More Effective Drug Testing: Tools, Interpretation, and Challenges. Pharmacodynamics. Pharmacokinetics. Dose Blood Receptors Effects

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1 More Effective Drug Testing: Pharmacokinetics Pharmacodynamics Tools, Interpretation, and Challenges Dose Blood eceptors Effects Absorption Distribution Dr. Leo Kadehjian Palo Alto, California Metabolism Elimination Urine, sweat, oral fluid, hair, Correlating Test esults to Effects: What Can Be Said? orensic Challenges: Specimens, Technologies Body fluid levels Blood levels Brain levels eceptor levels Likelihood of impairment Degree of impairment Urine: Adulteration, substitution, dilution, interpretation ral fluid: Adulteration, interpretation n-site: Subjectivity, performance air: Contamination, bias, ADA, standards Sweat: Contamination, tampering, standards culomotor: Science, standards orensic Issues for Laboratories / Toxicologists Admissibility of evidence Legal standards: peer review, known error rate, standards, Evidentiary weight Chain of custody, laboratory performance, interpretation, Legal requirements for decisionmaking Beyond a reasonable doubt, preponderance, Laboratory liability Duty owed, negligence, privacy of records/ipaa 1% 5% Beyond a reasonable doubt Preponderance of the evidence Probable cause easonable suspicion Expert liability Peer oversight % Mere suspicion Dowling,

2 on-users Users Qualitative (positive, negative) Test + alse + True + Unconfirmed + vs. Quantitative (ng/ml, immunoreactive equivalents, rate units) Test - alse - vs. True - Semi-quantitative (no such thing?) Antibody Specificity: Cross-eactivity Assay response Positive sample Cut-off Antigen egative sample Antibody Cross-reactants o cross-reactivity Estimated concentration Cut-off Estimated concentration Derivatized sample Gas Chromatography / Mass Spectrometry Column Detector Cutoff Level established administratively at or above which a result is reported as positive and below which is reported as negative Carrier gas + ven Ion detector Gas chromatogram Limit of Quantitation (LQ) Level at which a result may be reported as a quantitative value (e.g. ng/ml) with acceptable accuracy (e.g. ±95%) Limit of Detection (LD) Ionizer Charge / mass separation Mass spectrum Level at which a result can be clearly distinguished from the range of results for drug-free specimens 2

3 Drug-free Limit of Detection (LD) LD / LQ / Cutoff Concentration Limit Cutoff of (Administrative) Quantitation (LQ) IDT 538 (34%) GC/MS Standard cutoffs GC/MS LD L. Kadehjian, 21 San Mateo County Truth in Testing Standard immunoassay screening cutoffs DA-cleared immunoassay screening device Limit of quantitation GC/MS confirmation testing ederally-certified (SAMSA) laboratory Established scientific methods and procedures egulatory recognition (SAMSA policy) Case law support on-users Immunoassay screen Users Positive Confirmation (GC/MS) egative Unconfirmed Confirmed Positive SAMSA Drug Presence Criteria U.S. v. Klimek (SDY, 3/2/4) Mandatory Guidelines for ederal Workplace Drug Testing Programs Subpart B--Scientific and Technical equirements Section 2.4 Laboratory Analysis Procedures (j) etesting a Specimen for Drugs. (2) Because some drugs or drug metabolites may deteriorate during storage, the retest of an aliquot of a single specimen or the test of a split (Bottle B) specimen is not subject to a specific drug cutoff requirement, but must provide data sufficient to confirm the presence of the drug or metabolite. SAMSA, , 4/13/4 Drug use violation of supervised release Positive on-site immunoassay (3 ng/ml cut-off) egative laboratory screening immunoassay (181 ng/ml) egative GC/MS confirmation (118 ng/ml BE) Creatinine 29.6 mg/dl s.g. 1.3 = diluted, invalid 3

