Unified Drug Testing by Online SPE-LC/MS/MSFocus on Productivity Achieved Through Ease of Use:

One totally automated method measures ALL the drugs in urine and/or oral Fluids

Mark Hayward,2 Rick Youngblood,2 Kim Gamble,2 Martin Johnson,1 and Matthew T. Hardison1

1Assurance Scientific Laboratories, 727 Memorial Dr. Suite 103, Bessemer AL 35022

2ITSP Solutions Inc., 10 South Carolina St., Hartwell GA 30643

SPE cartridge

SyringePositive pressure micro scale SPE

Automated like this!

Measurement of drugs of abuse in urine and/or oral fluids (OF) is common

• Pre-employment screening• DOT / federal mandated testing• Law enforcement• Compliance / diagnostic determinations by physicians

– Latter two are growing rapidly!• Fastest-growing & preferred approach is LC/MS/MS

– Due to high degree of certainty for simultaneous identification and concentration determination

• Continued growth in the use of LC/MS/MS for the measurement of drugs of abuse in urine and OF seems certain

Still, there are several technical challenges that need to be met

• Easily measure low dose drugs at/near 1 ng/g– For medical purposes [Pesce, et. al. 2012 AACC conference] as well

as for zero tolerance testing• Simplicity for performing measurements with lab technicians

– Automation: load samples / run list (prioritized queuing for STAT samples)

– All LC/MS/MS peaks sufficiently intense for automatic integration• Ability to achieve high productivity for all work

– Needs apply to ALL testing! [not just high volume tests]– Investing 90% effort in 10% of tests is not acceptable

• Minimizing the labor and number of workflows required– Simplicity has always been crucial– As volume and number of tests continues to grow, simplicity grows

in importance!

Pain Management Drug Monitoring• Required to prevent abuse, addiction, diversion,

mortality and morbidity (urine drug testing)• Nevertheless, must meet patient needs first (and not

penalize low, irregular dosing)• Production environment: assembly line • Needs to be easy, robust, and have low labor

requirements to measure all relevant drugs at all relevant concentrations

• Needs sufficient capacity relative to capital investment: ≥100 reimbursable reports per day per LC/MS/MS

How does this impact one's approach toward the measurement methodology?

Measurement range (defining the challenge):low single digit ng/g for some opioids and benzos

Pesce, et. al.

2012 AACC conference

Dilute and shoot is insufficientMeasurement at these levels usually requires some

pre-concentration of the sample SPE, LLEAt the same time, this needs to be easy! automation

Approach chosen: SPE performed with LC/MS/MS autosampler

• Automated (serial) pre-concentration of samples, so that all drugs can be measured in one method

• Remove salts, proteins, and cells for robust LC/MS/MS operation– Very little high LogP (greasy) interferences– Primary role is to filter, pre-concentrate, and remove salts / other H2O soluble

interferences– Reverse phase should be sufficient

• Modest capital investment: must buy LC autosampler regardless choose one that does more of the work CTC/PAL ITSP

ITSP = Instrument Top Sample Prep

What is ITSP?Micro-SPE

performed by a CTC/PAL

ITSP SPE cartridge10-45 mg sorbent

10 mg most common and has 32 l internal volume

ITSP SPE cartridgebeing discarded after use

ITSP SPE: overall system, AKA your autosampler!

Photos: Assurance Scientific Laboratories

Precise syringe driven flow

ITSP = Instrument Top Sample Prep

Technology Capabilities SPE Technologies

ITSP syringe flow SPE Parallel tube and plate based SPE

Pipette based SPE (packed sorbent)

Pipette based SPE (loose sorbent, dispersive)

HPLC Pump flow SPE (2D HPLC)

Total automation YY - but separate workflow flow

from LC/MS and GC/MS [extra robots = extra $$$]

Y - but separate workflow flow from LC/MS and GC/MS [extra

robots = extra $$$]

Y - but separate workflow flow from LC/MS and GC/MS [extra

robots = extra $$$]

