Drug Testing Integrity

Opioid Risk Management
June 26-27, 2008
Ways to Deceive Drug
Testing
Theodore F. Shults, JD, MS
Chairman
American Association of Medical Review Officers
Durham, NC
1

The Smoking Thoroughbred
2

1. Eliminate the evidence – substitution,
dilution
2. Attack the immunoassay – pH, interfering
substances
3. Attack the drug metabolite – oxidation, pH
4. Avoid the test
5. Hire a lawyer
6. Find another doctor
7. Deny, deny, deny…
Basic Strategies to Beat the Test
3

• Drug addicts and users have always had
methods and practices to beat a drug test
• Common approaches
◦ Drink vinegar
◦ Dilute your urine
◦ Drink “Health Inca Tea”
◦ Adulterate your specimen
• Bleach; soap; battery acid
◦ Self-catheterization
◦ Substitution
Drug Culture:
Mythology and Practices
4

• Death
Investigations
• Criminal
Investigations
(DUI, DWI)
• Court ordered:
• Custody
• Parole
• Probation
• Doping Control
(Sports)
• Life Insurance
Underwriting
• Drug Deterrence
and Control
(workplace/schools)
• Emergency
Medicine
• Pain Management
• “Wellness”
• Fitness for Duty
Drug Testing Environments
5

• 1990s: Workplace Drug Testing and
the Internet come of age.
• Small cottage industry festers into
multi-million-dollar industry to assist
drug users in beating the test.
• Selling hope.
Commercialization of “Beating the
Drug Test”
6

◦ Lab profits are based on rapid negative test
results
◦ Everyone loves negative tests
◦ Regulatory emphasis on costs of regulations
◦ Technical mistakes and leadership failures –
• The substituted-specimen fiasco
◦ Privacy concerns prohibit observed collection
without “individualized suspicion”
◦ HHS Mandatory Guidelines – All adulterated
tests are now “invalids”
Fostering the Growth of
the Beat-the
the-Test
Industry
7

Explosion of Products
8

• The media breakout product for the “beat the drug
test” industry has clearly been the Whizzinator.
• Minnesota Vikings running back Onterrio Smith was
caught in possession of this device in May 2005 at the
Minneapolis-St. Paul International Airport, which
resulted in his suspension.
• Actor Tom Sizemore has also brought the Whizzinator
into the public eye after having been caught with one
attempting to evade drug tests.
• The United States Congress held hearings on the
Whizzinator on May 17, 2005.
Mr. Whizzinator Goes to
Washington (Under Subpoena)
9

Rep. Bart Stupak (D-Mich.) bemoans
the Whizzinator while holding an
advertisement for the device. At left is
Ed Whitfield (R-Ky.), the subcommittee
chairman.
Photo Credit: By Robert A. Reeder --
The Washington Post
10

• “The sheer number of these
products, and the ease with which
they are marketed and distributed
through the Internet, present
formidable obstacles to the integrity
of the drug testing process.”
◦ GAO-05-653T: “Drug Tests: Products to Defraud
Drug Use Screening Tests Are Widely Available.”
11

“Number 1 is a disposable urinating device
with enough premixed synthetic urine for
2 complete tests. It has been irradiated in
order to destroy all bacteria giving Number 1
a one-year shelf life.” 14

$49.95
ORDER NOW!
•Contains everything you need for 2 tests!
•Highest quality synthetic urine available!
•Adjustable belt included!
•No mixing required!
•Male & Female usage!
•Most advanced heating system!
•1 year shelf life!
•No need to freezing or refrigeration!
•Satisfaction Guaranteed!
15

Where does this go?
16

• High-Tech Meets Low-Tech
The Three Amigos
17

Chemical Warfare:
The Adulterants
18

in vitro Adulterants Available
Commercially
Adulterant Class Identity
Mary Jane
SuperClean 13
Surfactant
Lemon Scented
Detergent
UrinAid Fixative Glutaraldehyde
Amber-13 Acid 1.7 N HCI
THC-Free Acid 2.1 N HCI
21

in vitro Adulterants Available
Commercially
Adulterant Class Identity
Klear Oxidant Potassium Nitrite*
Whizzies Oxidant Sodium Nitrite*
Randy’s Clear Oxidant Nitrite
22

in vitro Adulterants Available
Commercially
Adulterant Class Identity
Urine Luck Oxidant Pyridinium
chlorochromate*
LL418 Oxidant Pyridinium
chlorochromate*
Sweet Pee’s
Spoiler
Oxidant
Pyridinium
chlorochromate*
Randy’s Klear II Oxidant Pyridinium
chlorochromate*
23

