1. Emerging Issues in Drug Testing
Greg Skipper, MD
Director, Professional Health Services
Promises Treatment Centers
Los Angeles, CA

2. Drug Testing is Effective and Underutilized
When testing is frequent, random and tied to immediate moderate consequences drug use is deterred.

3. Long-Term PHP Drug Test Results

4. Difficult Cases Patient prescribed hydrocodone
Urine test negative for opioids
Urine test positive for hydromorphone only?
Oxymorphone?
Codeine?

5. Difficult Cases

6. Difficult Cases Patient prescribed oxycodone
Urine test negative for opioids
Urine test positive for hydrocodone
Oxymorphone?
Codeine?

7. 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 patients
CONCLUSIONS: 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.

8. Difficult Cases Patient prescribed Valium
Urine test positive for oxazepam only
Temazepam

10. Difficult Cases Patient on xanax (alprazolam) or Klonopin (Clonzaepam)
Urine test negative for benzo’s?

11. Sensitivity vs Specificity
Are they always mutually exclusive?
Highly sensitive
More prone to false positive?
Highly specific
More prone to false negative?

12. Screening vs Confirmation Tests
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)

13. Matrices

14. MRO function Is there a cause for positive other than illicit use?
Legitimate prescription
False positive – at least two types

15. 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

16. 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

17. 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

18. Crossreactivity

19. 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

20. 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

21. 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

22. 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

23. Hair
Testing

24. Nail Testing Good alternative to hair testing
Similar repository window
Less prone to adulteration from chemicals
Thicker than hair

25. Saliva Testing DHHS - 5 DRUGS, ALCOHOL SIMILAR TO PLASMA
INCREASINGLY USED
(ie dilute urines)

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

27. New Alcohol Monitoring Technologies

28. In the beginning… Blood alcohol Breath alcohol Urine alcohol GGT, MCV
Limitations when used for alcohol monitoring
GGT, MCV
Carbohydrate Deficient Transferrin

29. Current Technologies Random field breathalyzer
Multiple daily ID home breathalyzer
Transcutaneous alcohol monitoring
New markers
EtG – EtS – PEth
Urine – Hair/Nails – Saliva – Blood

30. Frequent / Random Breathalyzer
24/7 Program in South Dakota
Random testing field programs
BAT Mobile

31. 24/7 South Dakota House bill 1072 Rules: Results - 2007
Type, frequency, time, location, fees ($1 for each breath test), consequences
Usually twice a day on site in local police dept
Results
1,021 participants, 165,456 tests, 359 no shows = 99.8% show rate
Of 165,456 tests 534 failed tests

32. 24/7 South Dakota Of 165,456 tests 534 failed tests
Rate of improvement for individuals - good

33. Positive ID Home Breathalyzers
New home breathalyzer technologies
MEMS 3000
Smart Start In-Hom
Mobile Breath

35. MobileBreath®

36. Soberlink
Smart 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

37. Soberlink

38. Transcutaneous Monitors
SCRAM
TAD

40. Intermittent Transcutaneous Alcohol Monitoring
– to locate provider

41. Unique Alcohol Metabolites
Ethylglucuronide (EtG)
Urine
Hair/Nails
Saliva

42. 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

43. 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

44. Alcohol Metabolites
Phosphatidyl Ethanol (PEth)

45. 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
Admitted drinking after positive PEth 1 6
Denied drinking after positive PEth
Denied drinking - negative PEth 5 28
Not Drinking

46. 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.

47. 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

48. 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

49. HOPE Drug Test Results