neotox | winter/spring 2016

NeoTox

4Addressing substance abuse in pregnancy in West Virginia

8Breaking barriers in determining prenatal alcohol exposure

13Buprenorphine use surpasses methadone use nationally

Clarity in Newborn Toxicology | v.7 i.1

Seeking the TruthWest Virginia’s efforts to

uncover the hard facts

of maternal drug and

alcohol abuse

Winter/Spring

2016

2 Winter/Spring 2016 NeoTox

Letter from the editor

TOUGH TOPICSExamining the trends in prenatal drug and alcohol use.

Discussing alcohol and drugs during pregnancy is always a tough topic. Drug abuse among pregnant women is continuing to rise and many organizations are starting to take note of the statistics that are shifting in their regions. Along with the need to understand trending use in the different areas of our country, is the need to also understand the long term results of these trends.

This issue touches on both topics. The first article discusses the West Virginia Perinatal Partnership

and the state’s prevalence of maternal substance abuse. The latter discusses the future of prenatal alcohol screening and the promise it might hold for underdiagnosed occurrences of FASD and FAS.

As always, we hope you find this issue valuable. If so, please consider sharing it online. This helps us

reach even more people with our information. This, and past issues, are available under the Resources tab on our website.

We are always looking for article submissions that would be beneficial to our readers. If you would like to

tell your unique story about newborn drug testing, applications, or outcomes, please feel free to contact us via [email protected]. Submissions are not guaranteed to be published. All thoughts are welcome.

Thanks for reading,Michelle Lach, Editor-in-Chief

3USDTL

Table of Contents

4

ADDRESSING SUBSTANCE ABUSE IN PREGNANCY: ONE STATE’S MISSION Stefan Maxwell, MB.,BS., FAAP

While the statistics were already alarming, those working with babies in West Virginia knew data greatly underreported the problem and aimed to provide a more accurate assessment of the prevalence of maternal substance abuse.

8

OVERCOMING OBSTACLES IN IDENTIFYING PRENATAL ALCOHOL EXPOSUREStefan Maxwell, MB.,BS., FAAP

Determining the prevalence of maternal alcohol consumption is difficult, but studies show the future of prenatal alcohol screening is promising.

13

DATA IN ACTION

CESAR FAX: 2014 NFLIS finds nearly three times more buprenorphine than methadone reports.

14

NATIONAL POSITIVITY RATES

USDTL quarterly national results for drug and alcohol testing in umbilical cord and meconium specimens.

Original images from iStock.

NeoToxWinter/Spring 2016

volume 7issue 1

Editor-in-Chief Michelle Lach, MSIMC

Managing & Design EditorDru Wagner, MA

Science Advisory BoardDouglas Lewis, D.Sc.

Joseph Jones, MS NRCC-TCAdam Negrusz, Ph.D. F-ABFTAileen Baldwin, Ph.D., MPH

NeoTox is a quarterly news magazine of science, data, and news about perinatal toxicology and substance exposure issues. It is our mission to distill the technical world of toxicology, drug testing, and addiction science into plain words. If you have suggestions for topics you would like to know more about, let us know.

[email protected]

1700 S. Mount Prospect Rd.Des Plaines, IL, 60018

847.235.2367

© 2016 USDTL All Rights Reserved.

USDTL.com

ADDRESSING SUBSTANCE ABUSE IN PREGNANCY: ONE STATE’S MISSIONWhile the statistics were already alarming, those working with babies in West Virginia knew data greatly underreported the problem and aimed to provide a more accurate assessment of the prevalence of maternal substance abuse.

by Stefan Maxwell, MB.,BS., FAAP

There has been a recent focus, particularly in West Virginia, on the use of opioids during pregnancy and resulting neonatal abstinence syndrome (NAS) in infants, which has risen to alarming proportions. Substance abuse in pregnancy is a serious health concern for both the mother and her child. For the mother, episodes of drug withdrawal, perhaps coupled with inebriation and illnesses related to high risk behavior may occur, sometimes with near-fatal consequences or death. As the fetus is exposed to these substances, the effect on its development can vary depending on the concentration of drug, the frequency of exposure and the stage of development when the exposure occurs. The newborn is susceptible to neonatal abstinence syndrome or other neurobehavioral effects that present shortly after birth, potential congenital malformations, intrauterine growth restriction, prematurity and long-term adverse effects on growth and cognitive development.

