Death due to intravenous use of α-pyrrolidinopentiophenone

To the Editor: Sellors and colleagues report a fatality where urine drug testing (UDT) failed to detect the drug of overdose detected on the coronial blood assay.1 This highlights how clinical care may be handicapped by older testing technology.

Historically, UDT was used for forensic and occupational safety testing. Medicare subsidises UDT that relies on an immunoassay and on standards designed for forensic and occupational safety purposes. The target substances and cut-off values are potentially inappropriate for contemporary use. When prescribing opioid analgesia for chronic pain,2 palliative care or emergency care, physicians need to know whether psychoactive substance use is complicating presentations or whether there may be drug diversion.3 Limitations of UDT include failure to detect buprenorphine, fentanyl, oxycodone (except at very high levels), anabolic steroids, synthetic cannabinoids and most designer and emerging drugs.1,2

Clinicians who wish to test for the presence of specific substances using refined and state-of-the-art technology such as mass spectrophotometry may find that laboratories are unwilling to assist because of the high cost of infrastructure, including highly trained personnel and expensive equipment. Where available, the effort and costs associated with the detection of novel substances is prohibitively expensive. Currently, these confirmatory tests are not subsidised by Medicare. Thus the costs of these tests may be passed on to consumers, who may be unwilling to pay for them.

The case described by Sellors et al presents a timely opportunity for a review of the UDT Medicare subsidy so that it can adequately support diagnosis and improve clinical outcomes.