1. Drug Test Training Guide

2. Contents How are drug tests made? Accuracy Which drugs can be tested for Detection times Testing methods How to use a drug test – Urine How to use a drug test – Saliva Test results explained Cross Re-activity Alcohol Testing Adulteration Questions and Answers

3. How are drug tests made? Immunochromatographic assays, also called lateral flow tests or simply strip tests, have been around for some time. The benefits of immunochromatographic tests include: 1. User-friendly format. 2. Very short time to get test result. 3. Long-term stability over a wide range of climates. 4. Relatively inexpensive to make. These features make strip tests ideal for applications such as home testing, rapid point of care testing. Test urine is delivered into a sample site located at one end of the porous membrane. When the drug is present in the urine test sample, the drug or drug metabolite competes for the limited antibody sites on the microspheres. When an adequate amount of drug is present an attachment of the coloured microspheres go to the probe site on the membrane.

4. How are drug tests made? Therefore, a positive urine sample will inhibit the formation of a precipitin line at the probe area. A reference or control line with a secondary antibody reaction is added to the membrane test to indicate that the test is viable. This control line should always be present before making any test interpretation.

5. How are drug tests made? Normally, a negative urine sample will produce two coloured lines (the formation of a visible precipitin at the test zone in addition to the control line), and a positive urine sample will show only one line (the control line).

6. Accuracy! A side-by-side comparison has been conducted using the Multi-Drug One Step Screen Test Panel (Urine) and commercially available rapid drug tests. Testing was performed on approximately 300 specimens previously collected from persons presented for Drug Screen Testing. The following results were recorded:

7. Accuracy! Presumptive positive results were confirmed by GC/MS. The following results were recorded: In conclusion to the above information the One Step Drug test has an average accuracy of 97.5%

8. Which drugs can be tested for AMP - Amphetamine BAR - Barbiturates BUP - Buprenorphine/Subutex BZO - Benzodiazepines COC - Cocaine/Benzoylecgonine MDMA - Ecstasy MET - Methamphetamine MOP - Morphine MTD - methadone OPI - Opiates OXY - Oxycodone PCP - Phencyclidine PPX - Propoxyphene TCA - Tricyclic Antidepressants THC - Marijuana/Cannabis KET – Ketamine

9. Detection Times and Cut – Off Levels URINE DRUG SCREENS Test CodeTypeCut-off LevelRetention Times (Guide) AMP Amphetamines1000 ng/mL2 - 4 days BARBarbiturates300 ng/mL1 - 10 days (Phenobarbital 14 days+) BZO Benzodiazepines300 ng/mL1 day – 10 weeks BUP Buprenorphine10 ng/mL3 – 5 days THC Cannabis50 ng/mL7 – 30+ days COC Cocaine300 ng/mL2 – 4 days MTD Methadone300 ng/mL1 – 4 days MAMP/MET Methamphetamines1000 ng/mL2 – 4 days MOP/OPI Opiates300/2000 ng/mL2 - 4 days OXY Oxycodone100ng/mL1 – 3 days PCP 25 ng/mL3 - 8 days PPX Propoxyphene300 ng/mL1 – 4 days TCA 1000 ng/mL1 – 9 days KET Ketamine1000 ng/mL1 – 7 days

10. Detection Times and Cut – Off Levels ORAL SALIVA SCREENS TypeCut off LevelRetention Times (Guide) Amphetamines50ng/ml10 minutes - 72 hours Benzodiazepines10 minutes - 72 hours Cannabis12ng/ml10 minutes - 24 hours Cocaine20ng/ml 10 minutes - 24 hours Methadone30ng/ml10 minutes - 48 hours Methamphetamines50ng/ml 10 minutes - 72 hours Opiates40ng/mlCodeine: 1 hour – 7 hours, single dose Opiate: 1 hour- 48 hours PCP10ng/ml24 hours

11. Testing Methods Choice of testing method to be used Saliva Person is under the influence Recent use of drugs Urine Drug use suspected to have occurred Collection and Adulteration / substitution Methods to be in place Hair Long term drug abuse suspected

12. Testing methods - Urine Urine testing has been an industry standard form of testing for many years, so there is a wide range of products available from many different manufacturers. The reason why urine has been used for so long is that it sits perfectly between saliva and hair testing. The main reason for this is that with urine you will be able to get an idea as to someone's drug use within the past week depending on the drug of choice. This can help to determine if the patient has taken anything other than their drug of choice, such as an over the counter medicine or if they have changed their drug of choice.

