Advanced Drug Detection Questions & Answers By: Paul L. Cary Toxicology Laboratory University of Missouri.

Advanced Drug Detection

Questions & Answers

By: Paul L. CaryBy: Paul L. Cary

Toxicology LaboratoryToxicology Laboratory

University of MissouriUniversity of Missouri

What is meant by the What is meant by the term “zero tolerance” term “zero tolerance” drug testing? Why do drug testing? Why do drug tests use a drug tests use a cutoff anyway? Isn’t cutoff anyway? Isn’t it possible to detect it possible to detect drugs down to a level drugs down to a level of zero? of zero?

Negative or None Detected Results indicates that no drugs or indicates that no drugs or breakdown products breakdown products (metabolites), tested for, were (metabolites), tested for, were detected in the sample testeddetected in the sample tested

does not mean NO drugs present does not mean NO drugs present

Negative/None Detected Interpretation

donor is not using a drug that can be detected by donor is not using a drug that can be detected by the test the test OROR

donor not using enough drugdonor not using enough drug donor’s drug use is too infrequentdonor’s drug use is too infrequent collection too long after drug usecollection too long after drug use urine is tamperedurine is tampered test being used not sensitive enoughtest being used not sensitive enough

Negative/None Detected Interpretation

assess none detected drug testing assess none detected drug testing results in the context of your results in the context of your client’s overall program compliance client’s overall program compliance (or non-compliance) and their life’s (or non-compliance) and their life’s skills success (or lack thereof)skills success (or lack thereof)

Positive Test Result Interpretation indicates that drug(s) or breakdown indicates that drug(s) or breakdown products (metabolites), tested for, were products (metabolites), tested for, were detected in the sample testeddetected in the sample tested

drug presence is above the “cutoff” leveldrug presence is above the “cutoff” level greatest confidence achieved with greatest confidence achieved with confirmationconfirmation

ALWAYS confirm positive results in ALWAYS confirm positive results in original sample original sample

Typical Cutoff Levelsscreening &

confirmation amphetamines *amphetamines * 1000 ng/mL1000 ng/mL 500 ng/mL500 ng/mL benzodiazepinesbenzodiazepines 300 ng/mL300 ng/mL variablevariable cannabinoids * cannabinoids * 50 ng/mL50 ng/mL 15 ng/mL15 ng/mL cocaine (crack)*cocaine (crack)* 300 ng/mL300 ng/mL 150 ng/mL150 ng/mL opiates (heroin) *opiates (heroin) * 300/2000 ng/mL 300/2000 ng/mL variablevariable phencyclidine (Pphencyclidine (PCP) * CP) * 25 ng/mL25 ng/mL 25 25 ng/mLng/mL

alcoholalcohol 20 mg/dL20 mg/dL 10 mg/dL10 mg/dL

* SAMHSA (formerly NIDA) drugs* SAMHSA (formerly NIDA) drugs

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

Drug tests & cross reactivity: screening tests can and do react to screening tests can and do react to “non-target” compounds“non-target” compounds amphetaminesamphetamines benzodiazepinesbenzodiazepines

obtain list of interfering compounds obtain list of interfering compounds from lab or on-site test vendorfrom lab or on-site test vendor

on-site testing devices (“instant” on-site testing devices (“instant” tests) are only 60-70% accuratetests) are only 60-70% accurate

confirm positive resultsconfirm positive results

Client Accountability: the court should not assume the role of client “excuse the court should not assume the role of client “excuse evaluator”evaluator”

clients need to be held responsible for their own behavior and clients need to be held responsible for their own behavior and maintaining a drug-free physiologymaintaining a drug-free physiology

if testing performed appropriately (with confirmation) – if testing performed appropriately (with confirmation) – HOW the drug got into their sample is mostly irrelevantHOW the drug got into their sample is mostly irrelevant a positive drug test results put the client in violationa positive drug test results put the client in violation as a practical and resource matter – the court cannot afford to as a practical and resource matter – the court cannot afford to argue over or dispute with every client who has a positive test argue over or dispute with every client who has a positive test result or comes up with a new excuseresult or comes up with a new excuse

I heard that urine I heard that urine drug concentrations drug concentrations have no meaning or have no meaning or interpretive value for interpretive value for assessing client drug assessing client drug use behavior - is that use behavior - is that true ? true ?

