Test Catalog

Test Id : MAMMX

Order This Test

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

Download
Overview

Test Catalog

Useful For
Suggests clinical disorders or settings where the test may be helpful

Detecting in utero heroin 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 always under the control of personnel involved with testing the specimen; 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
Lists tests that are always performed, at an additional charge, with the initial tests.

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

Method Name
A short description of the method used to perform the test

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

NY State Available
Indicates the status of NY State approval and if the test is orderable for NY State clients.

Yes

Reporting Name
Lists a shorter or abbreviated version of the Published Name for a test

6-MAM Confirmation, CoC, M

Aliases
Lists additional common names for a test, as an aid in searching

6-MAM (6-Monoacetylmorphine)

Acetylmorphine

Diacetylmorphine (Heroin)

Heroin Metabolite

Specimen Type
Describes the specimen type validated for testing

Meconium

Shipping Instructions

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

Specimen Required
Defines the optimal specimen required to perform the test and the preferred volume to complete testing

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

Specimen Volume: 1 g (approximately 1 teaspoon)

Collection Instructions:

1. Collect entire random meconium specimen.

2. Send specimen frozen. When refrigerated, a significant percentage of 6-monoacetylmorphine will convert to morphine in less than 24 hours.

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

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.

Specimen Minimum Volume
Defines the amount of sample necessary to provide a clinically relevant result as determined by the testing laboratory. The minimum volume is sufficient for one attempt at testing.

0.3 g (approximately 1/4 teaspoon)

Reject Due To
Identifies specimen types and conditions that may cause the specimen to be rejected

Grossly bloody Reject; Pink OK

Specimen Stability Information
Provides a description of the temperatures required to transport a specimen to the performing laboratory, alternate acceptable temperatures are also included

Specimen Type Temperature Time Special Container
Meconium Frozen 14 days

Useful For
Suggests clinical disorders or settings where the test may be helpful

Detecting in utero heroin 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 always under the control of personnel involved with testing the specimen; 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.

Clinical Information
Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test

Heroin (diacetylmorphine) is a semisynthetic opiate that is closely related to morphine. It is no longer used clinically in the United States, although 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 but 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 increases the risk of prematurity and being small for gestational age. Furthermore, infants who have been exposed to heroin exhibit an early onset of withdrawal symptoms compared with infants who have been exposed to methadone. Infants exposed to heroin 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 the drug into bile and amniotic fluid. The 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 it 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 each individual who collected, handled, and 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
Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.

Negative

 

Positive results are reported with a quantitative liquid chromatography tandem mass spectrometry result.

Cutoff concentration: 5 ng/g

Interpretation
Provides information to assist in interpretation of the test results

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.

Cautions
Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances

Because the results of this test may have legal ramifications, it is recommended that testing be performed using chain of custody. A kit including all the materials necessary to complete chain of custody is available to ensure the test results are appropriate for legal proceedings.

 

The short half-life of 6-monoacetylmorphine (6-MAM) may prevent its detection in heroin users.

 

6-MAM is metabolized to morphine, but the presence of morphine alone is not sufficient evidence to prove heroin use. 6-MAM is the only definitive metabolite of heroin.

Clinical Reference
Recommendations for in-depth reading of a clinical nature

1. Giovannelli M, Bedforth N, Aitkenhead A. Survey of intrathecal opioid usage in the UK. Eur J Anaesthesiol. 2008;25(2):118-122

2. Levine B, ed. Principles of Forensic Toxicology. 4th ed. AACC Press; 2013

3. Brunton LL, Hilal-Dandan R, Knollmann BC, eds. Goodman and Gilman's: The Pharmacological Basis of Therapeutics. 13th ed. McGraw-Hill; 2018

4. Szeto HH. Kinetics of drug transfer to the fetus. Clin Obstet Gynecol. 1993;36(2):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, Asensio DC, Naluz A. Drug screening of meconium in infants of drug-dependent mothers: an alternative to urine testing. J Pediatr. 1989;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;60(1):45-56; quiz 73-74

8. Langman LJ, Bechtel LK, Holstege CP. Clinical toxicology. In: Rifai N, Chiu RWK, Young I, Burnham CAD, Wittwer CT, eds. Tietz Textbook of Laboratory Medicine. 7th ed. Elsevier; 2023:chap 43

9. Baselt RC. Disposition of Toxic Drugs and Chemical in Man. 12th ed. Biomedical Publications; 2020

Method Description
Describes how the test is performed and provides a method-specific reference

Meconium is mixed with internal standard and extracted with methanol. The methanolic extract is further processed by solid-phase extraction. The extract is analyzed by liquid chromatography tandem mass spectroscopy.(Unpublished Mayo method)

PDF Report
Indicates whether the report includes an additional document with charts, images or other enriched information

No

Day(s) Performed
Outlines the days the test is performed. This field reflects the day that the sample must be in the testing laboratory to begin the testing process and includes any specimen preparation and processing time before the test is performed. Some tests are listed as continuously performed, which means that assays are performed multiple times during the day.

Monday through Sunday

Report Available
The interval of time (receipt of sample at Mayo Clinic Laboratories to results available) taking into account standard setup days and weekends. The first day is the time that it typically takes for a result to be available. The last day is the time it might take, accounting for any necessary repeated testing.

2 to 3 days

Specimen Retention Time
Outlines the length of time after testing that a specimen is kept in the laboratory before it is discarded

2 weeks

Performing Laboratory Location
Indicates the location of the laboratory that performs the test

Rochester

Fees :
Several factors determine the fee charged to perform a test. Contact your U.S. or International Regional Manager for information about establishing a fee schedule or to learn more about resources to optimize test selection.

  • Authorized users can sign in to Test Prices for detailed fee information.
  • Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
  • Prospective clients should contact their account representative. For assistance, contact Customer Service.

Test Classification
Provides information regarding the medical device classification for laboratory test kits and reagents. Tests may be classified as cleared or approved by the US Food and Drug Administration (FDA) and used per manufacturer instructions, or as products that do not undergo full FDA review and approval, and are then labeled as an Analyte Specific Reagent (ASR) product.

This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.

CPT Code Information
Provides guidance in determining the appropriate Current Procedural Terminology (CPT) code(s) information for each test or profile. The listed CPT codes reflect Mayo Clinic Laboratories interpretation of CPT coding requirements. It is the responsibility of each laboratory to determine correct CPT codes to use for billing.

CPT codes are provided by the performing laboratory.

80356

G0480 (if appropriate)

LOINC® Information
Provides guidance in determining the Logical Observation Identifiers Names and Codes (LOINC) values for the order and results codes of this test. LOINC values are provided by the performing laboratory.

Test Id Test Order Name Order LOINC Value
MAMMX 6-MAM Confirmation, CoC, M 29345-6
Result Id Test Result Name Result LOINC Value
Applies only to results expressed in units of measure originally reported by the performing laboratory. These values do not apply to results that are converted to other units of measure.
36202 6-Monoacetylmorphine 29345-6
36203 Interpretation 69050-3
36204 Chain of Custody 77202-0

Test Setup Resources

Setup Files
Test setup information contains test file definition details to support order and result interfacing between Mayo Clinic Laboratories and your Laboratory Information System.

Excel | Pdf

Sample Reports
Normal and Abnormal sample reports are provided as references for report appearance.

Normal Reports | Abnormal Reports

SI Sample Reports
International System (SI) of Unit reports are provided for a limited number of tests. These reports are intended for international account use and are only available through MayoLINK accounts that have been defined to receive them.

SI Normal Reports | SI Abnormal Reports