a best practices review of drug detection for court ... best practices review of drug detection for...

A Best Practices Review ofDrug Detection for Court

Professionals

By: Paul L. CaryBy: Paul L. CaryToxicology LaboratoryToxicology LaboratoryUniversity of MissouriUniversity of Missouri

The law is not black andwhite and neither is science.““. . there is a substantial gap between the. . there is a substantial gap between thequestions that the legal community would likequestions that the legal community would liketo have answered by drug testing and the answersto have answered by drug testing and the answersthat the scientific community is able to provide.that the scientific community is able to provide.The real danger lies in the legal communityThe real danger lies in the legal community’’ssfailurefailure to to ““mind the gapmind the gap”” by drawing unwarranted by drawing unwarrantedinferencesinferences from drug testing results.from drug testing results.””

Best Practices!

Best Practices frequency of testingfrequency of testing random testingrandom testing witness collection & specimen integritywitness collection & specimen integrity custody & controlcustody & control accurate results & confirmationaccurate results & confirmation rapid turn-around timerapid turn-around time

Drug Testing Basics

Reasons for Drug Testing - WHY? act as a deterrent to future drug useact as a deterrent to future drug use identify participants who are maintainingidentify participants who are maintaining

abstinenceabstinence identify participants who have relapsedidentify participants who have relapsed

rapid interventionrapid intervention efficient utilization of limited resourcesefficient utilization of limited resources

provides incentive, support and accountabilityprovides incentive, support and accountabilityfor participantsfor participants

adjunct to treatment & frames sanction decisionsadjunct to treatment & frames sanction decisions

Why Do We Drug Test? addiction is an insidious diseaseaddiction is an insidious disease

relentless, unforgiving, goal is the death ofrelentless, unforgiving, goal is the death ofits hostits host

tells the brain to use at all coststells the brain to use at all costs demonstrated to support recoverydemonstrated to support recovery frames/revises treatment plansframes/revises treatment plans

““thermometerthermometer”” analogue analogue demonstrated to support refusal skillsdemonstrated to support refusal skills frequency should not decrease with phasefrequency should not decrease with phase

progressionprogression

Drug Testing Specimens

urine - current specimen of choiceurine - current specimen of choice generally readily available - large quantitiesgenerally readily available - large quantities contains high concentrations of drugscontains high concentrations of drugs good analytical specimengood analytical specimen provides both recent and past usageprovides both recent and past usage

alternative specimensalternative specimens breathbreath hairhair sweat - patch testsweat - patch test saliva - oral fluidssaliva - oral fluids

Characteristics of a Good Drug Test:Characteristics of a Good Drug Test:

scientifically valid employs proven methods & techniques accepted by the scientific community

legally defensible able to withstand challenge established court track record scrutinized by legal/judicial review

therapeutically beneficial provides accurate profile of client’s drug use provides rapid results for appropriate response

When to Test? KEEP KEEP ‘‘EM GUESSING !EM GUESSING ! effective drug testing effective drug testing mustmust be random be random

unexpected, unannounced, unanticipatedunexpected, unannounced, unanticipated limit time between notification & testinglimit time between notification & testing

test as often as possible - twice weeklytest as often as possible - twice weekly consider use of multiple specimens (hair, saliva,consider use of multiple specimens (hair, saliva,

sweat)sweat) testing frequency remains constant throughouttesting frequency remains constant throughout

phase progressionphase progression

Drug Testing Reality Check

When developing and administering your drugWhen developing and administering your drugtesting program testing program assumeassume that the participants you that the participants youare testing know are testing know moremore about urine drug testing about urine drug testingthan you do!than you do!

Sources:Sources: InternetInternet High Times magazineHigh Times magazine other court clientsother court clients

Client Contracts

The Importance of “Specificity”in a Client Contract:

““I understand . . . . . .I understand . . . . . .”” I will I will be tested for the presence of drugs in mybe tested for the presence of drugs in my

system on a random basis according to proceduressystem on a random basis according to proceduresestablished by the Drug Court Team and/or myestablished by the Drug Court Team and/or mytreatment provider.treatment provider.

I understand that I will be given a location and timeI understand that I will be given a location and timeto report for my drug test.to report for my drug test.

I understand that it is my responsibility to report toI understand that it is my responsibility to report tothe assigned location at the time given for the test.the assigned location at the time given for the test.


I understand that if I am late for a test, or miss a test,I understand that if I am late for a test, or miss a test,it will be considered as a positive test forit will be considered as a positive test fordrugs/alcohol and that I may be sanctioned.drugs/alcohol and that I may be sanctioned.

I understand that if I fail to produce a urineI understand that if I fail to produce a urinespecimen or if the sample provided is not ofspecimen or if the sample provided is not ofsufficient quantity, it will be considered as a positivesufficient quantity, it will be considered as a positivetest for drugs/alcohol and that I may be sanctioned.test for drugs/alcohol and that I may be sanctioned.

I understand that if I produce a dilute urine sampleI understand that if I produce a dilute urine sampleit will be considered as a positive test forit will be considered as a positive test fordrugs/alcohol and that I may be sanctioned.drugs/alcohol and that I may be sanctioned.


I have been informed that the ingestion of excessiveI have been informed that the ingestion of excessiveamounts of fluids can result in a diluted urineamounts of fluids can result in a diluted urinesample and I understand that my urine sample willsample and I understand that my urine sample willbe tested to ensure the sample is not dilute.be tested to ensure the sample is not dilute.

I understand that substituting or altering myI understand that substituting or altering myspecimen or trying in any way to modify my bodyspecimen or trying in any way to modify my bodyfluids for the purposes of changing the drug testingfluids for the purposes of changing the drug testingresults will be considered as a positive test forresults will be considered as a positive test fordrugs/alcohol and will result in sanctioning anddrugs/alcohol and will result in sanctioning andmay be gromay be grounds for immediate termination fromunds for immediate termination fromdrug court.drug court.

Challenging UrineCollection Strategies

“Witnessed” collection (for urine)

single most important aspect of effectivesingle most important aspect of effectivedrug testing programdrug testing program

urine collections not witnessed are of littleurine collections not witnessed are of littleor no assessment valueor no assessment value

denial component of substance abusedenial component of substance abuserequires requires ““direct observationdirect observation”” collections of collections ofparticipantsparticipants

Sample Collection: pre-collection preparationpre-collection preparation

site selectionsite selectionminimize access to water sourcesminimize access to water sourcesuse an area with a scant floorplanuse an area with a scant floorplan find privacy & securityfind privacy & security

gather supplies beforehandgather supplies beforehand obtain proper collection receptacleobtain proper collection receptacle

removal of outer clothingremoval of outer clothing

Sample Collection: (continued)

wash hands prior to donationwash hands prior to donation ““witnesswitness”” collection collection additional clothing removaladditional clothing removalbody inspectionbody inspection squat and coughsquat and cough

label sample correctlylabel sample correctly

Sample Collection: (continued) accept sample & inspectaccept sample & inspect

temperature (90-100temperature (90-100˚̊ F) F) color (no color color (no color diluted ?) diluted ?) odor (bleach, sour apples, aromatics,odor (bleach, sour apples, aromatics,

vinegar, etc.)vinegar, etc.) solids or other unusual particulatessolids or other unusual particulates

store sample properlystore sample properly forensic sample - custody documentsforensic sample - custody documents

Developing control strategies to preventDeveloping control strategies to preventsample tampering is criticalsample tampering is critical.

Once clients Once clients understand that they cannotunderstand that they cannotbeat the system, they are much more likelybeat the system, they are much more likelyto engage in the therapeutic processto engage in the therapeutic processtoward recovery.toward recovery.

Drug Testing Methods

Two-Step Testing ApproachTwo-Step Testing Approach

screening test screening test –– designed to separate negative designed to separate negativesamples from samples that aresamples from samples that are““presumptivelypresumptively”” positive positive

confirmation test confirmation test –– follow-up procedure follow-up proceduredesigned to validate positive test resultsdesigned to validate positive test results distinctly different analytical techniquedistinctly different analytical technique more specific and more sensitivemore specific and more sensitive

Step One – Screening

often based on immunoassay technologyoften based on immunoassay technology more drug more drug –– more binding - more more binding - more ““colorcolor””

produced produced –– more instrument detector more instrument detectorresponseresponse

numerous commercial manufacturersnumerous commercial manufacturers designed for high throughputdesigned for high throughput

instrumentation or on-site devicesinstrumentation or on-site devices

On-site DOA screening

often based on immunoassay technologyoften based on immunoassay technology concept of color concept of color ““switchswitch”” ““dynamicdynamic”” versus versus ““staticstatic”” calibration calibration hand-held cassettes or test-cup deviceshand-held cassettes or test-cup devices one test at a time - no batchingone test at a time - no batching available in DOA panels or single drugsavailable in DOA panels or single drugs numerous commercial manufacturersnumerous commercial manufacturers

differential sensitivity & selectivitydifferential sensitivity & selectivity

On-site Drug Detection:

Follow package insert guidance exactly!

On-site Drug Detection:

Intensity of band is NOT quantitative!

Step Two - Confirmation

gas chromatography-mass spectrometrygas chromatography-mass spectrometry(GC/MS) or LC/MS(GC/MS) or LC/MS drug molecules separated by physicaldrug molecules separated by physical

characteristicscharacteristics identified based on chemical identified based on chemical ““finger-printfinger-print”” considered considered ““gold standardgold standard””

other chromatographic techniquesother chromatographic techniques

Why confirm ? Is it really necessary to confirm drugs thatIs it really necessary to confirm drugs that

tested positive by initial screening tests?tested positive by initial screening tests? Why Why cancan’’t the court adjudicate casest the court adjudicate cases

based on the screening test results?based on the screening test results?

