Drug Testing Integrity
Drug Testing Integrity
Drug Testing Integrity
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
Opioid Risk Management<br />
June 26-27, 2008<br />
Ways to Deceive <strong>Drug</strong><br />
<strong>Testing</strong><br />
Theodore F. Shults, JD, MS<br />
Chairman<br />
American Association of Medical Review Officers<br />
Durham, NC<br />
1
The Smoking Thoroughbred<br />
2
1. Eliminate the evidence – substitution,<br />
dilution<br />
2. Attack the immunoassay – pH, interfering<br />
substances<br />
3. Attack the drug metabolite – oxidation, pH<br />
4. Avoid the test<br />
5. Hire a lawyer<br />
6. Find another doctor<br />
7. Deny, deny, deny…<br />
Basic Strategies to Beat the Test<br />
3
• <strong>Drug</strong> addicts and users have always had<br />
methods and practices to beat a drug test<br />
• Common approaches<br />
◦ Drink vinegar<br />
◦ Dilute your urine<br />
◦ Drink “Health Inca Tea”<br />
◦ Adulterate your specimen<br />
• Bleach; soap; battery acid<br />
◦ Self-catheterization<br />
◦ Substitution<br />
<strong>Drug</strong> Culture:<br />
Mythology and Practices<br />
4
• Death<br />
Investigations<br />
• Criminal<br />
Investigations<br />
(DUI, DWI)<br />
• Court ordered:<br />
• Custody<br />
• Parole<br />
• Probation<br />
• Doping Control<br />
(Sports)<br />
• Life Insurance<br />
Underwriting<br />
• <strong>Drug</strong> Deterrence<br />
and Control<br />
(workplace/schools)<br />
• Emergency<br />
Medicine<br />
• Pain Management<br />
• “Wellness”<br />
• Fitness for Duty<br />
<strong>Drug</strong> <strong>Testing</strong> Environments<br />
5
• 1990s: Workplace <strong>Drug</strong> <strong>Testing</strong> and<br />
the Internet come of age.<br />
• Small cottage industry festers into<br />
multi-million-dollar industry to assist<br />
drug users in beating the test.<br />
• Selling hope.<br />
Commercialization of “Beating the<br />
<strong>Drug</strong> Test”<br />
6
◦ Lab profits are based on rapid negative test<br />
results<br />
◦ Everyone loves negative tests<br />
◦ Regulatory emphasis on costs of regulations<br />
◦ Technical mistakes and leadership failures –<br />
• The substituted-specimen fiasco<br />
◦ Privacy concerns prohibit observed collection<br />
without “individualized suspicion”<br />
◦ HHS Mandatory Guidelines – All adulterated<br />
tests are now “invalids”<br />
Fostering the Growth of<br />
the Beat-the<br />
the-Test<br />
Industry<br />
7
Explosion of Products<br />
8
• The media breakout product for the “beat the drug<br />
test” industry has clearly been the Whizzinator.<br />
• Minnesota Vikings running back Onterrio Smith was<br />
caught in possession of this device in May 2005 at the<br />
Minneapolis-St. Paul International Airport, which<br />
resulted in his suspension.<br />
• Actor Tom Sizemore has also brought the Whizzinator<br />
into the public eye after having been caught with one<br />
attempting to evade drug tests.<br />
• The United States Congress held hearings on the<br />
Whizzinator on May 17, 2005.<br />
Mr. Whizzinator Goes to<br />
Washington (Under Subpoena)<br />
9
Rep. Bart Stupak (D-Mich.) bemoans<br />
the Whizzinator while holding an<br />
advertisement for the device. At left is<br />
Ed Whitfield (R-Ky.), the subcommittee<br />
chairman.<br />
Photo Credit: By Robert A. Reeder --<br />
The Washington Post<br />
10
• “The sheer number of these<br />
products, and the ease with which<br />
they are marketed and distributed<br />
through the Internet, present<br />
formidable obstacles to the integrity<br />
of the drug testing process.”<br />
◦ GAO-05-653T: “<strong>Drug</strong> Tests: Products to Defraud<br />
<strong>Drug</strong> Use Screening Tests Are Widely Available.”<br />
11
“Number 1 is a disposable urinating device<br />
with enough premixed synthetic urine for<br />
2 complete tests. It has been irradiated in<br />
order to destroy all bacteria giving Number 1<br />
a one-year shelf life.” 14
$49.95<br />
ORDER NOW!<br />
•Contains everything you need for 2 tests!<br />
•Highest quality synthetic urine available!<br />
•Adjustable belt included!<br />
•No mixing required!<br />
•Male & Female usage!<br />
•Most advanced heating system!<br />
•1 year shelf life!<br />
•No need to freezing or refrigeration!<br />
•Satisfaction Guaranteed!<br />
15
Where does this go?<br />
16
• High-Tech Meets Low-Tech<br />
The Three Amigos<br />
17
Chemical Warfare:<br />
The Adulterants<br />
18
in vitro Adulterants Available<br />
Commercially<br />
Adulterant Class Identity<br />
Mary Jane<br />
SuperClean 13<br />
Surfactant<br />
Lemon Scented<br />
Detergent<br />
UrinAid Fixative Glutaraldehyde<br />
Amber-13 Acid 1.7 N HCI<br />
THC-Free Acid 2.1 N HCI<br />
21
in vitro Adulterants Available<br />
Commercially<br />
Adulterant Class Identity<br />
Klear Oxidant Potassium Nitrite*<br />
Whizzies Oxidant Sodium Nitrite*<br />
Randy’s Clear Oxidant Nitrite<br />
