A Comprehensive Review of CourtDirected Drug Detection

1
A Comprehensive Review of Court-Directed Drug
Detection

• By Paul L. Cary
• Toxicology Laboratory
• University of Missouri

2
The law is not black and white and neither is
science.
. . there is a substantial gap between the
questions that the legal community would like
to have answered by drug testing and the answers
that the scientific community is able to
provide. The real danger lies in the legal
communitys failure to mind the gap by drawing
unwarranted inferences from drug testing
results.
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Drugs of Abuse Testing Discussion

• a few basic concepts about drug testing
• challenging collection strategies
• drug testing methods
• interpreting drug testing results
• eliminating the use of drug levels
• questions myths about drug testing
• specimen tampering
• The Business of How to Beat a Drug Test
• alternative specimens (other than urine)

4
Drug Testing Basics
5
Reasons for Drug Testing - WHY?

• Drug Court Key Component 5
• abstinence is monitored by frequent alcohol and
  other drug testing
• act as a deterrent to future drug use
• identify participants who are maintaining
  abstinence
• identify participants who have relapsed
• rapid intervention
• efficient utilization of limited resources
• provides incentive, support and accountability
  for participants
• adjunct to treatment frames sanction decisions

6
Drug Testing Specimens

• urine - current specimen of choice
• generally readily available - large quantities
• contains high concentrations of drugs
• good analytical specimen
• provides both recent and past usage
• alternative specimens
• breath
• hair
• sweat - patch test
• saliva - oral fluids
• eye scanning devices

7
Characteristics of a Good Drug Test

• scientifically valid
• employs proven methods techniques
• accepted by the scientific community
• legally defensible
• able to withstand challenge
• established court track record
• scrutinized by legal/judicial review
• therapeutically beneficial
• provides accurate profile of clients drug use
• provides rapid results for appropriate response

8
When to Test?

• KEEP EM GUESSING !
• effective drug testing must be random
• unexpected, unannounced, unanticipated
• limit time between notification testing
• test as often as possible - twice weekly
• consider use of multiple specimens (hair, saliva,
  sweat)
• design drug-specific testing regimes (cocaine
  test more frequently)
• use progressive testing strategies

9
Progressive Testing Strategies

• Phase I
• aggressive testing (twice weekly minimum)
• establishing client expectations/boundaries
• Phase II
• may reduce frequency as abstinence reward (once
  weekly minimum)
• return to aggressive testing if positive tests or
  other relapse indicators are determined to be
  present
• Phase III IV
• testing frequency dictated by client compliance
  drug court program policies

10
Drug Testing Reality Check

• When developing and administering your drug
  testing program assume that the participants you
  are testing know more about urine drug testing
  than you do!
• Sources
• Internet
• High Times magazine
• other court clients

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Which Drugs of Abuse Should be Tested? (limited
universe testing)

• amphetamines (speed)
• barbiturates, benzodiazepines
• cannabinoids (THC, marijuana)
• cocaine (crack)
• opiates (heroin)
• phencyclidine (PCP)
• alcohol

Modify this drug list as necessary to
reflect changing drug use patterns
12
Compounds NOT easily tested

• LSD and other hallucinogens
• inhalants
• date-rape drugs
• GHB
• flunitrazepam - (Rohypnol)
• anabolic steroids

13
Challenging Urine Collection Strategies
14
The witnessed collection (for urine)

• single most important aspect of effective drug
  testing program
• urine collections not witnessed are of little or
  no assessment value
• denial component of substance abuse requires
  direct observation collections of participants

15
Sample Collection

• pre-collection preparation
• site selection
• minimize access to water sources
• use an area with a scant floorplan
• find privacy security
• gather supplies beforehand
• obtain proper collection receptacle
• removal of outer clothing

16
Sample Collection (continued)

• wash hands prior to donation
• witness collection
• additional clothing removal
• body inspection
• squat and cough
• label sample correctly

17
Sample Collection (continued)

• accept sample inspect
• temperature (90-100 F)
• color (no color ? diluted ?)
• odor (bleach, sour apples, aromatics, vinegar,
  etc.)
• solids or other unusual particulates
• store sample properly
• forensic sample - custody documents

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Two final thoughts on collections . . . .

