The Truth about UA s (From the Trenches)

Transcription

1 The Truth about UA s (From the Trenches) Presenters: Richard Larsen, Deputy County Attorney, Davis County Attorney s Office Craig Webb, Bureau Chief of Investigations, Davis County Attorney s Office Special thanks to the following for providing much of the source material: National Association of Drug Court Professionals (NADCP) Paul L. Cary, Toxicology Laboratory, University of Missouri I. Introduction: A. Drug testing reality check: 1. What to expect from your clients: Expect that the participants involved in substance abuse testing know, think that they know, or act like they know more about drug testing than you do. 2. Sources of (mis)information: a. The internet b. High Times magazine and other similar publications c. Other court clients or friends B. Characteristics of a good drug test: 1. Scientifically valid a. Employs proven methods & techniques b. Accepted by the scientific community 2. Legally defensible a. Able to withstand legal challenges b. Established court track record c. Scrutinized by legal/judicial review 3. Therapeutically beneficial a. Provides accurate profile of client s drug use b. Provides rapid results for appropriate response II. Methods of drug testing (including advantages/disadvantages): There is no perfect drug testing specimen. Each has its advantages and disadvantages and each can provide a somewhat different picture of a person s substance use history. A. Urine: 1. Detection period: Typically days for most substances, but others may be hours (like for alcohol and GHB). 2. Disadvantages: Yuck factor (biological waste), invasive (witnessed collection procedures required including same gender observed collection), susceptible to tampering by the subject (dilution or adulteration), drug concentration is influenced by intake (allowing for tampering by dilution), sample collection can be time consuming, urine drug levels provide no interpretive data (no specific dose/concentration relationship), rapid results tests can have lower accuracy (more on that in the next slide). 3. Advantages: Shows more than just immediate use, typically large sample quantities are available, due to concentrated metabolites they are more easily detectable, numerous inexpensive testing options are available, some methods provide rapid/immediate results, test results can be confirmed by more accurate testing methods, uniform forensic criteria supported by years of court/legal case law, established cutoffs, quality assurance practices well-established, easily tested (on-site and at a laboratory). 4. Preferred drug testing method: Overall this is currently the best and most preferred method of drug testing in comparison to other testing methods. 1

2 B. Hair: 1. Detection period: Up to 90 days. However, it does not evidence recent drug use because the hair must have time to grow out of the scalp (which can take 7 to 10 days). It also may not be sensitive enough to detect a single drug use event. 2. Disadvantages: Expensive, inability to detect recent drug usage, limited testing facilities, no on-site testing, may not detect a single drug use event, date of drug use cannot be determined, arguable concerns about ethnic/hair color bias, tampering is possible. 3. Advantages: Lengthy detection period, noninvasive, no biohazard issues. C. Saliva - oral fluids: 1. Detection period: Typically within 24 hours after use for most drugs. 2. Disadvantages: Short detection window, specimen collection can be time consuming, limited confirmation testing, cutoffs not well established, limited number of detectable drugs, lower reliability/accuracy. 3. Advantages: Portable, reduces specimen tampering, noninvasive D. Sweat - patch test: 1. Detection period: Only monitors current use. Past exposure cannot be detected. FDA approved to be worn for 7 days. 2. Disadvantages: Cannot detect prior drug use, can be removed, limited number of drugs detected, limited confirmation tests. 3. Advantages: 24/7 monitoring, relatively tamper proof, noninvasive. E. Blood: 1. Detection period: Typically within hours of use. 2. Disadvantages: Invasive (medical staff required), no on-site testing, small sample volume, high potential for false negatives due to the typically low levels of drugs in the blood. 3. Advantages: No specimen tampering, positive test results are typically highly accurate. F. Breath: Primarily used for alcohol testing and it only gives a snapshot for current use/intoxication. III. Urine testing overview: A. Types of urine tests: 1. Dip tests: a. Advantages: Inexpensive, portable, fast results, numerous commercial manufacturers, can perform one test at a time (no batching). b. Disadvantages: Only 60-70% accurate, may have cross reactivity issues. c. How does it work: Often based on immunoassay technology (using reagents to test for chemical reactions). The test is either positive or negative. The brightness of the line is irrelevant it s either there or not (like a pregnancy test). 2. Chemistry-immuno analyzer tests: a. Advantages: High accuracy b. Disadvantages: More expensive, requires expensive machines/equipment and expensive reagents, may have cross reactivity issues. c. How does it work: This too is based on immunoassay technology, but it is much more sophisticated and highly accurate. 3. GC-MS/LC-MS (gas chromatography-mass spectrometry and light chromatography-mass spectrometry): a. Advantages: The most accurate testing method. b. Disadvantages: Requires extremely expensive machines/equipment. c. How does it work: Drug molecules are separated by physical characteristics and substances are identified based on chemical finger-print. B. Drug detection windows for urine: 1. Examples of Drug Detection Windows: (Source: Norchem company) a. Amphetamines/Methamphetamines: 1-2 days b. Ecstasy: 1-2 days c. Cocaine: 2-4 days d. Opiates: 2-4 days 2