22
in vitro Adulterants Available<br />
Commercially<br />
Adulterant Class Identity<br />
Urine Luck Oxidant Pyridinium<br />
chlorochromate*<br />
LL418 Oxidant Pyridinium<br />
chlorochromate*<br />
Sweet Pee’s<br />
Spoiler<br />
Oxidant<br />
Pyridinium<br />
chlorochromate*<br />
Randy’s Klear II Oxidant Pyridinium<br />
chlorochromate*<br />
23
Nitrites:<br />
Conclusions and Interpretation<br />
1. <strong>Testing</strong> for Nitrite; Nitrate is different and<br />
does not interfere<br />
2. Normal and medical nitrite concentrations<br />
in urine well below 500 mcg/mL<br />
3. Nitrite is oxidizing agent and may<br />
deteriorate with time in unpreserved urine<br />
4. Concentrations of nitrite in adulterated<br />
urine are high<br />
5. Cutoff distinguishes normal from<br />
adulterated urine<br />
24
Chromium:<br />
Conclusions and Interpretation<br />
1. Cr +6 extremely toxic — not to be confused with Cr +3<br />
2. Urine concentrations in adulterated urine generally<br />
1000 times greater than normal<br />
3. Cr +6 not expected in urine of an asymptomatic<br />
individual<br />
4. Urine concentrations found in adulteration cases<br />
exceed highest toxic case reported<br />
5. No established cutoff — 20 mcg/mL Limit of<br />
Detection required by new regulations<br />
25
in vitro Adulterants Available<br />
Commercially<br />
Adulterant Class Identity<br />
Mary Jane<br />
SuperClean 13<br />
Surfactant<br />
Lemon Scented<br />
Detergent<br />
UrinAid Fixative Glutaraldehyde<br />
Amber-13 Acid 1.7 N HCI<br />
THC-Free Acid 2.1 N HCI<br />
26
in vitro Adulterants Available<br />
Commercially<br />
Adulterant Class Identity<br />
Klear Oxidant Potassium Nitrite*<br />
Whizzies Oxidant Sodium Nitrite*<br />
Randy’s Clear Oxidant Nitrite<br />
27
in vitro Adulterants Available<br />
Commercially<br />
Adulterant Class Identity<br />
Urine Luck Oxidant Pyridinium<br />
chlorochromate*<br />
LL418 Oxidant Pyridinium<br />
chlorochromate*<br />
Sweet Pee’s<br />
Spoiler<br />
Oxidant<br />
Pyridinium<br />
chlorochromate*<br />
Randy’s Klear II Oxidant Pyridinium<br />
chlorochromate*<br />
28
Strategies to Manage the<br />
<strong>Integrity</strong> of <strong>Drug</strong> <strong>Testing</strong><br />
in Pain Management<br />
Who is fooling who here?<br />
29
• <strong>Drug</strong> <strong>Testing</strong> in Pain Management presents<br />
different legal framework than<br />
workplace/forensic drug testing<br />
• Doctor-Patient Relationship<br />
• Diagnostic / Management Goals<br />
• Patients cooperation is “voluntary”<br />
• Cooperation is a condition of treatment<br />
• This allows for:<br />
◦ Expanded panel of drugs to test<br />
◦ Lower cutoffs<br />
◦ Expanded panel of methods<br />
◦ Observed collections for urine<br />
Different Legal Framework<br />
30
• Policy Considerations<br />
◦ Make integrity violation more serious than<br />
positive drug test.<br />
◦ Patients need to know that integrity testing<br />
and validation of specimens is being done.<br />
◦ Clearly define what constitutes a “refusal to<br />
test” (e.g., missing a test).<br />
◦ Patients should have opportunity to selfdisclose<br />
changes in medications (legal and<br />
illegal)<br />
◦ Test your collectors<br />
Counter-Strategies:<br />
Policy Considerations<br />
31
◦ Multiple specimen testing needed<br />
◦ NOT JUST URINE!<br />
◦ Oral fluid<br />
◦ Sweat Patch Tests<br />
◦ Hair (beard shaving may give short-term<br />
window)<br />
◦ Understand the limits and trade-offs<br />
◦ Randomly change methods<br />
Counter-Strategies:<br />
Alternative Tests Needed<br />
32
• Gown patient<br />
• Observed collection<br />
• Grab two separate voids<br />
◦ (compare creatinine/specific gravity between<br />
voids) (no need for large volumes here)<br />
• Dipstick adulteration test<br />
• Two collectors present<br />
Urine <strong>Testing</strong> Control Options<br />
33
• On-Site Screening for Adulterants<br />
◦ Simple dipstick sufficient to screen for all<br />
adulterants<br />
Counter-Strategies<br />
34
The effects of adulterants and<br />
selected ingested compounds<br />
on drugs-of<br />
of-abuse testing in<br />
urine.<br />
Dasgupta A : Am J Clin Pathol. 2007 Sep;128(3):491-<br />
503<br />
35
• These adulterants can successfully<br />
mask drug testing if the concentrations<br />
of certain abused drugs are moderate.<br />
Several spot tests have been described<br />
to detect the presence of such<br />
adulterants in urine.<br />
• Urine dipsticks are commercially<br />
available for detecting the presence of<br />
such adulterants, along with<br />
performance of tests for creatinine, pH,<br />
and specific gravity.<br />
36
• How do you manage positive test results?<br />
• How do you manage negative results?<br />
How do you manage the pain patient who<br />
is a substance abuser?<br />
• How do you manage medical marijuana<br />
patient?<br />
Open Questions<br />
37