Analyses from the Kid’s Inpatient Database reported increased maternal opiate use from 1.2 to 5.6 per 1000 hospital births from 2000 to 2009, and a rising incidence of NAS from 1.2 to 5.8 per 1000 hospital births per year from 2000 to 2012.1,2 In addition, the admission rate to 299 neonatal intensive care units (NICU) in the United States

rose from 7 to 27 cases per 1000 admissions from 2004 to 2013, with an increase in the median length of stay from 13 to 19 days.3 In each of the three Level III NICU hospitals in West Virginia, we are experiencing much higher rates of this epidemic. In 2013, Cabell-Huntington Hospital had greater than 100 cases of NAS per 1000 births. According to the most recent report by the West Virginia Maternal and Infant Mortality review team, 27% of maternal mortality from 2007 to 2012 was a result of drug abuse. There has also been a 214% increase in the rates of prescription drug overdoses in West Virginia between 2001 and 2010. According to the Centers for Disease Control (CDC) the state continues to have the highest incidence of deaths from opioid overdose in the country with 35.5 deaths per 100,000, an increase of 10% from 2013.4

Back in 2006, realizing that the state of West Virginia had some of the worst health outcomes in the country related to low birth weight, infant mortality, and teen pregnancy, the West Virginia Perinatal Partnership (WVPP) was formed. This partnership brought together a wide cross-section of

5USDTL

Back in 2006, realizing that the state of West Virginia had some of the worst health outcomes in the country related to low birth weight, infant mortality, and teen pregnancy, the West Virginia Perinatal Partnership (WVPP) was formed.

Winter/Spring 2016 NeoTox6

providers, chairs and directors of perinatal health organizations, deans and representatives from the three medical schools in the state, and payers of health care in West Virginia. After almost two years of investigation, including surveys of providers, chart reviews and hospital discharge diagnoses, the inclusion of questions on our birth score data form (a form filled out on all births, with a compilation of data that comprises a “score” that identifies “high risk” infants) the incidence of substance use during pregnancy was estimated to be in 5% of births. Those of us taking care of babies in the

state knew that the incidence was much higher, and felt the available data seriously underreported the extent of the problem.

We believed that to obtain a more accurate assessment of the prevalence of substance abuse during pregnancy across the state we should conduct an anonymous sampling of umbilical tissue to screen for multiple drug metabolites and alcohol, rather than relying on medical records and self-report. With funding from the West Virginia Department of Health and Human Services we were able to collect 759 umbilical cord samples

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from eight birthing hospitals across the state in August 2009.5 Of the 759 samples collected, there were 115 (15%) cord specimens that were positive for drugs. Marijuana was the most prevalent drug detected, followed by opiates, benzodiazepines, and methadone. Many of these samples showed significant polysubstance usage, particularly among patients using benzodiazepines and methadone. There was also significant regional variation in drug use, ranging from 10% at Thomas Memorial (South Charleston) and City Hospital (Martinsburg) to 19% at Raleigh General (Beckley). With almost 1 in 6 babies being born with evidence of drug exposure, this study clearly demonstrated the significance of the problem of substance abuse during pregnancy in West Virginia.

Whereas it is of paramount importance to respond appropriately to this epidemic of opioid usage during pregnancy and the rising incidence of neonatal abstinence syndrome, it is also of urgent need to address the issue of alcohol use in pregnancy, which I believe is grossly under-recognized. Maternal alcohol use and prenatal alcohol exposure remain a serious public health problem worldwide. Alcohol freely crosses the placenta and is known to be teratogenic, interfering with normal prenatal development.6

In West Virginia, reported rates of alcohol use

during pregnancy from birth certificate or birth score forms have been estimated at 1.2%. This rate is likely an underestimate of actual prevalence rates of alcohol use during pregnancy, based on the findings from the aforementioned pilot study that screened umbilical cord samples for drugs and

alcohol. Using detection of PEth in the umbilical cord tissue as an indication of alcohol exposure, this study found an overall detection rate of alcohol use during pregnancy of 5.1% across all of West Virginia, with a range of 5 to 15% positivity among the different hospitals.5 At the Women and Children’s Hospital and the Women’s Medicine Center Clinic in Charleston, this umbilical cord tissue study revealed a rate of alcohol use of 8.3%,where rates from the birth certificate and birth score forms was 0.7%. The results of this study clearly demonstrated that alcohol use by pregnant women was being grossly under-reported and new methods for screening women during prenatal care was necessary to identify these women to improve early prevention and intervention.