• find a method to assess the quality of your
  collection procedures
• exit interviews
• sending through fake donors
• understand that the collection process is your
  first line of defense for a valid sample

19
Drug Testing Methods
20
Two-Step Testing Approach

• screening test designed to separate negative
  samples from samples that are presumptively
  positive
• confirmation test follow-up procedure designed
  to validate positive test results
• distinctly different analytical technique
• more specific and more sensitive

21
Step One Screening

• often based on immunoassay technology
• more drug more binding - more color produced
  more instrument detector response
• numerous commercial manufacturers
• designed for high throughput instrumentation or
  on-site devices

22
On-site DOA screening

• often based on immunoassay technology
• concept of color switch
• dynamic versus static calibration
• hand-held cassettes or test-cup devices
• one test at a time - no batching
• available in DOA panels or single drugs
• numerous commercial manufacturers (15)
• differential sensitivity selectivity

23
On-site Testing Devices
24
Drug tests cross reactivity

• screening tests can and do react to non-target
  compounds
• amphetamines
• benzodiazepines
• obtain list of interfering compounds from lab or
  on-site test vendor
• initial screening (instant tests) are only
  60-70 accurate
• confirm positive results

25
Step Two - Confirmation

• gas chromatography-mass spectrometry (GC/MS)
• drug molecules separated by physical
  characteristics
• identified based on chemical finger-print
• considered gold standard
• other chromatographic techniques

26
Types of Confirmation

• GC/MS - reference laboratory
• court pays
• participant pays
• non-GC/MS confirmation
• in-house retesting by a different on-site device
• guilty plea to the court

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Interpretation ofDrug Test Results
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Negative or None Detected Results

• indicates that no drugs or breakdown products
  (metabolites), tested for, were detected in the
  sample tested
• no such thing as zero tolerance or drug free
• negative does not mean NO drugs present

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Negative/None Detected Interpretation

• client is not using a drug that can be detected
  by the test
• Other possible explanations
• client not using enough drug
• clients drug use is too infrequent
• collection too long after drug use
• urine is tampered
• test being used not sensitive enough
• client using drug not on testing list

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Negative/None Detected Interpretation

• no need to second-guess every negative result
• not suggesting withholding positive reinforcement
  rewards for positive behaviors
• drug testing is a monitoring tool
• assess none detected drug testing results in the
  context of your clients overall program
  compliance (or non-compliance) and their lifes
  skills success (or lack thereof)

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Positive Test Result Interpretation

• indicates that drug(s) or breakdown products
  (metabolites), tested for, were detected in the
  sample tested
• drug presence is above the cutoff level
• greatest confidence achieved with confirmation
• ALWAYS confirm positive results in original
  sample

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What is a cutoff level ?

• a drug concentration, administratively
  established for a drug test that allows the test
  to distinguish between negative and positive
  sample - threshold
• cutoffs are not designed to frustrate CJ
  professionals
• cutoffs provide important safeguards
• scientific purposes (detection accuracy)
• legal protections (evidentiary admissibility)
• measured in ng/mL ppb

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Typical Cutoff Levels screening confirmation

• amphetamines 1000 ng/mL 500 ng/mL
• benzodiazepines 300 ng/mL variable
• cannabinoids 20 50 ng/mL 15 ng/mL
• cocaine (crack) 300 ng/mL 150 ng/mL
• opiates (heroin) 300/2000 ng/mL variable
• phencyclidine (PCP) 25 ng/mL 25 ng/mL
• alcohol 20 mg/dL 10 mg/dL
• SAMHSA (formerly NIDA) drugs

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No such thing as zero tolerance testing

• drug tests not capable of testing to 0 ng/mL
• each drug each drug test has a limit of
  detection
• drug courts urged to utilize standardized
  cutoffs
• potential hazards of a zero-tolerance approach
  (use of non-traditional cutoffs)
• testing accuracy (increase in false-positives)
• courts justification for abnormally low cutoffs
• can/will your laboratory defend low cutoffs
• increased challenges/scrutiny to positive results
• lowered cutoffs may include inadvertent
  exposures

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Isnt any amount of drug in a clients system a
violation?

• punishment model vs. therapeutic model
• drug testing results (which form the foundation
  for incentives sanctions) need to be
  scientifically accurate legally defensible
• protection of client rights the court

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Exceptional (lowered) cutoffs in an effort to
catch covert client drug use

• provides only a marginal increase in drug
  detection
• opens your court to increased scrutiny associated
  with potential false positives and resulting
  inappropriate sanctions
• its all about credibility
• its all about confidence

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How should I deal with a client who claims to
have used or ingested something that caused a
false positive?
38
Client Accountability

• the court should not assume the role of client
  excuse evaluator
• clients need to be held responsible for their own
  behavior and maintaining a drug-free physiology
• if testing performed appropriately (with
  confirmation)
• HOW the drug got into their sample is mostly
  irrelevant
• a positive drug test results put the client in
  violation
• as a practical and resource matter the court
  cannot afford to argue over or dispute with every
  client who has a positive test result or comes up
  with a new excuse

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The Issue of UrineDrug Concentrations
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Drug Tests are Qualitative

• screening/monitoring drug tests are designed to
  determine the presence or absence of drugs - NOT
  their concentration
• drug tests are NOT quantitative

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Drug concentrations or levels associated with
urine testing are, for the most part, USELESS !