FALSE POSITIVESFALSE POSITIVES

Drug tests & cross reactivity: screening tests can and do react to screening tests can and do react to ““non-non-

targettarget”” compounds compounds amphetaminesamphetamines benzodiazepinesbenzodiazepines

obtain list of interfering compounds fromobtain list of interfering compounds fromlab or on-site test vendorlab or on-site test vendor

initial screening (initial screening (““instantinstant”” tests) may only tests) may onlybe 60-70% accuratebe 60-70% accurate

confirm positive resultsconfirm positive results

Interpretation ofDrug Test Results

Negative or None Detected Results

indicates that no drugs or breakdownindicates that no drugs or breakdownproducts (metabolites), tested for, wereproducts (metabolites), tested for, weredetected in the sample testeddetected in the sample tested

no such thing as no such thing as ““zerozero”” tolerance or tolerance or““drug freedrug free””

negative does not mean NO drugsnegative does not mean NO drugspresentpresent

Negative/None Detected Interpretation

client is not using a drug that can be detectedclient is not using a drug that can be detectedby the testby the test

Other possible explanationsOther possible explanations client not using enough drugclient not using enough drug clientclient’’s drug use is too infrequents drug use is too infrequent collection too long after drug usecollection too long after drug use urine is tamperedurine is tampered test being used not sensitive enoughtest being used not sensitive enough client using drug not on testing listclient using drug not on testing list

Negative/None Detected Interpretation

nono need to second-guess every need to second-guess every ““negativenegative”” result result notnot suggesting withholding suggesting withholding positivepositive

reinforcement & rewards for positive behaviorsreinforcement & rewards for positive behaviors drug testing is a monitoring tooldrug testing is a monitoring tool assess none detected drug testing results in theassess none detected drug testing results in the

context of your clientcontext of your client’’s overall programs overall programcompliance (or non-compliance) and their lifecompliance (or non-compliance) and their life’’ssskills success (or lack thereof)skills success (or lack thereof)

Positive Test Result Interpretation

indicates that drug(s) or breakdownindicates that drug(s) or breakdownproducts (metabolites), tested for, wereproducts (metabolites), tested for, weredetected in the sample testeddetected in the sample tested

drug presence is above the drug presence is above the ““cutoffcutoff”” level level greatest confidence achieved withgreatest confidence achieved with

confirmationconfirmation ALWAYS confirm positive results inALWAYS confirm positive results in

original sampleoriginal sample

Typical Cutoff Levelsscreening & confirmation

amphetamines *amphetamines * 500500 ng/mL ng/mL 250250 ng/mL ng/mL benzodiazepinesbenzodiazepines 300 ng/mL300 ng/mL variablevariable cannabinoids * cannabinoids * 20 & 50 ng/mL20 & 50 ng/mL 15 ng/mL15 ng/mL cocaine (crack)*cocaine (crack)* 150150 ng/mL ng/mL 100100 ng/mL ng/mL opiates (heroin) *opiates (heroin) * 300/2000 ng/mL 300/2000 ng/mL variablevariable phencyclidine (Pphencyclidine (P CP) * CP) * 25 ng/mL25 ng/mL 25 ng/mL25 ng/mL alcoholalcohol 20 mg/dL20 mg/dL 10 mg/dL10 mg/dL

* SAMHSA (formerly NIDA) drugs* SAMHSA (formerly NIDA) drugs

What is a “cutoff” level ?

cutoffs are not designed to frustrate CJ professionalscutoffs are not designed to frustrate CJ professionals a drug concentration, a drug concentration, administrativelyadministratively established established

for a drug test that allows the test to distinguishfor a drug test that allows the test to distinguishbetween negative and positive sample - between negative and positive sample - ““thresholdthreshold””

cutoffs provide important safeguards:cutoffs provide important safeguards: scientific purposes (detection accuracy)scientific purposes (detection accuracy) legal protections (evidentiary admissibility)legal protections (evidentiary admissibility)

measured in ng/mL = ppbmeasured in ng/mL = ppb

Good Cop –Bad Cop

How should I deal with aHow should I deal with aclient who claims to have usedclient who claims to have usedor ingested something thator ingested something thatcaused a caused a ““falsefalse”” positive? positive?

Client Accountability: the court should not assume the role of client the court should not assume the role of client ““excuseexcuse

evaluatorevaluator”” clients need to be held responsible for their own behaviorclients need to be held responsible for their own behavior

and maintaining a drug-free physiologyand maintaining a drug-free physiology if testing performed appropriately (with confirmation) if testing performed appropriately (with confirmation) –– HOW the drug got into their sample is mostly irrelevantHOW the drug got into their sample is mostly irrelevant a positive drug test results put the client in violationa positive drug test results put the client in violation as a practical and resource matter as a practical and resource matter –– the court cannot the court cannot

afford to argue over or dispute with every client who hasafford to argue over or dispute with every client who hasa positive test result or comes up with a new excusea positive test result or comes up with a new excuse

Therapeutic Use of Test Results Isn’t any amount of drug in a client’s sample a violation

worthy of sanction? punishment model vs. therapeutic model

therapeutic – enhance behaviors that lead to recovery learning to live with addiction is a gradual process elimination of client resistance to change is critical drug testing is a large component of the drug court

experience its perceived fairness is critical to outcomes

Therapeutic Use of Test Results drug testing has the potential to build resistance particularly if a client is falsely accused it may be better to let a client “get away with one” risk a false accusation & re-establishment of resistance resistance leads to learned helplessness & loss of

engagement clients should be held responsible consequences are critical to outcomes But . . . the prudent use of drug testing results can certainly

enhance the path to recovery

Doctor Relationship physician - patient relationshipphysician - patient relationship drug court practitionerdrug court practitioner’’s roles roleclient monitoring/supervisionclient monitoring/supervision

doctor as patient advocatedoctor as patient advocate doctor as co-dependentdoctor as co-dependent dynamic for changedynamic for change reach out to healthcare professionalsreach out to healthcare professionals

The Issue of UrineDrug Concentrations

Drug Tests are Qualitative

screening/monitoring drug tests arescreening/monitoring drug tests aredesigned to determine the presence ordesigned to determine the presence orabsence of drugs - NOT theirabsence of drugs - NOT theirconcentrationconcentration

drug tests are NOT quantitativedrug tests are NOT quantitative

Drug concentrations or levels associatedwith urine testing are, for the most part,USELESS !

cannabinoidscannabinoids 517 517 ng/mLng/mL opiates opiates negativenegative cocaine metabolite cocaine metabolite negativenegative amphetamines amphetamines negativenegative

The Twins

A B

200 mg Wonderbarb@ 8:00 AM

Collect urine 8:00 PM12 hours later

The Twins - urine drug test results

A BWonderbarb = 638 ng/mL Wonderbarb = 3172 ng/mL


A B

physiological make up

exact amount drug consumed

exact time of ingestion

exact time between drug exposure and urine collection

AND YET . . . . .


A BWonderbarb = 638 ng/mL Wonderbarb = 3172 ng/mL

Twin B’s urine drug level is 5 times higher

than Twin A

Are any of the following questionsbeing asked in your court?

How positive is he/she?How positive is he/she? Are his/her levels increasing or decreasing?Are his/her levels increasing or decreasing? Is that a high level?Is that a high level? Is he/she almost negative?Is he/she almost negative? Is this level from new drug use or continuedIs this level from new drug use or continued

elimination from prior usage?elimination from prior usage? What is his/her baseline THC level?What is his/her baseline THC level? Does that level indicate relapse?Does that level indicate relapse? Why is his/her level not going down? (or up?)Why is his/her level not going down? (or up?)

Urine drug concentrations are of little or nointerpretative value. The utilization ofurine drug test levels by drug courtsgenerally produces interpretations that areinappropriate, factually unsupportable andwithout a scientific foundation. Worst ofall for the court system, these urine druglevel interpretations have no forensic merit.

THE ISSUE

Scientific Rationale

Technical IssuesTechnical Issues testing not lineartesting not linear tests measure total drug concentrationstests measure total drug concentrations

PhysiologicalPhysiological variability of urine outputvariability of urine output differential elimination of drug componentsdifferential elimination of drug components

THIS ? does 219 mean new use?

639 is really high for THC, isn’t it?

432 indicates he going up, right?

115 is down from yesterday, probably continued elimination?

is 22 above the cutoff?

don’t we need to considerrelapse at 57?

307 – well she’s almost negative, correct?

I think 1200 is a new record, isn’t it?

515 is much higher thanlast week, right?

OR THIS ? Negative or Positive

The Drug DetectionWindow

Drug Detection Times - by Drug(this is general guidance!)

amphetamines: up to 4 daysamphetamines: up to 4 days cocaine: up to 72 hourscocaine: up to 72 hours opiates: up to 5 daysopiates: up to 5 days PCP: up to 6 daysPCP: up to 6 days barbiturates: up to a weekbarbiturates: up to a week benzodiazepines: up to a weekbenzodiazepines: up to a week . . then there. . then there’’s alcohol & cannabinoidss alcohol & cannabinoids

Cannabinoid Detection in Urine

Conventional wisdom has led to the commonassumption that cannabinoids will remaindetectable in urine for 30 days or longer followingthe use of marijuana.

