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Emerging Issues in Drug Testing. Greg Skipper, MD Director, Professional Health Services Promises Treatment Centers Los Angeles, CA gskipper@promises.com 310-633-4595. Drug Testing is Effective and Underutilized.

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Emerging Issues in Drug Testing

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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



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.

Long term php drug test results

Long-Term PHP Drug Test Results

Difficult cases

Difficult Cases

  • Patient prescribed hydrocodone

    • Urine test negative for opioids

    • Urine test positive for hydromorphone only?

    • Oxymorphone?

    • Codeine?

Difficult cases1

Difficult Cases

Difficult cases2

Difficult Cases

  • Patient prescribed oxycodone

    • Urine test negative for opioids

    • Urine test positive for hydrocodone

    • Oxymorphone?

    • Codeine?

Emerging issues in drug testing

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

Emerging issues in drug testing



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

New alcohol monitoring technologies

NewAlcohol Monitoring Technologies

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



Transcutaneous monitors

Transcutaneous Monitors



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

Hope drug test results

HOPE Drug Test Results

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