• cocaine metabolite 517 ng/mL
• opiates negative
• cannabinoids negative
• amphetamines negative

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The Twins
200 mg Wonderbarb _at_ 800 AM Collect urine 800
PM 12 hours later
A
B
43
The Twins - urine drug test results
A
B
Wonderbarb 638 ng/mL
Wonderbarb 3172 ng/mL
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The Twins - urine drug test results
physiological make up exact amount drug
consumed exact time of ingestion exact time
between drug exposure and urine collection AND
YET . . . . .
A
B
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The Twins - urine drug test results
Twin Bs urine drug level is 5 times higher
than Twin A
A
B
Wonderbarb 638 ng/mL
Wonderbarb 3172 ng/mL
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Are any of the following questions being asked in
your court?

• How positive is he/she?
• Are his/her levels increasing or decreasing?
• Is that a high level?
• Is he/she almost negative?
• Is this level from new drug use or continued
  elimination from prior usage?
• What is his/her baseline THC level?
• Does that level indicate relapse?
• Why is his/her level not going down? (or up?)

47
THE ISSUE
Urine drug concentrations are of little or no
interpretative value. The utilization of urine
drug test levels by drug courts generally
produces interpretations that are inappropriate,
factually unsupportable and without a scientific
foundation. Worst of all for the court system,
these urine drug level interpretations have no
forensic merit.
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Where do urine drug levels come from?
higher drug level
lower drug level
20 ng/mL
POSITIVE RESULT
NEGATIVE RESULT
screening drug testing cutoff
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The Vicious Cycle
Courts provided with a number assume it has
value and requires interpretation
Labs know the urine levels are of little or no
inter- pretive value, and yet are
reported because of customer demand
Courts become dependent on urine levels
attempting to define client drug use behavior and
justify sanctions rewards
Labs are reluctant to discontinue practice and
risk revenue loss or customer dissatisfaction
50
Scientific Rationale

• Technical Issues
• testing not linear
• tests measure total drug concentrations
• Physiological
• variability of urine output
• differential elimination of drug components

51
Expected Values When the test is used as a
qualitative assay, the amount of drugs and
metabolites detected by the assay in any given
specimen cannot be estimated. The assay results
distinguish between positive and negative
specimens only.
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THIS ?
432 indicates he going up, right?
is 22 above the cutoff?
does 219 mean new use?
307 well shes almost negative, correct?
639 is really high for THC, isnt it?
I think 1200 is a new record, isnt it?
115 is down from yesterday, probably continued
elimination?
515 is much higher than last week, right?
dont we need to consider relapse at 57?
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OR THIS ?
Negative or Positive
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Advantages of Eliminating Drug Levels

• court decisions have a strong scientific basis
  forensically sound
• no longer attempt to interpret data that is not
  interpretable
• greater confidence in decision making process
• removes ambiguity associated with
  manipulating numbers that few in drug court are
  trained to do
• adds additional fairness/equity in sanctions
  rewards process

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Final Thought
However well-intentioned, the use of urine drug
testing levels cannot be supported by the science
and represents an adjudication practice that is
not forensically defensible. An unambiguous and
equitable evidentiary foundation that will pass
both scientific and legal scrutiny is crucial to
the continued success of drug courts (criminal
justice).
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On-site Drug Detection
Follow package insert guidance exactly!
57
On-site Drug Detection
Intensity of band is NOT quantitative!
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The Drug Detection Window
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Defining the detection window

• the length of time in days following the last
  substance usage that urine samples will continue
  to produce positive drug test results
• the number of days until last positive
• NOT - how long drugs will remain in a clients
  system
• reasonable estimate based upon many factors
  drug use, biological and testing issues

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Factors Influencing Detection Window

• drug dose
• route of entry into body
• duration frequency of use
• rate of metabolism
• testing sensitivity
• specificity of testing method

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Relative Detection Times by Specimen
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Drug Detection Times - by Drug(this is general
guidance!)

• amphetamines up to 4 days
• cocaine up to 72 hours
• opiates up to 5 days
• PCP up to 6 days
• barbiturates up to a week
• benzodiazepines up to a week
• . . then theres alcohol cannabinoids

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Cannabinoid Detection in Urine

• Conventional wisdom has led to the common
  assumption that cannabinoids will remain
  detectable in urine for 30 days or longer
  following the use of marijuana.
• RESULT
• delay of therapeutic intervention
• hindered timely use of judicial sanctioning
• fostered denial of marijuana usage by clients

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Perpetuating 30-Plus Day Assumption

• Substance abuse treatment literature that
  proclaims, some parts of the body still retain
  THC even after a couple of months.
• Drug abuse information targeted toward teens
  Traces of THC can be detected by standard urine
  and blood tests for about 2 days up to 11 weeks.
• Health information websites that provide the
  following guidance At the confirmation level of
  15 ng/mL, the frequent user will be positive for
  perhaps as long as 15 weeks.
• And, last but not least Dr. Drew Pinsky (a.k.a.
  Dr. Drew) who has been the co-host on the popular
  call-in radio show "Loveline" for 17 years who
  states Pot stays in your body, stored in fat
  tissues, potentially your whole life.