Y - requires additional pumps, valves, and fixed columns [extra LC

hardware = extra $$$]

On-line operation w/ LC/MS/MS Y N N N Y

On-line operation w/ GC/MS/MS Y N N N N

Accurate Flow Control Y N N N YSingle use sorbent Y Y Y Y N

All sorbents available Y Y N N NPre-concentrate

w/o dry down Y N N N Y

Fast Y N Y N YMethod development

automation Y N N N N

Off-line operation to feed multiple instruments Y Y Y Y N

Full chain of custody Y - bar code reading possible at every step

Y - with manual labeling and recording of each step N N N

Works with any MS software

Y - SW pre-embedded in all major MS brands

N - separate work flow N - separate work flow N - separate work flow Y - each MS manufacturer has some unique form of 2D HPLC

Ease of use & maintenance

Y - the PAL is a HPLC/GC autosampler & requires same skills & maintenance

Conceptually simple, but laborious and flow control is

challenging. Robots similar to pipette based SPE.

Easy to do once one has bought, set up, and learned how to use separate robotic

pipette systems ($$$)

Easy to do once one has bought, set up, and learned how to use separate robotic

pipette systems ($$$)N

Pros Automation, accuracy, & multiple tests on single system set up Many methods in literature

Easy to do once one has bought, set up, and learned how to use separate robotic

pipette systems ($$$)

Easy to do once one has bought, set up, and learned how to use separate robotic

pipette systems ($$$)Single workflow automation

Cons None Laborious and lack of accurate flow control

Limited sorbent choices and bed masses. Flow control not

proven.

Not proven to improve sample condition and no control of

flow over sorbent

Requires significant expertise and one never knows

when/how SPE column will fail (limits applications)

Comparison of SPE technologies

Understanding ITSP and how it differs from other approaches

• ITSP has precise flow control allowing separations to be performed at their Van Deemter optimum velocity

• This yields separation performance that is difficult (if not impossible) to achieve with other SPE approaches

• ITSP also is a completely unique form of SPE in that it is a truly low volume device (32 l)

• This allows elution to performed precisely with l volumes (ca. 50 l ready for direct injection on LC/MS or GC/MS)

• This allows ITSP to easily pre-concentrate samples by loading 1-10 ml of sample while eluting with <100 l of solvent

• Other forms of SPE require larger volumes for elution (10 to 50x) and significant pre-concentration can only be achieved by adding a separate slow, laborious dry-down step

• No other SPE approach can achieve the precise chromatographic separations, pre-concentration of sample, robust operation, and total automation achieved simultaneously by ITSP

0 1 2 3 4 5 6 7 8

80

85

90

95

100

SCX %-Recovery in 20% WaterSCX %-Recovery in 80% WaterReverse Phase %-Recovery

SPE is Chromatography!Optimized outcomes require accurate flowAre you optimized? Or just guessing?

OxycodoneVan Deemter curves

for SPE by ITSP

SCX optimum velocity = 0.37 mm/s (1.2 l/s by ITSP) with little room for error!

RP optimum velocity = 1.5 mm/s

(4x higher than SCX!)

SPE flow driven pneumatically or by vacuum cannot achieve and maintain optimal flow!

ITSP

= T

OTA

L CO

NTR

OL

OF

YOU

R SP

E! ITSP = TOTAL CO

NTRO

L OF YO

UR SPE!

Flow (l/s) [5 l/s = 1.5 mm/s]

% R

ecov

ery

SPE-LC/MS/MS method developmenthelicopter view of strategy

• Focus on simplicity and minimization of steps• Prioritize hardest to measure drugs (lowest concentration,

low dose opioids and benzos) over the easy to measure drugs for recovery optimization and pre-concentration

• Focus on relative recoveries for elution pre-concentrate• Choose balanced LC/MS conditions that allow separation

and measurement of both acidic and basic drugs as well as polar and non-polar drugs (1 method, all drugs!)

