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Emerging Issues in Drug Testing. Greg Skipper, MD Director, Professional Health Services Promises Treatment Centers Los Angeles, CA [email protected] 310-633-4595. Drug Testing is Effective and Underutilized.

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emerging issues in drug testing

Emerging Issues in Drug Testing

Greg Skipper, MD

Director, Professional Health Services

Promises Treatment Centers

Los Angeles, CA

[email protected]


drug testing is effective and underutilized
Drug Testing is Effective and Underutilized
  • When testing is frequent, random and tied to immediate moderate consequences drug use is deterred.
difficult cases
Difficult Cases
  • Patient prescribed hydrocodone
    • Urine test negative for opioids
    • Urine test positive for hydromorphone only?
    • Oxymorphone?
    • Codeine?
difficult cases2
Difficult Cases
  • Patient prescribed oxycodone
    • Urine test negative for opioids
    • Urine test positive for hydrocodone
    • Oxymorphone?
    • Codeine?

Anomalous observations of hydrocodone in patients on oxycodone.

West R et al, Clin Chim Acta. 2010 Aug 27.

BACKGROUND: Oxycodone preparations are known to have small amounts of hydrocodone as an impurity estimated to be <0.1%. We established the concentration of unexpected hydrocodone in patients taking oxycodone.

METHODS: 30,000 pain patients

CONCLUSIONS: When oxycodone is >100,000ng/ml, hydrocodone should be <1500ng/ml. When oxycodone is <100,000ng/ml then hydrocodone should be <500ng/ml. Values greater than these indicate non-prescribedhydrocodone use. Clinicians and laboratories testing urine for drugs should be aware of the possibility of low concentrations of hydrocodone in the urine of patients taking high doses of oxycodone.

difficult cases3
Difficult Cases
  • Patient prescribed Valium
    • Urine test positive for oxazepam only
    • Temazepam
difficult cases4
Difficult Cases
  • Patient on xanax (alprazolam) or
  • Klonopin (Clonzaepam)
    • Urine test negative for benzo’s?
sensitivity vs specificity
Sensitivity vs Specificity
  • Are they always mutually exclusive?
  • Highly sensitive
    • More prone to false positive?
  • Highly specific
    • More prone to false negative?
screening vs confirmation tests
Screening vs Confirmation Tests
  • Screening
    • Immunoassays, ELISA, EMIT, DRI, Dipstick
    • Tend to be highly sensitive
    • Not so specific
  • Confirmation
    • GC/MS, LC/MS, LC/MS/MS
    • Highly specific
    • Not so sensitive (because of restricted panel)
mro function
MRO function
  • Is there a cause for positive other than illicit use?
    • Legitimate prescription
    • False positive – at least two types
legitimate use
Legitimate Use?
  • Coca tea?
  • Cocaine positive from sex?
  • ENT procedure?
  • Hemp oil? Hemp cereal? Hemp cosmetics? Hemp granola bars? Hemp lip balm?
  • Sprained ankle and was given heroin while visiting Great Britain?
  • THC? Ever legal in US?
    • Passive inhalation
  • Poppy seeds
poppy seeds
Poppy Seeds
  • Over 1,000 species of poppy seeds
  • Used in cooking
    • Baking
    • Salad dressings
    • Curry sauces
  • Morphine level >1,000, >2,000, >5,000, >15,000 ????
  • Urine concentration can be a clue
accidental exposure
Accidental Exposure
  • Marijuana brownie
  • Someone else’s medication
  • Took pill and didn’t know what it was
  • Drank punch and didn’t know it had alcohol in it
  • Vacuuming up someone else’s cocaine and turned vacuum clearner on reverse and blew it into the air
positive amphetamine due to l isomer
Positive Amphetamine due to l-isomer
  • Vics inhaler, selegiline, EMSAM patch
    • D & L Isomer test
      • >80% l-amphetamine consistent w/
  • Pseudoephedrine converted to amphetamine inside the GC/MS machine
    • Retest
  • Creatinine <20mg/dl and sp gr <1.003
    • Creatinine <20 but >10 mg/dl can be from innocent excess water
    • Creatinine <10mg/dl but >5mg/dl not likely innocent
    • Creatinine <5mg/dl probably substitution
    • Creatinine <2mg/dl definitely substituted
what to do
What to do?
  • Creatinine <20 but >10 mg/dl can be from innocent excess water
    • Warn, observed, obtain hair/nails or saliva test
  • Creatinine <10mg/dl but >5mg/dl not likely innocent
    • Hair/nail, saliva, observed, evaluation
  • Creatinine <5mg/dl probably substitution
    • Assume substitution, verify observed, retest sample
emerging technologies
Emerging Technologies
  • Quick Test Kits
  • Better confirmation tests: LC/MS/MS
  • More extensive testing panels
  • Increased Use of Flex Testing
  • Improved testing for ethanol (EtG, EtS, etc)
  • Devices: TAD, SCRAM, Soberlink



nail testing
Nail Testing
  • Good alternative to hair testing
  • Similar repository window
  • Less prone to adulteration from chemicals
  • Thicker than hair
saliva testing
Saliva Testing