To determine the most efficacious method of

Continued on page 12, Substance Abuse

Of the 759 samples collected, there were 115 (15%) cord specimens that were positive for drugs. Marijuana was the most prevalent drug detected, followed by opiates, benzodiazepines, and methadone.

1 in 6In this study, nearly

babies were born with evidence of drug exposure

5.1%In this study,

of the umbilical cord tissue tested positive for alcohol exposure

214%There has been a

increase in the rates of prescription drug overdoses in West Virginia in 2001 and 2010


OVERCOMING OBSTACLES IN IDENTIFYING PRENATAL ALCOHOL EXPOSUREDetermining the prevalence of maternal alcohol consumption is difficult, but studies show the future of prenatal alcohol screening is promising.

by Stefan Maxwell, MB.,BS., FAAP

Infants whose mothers consume alcohol during pregnancy can have a range of neurobehavioral and developmental disabilities that are collectively referred to as fetal alcohol spectrum disorders (FASD). The extent of damage is dependent on the duration and magnitude of alcohol exposure and developmental timing.1,2 The most severe cases from chronic exposure to high levels of alcohol are diagnosed with fetal alcohol syndrome (FAS), a disorder defined by growth deficiencies and specific facial and nervous system malformations.

Determining the prevalence of FASD in populations is challenging, as identifying children affected by prenatal alcohol exposure is a difficult task that results in under diagnosis of FASD. Historically, prevalence rates of FAS and FASD have utilized surveillance systems, medical and other records, or special referral clinics and have likely

underestimated the actual prevalence rates.3,4 The Centers for Disease Control and Prevention (CDC) has estimated that FAS occurs at a rate of 0.2 to 1.5 per 1000 children5,6 and the Institute of Medicine (IOM) estimates 0.5 to 3 infants with FAS per 1000 children.7 More current estimates in the United States range from 0.2 to 7 infants with FAS per

1000 children and up to 2% to 5% of school age children with an extended diagnosis of FASD.8,9

There are several barriers to the early recognition and accurate diagnosis of children and adolescents with FASD. There is frequently a lack of clear physical findings in children affected by alcohol exposure, confusing language and diagnostic terminologies applied to these children, and the stigmata associated with alcohol use in pregnancy, which leads to inaccurate history-taking in prenatal visits. In a recent study by Chasnoff et al. (2015) a comprehensive evaluation was completed on 547 children that had been referred to their children’s mental health clinic to assess the rate of missed diagnoses and misdiagnosis of FASD. They found that among the children that met criteria for a diagnosis of FASD, 80.1% had a missed diagnosis for FASD and a misdiagnosis within the

spectrum of FASD in 6.4% of the children.10 In that study, attention deficit/hyperactivity disorder (ADHD) was the most common referral diagnosis for

children who were ultimately diagnosed with FASD. One important factor leading to misdiagnosis and

missed diagnoses of FAS and FASD is that there is no medical test available to document alcohol exposure during pregnancy. A majority of infants exposed to alcohol during pregnancy have no clear physical features of FAS at birth, and consequently

Historically, prevalence rates of FAS and FASD have utilized surveillance systems, medical and other records, or special referral clinics and have likely underestimated the actual prevalence rates.

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are not diagnosed with FASD until much later in childhood. The availability of a reliable marker to ascertain alcohol exposure in early postnatal life could assist in the diagnosis of these children much sooner. These children could then be targeted for early intervention and developmental assessments much earlier in life, particularly helping children from birth to 3 years of age take advantage of early neuroplasticity and reduce the long-term adverse effects of fetal alcohol exposure.

Confirmation of exposure to alcohol during pregnancy has typically relied on maternal history documentation, including approved screening instruments (AUDIT-C, T-ACE, 4 Ps Plus, TWEAK, TQDH), or detection of ethanol or ethanol metabolites in urine, hair, or nails. These methods can be unreliable if pregnant women do not give an accurate drinking history due to recall bias or fear of stigmatization and embarrassment, and urine testing can only detect alcohol consumption for up to 36 hours. In the infant, there are also biological markers of alcohol exposure that can be detected in urine, meconium, umbilical cord tissue or more recently, from the heel stick blood spot that is collected from every newborn for routine genetic screening tests.

