Drug Court

Myth

Cannabis levels are really useful in determining relapse.

Reality

• Basically…not • See the monograph on the NDCI.org

Myth

: The presence of urine sediment (material that settles to the bottom of the collection cup) is a good indicator of sample tampering.

True or False

Urine sediment occurs naturally & is comprised of: cells - (epithelial, kidney, blood) casts - (cylindralical particles formed by WBC, RBC, granular material, fat, etc.

crystals organisms (bacteria, yeast, fungi)

Myth Treatment doesn’t work. Nobody can change.

Myth Treatment doesn’t work. Nobody can change.

Myth: A urine creatinine level of 475 ng/mL is reasonable evidence to indicate specimen tampering.

True or False

Normal Urine Creatinine:

• 2005 study “Urinary Creatinine Concentrations in the U.S. Population” determine the mean (based upon 22,245 participants) was 130 mg/dL – less than 1% below 20 mg/dL – less than 1% greater than 400 mg/dL • it’s all about patterns

Creatinine Math

• healthy adult produces/eliminates approximately 1 mg of creatinine per minute or about 1440 mg in a 24-hour day. • in order to achieve a urine creatinine level of 475 mg/dL • the client would only be excreting only about 11.4 ounces of urine in a 24-hour period (or about a cup and a half). • proof of tampering "beyond a reasonable doubt" - no.

Myth

Methadone/Suboxone are: • Evil • Just another Addiction • Can’t work with Drug Court

ORT Substitutes One Addictive Drug With Another?

• ORT uses medication (methadone/Suboxone) to overcome craving and need for illicit opioids.

• ORT pharmacologic actions differ from other opioids; not mere substitute.

– Orally effective, long acting, cross tolerance (blockade) • Addictive, opioid-seeking, behaviors cease.

• ORT benefits overshadow reliance on dependency-producing medication.

• Consequences of untreated opioid addiction include: destitution, prison, disease, and/or early death.

MMT Patients Get “High”?

• At

appropriate and adequate

stable doses, normal function – no lasting euphoria or sedation.

• Adequate methadone dose avoids extremes of intoxication

or

withdrawal.

• After dosing,

some

patients may “sense” onset of methadone effects or have vague feelings of “well-being” (soon wears off after blood level peaks) .

Taming the Roller Coaster

Adequate

methadone smooths peaks & valleys – shifting from opioid intoxication to withdrawal. Patients can live more comfortably normal lives throughout each day.

ORT Patients Abuse Other Drugs?

• ORT not a “cure” for addiction.

– Addresses illicit opioid withdrawal and craving.

• Pharmacologically little effect on alcohol, cocaine, etc.

• With

adequate

ORT, most patients

do

eliminate or reduce other drug abuse.

• Ongoing counseling, psychosocial treatment, needed services and self help groups are important.

Benefits to Drug Court • It can save lives!

• The treatment does work with Drug Court • Fairfield County, Ohio –62% grad rate with Suboxone –13% grad rate without

Myth Methadone/Suboxone are: • Evil • Just another Addiction • Can’t work with Drug Court

Myth: A urine with a negative EtG and an ethyl sulfate (EtS) concentration of 457 ng/mL is inclusive to establish the consumption of alcohol by a client.

True or False

EtS Without EtG

• EtG “discovered” first • large lab testing 2000 samples a month, incidence of EtS without EtG = 3% • EtG can be “eaten” by bacteria (e. coli) • client with UTI could destroy EtG • reasonable EtS cutoff = 100 ng/mL using LC/MS/MS

Myth

Poppy seed bagels can cause a positive reaction on a urine test

Myth: A reasonable “failure to confirm” rate (presumptively positive sample that fails to confirm by GC/MS)is about 25%.

True or False

Failure to confirm rate should be in the low single digits.

Issues to consider:

Failure to Confirm

• discrepant cutoffs • misreading of on-site device – “Any band, even if faint, partial or broken, indicates a negative result. The absence of color is a presumptive positive result.” • cross-reactivity - false positive – amphetamines & benzodiazepines • re-screening at confirmation lab

Myth Everyone needs residential treatment

Reality

• Some need it • Many/most don’t • Long term residential is expensive • Some jurisdictions don’t have it • Being in the community helps develop connections: court, judge, self help, etc.

• And remember…only a trained treatment person can determine clinical level of care.

Myth Everyone needs residential treatment

Myth

A client with diabetes is likely to produce dilute specimens (with urine creatinine levels of less tha 20 mg/mL) because of his/her disease.

True or False

Diabetes & Creatinine

• To the research: – some people with diabetes have slightly lower urinary creatinine levels – this finding is not universal across all racial/ethnic groups or even age groups.

– non-Hispanic blacks with diabetes had urinary creatinine levels about 30 mg/dL lower than those without diabetes – no significant differences were observed in other racial/ethnic groups. – similar variations were observed in different age group categories – urinary creatinine levels for persons with diabetes 30-39 years of age were about 40 mg/dL lower than those without diabetes in the same age group.

Diabetes & Creatinine

• how to apply this research to drug court • question is whether diabetes causes dilute urine samples - the answer is NO!

• average urine creatinine level for a non Hispanic black participant, 20-49 years of age is 180 mg/dL - subtract 30 mg/dL of creatinine for a diabetic condition, starting with an average urine creatinine level of 150 mg/dL

Creatinine Facts

• some diseases that produce low urinary creatinines – muscle wasting disease - RARE – some kidney aliments - RARE • low creatinines ARE NOT routinely associated with: – pregnancy – diabetes – obesity – exercise – high-blood pressure – being vegetarian

Myth

A client with diabetes is likely to produce dilute specimens (with urine creatinine levels of less tha 20 mg/mL) because of his/her disease.

True or False

Myth

If taken in large dosages, niacin (vitamin B-3) can be utilized by clients to speed the elimination of THC from their bodies resulting in a shorter detection window for cannabinoids. True or False

All About Niacin

• niacin - vitamin that affects more than 50 metabolic functions, releasing energy from carbohydrates • absolutely NO scientific or medical data indicating niacin has ANY effect on a urine drug test • adds a more intense "yellow" color to the urine • niacin used to disguise diluted samples • niacin overdose is often accompanied by skin“flushing”

Myth

If taken in large dosages, niacin (vitamin B-3) can be utilized by clients to speed the elimination of THC from their bodies resulting in a shorter detection window for cannabinoids. True or False

Myth

Well I got my recovery doing it this way so everyone should do it exactly like me.

Reality

• Everyone has different needs/ experiences • Show what worked for you, don’t force it • Take what fits and leave the rest

thanks to

• Dave Wallace – Photographer • Meghan Wheeler • Cinderella • The nice popcorn lady • The eventually nice Secret Service