4 U.S. v. Klimek (SDY, 3/2/4) U.S. v. Klimek (SDY, 3/2/4) The results of a drug test shall be subject to confirmation only if the results are positive, A drug test confirmation shall be a urine drug test confirmed using gas chromatography/mass spectrometry techniques 18 U.S.C. 3563(e) (probation) 18 U.S.C. 3583(d) (supervised release) The program shall include such standards and guidelines as the Director may determine necessary to ensure the reliability and accuracy of the drug testing programs 18 U.S.C. 368 P.L Violent Crime Control and Law Enforcement Act of 1994 owever, the test result did not mean that Klimek did not have cocaine in his system. ere, a GC/MS test was performed, and it confirmed that cocaine metabolite was present in Klimek s system. It should go without saying that it violates the terms of Klimek s supervised release to have AY cocaine metabolite in his system. Even if I assume that the fixing of a cut-off level for GC/MS represents the Director s conclusion that Klimek s test result is questionable, that is simply a factor going to the weight of the drug testing evidence before me. U.S. v. Klimek (SDY, 3/2/4) U.S. v. Klimek, 2nd Cir., 6/8/5 there is nothing magical about the cut-off level selected by the A; equally reputable organizations involved in drug testing specify lower cut-off levels. The results of the specimen validity test strongly suggest an effort to beat the test and are most persuasively interpreted in that way. Even more significantly, the confirmation test performed on defendant s sample once it was normalized for dilution would have evinced a cocaine metabolite concentration of 46 nanograms per milliliter, well above the cutoff level of 15 nanograms per milliliter. And because I find that the results of the GC/MS test conducted on Klimek s urine sample satisfy the Congressionallymandated requirement that a contested drug test be confirmed using GC/MS U.S. v. Klimek, 2nd Cir., 6/8/5 We need not decide at this time whether Sections 3583(d) and 368 preclude a district court from revoking a defendant s supervised release based solely on a test result that fell below the cutoff level. egative does T mean o drug 4

5 Abused Prescription Drugs United States Drug Consumption pioids CS Depressants Morphine, codeine, etc. xycodone (xycontin) Buprenorphine Methadone entanyl Meperidine Propoxyphene Benzodiazepines on-benzos Barbiturates TC Ephedrine, etc. Dextromethorphan Antihistamines Stimulants Cocaine Amphetamine Methamphetamine Methylphenidate ther Carisoprodol Ketamine Steroids 4.6% of world population Consumes 2/3 of illicit drug supply Consumes 8% of global opioid supply Consumes 99% of global hydrocodone supply L. Manchikanti and A. Singh, % increase Increase in Abuse of Controlled Drugs + 542% ew teenager opioid abuse + 212% 12 to 17 yr. olds abusing + 15% Prescriptions + 81% Adults abusing + 14% U.S. Population L. Manchikanti, etail Sales of pioids (millions of grams) 74 mg/person 329 mg/person +347% Ç Å Ç Å É É xycodone +732% ydrocodone +244% (#1 prescribed drug in U.S.) Codeine -25% Morphine +196% Methadone +1177% Meperidine -28% ydromorphone +274% entanyl +479% www. deadiversion.usdoj.gov Past Year Initiates in Illicit Drug Use Thousands É É É É É É É Tranquilizers É É É Cocaine Stimulants Ç Ç Ç Ç Ç Ç Ç Ç Ç Ç Pain relievers Marijuana Sedatives eroin L. Manchikanti, 26 Concentration Abuse Supra-therapeutic use, misuse Therapeutic use 5