A new assay that has become available recently is for detecting Phosphatidylethanol (PEth) in dried blood spot cards. PEth can form in red blood cells as a component of the cellular membrane only when ethanol is present, and is therefore a direct alcohol biomarker. This assay is a highly sensitive liquid

chromatography-tandem mass spectrometry (LC-MS/MS) method for the extraction and detection of PEth from dried blood spots on filter paper.11 Detection of PEth can indicate alcohol consumption for up to a 3-week period after moderate to heavy drinking. There are a growing number of published studies that suggest screening newborn dried blood cards for detection of PEth could also be a feasible and effective method to detect prenatal alcohol exposure. Studies have demonstrated that

the dried blood cards that are used to collect newborn blood samples for genomic screening can stabilize PEth at room temperature for six to

nine months and even longer when stored at lower temperatures.12,13,14 Ongoing studies by Bakhireva et al. (2014) have demonstrated that PEth screening of newborn dried blood cards is a feasible and highly specific method for detecting prenatal alcohol exposure and is also more sensitive than other currently used newborn alcohol biomarkers.15 Further research studies by USDTL and outside research groups that have partnered with USDTL to utilize PEth screening are aiming to establish the evidentiary utility of PEth as a biological screening test for prenatal alcohol exposure and the predictive ability of PEth to determine level of risk for the development of disabilities related to FASD.

References1. Spagnolo A. Teratogenesis of alcohol. Annali dell’Istituto

superiore di sanita. 1993;29(1):89-96. Epub 1993/01/01.

PubMed PMID: 8129276

2. May PA, Blankenship J, Marais AS, Gossage JP, Kalberg

WO, Joubert B, et al. Maternal alcohol consumption

producing fetal alcohol spectrum disorders (FASD):

A majority of infants exposed to alcohol during pregnancy have no clear physical features of FAS at birth, and consequently are not

diagnosed with FASD until much later in childhood.

11USDTL

Quantity, frequency, and timing of drinking. Drug

and alcohol dependence. 2013. Epub 2013/08/13. doi:

10.1016/j.drugalcdep.2013.07.013. PubMed PMID:

23932841.

3. Jones KL, Smith DW Recognition of the fetal alcohol

syndrome in early infancy. Lancet. 1973, 302(7836): 999-

1001.

4. May PA, Baete A, Russo J et al. Prevalence and

characteristics of fetal alcohol spectrum disorders.

Pediatrics. 2014, 134 (5) 855-866.

5. Centers for Disease Control and Prevention (CDC)

Surveillance for fetal alcohol syndrome using multiple

sources---Atlanta GA, 1981-1989. MMWR Morb Mortal

Wkly Rep. 1997;46(47):1118-1120.

6. Centers for Disease Control and Prevention (CDC)

Update trends in fetal alcohol syndrome---United States,

1979-1993. MMWR Morb Mortal Wkly Rep. 1995; 44(13):

249-251.

7. Stratton KR, Howe CJ, et al. Fetal Alcohol Syndrome

Diagnosis, Epidemiology, Prevention and Treatment.

Washington DC National Academy Press. 1996.

8. May PA, Gossage JP, et al. Prevalence and epidemiologic

characteristics of FASD from various research methods

with an emphasis on recent in-school studies. Dev. Disabil

Res Rev. 2009;15(3):176-192.

9. Sampson PD, Streissguth AP, et al. Incidence of fetal

alcohol syndrome and prevalence of alcohol-related

neurodevelopmental disorder. Teratology. 1997;56(5):317-

326.

10. Chasnoff IJ, Wells AM, King L. Misdiagnosis and

Missed diagnoses in Foster and Adopted Children with

Prenatal Alcohol Exposure. Pediatrics. 2015;135(2):264-

270.

11. Jones JJ, M.; Plate, C.; Lewis, D. The detection of

1-palmitoyl-2-oleoyl-sn-glycero-3-phosphoethanol in human

dried blood spots. Analytical Methods. 2011;3(5):1101-6.

12. Faller A, Richter B, Kluge M, Koenig P, Seitz HK,

Skopp G. Stability of phosphatidylethanol species in

spiked and authentic whole blood and matching dried

blood spots. Int J Legal Med. 2012.

