International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Covert Drug Abuse among Patients Hospitalized in the Psychiatric Ward of a University Hospital Javad Razani, Francis A. Farina & Roy Stern To cite this article: Javad Razani, Francis A. Farina & Roy Stern (1975) Covert Drug Abuse among Patients Hospitalized in the Psychiatric Ward of a University Hospital, International Journal of the Addictions, 10:4, 693-698, DOI: 10.3109/10826087509026744 To link to this article: http://dx.doi.org/10.3109/10826087509026744
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The International Journal of the Addictions, 10(4), pp. 693-698, 1975
Covert Drug Abuse among Patients Hospitalized in the Psychiatric Ward of a University Hospital Javad Razani," M.D. University of Southern California School of Medicine Los Angeles, California
Francis A. Farina, Ph.D. Roy Stern, M.D. Temple University Hospital Philadelphia, Pennsylvania
* At the time of the study, Dr. Razani was on the Staff, Department of Psychiatry, Temple University Hospital, Philadelphia, Pennsylvania. Correspondence and requests for reprints should be addressed to Javad Razani, M.D., P.O. Box 1652-12, Tehran, Iran. 693 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, o r by any information storage and retrieval system, without permission in writing from the publisher.
RAZANI, FARINA, A N D STERN
694
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
Abstract
Fourty-four consecutive admissions less than 41 years of age to the Psychiatric Ward of Temple University Hospital were screened by urine chromatographic analysis for detection of amphetamines, barbiturates, and narcotics. The survey showed a majority of the patients (66 %) had detectable levels of drugs of abuse in their urine at least once. As many as 52 % had evidence of covert drug abuse while in the hospital. The amphetamines were, by far, the most frequently abused drugs. Abuse was episodic and no obvious dependence was encountered. The value of urine screening in hospitalized psychiatric patients, especially with regard to its usefulness in evaluation of unexpected changes in their moods and behavior on the ward, is noted. Routine urine chromatographic screening for drugs commonly abused by hospitalized psychiatric patients is recommended. Several studies showed a significant degree of covert drug abuse among psychiatric inpatients in a variety of settings. Robinson and Wolkind (1970) found, by gas chromatography, quantities of nonprescribed amphetamines in the urines of 30% of patients in a psychiatric hospital. Bakewell and Wilker (1966) estimated that 6.8% of admissions to a university hospital psychiatric ward were physically dependent on sedatives. Blumberg et al. (1971) found by urine screening that at least 60% of 334 patients admitted to Hillside Hospital, Glen Oaks, New York, covertly used psychoactive drugs, predominantly barbiturates. In view of these reports, we carried out a urinary drug-screening study of patients in the Psychiatric Ward of Temple University Hospital. In this report the incidence of covert detectable abuse of amphetamines, barbiturates, and narcotics in our open acute psychiatric ward is described with its implications for the clinician in evaluation of alterations of mood and changes in behavior of psychiatric inpatients.
PATIENT POPULATION A total of 44 consecutive patients under 41 years of age (age range 15 to 40 with a mean of 24) admitted to the Psychiatric Ward during a 12-week period were studied. The Psychiatric Ward is a 28-bed acute facility, located in an urban ghetto (North Philadelphia) with referrals from a community mental health center, the attending staff of the Depart-
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
COVERT DRUG ABUSE IN A UNIVERSITY HOSPITAL
695
ment of Psychiatry, and transfers from the other specialty wards of the general hospital. The majority of admissions are voluntary, with the average length of stay about 21 days. The average duration of stay for the patients in our study was 22 days with a range of 4 to 64 days. Twelve patients had a hstory of recent or distant drug abuse, including marijuana, LSD, and other psychoactive drugs not measurable by our technique. Of these 12 patients, three had been admitted specifically for heroin withdrawal. Patients are allowed to have visitors and have weekend and weekday passes. In suspected drug abuse cases, patients are carefully observed and any covert drug abuse in the facility is grounds for discharge. Urine samples were obtained at the time of admission, on discharge, and every Monday. Mondays were selected because of the possibility of drug abuse in patients while on a weekend pass. A total of 176 urine collections were made with an average of four urine collections per patient. The true purpose of urine collections remained unknown both to the patients and to the nursing staff, who believed collections were made for “kidney function” tests.
