Drug Testing

Drug Testing
Helen
Harberts
LADCP
2014
[email protected]
Internet wisdom…
“Take a 5 hour energy bottle a clean
sample a sunglasses bag with string
put the bottle in bag tie the string to
your belt buckle let it hang under
your nuts put on 3 pairs of boxer
briefs sum sweatpants and sum
jeans this is what I'm going to try in
a week. The only thing that can fail
me is if they watch me pee it's for a
job does anyone no if they watch”
As long as no one is following you into
the stall and watches you pee, then get a
condom and fill it with warm water + a
little bit of yellow food coloring. Hide
scissors on you somewhere, and when
you go take the test, cut the top on the
condom (where you tied it off) and pour it
into the cup.
That's what I did when I was on probation
and it worked.
Understand….
• We test to support recovery
• We test to assist with refusal skills
• We test to determine if treatment is
working
• We test to support incentive & sanction
• We test to “help ya”, not to “catch ya”.
Understand…..
• Drug testing is a guide, but not perfect.
• This is big business and serious
business
• Drug testing must be done correctly, or
the results are pointless.
Quick Fix
Quick Fix Whizzinator Pack
One Whizzinator
One Quick Fix
• $149.95
http://www.quickfixurine.com/
OBSERVED TESTING IS
NOT AN OPTION
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Yes, it is icky.
Yes, it is uncomfortable
Yes, it presents unique challenges
It is mandatory.
Not mirrors, not privacy screens, DIRECT
OBSERVATION
So what makes a good test?
• Scientifically valid
– Proven methods and techniques
– Accepted by all the science wonks
• Therapeutically beneficial
– Provides accurate profile of participants drug uses
– Gives us rapid results for rapid response
• Legally defensible
– Able to withstand court challenge
– Established court track record
– Scrutinized legal & judicial review
What do we test?
–urine - current specimen of choice
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generally readily available - large quantities
contains high concentrations of drugs
good analytical specimen
provides both recent and past usage
EtS, EtG
–other specimens
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Hair-know your limits.
sweat - patch test
saliva - oral fluids-better.
Eye scanning devices-ugh
Breath-for ETOH, lots of breath
How to conduct at test:
• Impersonal, like a doctor’s office
• Impeccable chain of evidence in both
appearance and fact
• Do it exactly the same way every time.
You will need to testify from habit and
custom.
Questions:
Same every time
• Have you used any drugs or alcohol
since I last saw you?
• Is there anything I need to know before
this test?
• Will this test be clean or not?
Get your stuff in order!
• Get all of your paperwork ready WITH
the client. You sign, they sign,
everything.
• CHECK Photo ID each time.
• If possible design a urine testing room
that works better than a standard room.
• Removal of all outer clothing like coats.
Always the same process:
• Wash hands before (and after) donation
• Proper collection receptacle
• Witness collection process.
Actual testing:
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Drop your drawers…all of them
Turn around 360 degrees
Women: squat and cough 3X
Men and women: start, stop, start.
Squat and Cough….. Really?
“Tech Rawlinson instructed the defendant to
squat to the ground with her knees and feet
shoulder width apart, and to cough as hard as
she could. Ms. Doe then squatted as
instructed and coughed with her hand over
her mouth.
Tech Rawlinson heard a
loud thumping sound on the floor
immediately after Ms. Doe coughed. “
You don’t do it…
this is what gets past you.
Done?
• Accept sample and inspect
– Temperature strip/check (90-100 degrees F)
– Color (note for lab) no color =? Inappropriate?
– Odors (bleach, sour apples, aromatics, vinegar,
etc.)
– Solid stuff, or unusual particulates.
• Visual line of sight, and label with
probationer.
Collection continued:
• Store the sample appropriately.
• THIS IS EVIDENCE!
• Develop detailed policy and train everyone
on it! Cross train everyone.
• Do quality control, interview, send fake
donor. Double check and observe
technique.
