, most commonly ethanol, and the simultaneous use of both drugs can be determined by the presence of the unique metabolite cocaethylene.(4)
Intrauterine drug exposure to cocaine has been associated with placental abruption, premature labor, small for gestational age status, microcephaly, and congenital anomalies (eg, cardiac and genitourinary abnormalities, necrotizing enterocolitis, and central nervous system stroke or hemorrhage).(6)
The disposition of drug in meconium, the first fecal material passed by the neonate, is not well understood. The proposed mechanism is that the fetus excretes drug into bile and amniotic fluid. Drug accumulates in meconium either by direct deposition from bile or through swallowing of amniotic fluid.(7) The first evidence of meconium in the fetal intestine appears at approximately the 10th to 12th week of gestation, and slowly moves into the colon by the 16th week of gestation.(8) Therefore, the presence of drugs in meconium has been proposed to be indicative of in utero drug exposure up to 5 months before birth, a longer historical measure than is possible by urinalysis.(7)
Detection of in utero drug exposure up to 5 months before birth
The presence of any of the following: cocaine, benzoylecgonine, cocaethylene, or m-hydroxybenzoylecgonine, at > or =50 ng/g is indicative of in utero drug exposure up to 5 months before birth.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
Since the evidence of illicit drug use during pregnancy can be cause for separating the baby from the mother, a kit is available that includes all the materials necessary to complete the chain-of-custody to ensure that the test results are appropriate for legal proceedings.
Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
Positives are reported with a quantitative LC-MS/MS result.
Cocaine by LC-MS/MS: >50 ng/g
Benzoylecgonine by LC-MS/MS: >50 ng/g
Cocaethylene by LC-MS/MS: >50 ng/g
m-Hydroxybenzoylecgonine by LC-MS/MS: >50 ng/g
Clinical References Provides recommendations for further in-depth reading of a clinical nature
1. Isenschmid DS: Cocaine. In Principles of Forensic Toxicology. Edited by B Levine. Second edition Washington DC, AACC Press, 2003:207-228
2. US Drug Enforcement Administration: Cocaine. Retrieved 9/3/09. Available at www.usdoj.gov/dea/concern/cocaine.html
3. National Institute on Drug Abuse: NIDA InfoFacts: Crack and Cocaine. Retrieved 9/3/09. Available at www.nida.nih.gov/InfoFacts/cocaine.html
4. Isenschmid DS: Cocaine-Effects on Human Performance and Behavior. Forsensic Sci Rev 2002;14:61
5. Kolbrich EA, Barnes AJ, Gorelick DA, et al: Major and minor metabolites of cocaine in human plasma following controlled subcutaneous cocaine administration. J Anal Toxicol 2006;30:501-510
6. Kwong TC, Ryan RM: Detection of intrauterine illicit drug exposure by newborn drug testing. National Academy of Clinical Biochemistry. Clin Chem 1997;43:235-242
7. Ostrea EM Jr, Brady MJ, Parks PM, et al: Drug screening of meconium in infants of drug-dependent mothers; an alternative to urine testing. J Pediatr 1989;115:474-477
8. Ahanya SN, Lakshmanan J, Morgan BL, Ross MG: Meconium passage in utero: mechanisms, consequences, and management. Obstet Gynecol Surv 2005;60:45-56