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Cannabinoids - Recent/Relevant Research

• 30 day detection window often exaggerates
  duration of detection window
• reasonable pragmatic court guidance
• detection time at 50 ng/mL cutoff
• up to 3 days for single event/occasional use
• up to 10 days for heavy chronic use
• detection time at 20 ng/mL cutoff
• up to 7 days for single event/occasional use
• up to 21 days for heavy chronic use

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Addressing Imperatives for Cannabinoids

• acknowledge research reporting prolonged THC
  elimination
• establish a reasonable and pragmatic detection
  window guidance for the vast majority of case
  adjudications
• sound judicial practice requires that court
  decisions be based upon case-specific information
• in unconventional situations that confound the
  court, qualified toxicological assistance should
  be sought

67
Recent Cannabinoid Use versus Non-recent use
(double sanction issue)

• How do drug courts discriminate between new drug
  exposure and continued elimination from previous
  (chronic) use ?
• an issue only in first phase of program
• only drug that poses concern is cannabinoids
• two negative test rule two back-to-back
  negative drug tests post clean out

68
Drug Courts Competing Imperatives

• the need for rapid therapeutic intervention
  (sanctioning designed to produce behavioral
  change)
• the need to ensure that the evidentiary
  standards, crafted to protect client rights, are
  maintained

69
Interpreting Individual Drug Class Results
70
Amphetamines - Results Interpretation

• screening tests - drug class assays
• interpret positive results with caution
• some screening assays often have cross-reactivity
  with structurally similar compounds
• phenylpropanolamine - PPA
• ephedrine
• confirm results whenever possible
• detection time up to 4 days

71
Cannabinoids - Results Interpretation

• drug specific assays
• cutoff levels 20 50 ng/mL
• positive results indicate presence of
  cannabinoids - virtually no interferences
• difficult to separate recent from non-recent use
  due to lipophilic properties
• detection time variable and complicated
• no passive inhalation
• Marinol

72
Cocaine - Results Interpretation

• drug specific assays
• positive results indicate presence of cocaine
  metabolites
• virtually no interferences
• positive results almost always associated with
  illicit drug use
• detection time up to 3 days maximum
• negative result may not be clear indication of
  non-use

73
Opiates - Results Interpretation

• screening tests - drug class assays
• positive results indicate presence of opiates
• most assays not reactive toward synthetic
  narcotic analgesics meperidine (Demerol),
  propoxyphene (Darvon), methadone, pentazocine
  (Talwin), fentanyl (Sublimaze)
• poppy seed interference
• difficult to separate legitimate use from abuse
• detection time up to 4 days following
  therapeutic use of codeine or morphine

74
Alcohol - Results Interpretation

• screening tests specific for ethanol, ethyl
  alcohol
• positive results indicate presence alcohol
• alcohol is rapidly cleared from the body
• negative results dont necessarily document
  abstinence
• detection time hours
• example - person intoxicated at 1100 PM, collect
  second urine sample of next day (1100 AM), most
  likely test negative for alcohol

75
Can alcohol be produced in a urine specimen as a
result of fermentation - leading to a false
positive result ?
76
(C6H12O6) yeast 2 CH3CH2OH 2
CO2
77
Ethyl Glucuronide (EtG) New Strategy for
Monitoring Alcohol Abstinence
78
Alcohol is the most commonly abused substance by
drug court clients and the most difficult
substance to detect in abstinence monitoring.
79
Ethyl Glucuronide
80
EtG new testing method for monitoring alcohol
abstinence
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Advantages of Ethyl Glucuronide

• unique biological marker of alcohol use (no false
  positives)
• direct marker indicating recent use
• longer detection window than alcohol
• stable in stored specimens (non-volatile)
• is not formed by fermentation
• is not detected in the urine of abstinent subjects

82
Disadvantages of Ethyl Glucuronide

• testing available at relatively few laboratories
• EtG testing more costly than abused drugs
• expensive LC/MS/MS technology
• introduction of new testing approaches
• most significant concern casual, inadvertent,
  environmental alcohol exposure causing positive
  results

83
Urine EtG Concentrations Following Alcohol
Consumption

• one 3.2 beer detection up to 24 hours
  (alcohol - 90 minutes)
• three 3.2 beers detection up to 48 hours
  (alcohol - 3.5 hours)

84
As of the Summer of 2006

• use of EtG testing in drug courts was showing
  significant growth
• courts were pleased to have a new abstinence
  monitoring tool
• issues regarding testing methodologies and
  concerns about cutoff levels were actively being
  discussed and debated
• THEN . . . . . .

