Drug Testing Basics for Courts-Mandated Testing. By: Paul L. Cary Toxicology Laboratory University of Missouri

Transcription

1 Drug Testing Basics for Courts-Mandated Testing By: Paul L. Cary Toxicology Laboratory University of Missouri

2 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

3 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 (look for FDA approval)

4 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 client s drug use provides rapid results for appropriate response

5 When to Test? KEEP EM GUESSING! effective drug testing must be random unexpected, unannounced, unanticipated limit time between notification & testing random testing challenges denial test as often as possible - twice weekly consider use of multiple specimens (hair, saliva, sweat)

6 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

7 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

8 Compounds NOT easily tested: LSD and other hallucinogens inhalants date-rape drugs GHB flunitrazepam - (Rohypnol ) anabolic steroids

9 Client Contract

10 The Importance of Specificity in a Client Contract: I understand I will be tested for the presence of drugs in my system on a random basis according to procedures established by the Drug Court Team and/or my treatment provider. I understand that I will be given a location and time to report for my drug test. I understand that it is my responsibility to report to the assigned location at the time given for the test.

11 The Importance of Specificity in a Client Contract: I understand that if I am late for a test, or miss a test, it will be considered as a positive test for drugs/alcohol and that I may be sanctioned. I understand that if I fail to produce a urine specimen or if the sample provided is not of sufficient quantity, it will be considered as a positive test for drugs/alcohol and that I may be sanctioned. I have been informed that the ingestion of excessive amounts of fluids can result in a diluted urine sample and I understand that my urine sample will be tested to ensure the sample is not dilute.

12 The Importance of Specificity in a Client Contract: I understand that if I produce a dilute urine sample it will be considered as a positive test for drugs/alcohol and that I may be sanctioned. I understand that substituting or altering my specimen or trying in any way to modify my body fluids for the purposes of changing the drug testing results will be considered as a positive test for drugs/alcohol and will result in sanctioning and may be grounds for immediate termination from drug court.

13 Most Important Urine Collection Strategy

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 The Power of Denial PASCO, Wash. March Sheriff s detectives in Franklin County said a man had his friend shoot him in the shoulder so he wouldn t have to go to work. Deputies and emergency personnel responded to a shooting that was first called into 911 as a drive-by. When he first spoke with deputies, Daniel Kuch told them he d been the victim of a drive-by shooting while he was jogging Thursday. But detectives said that his story was not adding up and began to investigate further and finally police say that Kuch later acknowledged that he asked a friend to shoot him so he could get some time off work and avoid a drug test.

16 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

17 Sample Collection: (continued) wash hands prior to donation witness collection additional clothing removal body inspection squat and cough label sample correctly

18 Sample Collection: (continued) accept sample & inspect temperature ( F) color (no color diluted?) odor (bleach, sour apples, aromatics, vinegar, etc.) solids or other unusual particulates store sample properly forensic sample - custody documents

19 Developing control strategies to prevent sample tampering is critical. Once clients understand that they cannot beat the system, they are much more likely to engage in the therapeutic process toward recovery.

20 Drug Testing Methods

21 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

22 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

23 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 differential sensitivity & selectivity

24 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

25 Why confirm? Is it really necessary to confirm drugs that tested positive by initial screening tests? Why can t the court adjudicate cases based on the screening test results? FALSE POSITIVES

26 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 & on-site testing devices ( instant tests) have decreased accuracy confirm positive results

27 Interpretation of Drug Test Results

28 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

29 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 client s 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

30 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

31 The Issue of Urine Drug Concentrations

32 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

33 Drug concentrations or levels associated with urine testing are, for the most part, USELESS! cannabinoids opiates cocaine metabolites amphetamines 517 ng/ml negative negative negative

34 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.

