Transcript Understanding Abused Drugs Testing Results

Four Key Issues for CourtDirected Drug Testing
By: Paul L. Cary
Toxicology Laboratory
University of Missouri
The law is not black and
white and neither is science.
“. . there is a substantial gap between the
questions that the legal community would like
to have answered by drug testing and the answers
that the scientific community is able to provide.
The real danger lies in the legal community’s failure
to “mind the gap” by drawing unwarranted
inferences from drug testing results.”
Four Key Issues
interpreting urine drug testing results
 eliminating the use of urine drug
levels in court proceedings
 establishing a pragmatic cannabinoid
detection window
 monitoring alcohol abstinence using
EtG determinations
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Interpretation of
Urine Drug Test Results
Negative or None Detected Results
indicates that no drugs or breakdown
products (metabolites), tested for, were
detected in the sample tested
 no such thing as “zero” tolerance or
“drug free”
 negative does not mean NO drugs
present
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Negative/None Detected Interpretation
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client is not using a drug that can be detected
by the test
Other possible explanations
client not using enough drug
client’s drug use is too infrequent
collection too long after drug use
urine is tampered
test being used not sensitive enough
client using drug not on testing list
Negative/None Detected Interpretation
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no need to second-guess every “negative” result
not suggesting withholding positive
reinforcement & rewards for positive behaviors
drug testing is a monitoring tool
assess none detected drug testing results in the
context of your client’s overall program
compliance (or non-compliance) and their life’s
skills success (or lack thereof)
Positive Test Result Interpretation
indicates that drug(s) or breakdown
products (metabolites), tested for, were
detected in the sample tested
 drug presence is above the “cutoff” level
 greatest confidence achieved with
confirmation
 ALWAYS confirm positive results in
original sample
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What is a “cutoff” level ?
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a drug concentration, administratively established for a
drug test that allows the test to distinguish between
negative and positive sample - “threshold”
cutoffs are not designed to frustrate CJ professionals
cutoffs provide important safeguards:
 scientific purposes (detection accuracy)
 legal protections (evidentiary admissibility)
measured in ng/mL = ppb
Typical Cutoff Levels
screening & confirmation
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amphetamines *
benzodiazepines
cannabinoids *
cocaine (crack)*
opiates (heroin) *
phencyclidine (P CP) *
alcohol
*
1000 ng/mL
300 ng/mL
20 & 50 ng/mL
300 ng/mL
300/2000 ng/mL
25 ng/mL
20 mg/dL
SAMHSA (formerly NIDA) drugs
500 ng/mL
variable
15 ng/mL
150 ng/mL
variable
25 ng/mL
10 mg/dL
No such thing as “zero tolerance” testing
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drug tests not capable of testing to “0” ng/mL
each drug & each drug test has a limit of detection
drug courts urged to utilize “standardized” cutoffs
potential hazards of a “zero-tolerance” approach (use of
non-traditional cutoffs)
 testing accuracy (increase in false-positives)
 court’s justification for abnormally low cutoffs
 can/will your laboratory “defend” low cutoffs
 increased challenges/scrutiny to positive results
 lowered cutoffs may include “inadvertent” exposures
Isn’t any amount of drug in a client’s
system a violation?
punishment model vs. therapeutic
model
 drug testing results (which form the
foundation for incentives & sanctions)
need to be scientifically accurate &
legally defensible
 protection of client rights & the court
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Exceptional (lowered) cutoffs in an effort
to “catch” covert client drug use:
provides only a marginal increase in drug
detection
 opens your court to increased scrutiny
associated with potential false positives and
resulting inappropriate sanctions
 it’s all about credibility
 it’s all about confidence
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The Issue of Urine
Drug Concentrations
Drug Tests are Qualitative
screening/monitoring drug tests are
designed to determine the presence or
absence of drugs - NOT their
concentration
 drug tests are NOT quantitative
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Drug concentrations or levels associated
with urine testing are, for the most part,
USELESS !
cocaine metabolite
 opiates
 cannabinoids
 amphetamines
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517 ng/mL
negative
negative
negative
The Twins
200 mg Wonderbarb
@ 8:00 AM
Collect urine 8:00 PM
12 hours later
A
B
The Twins - urine drug test results
A
Wonderbarb = 638 ng/mL
B
Wonderbarb = 3172 ng/mL
The Twins - urine drug test results
physiological make up
exact amount drug consumed
exact time of ingestion
exact time between drug
exposure and urine collection
A
AND YET . . . . .