13. Testing methods – Oral/Saliva Oral fluid consists of saliva plus many other fluids that enter the mouth from the lungs, nasal passage and throat. Oral fluid is very close to blood serum, so if the drug is in the oral fluid it will also be in the blood. This means that the drug will have passed into the brain so therefore the patient will be impaired by the drug, so by using an oral fluid test you will be able to detect if the patient has used within the past 24 to 48 hours. The oral fluid collector that we provide will collect both saliva and oral fluid.

14. Testing methods – Hair Hair testing for drug of abuse is becoming more popular. The reason for this is that you can get up to a 3 month drug use history. This form of testing is really only used by the Police. The way hair testing works is very simple. The drug goes into the blood stream and gets trapped in the hair shaft as it grows in the root follicle. Since hair is an inert protein, the drug/s remain trapped there until the hair is cut. The earliest that you would be able to test for a drug using hair would be about 7-10 days after the drug has been taken. This will allow enough hair growth to be used as a sample. The drug/s can not be washed out or effected by chemicals because the drug/s remain locked away in the centre of the hair known as the hair cortex.

15. How to use a drug test – Urine Panel Remove the test panel from the foil pouch (do not break the seal of the foil pouch until you are ready to begin the test). Using a plastic cup, obtain a urine sample from the individual who is being tested. Pull the protective cap off the bottom of the test panel to reveal the absorbent testing strip/s, do not touch the strip/s and do not throw away the protective cap. Carefully dip the testing strip/s into the urine sample, ensuring that the urine does not come into contact with the plastic case of the test. Allow the test to absorb the urine for about 10-15 seconds. After 15 seconds, remove the test from the urine and replace the protective cap. Lay the test panel on a clean flat surface while the test lines develop. You can read negative results as soon as they appear but positive results must be read at least 5 minutes after removing from urine. All results should be read within 10 minutes, otherwise a false reading may occur.

16. How to use a drug test – Urine Cup Open the bag containing the plastic drug cup and remove the cup. The person to be tested for the presence of drugs needs to urinate into the drug cup. Ensure the specimen reaches the minimum fill volume line on the label. There is a temperature bar on the label of the drugs cup. If the temperature does not show a green colour then the test may have been tampered with. Human urine should be between 90-100ºF. Secure the cap on to the cup by screwing the lid back on. On a flat surface remove the pink plastic clip and firmly push the key in. When ready, peel off the label to view the results. You can read the results after 5 minutes. Do not interpret the results after 10 minutes.

17. Drug test results explained - Urine Read the results of each strip individually and independent of one another. You will see two letters on the cassette or panel by the test strip/s, ‘C’ this is the control band and ‘T’, this is the test band. A pink/red coloured line should appear on each strip of the control band (C), this confirms each strip has worked properly. If no line appears in the control band (C) that strip hasn’t worked properly and you may need to do a further test. A second pink/red coloured line, no matter how faint should now appear in the test band (T), this is a negative result. If no further line appears in the test band (T) then the individual has tested positive for that drug of abuse. The labels on the test will tell you which drug each individual strip is testing for. Remember a negative urine sample will produce two lines, and a positive urine sample will produce only one line in the control band (C).

18. How to use a drug test – Oral Fluid (MTD) Test procedure 1. Remove the collection sponge and test cube from the sealed pouch. 2. Tear off the packaging around the collection sponge. 3. Insert the sponge end of the saliva collector into the mouth. Actively swab the inside of the mouth and tongue to collect oral fluid for a total of 3 minutes (until the sponge becomes fully saturated). Gentle pressing of the sponge between the tongue and teeth will assist saturation. No hard spots should be felt on the sponge when saturated. See step 2. 4. Hold the test cube vertically and place the collection sponge into the test cube. Make sure to fit the groove of the collection sponge onto the guide rail inside the test cube. Now press the sponge firmly down. See step 3. 5. When you are completely happy that you have collected enough saliva sample firmly press down on the lid till it is tightly sealed. This will allow all of the saliva to be extracted from the collection sponge. See step 4. Note: If the amount of saliva pressed into the test cube is not adequate for testing, collect more saliva by re-inserting the collection sponge in the mouth and follow steps 2, 3 and 4 again. 6. Wait for the coloured line(s) to appear on the test device. Read results at 10 minutes. Do not interpret results after 1 hour. See step 5. Note: When carrying out the test the oral cube must remain in a vertical position at all times.

