6-Monoacetylmorphine (6-MAM), Confirmation, Meconium
NY State Approved Indicates the status of NY State approval and if the test is orderable for NY State clients.
Detection of in utero drug exposure up to 5 months before birth
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Reporting Name A shorter/abbreviated version of the Published Name for a test; an abbreviated test name
6-MAM Confirmation, M
Specimen Type Describes the specimen type needed for testing
Specimen Required Defines the optimal specimen. This field describes the type of specimen required to perform the test and the preferred volume to complete testing. The volume allows automated processing, fastest throughput and, when indicated, repeat or reflex testing.
Chain of custody is recommended for this test. Chain-of-Custody Meconium Kit (Supply T653) is available upon request.
Container/Tube: Stool container (Supply T288)
Specimen Volume: 1 g (approximately 1 teaspoon)
1. Collect entire random meconium specimen.
2. Send specimen frozen. When refrigerated, a significant percentage of 6-MAM will convert to morphine in <24 hours.
1. For chain-of-custody information, see Chain-of-Custody Meconium Kit (Supply T653).
2. Specimen that arrives with a broken seal does not meet the chain-of-custody requirements.
3. The laboratory recommends sending chain-of-custody specimens by overnight shipment.
Specimen Minimum Volume Defines the amount of specimen required to perform an assay once, including instrument and container dead space. Submitting the minimum specimen volume makes it impossible to repeat the test or perform confirmatory or perform reflex testing. In some situations, a minimum specimen volume may result in a QNS (quantity not sufficient) result, requiring a second specimen to be collected.
0.3 g (approximately 1/4 teaspoon)
Grossly bloody reject; Pink OK
Specimen Stability Information Provides a description of the temperatures required to transport a specimen to the laboratory. Alternate acceptable temperature(s) are also included.
|Meconium||Frozen (preferred)||14 days|
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
Heroin (diacetylmorphine) is a semisynthetic opiate that is closely related to morphine. It is no longer used clinically in the United States, though it is used elsewhere for rapid relief of pain.(1) Like morphine and other opiates, its relaxing and euphoric qualities make heroin a popular drug of abuse. Heroin is commonly injected intravenously, although it can be administered by other means such as snorting, smoking, or inhaling vapors.
Heroin shares the core structure of morphine, with the addition of 2 acetyl groups, which are thought to enhance its permeation into the central nervous system.(2,3) Heroin is metabolized by sequential removal of these acetyl groups; loss of the first acetyl converts heroin into 6-monoacetylmorphine (6-MAM).(2,3) Heroin is rarely found in meconium since only 0.1% of a dose is excreted unchanged. 6-MAM is a unique metabolite of heroin, and its presence is a definitive indication of heroin use. Like heroin, 6-MAM has a very short half-life; however, its detection time in meconium, the first fecal material passed by the neonate, is uncharacterized. 6-MAM is further metabolized into morphine, the dominant metabolite of heroin, and morphine will typically be found in a specimen containing 6-MAM.
Opiates, including heroin, have been shown to readily cross the placenta and distribute widely into many fetal tissues.(4) Opiate use by the mother during pregnancy increased the risk of prematurity and being small for gestational age. Furthermore, heroin-exposed infants exhibit an early onset of withdrawal symptoms compared with methadone-exposed infants. Heroin-exposed infants demonstrate a variety of symptoms including irritability, hypertonia, wakefulness, diarrhea, yawning, sneezing, increased hiccups, excessive sucking, and seizures. Long-term intrauterine drug exposure may lead to abnormal neurocognitive and behavioral development as well as an increased risk of sudden infant death syndrome.(5)
The disposition of drug in meconium 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 deposit from bile or through swallowing of amniotic fluid.(6) 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.(7) Therefore, the presence of drugs in meconium has been proposed to be indicative of in utero drug exposure during the final 4 to 5 months of pregnancy, a longer historical measure than is possible by urinalysis.(6)
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.