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

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37 OR THIS? Negative or Positive

38 The Drug Detection Window

39 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 client s system reasonable estimate based upon many factors drug use, biological and testing issues

40 Factors Influencing Detection Window: drug dose route of entry into body duration & frequency of use rate of metabolism testing sensitivity specificity of testing method

41 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 there s alcohol & cannabinoids

42 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

43 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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45 Alcohol - Results Interpretation screening tests specific for ethanol, ethyl alcohol positive results indicate presence alcohol alcohol is rapidly cleared from the body negative results don t necessarily document abstinence detection time = hours example - person intoxicated at 11:00 PM, collect second urine sample of next day (11:00 AM), most likely test negative for alcohol

46 Ethyl Glucuronide (EtG) New Strategy for Monitoring Alcohol Abstinence

47 Alcohol is the most commonly abused substance by drug court clients and the most difficult substance to detect in abstinence monitoring.

48 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

49 Disadvantages of Ethyl Glucuronide testing available at relatively few laboratories historically testing more costly introduction of numerous testing approaches besides LC/MS/MS most significant concern casual, inadvertent, environmental alcohol exposure causing positive results

50 Sources of Incidental Alcohol Exposure medications (Nyquil) mouthwashes (Listermint & Cepacol) tincture of gingko biloba (herbal - memory) foods containing alcohol (such as vanilla extract, baked Alaska, cherries jubilee, etc.) non-alcoholic beers (O Doul s) colognes & body sprays insecticides (DEET) alcohol-based hand sanitizers (Purell)

51 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

52 And now, there s EtS (ethyl sulfate) - a second alcohol metabolite. Cutoff (100 ng/ml):

53 Specimen Validity

54 What the heck is creatinine and why should I care?

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

56 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

57 EVERY urine sample used for drug detection should be tested for creatinine!

58 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

59 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 normal urine creatinine is 130 mg/dl (based on 2005 study of over 22,000 subjects)

60 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

61 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)

62 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

63 Specimen Tampering

64 Basics of Specimen Tampering - The Three Approaches dilution adulteration substitution

65 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 ( F) use laboratory employs specimen validity tests & use with on-site devices

66 Monitoring for Prescription Drugs

67 Challenge with Prescription Drugs therapeutic use versus abuse QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. therapeutic use various stages of misuse abuse

68 Drug testing is an excellent tool for the abstinence monitoring of court clients, however it provides limited information for the differentiation between the appropriate therapeutic use of prescribed medications and the misuse/abuse of those same drugs - regardless of the specimen tested.

69 Alternative Control Strategies (other than drug testing)

70 Healthcare Contact Form form used by clients to document contact with healthcare professionals clients required to use contact form for each visit where medications are being used during a procedure or prescribed for use sanction for failure to use form place requirement in client contract client seek prior permission to see doctor

71 I (client name), am a participant in drug court. This program is a court monitored recovery program for addicts. As a result, I am subject to frequent and random drug testing. Therefore, I must report to the court my visit today. As I am in recovery, I would respectfully request that you take this into consideration and offer non-narcotic medications, if possible, when drugs are necessary for my medical treatment. Physician (Name) Physician (Signature) If you have any questions or concerns, please feel free to call the court and talk to my case specialists. If this patient fails to present this form to the nurse and physician prior to receiving medication or a prescription for medication, please notify the court. Please list the medications prescribed today:

72 Doctor Relationship doctor - patient relationship drug court practitioner s role client monitoring/supervision doctor as patient advocate doctor as co-dependent dynamic for change reach out to healthcare professionals

73 Other Control Strategies search & seizure (client contract) car, home, possessions pill counts no out-of-state prescriptions use of specified pharmacies loss of completion credits/time while on certain prescription meds

74 Electronic Prescription Monitoring database all scheduled prescriptions for a specified time period patient/client prescriber/doctor dispenser/pharmacy does not violate HIPAA

75 Electronic Prescription Monitoring powerful tool for law enforcement reduce pill mill doctors reduce prescription abuse of all kinds available in 34 states therapeutic information for drug court practitioners

76 address: