Presentation on theme: "Urine Creatinine & Sample Tampering"— Presentation transcript:
1Urine Creatinine & Sample Tampering By: Paul L. CaryToxicology LaboratoryUniversity of Missouri
2The ramifications of a positive drug test (i. e The ramifications of a positive drug test (i.e. sanction, program expulsion, imprisonment, etc.) combined with the denial component of substance abuse often create circumstances whereby clients feel the need to “beat the drug test” by tampering with the sample. Sample tampering represents a significant challenge to a the court’s mission and can threaten to undermine the legitimacy of the court’s policies and procedures as well as it’s decisions. It’s a matter of control.
3Creatinine testing is a specimen validity issue Creatinine testing is a specimen validity issue! The most common form of specimen tampering is sample dilution.
4Why Use Urine for Drug Testing? generally readily available in large quantitiesdrug & metabolites are highly concentratedextensive scientific basis for methodologyresults accepted in courtprovides both recent and past usageuniform testing criteria (established cutoffs)easily tested (laboratory & on-site)quality assurance practices well-established
5Problems With Urine as a Specimen: YUCK factor!biological waste productdistasteful qualities & invasive collectionNOT QUANTITATIVE – cannot use concentration to evaluate client drug use historysusceptible to tamperingdrug concentration influenced by fluid intakenecessities witnessed collection
7What is creatinine ?creatinine is produced as a result of muscle metabolismcreatinine is produced by the body at a relatively constant rate throughout the daycreatinine is a compound that is unique to biological material (i.e. urine, other body fluids)creatinine measurements can:determine the “strength” or concentration of a urine sampleensure the sample being tested IS urine
8EVERY urine sample used for drug detection should be tested for creatinine!
9Two Types of Urine Specimen Dilution pre collection dilutionconsumption of large quantities of fluids prior to collectionpost collection dilutionadding fluid to specimen post collection
10Pre-Collection Dilution high-volume ingestion of fluids (water loading, flushing, hydrating, etc.)may be in conjunction with products designed to “enhance” drug elimination or removal of drugs (Gold Seal, Clean ‘n Clear, Test-Free, Naturally Klean, etc.)no evidence these products have any additional effect on drug elimination
11Water contains no drugs! easiest, cheapest, simplesturines with a creatinines of less than 20 mg/dL are considered “dilute” and rarely reflect an accurate picture of recent drug usedilute samples are more like water than like urineall drug court/criminal justice samples should be screened for creatinine
12How are creatinine measurements used ? normal human creatinine levels will vary during the day based upon fluid intake - healthy individuals will rarely produce urine samples with creatinines of less than 20 mg/dLincidence of creatinines less than 20 mg/dL in a “normal” population is approximately 1%urines with a creatinines of less than 20 mg/dL are considered “dilute” and often do not reflect an accurate picture of recent drug use
13Creatinine Facts some diseases that produce low urinary creatinines muscle wasting disease - RAREsome kidney aliments - RARElow creatinines ARE NOT routinely associated with:pregnancydiabetesobesityexercisehigh-blood pressurebeing vegetarian
14The “Normal” Creatinine incidence of low creatinines in a population undergoing random drug testing is significantly (up to 10 times) greater than a non-drug tested populationany fluid intake dilutes the concentration of drugs in urine (along with the creatinine)normal urine creatinine: study “Urinary Creatinine Concentrations in the U.S. Population” determine the mean (based upon 22,245 participants) was 130 mg/dLless than 1% below 20 mg/dLless than 1% greater than 400 mg/dL
15More Creatinine Issues rapid ingestion (90 minutes) of 2-4 quarts of fluid will almost always produce low creatinines & negative urine drug tests within one hourrecovery time of urine creatinine and drug concentrations can take up to 10 hoursincidence of drugs in urine of diluted specimens is over 5 times greater than in samples with normal creatinine levels
16“Dilute” Result Interpretation: negative or none detected results should never be interpreted as indicating no drug use (abstinence), because if, in fact, drugs were present, they probably could not be detected by the testpositive drug test results from a dilute sample however, are considered valid (donor was not able to dilute the sample sufficiently to deceive the test)
17The “Inadvertent” Dilute “My sample is dilute because I work as a roofer, on a black roof, in the middle of August when the temperature is 400˚ F.”it is possible for a client to achieve a urine creatinine of less than 20 mg/dL under extreme conditionscourt needs to develop creative solutions:collect samples before workcollect samples on days offuse alternative specimens
18Creatinine Sanctions no national standard adjudicate as “tampered” sample - more severely than positive sampleadjudicate as “positive” sample - court utilizes positive sample sanctionsadjudicate as “dilute” sample - unique sanctionssome courts allow one “dilute” sample per phase/quarterregardless of sanction - court MUST address this issue
19Two final thoughts about dilute urine samples . . . . . a creatinine of less than 20 mg/dL (associated with a drug test) is nearly always an attempt by the donor to avoid drug use detection - REGARDLESS of how much liquid was consumed in order to achieve this resultplace a dilute sample prohibition in your client contract and sanction for repeat dilute samples
22The Creatine Supplement Issue: creatine is the pre-cursor of creatininecreatine supplements may increase the amount of creatine in the musclesmuscles may be able to generate more energy or generate energy at a faster ratecreatine supplements (along with training) may improve performance by increasing energy for activities such as sprinting and weightliftingbut that’s NOT why our clients take it!
