You Can t Fool the Bladder Police. Effective Use of Urine Drug Screening

Transcription

1 You Can t Fool the Bladder Police Effective Use of Urine Drug Screening

2 Why Test? Accountability Create and maintain safe treatment environment Compliance with licensing or policy

3 Collection Supervised or unsupervised When to collect Staff training Temperature monitored cups Adulterant testing

4 In-house Testing Cost Type of test kit What to test for Staff training Staff issues Client privacy When to test

5 Lab Testing Prescription What to test for When to test Staff training Completing forms Storage and pick up

6 Testing How it Works Drug Testing Systems One Test Systems Use immunoassay (IA) to detect the presence of drugs and Are most often used for medical purposes in clinical and rehabilitation settings Two Test Systems Commonly use immunoassay as an initial test followed by a more specific confirmatory test using a different technology and Are used for results requiring a high level of certainty John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

7 Testing How it Works What is an Immunoassay? An immunoassay is a biochemical test that measures the concentration of a substance in a liquid (a portion of a biological specimen) using the reaction of an antibody or antibodies to its antigen (drug) John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

8 Testing How it Works What are Antibodies and Antigens? Antibodies are a type of protein produced by the immune system in response to foreign substances (antigens) Antibodies bind to the antigen responsible for their production John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

9 Testing How it Works Immunoassay Principles I Antibodies: Usually harvested from sheep or rabbits Usually IgG (represented as a Y ) Developed against classes of drugs Recognize antigen (drug) by its shape Y Common end Shape recognition end John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

10 Testing How it Works Immunoassay Principles II Use Tagged Drug Targets Indicator (Tag) is bound to the target drug Tag may be an enzyme a fluorophore a particle Detection is based on competitive binding Antibodies bind with Drug in Sample OR with Tagged Drug Targets Tag Drug John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

11 Testing How it Works Immunoassay principles Sample WITH drug in it Add an antibody Incubate Y John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

12 Testing How it Works Immunoassay Principles III Antibody binds drug in the sample Add tagged drug target Little or no antibody binding of the tagged compound Little or no change in signal Y John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

13 Testing How it Works Immunoassay Principles IV Sample WITHOUT drug in it Add an antibody Incubate Add tagged drug target Y John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

14 Testing How it Works Immunoassay Principles Antibody binds with the tagged compound Binding causes change in signal produced John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

15 Testing How it Works Testing with Immunoassays Immunoassays are used to screen donor specimens for the possible presence of a drug or a class of drugs These tests may be conducted on-site as part of the collection process or in a laboratory or other facility On-site testing is normally conducted with a Point of Collection Test (POCT) device Most testing is conducted in laboratories which have validated procedures and validated analytical instrumentation Immunoassays allow some laboratories to test more than 10,000 donor specimens a day John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

16 Testing How it Works Immunoassay Specificity Specificity is the affinity of an immunoassay for the target drug Specificity is measured by cross reactivity: the response exhibited when an immunoassay reacts with a compound other than the target drug Specificity limits the conclusions that can be drawn from immunoassay results John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

17 Testing How it Works Low Specificity An immunoassay with low specificity will react with many antigens (drugs) with similar structure Example: One Amphetamine immunoassay with a cutoff of 300 ng/ml of D-Amphetamine gives a positive result with: D,L-Amphetamine (300 ng/ml), Phentermine (400 ng/ml), Tranylcypromine (500 ng/ml), Methamphetamine (1,000 ng/ml), Ephedrine (1,000 ng/ml), or Phenylpropanolamine (1,000 ng/ml) Therefore, a positive result from this immunoassay test would not prove use of amphetamine John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

18 Tampering Diluting Doping Substitution

19 Tampering Diluting Hyper saturating the body with fluids to dilute metabolites possibly below the 50 ng/ml threshold, depending on your metabolism. AZO Niacin Vinegar Fiber pills Ready Clean pills Rapid Cleanse Detox Tea Goldenseal Certo QCarbo XXtra Clean Quick Flush Terminator Gold Clear Choice MC1 Vale Triple Strength

