Emerging Issues in Drug Testing

Greg Skipper, MDDirector, Professional Health Services

Promises Treatment CentersLos Angeles, CA

gskipper@promises.com310-633-4595

Drug Testing is Effective and Underutilized• When testing is frequent, random and tied to

immediate moderate consequences drug use is deterred.

Long-Term PHP Drug Test Results

Difficult Cases

• Patient prescribed hydrocodone–Urine test negative for opioids–Urine test positive for hydromorphone only?–Oxymorphone?–Codeine?

Difficult Cases

Difficult Cases

• Patient prescribed oxycodone–Urine test negative for opioids–Urine test positive for hydrocodone–Oxymorphone?–Codeine?

Anomalous observations of hydrocodone in patients on oxycodone.West R et al, Clin Chim Acta. 2010 Aug 27.

BACKGROUND: Oxycodone preparations are known to have small amounts of hydrocodone as an impurity estimated to be <0.1%. We established the concentration of unexpected hydrocodone in patients taking oxycodone.METHODS: 30,000 pain patientsCONCLUSIONS: When oxycodone is >100,000ng/ml, hydrocodone should be <1500ng/ml. When oxycodone is <100,000ng/ml then hydrocodone should be <500ng/ml. Values greater than these indicate non-prescribedhydrocodone use. Clinicians and laboratories testing urine for drugs should be aware of the possibility of low concentrations of hydrocodone in the urine of patients taking high doses of oxycodone.

Difficult Cases

• Patient prescribed Valium–Urine test positive for oxazepam only–Temazepam

Difficult Cases

• Patient on xanax (alprazolam) or• Klonopin (Clonzaepam)

–Urine test negative for benzo’s?

Sensitivity vs Specificity

• Are they always mutually exclusive?• Highly sensitive

–More prone to false positive?• Highly specific

–More prone to false negative?

Screening vs Confirmation Tests

• Screening– Immunoassays, ELISA, EMIT, DRI, Dipstick– Tend to be highly sensitive– Not so specific

• Confirmation– GC/MS, LC/MS, LC/MS/MS– Highly specific– Not so sensitive (because of restricted panel)

Matrices

MRO function

• Is there a cause for positive other than illicit use?– Legitimate prescription– False positive – at least two types

Legitimate Use?• Coca tea?• Cocaine positive from sex?• ENT procedure?• Hemp oil? Hemp cereal? Hemp cosmetics? Hemp

granola bars? Hemp lip balm?• Sprained ankle and was given heroin while

visiting Great Britain?• THC? Ever legal in US?

– Passive inhalation• Poppy seeds

Poppy Seeds

• Over 1,000 species of poppy seeds• Used in cooking

– Baking– Salad dressings– Curry sauces

• Morphine level >1,000, >2,000, >5,000, >15,000 ????

• Urine concentration can be a clue

Accidental Exposure

• Marijuana brownie• Someone else’s medication• Took pill and didn’t know what it was• Drank punch and didn’t know it had alcohol in

it• Vacuuming up someone else’s cocaine and

turned vacuum clearner on reverse and blew it into the air

Crossreactivity

Positive Amphetamine due to l-isomer

• Vics inhaler, selegiline, EMSAM patch–D & L Isomer test

• >80% l-amphetamine consistent w/• Pseudoephedrine converted to

amphetamine inside the GC/MS machine–Retest

Dilutes

• Creatinine <20mg/dl and sp gr <1.003–Creatinine <20 but >10 mg/dl can be from

innocent excess water–Creatinine <10mg/dl but >5mg/dl not likely

innocent–Creatinine <5mg/dl probably substitution–Creatinine <2mg/dl definitely substituted

What to do?• Creatinine <20 but >10 mg/dl can be from

innocent excess water– Warn, observed, obtain hair/nails or saliva test

• Creatinine <10mg/dl but >5mg/dl not likely innocent– Hair/nail, saliva, observed, evaluation

• Creatinine <5mg/dl probably substitution– Assume substitution, verify observed, retest

sample

Emerging Technologies• Quick Test Kits• Better confirmation tests: LC/MS/MS• More extensive testing panels• Increased Use of Flex Testing• Improved testing for ethanol (EtG, EtS, etc)• Devices: TAD, SCRAM, Soberlink

HairTesting

Nail Testing• Good alternative

to hair testing• Similar repository

window• Less prone to

adulteration from chemicals

• Thicker than hair

Saliva Testing DHHS - 5 DRUGS, ALCOHOL SIMILAR TO PLASMA INCREASINGLY USED

(ie dilute urines)