85
On September 25, 2006 everything changed!
86
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SAMHSA CSAT Advisory (9-25-06)
Currently, the use of an EtG test in determining
abstinence lacks sufficient proven specificity
for use as primary or sole evidence that an
individual prohibited from drinking, in a
criminal justice or a regulatory compliance
context, has truly been drinking. Legal or
disciplinary action based solely on a positive
EtG, is inappropriate and scientifically
unsupportable at this time. These tests should
currently be considered as potential valuable
clinical tools, but their use in forensic
settings is premature.
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What prompted SAMHSA Advisory ?

• the science of EtG testing - our capability to
  employ highly sensitive testing procedures to
  detect recent ethyl alcohol exposure - has
  outpaced our ability to appropriately interpret
  the test results in a forensically defensible
  manner
• consumption vs. unintended exposure
• CSAT (National Advisory Council) concluded that
  there is inadequate research data about the
  populations being tested

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Sources of Incidental Alcohol Exposure

• OTC medications (Nyquil)
• mouthwashes (Listermint Cepacol)
• herbal/homeopathic medications (i.e., tincture
  of gingko biloba - memory)
• foods containing alcohol (such as vanilla
  extract, baked Alaska, cherries jubilee, etc.)
• non-alcoholic beers (ODouls, Sharps)
• colognes body sprays
• insecticides (DEET)
• alcohol-based hand sanitizers (Purell, GermX)

90
Ethyl Glucuronide (EtG) Where Do We Go From
Here?
91
FOLLOW-UP
92
Positive EtG Result (500 ng/mL)

• a result reported as EtG positive in excess of
  the 500 ng/mL cutoff is consistent with the
  recent ingestion of alcohol-containing products
  (1-2 days prior to specimen collection) by a
  monitored client
• studies examining incidental exposure widely
  conclude that results in excess of the 500 ng/mL
  cutoff are not associated with inadvertent or
  environment ethanol sources

93
Negative EtG Result (500 ng/mL)

• a result reported as EtG negative is indicative
  of a client who has not ingested beverage alcohol
  within 1-2 days prior to specimen collection
• a negative result is not proof of abstinence
• advertised 80-hour window of detection not
  real-world applicable

94
Options for Client Sanctioning

• positive urine EtG - cutoff of at least 500 ng/mL
• combined with
• a client admission of use/relapse
• identification of behavioral indicators
• alcohol-related arrest or incident
• alcohol-related job action
• client seen in bar/tavern
• a violation of EtG-specific contract

95
Two other considerations

• ethyl sulfate
• new EtG screening test

96
Dont abandon EtG testing - adjust your methods
and cutoffs to address legitimate client
forensic concerns.
97
Specimen Validity
98
What the heck is creatinine and why should I
care ?
99
What does it mean when a sample is reported as
dilute or as having a low creatinine ?
100
What is creatinine ?

• creatinine is produced as a result of muscle
  metabolism
• creatinine is produced by the body at a
  relatively constant rate throughout the day
• creatinine is a compound that is unique to
  biological material (i.e. urine, other body
  fluids)
• creatinine measurements can
• determine the strength or concentration of a
  urine sample
• ensure the sample being tested IS urine

101
EVERY urine sample used for drug detection
should be tested for creatinine!
102
Two Types of Urine Specimen Dilution

• pre collection dilution
• consumption of large quantities of fluids prior
  to collection
• post collection dilution
• adding fluid to specimen post collection

103
Pre-Collection Dilution

• high-volume ingestion of fluids (water loading,
  flushing, hydrating, etc.)
• may be in conjunction with products designed to
  enhance drug elimination or removal of drugs
  (Gold Seal, Clean n Clear, Test-Free, Naturally
  Klean, etc.)
• no evidence these products have any additional
  effect on drug elimination

104
Water contains no drugs!

• easiest, cheapest, simplest
• urines with a creatinines of less than 20 mg/dL
  are considered dilute and rarely reflect an
  accurate picture of recent drug use
• dilute samples are more like water than like
  urine
• all drug court/criminal justice samples should be
  screened for creatinine

105
How are creatinine measurements used ?

• normal human creatinine levels will vary during
  the day based upon fluid intake - healthy
  individuals will rarely produce urine samples
  with creatinines of less than 20 mg/dL
• incidence of creatinines less than 20 mg/dL in a
  normal population is approximately 1
• urines with a creatinines of less than 20 mg/dL
  are considered dilute and often do not reflect
  an accurate picture of recent drug use