RESULT: delay of therapeutic intervention hindered timely use of judicial sanctioning fostered denial of marijuana usage by clients

Cannabinoids - Recent/Relevant Research

30+ day detection window often exaggerates30+ day detection window often exaggeratesduration of detection windowduration of detection window

reasonable & pragmatic court guidancereasonable & pragmatic court guidance detection time: at 50 ng/mL cutoffdetection time: at 50 ng/mL cutoff

up to 3 days for single event/occasional use up to 3 days for single event/occasional use up to 10 days for heavy chronic use up to 10 days for heavy chronic use

detection time: at 20 ng/mL cutoffdetection time: at 20 ng/mL cutoff up to 7 days for single event/occasional use up to 7 days for single event/occasional use up to 21 days for heavy chronic use up to 21 days for heavy chronic use

Recent Cannabinoid Use versus Non-recentuse (double sanction issue):

How do drug courts discriminate between newHow do drug courts discriminate between newdrug exposure and continued elimination fromdrug exposure and continued elimination fromprevious (chronic) use ?previous (chronic) use ? an issue only in first phase of programan issue only in first phase of program only drug that poses concern is cannabinoidsonly drug that poses concern is cannabinoids ““two negative testtwo negative test”” rule rule –– two back-to-back two back-to-back

negative drug tests post clean outnegative drug tests post clean out

Opiates - Results Interpretation

screening tests - drug class assaysscreening tests - drug class assays positive results indicate presence of opiatespositive results indicate presence of opiates most assays not reactive toward syntheticmost assays not reactive toward synthetic

narcotic analgesics; meperidine (Demerol),narcotic analgesics; meperidine (Demerol),propoxyphene (Darvon), methadone,propoxyphene (Darvon), methadone,pentazocine (Talwin), fentanyl (Sublimaze)pentazocine (Talwin), fentanyl (Sublimaze)

difficult to separate legitimate use from abusedifficult to separate legitimate use from abuse detection time: up to 4 days followingdetection time: up to 4 days following

therapeutic use of codeine or morphinetherapeutic use of codeine or morphine

Alcohol - Results Interpretation

screening tests specific for ethanol, ethyl alcoholscreening tests specific for ethanol, ethyl alcohol positive results indicate presence alcoholpositive results indicate presence alcohol alcohol is rapidly cleared from the bodyalcohol is rapidly cleared from the body negative results donnegative results don’’t necessarily documentt necessarily document

abstinenceabstinence detection time = hoursdetection time = hours example - person intoxicated at 11:00 PM, collectexample - person intoxicated at 11:00 PM, collect

second urine sample of next day (11:00 AM),second urine sample of next day (11:00 AM),most likely test negative for alcoholmost likely test negative for alcohol

EtG & EtS – Strategy forMonitoring Alcohol

Abstinence

Alcohol is the most commonlyabused substance by drug courtclients and the most difficultsubstance to detect in abstinencemonitoring.

Advantages of Ethyl Glucuronide& Ethyl Sulfate unique biological marker of alcohol use (no falseunique biological marker of alcohol use (no false

positives)positives) direct marker indicating recent usedirect marker indicating recent use longer detection window than alcohollonger detection window than alcohol stable in stored specimens (non-volatile)stable in stored specimens (non-volatile) is not formed by fermentationis not formed by fermentation is not detected in the urine of abstinent subjectsis not detected in the urine of abstinent subjects

Extending the detection window

Disadvantages of EtG/EtS testing available at relatively few laboratoriestesting available at relatively few laboratories EtG EtG testing more costly than abused drugstesting more costly than abused drugs

expensive expensive LC/MS/MS technologyLC/MS/MS technology introduction of new testing approachesintroduction of new testing approaches

most significant concern most significant concern –– casual, inadvertent, casual, inadvertent,environmental alcohol exposure causing positiveenvironmental alcohol exposure causing positiveresultsresults

Sources of “Incidental” Alcohol Exposure OTC medications (Nyquil, Vicks Formula 44)OTC medications (Nyquil, Vicks Formula 44) mouthwashes (Listermint & Cepacol)mouthwashes (Listermint & Cepacol) herbal/homeopathic medications (i.e., tinctureherbal/homeopathic medications (i.e., tincture

of gingko biloba - memory)of gingko biloba - memory) foods containing alcohol (such as vanillafoods containing alcohol (such as vanilla

extract, baked Alaska, cherries jubilee, etc.)extract, baked Alaska, cherries jubilee, etc.) ““non-alcoholicnon-alcoholic”” beers (O beers (O’’DoulDoul’’s, Sharps)s, Sharps) colognes & body sprayscolognes & body sprays insecticides (DEET)insecticides (DEET) alcohol-based hand sanitizers (Purell, GermX)alcohol-based hand sanitizers (Purell, GermX)

Is a positive urine EtG/EtS testresult a definitive indicator ofrelapse or prohibited drinking?

Is a positive urine EtG/EtS testresult sufficient justification forclient sanctioning?

Consensus Cutoffs:

EtG EtG minimum of 500 minimum of 500 ng/mLng/mLEtS EtS minimum of 100 minimum of 100 ng/mLng/mL

Positive EtG Result (500 ng/mL):

a result reported as EtG positive in excess of the 500a result reported as EtG positive in excess of the 500ng/mL cutoff is consistent with the recent ingestionng/mL cutoff is consistent with the recent ingestionof alcohol-containing products (1-2 days prior toof alcohol-containing products (1-2 days prior tospecimen collection) by a monitored clientspecimen collection) by a monitored client

studies examining studies examining ““incidentalincidental”” exposure widely exposure widelyconclude that results in excess of the 500 ng/mLconclude that results in excess of the 500 ng/mLcutoff are cutoff are notnot associated with inadvertent or associated with inadvertent orenvironment ethanol sourcesenvironment ethanol sources

Negative EtG Result (500 ng/mL):

a result reported as EtG negative isa result reported as EtG negative isindicative of a client who has not ingestedindicative of a client who has not ingestedbeverage alcohol within 1-2 days prior tobeverage alcohol within 1-2 days prior tospecimen collectionspecimen collection

a negative result is a negative result is notnot proof of abstinence proof of abstinence advertised advertised ““80-hour80-hour”” window of detection window of detection

not not ““real-worldreal-world”” applicable applicable

Best Practices for EtG/EtS Testing:

provide those being monitored withprovide those being monitored withan alcohol use advisory document -an alcohol use advisory document -EtG/EtS EtG/EtS specific contract - specific contract - mandatorymandatory

useuse appropriate cutoffs:appropriate cutoffs:EtG EtG - 500 - 500 ng/mLng/mLEtS EtS - 100 - 100 ng/mLng/mL

test for test for EtS EtS (ethyl sulfate) - biomarker(ethyl sulfate) - biomarkerof choiceof choice

The Effective Use ofUrine CreatinineMeasurements in

Abstinence Monitoring

The most common form ofspecimen tampering is sample

dilution.

Creatinine testing is a specimenvalidity issue!

EVERY urine sample collectedfor drug detection should be

tested for creatinine!

You can’t intervene to changebehavior if you don’t know a

client has relapsed!

What Is Creatinine &Why Measure It?

What is creatinine ?

creatinine is produced as a result of muscle metabolismcreatinine is produced as a result of muscle metabolism creatinine is produced by the body at a relativelycreatinine is produced by the body at a relatively

constant rate throughout the dayconstant rate throughout the day creatinine is a compound that is unique to biologicalcreatinine is a compound that is unique to biological

material (i.e. urine, other body fluids)material (i.e. urine, other body fluids) creatinine measurements can:creatinine measurements can:

determine the determine the ““strengthstrength”” or concentration of a urine or concentration of a urinesamplesample

ensure the sample being tested ensure the sample being tested ISIS urine urine

Two Types of Urine SpecimenDilution

pre collection dilutionpre collection dilution consumption of large quantitiesconsumption of large quantities

of fluids of fluids priorprior to collection to collection post collection dilutionpost collection dilution adding fluid to specimen adding fluid to specimen postpost

collectioncollection

Pre-Collection Dilution high-volume ingestion of fluids (water loading,high-volume ingestion of fluids (water loading,

flushing, hydrating, etc.)flushing, hydrating, etc.) may be in conjunction with products designed tomay be in conjunction with products designed to

““enhanceenhance”” drug elimination or removal of drugs drug elimination or removal of drugs(Gold Seal, Clean (Gold Seal, Clean ‘‘n Clear, Test-Free, Naturallyn Clear, Test-Free, NaturallyKlean, etc.)Klean, etc.)

no evidence these products have any additionalno evidence these products have any additionaleffect on drug eliminationeffect on drug elimination

Client has a bladder full of urine with a drug concentration of greater than the cutoff level of the test - thus producing a positive result.

Urine in the bladder is diluted bythe consumption of large amounts ofnon-drug containing fluid; which results in a drug concentration that is less than the cutoff level of the test - thus producing a negative result.