13. Bakhireva LN, Shrestha S, Gutierrez HL, Berry M,

Schmitt C, Sarangarm D. Stability of Phosphatidylethanol

in Dry Blood Spot Cards. Alcohol. 2015. Epub

2015/11/01. doi: 10.1093/alcalc/agv120. PubMed

PMID: 26519350

14. Baldwin AE, Plate C , Shu I, Jones J, Lewis D.

Retrospective Assessment of Prenatal Alcohol Exposure

by Detection of Phosphatidylethanol in Stored Dried

Blood Spot Cards; an Objective Method for Determining

Prevalence Rates of Alcohol Consumption During

Pregnancy. International Journal of Alcohol and Drug

Research. 2015, 4(2), 131-137.

15. Bakhireva LN, Leeman L, Savich RD, Cano

S, Gutierrez H, Savage DD, et al. The validity of

phosphatidylethanol in dried blood spots of newborns

for the identification of prenatal alcohol exposure. Alcohol

Clin Exp Res. 2014;38(4):1078-85. Epub 2014/02/12. doi:

10.1111/acer.12349. PubMed PMID: 24511895.

Dr. Stefan Maxwell has served the mothers and babies at CAMC Women and Children’s Hospital in Charleston, West Virginia, as Chief of Pediatrics and Medical Director of the NICU for over 25 years. He is a founding member of PEDIATRIX Medical Group and has served on the West Virginia Perinatal Partnership Central Advisory Council since 2006, providing leadership as Chair of the Central Advisory Council since 2013 and as Chair of the Committee on Substance Use During Pregnancy for over 9 years. In addition, Stefan is a Clinical Associate Professor of Pediatrics at West Virginia University School of Medicine.


With almost 1 in 6 babies being born with evidence of drug exposure, this study clearly demonstrated the significance of the

problem of substance abuse in pregnancy in West Virginia.

Substance Abuse, continued from page 7.

screening for alcohol use during prenatal care, we recently conducted a prospective observational study of women presenting for their first prenatal visit to the obstetric clinic at Women and Children’s hospital. Our hospital currently conducts universal screening for drugs and alcohol use using urine toxicology testing. The purpose of this study was to compare the detection rates of alcohol use during

pregnancy between the clinic’s current practice of medical history assessment and a urine screen for ethanol with a method that would include medical history assessment and screening PEth from a blood spot collected by a finger stick. After testing a total of 314 patients, it was clear that screening with PEth identified significantly more patients than urine ethanol screening, with a detection rate of 7% versus 1.6%. This study also found that self-reporting of alcohol use during pregnancy was not as reliable as PEth screening, as only 1.9% of the study population reported alcohol use.

These initial prospective observational studies have indicated the need for further action with regards to the prevalence of substance abuse and alcohol consumption during pregnancy in West Virginia in order to address the potential maternal and neonatal consequences. It appears that there may be an alarming number of infants, at least in this population of clinic patients that have been exposed to drugs and/or alcohol during pregnancy which may have lasting consequences. These babies may not be diagnosed to have neurodevelopmental deficits until later in childhood or even in early adolescence, and then may be misdiagnosed or their diagnosis may be missed altogether.

References1. Patrick, SW, Schumacher, RE, et al. Neonatal

abstinence syndrome and associated health care

expenditures. United States, 2000-2009, JAMA. 2012;

307:1934.

2. Patrick, SW, Davis, MM, et al. Increasing incidence

and geographic distribution of neonatal abstinence

syndrome: United States 2009-2012. J Perinatol. 2015;

35:650.

3. Tolia, VN, Patrick, SW, et al. Increasing incidence of

the neonatal abstinence syndrome in US neonatal ICUs.

N Engl J Med. 2015 372:2118.

4. Rudd, RA, Aleshire, N, Zibbell, JE, Gladden, RM.

Increases in Drug and Opioid

Overdose Deaths - United States,

2000-2014. MMWR Morb Mortal Wkly

Rep. 2016;64(50-51):1378-82. Epub

2016/01/01. doi: 10.15585/mmwr.

mm6450a3. PubMed PMID: 26720857.

5. Stitely, ML, Calhoun, B, Maxwell, S. et al. Prevalence

of drug use in pregnant West Virginia patients. WV Med

J. 2010; 106:48-52.

6. Jones, KL, Smith, DW, Ulleland, CN, Streissguth,

P. Pattern of malformation in offspring of chronic

alcoholic mothers. Lancet. 1973;1(7815):1267-71. Epub

1973/06/09. PubMed PMID: 4126070.