20 Tampering Doping Adding different chemicals that defeat immunoglobulin/antigen binding Bleach (powdered) Water Ammonia Blood Draino Goldenseal Hydrogen Peroxide Lemon Juice Liquid Soap Mary Jane s SuperClean 13 Purifyit Sodium Nitrate Table Salt Vinegar Visine WD 40

21 Tampering Substitution Concealed container Injection Catheterization Cigar containers/droppers

22 Tampering - Countermeasures Color Temperature Creatinine ph Specific gravity

23 False Positives Generic Name Brand Possible False Positive Efavirenz Sustiva Positive for Cannabinoids (THC) [Urinary metabolite(s) only; parent compound is non-reactive] Flunitrazepam Rohypnol Positive for Benzodiazepines (BZO) Lamotrigine Lamitcal Positive for Phencyclidine (PCP)

24 False Positives Generic Name Brand l- Vick's Methamphetamine Inhaler HCL Phenytoin Possible False Positive Positive for Methamphetamine (mamp) Dilantin Possible Positive for Barbiturates (BAR) Urinary metabolite(s) only; parent compound is non-reactive

25 False Positives Generic Name Brand Possible False Positive Procaine Novocain Positive for Opiates (OPI, MOP) Ranitidine Pylorid, Zantac Positive for Methamphetamine (M-AMP) Urinary metabolite(s) only; parent compound is nonreactive

26 False Positives Generic Name Brand Possible False Positive Sertraline Zoloft Potential Positive for Benzodiazepines (BZO) Venlafaxine Effexor or Effexor XL Potential Positive for Phencyclidine (PCP)

27 False Positives All positives require clinical intervention Review clients medications before engaging in a clinical intervention If a client reports taking a medication that may cause a false positive, a confirmatory test should be completed

28 False Negatives Time elapsed since use Improperly obtained or secured specimen Tampered sample

29 Detection Times Drug Amphetamines Barbituates Approximate Detection Time 2-4 days Short-Acting (Secobarbital) 1 day Long-Acting (Phenobarbital) 2-3 weeks Benzodiazepines 3-7 days

30 Detection Times Drug Cannabinoids Cocaine Codeine Approximate Detection Time 3-30 days 2-4 days 2-5 days Euphorics (MDMA, Psilocybin) 1-3 days

31 Detection Times Drug LSD Methadone Methaqualone Opiates Phencyclidine (PCP) Approximate Detection Time 1-4 days 3-5 days 14 days 2-4 days 2-4 days

32 Detection Times Drug Phenobarbital Propoxyphene Steroids (Anabolic) Oral Parenterally Approximate Detection Time days 6 hours to 2 days 14 days 1 month

33 Clinical Interventions Drug testing is a clinical intervention Upon admission, always explain the role of drug testing Drug testing may be scheduled, random, or suspicious Prior to securing the urine, ask the client about changes in medication and if the client has used Always explain the why of a particular drug test If the drug test is suspicious, discuss the behaviors that brought about suspicion Review test results with client immediately upon receipt, regardless of result

34 Clinical Interventions Negative drug screen Congratulate the client Review what drugs were tested for Ask the client about use of drugs not tested Ask about issue/problems when the sample was secured

35 Clinical Interventions Positive drug screen Tell the client you have the results and ask if the client has anything to share Review what drugs were tested for and indicate what was positive Allow the client time to respond Ask the client about use of drugs not tested Ask about when the client used, the circumstances Review/discuss consequences If discharge, make appropriate referral If no discharge, develop relapse prevention plan

36 Resources

37 Resources Collins, Jennifer. Laboratory Perspective on Additional Drug Testing and Associated Costs. MEDTOX Laboratories, Inc. Mitchell, John M. Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences. RTI International TROUBLESHOOTING GUIDE DRUGS OF ABUSE. Innovacon, Inc. San Diego, CA