Atypical urinary opiate excretion pattern

Heroin is rapidly metabolized in humans to 6-acetylmorphine (6-AM), which is further metabolized to morphine and morphine conjugates. Urinary 6- AM is the best diagnostic indicator of heroin abuse. This metabolite however, is usually present in urine at less than 3% of the concentration of urinary total morphine (MOR). We present two case studies of 43-year-old, apparently identical, male twins who displayed an atypical pattern of opiate metabolism. The subjects had a history of opiate abuse, and they are currently in a substance-abuse treatment program. Urine specimens submitted by these subjects for periodic clinical urine drug testing occasionally gave positive responses for opiates by enzyme immunoassay. These samples were then submitted for confirmation analysis using a mixed-mode solid-phase extraction sample preparation, trimethylsilyl derivatization, and capillary gas chromatography-electron impact-mass spectrometry confirmation analysis. These specimens contained as much as 2000 ng/mL of 6-AM with less than 350 ng/mL of MOR, which yielded 6-AM/MOR ratios as large as 1100%. Additional urine samples from these subjects that screened negative for opiates were also tested for the presence of 6-AM. Clinically significant concentrations of 6- AM were found in some of these samples.