106
Creatinine Facts

• some diseases that produce low urinary
  creatinines
• muscle wasting disease - RARE
• some kidney aliments - RARE
• low creatinines ARE NOT routinely associated
  with
• pregnancy
• diabetes
• obesity
• exercise
• high-blood pressure
• being vegetarian

107
The Normal Creatinine

• incidence of low creatinines in a population
  undergoing random drug testing is significantly
  (up to 10 times) greater than a non-drug tested
  population
• any fluid intake dilutes the concentration of
  drugs in urine (along with the creatinine)
• normal urine creatinine 2005 study Urinary
  Creatinine Concentrations in the U.S. Population
  determine the mean (based upon 22,245
  participants) was 130 mg/dL
• less than 1 below 20 mg/dL
• only 3 greater than 300 mg/dL

108
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109
More Creatinine Issues

• rapid ingestion (90 minutes) of 2-4 quarts of
  fluid will almost always produce low creatinines
  negative urine drug tests within one hour
• recovery time of urine creatinine and drug
  concentrations can take up to 10 hours
• incidence of drugs in urine of diluted specimens
  is over 5 times greater than in samples with
  normal creatinine levels
• dont allow physicians to become a clients
  co-dependent

110
Dilute Result Interpretation

• negative or none detected results should never be
  interpreted as indicating no drug use
  (abstinence), because if, in fact, drugs were
  present, they probably could not be detected by
  the test
• positive drug test results from a dilute sample
  however, are considered valid (donor was not able
  to dilute the sample sufficiently to deceive the
  test)

111
The Inadvertent Dilute

• My sample is dilute because I work as a roofer,
  on a black roof, in the middle of August when the
  temperature is 400 F.
• it is possible for a client to achieve a urine
  creatinine of less than 20 mg/dL under extreme
  conditions
• court needs to develop creative solutions
• collect samples before work
• collect samples on days off
• use alternative specimens

112
Creatinine Action Levels

• urine creatinine of less than 20 mg/dL is
  actionable
• urine creatinine of less than 50 mg/dL is not
  actionable - HOWEVER may be grounds for increased
  client surveillance (i.e., increase testing,
  increase treatment)
• urine creatinine of greater than 300 mg/dL is
  rare and abnormal
• warning regarding unauthorized use of supplements
• increased surveillance/medical evaluation
• urine creatinine of greater than 400 mg/dL is
  actionable
• place creatine prohibition in client contract

113
Creatinine Sanctions

• no national standard
• adjudicate as tampered sample - more severely
  than positive sample
• adjudicate as positive sample - court utilizes
  positive sample sanctions
• adjudicate as dilute sample - unique sanctions
• some courts allow one dilute sample per
  phase/quarter
• regardless of sanction - court MUST address this
  issue

114
Two final thoughts about dilute urine samples .
. . . .

• a creatinine of less than 20 mg/dL (associated
  with a drug test) is nearly always an attempt by
  the donor to avoid drug use detection -
  REGARDLESS of how much liquid was consumed in
  order to achieve this result
• place a dilute sample prohibition in your client
  contract and sanction for repeat dilute samples

115
Drug Detection Mythology - Kill the Myths!
116
Myth 1

• Passive inhalation of marijuana smoke can cause a
  positive drug test result.
• NO - not if standard cutoffs are used
• THC (cannabinoid) assay uses variable cutoffs
  (20, 50, 100 ng/mL)
• passive inhalation research indicates less than
  10 ng/mL in volunteer urines
• no passive inhalation for crack

117
Myth 2

• Advil (ibuprofen) causes false-positive drug
  tests for marijuana
• NO!
• problem with EMIT method corrected 15 years ago
  
• no medication - prescription/OTC causes
  false-positive drug tests for marijuana

118
Myth 3

• Consuming poppy seeds causes false-positive
  drug tests for heroin
• NO! - but?
• poppy seeds contain trace amounts of both codeine
  and morphine
• can causes positive drug test results for
  opiate class
• confirm positive opiates

119
Myth 4

• Drinking vinegar or cranberry juice will produce
  a negative urine drug test.
• NO!
• theory is to cause a pH shift, making the urine
  sample acidic - altering the chemistry of
  immunoassay tests
• in reality - the body detoxifies the acid
  dilutes to physiological pH

120
Myth 5

• consuming vitamins purges marijuana from the
  system - quicker clean urine (niacin - B3)
• NO!
• theory is vitamins increase metabolism
• in reality - no systemic changes
• however, vitamin DO produce urine coloration -
  check creatinine