6 Urine Drug Concentrations (ng/ml): 1,922 Chronic Pain Patients Mean Median ange Amphetamine Methamphetamine 1,163 15,674 3,91 1, , ,591 xycodone 7,599 2, ,9 xymorphone 4,93 1, ,36 ydrocodone 2,953 1, ,2 ydromorphone 1, ,526 Methadone 4,167 2, ,322 Meperidine ormeperidine 3,86 3,49 1,138 1, , ,98 E. Cone et al., 28 Amphetamine: Adderall, X Synthesized 1887 d-isomer 3-4x CS activity vs. l-isomer Dosing: Therapeutic: 5 3 mg (3 19 mg) Abuse: up to 2, mg/d Therapeutic urine concentrations: 5 mg: 62 3,16 ng/ml 1 mg: 3,345 (62 12,191) 2 x 1 mg: 6,76 (1,339 15,359) 2 mg: 2,645 5,948 ng/ml 2 mg x 5 d: 5,739 19,172 ng/ml Abusers urine concentrations: 1, 1, ng/ml atalities: 237, ng/ml (25, 7,) 3% 4% eliminated unchanged (74% in acidic urine, 1% in alkaline urine) Urine Levels of xycodone xycodone, ng/ml n = 2 5 mg oral 64 and 4 ( 24 hr) Baselt and Stewart, 1978 n = 9 1 mg im 2 mg oral ~5 1, ( 24 hr) Poyhia et al., 1992 Utility of Urine Drug Levels Evidence of use ( negative vs. no drug ) Unconfirmed positive vs. false positive Consistency of results with claims of donor n = 2 1 mg im 2 mg im 2,5 and 75 (5 9 hr) 2,5 1, ( 3 9 hr) 6 8 (2 9 hr) Smith et al., 1995 enewed use vs. residual Likelihood of dosing scenarios n = 1 7 mg/day 12, 9 Weinstein and Gaylord, 1979 Likelihood of impairment Issues in the Use of Urine Drug Levels Test technology Immunoassay (instrumented vs. non-instrumented GC/MS ew Drugs of Abuse: Detection and Challenges Laboratory reports Qualitative, quantitative, semi-quantitative Dr. Leo Kadehjian Palo Alto, California Interpretation Use, time of use, dosing, impairment 6

7 ew Drugs: Designer Drugs Legal ighs Cannabis istory 198s entanyls Late 198s ing-substituted phenethylamines 199s Tryptamines ( oxy ) 2s Salvia divinorum Synthetic opioids, cocaine derivatives Synthetic cathinones Spice, synthetic cannabinoids Benzylpiperazines 2327 BC Documented use of cannabis, ung dynasty 1937 Marijuana Tax Act 1964 Identification of 9 -TC 197 Controlled Substances Act: Marijuana Schedule Marinol (dronabinol) DA approved: nausea 1988 CB 1 receptor identified 199 CB 1 receptor cloned 1992 Endogenous ligand Anandamide ( Internal bliss ) 1993 CB 2 receptor cloned 1994 CB 1 receptor antagonist S A, imonabant (Acomplia) 1996 Medical marijuana initiatives (CA, AZ) 1998 CB 2 receptor antagonist S Synthetic TC Analogues Synthetic TC Analogues 9 -Tetrahydrocannabinol (Dronabinol) abilone (Cesamet) anti-nausea U-21 (Dexanabinol) CP 47,497 CP 55,94 9 -Tetrahydrocannabinol (Dronabinol) Synthetic TC Analogues Spice esources Synthetic Cannabinoids and Spice (29) W 18 WI 55,212 CB 1 agonist Understanding the Spice Phenomenon (29) Spice K2 CB 1 agonist.w. uffman, Clemson University, SC Tetrahydrocannabinol 45 papers on cannabinoids, synthetics 7

8 2 S( )-Cathinone Catha edulis Khat Khat and Cat 2 2 Methcathinone (racemic) Cat S( )-Cathinone Catha edulis Khat Khat, Cat and Mephedrone 2 Methcathinone (racemic) Cat 4-Methylmethcathinone (Mephedrone) S(+)-Amphetamine S(+)-Methamphetamine S(+)-Amphetamine S(+)-Methamphetamine 2 l Ephedrine S(+)-Amphetamine S(+)-Methamphetamine S( )-Cathinone Catha edulis Khat MDMA, Ecstasy 2 Methcathinone (racemic) Cat Methylenedioxypyrovalerone MDPV 4-Methylmethcathinone (Mephedrone) Methylenedioxypyrovalerone MDPV MDMA, Ecstasy LSD 2 3 P Psilocybin Bufotenine Piperine Piper nigrum Piperidine Piperazine armaline Dimethyltryptamine (DMT) 3 C oxy Benzylpiperazine Schedule 1 (24) 1-(3-chlorophenyl)piperazine mcpp Cl 5-T 2C agonist 8