Sweat Testing DHHS - 5 DRUGS PAROLE/PROBATION Less invasive than hair testing

NewAlcohol Monitoring

Technologies

In the beginning…

• Blood alcohol• Breath alcohol• Urine alcohol

– Limitations when used for alcohol monitoring• GGT, MCV• Carbohydrate Deficient Transferrin

Current Technologies

• Random field breathalyzer• Multiple daily ID home breathalyzer• Transcutaneous alcohol monitoring• New markers

– EtG – EtS – PEth– Urine – Hair/Nails – Saliva – Blood

Frequent / Random Breathalyzer

• 24/7 Program in South Dakota• Random testing field programs

– BAT Mobile

24/7 South Dakota• House bill 1072• Rules:

– Type, frequency, time, location, fees ($1 for each breath test), consequences

– Usually twice a day on site in local police dept• Results - 2007

– 1,021 participants, 165,456 tests, 359 no shows = 99.8% show rate

– Of 165,456 tests 534 failed tests

24/7 South Dakota– Of 165,456 tests 534 failed tests– Rate of improvement for individuals - good

Positive ID Home Breathalyzers

• New home breathalyzer technologies– MEMS 3000– Smart Start In-Hom– Mobile Breath

MobileBreath®

SoberlinkSmart Phone Compatible and Required:Requires Android OS 2.2 or higher, or Blackberry OS 5.0 or higher (device must be Bluetooth enabled). Apple iPhone compatibility coming soon.Photo Identification:Guarantee's the identity of the user. Facial recognition coming soon.Fuel Cell Sensor:Provides highly accurate and reliable results.DIMENSIONS:Product Height: 4.75" (121mm)Product Width: 1.5" (38mm)Product Depth: 2.875" (73mm)WEIGHT:Product Weight: 6oz (190g)WARRANTY:1 Year Limited Warranty

Soberlink

Transcutaneous Monitors

• SCRAM• TAD

•www.alcoholmonitoring.com – to locate provider

Intermittent Transcutaneous Alcohol Monitoring

Unique Alcohol Metabolites

• Ethylglucuronide (EtG)– Urine– Hair/Nails– Saliva

Urine EtG (and EtS)

• 1-4 days possible duration• Normalization important

– (100/uCreat) x uEtG = Normalized EtG• Important to warn about things to avoid

– Foods, mouthwash, handgel, etc.etc.• May be important to have participant sugar

fast (4-6 hours) before submitting sample – Juices, fruits, etc contain small amounts etoh

Alcohol Metabolites

• Phosphatidyl Ethanol (PEth)– Blood

• A group of phospholipids formed by alcohol on cell membranes - phospholipase D

• Positive only after significant alcohol exposure (approx 7 drinks over a week)

• Stays positive (>20ng/ml) for 2-3 weeks• Level correlates well with amount of alcohol consumed

Alcohol Metabolites• Phosphatidyl Ethanol (PEth)

Combination Strategies• Using PEth to confirm drinking following positive

EtG/EtS when drinking denied• Study: 18 positive EtGs

Finding # % Conclusion

Admitted drinking after positive EtG/EtS

8 44 Drinking

Admitted drinking after PEth explained 3 17 DrinkingAdmitted drinking after positive PEth 1 6 DrinkingDenied drinking after positive PEth 1 6 DrinkingDenied drinking - negative PEth 5 28 Not Drinking

Settings / Strategies

–Normalize values to creatinine of 100md/dl (labs should automatically make this calculation)

–Have participants sign consent regarding their responsibility to avoid alcohol

–Re-advise to avoid all alcohol (including ripe fruits, juices, anything containing sugar) on day of test.

HOPE Probation• HOPE probationers have the most serious felony drug

and crime problems and are identified as likely to violate their conditions of community supervision

• HOPE utilizes intensive random drug testing for up to 6 years

• Responds to detected violations of probation (drug use, missed probation meetings, etc.) with clear, swift, short-term sanctions

Randomized Control Trial of HOPE vs. Standard Probation

• In one-year period, HOPE probationers were:- 55% less likely to be arrested for a new crime- 72% less likely to use drugs- 61% less likely to skip appointments with their

supervisory officer- 53% less likely to have their probation revoked

• HOPE probationers were sentenced to, on average, 48% fewer days of incarceration than the control group

HOPE Drug Test Results