3 e. Benzodiazepines: days f. THC: i. Light Use: 1-5 days ii. Extremely Heavy Use: 3 weeks+ (but see the further explanation below) 2. More on the THC detection window in urine: a. It doesn t stick around at a testable level as long as many claim: Conventional wisdom has led to the common assumption that cannabinoids (marijuana) will remain detectable in urine for 30 days or longer following the use of marijuana. This is not accurate according to the research. This mistaken belief encourages dishonesty about the recentness of use, which in turn can cause a delay of therapeutic intervention. b. The claimed 30+ day detection window exaggerates the true duration of the detection window. c. The real detection window according to the research: i. For detection at a 50 ng/ml cutoff: 1. Up to 3 days for single event/occasional use 2. Up to 10 days for heavy chronic use ii. For detection time at a 20 ng/ml cutoff: 1. Up to 7 days for single event/occasional use 2. Up to 21 days for heavy chronic use 3. Alcohol detection window (for screening tests specific for ethanol, ethyl alcohol): a. Detection time is only hours long: For example, a person who is intoxicated at 11:00 p.m. who provides a urine sample the next day at 11:00 a.m. will most likely test negative for alcohol. As a result, i. A positive drug test typically demonstrates extremely recent use. ii. Negative results don t necessarily document abstinence. Use could have occurred outside of the testing window. IV. Urine test manipulation/cheating: A. People are often motivated to try to cheat drug tests: 1. Often those being tested are tempted to manipulate test results because they perceive it as in their best interest. 2. Ensuring that drug tests are accurate and reliable in the long run are best for all parties involved in the system. B. Cheating methods: 1. Timing use around the testing schedule: If clients understand the length of time that substances can be tested for and can predict the testing schedule, they can time their use to avoid testing positive in spite of their lack of abstinence. 2. Urine specimen substitution: a. Definition: Replacing the donor s urine sample with another drug-free specimen. b. Types of substitution: i. Biological substitution: Using someone else s clean urine. ii. Non-biological substitution: Replacing urine with a urine look-a-like sample (flat Mountain Dew, apple cider, water with food coloring, etc.) 3. Urine specimen adulteration: a. What is specimen adulteration? The addition of foreign substances designed to mask drug presence. b. This is post-collection tampering. c. Types of adulterants: i. Low-tech adulterants that cause ph shift (lime, vinegar, bleach, ammonia, lemon, Drano). ii. Low-tech adulterants that disrupt testing chemistry (salt, methanol, detergent). iii. High-tech adulterants: specialty products specifically designed to alter drug test results. 3

