title: Comparison of clonazepam compliance by measurement of urinary concentration by immunoassay and LC-MS/MS in pain management population.
abstract: BACKGROUND
  Physicians determine patient compliance with their medications by use of urine drug testing. It is known that measurement of benzodiazepines is limited by immunoassay specificity and cutoff limits and therefore does not offer physicians an accurate picture of their patients' compliance with these medications. A few studies have used lower cutoffs to demonstrate patient compliance.
  
  
  OBJECTIVE
  To define more appropriate cutoffs for compliance monitoring of patients prescribed clonazepam as determined using immunoassay and liquid chromatography-tandem mass spectrometry (LC-MS/MS).
  
  
  METHODS
  A diagnostic accuracy study of the urinary excretion of clonazepam.
  
  
  METHODS
  Millennium Laboratories performed measurements on the urinary excretion of pain patients prescribed clonazepam as the indicator test. This benzodiazepine was chosen because it forms one major metabolite, 7-aminoclonazepam which is specific for that drug. Patients whose only benzodiazepine medication was clonazepam were selected as the test population. The Millennium Laboratories test database was filtered first to select patients on clonazepam, then a second filter was used to eliminate patients with any other listed benzodiazepine medications. Samples were tested using the Microgenics DRI benzodiazepine assay with a 200 ng/mL cutoff. The same samples were quantitatively assessed for 7-aminoclonazepam by LC-MS/MS with a cutoff of 40 ng/mL. The results from the immunoassay were scored as positive or negative while the quantitative results from the LC-MS/MS were also scored as positive or negative depending upon their concentration.
  
  
  RESULTS
  Samples from 180 patients met these medication criteria. The positivity rates were 21% (38 samples) by immunoassay. The positivity rate was 70% (126 samples) if the LC-MS/MS cutoff was set at 200 ng/mL. However, the positivity rate was 87% (157 samples) if the LC-MS/MS was set at 40 ng/mL. Concentration distributions revealed a significant fraction (7%) in the 40 - 100 ng/mL range.
  
  
  CONCLUSIONS
  A limitation of the study was the inability to measure lower than 40 ng/mL. There may be another fraction of the population that was positive below the cutoff value.
  
  
  CONCLUSIONS
  The difference in positivity rate between the immunoassay and the LC-MS/MS result showed that the nominal 200 ng/mL cutoff of the immunoassay did not apply to 7-aminoclonazepam. This low immunoassay positivity rate is inconsistent with the manufacturer's published cross reactivity data for clonazepam and 7-aminoclonazepam. These data illustrate the limitations of using a 200 ng/mL cutoff to monitor clonazepam compliance and suggest that a cutoff of 40 ng/mL or less is needed to reliably monitor use of this drug.
authors.affiliation: Millennium Laboratories Research Institute, San Diego, CA 92127, USA. cwest@becausepainatters.com
authors.forename: Robert
authors.initials: R
authors.lastname: West
authors.forename: Amadeo
authors.initials: A
authors.lastname: Pesce
authors.forename: Cameron
authors.initials: C
authors.lastname: West
authors.forename: Bridgit
authors.initials: B
authors.lastname: Crews
authors.forename: Charles
authors.initials: C
authors.lastname: Mikel
authors.forename: Perla
authors.initials: P
authors.lastname: Almazan
authors.forename: Murray
authors.initials: M
authors.lastname: Rosenthal
authors.forename: Sergey
authors.initials: S
authors.lastname: Latyshev
mesh_terms: D002853:Chromatography, Liquid / Q000379:methods / Q000706:statistics & numerical data; D019411:Clinical Laboratory Techniques / Q000379:methods* / Q000706:statistics & numerical data; D002998:Clonazepam / Q000032:analysis / Q000652:urine*; D015331:Cohort Studies; D003429:Cross Reactions; D005189:False Positive Reactions; D053593:Forensic Toxicology / Q000379:methods; D018757:GABA Modulators / Q000032:analysis / Q000652:urine; D006801:Humans; D007118:Immunoassay / Q000379:methods / Q000706:statistics & numerical data; D013058:Mass Spectrometry / Q000379:methods / Q000706:statistics & numerical data; D010146:Pain / Q000188:drug therapy; D011237:Predictive Value of Tests; D012015:Reference Standards; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D015813:Substance Abuse Detection / Q000379:methods*; D019966:Substance-Related Disorders / Q000175:diagnosis* / Q000652:urine*; D016482:Urinalysis / Q000379:methods*; D016903:Drug Monitoring
chemical_list: D018757:GABA Modulators; D002998:Clonazepam