19. Drug test results explained – Oral Fluid You will see a letter at the top of the cassette ‘C’ this is the control band. The control line should appear on both sides this indicates the test has worked correctly. If there is no control line (C) then the test is invalid. Insufficient specimen volume or carrying out the procedure incorrectly is the most likely reason for the control line failing to appear. Negative: If a second pink/red coloured line, no matter how faint appears next to each specific drug (e.g. COC), this is a negative result. Positive: If no line appears next to any of the drug names then the individual has tested positive for that drug of abuse. Remember a negative oral fluid sample will produce a line and a oral fluid sample will not produce any line.

20. Cross Re-activity A False Positive urine test result occurs when a sample initially tests Positive, but is determined later that the individual had a legitimate and legal purpose for ingesting the substance in question. This is otherwise know as a cross reaction. Drug test cross re-actions can occur for any of the following reasons; Prescription Drugs: Many prescription drugs are used illegally and will be detected by urine tests (primarily Amphetamines, Barbiturates, Opiates and Benzodiazepines). There are times when the patient will test positive but is being issued with prescription drugs. On finding a result of this nature it is advised that you clarify this with your patient first before coming to a decision. To help to remove any embarrassment for you or the patient maybe ask the patient before hand about medications.

21. Cross Re-activity Administered Drugs: This includes drugs administered by a medical professional during an office visit or surgery. For example, Morphine is often administered to relieve pain during surgery or childbirth. Like prescription drugs, many administered drugs are used illegally and will be detected by urine tests. Over-The-Counter (OTC) Medications: In the past, Positives caused by OTC medications were a great concern in this industry. Over the years, however, drug testing technology has improved significantly and cross reactions caused by OTC medications are now a lot lower. Some of the products that could cause a cross reaction are as follows: Codeine – Opiates e.g. 40mg tablets taken 4 x a day = 2000ng/mL (Cut-off level for Heroin) Valium - Benzodiazepines Ranitidine – Methamphetamine Vick's Inhaler – Methamphetamine Poppy Seeds - Opiates

22. Alcohol Testing UK Limits The legal limit for alcohol levels in the body while in control of a vehicle vary from Country to Country and can be defined by several different standards, the following of which are the most common: 35 microgram's 80 mg/100mLl 0.35 mg/L - BrAC 0.08% BAC There are two ways to express the alcohol content inside the body. They are Blood Alcohol Content (BAC) and Breath Alcohol Content (BrAC).

23. Alcohol Testing The relation between the Blood Alcohol Content (BAC) and the Breath Alcohol Content (BrAC) is as follows; BAC (in %) = BAC (in g/100ML) = BrAC (in mg/L) divide by 0.20 Example: 0.02%BAC = 0.02g/mL - BAC 0.02%BAC = 0.10mg/L – BrAC The body absorbs alcohol into the blood stream through the digestive system. It takes at least 30 minutes for the alcohol to be absorbed. From then on the blood alcohol concentration will at it’s highest between 30 and 90 minutes. After this time the level reduces approx. 0.1mg/mL to 0.2mg/mL per hour.

24. Alcohol Testing The UK limit is expressed in the following measurements; BAC Value (in mg/mL) – 0.08 BrAC Value (in mg/L) – 0.35 The most accurate form of testing alcohol is via Blood. This though is costly and is not always the easiest option available. For testing on site there are 2 types of test available; Rapid Alcohol Saliva Test AL-6000 ALCOSCAN Each one will be explained in more detail on the following slides.

25. Alcohol Testing - Saliva The unit of measurement for the Saliva test is BLOOD ALCOHOL CONTENT (BAC). If you were at the drink drive limit in the UK your result on the saliva test would be as the colour Blue/0.08% on the foil pouch.

26. Alcohol Testing – Breath AL6000 The unit of measurement for the breathalyser test is BREATH ALCOHOL CONTENT (BrAC). Alcoscan AL-6000 is a hand held, portable breath alcohol tester to check subject's breath alcohol concentration with reliable accuracy and it is available to test in Passive mode. Breathalyser with Replaceable Calibrated Sensor Module. No Calibration Service required!