4 4. Dilution: a. Dilution s goal: Lowering the concentration of drugs in the urine using a drug free liquid, to the point that the drug concentration level is below the test s cutoff level producing a negative test result. b. Dilution is the most common form of specimen tampering. c. Water is the easiest, cheapest, simplest method of dilution. d. Pre-collection dilution: i. High-volume ingestion of fluids (sometimes called water loading, flushing, hydrating, etc.) ii. Products designed to enhance drug elimination or removal may be used in conjunction with other fluids (Gold Seal, Clean n Clear, Test-Free, Naturally Klean, etc.) (although there is no evidence these products have any additional effect on drug elimination). e. Post-collection dilution: i. What is post collection dilution? Agents added after sample collection designed to dilute drug concentration in the sample. ii. What diluting agents are used? Water, clean urine, other fluids. 5. Substance shifting: a. Definition: Switching to the use of alternative substances that the test subject believes will allow him or her to avoid detection during drug testing procedures. b. Types of substances: i. Substances not commonly tested for. Example: GHB ii. Substances where they can claim a cross reactivity defense. Example: Wellbutrin and ecstasy. iii. New designer substances. Created in large part to avoid testing procedures. c. Designer drugs: i. What are designer drugs? Drugs, which are created or reformulated to get around existing drug laws, usually by modifying the molecular structures of existing illegal drugs to varying degrees. Examples: Synthetic cannabinoids (ex: Spice & K2), cathinone drugs (ex: bath salts ), new opiate derivatives (ex: Krokodil & Kratom), new amphetaminelike stimulants (ex: DragonFly). ii. Why are designer drugs created and manufactured? To make an illegal drug legal, to make the drug more difficult to detect - outpace testing tools, to prolong the effect of the drug and/or increase the potency of the drug, and/or to select the desired effect. V. Best practices for obtaining reliable urine drug test results: A. Why should you care about ensuing reliable tests? In the long run this benefits all parties within the system. Even the person being tested has an interest in proving he or she is actually clean. B. Best practices for reliable drug testing: (per the National Association of Drug Court Professionals Adult Drug Court Best Practices Standards Volume II ) 1. Frequent testing: How frequent is frequent enough? a. Drug and alcohol testing must be performed frequently enough to ensure substance use is detected quickly and reliably. b. Tests that have short detection windows require more frequent testing. c. For urine testing, random tests at least twice weekly for a prolonged period is necessary to get an accurate reflection of drug use/abstinence. 2. Random Testing: To be effective, tests have to keep the recipient guessing. a. Testing for drugs and alcohol must be random and unpredictable. b. If the test recipient knows a test is coming, the test becomes an I.Q. test, not a substance abuse test (it tests whether the person tested is smart enough to time his or her use around the testing schedule). c. Testing programs must: 4

5 i. Be truly random: There must be a random equal chance of being tested on any given day INCLUDING on weekends and holidays. ii. Limit time between notification and testing: A test should be supplied no longer than 8 hours following notification of the required test. 3. Duration of testing: a. A single clean test does not prove abstinence: This is because i. Use may have occurred outside the testing window. ii. Use may have been of a small enough quantity not to reach the cut-off level. iii. Some forms of testing may not be sensitive enough to detect a single use episode (for example: hair follicle testing). b. How long must people test? Things to keep in mind when determining testing duration: i. To establish evidence of abstinence: For urine testing, random tests at least twice weekly for a prolonged period is necessary to get an accurate reflection of drug use/abstinence. But, ii. To guard against the risk of relapse: Temporary abstinence does not mean that the addiction is cured. Even when someone has a period of clean tests, relapse is still a threat and it is difficult to predict when it may occur. 4. Breadth of testing: a. Must test for the full range of substances that are likely to be used. b. Shortcomings of limited/standard panels (like NIDA 5 or standard eight-panel tests): Clients can engage in evasion strategies by switching their substances use, such as i. Opiate switching: heroin to oxycodone ii. THC alternatives: marijuana to Spice/K2 iii. GHB use iv. Other designer drugs (bath salts, etc.) c. Suggestions for more accurate long term test results: i. Randomized drug testing panels (don t always test for the exact same things) ii. Consider alternative specimen options (oral fluids, etc.) d. Drug testing for designer drugs: i. It can be difficult to do, but not impossible. ii. New immunoassay products are being brought to the market, but iii. Limited laboratory-based confirmation testing (LC/MS/MS reference method). iv. The evolutionary landscape of the substances increases the risk of false negative results. 5. Witnessed collection: a. Direct observation of collections of samples is a mandatory aspect of effective/accurate drug testing. b. Urine collections not witnessed are of little or no assessment value because of the possibility of adulteration/manipulation of the testing sample, such as: i. Fake bladders (external and internal) ii. Dipping (submitting toilet water as part or all of the sample) iii. Contamination of collection cups. 6. Ensuring valid specimens: a. Recommended procedures for ensuring valid samples: i. Wash hands: Require test recipients to wash hands prior to donation. ii. Witness collection: 1. Require test recipients to remove additional clothing. 2. Body inspection (to make sure no external bladders are being used). 3. Have participants squat and cough (to make sure no internal bladders are being used). iii. Label the sample correctly: Accurately document the correct donor and other collection information. iv. Sample inspection: Check the following: 5