Drug Tests are Qualitative

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

drug tests are NOT quantitativedrug tests are NOT quantitative

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

cocaine metabolitecocaine metabolite 517 ng/mL517 ng/mL opiates opiates negativenegative cannabinoids cannabinoids negativenegative amphetamines amphetamines negativenegative

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.

THE ISSUE:

Scientific Rationale

Technical IssuesTechnical Issues testing not lineartesting not linear tests measure total drug tests measure total drug concentrationsconcentrations

PhysiologicalPhysiological variability of urine outputvariability of urine output differential elimination of drug differential elimination of drug componentscomponents

The Vicious Cycle

Labs know theurine levels are of little or no inter-pretive value, and yet are reportedbecause of customerdemand

Courts provided with a number assumeit has value andrequires interpretation

Courts becomedependent onurine levels attempting to define client drug use behavior and justify sanctions & rewards

Labs are reluctantto discontinue practice and riskrevenue loss or customerdissatisfaction

“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.”

Advantages of Eliminating Drug Levels court decisions have a strong scientific basis court decisions have a strong scientific basis & forensically sound& forensically sound

no longer attempt to interpret data that is no longer attempt to interpret data that is not interpretablenot interpretable

greater confidence in decision making processgreater confidence in decision making process removes ambiguity associated with manipulating removes ambiguity associated with manipulating numbers that few in drug court are trained to numbers that few in drug court are trained to dodo

adds additional fairness/equity in sanctions & adds additional fairness/equity in sanctions & incentives processincentives process

NDCI Practitioner Fact Sheet:

http://www.ndci.org/publications/drugtestingfactsheet.pdf

Does marijuana really Does marijuana really stay in a client’s stay in a client’s body for 30 days or body for 30 days or longer after use? longer after use?

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

Many of the early cannabinoid studies often cited as proof of 30+ day detection periods suffered from . . .

unable to ensure abstinence unable to ensure abstinence duringduring the studythe study

detection cutoffs used very lowdetection cutoffs used very low used testing methods no longer used testing methods no longer available - poor specificityavailable - poor specificity

Cannabinoids - Recent/Relevant Research

30+ day detection window often exaggerates 30+ day detection window often exaggerates duration of detection windowduration of detection window

reasonable & pragmatic court guidancereasonable & pragmatic court guidance detection time: at 50 ng/mL cutoffdetection time: at 50 ng/mL cutoff

1 - 3 days for single event/occasional 1 - 3 days for single event/occasional useuse

up to 10 days for heavy chronic useup to 10 days for heavy chronic use detection time: at 20 ng/mL cutoffdetection time: at 20 ng/mL cutoff

5-7 days for single event/occasional use5-7 days for single event/occasional use up to 21 days for heavy chronic useup to 21 days for heavy chronic use

Recent Cannabinoid Use versus Non-recent use (double sanction issue): How do drug courts discriminate between How do drug courts discriminate between new drug exposure and continued new drug exposure and continued elimination from previous (chronic) use ?elimination from previous (chronic) use ? an issue only in first phase of programan issue only in first phase of program only drug that poses concern is only drug that poses concern is cannabinoidscannabinoids

““two negative test” rule – two back-to-two negative test” rule – two back-to-back negative drug tests post clean outback negative drug tests post clean out

Full Text of:Full Text of:

The Marijuana Detection Window: The Marijuana Detection Window: Determining the Length of Time Determining the Length of Time Cannabinoids Will Remain Detectable in Cannabinoids Will Remain Detectable in Urine following Smoking: A Critical Urine following Smoking: A Critical Review of Relevant Research and Review of Relevant Research and Cannabinoid Detection Guidance for Drug Cannabinoid Detection Guidance for Drug Courts, Courts, Drug Court ReviewDrug Court Review (publication (publication of the National Drug Court Institute, of the National Drug Court Institute, Arlington VirginiaArlington Virginia Volume V, Issue 1, Spring Volume V, Issue 1, Spring 2006, pages 23-582006, pages 23-58..