9 Kava-kava Piper methysticum South Seas Trazodone (Desyrel) antidepressant Cl 1-(3-chlorophenyl)piperazine mcpp efazodone (Serzone) SI ypophagia Cl Sedative, anti-anxiety agent Kawain Yangonin 5-T 2C agonist Cl Methysticin ew Drugs esources IDA: DEA: dea.gov Microgram ournal, Bulletin Salvinorin A Salvia divinorum European Monitoring Centre for Drug and Drug Addiction: since 1997 Early-Warning System (11 substances identified) new substances Erowid: erowid.org oints Space Time esults Max. eference 4 Passive Inhalation of Marijuana: Single Exposure Studies small room 1 hr eg < 6 ng/ml Mulé et al., small van.5 hr eg 11.6 ng/ml iedbala et al., 25 4 small van 1 hr eg 14.7 ng/ml iedbala et al., 25 Passive Inhalation of Marijuana: Multiple Exposure Studies oints Space Time esults Max. eference 4 small room 1 hr 3 days Pos (1/27) 2 ng/ml Perez-eyes et al., small room 4 hr eg 3.4 ng/ml iedbala et al., 24 6 small room 1 hr eg 6.8 ng/ml Law et al., small room 1 hr 6 days Pos ( 7 hrs) 34.5 ng/ml Cone et al., 1986, small car.5 hr eg <2 ng/ml Mørland et al., small room 1 hr eg <2 ng/ml Perez-eyes et al., 1983? coffee shop 3 hr eg 2 ng/ml öhrich et al., small room 2 hr x days Pos (5/17) 32.2 ng/ml erslew et al., station wagon small car 1 hr.5 hr Pos (1/23) Pos (3 days) 2 ng/ml 3 ng/ml Perez-eyes et al., 1983 Mørland et al., small room 1 hr 6 days Pos ( 6 days) 1 ng/ml Cone et al., 1986,

10 Passive Inhalation of Crack Cocaine Cocaine exposure Test results eference Dose Space Time Max. BE levels eference 2 mg 4 x 5 1/2 hr 15 ng/ml Baselt et al., 1991 andle 2 x $1 bills immersed in coca paste Immerse hands in coca paste 72 ng/ml BE ust below 3 ng/ml ElSohly et al., mg 2 mg 87.5 mg sidestream 7 x 8 7 x 8 11 x 15 1 hr 1 hr 4 hr ng/ml ng/ml 6 ng/ml Cone et al., 1995 Cone et al., 1995 Cone et al., 1995 Immerse fingers, 4% solution 2 drops, 4% solution, back of hand Inhale 4% aerosol, nasal procedure All EMIT negative Kavanagh et al., C C 2 Ethanol Alcohol dehydrogenase 3 C Acetaldehyde Markers of Ethanol Ingestion Ethyl palmitate (16:) atty acid ethyl esters C 2 Ethanol Ethyl glucuronide Aldehyde dehydrogenase _ 3 C Acetate atty acid atty acid P Phosphatidyl ethanol S Ethyl sulfate n = 9 n = 3 4 EtG: Passive Exposure: and Sanitizer 1 6% Et, 2 x/d (= 1 g Et), x 5 d 62% Et, every 3, 6 min <1 114 ng/ml osano and Lin, 28 5 ng/ml ohrig, 26 n = 2 every 15 min for 8 hr 1/2 pos, 62 ng/ml ohrig, 26 EtG: Innocent ral Exposure 2 x 12 oz non-alcoholic beer 93 ng/ml AACC / Quest, 26 1 tsp communion wine (9% Et) yquil (25% Et), 3 x 1 oz 77 ng/ml AACC / Quest, ng/ml AACC / Quest, 26 n = 24 conditions not specified pos, cutoff not specified ASAM, 26 (Wall St..) n = 1 repeated throughout day 77 ng/ml Wall St.., 26 4 oz mouthwash n = 9 (12% Et), gargle every 3 sec, 5 min 2/39 >5 ng/ml 8/2 <1 ng/ml 17/2 <25 ng/ml 1 >3 ng/ml Costantino, 25, 26 62% Et, throughout day 47 ng/ml AACC / Quest, 26 n = 11 gargle 3 x d, 5 d 1/55 >5 ng/ml all <1 ng/ml Costantino, 25, 26 1