6 1. Temperature ( F) (evidence of a sample from another donor) 2. Color (evidence of dilution) 3. Odor (bleach, sour apples, aromatics, vinegar, etc.) (evidence of adulterationsomething other than human urine) 4. Solids or other unusual particulates (evidence of adulteration-something other than human urine) v. Store the sample properly. vi. Maintain documented custody and control. vii. Maintain a sample for confirmation testing purposes for a reasonable time period. 7. Accurate and reliable testing procedures: a. How do we test for dilution? i. Creatinine testing is the best method to ensure specimen validity. ii. To ensure validity of the test result, every urine sample collected for drug detection should be tested for creatinine. iii. Urines with a creatinine level of less than 20 mg/dl are considered dilute and are invalid samples. At this level they rarely reflect an accurate picture of recent drug use because at that point the dilute samples are more like water than like urine. iv. Urine samples with a creatinine level of less than 20 mg/dl are extremely rare in the absence of intentional dilution (more on this in a moment). b. What is creatinine? i. Creatinine is produced as a result of muscle metabolism. ii. Creatinine is produced by the body at a relatively constant rate throughout the day. iii. Creatinine is a compound that is unique to biological material (i.e. urine, other body fluids). iv. As a result creatinine measurements can: 1. Determine the strength or concentration of a urine sample. 2. Ensure the sample being tested is actually urine. v. Interpreting urine creatinine levels: 1. Normal urine creatinine: 130 mg/dl. 2. Frequency of abnormal creatinine rates: Less than 1% below 20 mg/dl; Less than 1% greater than 400 mg/dl. 3. Study details: These rates are from Urinary Creatinine Concentrations in the U.S. population. This was a 2005 study involving 22,245 participants. This study was not associated with drug testing. Its subjects came from a variety of ethnic groups. Samples were collected in the a.m., mid-day, and p.m. vi. Low creatinine levels: 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. Even in the extremely rare case that it is not intentional, the low creatinine level negates the validity of a negative drug test. 1. Negative or none detected results should never be interpreted as indicating no drug use (abstinence), because if drugs were present, they probably could not be detected by the test. 2. Positive drug test results from a dilute sample, however, are considered valid (because the donor was not able to dilute the sample sufficiently to deceive the test). vii. How are creatinine levels intentionally decreased? 1. Rapid ingestion: (90 minutes) Consumption of 2-4 quarts of within approximately 90 minutes of testing will almost always produce low creatinine levels and negative urine drug tests. Full recovery time of accurate urine creatinine levels and drug concentrations can take up to 10 hours. 2. Water loading: Intentionally keeping the body consistently overly-hydrated. 6