METHOD OF ANALYSIS A thin-layer chromatographic analysis of the urine was used. Analysis of chloroform extracts of urines were performed using a procedure based on the methods of Davidow et al. (1966, 1968) and Mule (1969). Eastman Chromagram sheets coated with No. 6060 silica gel and backed with Mylar plastic were used for separating and identifying drugs. One sheet was used for detection of barbiturates and two for determination in duplicate of amphetamines, opiates, methadone, and quinine. The duplicate plates were chromatographed in different solvent systems, and positive results were reported only when both sheets showed spots for the drug. Individual standards, mixed standards, and “spiked” urine controls were run with patient samples on each thin-layer plate. Quinine was detected by its fluorescence under an ultraviolet lamp at 254 nm. Barbiturates were detected by spraying with ammoniacal silver nitrate (Clark, 1969), amphetamines with ninhydrin, and the remaining drugs with chloroplatinate. Since this was an experimental study, no action was taken when drug abuse was detected and the ward physicians remained unaware of the study results. Whenever a patient was on a medication prescribed by the ward physician, e.g., barbiturates or methadone, the positive urine results were discounted.
RAZANI, FARINA, A N D STERN
696
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
RESULTS On admission, 18 of the 44 patients, or about 41 %, had positive urine tests (34 ”/, had positive urine amphetamine tests). Twenty-three patients (52 %) showed evidence of covert drug abuse while in the hospital, which was detected in at least one urine screening (45% covertly abused amphetamines, 9 % abused barbiturates, and 5 % narcotics). Overall, 29 of 44, or 66%, had at least one positive urine test either on admission and/or while in the hospital with an overall 57% positive urine amphetamine tests (Table 1). Six cases of multiple abuse were detected with various combinations of amphetamines, barbiturates, and narcotics. No patient was found to have more than one positive test for narcotics, more than three for barbiturates, or more than five for amphetamines. Twenty-two of 24 patients who had four or more urine screenings while in the hospital had at least one positive urine, but only seven of the 20 who had less than four urine screenings were detected to have one or more positive urine (Table 2). This finding confirms the observation by Blumberg et al. (1971) that multiple urine screenings in the hospital enhances the chances of detecting potential abuse. Of the 18 patients with positive tests o n admission, 12 continued the abuse in the hospital ( 6 6 7 3 ; while of 26 patients with negative tests on Table 1 Incidence of at Least One Positive Urine Finding in a Total of 44 Patients On admission
All drugs of abuse Amphetamines
While in the hospital
On admission and/ or in the hospital
No.
%
No.
%
No.
%
18 15
41 34
23 20
52 45
29 25
66 57
Table 2 Number of Urine Screenings and Positive Findings of Drug Abuse
Number of urine screenings
Four or more At least one positive urine
No positive urine TOTALS
Less than four
22 2
7 13
24
20
COVERT DRUG ABUSE IN A UNIVERSITY HOSPITAL
697
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
admission, 11 abused drugs covertly in the hospital (42 %). Although this shows a tendency for patients with positive urine tests on admission to continue covert abuse in the hospital, the relation was not statistically significant (chi-square test p + 0.12).
DISCUSSION In contrast to the findings of Blumberg et al. (1971), amphetamines were detected at least five times as often as barbiturates or narcotics and, thus, by a large margin appeared to be the most widely abused drug in this sample. Since in 'our study urine collections were on a fixed schedule, the true incidence of drug abuse in randomly collected urines as described by Goldstein and Brown (1970) cannot be ascertained. Our observations may further underestimate the true degree of drug abuse since we could not measure such commonly abused drugs as LSD, marijuana, and mescaline, and since some patients with a short stay had relatively few urine collections. The pattern of detection suggested an episodic covert abuse of' drugs, ai:d this empliasizes the value of multiple determinations rather than the use of single samples collected at random. There were no observed instances of physical dependence. Alterations in laboratory tests in patients who abuse drugs, such as pointed out by Lubran (1969), are always a possibility. For example, De Angelis (1972) has shown that opiates can elevate enzymes, such as SGOT and amylase, and amphetamines can lower blood sugar. Interaction of psychopharmacological agents with the drugs of abuse, especially the possibility of a hypertensive crisis in the case of amphetamines with monoamine-oxidase inhibitors, should also be kept in mind. These findings point out the value of urine screening for detection of drug abuse among hospitalized psychiatric patients, and its paramount significance for the clinician in evaluating the unexpected changes in mood or behavior of the patients and their response to psychopharmacological agents. ACKNOWLEDGMENTS
The authors wish to thank Dr. Roy Gustavson of the Biochemistry Laboratory for his help in setting up the technique for our urine screenings, and the Psychiatric Ward Staff, especially Mrs. Mary Ellen Brower and Miss Jan Main of the Nursing Staff, for their sincere help and cooperation in completing this study.