B
The Twins - urine drug test results
Twin B’s urine drug
level is 5 times higher
than Twin A
A
Wonderbarb = 638 ng/mL
B
Wonderbarb = 3172 ng/mL
Are any of the following questions
being asked in your court?
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How positive is he/she?
Are his/her levels increasing or decreasing?
Is that a high level?
Is he/she almost negative?
Is this level from new drug use or continued
elimination from prior usage?
What is his/her baseline THC level?
Does that level indicate relapse?
Why is his/her level not going down? (or up?)
THE ISSUE
Urine drug concentrations are of little or no
interpretative value. The utilization of
urine drug test levels by drug courts
generally produces interpretations that are
inappropriate, factually unsupportable and
without a scientific foundation. Worst of
all for the court system, these urine drug
level interpretations have no forensic merit.
Where do urine drug levels come from?
higher drug level
20 ng/mL
lower drug level
NEGATIVE RESULT
POSITIVE RESULT
screening drug testing cutoff
Scientific Rationale
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Technical Issues
 testing
not linear
 tests measure total drug concentrations
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Physiological
 variability
of urine output
 differential elimination of drug components
“Expected Values:
When the test is used as a qualitative assay,
the amount of drugs and metabolites detected
by the assay in any given specimen cannot be
estimated. The assay results distinguish
between positive and negative specimens only.”
THIS ?
432 indicates he going up, right?
is 22 above the cutoff?
does 219 mean new use?
307 – well she’s almost
negative, correct?
639 is really high for THC, isn’t it?
115 is down from yesterday,
probably continued elimination?
515 is much higher than
last week, right?
I think 1200 is a new
record, isn’t it?
don’t we need to consider
relapse at 57?
OR THIS ?
Negative or Positive
Advantages of Eliminating Drug Levels
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court decisions have a strong scientific basis &
forensically sound
no longer attempt to interpret data that is not
interpretable
greater confidence in decision making process
removes ambiguity associated with
manipulating numbers that few in drug court are
trained to do
adds additional fairness/equity in sanctions &
rewards process
Final Thought:
However well-intentioned, the use of urine
drug testing levels cannot be supported by the
science and represents an adjudication practice
that is not forensically defensible. An
unambiguous and equitable evidentiary
foundation that will pass both scientific and legal
scrutiny is crucial to the continued success of
drug courts (criminal justice).
The Cannabinoid
Detection Window
Cannabinoid Detection in Urine
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Conventional wisdom has led to the common
assumption that cannabinoids will remain detectable in
urine for 30 days or longer following the use of
marijuana.
RESULT:
 delay of therapeutic intervention
 hindered timely use of judicial sanctioning
 fostered denial of marijuana usage by clients
Perpetuating 30-Plus Day Assumption
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Substance abuse treatment literature that proclaims, “some parts of the
body still retain THC even after a couple of months”.
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Drug abuse information targeted toward teens “Traces of THC can be
detected by standard urine and blood tests for about 2 days up to 11
weeks”.
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Health information websites that provide the following guidance; “At the
confirmation level of 15 ng/ml, the frequent user will be positive for
perhaps as long as 15 weeks.”
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And, last but not least Dr. Drew Pinsky (a.k.a. Dr. Drew) who has been
the co-host on the popular call-in radio show "Loveline" for 17 years who
states; “Pot stays in your body, stored in fat tissues, potentially your
whole life.”
Cannabinoids - Recent/Relevant Research
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30+ day detection window often exaggerates
duration of detection window
reasonable & pragmatic court guidance
detection time: at 50 ng/mL cutoff
 up to 3 days for single event/occasional use
 up to 10 days for heavy chronic use
detection time: at 20 ng/mL cutoff
 up to 7 days for single event/occasional use
 up to 21 days for heavy chronic use
Addressing Imperatives for Cannabinoids
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acknowledge research reporting prolonged THC
elimination
establish a reasonable and pragmatic detection
window guidance for the vast majority of case
adjudications
sound judicial practice requires that court decisions
be based upon case-specific information
in unconventional situations that confound the
court, qualified toxicological assistance should be
sought
Recent Cannabinoid Use versus Non-recent
use (double sanction issue):
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How do drug courts discriminate between new
drug exposure and continued elimination from
previous (chronic) use ?