121
Myth 6

• blood is a good alternative specimen for drugs of
  abuse testing
• FALSE!
• sample of limited volume
• dirtysample (protein, blood cells, lipids)
• drugs in low concentrations
• parent drugs with short half-life
• many testing methods not sufficiently sensitive

122
Specimen Tampering
123
Basics of Specimen Tampering - The Three
Approaches

• dilution
• adulteration
• substitution

124
Urine Specimen Dilution

• most common form of tampering
• pre collection dilution (hydration, water
  loading, diuretics)
• post collection dilution
• creatinine measurement
• dilution detection (validity checks)

125
Pre-Collection Dilution

• high-volume ingestion of fluids (water loading,
  flushing, hydrating, etc.)
• may be in conjunction with products designed to
  enhance drug elimination or removal of drugs
  (Gold Seal, Clean n Clear, Test-Free, Naturally
  Klean, etc.)
• no evidence these products have any additional
  effect on drug elimination

126
Post-Collection Dilution

• agents added after sample collection designed to
  dilute or thin drug concentration in urine
• diluting agents (water, clean urine, other
  fluids)
• purpose of direct observation at collection

127
Urine Specimen Adulteration

• addition of foreign substances designed to mask
  drug presence
• post-collection tampering
• low-tech adulterants that cause pH shift (lime,
  vinegar, bleach, ammonia, lemon, drano)
• low-tech adulterants that disrupt testing
  chemistry (salt, methanol, detergent)
• five common high-tech adulterants

128
Urinaid, Byrd Laboratories

• gluteraldehyde
• sterilization chemical
• deactivates most screening tests - producing
  false negative results
• can be identified by laboratories employing
  specimen validity tests
• effects can not be reversed

129
Klear Whizzies

• potassium nitrite, sodium nitrite
• analytical chemistry
• compromises the confirmation (GC/MS) of some
  drugs, notably carboxy-THC
• oxidizes drug and standards
• can be identified by laboratories employing
  specimen validity tests (SVT)
• effects can be reversed

130
Urine Luck

• pyridinium chlorochromate/dichromate
• oxidizing agent in organic synthesis
• compromises the confirmation (GC/MS) carboxy-THC
  and opiates
• can also effect screening tests
• oxidizes drug and standards
• can be identified by laboratories employing
  specimen validity tests (SVT)
• effects can not be reversed

131
Stealth

• peroxidase (vegetable source) peroxide
• oxidizing agent
• compromises the confirmation (GC/MS) carboxy-THC
  and opiates
• can also effect screening tests
• oxidizes drug and standards
• difficult to identify
• effects can not be reversed

132
Other Adulterants

• Mary Jane Superclean 13 (surfactant)
• Clear Choice (gluteraldehyde)
• Amber-13 (acid)
• THC-Free (acid)
• Lucky Labs 418 (oxidant)
• Sweet Pees Spoiler (oxidant)
• Randys Klear Klear II (oxidants)

133
Latest Update New Adulterants

• Bake N Shake (sodium persulfate)
• Urine Luck 6.6 (hydrofluoric acid)
• Clear-X (potassium nitrite)
• Diamond Purifier (unknown)
• Eradicator (probably chromate)
• NuKlear (unknown)
• Purafyzit (probably chromate)
• Randomizer (unknown)

134
Urine Specimen Substitution

• replacing donor urine sample with another
  drug-free specimen
• biological substitution - someone elses clean
  urine
• non-biological substitution - replacing urine
  with urine look-a-like sample (diet Mountain
  Dew, water with food coloring)
• non-biologicals can be detected with creatinine
  testing

135
Controlling Specimen Tampering

• develop challenging collection strategy - ie.
  make the testing unannounced and RANDOM!
• directly observed collections is the most
  effective approach to preventing adulteration and
  substitution
• inspect sample - train collection staff
• keep abreast of tampering techniques
• take temperature measurements (90 - 100 F)
• use laboratory employs specimen validity tests
  use with on-site devices

136
Checking for Adulterants

• not necessary on all samples
• creatinine - YES
• suspicious sample collection
• unusual sample characteristics
• client suspected of relapse who continues to
  produce negative test results

137
Specimen Validity Tests (SVT)

• creatinine, UUN
• specific gravity
• pH
• nitrites
• gluteraldehyde
• pyridine
• chromium

Request SVT from testing laboratory or use
dip-stick SVT products for on-site testing
138
How to Beat a Drug Test
139
Alternative Specimens(other than urine)
140
So whats wrong with urine?

