Ways to Deceive Drug Testing

(1)

Ways to Deceive Drug

Testing

Theodore F. Shults, JD, MS Chairman American Association of Medical Review Officers Durham, NC

Opioid Risk Management June 26-27, 2008

(2)

The Smoking Thoroughbred

(3)

Basic Strategies to Beat the Test

1.

Eliminate the evidence –

substitution,

dilution

2.

Attack the immunoassay –

pH, interfering

substances

3.

Attack the drug metabolite –

oxidation, pH

4.

Avoid the test

5.

Hire a lawyer

6.

Find another doctor

7.

Deny, deny, deny…

(4)

Drug Culture:

Mythology and Practices

y

Drug addicts and users have always had

methods and practices to beat a drug test

y

Common approaches

◦ Drink vinegar

◦ Dilute your urine

◦ Drink “Health Inca Tea”

◦ Adulterate your specimen

x Bleach; soap; battery acid

◦ Self-catheterization

(5)

Drug Testing Environments

y

Death

Investigations

y

Criminal

Investigations

(DUI, DWI)

y

Court ordered:

x Custody x Parole x Probation y

Doping Control

(Sports)

y

Life Insurance

Underwriting

y

Drug Deterrence

and Control

(workplace/schools)

y

Emergency

Medicine

y

Pain Management

y

“Wellness”

(6)

Commercialization of

“

Beating the

Drug Test

”

y

1990s: Workplace Drug Testing and

the Internet come of age.

y

Small cottage industry festers into

multi-million-dollar industry to assist

drug users in beating the test.

(7)

Fostering the Growth of

the

Beat

-

the

-

Test

Industry

◦ Lab profits are based on rapid negative test results

◦ Everyone loves negative tests

◦ Regulatory emphasis on costs of regulations

◦ Technical mistakes and leadership failures –

x The substituted-specimen fiasco

◦ Privacy concerns prohibit observed collection without “individualized suspicion”

◦ HHS Mandatory Guidelines – All adulterated tests are now “invalids”

(8)

Explosion of Products

(9)

Mr. Whizzinator Goes to

Washington (Under Subpoena)

y The media breakout product for the “beat the drug

test” industry has clearly been the Whizzinator.

y Minnesota Vikings running back Onterrio Smith was

caught in possession of this device in May 2005 at the Minneapolis-St. Paul International Airport, which

resulted in his suspension.

y Actor Tom Sizemore has also brought the Whizzinator

into the public eye after having been caught with one attempting to evade drug tests.

y The United States Congress held hearings on the

(10)

Rep. Bart Stupak (D-Mich.) bemoans the Whizzinator while holding an advertisement for the device. At left is Ed Whitfield (R-Ky.), the subcommittee

chairman.

Photo Credit: By Robert A. Reeder --The Washington Post

(11)

y

“The sheer number of these

products, and the ease with which

they are marketed and distributed

through the Internet, present

formidable obstacles to the integrity

of the drug testing process.”

◦ GAO-05-653T: “Drug Tests: Products to Defraud Drug Use Screening Tests Are Widely Available.”

(12)

(13)

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“Number 1 is a disposable urinating device

with enough premixed synthetic urine for

2 complete tests. It has been irradiated in

order to destroy all bacteria giving Number 1

a one-year shelf life.”

14

(15)

$49.95

ORDER NOW!

•Contains everything you need for 2 tests!

•Highest quality synthetic urine available!

•Adjustable belt included!

•No mixing required!

•Male & Female usage!

•Most advanced heating system!

•1 year shelf life!

(16)

Where does this go?

