CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
January 2020—CAP Publications released this month the second edition of Clinical Toxicology Testing—A Guide for Laboratory Professionals, edited by Barbarajean Magnani, PhD, MD; Tai C. Kwong, PhD; Gwendolyn A. McMillin, PhD; and Alan H.B. Wu, PhD. The first edition was published in 2012.
The book has 29 chapters divided into three sections: toxicology testing in the clinical setting, toxicokinetics and methodologies for the toxicology laboratory, and specific analytes (drugs and drug classes).
CAP TODAY spoke with Dr. Magnani about the new book. She is director of toxicology and chief of clinical pathology, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and professor of anatomic and clinical pathology, and professor of medicine, Tufts University School of Medicine, Boston. Here is what she told us. (See excerpt below.)
What can you tell us about the new chapters in this second edition?
This exciting new edition brings updated and expanded chapters to reflect the ever-growing field of toxicology in a clinical laboratory setting. The new chapters are “Clinical Pathology Consultation for Pain Management Services,” which provides case study examples for the interpretation of toxicology results from patients on chronic opioid therapy; “Special Considerations in Pediatric Toxicology,” which provides practical and testing perspectives; “Method Validation in Toxicology Testing”; and “Novel Psychoactive Substances.”
Can you highlight for us a few of the updates (separate from the new chapters) that readers of the new edition can expect to see?
Several individual chapters have expanded on previous work, including “Laboratory-Based Screening Assays in Support of Pain Management,” “Approaches to Broad-Spectrum Drug Testing in the Clinical Laboratory,” and “Alternate Specimens for Drugs-of-Abuse Testing: Oral Fluid.”
How does this book differ from other clinical toxicology testing books on the market?
This book focuses not only on specific analytes but also on practice settings that pathologists and other lab medicine professionals encounter while supporting clinical toxicology testing. For those pathologists whose primary practice focus is not toxicology, this is a good go-to reference for how to provide toxicology services. Chapters on regulatory considerations, workplace drug testing, the hospital autopsy and toxicology, and pharmacogenomic testing are particularly useful. In addition, understanding newly emerging designer drugs, how to interpret drug testing results, and assessing different methodologies are also important considerations for a successful toxicology laboratory. Lastly, laboratories will find the templates for drug testing, frequently asked questions on clinical drugs of abuse testing, and information about CAP proficiency testing a unique resource.
In addition to you and your three co-editors, there are 20 contributing editors. What can you tell us about the contributors, and are some of them new to this edition?
The CAP Toxicology Committee is a vital international resource to the clinical laboratory industry and has been fortunate to have as its members eminent scientific experts, many of whom have contributed to the writing of this book, as well as many equally renowned invited contributors who have authored many other books and peer-reviewed articles. The authors represent different toxicology perspectives and practices, including academic medical centers, nationally recognized reference laboratories, and forensic disciplines. This diversity of experience provides a well-rounded and useful guide for all who engage in toxicology testing.
What is the one biggest challenge for clinical toxicology laboratories today?
The opioid crisis has placed considerable demands on the clinical laboratory, and laboratory professionals have been asked to partner with their clinical colleagues to help determine compliance with prescribed medications. Understanding the metabolism of specific drugs, the limitations of the various drug assays, and newly emerging designer drugs provides challenges for any toxicology laboratory.n
To order (PUB227: $80 for CAP members, $100 for nonmembers), go to www.cap.org (Shop tab) or call 800-323-4040 option 1. The ebook ( ebooks.cap.org) is $78. If you are interested in writing a book, contact Caryn Tursky at ctursky@cap.org.
Clinicians challenged with drug testing interpretation should be able to turn to laboratory professionals for guidance and clarification, and in some cases a clinical pathology consultation may be warranted. The most appropriate CPT code for that service is 80500 or 80502, say Dr. Magnani, Nicholas Heger, PhD, and Tai C. Kwong, PhD, in their chapter “Clinical Pathology Consultation for Pain Management Services.” Here is the first of seven cases they include in their chapter (modified to protect patient health information).
Case 1
Clinical Pathology Consultation
Comprehensive review of patient’s history and medical records 80502; complex diagnostic problem
Patient: NAME and MRN
Diagnosis: Chronic pain: opioid-requiring (ICD10-F11.20)
The patient is a 70-year-old female with a history of hypertension, migraines, depression, degenerative joint disease, and chronic pancreatitis. The patient also complains of chronic pain and stiffness in her joints. In June she fractured her right foot and is currently wearing a boot. She currently takes Dilaudid (hydromorphone) and MS Contin (morphine) for pain. During a recent visit with her primary care doctor, a urine drug screen was performed and found to be presumptively positive for buprenorphine, methadone, THC-cannabinoids, and opiates. The patient’s physician has requested a formal toxicology consultation in light of the unexpected positive buprenorphine and methadone results.