6-MAM by LC-MS/MS: >5 ng/g
The presence of 6-monoacetylmorphine (6-MAM) in meconium is definitive for heroin use by the mother. However, the absence of 6-MAM does not rule-out heroin use, because of its short half-life.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
Because the results of this test may have legal ramifications, it is recommended that testing be performed using chain of custody. A kit including all the materials necessary to complete chain of custody is available to ensure the test results are appropriate for legal proceedings.
The short half-life of 6-monoacetylmorphine (6-MAM) may prevent its detection in heroin users.
6-MAM is metabolized to morphine, but the presence of morphine alone is not sufficient evidence to prove heroin use. 6-MAM is the only definitive metabolite of heroin.
Send frozen if possible. When refrigerated, a significant percentage of 6MAM will convert to morphine in less than 24 hours.
Clinical Reference Provides recommendations for further in-depth reading of a clinical nature
1. Giovannelli M, Bedforth N, Aitkenhead A: Survey of intrathecal opioid usage in the UK. Eur J Anaesthesiol 2008;25:118-122
2. Principles of Forensic Toxicology. Second edition. Washington DC, AACC Press, 2003 pp 187-205
3. Goodman and Gilman's: The Pharmacological Basis of Therapeutics, 10th edition. New York, McGraw-Hill Professional, 2001 pp 590-592
4. Szeto HH: Kinetics of drug transfer to the fetus. Clin Obstet Gynecol 1993;36:246-254
5. Kwong TC, Ryan RM: Detection of intrauterine illicit drug exposure by newborn drug testing. Clin Chem 1997;43(1):235-242
6. 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 Sep;115(3):474-477
7. Ahanya SN, Lakshmanan J, Morgan BL, Ross MG: Meconium passage in utero mechanisms, consequences, and management. Obstet Gynecol Surv 2005 Jan;60(1):45-56; quiz 73-74
Method Description Describes how the test is performed and provides a method-specific reference
Meconium is mixed with internal standard and extracted with methanol. The methanolic extract is further processed by solid-phase extraction. The extract is analyzed by HPLC with detection by tandem mass spectrometry.(Unpublished Mayo method)
Day(s) and Time(s) Test Performed Outlines the days and times the test is performed. This field reflects the day and time the sample must be in the testing laboratory to begin the testing process and includes any specimen preparation and processing time required before the test is performed. Some tests are listed as continuously performed, which means assays are performed several times during the day.
Monday through Sunday; Varies
Analytic Time Defines the amount of time it takes the laboratory to setup and perform the test. This is defined in number of days. The shortest interval of time expressed is "same day/1 day," which means the results may be available the same day that the sample is received in the testing laboratory. One day means results are available 1 day after the sample is received in the laboratory.
Specimen Retention Time Outlines the length of time after testing that a specimen is kept in the laboratory before it is discarded
Performing Laboratory Location The location of the laboratory that performs the test
Test Classification Provides information regarding the medical device classification for laboratory test kits and reagents. Tests may be classified as cleared or approved by the US Food and Drug Administration (FDA) and used per manufacturer's instructions, or as products that do not undergo full FDA review and approval, and are then labeled as an Analyte Specific Reagent (ASR), Investigation Use Only (IUO) product, or a Research Use Only (RUO) product.
This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the U.S. Food and Drug Administration.
CPT Code Information Provides guidance in determining the appropriate Current Procedural Terminology (CPT) code(s) information for each test or profile. The listed CPT codes reflect Mayo Medical Laboratories interpretation of CPT coding requirements. It is the responsibility of each laboratory to determine correct CPT codes to use for billing.
LOINC® Code Information Provides guidance in determining the Logical Observation Identifiers Names and Codes (LOINC) values for the result codes returned for this test or profile.
|Result ID||Reporting Name||LOINC Code|
|32011||Chain of Custody||In Process|