(17)

The Three Amigos

(18)

Chemical Warfare:

The Adulterants

(19)

(20)

(21)

in vitro

Adulterants Available

Commercially

Adulterant

Class

Identity

Mary Jane

SuperClean 13 Surfactant Lemon ScentedDetergent UrinAid Fixative Glutaraldehyde

Amber-13 Acid 1.7 N HCI

(22)

in vitro

Commercially

Adulterant

Class

Identity

Klear Oxidant Potassium Nitrite* Whizzies Oxidant Sodium Nitrite* Randy’s Clear Oxidant Nitrite

(23)

in vitro

Commercially

Adulterant Class Identity

Urine Luck Oxidant Pyridinium

chlorochromate* LL418 Oxidant Pyridinium chlorochromate* Sweet Pee’s Spoiler Oxidant Pyridinium chlorochromate*

Randy’s Klear II Oxidant Pyridinium

(24)

Nitrites:

Conclusions and Interpretation

1. Testing for Nitrite; Nitrate is different and does not interfere

2. Normal and medical nitrite concentrations in urine well below 500 mcg/mL

3. Nitrite is oxidizing agent and may

deteriorate with time in unpreserved urine

4. Concentrations of nitrite in adulterated urine are high

5. Cutoff distinguishes normal from adulterated urine

(25)

Chromium:

Conclusions and Interpretation

1. Cr+6 _{extremely toxic}— _{not to be confused with Cr}+3

2. Urine concentrations in adulterated urine generally 1000 times greater than normal

3. Cr+6 _{not expected in urine of an asymptomatic}

individual

4. Urine concentrations found in adulteration cases exceed highest toxic case reported

5. No established cutoff — 20 mcg/mL Limit of Detection required by new regulations

(26)

in vitro

Commercially

Adulterant

Class

Identity

Mary Jane

SuperClean 13 Surfactant Lemon ScentedDetergent UrinAid Fixative Glutaraldehyde

Amber-13 Acid 1.7 N HCI

(27)

in vitro

Commercially

Adulterant

Class

Identity

Klear Oxidant Potassium Nitrite* Whizzies Oxidant Sodium Nitrite* Randy’s Clear Oxidant Nitrite

(28)

in vitro

Commercially

Adulterant Class Identity

Urine Luck Oxidant Pyridinium

chlorochromate* LL418 Oxidant Pyridinium chlorochromate* Sweet Pee’s Spoiler Oxidant Pyridinium chlorochromate*

Randy’s Klear II Oxidant Pyridinium

(29)

Strategies to Manage the

Integrity of Drug Testing

in Pain Management

(30)

Different Legal Framework

y

Drug Testing in Pain Management presents

different legal framework than

workplace/forensic drug testing

y

Doctor-Patient Relationship

y

Diagnostic / Management Goals

y

Patients cooperation is “voluntary”

y

Cooperation is a condition of treatment

y

This allows for:

◦ Expanded panel of drugs to test

◦ Lower cutoffs

◦ Expanded panel of methods

(31)

Counter

-

Strategies:

Policy Considerations

y

Policy Considerations

◦ Make integrity violation more serious than positive drug test.

◦ Patients need to know that integrity testing and validation of specimens is being done.

◦ Clearly define what constitutes a “refusal to test” (e.g., missing a test).

◦ Patients should have opportunity to self-disclose changes in medications (legal and illegal)

(32)

Counter

-

Strategies:

Alternative Tests Needed

◦

Multiple specimen testing needed

◦

NOT JUST URINE!

◦

Oral fluid

◦

Sweat Patch Tests

◦

Hair (beard shaving may give short-term window)

◦

Understand the limits and trade-offs

(33)

Urine Testing Control Options

y

Gown patient

y

Observed collection

y

Grab two separate voids

◦ (compare creatinine/specific gravity between voids) (no need for large volumes here)

y

Dipstick adulteration test

y

Two collectors present

(34)

Counter

-

Strategies

y

On-Site Screening for Adulterants

◦ Simple dipstick sufficient to screen for all adulterants

(35)

The effects of adulterants and

selected ingested compounds

on drugs

-

of

-

abuse testing in

urine.

Dasgupta A

Dasgupta A : : Am J Clin PatholAm J Clin Pathol. . 2007 Sep;128(3):4912007 Sep;128(3):491- -503

(36)

y These adulterants can successfully

mask drug testing if the concentrations of certain abused drugs are moderate. Several spot tests have been described to detect the presence of such

adulterants in urine.

y Urine dipsticks are commercially

available for detecting the presence of such adulterants, along with

performance of tests for creatinine, pH, and specific gravity.

(37)

Open Questions

y

How do you manage positive test results?

y

How do you manage negative results?

How do you manage the pain patient who

is a substance abuser?

y

How do you manage medical marijuana

(38)