When should we test?
• When does this disease sleep? Never!
– Keep them guessing
– Mix up testing schedules
– Mix up specimen types (hair, urine, sweat,
oral fluids)
– It must be random
– Limit time between notification and testing
– Design drug specific regimens (cocaine)
Assume alcohol
• Use transdermal devices
• PBT presumptive breath tests
• Anything that will let you do immediate
alcohol tests.
• Check in group. Check after they use the
bathroom. Watch for alcohol at all times.
What are you testing for?
• Poly substance is the rule, not the
exception.
• Watch for alcohol (especially with opiates
and benzos and pot)
• Switching drugs of choice is common.
Remember: we test for the “usual
suspects”, not everything!
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Amphetamines
Benzodiazepines
Cannabinoids
Cocaine
Opiates (organic)
PCP (?), MDMA(?)
Alcohol
Other tests?
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EtG, EtS
Naltrexone, suboxone
Approved doses of medications
Antidepressants,etc.
Designer drugs
Synthetic opiates
How long can we detect drugs by
specimen?
• general estimates
• urine: 1-7 days
– excluding alcohol & THC
– necessitates twice weekly screening
• sweat (patch): 7 days
• saliva (oral fluids): up to 48-72 hours
• hair: up to 90 days-but useless for other things
• breathalyzer: few hours (.02 per hour)
• EtG: up to 48 hours at 500 cut off.
Two step approach
• Screening test-coarse test. Designed to
separate negative samples from samples
that are “presumptively” positive
• Confirmation test- a follow up procedure
designed to validate positive test results.
– Distinctively different analytical technique
– MUCH more specific and more sensitive.
Confirmation Tests:
• Gas chromatography-mass spectrometry, or
(GC/MS) or other mass spec process
– Drug molecules separated by physical characteristics
– Identifies drugs based on chemical “fingerprint”
– This is the gold standard.
• Other chromatography techniques
– Thin layer, etc. but you can confirm via
GC/MS as needed.
I got results. What do they
mean?
• Negative, or none detected.
• Positive
• Dilute
None, or none detected
• Tells you no drugs or metabolites, that you
tested for, were detected in the sample
tested above cut off.
• It does NOT mean, no drugs were present
• Your participant may be clean….or,…
• They may be using a drug you didn’t look
for
• Or, they may not be using enough of the
drug
• Or, they aren’t using it frequently enough
• Or, you collected too long after use
• Or, they tampered with the test
• Or, the test isn’t sensitive enough
• Could be they bought bad dope!
“second sense”
• If you think something else is going on,
look closer!
• Change what you are doing!
– Do a home visit, change samples, look closer!
• Testing is a tool. It is only one tool.
– You may be seeing relapse before the use
happens.
“Positive” test results means….
• That the drug, or the metabolites, that you
tested for, are detected in the sample
• Their presence is above the “cut-off” level.
• Your greatest confidence comes with
confirmation.
• BE CAREFUL about instant tests without
an admission! Get confirmation as
needed.
What is a “cutoff” level ?
• a concentration, administratively
established, to distinguish between
negative and positive - “threshold”
• established above the sensitivity limit
• different for screening & confirmation
• also referred to as threshold value
• measured in ng/mL = ppb
It is important to understand and
remember about cut-off levels
on the various tests-you must
understand this for many
reasons.
Typical Cutoff Levels
screening & confirmation
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amphetamines *
benzodiazepines
cannabinoids *
cocaine (crack)*
opiates (heroin) *
phencyclidine (PCP) *
alcohol
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500 ng/mL
250 ng/mL
300 ng/mL
variable
20/50 ng/mL
15 ng/mL
150 ng/mL
100 ng/mL
300/2000 ng/mL variable
25 ng/mL
25 ng/mL
20 mg/dL
10 mg/dL
* SAMHSA (formerly NIDA) drugs
If you have a GC/MS confirmation
grade positive test and a secure
chain of evidence, the issue is
settled via science.