Dr. Stefan Maxwell has served the mothers and babies at CAMC Women and Children’s Hospital in Charleston, West Virginia, as Chief of Pediatrics and Medical Director of the NICU for over 25 years. He is a founding member of PEDIATRIX Medical Group and has served on the West Virginia Perinatal Partnership Central Advisory Council since 2006, providing leadership as Chair of the Central Advisory Council since 2013 and as Chair of the Committee on Substance Use During Pregnancy for over 9 years. In addition, Stefan is a Clinical Associate Professor of Pediatrics at West Virginia University School of Medicine.

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BUPRENORPHINE USE SURPASSES

METHADONE USE

2014 NFLIS Finds Nearly Three Times More Buprenorphine Than Methadone Reports

The National Forensic Laboratory Information System (NFLIS) collects drug test results from law enforcement-encountered drug items submitted to and analyzed by state and local forensic laboratories across the country. NFLIS data can provide valuable information about trends in the drugs seized by U.S. law enforcement. In 2014, the number of NFLIS reports for buprenorphine reached a high of 15,209, almost three times the number of methadone reports (5,559). Buprenorphine reports increased from 90 in 2003

(one year after buprenorphine was approved to treat opioid dependence) to 15,209 in 2014. In contrast, methadone reached a peak of 10,016 reports in 2009, and has since decreased each year. In 2014, the Northeast had the highest rate of buprenorphine reports (9.79 per 100,000 persons aged 15 or older), while the West had the lowest rate (2.09 per 100,000 persons). More information about buprenorphine can be found in the CESAR FAX Buprenorphine Series, available online at http://go.umd.edu/cesarfaxbuprenorphine.

NOTES: Estimates are calculated using the National Estimates Based on All Reports (NEAR) methodology, which has strong statistical advantages for producing national and regional estimates. Estimates are based on drug cases and items submitted to participating state and local laboratories during the calendar year and analyzed within three months of the end of the calendar year. Up to three drugs can be reported for each drug item (or exhibit) analyzed by a laboratory. State and local policies related to the enforcement and prosecution of specific drugs may affect drug item submissions to laboratories for analysis. Laboratory policies and procedures for handling drug evidence may also vary. For example, some analyze all items submitted, while others analyze only selected items. Many laboratories do not analyze drug evidence if the criminal case was dismissed from court or if no person could be linked to the item. Thus, NFLIS data might underestimate the availability of drugs in the illicit market that state or local labs do not systematically identify.

SOURCES: Adapted by CESAR from data provided by the U.S. Drug Enforcement Administration (DEA), Office of Diversion Control, Drug and Chemical Evaluation Section, Data Analysis Unit and from NFLIS Annual Reports (available online at https://www.nflis.deadiversion.usdoj.gov/Reports.aspx).

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2,409

3,892

5,7196,901

7,5398,221

9,202 9,13610,016

9,477

8,8538,071

6,5425,559

36 19 90 360 7921,537

2,855

4,961

7,508

10,53710,92211,80111,992

15,209

Methadone

Buprenorphine

Estimated Number of Total NFLIS Reports for Methadone and Buprenorphine, 2001-2014

Meconium Specimens

Amphetamines | 5.9%

Cocaine | 3.2%

Opiates | 9.2%

Cannabinoids | 22.5%

Oxycodone | 1.4%

Meperidine | 0.8%

Tramadol | 1.8%

Buprenorphine | 8.0%

Fatty Acid Ethyl Esters | 11.7%

Barbiturates | 1.2%

Methadone | 4.4%

20 30100

Not shown: Phencyclidine 0.0%, Propoxyphene 0.0%

Report date range: October 1, 2015 – December 31, 2015

* These data report national positivity rates for newborn toxicology tests conducted by USDTL on behalf of external clients and are not reflective of systematic research results.

15USDTL

Benzodiazepine | 0.2%

EVENTS & EXHIBITS

• March 4-6 – Cool Topics in Neonatology 22nd Annual Conference – Coronado, CA

• March 7-8 – 41st Annual March of Dimes Perinatal Nursing Conference – Lombard, IL

• April 21-24 – 13th National Advanced Practice Neonatal Conference – San Diego, CA

• April 24-26 – Wisconsin Association for Perinatal Care – Elkhart Lake, WI

• April 27-28 – Illinois Section AWHONN – Peoria, IL• May 18-20 – Nationwide Children’s Hospital Perinatal/

Neonatal Conference – Lewis Center, OH

1700 S. Mount Prospect Rd. | Des Plaines, IL 60018 | 800.235.2367 | www.USDTL.com

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