• Establish linear scalability and stoichiometry in sample loading as a data driven way to establish the validation readiness of the method

• Leverage automation to achieve rapid method development and execution ITSP with the CTC/PAL

• Develop the method for urine first, then adapt to oral fluid

Serially automated SPE method development Parallel testing of C18 and DVB SPE phases (3x): each step is a sample list!

Hands on view of strategy

• Test SPE cartridge wash with various solvents (3x cartridge volume) and no wash: rinse cartridge with water, load spiked urine & measure drug breakthroughs (choose wash solvent)

• Test SPE cartridge conditioning & loaded sample wash with buffers (at 3x cartridge volume): load spiked urine & measure drug breakthroughs (choose conditioning/wash buffer)

• Test SPE cartridge elution with various solvents and measure drug recoveries (choose elution solvent and measure optimal flow)

• Test SPE cartridge elution at multiple volumes with various buffers in chosen elution solvents and measure drug recoveries (pre-concentrate) while monitoring LC separation (choose elution buffer based on LC separation first, then recoveries)

• Vary sample amount over a range of at least 10x and measure drug recoveries. If linear stoichiometry is not observed, re-optimize above steps based on data. If linear, re-optimize LC/MS/MS, choose sample amount, then validate!

Automated method development• Run each of the 5 lists sequentially (described in previous

slide) transferring optima measured into next list• Optima results:– Sorbent: C18 end-capped (gives higher recovery for benzos /

opioids)– Conditioning: MeOH, then NH4OAc buffer– Loading: ≥0.5% NH4OAc in sample, Flow 5 l/s– Wash: aqueous NH4OAc (≥0.5%)– Elution: 0.2% NH4OAc in MeOH, 75 l at 5 l/s (pre-

concentrates lowest concentration drugs most)– Sample load range: 100 – 500 l is linear at 0.5% NH4OAc in

sample (can be increased with higher %NH4OAc in sample)

Minimizes breakthrough

Test compatibility of SPE eluent with LC separation (SPE – LC interfacing)

5x10

00.025

0.050.075

0.10.125

0.150.175

0.20.225

0.250.275

0.30.325

0.350.375

0.40.425

0.450.475

0.50.525

0.550.575

0.60.625

0.650.675

0.70.725

0.750.775

0.80.825

0.850.875

0.90.925

0.950.975

11.025

1.051.075

1.11.125

1.151.175

1.21.225

1.251.275

1.31.325

1.35

Cpd 9: Codeine: +ESI MRM Frag=140.0V CID@31.0 (300.0000 -> 199.0000) C18 80% ACN elution 0.175% NH4 Acetate 2ul Loop.d

1.395

1.179

Counts vs. Acquisition Time (min)0.88 0.9 0.92 0.94 0.96 0.98 1 1.02 1.04 1.06 1.08 1.1 1.12 1.14 1.16 1.18 1.2 1.22 1.24 1.26 1.28 1.3 1.32 1.34 1.36 1.38 1.4 1.42 1.44 1.46 1.48 1.5 1.52 1.54 1.56 1.58 1.6 1.62 1.64 1.66 1.68 1.7 1.72 1.74 1.76 1.78

Codeine

Hydrocodone

80% ACN

Buffered 80% ACN

Of course, chemical presentation of the sample from SPE to LC is important

Just like with SPE, control of the pH (ionization state) controls retention

Buffer: NH4OAcLC column: C18

B = ACN

Elution in 80% ACN limits LC injection volume to 2 l (2.1 x 50 mm column). Elution in 100% MeOH (buffered) allows 5 l LC injection. Viscosity has an equally important role in LC injection along with pH.