Remember that this is evidence
and subject to due process.
Specific drug test results
• Opiates:
• Tests by CLASS of drug
• Beware of synthetic opiates-they require separate
panel and tests (demerol, darvon, methadone,
fentanyl, etc.
• Poppy seeds: they WILL interfere-no poppy seeds!
• Sometimes folks legitimately need them, monitor
closely and move off them ASAP
• Detection time: up to 4 days.
Cocaine
• Drug specific assay
• If it is positive, it is
cocaine.
• No interferences
• Illicit use is the rule
• Detection: up to 3
days, but 36 hours.
• Negative test: may still
be using coke.
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Test aggressively
Watch for PAWS
Solarcaine? No
Benzocaine? No
Novacaine? No.
Nothing but cocaine
tests positive for
cocaine.
Cannabis
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• Critical issues:
Drug specific assay
• Recent vs. non recent
No interferences
use
NO passive inhalation
Marinol or Sativex will • Cut off levels are critical:
50 ng/mL vs. 20 ng/mL
test positive.
Detection: at 50 ng/mL
• 10 days for heavy
chronic use,
• 1-3 for occasional use.
Recent vs. Non recent use:
• How do you discriminate between new
drug exposure and continued elimination
from previous use? (clean out time)
• Only applies to cannabis.
• “two negative test” rule-two back to back
negative tests post clean out. Positive
after that? New use!
But, it stays in the body for 30 days!
• Maybe, but not above the cut off levels!
• Detection times: at 50 ng/mL cutoff
– Up to 3 days for occasional use
– Up to 10 days for heavy chronic use
• Detection time at 20 ng/mL cutoff
– Up to 7 days for occasional use
– Up to 21 days for heavy chronic use.
Yes, there are old studies
• That say it takes 30 days
– Old, bad research
– They did not ensure abstinence during study
– They used very low cutoff levels
– Used machines and methods no longer
available with poor specificity.
Try these instead!
www.ndci.org
Just say NO to “levels”
Drug Tests are Qualitative
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screening/monitoring drug tests are designed to
determine the presence or absence of drugs - NOT
their concentration
drug tests are NOT quantitative
drug concentrations or levels associated with urine
testing are not useful for interpretation (i.e.
distinguishing between recent use and continued
elimination)
A confirmation test is positive or negative-there is
no value to numeric levels.
Drug concentrations or levels associated
with urine testing are, for the most part,
USELESS !
• cocaine metabolite
• opiates
• cannabinoids
• amphetamines
517 ng/mL
negative
negative
negative
The Twins-by Paul Cary
200 mg
Wonderbarb
@ 8:00 AM
A
B
Collect urine
8:00 PM
12 hours later
The Twins - urine drug test results
A
Wonderbarb = 638 ng/mL
B
Wonderbarb = 3172 ng/mL
The Twins - urine drug test results
Exact physiological make up
exact amount drug consumed
exact time of ingestion
exact time between drug
exposure and urine collection
A
AND YET . . . . .
B
The Twins - urine drug test results
Twin B’s urine drug
level is 5 times higher
than Twin A
A
Wonderbarb = 638 ng/mL
B
Wonderbarb = 3172 ng/mL
Why the difference in urine drug
concentrations between twins?
• Twin A ate and drank normally during the day
– consumed foods and liquids diluted urine pool
• Twin B fasted - urine more concentrated = high
drug level
• reduced variables associated with twins to near
zero, still could not use urine drug levels
• don’t know nearly as much information about our
own clients regarding drug use
“But the levels of THC are falling!...”
• Simple rule to help you remember:
–You are either pregnant…or
you’re not
–You are either dirty for
detectable drugs…or you’re not.
What the heck is creatinine and
why should I care ?
What is creatinine ?