DILUTION GOAL

Water contains no drugs! easiest, cheapest, simplesteasiest, cheapest, simplest urines with a creatinines of less than 20 mg/dL areurines with a creatinines of less than 20 mg/dL are

considered considered ““dilutedilute”” and rarely reflect an accurate and rarely reflect an accuratepicture of recent drug usepicture of recent drug use

dilute samples are more like water than like urinedilute samples are more like water than like urine incidence of low creatinines in a populationincidence of low creatinines in a population

undergoing random drug testing is significantly (upundergoing random drug testing is significantly (upto 10 times) greater than a non-drug tested populationto 10 times) greater than a non-drug tested population

The “Normal” Urine Creatinine normal urine creatinine: 2005 study normal urine creatinine: 2005 study ““UrinaryUrinary

Creatinine Concentrations in the U.S. PopulationCreatinine Concentrations in the U.S. Population””determine the mean (based upon 22,245determine the mean (based upon 22,245participants) was 130 participants) was 130 mg/dLmg/dL

study was not associated with drug testingstudy was not associated with drug testing subjects came from a variety of ethnic groupssubjects came from a variety of ethnic groups samples were collected AM, mid-day, and PMsamples were collected AM, mid-day, and PM less than 1% below 20 less than 1% below 20 mg/dLmg/dL less than 1%less than 1% greater than 400 greater than 400 mg/dLmg/dL

How are creatinine measurements used ?

urine samples with a urine samples with a creatinine creatinine of less than 20of less than 20mg/dL should be considered mg/dL should be considered ““dilutedilute””

a dilute sample does not accurately reflect the recenta dilute sample does not accurately reflect the recentdrug use history of the person being testeddrug use history of the person being tested

normal human creatinine levels will vary during thenormal human creatinine levels will vary during theday based upon fluid intake - healthy individualsday based upon fluid intake - healthy individualswill rarely produce urine samples with creatinines ofwill rarely produce urine samples with creatinines ofless than 20 less than 20 mg/dLmg/dL

meets a meets a ““preponderancepreponderance”” standard standard

Creatinine Facts some diseases that produce low urinary creatininessome diseases that produce low urinary creatinines

muscle wasting disease - RAREmuscle wasting disease - RARE some kidney aliments - RAREsome kidney aliments - RARE

low creatinines ARE NOT routinely associated with:low creatinines ARE NOT routinely associated with: pregnancypregnancy diabetesdiabetes obesityobesity exerciseexercise high-blood pressurehigh-blood pressure being vegetarianbeing vegetarian

More Creatinine Issues

rapid ingestion (90 minutes) of 2-4 quarts ofrapid ingestion (90 minutes) of 2-4 quarts offluid will almost always produce lowfluid will almost always produce lowcreatinines & negative urine drug tests withincreatinines & negative urine drug tests withinone hourone hour

recovery time of urine creatinine and drugrecovery time of urine creatinine and drugconcentrations can take up to 10 hoursconcentrations can take up to 10 hours

“Dilute” Result Interpretation: negative or none detected results should never be

interpreted as indicating no drug use (abstinence),because if, in fact, drugs were present, they probablycould not be detected by the test

positive drug test results from a dilute samplehowever, are considered valid (donor was not ableto dilute the sample sufficiently to deceive the test)

Two final thoughts about diluteurine samples . . . . .

a creatinine of less than 20 mg/dL (associatedwith a drug test) is nearly always an attempt bythe donor to avoid drug use detection -REGARDLESS of how much liquid wasconsumed in order to achieve this result

place a dilute sample prohibition in your clientcontract and sanction for repeat dilute samples

SUMMARY TEST FOR CREATININE!TEST FOR CREATININE! incorporate creatinine guidance in your SOPsincorporate creatinine guidance in your SOPs

and client contractand client contract institute a dilute sample prohibitioninstitute a dilute sample prohibition understand very low urine creatinine levels areunderstand very low urine creatinine levels are

NOT normal occurrencesNOT normal occurrences dilute dilute samples aresamples are nearly always nearly always an attempt by an attempt by

the donor to avoid drug use detectionthe donor to avoid drug use detection sanction for repeat dilute testssanction for repeat dilute tests follow urine follow urine creatinine creatinine patternspatterns

Specimen Tampering

Basics of Specimen Tampering -The Three Approaches

dilutiondilution adulterationadulteration substitutionsubstitution

Urine Specimen Adulteration

addition of foreign substances designed to addition of foreign substances designed to ““maskmask””drug presencedrug presence

post-collection tamperingpost-collection tampering low-tech adulterants that cause low-tech adulterants that cause ““pH shiftpH shift”” (lime, (lime,

vinegar, bleach, ammonia, lemon, drano)vinegar, bleach, ammonia, lemon, drano) low-tech adulterants that disrupt testing chemistrylow-tech adulterants that disrupt testing chemistry

(salt, methanol, detergent)(salt, methanol, detergent) ““high-techhigh-tech”” adulterants adulterants

Urinaid, Byrd Laboratories

gluteraldehydegluteraldehyde sterilization chemicalsterilization chemical deactivates most screening tests -deactivates most screening tests -

producing false negative resultsproducing false negative results can be identified by laboratoriescan be identified by laboratories

employing specimen validity testsemploying specimen validity tests effects can not be reversedeffects can not be reversed

Klear & Whizzies

potassium nitrite, sodium nitritepotassium nitrite, sodium nitrite analytical chemistryanalytical chemistry compromises the confirmation (GC/MS) of somecompromises the confirmation (GC/MS) of some

drugs, notably carboxy-THCdrugs, notably carboxy-THC oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories employingcan be identified by laboratories employing

specimen validity tests (SVT)specimen validity tests (SVT) effects can be reversedeffects can be reversed

Urine Luck pyridinium chlorochromate/dichromatepyridinium chlorochromate/dichromate oxidizing agent in organic synthesisoxidizing agent in organic synthesis compromises the confirmation (GC/MS) carboxy-compromises the confirmation (GC/MS) carboxy-

THC and opiatesTHC and opiates can also effect screening testscan also effect screening tests oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories employingcan be identified by laboratories employing

specimen validity tests (SVT)specimen validity tests (SVT) effects can not be reversedeffects can not be reversed

Urine Specimen Substitution replacing donor urine sample with another drug-replacing donor urine sample with another drug-

free specimenfree specimen biological substitution - someone elsebiological substitution - someone else’’s s ““cleanclean””

urineurine non-biological substitution - replacing urine withnon-biological substitution - replacing urine with

urine urine ““look-a-likelook-a-like”” sample (diet Mountain Dew, sample (diet Mountain Dew,water with food coloring)water with food coloring)

non-biologicals can be detected with creatininenon-biologicals can be detected with creatininetestingtesting

Specimen Validity Tests (SVT)Specimen Validity Tests (SVT) creatinine, UUNcreatinine, UUN specific gravityspecific gravity pHpH nitritesnitrites gluteraldehydegluteraldehyde pyridinepyridine chromiumchromium

Request SVT from testing laboratory or usedip-stick SVT products for on-site testing

Controlling Specimen Tampering develop challenging collection strategy - ie. makedevelop challenging collection strategy - ie. make

the testing unannounced and RANDOM!the testing unannounced and RANDOM! directly observed collections is the most effectivedirectly observed collections is the most effective

approach to preventing adulteration andapproach to preventing adulteration andsubstitutionsubstitution

inspect sample - train collection staffinspect sample - train collection staff keep abreast of tampering techniqueskeep abreast of tampering techniques take temperature measurements (90take temperature measurements (90˚̊ - 100 - 100˚̊ F) F) use laboratory employs specimen validity testsuse laboratory employs specimen validity tests

& use with on-site devices& use with on-site devices

Drug DetectionMythology - Kill the

Myths!

Myth #1

Passive inhalation of marijuana smokePassive inhalation of marijuana smokecan cause a can cause a ““positivepositive”” drug test result. drug test result.

NO - not if standard cutoffs are usedNO - not if standard cutoffs are used THC (cannabinoid) assay uses variableTHC (cannabinoid) assay uses variable

cutoffs (20, 50, 100 ng/mL)cutoffs (20, 50, 100 ng/mL) passive inhalation research indicatespassive inhalation research indicates

less than 10 ng/mL in volunteer urinesless than 10 ng/mL in volunteer urines no passive inhalation for no passive inhalation for ““crackcrack””

Myth #2

Consuming poppy seeds causes Consuming poppy seeds causes ““false-false-positivepositive”” drug tests for heroin drug tests for heroin

NO! - but?NO! - but? poppy seeds contain trace amounts ofpoppy seeds contain trace amounts of

both codeine and morphineboth codeine and morphine can causes can causes ““positivepositive”” drug test results drug test results

for for ““opiateopiate”” class class confirm positive opiatesconfirm positive opiates

Myth #3

Drinking vinegar or cranberry juice willDrinking vinegar or cranberry juice willproduce a produce a ““negativenegative”” urine drug test. urine drug test.

NO!NO! theory is to cause a theory is to cause a ““pH shiftpH shift””, making, making

the urine sample acidic - altering thethe urine sample acidic - altering thechemistry of immunoassay testschemistry of immunoassay tests

in reality - the body detoxifies the acid &in reality - the body detoxifies the acid &dilutes to physiological pHdilutes to physiological pH

Myth #4

consuming vitamins purges marijuanaconsuming vitamins purges marijuanafrom the system - quicker clean urinefrom the system - quicker clean urine(niacin - B3)(niacin - B3)

NO!NO! theory is vitamins increase metabolismtheory is vitamins increase metabolism in reality - no systemic changesin reality - no systemic changes however, vitamin however, vitamin DODO produce urine produce urine

coloration - check creatininecoloration - check creatinine

email address:[email protected]@health.missouri.edu

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PREFACEThe duration of the urinary cannabinoid detection window is not settledscience. The number of days, following the cessation of marijuana smoking, necessary for cannabinoids to become non-detectable usingtraditional drug testing methods is the subject of debate among forensictoxicologists and a matter of on-going scientific research. This articlemakes no pretense to limit this important discussion, but rather, seeksto enhance it. It is hoped that drug court practitioners will find that thisinformation clarifies some of the complex issues associated with theelimination of marijuana from the human body.

Conventional wisdom has led to the common assumption that cannabinoidswill remain detectable in urine for 30 days or longer following the use of marijuana. These prolonged cannabinoid elimination projections havelikely resulted in the delay of therapeutic intervention, thwarted the timely use of judicial sanctioning, and fostered the denial of marijuanausage by drug court participants.

This review challenges some of the research upon which the 30-plus dayelimination assumption is based. Careful scrutiny of these studies shouldnot be interpreted as an effort to discredit the findings or the authors of this research. However, as our knowledge evolves, the relevancy ofpreviously published scientific data should be evaluated anew. One factis clear—more research is needed in the area cannabinoid elimination.

THE MARIJUANA DETECTION WINDOW: DETERMINING

THE LENGTH OF TIME CANNABINOIDS WILL REMAIN

DETECTABLE IN URINE FOLLOWING SMOKINGA CRITICAL REVIEW OF RELEVANT RESEARCH AND CANNABINOIDDETECTION GUIDANCE FOR DRUG COURTS

By Paul L. Cary, M.S.

DRUG COURTPRACTITIONERF A C T S H E E T

Merely attempting to formulate cannabinoiddetection guidance invites controversy. Somewill argue that the proposed detection windowdefined in this article is too short. Others willsuggest the opposite. Still others will insistthat the scientific evidence is insufficient toallow the establishment of such guidance. To some degree, each position has merit. Nodetection window guidance, regardless of theextent of scientific support, will encompassevery set of circumstances or all client situations.If nothing else, the research demonstrates thatthere is significant variability between individualsin the time required to eliminate drugs.

These facts, however, should not precludethe development of reasonable and pragmaticguidance, supported by scientific research, foruse in the majority of drug court adjudications.It is widely accepted that in order to instillsuccessful behavioral changes in a substanceabusing population, that consequences needto be applied soon after the identification ofrenewed or continued drug use. In a drug courtcontext, the application of judicial sanctionsand the initiation of therapeutic interventionshave been needlessly delayed due to a lack of coherent guidance regarding the length oftime cannabinoids will likely remain detectablein urine following the cessation of marijuanasmoking. The purpose of this article is to provide that much needed guidance.

INTRODUCTION

In a recent forensic publication, Dr. MarilynHuestis wrote: “Monitoring acute cannabisusage with a commercial cannabinoidimmunoassay with a 50-ng/mL cutoff concen-tration provides only a narrow window ofdetection of 1–2 days,” (2002). In a 1985 article by Ellis et. al., researchers concluded;“that under very strictly supervised absti-nence, chronic users can have positive resultsfor cannabinoids in urine at 20 ng/mL orabove on the EMIT-d.a.u. assay 1 for as manyas 46 consecutive days from admission, andcan take as many as 77 days to drop below

the cutoff calibrator for ten consecutive days.”Based upon these seemingly divergent findings,it is not difficult to comprehend why judges,attorneys and other drug court professionalsare in a quandary regarding the length of timemarijuana can remain detectable in urine following use. The dilemma—if the scientificresearch seems not to be able to achieve consensus on the urinary cannabinoid detectionwindow, how are those responsible for courtmandated drug supervision programs supposeto understand and resolve this issue?

Like many other scientific and technical topicsthat have been thrust into the judicial environ-ment, the detection window of marijuana is both complex and controversial, yet theunderstanding of the pharmacology of thispopular substance is crucial to the adjudicationof cases in which marijuana usage is involved.While the difficulties associated with estab-lishing the length of time a drug will continueto test positive in urine after use are not uniqueto marijuana, the problem is exacerbated bythe extended elimination characteristics ofcannabinoids relative to other drugs of abuse,most notably after chronic use.

The questions posed by drug court professionalsrelated to cannabinoid detection in urine include:

• How many days is it likely to take for a chronicmarijuana user to reach a negative urine drugtest result?

• How long can cannabinoids be excreted anddetected in urine after a single exposure tomarijuana?

• How many days of positive urine drug tests for cannabinoids constitutes continued marijuana usage?

• How often should a client’s urine be tested to monitor for continued abstinence frommarijuana?

• How many days should the court wait beforeretesting a client after a positive urine drugtest for cannabinoids has been obtained?

• How should the court interpret a positiveurine drug test for cannabinoids after a clienthas completed an initial 30-day detoxificationperiod designed to “clean out” their system?

NATIONAL DRUG COURT INSTITUTE

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To one degree or another, answering thesequestions depends upon the ability of the courtto estimate the length of time cannabinoidswill likely remain detectable in urine followingthe use of marijuana by a drug court client.Thus, the cannabinoid detection windowbecomes a determinative factor in the appro-priate interpretation of urine drug testingresults for marijuana. The lack of adequateguidance has hindered the development ofthese standards for use in drug court.

It is important to note that while courts may be seeking absolute answers (an exactcannabinoid detection window), the scienceof drug detection in urine can only providereasonable best estimates. The law is notalways black and white; neither is science.Therefore, precise “yes/no” answers or exact detection windows are generally notattainable. Sensible guidance for the interpre-tation of urine cannabinoid results by drugcourts, however, is achievable.

FRAMING THE QUESTION

Simply put, the detection window is the lengthof time in days following the last substanceusage that sequentially collected urine sampleswill continue to produce positive drug testresults—in other words, the number of daysuntil last positive sample. This time period isnot the same as the length of time a drug willremain in someone’s system—that concept is, in reality, indeterminable (given that thereis no analytical method capable of detectingthe presence of a single molecule of drug in adonor’s body). The question being addressedherein is not how long minute traces of mari-juana will remain in a client’s tissues or fluidsafter smoking, but rather how long thoseresidual cannabinoid metabolites will continueto be excreted in urine in sufficient quantitiesto produce a positive drug test (by standardscreening and confirmation testing).

For those compounds with uncomplicatedmetabolic pathways or for those drugs thatare not significantly retained in body storagecompartments, detection times have beenestablished and generally accepted. Theseinclude urinary detection windows for drugssuch as cocaine (1-3 days), amphetaminesand opiates (1-4 days), and PCP (1-6 days)(Baselt, 2004). For marijuana, the urine elimi-nation profile used to establish the detectionwindow is more complex. It is well docu-mented and understood that cannabinoids arelipid-soluble compounds that preferentiallybind to fat-containing structures within thehuman body (Baselt, 2004). This and otherchemical characteristics can prolong the elimi-nation half-life of cannabinoids and extend thedetection window beyond that of other abusedsubstances. Chronic marijuana use, whichexpands body stores of drug metabolitesfaster than they can be eliminated, furtherincreases cannabinoid detection time in urine.

VARIABLES

Estimating the detection time of a drug in urineis a complex task because of the many factorsthat influence a compound’s elimination fromthe body. Additionally, technical aspects of thetesting methods themselves also affect howlong a drug will continue to be detected in urine.The pharmacological variables affecting theduration of detection include drug dose, routeof administration, duration of use (acute orchronic), and rate of metabolism. Detectiontime is also dependent upon analytical factorsincluding the sensitivity of the test (cutoffconcentration) and the method’s specificity(the actual drug and/or metabolite that isbeing detected).

DRUG COURT PRACTITIONER F A C T S H E E T

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Study subjects with exceptionally longcannabinoid detection times (30-plusdays) were just that-exceptional.

Generally speaking, the following factorsaffect the marijuana detection windowaccordingly:

• Drug DoseThe higher the dose; the longer the detectionwindow. The percentage of psychologicallyactive delta-9 THC in marijuana plant materialvaries considerably, making dosage difficult to estimate.

• Route of EntryInhalation (smoking) is the only route ofadministration to be evaluated in this review.

• Duration/Frequency of UseThe longer the duration and the greater thefrequency of cannabinoid usage (chronic); the greater the body storage of fat-solublemetabolites; the longer the cannabinoiddetection window. Drug surveillance pro-grams may be able to define use patternsbased on client self-reporting, arrest reports,documentation of previous treatment, orother court records.

• Metabolism RateThe higher the metabolic functions of the client;the faster cannabinoids are broken down; the shorter the detection window. Monitoringprograms cannot determine this parameter.

• Test SensitivityThe lower the cutoff concentration; the moresensitivity the testing method toward cannabi-noids; the longer the detection window. Courtstaff can select between various cannabinoidtesting cutoffs.

• Test SpecificityThe less specific the testing method; thegreater number of cannabinoid metabolitesdetected; the longer the detection window.This is difficult for monitoring programs toassess without technical assistance.

Of these variables, drug courts are effectivelylimited to controlling only the sensitivity of the drug test itself (i.e., cutoff concentration).Initial screening test cutoffs for cannabinoidsin urine generally include thresholds at 20, 50,and 100 ng/mL. The choice of testing cutoffhas a profound effect on the cannabinoiddetection window. The only other factor thatcan assist the court in the interpretation ofcannabinoid testing results and the estimationof a client’s detection window is attemptingto define the duration and extent of a client’smarijuana use over time (acute or chronic).

The differentiation between acute (a singleuse event or occasional use) versus chronic(persistent, long-term, continued usage) isimportant to establishing reliable detectionbenchmarks. As a result, drug court practitionersshould attempt to gather as much informationas they can about client drug use behaviorand patterns.

Finally, the detection window by its verynature is subject to the timing of events outside the purview of the court. The last useof marijuana by a client prior to a positive testis often unknown to drug court staff. Thus,the real interval between drug usage and first detection can rarely be ascertained. For example, if a client smoked marijuana onMonday and a urine sample collected onFriday produced a positive result, the windowof detection is 4 days shorter than if that sameclient had smoked on Thursday and produced apositive cannabinoid test on Friday. Therefore,the actual detection window for marijuana willalmost always be longer than the analyticallyderived detection window as determined viapositive tests.

RESEARCH REVIEW

Research associated with the detection windowof cannabinoids in urine spans several decades.While these studies have produced a signifi-cant amount of valuable information aboutmarijuana elimination, older studies (primarilythose performed in the 1980’s) have alsoyielded some unintended consequences aspertains to the detection window. The tech-nologies of drug testing and the methodologiesused in drug detection have advanced rapidlyin recent years. Consequently, cannabinoiddetection studies performed twenty years ago (employing older immunoassays methods)utilized drug testing methods that are eitherno longer in widespread use or assays thathave been extensively reformulated.

As cannabinoid screening tests evolved, theseimproved assays became more selective inthe manner in which they detected marijuanametabolites (breakdown products). As detection


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Table 1. Review of Cannabinoid Studies Reporting Long Detection Times

MaximumDetection TimesDetermined forCannabinoids

Factors Potentially Affecting the Relevance of Study Findings to Cannabinoid Detection Window Interpretation

Year Author

36 days Retrospective case study of a single patient; report on 6 similar cases included; no testing data provided in publication; no cannabinoid cutoff given

1982 Dackis et al.

37 days 27 subjects studied, no testing data provided in publication;cannabinoid cutoff not provided; “calculated” cannabinoidcutoff less than 10 ng/mL; 37 day detection derived from95% confidence interval for calculated elimination half-life;actual length of positivity averaged 9.7 days (5-20 days);authors acknowledge subjects may have been able toobtain marijuana during study; possibility supported bystaff monitoring subjects

1983 Cridland et al.

40 days 10 subjects studied; self-reported as chronic users; subjectshoused on unrestricted drug treatment ward; marijuanause during study suspected by authors and confirmed byseveral subjects

1984 Swatek

67 days 86 subjects studied; self-reported as chronic users; subjectstreated on “closely supervised” ward; single case of anindividual’s time to last positive urine (at or above 20 ng/mL) of 67 days (77 days to drop below the cutoff calibra-tor for ten consecutive days); spikes in urine cannabinoidlevels during the study are not explained by the authors

1985 Ellis et al.

25 days 11 subjects studied for cannabinoid elimination patterns(70 participants in entire study); only one subjectremained positive for 25 days; mean elimination for self-reported “heavy” users was 13 days; immunoassayused in study not commercially available since 1995.

1985 Schwartz et al.

25 days 13 subjects studied; self-reported as chronic users; subjectabstinence not supervised during study; subjects allowedto smoke marijuana before and on the day of test drugadministration; only one subject tested positive beyond 14 days

1989 Johansson& Halldin

25 days Subject detection times determined using methods with a 5 ng/mL cannabinoid cutoff concentration

1994 Iten

32 days 19 subjects studied - half withdrew from study prior tocompletion; subjects were prisoners housed in generalpopulation with no additional surveillance; participantsnot asked to report new drug use during study; marijuanause during study suspected by authors

1999 Smith-Kielland et al.

specificity increased, the length of timecannabinoids were being detected in urinedecreased. The greater the cannabinoid testingspecificity, the shorter the detection window.Studies have demonstrated that detectiontimes of cannabinoid metabolites in urinemonitored by immunoassay have decreasedover the past two decades (Huestis, 2002;Huestis, Mitchell, & Cone, 1994). Therefore,the results of cannabinoid elimination investigations performed in the 1980’s mayno longer be applicable to estimating thedetection window for marijuana in urine usingtoday’s testing methodologies. Not to men-tion that twenty years ago, the routine use ofon-site drug testing devices was nonexistent.

Studies of chronic marijuana users reportingprolonged cannabinoid excretion profiles haveprovided the basis for the common assump-tion that marijuana can be detected in urinefor weeks or even months following use. In general, cannabinoid elimination studies thathave manifested exceptionally long detectiontimes suffer from a variety of research designshortcomings that raise concerns about theirusefulness in establishing a reliable cannabi-noid detection window for use in the moderndrug court movement. Table I examines some of the potentially limiting factors fromstudies that produced prolonged cannabinoiddetection times.

The research studies presented in Table 1contain numerous design details that confoundthe use of the data presented in establishinga reasonable and pragmatic cannabinoiddetection window for drug court proceedings.The most serious of these obfuscating factorsis the inability to assure marijuana abstinenceof the subjects during the studies. The adverse

effect of this flaw on determining the truecannabinoid elimination time after marijuanacessation is significant. Drug use during anelimination study would extend the durationcannabinoids would be detected in the urineof subjects and would produce inaccuratelylong detection windows. In several cases, theauthors themselves in their own review ofresults raise this concern. Other study designissues that may limit their usefulness includethe use of detection methods with cannabinoidcutoff concentrations far below those tradi-tionally utilized in criminal justice programs, theuse of testing methods no longer commerciallyavailable and the use of immunoassay drugtests with reduced cannabinoid specificity (ascompared with current immunoassay testingmethods). It is not the intention of this articleto discredit these studies, but rather to illus-trate the degree to which their prolongedcannabinoid detection findings have influencedthe understanding of the length of timecannabinoids can be detected in urine.

This critical evaluation (Table 1) is not present-ed to imply that these peer-reviewed articlesare unscientific or contain no information ofprobative value. It is insufficient, however, tomerely read the abstract of a scientific paperor the findings of a research study and drawthe conclusion that a drug court client canremain positive for 30 days or longer, basedupon the longest cannabinoid detection timereported therein. The data from these studiesare often misused to make such claims.

Despite the potential limitations affecting theinterpretation of the data produced by thestudies in Table 1, the research does presentsome general cannabinoid elimination trendsworth further examination. A closer evaluationof the study by Smith-Kielland, Skuterud, &Morland indicates that even with the factorsidentified as limiting its relevance, the aver-age time to the first negative urine sample ata cannabinoid cutoff of 20 ng/mL was just 3.8days for infrequent users and only 11.3 daysfor frequent users (1999). In the Swatek study,eight out of ten chronic subjects tested belowthe 50 ng/mL cutoff after an average of only


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The detection window for cannabinoidsin urine must be seen in the propercontext-as a reasonable estimate.

13 days (range 5-19 days) (1984). Johanssonand Halldin identified only one study subjectthat tested positive for longer than 14 dayswith all thirteen subjects having an averagelast day with detectable levels (using a 20ng/mL cutoff) of 9.8 days (1989). In otherwords, despite the potential factors restrictinginterpretation, those study subjects withexceptionally long cannabinoid detection times(30-plus days) were just that—exceptional. In several of the studies presented in Table 1,only a single subject was the source of themaximum cannabinoid detection time.Unfortunately, these rare occurrences havehad a disproportional influence on the overallcannabinoid detection window discussion in a manner that has led to the general assump-tion that 30-plus day detection times are routine in drug court clients—regardless ofuse patterns (chronic vs. acute). Moreover,this prolonged elimination assumption and its widespread use as exculpatory evidencehas most likely fostered client denial and hindered legitimate sanctioning efforts.

By contrast, the research associated with acutemarijuana usage and resulting cannabinoiddetection window is considerably morestraightforward and less contentious. In a 1995study using six healthy males (under continu-ous medical supervision), Huestis, Mitchell, & Cone determined that the mean detectiontimes following a low dose marijuana cigaretteranged from 1 to 5 days and after a high dosecigarette from 3 to 6 days at a 20 ng/mLimmunoassay cutoff concentration (average2.1 days and 3.8 days, respectively) (1995).They also concluded that immunoassays atthe 50 ng/mL cannabinoid cutoff provide onlya narrow window of detection of 1-2 days following single-event use. In 1996, Huestiset. al. published research focusing on carboxy-THC, the cannabinoid metabolite most oftenidentified by gas chromatography/mass spectrometry (GC/MS) confirmation methods.Using the 15 ng/mL GC/MS cutoff, the detec-tion time for the last positive urine sample(for six subjects following high dose smoking)was 122 hours—just over five days. In 2001,

Niedbala et. al. demonstrated similar resultswith 18 healthy male subjects following thesmoking of cigarettes containing an averageTHC content of 20-25 mg. Analyzing urinesamples at a 50 ng/mL immunoassay cutoffyielded an average cannabinoid detection time of 42 hours. These acute marijuana elimination studies conclude that after singleusage events cannabinoids are detected inurine for no more than a few days.

While studies of the cannabinoid detectionwindow in chronic substance users havebeen more difficult to accomplish, researchprotocols have been developed to overcomeconcerns about marijuana usage during thestudy. Using a well-crafted study design,Kouri, Pope, & Lukas in 1999 determined thecannabinoid elimination profiles of 17 chronicusers. Subjects were selected after reportinga history of at least 5000 separate “episodes”of marijuana use in their lifetime (the equiva-lent of smoking once per day for 13.7 years)plus continuing daily usage. Abstinence duringthe 28-day study was ensured by withdrawingthose subjects whose normalized urinecannabinoid levels (cannabinoid/creatinineratio) indicated evidence of new marijuana use.Kouri, et al, found that five of the 17 subjectsreached non-detectable levels (less than 20ng/mL) within the first week of abstinence,four during the second week, two during thethird week and the remaining six subjects still had detectable cannabinoid urinary levelsat the end of the 28-day abstinence period.Unfortunately, analytical results related to thecannabinoid testing in the article were scantas the primary objective of the study was toassess changes in aggressive behavior duringwithdrawal from long-term marijuana use.Even though this represents one of the beststudies of chronic marijuana users, interpreta-tion of this data for cannabinoid eliminationpurposes is limited because the actual drugtesting data is not available. Nonetheless,Kouri, et al, shows that after at least 5000marijuana smoking episodes, 30-day eliminationtimes are possible.