(ie dilute urines)

sweat testing
Sweat Testing
  • DHHS - 5 DRUGS
  • Less invasive than hair testing
in the beginning
In the beginning…

Blood alcohol

Breath alcohol

Urine alcohol

Limitations when used for alcohol monitoring


Carbohydrate Deficient Transferrin

current technologies
Current Technologies

Random field breathalyzer

Multiple daily ID home breathalyzer

Transcutaneous alcohol monitoring

New markers

EtG – EtS – PEth

Urine – Hair/Nails – Saliva – Blood

frequent random breathalyzer
Frequent / Random Breathalyzer

24/7 Program in South Dakota

Random testing field programs

BAT Mobile

24 7 south dakota
24/7 South Dakota

House bill 1072


Type, frequency, time, location, fees ($1 for each breath test), consequences

Usually twice a day on site in local police dept

Results - 2007

1,021 participants, 165,456 tests, 359 no shows = 99.8% show rate

Of 165,456 tests 534 failed tests

24 7 south dakota1
24/7 South Dakota

Of 165,456 tests 534 failed tests

Rate of improvement for individuals - good

positive id home breathalyzers
Positive ID Home Breathalyzers

New home breathalyzer technologies

MEMS 3000

Smart Start In-Hom

Mobile Breath


Smart Phone Compatible and Required:Requires Android OS 2.2 or higher, or Blackberry OS 5.0 or higher (device must be Bluetooth enabled). Apple iPhone compatibility coming soon.

Photo Identification:Guarantee\'s the identity of the user. Facial recognition coming soon.

Fuel Cell Sensor:Provides highly accurate and reliable results.


Product Height: 4.75" (121mm)

Product Width: 1.5" (38mm)

Product Depth: 2.875" (73mm)


Product Weight: 6oz (190g)


1 Year Limited Warranty

intermittent transcutaneous alcohol monitoring
Intermittent Transcutaneous Alcohol Monitoring

www.alcoholmonitoring.com – to locate provider

unique alcohol metabolites
Unique Alcohol Metabolites

Ethylglucuronide (EtG)




urine etg and ets
Urine EtG (and EtS)

1-4 days possible duration

Normalization important

(100/uCreat) x uEtG = Normalized EtG

Important to warn about things to avoid

Foods, mouthwash, handgel, etc.etc.

May be important to have participant sugar fast (4-6 hours) before submitting sample

Juices, fruits, etc contain small amounts etoh

alcohol metabolites
Alcohol Metabolites

Phosphatidyl Ethanol (PEth)


A group of phospholipids formed by alcohol on cell membranes - phospholipase D

Positive only after significant alcohol exposure (approx 7 drinks over a week)

Stays positive (>20ng/ml) for 2-3 weeks

Level correlates well with amount of alcohol consumed

alcohol metabolites1
Alcohol Metabolites

Phosphatidyl Ethanol (PEth)

combination strategies
Combination Strategies

Using PEth to confirm drinking following positive EtG/EtS when drinking denied

Study: 18 positive EtGs

settings strategies
Settings / Strategies

Normalize values to creatinine of 100md/dl (labs should automatically make this calculation)

Have participants sign consent regarding their responsibility to avoid alcohol

Re-advise to avoid all alcohol (including ripe fruits, juices, anything containing sugar) on day of test.

hope probation
HOPE Probation
  • HOPE probationers have the most serious felony drug and crime problems and are identified as likely to violate their conditions of community supervision
  • HOPE utilizes intensive random drug testing for up to 6 years
  • Responds to detected violations of probation (drug use, missed probation meetings, etc.) with clear, swift, short-term sanctions
randomized control trial of hope vs standard probation
Randomized Control Trial of HOPE vs. Standard Probation
  • In one-year period, HOPE probationers were:
    • 55% less likely to be arrested for a new crime
    • 72% less likely to use drugs
    • 61% less likely to skip appointments with their supervisory officer
    • 53% less likely to have their probation revoked
  • HOPE probationers were sentenced to, on average, 48% fewer days of incarceration than the control group