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, MSpecimen Type
MeconiumShipping 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 | Special Container |
---|---|---|---|
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 daysTest 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 | 29345-6 |
Result ID | Test Result Name | Result LOINC Value |
---|---|---|
36202 | 6-Monoacetylmorphine | 29345-6 |
36203 | Interpretation | 69050-3 |
36204 | Chain of Custody | 77202-0 |
Method Name
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Forms
1. Chain-of-Custody Request is included in the Chain-of-Custody Kit (T282).
2. If not ordering electronically, complete, print, and send a Therapeutics Test Request (T831) with the specimen.