You Can’t Fool the “Bladder Police”

Effective Use of Urine Drug Screening

Why Test?

• Accountability • Create and maintain safe treatment environment • Compliance with licensing or policy

Collection

• Supervised or unsupervised • When to collect • Staff training • Temperature monitored cups • Adulterant testing

In-house Testing

• Cost • Type of test kit • What to test for • When to test • Staff training • Staff issues • Client privacy

Lab Testing

• Prescription • What to test for • When to test • Staff training • Completing forms • Storage and pick up

Testing – How it Works • Drug Testing Systems

 One Test Systems  Use immunoassay (IA) to detect the presence of drugs and  Are most often used for medical purposes in clinical and rehabilitation settings  Two Test Systems  Commonly use immunoassay as an initial test followed by a more specific confirmatory test using a different technology and  Are used for results requiring a high level of certainty

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works What is an Immunoassay?

• An immunoassay is a biochemical test that measures the concentration of a substance in a liquid (a portion of a biological specimen) using the reaction of an antibody or antibodies to its antigen (drug)

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works What are Antibodies and Antigens?

• Antibodies are a type of protein produced by the immune system in response to foreign substances (antigens) • Antibodies bind to the antigen responsible for their production

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works

Immunoassay Principles I Antibodies: • Usually harvested from sheep or rabbits • Usually IgG (represented as a “Y”) • • Developed against classes of drugs Recognize antigen (drug) by its shape Common end Shape recognition end Y

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works Immunoassay Principles II

• Use Tagged Drug Targets   Indicator (Tag) is bound to the target drug “Tag” may be    an enzyme a fluorophore a particle • Detection is based on competitive binding  Antibodies bind with Drug in Sample OR with Tagged Drug Targets

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

“ Tag ” Drug

Testing – How it Works Immunoassay principles

• Sample WITH drug in it • Add an antibody • Incubate Y

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works Immunoassay Principles III

• Antibody binds drug in the sample • Add tagged drug target • Little or no antibody binding of the tagged compound • Little or no change in signal

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Y

Testing – How it Works Immunoassay Principles IV

• Sample WITHOUT drug in it • Add an antibody • Incubate • Add tagged drug target Y

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works Immunoassay Principles

• Antibody binds with the tagged compound • Binding causes change in signal produced

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works

Testing with Immunoassays • Immunoassays are used to screen donor specimens for the possible presence of a drug or a class of drugs • These tests may be conducted on-site as part of the collection process or in a laboratory or other facility • On-site testing is normally conducted with a Point of Collection Test (POCT) device • Most testing is conducted in laboratories which have validated procedures and validated analytical instrumentation • Immunoassays allow some laboratories to test more than 10,000 donor specimens a day

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works Immunoassay Specificity

• Specificity is the affinity of an immunoassay for the target drug • Specificity is measured by cross reactivity:  the response exhibited when an immunoassay reacts with a compound other than the target drug • Specificity limits the conclusions that can be drawn from immunoassay results

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Testing – How it Works Low Specificity

• An immunoassay with low specificity will react with many antigens (drugs) with similar structure • Example: One Amphetamine immunoassay with a cutoff of 300 ng/mL of D-Amphetamine gives a positive result with:  D,L-Amphetamine (300 ng/mL), Phentermine (400 ng/mL), Tranylcypromine (500 ng/mL), Methamphetamine (1,000 ng/mL), Ephedrine (1,000 ng/mL), or Phenylpropanolamine (1,000 ng/mL)  Therefore, a positive result from this immunoassay test would not prove use of amphetamine

John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

Tampering

• Diluting • “Doping” • Substitution

Tampering

• Diluting  Hyper saturating the body with fluids to dilute metabolites possibly below the 50 ng/mL threshold, depending on your metabolism.         AZO Niacin Vinegar Fiber pills Ready Clean pills Rapid Cleanse Detox Tea Goldenseal         Certo QCarbo XXtra Clean Quick Flush Terminator Gold Clear Choice MC1 Vale Triple Strength