698
RAZANI, FARINA, AND STERN
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
REFERENCES BAKEWELL, W.E., and WILKER, A. Incidence in a university hospital psychiatric ward J. Amer. Med. Assoc. 196: 710-713, 1966. BLUMBERG, A.G., COHEN, M., HEATON, A.M., and KLEIN, D.F. Covert drug abuse among voluntary hospitalized psychiatric patients. J. Amer. Med. Assoc. 21 7 : 1659-1 661, 1971. CLARK, E.G.C. Isolation and Identification of Drugs. London: Pharmaceutical Press, 1969, pp. 36, 192, 805. DAVIDOW, B., LIPIETRI, N., and QUAME, B. A thin-layer chromatographic screening procedure for detecting drug abuse. Amer. J. Clin. Puthol. 50: 714-719, 1968. DAVIDOW, B., LIPIETRI, N., QUAME, B., SEARLE, B., FASTHICH, E., and SAVITSKY, J. A thin-layer chromatographic screening test for the detection of users of morphine or heroin. Amer. J. Clin. Pathol. 46: 58-62, 1966. DE ANGELIS, G . G . Testing for drugs-advantages and disadvantages. Intern. J. Addictions 7: 365-386, 1972. GOLDSTEIN, A., and BROWN, B.W: Urine testing schedules in methadone maintenance treatment of heroin addiction. J. Amer. Med. Assoc. 311-315, 1970. LUBRAN, M. The effects of drug on laboratory values. Med. Clin. N. Amer. 53 : 21 1222, 1969. MULE, S.J. Identification of narcotics, barbiturates, amphetamines, tranquilizers, and psychotomimetics in human urine. J. Chrornatogra. 39: 302- 31 I , 1969. ROBINSON, A.E., and WOLKIND, S.M. Amphetamine abuse among psychiatric inpatients: The use of gas chromatography. Brit. J. Psychiat. 116: 643-644, 1970.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Covert Drug Abuse among Patients Hospitalized in the Psychiatric Ward of a University Hospital Javad Razani, Francis A. Farina & Roy Stern To cite this article: Javad Razani, Francis A. Farina & Roy Stern (1975) Covert Drug Abuse among Patients Hospitalized in the Psychiatric Ward of a University Hospital, International Journal of the Addictions, 10:4, 693-698, DOI: 10.3109/10826087509026744 To link to this article: http://dx.doi.org/10.3109/10826087509026744
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 3
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [University of Saskatchewan Library]
Date: 03 April 2016, At: 22:03
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
The International Journal of the Addictions, 10(4), pp. 693-698, 1975
Covert Drug Abuse among Patients Hospitalized in the Psychiatric Ward of a University Hospital Javad Razani," M.D. University of Southern California School of Medicine Los Angeles, California
Francis A. Farina, Ph.D. Roy Stern, M.D. Temple University Hospital Philadelphia, Pennsylvania
* At the time of the study, Dr. Razani was on the Staff, Department of Psychiatry, Temple University Hospital, Philadelphia, Pennsylvania. Correspondence and requests for reprints should be addressed to Javad Razani, M.D., P.O. Box 1652-12, Tehran, Iran. 693 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, o r by any information storage and retrieval system, without permission in writing from the publisher.
RAZANI, FARINA, A N D STERN
694
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
Abstract
Fourty-four consecutive admissions less than 41 years of age to the Psychiatric Ward of Temple University Hospital were screened by urine chromatographic analysis for detection of amphetamines, barbiturates, and narcotics. The survey showed a majority of the patients (66 %) had detectable levels of drugs of abuse in their urine at least once. As many as 52 % had evidence of covert drug abuse while in the hospital. The amphetamines were, by far, the most frequently abused drugs. Abuse was episodic and no obvious dependence was encountered. The value of urine screening in hospitalized psychiatric patients, especially with regard to its usefulness in evaluation of unexpected changes in their moods and behavior on the ward, is noted. Routine urine chromatographic screening for drugs commonly abused by hospitalized psychiatric patients is recommended. Several studies showed a significant degree of covert drug abuse among psychiatric inpatients in a variety of settings. Robinson and Wolkind (1970) found, by gas chromatography, quantities of nonprescribed amphetamines in the urines of 30% of patients in a psychiatric hospital. Bakewell and Wilker (1966) estimated that 6.8% of admissions to a university hospital psychiatric ward were physically dependent on sedatives. Blumberg et al. (1971) found by urine screening that at least 60% of 334 patients admitted to Hillside Hospital, Glen Oaks, New York, covertly used psychoactive drugs, predominantly barbiturates. In view of these reports, we carried out a urinary drug-screening study of patients in the Psychiatric Ward of Temple University Hospital. In this report the incidence of covert detectable abuse of amphetamines, barbiturates, and narcotics in our open acute psychiatric ward is described with its implications for the clinician in evaluation of alterations of mood and changes in behavior of psychiatric inpatients.