What does it mean when a What does it mean when a sample is reported as sample is reported as “dilute” or as having a “dilute” or as having a “low creatinine” ?“low creatinine” ?

What is creatinine ?

creatinine is derived from the non-enzymatic creatinine is derived from the non-enzymatic dehydration of creatine in skeletal muscledehydration of creatine in skeletal muscle

creatinine is produced by the body at a creatinine is produced by the body at a relatively constant rate throughout the dayrelatively constant rate throughout the day

creatinine is a compound that is unique to creatinine is a compound that is unique to biological material (i.e. urine, other body biological material (i.e. urine, other body fluids)fluids)

creatinine can be measured to determine the creatinine can be measured to determine the “strength” or concentration of a urine sample“strength” or concentration of a urine sample

Water contains no drugs!

easiest, cheapest, simplesteasiest, cheapest, simplest urines with a creatinines of less than urines with a creatinines of less than 20 mg/dL are considered “dilute” and 20 mg/dL are considered “dilute” and rarely reflect an accurate picture of rarely reflect an accurate picture of recent drug userecent drug use

dilute samples are like water than dilute samples are like water than like urinelike urine

all drug court samples should be all drug court samples should be screened for creatininescreened for creatinine

How are creatinine measurements used ? normal human creatinine levels will vary normal human creatinine levels will vary during the day based upon fluid intake - during the day based upon fluid intake - healthy individuals will rarely produce healthy individuals will rarely produce urine samples with creatinines of less urine samples with creatinines of less than 20 mg/dL than 20 mg/dL

incidence of low creatinines in a incidence of low creatinines in a population undergoing random drug testing population undergoing random drug testing is 3 - 5 times greater than a non-drug is 3 - 5 times greater than a non-drug tested populationtested population

any fluid intake dilutes the concentration any fluid intake dilutes the concentration of drugs in urine (along with the of drugs in urine (along with the creatinine)creatinine)

Fluid intake & dilute samples:

rapid intake of 2 quarts of fluid rapid intake of 2 quarts of fluid routinely produces low creatinines & routinely produces low creatinines & negative urine drug tests within one negative urine drug tests within one hourhour

rapid intake of 4 quarts of fluid rapid intake of 4 quarts of fluid almost always produces low almost always produces low creatinines and negative urine drug creatinines and negative urine drug tests within one hourtests within one hour

limit fluid intake prior to limit fluid intake prior to collectioncollection

What is the most common What is the most common method client’s use to method client’s use to “beat the drug test” and “beat the drug test” and how can this cheating be how can this cheating be controlled ?controlled ?

Basics of Specimen Tampering - The Three Approaches

dilutiondilution adulterationadulteration substitutionsubstitution

Urine Specimen Dilution:

most common form of tamperingmost common form of tampering pre collection dilution (hydration, pre collection dilution (hydration, water loading, flushing)water loading, flushing)

post collection dilutionpost collection dilution creatinine measurementcreatinine measurement dilution detection (specimen dilution detection (specimen validity tests - SVT)validity tests - SVT)

Urine Specimen Adulteration

addition of foreign substances designed addition of foreign substances designed to “mask” drug presenceto “mask” drug presence

post-collection tamperingpost-collection tampering low-tech adulterants that cause “pH low-tech adulterants that cause “pH shift” (lime, vinegar, bleach, ammonia, shift” (lime, vinegar, bleach, ammonia, lemon, drano)lemon, drano)

low-tech adulterants that disrupt low-tech adulterants that disrupt testing chemistry (salt, methanol, testing chemistry (salt, methanol, detergent)detergent)

