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Test ID MAMMX 6-Monoacetylmorphine (6-MAM) Confirmation, Chain of Custody, Meconium

Useful For

Detection of in utero drug exposure up to 5 months before birth

 

Chain of custody is required whenever the results of testing could be used in a court of law. Its purpose is to protect the rights of the individual contributing the specimen by demonstrating that it was under the control of personnel involved with testing the specimen at all times; this control implies that the opportunity for specimen tampering would be limited. Since the evidence of illicit drug use during pregnancy can be cause for separating the baby from the mother, a complete chain-of-custody ensures that the test results are appropriate for legal proceedings.

Additional Tests

Test ID Reporting Name Available Separately Always Performed
COCH Chain of Custody Processing No Yes

Reporting Name

6-MAM Confirmation, CoC, M

Specimen Type

Meconium


Shipping Instructions


The laboratory recommends sending chain-of-custody specimens by overnight shipment.



Specimen Required


Supplies: Chain-of-Custody Meconium Kit (T653) includes the specimen containers, seals, and documentation required.

Specimen Volume: 1 g (approximately 1 teaspoon)

Collection Instructions: Collect entire random meconium specimen.

Additional Information: Specimen that arrives with a broken seal does not meet the chain of custody requirements.


Specimen Minimum Volume

0.3 g (approximately 1/4 teaspoon)

Specimen Stability Information

Specimen Type Temperature Time
Meconium Frozen 14 days

Clinical Information

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)

 

Chain of custody is a record of the disposition of a specimen to document who collected it, who handled it, and who performed the analysis. When a specimen is submitted in this manner, analysis will be performed in such a way that it will withstand regular court scrutiny.

Reference Values

Negative

Positives are reported with a quantitative LC-MS/MS result.

Cutoff concentration:

6-MAM by LC-MS/MS: 5 ng/g

Interpretation

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.

Clinical Reference

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

Day(s) and Time(s) Performed

Monday through Sunday; Varies

Analytic Time

2 days

Test Classification

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

80356

G0480 (if appropriate)

LOINC Code Information

Test ID Test Order Name Order LOINC Value
MAMMX 6-MAM Confirmation, CoC, M In Process

 

Result ID Test Result Name Result LOINC Value
36202 6-Monoacetylmorphine 29345-6
36203 Interpretation 69050-3
36204 Chain of Custody No LOINC Needed

Method Name

Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Forms

Chain-of-Custody Request Form is included in the Chain-of-Custody Kit (T653). A copy of this form is also available at http://www.mayomedicallaboratories.com/it-mmfiles/chain-of-custody-request-form.pdf.