7 viii. Naturally occurring low creatinine: 1. Some rare and serious diseases can produce low urinary creatinine levels. Such as muscle wasting diseases and some serious kidney aliments. 2. Low creatinine levels ARE NOT routinely associated with pregnancy, diabetes, obesity, hepatitis, exercise, high-blood pressure, or being vegetarian. ix. High creatinine: 1. The creatine supplement issue: Creatine is the pre-cursor of creatinine. Creatine supplements may increase the amount of creatine in the muscles. Creatine supplements (along with training) may improve performance by increasing energy for activities such as sprinting and weightlifting because muscles may be able to generate more energy or generate energy at a faster rate. But it also can be used to try to offset the effects of dilution. As a result, if you want accurate test results it should not be consumed by testing subjects. 2. Use of creatine supplements can backfire: While consuming over-the-counter creatine can disguise pre-collection hydration and a dilution efforts, in reality it is very difficult to coordinate the intake timing and volume of creatine and dilution liquid. Creatinine levels greater than 300 mg/dl should raise a red flag for sample manipulation. Creatinine greater than 400 mg/dl should be viewed as an invalid test and evidence of tampering. x. The morale of the creatinine story EVERY urine sample used for drug detection should be tested for creatinine. c. Drug tests & cross reactivity: i. Tests using immunoassay technology can react to non-target compounds creating false positive results in some circumstances. ii. Substances that have higher rates of cross reactivity: Amphetamines, benzodiazepines, ecstasy. iii. How do you ensure the accuracy of these tests? 1. Obtain a list of interfering compounds from lab or test vendor. 2. Have test recipients disclose all medications that they are using when the test is given. 3. Restrict the use of medications/substances that cause cross reactivity (false positives). 4. Do confirmation testing using the same sample with a more accurate testing method. 8. Rapid results: The faster results are received, the more effective the therapeutic and/or judicial response in encouraging long-term sobriety. VI. Interpreting urine test results: A. Cutoff levels: 1. 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. 2. Typical cutoff levels: This applies to most screening & confirmation tests (based on SAMHSA (formerly NIDA) standards) a. Amphetamines * 500 ng/ml 250 ng/ml b. Benzodiazepines 300 ng/ml variable c. Cannabinoids * 20 & 50 ng/ml 15 ng/ml d. Cocaine (crack)* 150 ng/ml 100 ng/ml e. Opiates (heroin) * 300/2000 ng/ml variable f. Phencyclidine (PCP) * 25 ng/ml 25 ng/ml g. Alcohol 20 mg/dl 10 mg/dl 3. Why cut-off standards? a. Cutoffs provide important safeguards: This includes detection accuracy and evidentiary admissibility. 7

8 b. These cut-off standards are designed to be high enough to eliminate the typical defenses such as I didn t use/it wasn t me, so it must have been... i. Second hand exposure (marijuana hot-boxing ). ii. External exposure, not ingestion (ex: hand sanitizer). B. Interpretative value of the drug levels : There really isn t any. 1. Urine drug tests that provide specific levels should be interpreted either as positive or negative. 2. There is generally no interpretative value of the drug level : Drug concentrations or levels associated with urine testing are, for the most part, USELESS. They possess little or no interpretative value. These urine drug level interpretations have no forensic merit and generally produce interpretations that are inappropriate, factually unsupportable, and without a scientific foundation. 3. Why? a. Technical issues: Tests measure total drug concentrations and are not linear. b. Physiological: There is a variability of urine output and a differential elimination of drug components between individuals. 4. As a result, no one should be using these phrases for urine drug tests: a. How positive is he/she? b. Are his/her levels increasing or decreasing? c. Is that a high level? d. Is he/she almost negative? e. Is this level from new drug use or continued elimination from prior usage? f. What is his/her baseline THC level? g. Does that level indicate relapse? h. Why is his/her level not going down (or up)? C. Negative or None Detected Results: 1. What does it mean? It means that no drugs or breakdown products (metabolites) tested for were detected in the sample tested. 2. But a negative test does not necessarily mean that the test subject has not been/is not using drugs. The following could still be occurring: a. The test subject is using a drug that cannot be detected by the test. b. The test subject is not using enough of the drug to test above the cut-off level. c. The test subject s drug use occurred outside the window of detection. d. The test sample may have been diluted, adulterated, or otherwise tampered with. 3. As a Result: a. There is no need to second-guess every negative result. b. Recognize the test for what it is, a monitoring tool. c. Assess a none detected drug testing results in the context of all other available evidence that might demonstrate drug use/abstinence. D. Positive test result: 1. What does it mean? It indicates that drug(s) or breakdown products (metabolites), tested for, were detected in the sample tested 2. Drug presence is above the cutoff level. 3. You may want to confirm test results to ensure against false positive results. a. The greatest accuracy is always achieved with confirmations tests. b. Confirmation tests should be done using the original sample. 8