common “high-tech” adulterantscommon “high-tech” adulterants

Urinaid, Byrd Laboratories

gluteraldehydegluteraldehyde sterilization chemicalsterilization chemical deactivates most screening tests - deactivates most screening tests - producing false negative resultsproducing false negative results

can be identified by laboratories can be identified by laboratories employing specimen validity checksemploying specimen validity checks

effects can not be reversed effects can not be reversed

Klear & Whizzies

potassium nitrite, sodium nitritepotassium nitrite, sodium nitrite analytical chemistryanalytical chemistry compromises the confirmation (GC/MS) compromises the confirmation (GC/MS) of some drugs, notably carboxy-THCof some drugs, notably carboxy-THC

oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories can be identified by laboratories employing specimen validity checksemploying specimen validity checks

effects can be reversedeffects can be reversed

Urine Luck pyridinium chlorochromate/dichromatepyridinium chlorochromate/dichromate oxidizing agent in organic synthesisoxidizing agent in organic synthesis compromises the confirmation (GC/MS) compromises the confirmation (GC/MS) carboxy-THC and opiatescarboxy-THC and opiates

can also effect screening testscan also effect screening tests oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories can be identified by laboratories employing specimen validity checksemploying specimen validity checks

effects can not be reversedeffects can not be reversed

Urine Specimen Substitution replacing donor urine sample with replacing donor urine sample with another drug-free specimen another drug-free specimen

biological substitution - someone else’s biological substitution - someone else’s “clean” urine“clean” urine

non-biological substitution - replacing non-biological substitution - replacing urine with urine “look-a-like” sample urine with urine “look-a-like” sample (diet Mountain Dew, water with food (diet Mountain Dew, water with food coloring) coloring)

non-biologicals can be detected with non-biologicals can be detected with creatinine testingcreatinine testing

Controlling Specimen Tampering

develop challenging collection strategy - develop challenging collection strategy - ie. make the testing unannounced and ie. make the testing unannounced and RANDOM!RANDOM!

directly observed collections is the most directly observed collections is the most effective approach to preventing effective approach to preventing adulteration and substitutionadulteration and substitution

inspect sample - train collection staffinspect sample - train collection staff keep abreast of tampering techniqueskeep abreast of tampering techniques take temperature measurements (90˚ - 100˚ take temperature measurements (90˚ - 100˚ F)F)

use laboratory employs specimen validity use laboratory employs specimen validity tests & use with on-site devices tests & use with on-site devices

Specimen Validity Tests (SVT)

creatinine, UUNcreatinine, UUN specific specific gravitygravity

pHpH nitritesnitrites gluteraldehydegluteraldehyde pyridinepyridine chromium chromium

Request SVT from testing laboratory or use dip-stick SVT products for on-site testing

The “witnessed” collection (for urine)

single most important aspect of single most important aspect of effective drug testing programeffective drug testing program

urine collections not witnessed urine collections not witnessed are of little or no assessment are of little or no assessment valuevalue

denial component of substance denial component of substance abuse requires “direct abuse requires “direct observation” collections of observation” collections of participantsparticipants

What’s the best What’s the best specimen for abused specimen for abused substance testing in a substance testing in a drug court population drug court population where we are where we are monitoring abstinence? monitoring abstinence?

Drug Testing Specimens

urine - current specimen of choiceurine - current specimen of choice generally readily available - large quantitiesgenerally readily available - large quantities contains high concentrations of drugscontains high concentrations of drugs good analytical specimengood analytical specimen provides both recent and past usageprovides both recent and past usage

alternative specimensalternative specimens breathbreath hairhair sweat - patch test sweat - patch test saliva - oral fluidssaliva - oral fluids eye scanning deviceseye scanning devices

Relative

Detection Times –by Specimen

Characteristics of a Good Drug Test:

scientifically valid employs proven methods & techniques accepted by the scientific community

therapeutically beneficial provides accurate profile of client’s drug use

provides rapid results for appropriate response

legally defensible able to withstand challenge established court track record scrutinized by legal/judicial review

Your Your Questions ?Questions ?

email address:

[email protected]@health.missouri.edu