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A 2001 research project by Reiter et al. alsoseemed to avoid many of the design issuescited as concerns in Table 1. Reiter’s casestudy involved 52 volunteer chronic substanceabusers drug tested on a detoxification ward.Daily urine and blood tests excluded illicitdrug consumption during the study. Using a20 ng/mL immunoassay cutoff, the maximumelimination time (last time urine tested abovethe cutoff) for cannabinoids in urine was433.5 hours (or just over 18 days); with amean elimination time of 117.5 hours (4.9days). When controlling for covert marijuanause by subjects during the study, chronicusers in this study did not exhibit detectableurine cannabinoid levels for even three weeks.

In aggregate, using the data from the fivestudies cited in this review that researchersdescribed as chronic marijuana users (evenincluding data from Table 1), the averagedetection window for cannabinoids in urine atthe lowest cutoff concentration of 20 ng/mLwas just 14 days (Ellis, et al, 2002; Iten, 1994;Niedbala, 2001; Schwartz, Hayden, & Riddile,1985; Swatek, 1984).

PERPETUATING THE 30-PLUSDAY ASSUMPTION

The assumption that cannabinoids can be rou-tinely detected in urine following the smokingof marijuana for 30 days or longer appearswidespread and longstanding. Exacerbatingthis problem is the nearly constant proliferationof published material that continually reinforcesthe 30-plus day cannabinoid detection windowinto the criminal justice psyche. Examples ofthe enormous body of information/literaturethat propagates the 30-plus day cannabinoiddetection times abound:

• Substance abuse treatment literature pro-claiming that “some parts of the body stillretain THC even after a couple of months.” 2

• Drug abuse information targeted toward teensthat often presents unrealistic cannabinoiddetection times such as; “Traces of THC canbe detected by standard urine and blood testsfor about 2 days up to 11 weeks.” 3

• Criminal justice publications that list thecannabinoid detection limits of a “ChronicHeavy Smoker” as “21-27 days.” 4

• Drug testing manufacturers’ pamphlets that state the time to last cannabinoid positive urine sample as “Mean = 27.1 days;Range = 3-77 days.” 5

• General information websites that offer“expert” advice concluding, “The averagetime pot stays in your system is 30 days.” 6

• Urine tampering promotions in magazinessuch as High Times and on websites that offer urine drug cleansing supplements andadulterants intended to chemically mask thepresence of drugs in urine often exaggeratethe detection window in an effort to promotethe continued use of their products. Some oftheir claims include: drug detection times inurine [for] “Cannabinoids (THC, Marijuana)20-90 days,” 7 and detection times for smokerswho use “5-6x per week—33-48 days.” 8

• Health information websites that provide thefollowing guidance; “At the confirmation levelof 15 ng/ml, the frequent user will be positivefor perhaps as long as 15 weeks.” 9

• Dr. Drew Pinsky (a.k.a. Dr. Drew), who has co-hosted the popular call-in radio showLoveline for 17 years, states that “Pot stays in your body, stored in fat tissues, potentiallyyour whole life.” 10

Based upon these information sources thatclaim cannabinoids elimination profiles of 25days, 11 weeks, 90 days, up to 15 weeks afteruse, and for “your whole life,” is it any wonderthat drug court professionals cannot reachconsensus on this issue? Is there any doubtwhy drug court clients make outlandishcannabinoid elimination claims in court? Theserepresent but a sampling of the many dubioussources that perpetuate the prolonged cannabi-noid detection window. As a consequence,the 30-plus day cannabinoid elimination periodremains a commonly assumed “fact.”

ESTABLISHING THE CANNABINOIDDETECTION WINDOW IN URINE

The detection window for cannabinoids inurine must be seen in the proper context—as a reasonable estimate. Detection times for cannabinoids in urine following smoking vary considerably between subjects even in


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controlled smoking studies using standardizeddosing techniques. Research studies have alsodemonstrated significant inter-subject differ-ences in cannabinoid elimination rates. Thetiming of marijuana elimination is further com-plicated by the uncertainty of the termination ofuse and continued abstinence. That said, gen-eral estimates for establishing a cannabinoiddetection window in urine can be advancedand accepted for use in drug courts. Basedupon the current state of cannabinoid elimina-tion knowledge and the drug testing methodsavailable in today’s market, the following practicalcannabinoid detection guidance is offered.

Based upon recent scientific evidence, atthe 50 ng/mL cutoff concentration for thedetection of cannabinoids in urine (usingthe currently available laboratory-basedscreening methods) it would be unlikely fora chronic user to produce a positive urinedrug test result for longer than 10 days afterthe last smoking episode. Although there areno scientific cannabinoid elimination studieson chronic users using non-instrumentedtesting devices, one would assume that ifthe on-site devices are properly calibratedat the 50 ng/mL cutoff level the detectionguidance would be the same.

At the 20 ng/mL cutoff concentration for thedetection of cannabinoids in urine (usingthe currently available laboratory-basedscreening methods) it would be uncommonfor a chronic marijuana smoker to producea positive urine drug test result longer than21 days after the last smoking episode.

For occasional marijuana use (or singleevent usage), at the 50 ng/mL cutoff level,it would be unusual for the detection ofcannabinoids in urine to extend beyond 3-4 days following the smoking episode(using the currently available laboratory-based screening methods or the currentlyavailable on-site THC detection devices). At the 20 ng/mL cutoff for cannabinoids,positive urine drug test results for the single event marijuana use would not beexpected to be longer than 7 days.

This cannabinoid detection guidance shouldbe applicable in the majority of drug courtcases. These parameters (acute vs. chronic),however, represent opposite ends of the marijuana usage spectrum. Clients will oftenexhibit marijuana-smoking patterns betweenthese two extremes resulting in an actualdetection window that lies within these limits.As noted in the Kouri, et al, study, researchsuggests that under extraordinary circum-stances of sustained, extended and on-goingchronic marijuana abuse (thousands of smoking episodes over multiple years) that 30-day urinary cannabinoid detection ispossible in some individuals at the 20 ng/mLcutoff (1999). However, the burden of prooffor documenting such aberrant and chronicmarijuana use patterns should fall on the drugcourt client or the client’s representatives. For a client to simply disclose “chronic” use isinsufficient corroboration.

Much has been made about marijuana researchthat has produced dramatically prolongedcannabinoid elimination times, particularly inthose subjects identified as chronic. This datahas often been used to explain continuingpositive cannabinoid test results in clients longafter their drug elimination threshold (resultingin negative urine drug tests) should have beenreached. The pertinent question: to whatextent does the scientific data (demonstrating30-plus day cannabinoid detection times inchronic users) influence the disposition ofdrug court cases? Put another way, do drugcourt practitioners need to be concernedabout the potential of extended cannabinoiddetection times impacting court decisions(i.e., sanctions)? In reality, the only timeframein which an individual’s chronic marijuana use(possibly leading to extended cannabinoidelimination) is relevant is during a client’sadmission into the drug court program. It isduring this initial phase that the court mayfind itself attempting to estimate the numberof days necessary for a client’s body to riditself of acquired cannabinoid stores and thetime required to produce negative drug testresults. In many programs, a detoxification


9

period is established for this purpose. Once inthe drug court program (following the initialdetoxification phase), the extent of a client’spast chronic marijuana usage does not influencethe cannabinoid detection window as long asappropriate supervision and drug monitoringfor abstinence continues on a regular basis. It would seem reasonable to assume thatchronic client marijuana usage of the extremelevels discussed here while within a properlyadministered drug court would be highlyunlikely. Therefore, the consequences ofchronic marijuana usage on the cannabinoiddetection window are effectively limited tothe initial entry phase of the program.

The cannabinoid detection window guidanceprovided herein relies upon the widely usedcutoff concentrations for the initial screeningtests—20 ng/mL and 50 ng/mL. For programsutilizing GC/MS confirmation for the validationof positive screening results, the confirmationcutoff has little influence on the length of the cannabinoid detection window in urine. A review of the potential result possibilitiesdemonstrates this point. If a drug court sampletests negative for cannabinoids on the initialscreen, the confirmation cutoff is obviouslyirrelevant because the sample is not submittedfor confirmation testing. If a sample bothscreens and confirms as positive for cannabi-noids (and is reported as positive), then thecutoff concentration of the confirmation analysis is also not relevant because the sam-ple would not have been sent for confirmationunless it produced a result greater than orequal to the cutoff level of the initial screeningtest. In other words, the confirmation proce-dure is merely validating the results (andtherefore the cutoff) of the original screening

test. The only scenario in which the confirma-tion cutoff could potentially impact the lengthof the cannabinoid detection window is if asample screened positive and the confirmationprocedure failed to confirm the presence ofcannabinoids (and the results of the drug testwere reported as negative). In this circum-stance, the cannabinoid detection windowmight be shorter than the estimate provided asguidance. This would be true on the conditionthat the confirmation cutoff concentration waslower than that of the screening procedure—which is nearly always the case. A shortercannabinoid detection window would not be seen as prejudicial to the client and mightactually be beneficial to the drug court.

Using this cannabinoid detection windowguidance, the drug court decision-making hierarchy should be able to establish reason-able and pragmatic cannabinoid detectionbenchmarks that both provide objective criteria for court decisions and protect clientsfrom inappropriate or unsupportable conse-quences. Some courts may choose to use thecannabinoid elimination information detailed in this paper exactly as presented to establisha marijuana detection window that will allowthe differentiation between abstinence andcontinued/renewed use. Other courts maydecide to build into the guidance an additionalsafety margin, granting clients further benefitof the doubt. Regardless of the approach,however, courts are urged to establish detec-tion benchmarks and utilize these scientificallysupportable criteria for case disposition.

Every day drug courts grapple with two seem-ingly disparate imperatives—the need for rapidtherapeutic intervention (sanctioning designedto produce behavioral change) and the need toensure that the evidentiary standards, craftedto protect client rights, are maintained. Whileadministrative decision-making in a drug court environment (or a probation revocationhearing) does not necessitate the same dueprocess requirements and protections thatexist in criminal cases, as professionals weare obliged to ensure that court decisionshave a strong evidentiary foundation.