11 n = 3 n = 2 n = 4 EtG: Innocent ral Exposure 2.5 L non-alcoholic beer 3 87 ng/ml Thierauf et al., 21 baker s yeast/sugar 12, 5 ng/ml Thierauf et al., 21 brewer s yeast /sugar D 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 regulatory compliance context, has truly been drinking. Legal or disciplinary action based solely on a positive EtG, or other test discussed in this Advisory, 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. SAMSA, Substance Abuse Treatment Advisory, 5 (4), September 26. SAMSA: Alternative Specimens Also, scientific advances in the use of head hair, sweat, and oral fluid in detecting drugs have made it possible for these specimens to be used in ederal programs with the same level of confidence that has been applied to the use of urine. SAMSA, ederal egister, 4/13/4, PharmChem Sweat Patch: PharmCheck Patch components: Gas permeable polyurethane outer membrane (Tegaderm ),.25 mm thick elease liner: cellulose tissue,.3 mm thick Cellulose absorbent pad: 3 x 5 cm (14 cm 2 ),.7 mm thick Patch sweat absorption: ~3 µl/day = ~2 ml/week Patch wear period: 1 2 weeks Patch processing: Eluted with 2.5 ml 75/25 Me/.5 M acetate buffer Immunoassay screen LC/MS/MS confirmation Sweat patch cut-off: Cocaine, BE: 1 ng/ml = 25 ng/patch Sweat Patch Drug Testing: Admissibility and Evidentiary Weight ral luid: Benefits and Issues Benefits Issues DA cleared collection device and immunoassays (controlled-dosing, field, procedural integrity studies) Ease of specimen collection Difficult to adulterate Low specimen volume Low drug concentrations ver 7 supporting publications in international peer-reviewed literature (only few challenges) ederal regulatory recognition (SAMSA Proposed ule 4/4) Majority of case law precedents supportive (especially recent) Better correlation with effects Established and growing scientific literature Minimal biohazard risks Good specimen stability Accurate testing methods Shorter detection times n-site testing limited o formal regulatory scheme o formal proficiency program Limited case law 11

12 Issues in air Testing air anatomy and physiology Mechanisms of incorporation of drugs Specimen stability Analytical methods Interpretation of results Donor subversion Admissibility and evidentiary weight Urine Specimen Validity Tests Department of ealth and uman Services Substance Abuse and Mental ealth Services Administration Mandatory Guidelines for ederal Workplace Drug Testing Programs evised Mandatory Guidelines 4/13/ Effective 11/1/4 1.% 8.% 6.% Drug Use, Dilution, and Detection 9.9% 1, DT specimens 758 dilute Positive at Limit of Detection Positive at S cut-offs equired Specimen Validity Tests: Urine Creatinine Specific gravity if creatinine <2 mg/dl 4.% 2.8% 2.% 1.2%.3%.% Dilute ormal (758 controls) s.g. <1.3 and / or creatinine <2 mg/dl ational Laboratory Certification Program, Program Document #25, 1993 p xidizing adulterants ( 1) itrites, pyridinium chlorochromate, chromium (VI), bleach, iodine, halogens, peroxidase, peroxide, others Additional as needed Urine Specimen Validity Testing Validity Testing Criteria: Urine Adulterated on-normal constituent Endogenous constituent at non-normal concentration Substituted Invalid Creatinine <2 mg/dl AD s.g. 1.1 or 1.2 Inconsistent creatinine, specific gravity itrite, p, possible presence of other adulterants Interference Appearance Dilute Creatinine 2 mg/dl but <2 mg/dl AD s.g. >1.1 but <1.3 Creatinine, mg/dl Inconsistent = Invalid 2 ormal Dilute Substituted Substituted 2 Inconsistent = Invalid Specific gravity