23The Creatine Supplement Issue: consuming over-the-counter creatine can disguise pre-collection hydration and a diluted urinecreatine converted to creatinine will mask the dilution effortsin reality - very difficult to coordinate the intake timing and volume of creatine and dilution liquidcreatinine greater than 300 mg/dL - increased monitoringcreatinine greater than 400 mg/dL - sanctionable
24What is Specific Gravity? measure of total dissolved solids in a liquidurine SpGr includes creatininealternative method of determining sample dilutionintroduced in 1988 with federal workplace drug testingcommon test performed by “forensic” labs
26My Advice on Specific Gravity use creatinine levels only to define “dilute” samplessamples less than 20 mg/dLscience-based approachvery defendable policyeasier to understand & explain to both clients & court professionals than SpGr
27SUMMARY TEST FOR CREATININE! incorporate creatinine guidance in your SOPs and client contractinstitute a dilute sample prohibitionunderstand low urine creatinine levels are NOT normaldilute samples are nearly always an attempt by the donor to avoid drug use detectionsanction for repeat dilute tests
29Basics of Specimen Tampering - The Three Approaches dilutionadulterationsubstitution
30Urine Specimen Dilution most common form of tamperingpre collection dilution (hydration, water loading, diuretics)post collection dilutioncreatinine measurementdilution detection (validity checks)
31Urine Specimen Adulteration addition of foreign substances designed to “mask” drug presencepost-collection tamperinglow-tech adulterants that cause “pH shift” (lime, vinegar, bleach, ammonia, lemon, drano)low-tech adulterants that disrupt testing chemistry (salt, methanol, detergent)five common “high-tech” adulterants
32Urinaid, Byrd Laboratories gluteraldehydesterilization chemicaldeactivates most screening tests - producing false negative resultscan be identified by laboratories employing specimen validity testseffects can not be reversed
33Klear & Whizzies potassium nitrite, sodium nitrite analytical chemistrycompromises the confirmation (GC/MS) of some drugs, notably carboxy-THCoxidizes drug and standardscan be identified by laboratories employing specimen validity tests (SVT)effects can be reversed
34Urine Luck pyridinium chlorochromate/dichromate oxidizing agent in organic synthesiscompromises the confirmation (GC/MS) carboxy-THC and opiatescan also effect screening testsoxidizes drug and standardscan be identified by laboratories employing specimen validity tests (SVT)effects can not be reversed
35Checking for Adulterants not necessary on all samplescreatinine - YESsuspicious sample collectionunusual sample characteristicsclient suspected of relapse who continues to produce negative test results
36Urine Specimen Substitution replacing donor urine sample with another drug-free specimenbiological substitution - someone else’s “clean” urinenon-biological substitution - replacing urine with urine “look-a-like” sample (diet Mountain Dew, water with food coloring)non-biologicals can be detected with creatinine testing
38Specimen Validity Tests (SVT) creatinine, UUNspecific gravitypHnitritesgluteraldehydepyridinechromiumRequest SVT from testing laboratory or use dip-stick SVT products for on-site testing
39Controlling Specimen Tampering develop challenging collection strategy - ie. make the testing unannounced and RANDOM!directly observed collections is the most effective approach to preventing adulteration and substitutioninspect sample - train collection staffkeep abreast of tampering techniquestake temperature measurements (90˚ - 100˚ F)use laboratory employs specimen validity tests & use with on-site devices
40Confront Specimen Tampering with Facts: actively engage clients about tampering issuesillustrates court’s tampering knowledgediscuss specimen tampering in courtprepare a fact-based presentation on the myths of tamperinghighlights the futility of tamperingtestimony from former clientsconstantly reinforce the “honesty” component of drug court
41Prepare a fact-based presentation on the myths of tampering – what does that mean?
47Sure Jell/Certo - Reality email Don't believe in the Certo or Sure Jel method. I tried it...failed all the drug tests I took every time I used it...I was being tested for marijuana for Arkansas Drug Court. Tested me every week...failed all three drug screens...they use a new on site screening machine that spins the sample around...supposedly it can even detect meth for up to 10 days...and can detect adulterants too...I cleaned up rather than try to cover up.
48Engage clients in an honest discussion regarding tampering!
49“Witnessed” collection (for urine) single most important aspect of effective drug testing programurine collections not witnessed are of little or no assessment valuedenial component of substance abuse requires “direct observation” collections of participantsThe importance of witnessed collection (for urine monitoring) can not be over-emphasized. As indicated on the slide, urine collections which are not witnessed are of little or no assessment value because of the propensity of drug court participants not to provide a legitimate sample (denial; efforts to hide relapse). The definition of “witnessed collections” is direct line-of-sight observation – basically staring at a participants genitals. Difficult? - yes! Uncomfortable? - no doubt! Necessary? - absolutely critical. Put another way; if drug courts don’t directly observe urine collections, they should not waste their time and money on testing efforts! It’s THAT important!The success of monitoring depends on a legitimate specimen for testing. The most likely guarantor that a legitimate specimen will be produced is with direct-observation collections. Remember, a drug court can employ the absolute best testing methods available, but that testing is worthless if the sample has been tampered with (by the participant) prior to the testing process.