Tampering

• “Doping”  Adding different chemicals that defeat immunoglobulin/antigen binding         Bleach (powdered) Water Ammonia Blood Draino Goldenseal Hydrogen Peroxide Lemon Juice         Liquid Soap Mary Jane’s SuperClean 13 Purifyit Sodium Nitrate Table Salt Vinegar Visine WD 40

Tampering

• Substitution  Concealed container  Injection   Catheterization Cigar containers/droppers

Tampering - Countermeasures

• Color • Temperature • Creatinine • pH • Specific gravity

False Positives

Generic Efavirenz Name Brand Sustiva Flunitrazepam Rohypnol Lamotrigine Lamitcal Possible False Positive Positive for Cannabinoids (THC) [Urinary metabolite(s) only; parent compound is non-reactive] Positive for Benzodiazepines (BZO) Positive for Phencyclidine (PCP)

False Positives

Generic l Brand Vick's Methamphetamine Inhaler HCL Phenytoin Name Dilantin Possible False Positive Positive for Methamphetamine (mAMP) Possible Positive for Barbiturates (BAR) Urinary metabolite(s) only; parent compound is non-reactive

False Positives

Generic Procaine Ranitidine Name Brand Novocain Pylorid, Zantac Possible False Positive Positive for Opiates (OPI, MOP) Positive for Methamphetamine (M-AMP) Urinary metabolite(s) only; parent compound is non reactive

False Positives

Generic Sertraline Name Brand Zoloft Venlafaxine Effexor or Effexor XL Possible False Positive Potential Positive for Benzodiazepines (BZO) Potential Positive for Phencyclidine (PCP)

False Positives

• All positives require clinical intervention • Review clients medications before engaging in a clinical intervention • If a client reports taking a medication that may cause a false positive, a confirmatory test should be completed

False Negatives

• Time elapsed since use • Improperly obtained or secured specimen • Tampered sample

Detection Times

Drug

Amphetamines Barbituates

Approximate Detection Time

2-4 days Short-Acting (Secobarbital) 1 day Long-Acting (Phenobarbital) 2-3 weeks Benzodiazepines 3-7 days

Detection Times

Drug

Cannabinoids

Approximate Detection Time

3-30 days Cocaine Codeine 2-4 days 2-5 days Euphorics (MDMA, Psilocybin) 1-3 days

Detection Times

Drug

LSD Methadone Methaqualone Opiates Phencyclidine (PCP)

Approximate Detection Time

1-4 days 3-5 days 14 days 2-4 days 2-4 days

Detection Times

Drug

Phenobarbital Propoxyphene Steroids (Anabolic) Oral Parenterally

Approximate Detection Time

10-20 days 6 hours to 2 days 14 days 1 month

Clinical Interventions

• Drug testing is a clinical intervention • Upon admission, always explain the role of drug testing • Drug testing may be scheduled, random, or suspicious • Prior to securing the urine, ask the client about changes in medication and if the client has used • Always explain the “why” of a particular drug test • If the drug test is “suspicious,” discuss the behaviors that brought about suspicion • Review test results with client immediately upon receipt, regardless of result

Clinical Interventions

• Negative drug screen  Congratulate the client  Review what drugs were tested for   Ask the client about use of drugs not tested Ask about issue/problems when the sample was secured

Clinical Interventions

• Positive drug screen  Tell the client you have the results and ask if the client has anything to share  Review what drugs were tested for and indicate what was positive       Allow the client time to respond Ask the client about use of drugs not tested Ask about when the client used, the circumstances Review/discuss consequences If discharge, make appropriate referral If no discharge, develop relapse prevention plan

Resources

Resources

• Collins, Jennifer. Laboratory Perspective on Additional Drug Testing and Associated Costs. MEDTOX Laboratories, Inc.

• Mitchell, John M. Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences . RTI International • TROUBLESHOOTING GUIDE DRUGS OF ABUSE. Innovacon, Inc. San Diego, CA • http://www.drug-test-facts.com

• • http://www.drugabuse.gov/nidahome.html

http://www.drugdetection.net/drug.htm