SPE eluent

SPE elution volumeAllows optimization for drug classes

40 50 60 70 80 90 1000.4

0.6

0.8

1

THCA6-MAMBuprenorphineCodeineDiazepamSecobarbitalPhencyclidine

Elution volume (ul)

Nor

mal

ized

resp

onse

Favors opiates, metabolites, and other illicits

Favors opioids, benzos, barbs, and THCABest for PM

C18 SPE data shown with MeOH elutionDVB with MeOH elution favors low volume elution for all drugs

k’ = 1.5 - 2 k’ = 2 - 3

Gains in sensitivity from lower volume elution using DVB do not outweigh the absolute recoveries observed with C18 SPE

k’ > 3

Dilutes all drugs

0 100 200 300 400 500 600 700 800 900 10000

0.5

1

MDMAFentanylAmphetamineDiazepamOxymorphonePentobarbitalTHCA

Sample loading: defining SPE cartridge capacity and linear working range

Linear range

Current TQs

Older TQs

500 l syringe loading sample at 5 l/s

Volume (l) of urine loaded on SPE cartridge

ROI optimumPre-concentration 1.5-3x

Nor

mal

ized

LC/M

S/M

S re

spon

se

C18 SPE, MeOH elution, 0.5% NH4OAc in sample

Linear response observed within 100 to 500 l sample load range for all PM drugsCurrent triple quads (TQs) can measure all PM drugs in the lower half of this rangeOpiates, metabolites, and other illicits saturate cartridge first at 500 to 1000 l sample loadPerformance below 100 l can be improved with smaller syringe and blowing out cartridge with air at each step (RTC) [also dilution to 200 l with PAL works nicely]ITSP cartridge volume is 32 l

Opioids and benzos are most optimized by design (recoveries >90%)

Opiates, metabolites, & illicits fully functional (recoveries 80-90%) Linear range can be

extended with higher %NH4OAc in sample

Focus on the LC/MS/MS also can be productive

6x10

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

0.55

0.6

0.65

0.7

0.75

0.8

0.85

0.9

0.95

1

1.05

1.1

1.15

1.2

1.25

1.3

1.35

1.4

1.45

1.5

1.55

Cpd 99: 11-nor-9-Carboxyl-THC: +ESI MRM Frag=120.0V CID@14.0 (345.0000 -> 327.2000) C1850 ul Elution.d

4.40

2

Counts vs. Acquisition Time (min)0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4 4.1 4.2 4.3 4.4

6x10

00.10.20.30.40.50.60.70.80.9

11.11.21.31.41.51.61.71.81.9

22.12.22.32.42.52.62.72.82.9

33.13.23.33.43.53.63.73.83.9

44.14.24.34.44.54.64.74.84.9

55.15.25.35.45.55.65.7

Cpd 96: 11-nor-9-Carboxyl-THC: +ESI MRM Frag=120.0V CF=0.000 DF=0.000 CID@14.0 (345.0000 -> 327.2000) 2000B.d

4.067

Counts vs. Acquisition Time (min)0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4 4.1

Original LC/MS/MSIt works4.5 min

Heat column, increase flow, add gradient segmentsImprove separation where peaks are crowdedDecrease time between well separated peaks4.1 minColumn switching / conditioning also saves overhead time

Acidic drugs can be measured under LC conditions used for basic drugs

4x10

00.10.20.30.40.50.60.7

0.80.9

11.11.21.31.41.51.61.71.81.9

22.1

2.22.32.42.52.62.72.82.9

33.13.23.33.43.53.6

3.73.83.9

44.14.24.34.44.54.6

Cpd 96: 11-nor-9-Carboxyl-THC: +ESI MRM Frag=120.0V CF=0.000 DF=0.000 CID@14.0 (345.0000 -> 327.2000) 2000B.d 1

Counts vs. Acquisition Time (min)2.4 2.45 2.5 2.55 2.6 2.65 2.7 2.75 2.8 2.85 2.9 2.95 3 3.05 3.1 3.15 3.2 3.25 3.3 3.35 3.4 3.45 3.5 3.55 3.6 3.65 3.7 3.75 3.8 3.85 3.9 3.95 4 4.05 4.1 4.15 4.2 4.25 4.3 4.35