13 Dilute Invalid creat <2 and s.g. >1.1 but <1.2 Substituted Adulterated SAMSA creat 2 but <2 and s.g. >1.1 but <1.3 p 3 but <4.5 creat 2 and s.g. 1.1 p 9 but <11 creat <2 and s.g. 1.1 or 1.2 p <3 or 11 on-normal substance on-normal level U.S. Courts creat 2 but <15 or s.g. 1.2 or 1.3 s.g. 1.1 or 1.45 creat <2 p 4 or >1 on-normal substance on-normal level Urine Production ate After Water Loading Urine 6 production 5 rate 4 (ml/min) Drink 1 L water Time (min) E. Baldes and. Smirk, 1934 Urine Production ate After Water Loading Urine production rate (ml/min) Drink 2 L water Time (min) Macallum and Benson, 199 Typical: Cut-off: Creatinine Specific Gravity ~15 mg/dl ~1.25 Dilute x 8 2 mg/dl 1.3 ng/ml Cut-off B Dilute x 8 Dilution: TC B r. B B ng/ml Cut-off Dilution: Cocaine Dilute x r. 13

14 Effect of Water Loading on Urine Cannabinoid Levels Cannabinoids, ng/ml 8 12 oz. Without water load Cutoff 4 With water load (4 x 1 qt) hr E. Cone et al., 1998 mg/dl Urine Creatinine B B A AÉ B É B É A É B B A B É B A A AÉ É All n= 22,245 AÉ B Male emale A on-ispanic White on-ispanic Black É Mexican American Age D. Barr et al., 24 Urine Creatinine: Diabetics vs. ormal Population Creatinine, mg/dl Diabetics, n = 1,284 AES III, n = 9, Creatine + 2 Creatinine Age de ine livarius et al., 26 D. Barr et al., Effect of Creatine Loading on Urine Creatinine Creatinine mg/dl n = 4 ral creatine: 2 g/day, 5 days, then 5 g/day, 5 days Before creatine loading During / after creatine loading opero-miller et al., 1998 # Subjects 1 8% Drug-free If 5% highly dilute 15% on-zero immunoreactive equivalents Cut-off 1% Positive 5% Positive Double detection rate Immunoreactive equivalents, ng/ml 14

15 Cannabinoids ng/ml Apr 16-Apr 23-Apr 3-Apr 7-May 14-May 21-May 28-May 4-un 11-un 18-un 25-un 2-ul 9-ul 16-ul ng/mg ng/ml mg/dl Apr Cannabinoids normalized Cannabinoids Creatinine 16-Apr 23-Apr 3-Apr May 14-May 21-May 28-May 4-un un un 25-un 2-ul 9-ul 16-ul Adjusting Cannabinoid Levels for Dilution / Concentration enewed Use vs. esidual? ng Cannabinoids / ml mg Creatinine / dl x 1 = ng Cannabinoids mg Creatinine Cannabinoids 5 ng Cannabinoids / ml 15 mg Creatinine / dl (normal) 5 ng Cannabinoids / ml 15 mg Creatinine / dl (dilute) x 1 = x 1 = 33 ng Cannabinoids mg Creatinine 333 ng Cannabinoids mg Creatinine // Time Cut-off Marijuana Detection Times for 6 Immunoassays and GC/MS Low dose igh dose ng/ml 15 ng/ml 88.6 uestis et al., ±SE Creatinine ormalized TC-C in Chronic Users ormalized TC-C ng/ml n = 17 5 doses lifetime use (= daily use for 14 years) Levels normalized to 1 mg/dl creatinine 5/17 (29%) negative 2 ng/ml) w/i 1 week 9/17 (53%) negative w/i 2 weeks 11/17 (65%) negative w/i 3 weeks Days after last use E. Kouri et al.,

16 enewed Use or esidual? With current 5 ng/ml cut-off: ccasional users: positive for 1 2 days, rarely longer Documented chronic users: positive for 2 3 weeks, rarely longer Examine every positive, review intervening negatives Positive after 1 month enewed use (conservative) enewed Use vs. esidual Levels from Prior Use? Issues for consideration: Time: between test results, from claimed last use Drug levels (normalized) Pattern: levels (normalized), time, specimen ratios Specimen validity: dilution, creatinine, normalization 5% increase in dilution-adjusted levels after 1 week (conservative) enewed use Donor claims, history 16