Nitrites:
Conclusions and Interpretation
1. Testing for Nitrite; Nitrate is different and
does not interfere
2. Normal and medical nitrite concentrations
in urine well below 500 mcg/mL
3. Nitrite is oxidizing agent and may
deteriorate with time in unpreserved urine
4. Concentrations of nitrite in adulterated
urine are high
5. Cutoff distinguishes normal from
adulterated urine
24

Chromium:
Conclusions and Interpretation
1. Cr +6 extremely toxic — not to be confused with Cr +3
2. Urine concentrations in adulterated urine generally
1000 times greater than normal
3. Cr +6 not expected in urine of an asymptomatic
individual
4. Urine concentrations found in adulteration cases
exceed highest toxic case reported
5. No established cutoff — 20 mcg/mL Limit of
Detection required by new regulations
25

in vitro Adulterants Available
Commercially
Adulterant Class Identity
Mary Jane
SuperClean 13
Surfactant
Lemon Scented
Detergent
UrinAid Fixative Glutaraldehyde
Amber-13 Acid 1.7 N HCI
THC-Free Acid 2.1 N HCI
26

in vitro Adulterants Available
Commercially
Adulterant Class Identity
Klear Oxidant Potassium Nitrite*
Whizzies Oxidant Sodium Nitrite*
Randy’s Clear Oxidant Nitrite
27

in vitro Adulterants Available
Commercially
Adulterant Class Identity
Urine Luck Oxidant Pyridinium
chlorochromate*
LL418 Oxidant Pyridinium
chlorochromate*
Sweet Pee’s
Spoiler
Oxidant
Pyridinium
chlorochromate*
Randy’s Klear II Oxidant Pyridinium
chlorochromate*
28

Strategies to Manage the
Integrity of Drug Testing
in Pain Management
Who is fooling who here?
29

• Drug Testing in Pain Management presents
different legal framework than
workplace/forensic drug testing
• Doctor-Patient Relationship
• Diagnostic / Management Goals
• Patients cooperation is “voluntary”
• Cooperation is a condition of treatment
• This allows for:
◦ Expanded panel of drugs to test
◦ Lower cutoffs
◦ Expanded panel of methods
◦ Observed collections for urine
Different Legal Framework
30

• Policy Considerations
◦ Make integrity violation more serious than
positive drug test.
◦ Patients need to know that integrity testing
and validation of specimens is being done.
◦ Clearly define what constitutes a “refusal to
test” (e.g., missing a test).
◦ Patients should have opportunity to selfdisclose
changes in medications (legal and
illegal)
◦ Test your collectors
Counter-Strategies:
Policy Considerations
31

◦ Multiple specimen testing needed
◦ NOT JUST URINE!
◦ Oral fluid
◦ Sweat Patch Tests
◦ Hair (beard shaving may give short-term
window)
◦ Understand the limits and trade-offs
◦ Randomly change methods
Counter-Strategies:
Alternative Tests Needed
32

• Gown patient
• Observed collection
• Grab two separate voids
◦ (compare creatinine/specific gravity between
voids) (no need for large volumes here)
• Dipstick adulteration test
• Two collectors present
Urine Testing Control Options
33

• On-Site Screening for Adulterants
◦ Simple dipstick sufficient to screen for all
adulterants
Counter-Strategies
34

The effects of adulterants and
selected ingested compounds
on drugs-of
of-abuse testing in
urine.
Dasgupta A : Am J Clin Pathol. 2007 Sep;128(3):491-
503
35

• These adulterants can successfully
mask drug testing if the concentrations
of certain abused drugs are moderate.
Several spot tests have been described
to detect the presence of such
adulterants in urine.
• Urine dipsticks are commercially
available for detecting the presence of
such adulterants, along with
performance of tests for creatinine, pH,
and specific gravity.
36

• How do you manage positive test results?
• How do you manage negative results?
How do you manage the pain patient who
is a substance abuser?
• How do you manage medical marijuana
patient?
Open Questions
37