• creatinine is derived from the non-enzymatic
dehydration of creatine in skeletal muscle
• 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 can be measured to determine the
“strength” or concentration of a urine sample
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
• urines with a creatinines of less than 20 mg/dL
are considered “dilute” and may not reflect an
accurate picture of recent drug use
• urines with a creatinines of less than 5 mg/dL are
considered “substituted” samples - not consistent
with normal human urine
But what about normalized creatinine?
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Interesting…yes
Possibly instructive….yes
Error rate: too high for my taste to sanction
Why would you build resistance?
Creatinine Facts
• incidence of creatinines less than 20 mg/dL in a
“normal” population is approximately 1%
• some diseases that produce low urinary
creatinines
• incidence of low creatinines in a population
undergoing random drug testing is 3 - 5 times
greater than a non-drug tested population
• any fluid intake dilutes the concentration of drugs
in urine (along with the creatinine)
More Creatinine Facts
• rapid intake of 2 quarts of fluid routinely produces
low creatinines & negative urine drug tests within
one hour
• rapid intake of 4 quarts of fluid almost always
produces low creatinines and 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
Bottom Line:
Dilute tests are a sign of a
problem and need to be taken
very seriously!
Helen’s opinion: not science
• Our participants are not a normal healthy
population
• First dilute: stern discussion
• Second dilute: send to doctor to be certain
all is OK
• Third dilute, if all is OK via doctor: ZAP.
So, what to do?
• Begin altering your schedule-double back
• Conduct a surprise field visit
• Check your testing regimen to be certain folks are
being observed…and not being given too long to
report for testing.
• First void in the AM
• Refer to a physician
• Offer catheter in lieu of water for shy bladder
HOW TO BEAT A DRUG TEST
Human imagination, money, and ingenuity,
coupled with a disease that is desperate to survive.
Four basic ways:
• Use a drug we are not testing for, or
have no test for. (Designer drugs)
• Dilute your test (before or after)
• Adulterate your test
• Substitution (clean or fake urine)
There are a variety of products on the
market which take cruel advantage of the
illness that has attacked our clients.
Can you imagine another disease where
this type of deceptive behavior is
acceptable and legal?
Dilution
• The easiest and most common form of
tampering!
– Drink lots of water or fluid
– Add fluid to solution after production of
test
– Folks may add products that say they help.
Most are consumer fraud.
Adulteration
• Various items added to the test to hide
or alter the presence of the drug
• It is post collection tampering
• Low tech: pH shift theory (lime, vinegar,
bleach, ammonia, lemon, drano)
• Low tech: disrupt testing chemistry (salt,
methanol, detergents)
• High tech adulterants
Specimen Validity Tests (SVT)
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creatinine, UUN
specific gravity
pH
nitrites
gluteraldehyde
pyridine
chromium
Request SVT from testing laboratory or
use dip-stick SVT products for onsite testing
Oral Fluids?
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Addiction makes
folks do strange
things….this, of
course, is an
example of an
attempted urine
substitution.
Urine specimen substitution
• Involves replacing donor urine with
another drug free specimen
– A biological substitution: someone else’s
clean urine
– Non biological substitution: colored water,
diet mountain dew, etc.
– If testing is observed NEITHER of
these methods should work.
THERE ARE SOME FANCY
DEVICES…
Some are gender neutral
Substitution
Substitution
“The urinator the
ultimate urine
testing device only
$149.95.
A digitally
temperature
controlled unit that
is reusable, reliable
and by far the most
superior product on
the market.”
BUT GUYS REALLY HAVE ALL
THE WILD DEVICES…
So, assume this is happening
• Monitor testing carefully
• Watch for “to go” containers during
community supervision
Remember:
• This is not about “gotcha”
• It is about helping folks to resist cravings and work
programs.
• It is about supporting recovery.
• It is about objectively measuring the presence of
disease.
• Remember what your proximal and distal goals are
and what the focus of our work is.
• Be patient, be kind, but NEVER underestimate the
power of this disease.