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No quality evidence directly supports histories, physical examinations, and opioid treatment agreements, although they are thought to be important. No quality trials were identified showing superiority of opioids, compared with nonsteroidal anti-inflammatory and other medications for treatment of chronic, noncancer pain. The use of opioid-sparing treatments associated with lower doses of postoperative opioids is also associated with better long-term functional outcomes. Selective use of opioids is recommended for patients with acute and postoperative pain. Consensus recommendations also include consideration of carefully conducted trials of chronic opioid treatment for highly select patients with subacute and chronic pain and to maintenance opioid prescriptions only if documented objective functional gain(s) results. A strong and reproducible dose-response relationship identifies a recommended morphine equivalent dose limit of no more than 50 mg/day. Higher doses should be prescribed only with documented commensurately greater functional benefit(s), comprehensive monitoring for adverse effects, informed consent, and careful consideration of risk versus benefit of such treatment. Chronic opioid use should be accompanied by informed consent, a treatment agreement, tracking of functional benefits, drug screening, and attempts at tapering.

It has been proposed that issues of external contamination of hair can be resolved by the presence of metabolites. This is true for some drugs in some circumstances. However, even if some metabolites such as cocaethylene are sufficiently definitive to indicate certainty of use, others such as benzoylecgonine can occur as contaminants. In addition, for phencyclidine, only the parent compound is determined. Therefore, effective washing procedures are needed to rule out contamination as the source of the parent or metabolite. The protection provided by cutoffs is also dependent on washing to remove surface contamination, which can range from very little to greater than 20 times the amount in the hair. In cocaine-positive head hair samples from 67 subjects with cocaine-positive urine tests, contamination of positive hair samples ranged from 0.7 to 8009 ng/10 mg hair, demonstrating that analyses of such samples to determine use is meaningless without removal of contamination. Wash procedures have been a focus of this laboratory for many years. In this paper, the effectiveness of our wash procedure was further challenged by application to negative hair (blonde, auburn, brown, and black) contaminated by soaking for 1 h in 1000, 10,000, and 50,000 ng cocaine/mL water. The uptake of the cocaine was approximately linear with increasing concentrations of cocaine in the soaking solutions. By application of the wash criterion, all samples were clearly identified as contaminated (i.e., negative). The effects of hair porosity on uptake of cocaine were also studied with 10 hair samples of all colors. Permed and unpermed samples were soaked in 10,000 ng cocaine/mL for 1 hour. All hair responded to the perm with increased uptake, and all were decontaminated or identified as contaminated (i.e., negative for cocaine use). Porosity, not hair color, determined the rate of penetration of hair by cocaine in solution, and, likewise, washing characteristics were unrelated to hair color.

In order to evaluate the effectiveness of a wash procedure using isopropanol followed by multiple extended phosphate buffer washes as compared with a methanol wash procedure previously reported, a contamination experiment was designed involving the soaking of human head hair in cocaine-contaminated aqueous solutions. Fourteen negative human head hair samples were soaked in a solution of cocaine HCl (1000 ng/mL) at room temperature for 1 h, then rinsed with distilled water and dried at room temperature. Using the extensive wash procedures (15-min isopropanol wash, followed by three 30-min phosphate buffer washes and then two 60-min washes), in no case would any of the samples be reported out as positive at a cut-off of 5 ng cocaine/ 10 mg hair. With the methanol procedure, 8 of the 14 methanol-washed samples exceeded a cut-off of 5 ng/10 mg hair. Extensive washing was shown to be far more effective for removal of external contamination than the methanol wash procedure reported. In all cases, the extensive aqueous wash protocol would allow the differentiation of ingestion versus external contamination, as defined by this soaking experiment. All samples underwent solid-phase extraction and derivatization followed by liquid chromatographic-tandem mass spectrometric analysis. Analysis was performed on a triple quadrupole API 2000 PerkinElmer Sciex mass spectrometer (MS) equipped with an atmospheric pressure ionization source via an ion spray interface. The MS operated in the positive Cl multiple reaction mode.

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