THCA

Pentobarbital Secobarbital

Workflow: minimizing cycle timePAL operation in the inject ahead mode

SPE 1 SPE 2 SPE 3LC/MS/MS 1 LC/MS/MS 2

4.5 min 4.5 min

…………

Total cycle time (SPE + LC/MS/MS) = 4.5 min

Summary: Drugs in urine• An online and automated SPE-LC/MS/MS method has been

developed for pain management (PM) monitoring in urine samples• The method is scalable and can be adapted to any LC/MS/MS simply

by adjusting the volume of urine loaded for SPE• Rather than using multiple panel focused methods, this single

method is used to measure all PM related drugs• Method development focus has been on the lowest dose, hardest to

measure prescribed drugs (suggests prioritization works!)

• Rework is limited to only the highest dose drugs in the highest dosed patients (inject less, bring into linear range)

• Robust operation and a cycle time (SPE + LC/MS/MS) of 4.5 min has been achieved

• The use of ITSP with the CTC/PAL for serial automation is a very efficient way to perform SPE method development: this method required 3 lab days using 1 SPE-LC/MS/MS system

Adapt method developed for urine to function equally well for oral fluid (OF)• First things first: choosing a sampling device• Many considered / criticized, primary concerns:• Sample stability• Volumetric sampling accuracy

• We added need for forensic acceptance and success when challenged at trial

• Quantisal sampling device chosen for its:• Highest volumetric accuracy (+/-10%)• Built in filtering (important: all OF samples require either

filtering or centrifugation)• >1 week sample stability• Greatest acceptance in clinical and forensic use

Adapt / test method for oral fluid (OF)• SPE and sample buffering increased to 2% NH4OAc to overcome built in

Quantisal buffering • High opiate / illicit drug recovery requires formation of drug-OAc ion

pair• Sample volume increased to 1 ml to achieve 0.1 ng/g cut offs• Drug concentrations lower in OF 13x pre-concentration

• Linear response for 71 drugs achieved• Method tested with 20 multi medication / not so good prognosis patient

samples where both urine and OF collected in parallel and tested with both LC/MS/MS and immunoassay– LC/MS/MS in complete agreement for urine and OF (no false neg) and “partying”

successfully detected in one sample set– Included patients dosed 1 mg/day opioids / benzos: easily measured / auto-

integrated at approx 0.5 ng/g in OF (0.1 ng/g cutoffs)– Immunoassay showed one of its deficiencies by not being able to detect /

confirm 1 mg/day dosed drugs (urine and OF)

Unified urine and oral fluid method results

• Lab time to adapt urine method to OF: 2 days• Again, leveraging the automation

• Method (urine & OF) validated to both clinical and forensic standards in multiple labs (cv 3-5%)

• Urine and OF can be measured in the same run• Still need to include blanks, calibrators, and QCs for

both• Method (urine & OF) in use for production work and

delivering 100-200 results overnight for each LC/MS/MS• High ROI readily achieved for top end LC/MS/MSs

What’s next? Larger range of tests ready to run with a single LC/MS/MS• We have successfully added Vit D (blood) measurement to individual

PAL systems already measuring drugs in urine / OF– These 3 tests are currently considered highest ROI in clinical lab– 2 cartridge types, 2 LC column types, all on-board, all the time

• We have drug methods for blood/serum/plasma/DPS/DBS samples to add to these systems (ion exchange SPE)– Includes DPS/DBS disk extraction and IS addition

• We are implementing SPE solvent sourcing to Fast Wash stations (up to 4) as an alternative to ink wells– Up to 8 solvents total using minimal PAL rail– Allows 2-4 weeks of solvent capacity (0.5-2 liter bottles)

• We are implementing 4 way valve cleaning solvent sourcing for DLW (multiple cleaning chemistries for multiple methods)

• This should allow 4 tests to be setup/ready to run on single PAL-LC/MS/MS systems requiring only method selection in MS software and perhaps loading color coded SPE cartridges