 an issue only in first phase of program
 only drug that poses concern is cannabinoids
 “two negative test” rule – two back-to-back
negative drug tests post clean out
Drug Court’s Competing Imperatives
the need for rapid therapeutic intervention
(sanctioning designed to produce behavioral
change)
 the need to ensure that the evidentiary
standards, crafted to protect client rights, are
maintained
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Ethyl Glucuronide (EtG) –
New Strategy for Monitoring
Alcohol Abstinence
Alcohol is the most commonly
abused substance by drug court
clients and the most difficult
substance to detect in abstinence
monitoring.
Ethyl Glucuronide
COOH
O
OH
O
OH
OH
Et
Advantages of Ethyl Glucuronide
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unique biological marker of alcohol use (no false
positives)
direct marker indicating recent use
longer detection window than alcohol
stable in stored specimens (non-volatile)
is not formed by fermentation
is not detected in the urine of abstinent subjects
Urine EtG Concentrations
Following Alcohol Consumption:
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one 3.2% beer
> 3800 ng/mL @ 4 hours
detection up to 24 hours
(alcohol - 90 minutes)
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three 3.2% beers
detection up to 48 hours
(alcohol - 3.5 hours)
Disadvantages of Ethyl Glucuronide
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testing available at relatively few laboratories
testing somewhat costly ($25.00 price point)
introduction of numerous testing approaches
besides LC/MS/MS
most significant concern – casual, inadvertent,
environmental alcohol exposure causing positive
results
On September 25,
2006 everything
changed!
SAMHSA CSAT Advisory (9-25-06)
“Currently, the use of an EtG test in determining
abstinence lacks sufficient proven specificity for use
as primary or sole evidence that an individual
prohibited from drinking, in a criminal justice or a
regulatory compliance context, has truly been
drinking. Legal or disciplinary action based solely on
a positive EtG, is inappropriate and scientifically
unsupportable at this time. These tests should
currently be considered as potential valuable clinical
tools, but their use in forensic settings is premature.”
Sources of “Incidental” Alcohol Exposure
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medications (Nyquil)
mouthwashes (Listermint & Cepacol)
tincture of gingko biloba (herbal - memory)
foods containing alcohol (such as vanilla
extract, baked Alaska, cherries jubilee, etc.)
“non-alcoholic” beers (O’Doul’s)
colognes & body sprays
insecticides (DEET)
alcohol-based hand sanitizers (Purell)
What prompted SAMHSA Advisory ?
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the science of EtG testing - our capability to employ
highly sensitive testing procedures to detect recent
ethyl alcohol exposure - has outpaced our ability to
appropriately interpret the test results in a forensically
defensible manner
consumption vs unintended exposure
CSAT (National Advisory Council) concluded that
there is inadequate research data about the populations
being tested
Positive EtG Result (500 ng/mL):
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a result reported as EtG positive in excess of the
500 ng/mL cutoff is consistent with the recent
ingestion of alcohol-containing products (1-2
days prior to specimen collection) by a
monitored client
studies examining “incidental” exposure widely
conclude that results in excess of the 500 ng/mL
cutoff are not associated with inadvertent or
environment ethanol sources
Current State of EtG Testing
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my biggest concern is that this advisory
will likely render ANY EtG result as
legally inadmissible (for sanctioning
purposes)
already seen large decrease in EtG
testing nationally
EtG still valuable for therapeutic
intervention
Options for Client Sanctioning
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positive urine EtG - cutoff of at least 500 ng/mL
combined with:
a client admission of use/replase
identification of behavioral indicators
 alcohol-related arrest or incident
 alcohol-related job action
 client seen in bar/tavern
a violation of EtG-specific contract
EtG- Specific Contract:
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outlines the behavioral requirements and
compliance standards necessary for continued
participation in drug court
educate, alert and advise drug court clients of
the potential (incidental) sources of alcohol that
could produce a positive urine EtG test result
listing the numerous commercial products that
contain ethyl alcohol and provides a list of
substances to avoid while in a drug court
program
email address:
 [email protected]