PATIENT POPULATION A total of 44 consecutive patients under 41 years of age (age range 15 to 40 with a mean of 24) admitted to the Psychiatric Ward during a 12-week period were studied. The Psychiatric Ward is a 28-bed acute facility, located in an urban ghetto (North Philadelphia) with referrals from a community mental health center, the attending staff of the Depart-
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
COVERT DRUG ABUSE IN A UNIVERSITY HOSPITAL
695
ment of Psychiatry, and transfers from the other specialty wards of the general hospital. The majority of admissions are voluntary, with the average length of stay about 21 days. The average duration of stay for the patients in our study was 22 days with a range of 4 to 64 days. Twelve patients had a hstory of recent or distant drug abuse, including marijuana, LSD, and other psychoactive drugs not measurable by our technique. Of these 12 patients, three had been admitted specifically for heroin withdrawal. Patients are allowed to have visitors and have weekend and weekday passes. In suspected drug abuse cases, patients are carefully observed and any covert drug abuse in the facility is grounds for discharge. Urine samples were obtained at the time of admission, on discharge, and every Monday. Mondays were selected because of the possibility of drug abuse in patients while on a weekend pass. A total of 176 urine collections were made with an average of four urine collections per patient. The true purpose of urine collections remained unknown both to the patients and to the nursing staff, who believed collections were made for “kidney function” tests.
METHOD OF ANALYSIS A thin-layer chromatographic analysis of the urine was used. Analysis of chloroform extracts of urines were performed using a procedure based on the methods of Davidow et al. (1966, 1968) and Mule (1969). Eastman Chromagram sheets coated with No. 6060 silica gel and backed with Mylar plastic were used for separating and identifying drugs. One sheet was used for detection of barbiturates and two for determination in duplicate of amphetamines, opiates, methadone, and quinine. The duplicate plates were chromatographed in different solvent systems, and positive results were reported only when both sheets showed spots for the drug. Individual standards, mixed standards, and “spiked” urine controls were run with patient samples on each thin-layer plate. Quinine was detected by its fluorescence under an ultraviolet lamp at 254 nm. Barbiturates were detected by spraying with ammoniacal silver nitrate (Clark, 1969), amphetamines with ninhydrin, and the remaining drugs with chloroplatinate. Since this was an experimental study, no action was taken when drug abuse was detected and the ward physicians remained unaware of the study results. Whenever a patient was on a medication prescribed by the ward physician, e.g., barbiturates or methadone, the positive urine results were discounted.
RAZANI, FARINA, A N D STERN
696
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
RESULTS On admission, 18 of the 44 patients, or about 41 %, had positive urine tests (34 ”/, had positive urine amphetamine tests). Twenty-three patients (52 %) showed evidence of covert drug abuse while in the hospital, which was detected in at least one urine screening (45% covertly abused amphetamines, 9 % abused barbiturates, and 5 % narcotics). Overall, 29 of 44, or 66%, had at least one positive urine test either on admission and/or while in the hospital with an overall 57% positive urine amphetamine tests (Table 1). Six cases of multiple abuse were detected with various combinations of amphetamines, barbiturates, and narcotics. No patient was found to have more than one positive test for narcotics, more than three for barbiturates, or more than five for amphetamines. Twenty-two of 24 patients who had four or more urine screenings while in the hospital had at least one positive urine, but only seven of the 20 who had less than four urine screenings were detected to have one or more positive urine (Table 2). This finding confirms the observation by Blumberg et al. (1971) that multiple urine screenings in the hospital enhances the chances of detecting potential abuse. Of the 18 patients with positive tests o n admission, 12 continued the abuse in the hospital ( 6 6 7 3 ; while of 26 patients with negative tests on Table 1 Incidence of at Least One Positive Urine Finding in a Total of 44 Patients On admission
All drugs of abuse Amphetamines
While in the hospital
On admission and/ or in the hospital
No.