27. Adulteration Adulteration testing is done to check the quality of a urine specimen. You are advised to carry out an adulteration before you carry out your drug test. In drugs of abuse testing, it is important to insure that the samples are clean and free from adulteration. Diluting a urine sample is probably the most common form of urine adulteration. Tests for adulterants, specific gravity and creatinine can aid in the detection of common methods for defeating urine drug tests including dilution, or adulteration of the sample with bleach, vinegar, visine, sodium bicarbonate, drano, soft drinks or hydrogen peroxide. Since tests for adulterants, specific gravity and creatinine detect many of the above common adulterants, some drug users are utilizing commercially available adulterants, including UrinAid, Stealth, Urineluck, Stealth 51, and INSTANT CLEAN ADD-IT-IVE. The active ingredient in UrinAid and other similar products is an aldehyde (glutaraldehyde).

28. Adulteration – What does it mean Adulteration is the tampering of a urine specimen with the intention of altering the test results. The use of adulterants can cause false negative results in drug tests by either interfering with the screening test and/ or destroying the drugs present in the urine. Dilution may also be employed in an attempt to produce false negative drug test results. One of the best ways to test for adulteration or dilution is to determine certain urinary characteristics such as creatinine, pH, and specific gravity and to detect the presence of glutaraldehyde, nitrite and oxidants /pyridinium chlorochromate (PCC) in urine.

29. Adulteration – elements explained Creatinine is a waste product of creatine; an amino-acid contained in muscle tissue and found in urine. 1 A person may attempt to foil a test by drinking excessive amounts of water or diuretics such as herbal teas to “flush” the system. Creatinine and specific gravity are two ways to check for dilution and flushing, which are the most common mechanisms used in an attempt to circumvent drug testing. Low creatinine and specific gravity levels may indicate dilute urine. The absence of creatinine (<5mg/dl) is indicative of a specimen not consistent with human urine. Specific gravity tests for sample dilution. The normal range is from 1.003 to 1.030. Values outside this range may be the result of specimen dilution or adulteration. Nitrite tests for commonly used commercial adulterants such as Klear or Whizzies. They work by oxidizing the major cannabinoid metabolite THC-COOH. 2 Normal urine should contain no trace of nitrite. Positive results generally indicate the presence of an adulterant. Glutaraldehyde tests for the presence of an aldehyde. Adulterants such as UrinAid and Clear Choice contain glutaraldehyde which may cause false negative screening results by disrupting the enzyme used in some immunoassay tests.³ Glutaraldehyde is not normally found in urine; therefore, detection of glutaraldehyde in a urine specimen is generally an indicator of adulteration. pH tests for the presence of acidic or alkaline adulterants in urine. Normal pH levels should be in the range of 4.0 to 9.0. Values outside of this range may indicate the sample has been altered. Oxidants/PCC (Pyridinium Chlorochromate) tests for the presence of oxidizing agents such as bleach and hydrogen peroxide. Pyridinium chlorochromate (sold under the brand name UrineLuck) is a commonly used adulterant.³ Normal human urine should not contain oxidants or PCC.

30. Questions and Answers How accurate are these types of tests? Better than 99% (close to cut-off levels) and 100% (at higher levels), compared to Laboratory Emit test machines. Every test is rigorously tested when manufactured, thus giving an average accuracy of 97.5%. Why is it so cost effective to use panel tests? By using a panel or cup test, the need for laboratory test is removed because the test results are shown there and then when the test is carried out. By using either our 10 Drug Panel all street drugs can be tested for at the same time and accurate results are available within 5 minutes. What does it mean if no test lines have appeared? Make sure that the test has been dipped into the urine for long enough (10 - 15 seconds) and that the testing device was not dipped into the sample past the marker line (above the marked area) otherwise the test will flood. If no test lines appear the test is invalid and should be repeated using a new test kit.

31. Questions and Answers What are cut-off levels? All tests have a cut-off level – the point at which there is not enough substance that can be detected. All levels are internationally agreed by SAMHSA (Substance Abuse and Mental Health Services Administration). Concentrations above the cut off levels are positive and concentrations below the cut off levels are negative. The cut off levels ensure that there is no risk of false positives. Different drugs have different cut off levels. How can I prevent urine adulteration? First, make sure that the donor has washed their hands before providing the sample. Wear gloves when carrying out the test. Use a sample cup with a temperature strip on it. This will help with identifying whether the urine sample is fresh. If still in doubt then use an adulteration strip to ensure that the test is clear of a number of different chemicals within the sample.