• generally readily available in large quantities
• drug metabolites are highly concentrated
• extensive scientific basis for methodology
• results accepted in court
• provides both recent and past usage
• uniform testing criteria (established cutoffs)
• easily tested (laboratory on-site)
• quality assurance practices well-established

141
Problems With Urine as a Specimen

• YUCK factor!
• biological waste product
• distasteful qualities invasive collection
• NOT QUANTITATIVE cannot use concentration to
  evaluate client drug use history
• susceptible to tampering
• drug concentration influenced by fluid intake
• necessities witnessed collection

142
Characteristics of a Good Drug Test

• scientifically valid
• employs proven methods techniques
• accepted by the scientific community
• legally defensible
• able to withstand challenge
• established court track record
• scrutinized by legal/judicial review
• therapeutically beneficial
• provides accurate profile of clients drug use
• provides rapid results for appropriate response

143
Alternative Specimens

• Sweat (patch)
• Hair
• Saliva (oral fluids)

144
Sweat Testing Advantages

• ability to monitor for extended periods
• FDA approval 7 days
• relatively client tamper-proof
• cost testing comparable to urine testing
• participant acceptability (non-invasive)
• low incident to allergic reactions
• approved by FDA

145
Sweat Testing Disadvantages

• large variation in sweat production
• cannot detect prior exposure
• application process critical
• risk of contamination during application/ removal
• limited collection devices
• few testing laboratories
• risk of accidentally removal
• concern over environmental contamination

146
Hair Testing Advantages

• provides long detection period (90 days)
• rapid, non-invasive sample collection
  (compared to urine)
• ease of obtaining, storing and shipping specimens
• potential for specimen tampering reduced
• second sample can be obtained
• no bio-hazard issues
• poppy seed interference not an issue

147
Hair Testing Disadvantages

• cost 20 to 55 per panel
• limited number of labs testing hair
• inability to detect recent drug usage (drugs
  dont appear in hair until 2 weeks after use)
• bias - hair color, ethnic origin, gender remain
  controversial
• hair testing for marijuana remains problematic
• possibility of drug entry from sweat and
  environmental sources

148
Saliva Testing Advantages

• non-invasive sample collection (compared compared
  to urine)
• potential for specimen tampering reduced
• data related to behavior/performance (saliva
  relationship to blood)
• useful in detecting recent drug use
• on-site testing devices available

149
Saliva Testing Disadvantages

• very short detection window (for many drugs the
  detection period is a matter of hours)
• heroin 4 - 8 hours (0 positives _at_ 24 hours)
• marijuana problematic, THC does not diffuse
  from blood into oral fluid
• cocaine 3 - 6 hours (0 positives _at_ 12 hours)
• relatively few laboratories providing commercial
  testing

150
EyeCheck
PassPoint
151
Eye Scanning Technology

• developed for safety-sensitive industries (i.e.,
  transportation, manufacturing, etc.)
• fitness impairment screener
• different measuring standards
• pupil response to infrared light
• variety of eye characteristics
• different decision algorithms
• measurements deviate from reference data
• comparison to individuals own sober scan

152
Unresolved Eye Scan Issues

• no peer-reviewed research studies demonstrating
  applicability of these devices to drug courts
  (i.e., unproven effectiveness)
• eye scans measure impairment - drug courts
  mission is to determine abstinence
• eye scanning detection - hours
• urine screening - days
• cross-reactivity toward fatigue sleep
  deprivation
• confirmation still required for positives
• cost savings claims unsupported

153
Unresolved Eye Scan Issues (continued)

• cannot be used
• individuals under the age of 16
• clients with head injuries
• clients who are pregnant
• clients with epilepsy
• clients with eye injuries
• eye scans may not be appropriate for individuals
  heavy duty drug users who have fried their
  brains from long term drug use

154
Each alternative specimen is unique and offers
a somewhat different pattern of information
concerning drug use over time. Each
specimen has unique strengths and weaknesses (as
does urine) regarding the information obtained
from drug testing.
SUMMARY ISSUES
155
Choice of Specimen

• urine remains the biological specimen of choice
  for qualitative detection of illicit drug use in
  the drug court setting
• alternative specimens/technologies may be
  considered as complimentary samples
• alternative specimens/technologies hold future
  promise for testing following resolution of
  legal/scientific issues
• some alternative specimens/technologies have
  significant advances primarily because they are
  non-invasive and reduced tampering potential

156
SUMMARY

• educate yourself about drug testing - understand
  its benefits limitations
• develop a program and put it in writing
• train front-line supervisory staff
• develop a challenging collection strategy -
  make sure its random
• institute appropriate safeguards in collection
  procedures to control tampering
• select appropriate testing facility or on-site
  methods

157
SUMMARY (continued)

• choose the specimen right for your program
• drug test often !
• confirm positive screening results whenever
  possible
• keep abreast of tampering techniques
• challenge your program - quality assurance
• develop a relationship with drug testing experts
  - testing laboratory or on-site device vendor
• understand that drug testing is only one part of
  the overall drug court supervision process

158
email address

• carypl_at_health.missouri.edu