%
No.
%
No.
%
18 15
41 34
23 20
52 45
29 25
66 57
Table 2 Number of Urine Screenings and Positive Findings of Drug Abuse
Number of urine screenings
Four or more At least one positive urine
No positive urine TOTALS
Less than four
22 2
7 13
24
20
COVERT DRUG ABUSE IN A UNIVERSITY HOSPITAL
697
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
admission, 11 abused drugs covertly in the hospital (42 %). Although this shows a tendency for patients with positive urine tests on admission to continue covert abuse in the hospital, the relation was not statistically significant (chi-square test p + 0.12).
DISCUSSION In contrast to the findings of Blumberg et al. (1971), amphetamines were detected at least five times as often as barbiturates or narcotics and, thus, by a large margin appeared to be the most widely abused drug in this sample. Since in 'our study urine collections were on a fixed schedule, the true incidence of drug abuse in randomly collected urines as described by Goldstein and Brown (1970) cannot be ascertained. Our observations may further underestimate the true degree of drug abuse since we could not measure such commonly abused drugs as LSD, marijuana, and mescaline, and since some patients with a short stay had relatively few urine collections. The pattern of detection suggested an episodic covert abuse of' drugs, ai:d this empliasizes the value of multiple determinations rather than the use of single samples collected at random. There were no observed instances of physical dependence. Alterations in laboratory tests in patients who abuse drugs, such as pointed out by Lubran (1969), are always a possibility. For example, De Angelis (1972) has shown that opiates can elevate enzymes, such as SGOT and amylase, and amphetamines can lower blood sugar. Interaction of psychopharmacological agents with the drugs of abuse, especially the possibility of a hypertensive crisis in the case of amphetamines with monoamine-oxidase inhibitors, should also be kept in mind. These findings point out the value of urine screening for detection of drug abuse among hospitalized psychiatric patients, and its paramount significance for the clinician in evaluating the unexpected changes in mood or behavior of the patients and their response to psychopharmacological agents. ACKNOWLEDGMENTS
The authors wish to thank Dr. Roy Gustavson of the Biochemistry Laboratory for his help in setting up the technique for our urine screenings, and the Psychiatric Ward Staff, especially Mrs. Mary Ellen Brower and Miss Jan Main of the Nursing Staff, for their sincere help and cooperation in completing this study.
698
RAZANI, FARINA, AND STERN
Downloaded by [University of Saskatchewan Library] at 22:03 03 April 2016
REFERENCES BAKEWELL, W.E., and WILKER, A. Incidence in a university hospital psychiatric ward J. Amer. Med. Assoc. 196: 710-713, 1966. BLUMBERG, A.G., COHEN, M., HEATON, A.M., and KLEIN, D.F. Covert drug abuse among voluntary hospitalized psychiatric patients. J. Amer. Med. Assoc. 21 7 : 1659-1 661, 1971. CLARK, E.G.C. Isolation and Identification of Drugs. London: Pharmaceutical Press, 1969, pp. 36, 192, 805. DAVIDOW, B., LIPIETRI, N., and QUAME, B. A thin-layer chromatographic screening procedure for detecting drug abuse. Amer. J. Clin. Puthol. 50: 714-719, 1968. DAVIDOW, B., LIPIETRI, N., QUAME, B., SEARLE, B., FASTHICH, E., and SAVITSKY, J. A thin-layer chromatographic screening test for the detection of users of morphine or heroin. Amer. J. Clin. Pathol. 46: 58-62, 1966. DE ANGELIS, G . G . Testing for drugs-advantages and disadvantages. Intern. J. Addictions 7: 365-386, 1972. GOLDSTEIN, A., and BROWN, B.W: Urine testing schedules in methadone maintenance treatment of heroin addiction. J. Amer. Med. Assoc. 311-315, 1970. LUBRAN, M. The effects of drug on laboratory values. Med. Clin. N. Amer. 53 : 21 1222, 1969. MULE, S.J. Identification of narcotics, barbiturates, amphetamines, tranquilizers, and psychotomimetics in human urine. J. Chrornatogra. 39: 302- 31 I , 1969. ROBINSON, A.E., and WOLKIND, S.M. Amphetamine abuse among psychiatric inpatients: The use of gas chromatography. Brit. J. Psychiat. 116: 643-644, 1970.