10

Science is not black and white and the state of our knowledge

is continually evolving.

Courts establishing detection windows forcannabinoids need to be aware of the exis-tence of research studies indicating prolongedelimination times in urine. It is not recom-mended, however, that drug courts manipulatetheir detection windows to include theseexceptional findings. Sound judicial practicerequires that court decisions be based uponcase-specific information. In weighing the evidence, courts also acknowledge the realitythat a particular client’s individualities or theuniqueness of circumstances may not alwaysallow the strict application of cannabinoiddetection window parameters in a sentencingdecision. These uncommon events, however,should not preclude the development ofcannabinoid detection windows for the use in the majority of court determinations.

CLIENT DETOXIFICATION: THE “CLEAN OUT” PHASE

As a result of the extended elimination ofcannabinoids (as compared to other abuseddrugs), some drug courts have instituted adetoxification stage or “clean out” period inthe first phase of program participation. Thisgrace period allows new clients a definedtime frame for their bodies to eliminate storesof drugs that may have built up over years of substance abuse without the fear of courtsanctions associated with a positive drug test. In many cases this detoxification periodextends for 30 days, which corresponds to the commonly held assumption that this represents the time period required formarijuana metabolites to be eliminated from a client’s system.

Regardless of the origin of the 30-day marijuanadetection window and its influence on theduration of the detoxification period, 30 daysis certainly an equitable time period for clientdrug elimination purposes. Simply becausethe science may not support the necessity ofa detoxification period of this duration doesnot mean that a court cannot use the 30-dayparameter in order to establish programexpectations. However, based upon the

cannabinoid detection guidelines presented inthis review, it is unlikely (utilizing reasonablephysiological or technology criteria) that a drugcourt client would continue to remain cannabi-noid positive at the end of this designatedabstinence period. After 30 days, using eithera 20 or 50 ng/mL testing cutoff, continuedcannabinoid positive urine drug tests almostcertainly indicate marijuana usage at somepoint during the detoxification period andshould provoke a court response to reinforceprogram expectations.

ABSTINENCE BASELINE

The abstinence baseline can either be a pointat which a client has demonstrated their abstinence from drug use via sequentiallynegative testing results (actual baseline) or a court-established time limit after which aclient should not test positive if that client has abstained from marijuana use (scientificbaseline). Each baseline has importance in a court-mandated drug monitoring program.The later has been the focus of this review. It is exemplified by establishing the detectionwindow for marijuana and utilizing positiveurine drug testing results to guide court intervention. Individuals who continue to produce cannabinoid positive results beyond the established detection window maximums(the scientific baseline) are subject to sanctionfor failing to remain abstinence during pro-gram participation.

The alternative approach uses negative testresults in establishing the actual abstinencebaseline. This has been referred to as the“two negative test approach” and has been


11

Courts are urged to establish detection benchmarks and utilizethese scientifically supportable criteria for case disposition.

previously described in the literature (Cary,2002). A drug court participant is deemed tohave reached their abstinence baseline whentwo consecutive urine drug tests yielding negative results for cannabinoids have beenachieved, where the two tests are separatedby a several day interval. Any positive drugtest result following the establishment of thisbaseline indicates new drug exposure. Thistechnique can be used with assays that testfor marijuana at either the 20 or 50 ng/mL cutoff concentration.11

CANNABINOID TESTING FOLLOWINGPOSITIVE RESULTS

Due to the prolonged excretion profile ofcannabinoids in urine (especially after chronicuse) some drug court programs wrestle with the issue of whether to continue urinedrug testing during the expected marijuanaelimination period. Simply put, why continuethe expense and sample collection burden for clients who have already tested positivefor cannabinoids knowing that the client maycontinue to produce positive cannabinoidresults for many days? There are at leastthree principle reasons drug courts are notadvised to suspend urine drug testing followinga positive result for cannabinoids.

First, most court-mandated testing includesdrugs other than marijuana. Client surveillanceoften encompasses testing for many of the popularly abused substances such asamphetamines, cocaine, opiates, and alcohol.Programs that forego scheduled testing runthe very real risk of missing covert drug usefor substances other than marijuana. If a drugcourt client knows a positive cannabinoid test will result in a drug testing “vacation,”they may use that non-testing period to usesubstances with shorter detection windows (i.e. cocaine or alcohol). By continuing to test,the court maintains its abstinence monitoringfor drugs besides marijuana.

Second, from a programmatic standpoint thesuspension of scheduled client drug testingsends the wrong therapeutic message. If a

drug court's policies and procedures require a certain schedule of testing, suspending testing for even a short period may appear to other program participants that the court is“rewarding” a client who has tested positive.Eliminating scheduled drug tests in responseto a positive cannabinoid result degrades the program’s efforts at maintaining clientbehavioral expectations.

Lastly, depending upon the cutoff concentrationof the drug test being used and whether theclient’s marijuana usage was an isolated event(rather than a full relapse), it is entirely possiblethat a client who has previously tested positivefor cannabinoids may test negative sooner thanthe cannabinoid detection window estimate.As indicated earlier, acute marijuana useresults in cannabinoid positive urine samplesfor only several days following exposure.Curtailing drug testing for longer than threedays extends unnecessarily the period ofuncertainty about a client’s recent behavior andmay delay appropriate therapeutic strategiesor sanction decisions.

COURT EXPECTATIONSAND CLIENT BOUNDARIES

One of the most important prerogatives ofdrug court (or any therapeutic court) is toclearly define the behavioral expectations forclients by establishing compliance boundariesrequired for continued program participation.Drug testing used as a surveillance tool definesthose boundaries and monitors client behaviorin order that the court can direct either incen-tives or sanctions as needed to maintain participant compliance. To fulfill this importantresponsibility, drug courts teams must agreeupon specific drug testing benchmarks inorder to apply court intervention strategies in an equitable and consistent manner.

The primary focus of this article is to promotethe establishment of a drug testing benchmarkthat defines the expected detection windowof cannabinoids in urine following the cessa-tion of smoking. In order for drug courts todetermine their cannabinoid detection window,


12

the program will need to consider the cutoffconcentration of the urine cannabinoid testbeing utilized and develop criteria for definingchronic marijuana users. Drug courts shouldalso take into account how the cannabinoiddetection window will be incorporated intotheir current policies and procedures and howthe detection window will be used in caseadjudication. Once established, the courtshould apprise program participants of theexpectations associated with the cannabinoiddetection window. Clients should understandthat sanctions will result if continued cannabi-noid positive tests occur beyond the estab-lished detection window (the drug eliminationtime limit after which a client should not testpositive if that client has abstained from marijuana use). Courts are reminded that thecannabinoid detection window may requirerevision if there are modifications to the drugtesting methods or if there are significantchanges in marijuana usage patterns in thecourt’s target population (i.e., significantincreases in chronic use).

Practitioners are reminded that the goal inestablishing a cannabinoid detection windowis not to ensure that a monitored client isdrug free. Chronic marijuana users may carryundetectable traces of drug in their bodies for a significant time after the cessation ofuse. Rather, the goal is to establish a giventime period (detection window limit) afterwhich a client should not test positive forcannabinoids as a result of continued excretionfrom prior usage.

Finally, the cannabinoid detection window is a scientifically supportable, evidence-basedeffort to establish a reasonable and practicalstandard for determining the length of timecannabinoids will remain detectable in urinefollowing the smoking of marijuana. Drug courtsare reminded that science is not black andwhite and that the state of our knowledge iscontinually evolving. While detection windowbenchmarks will and should guide the sanc-tioning process for violations of abstinent

behavior, courts are urged to judge a client’slevel of compliance on a case by case basisusing all of the behavioral data available to thecourt in conjunction with drug testing results.In unconventional situations that confound the court, qualified toxicological assistanceshould be sought.

Paul L. Cary, M.S. is the Director of the Toxicology & Drug Monitoring Laboratory, University of MissouriHealth Care, Columbia, Missouri; and NDCI FacultyResident Expert on drug testing issues. Mr. Cary can be reached at [email protected].

This document was published with support from theOffice of National Drug Control Policy, Executive Office of the President and the Bureau of Justice Assistance,U.S. Department of Justice.

References Baselt, R.C. (2004). In Disposition of Toxic Drugs

and Chemicals in Man, (7th ed.). Foster City,CA: Biomedical Publications.

Cary, P.L. (2002). The use creatinine-normalizedcannabinoid results to determine continuedabstinence or to differentiate between newmarijuana use and continuing drug excretionfrom previous exposure. Drug Court Review,4(1), 83-103.

Cridland, J.S., Rottanburg, D., & Robins, A.H. (1983).Apparent half-life of excretion of cannabinoidsin man. Human Toxicology 2(4), 641-644.

Dackis, C.A., Pottash, A.L.C., Annitto, W., & Gold,M.S. (1982). Persistence of urinary marijuanalevels after supervised abstinence. AmericanJournal of Psychiatry, 139(9), 1196-1198.

Ellis, G.M., Mann, M.A., Judson, B.A., Schramm,N.T., & Tashchian, A. (1985). Excretion patternsof cannabinoid metabolites after last use in agroup of chronic users. Clinical Pharmacologyand Therapeutics, 38(5), 572-578.

Huestis, M.A. (2002). Cannabis (marijuana): Effectson human behavior and performance. ForensicScience Review, 14(1/2), 15-60.

Huestis, M.A., Mitchell, J.M., & Cone, E.J. (1994).Lowering the federally mandated cannabinoidimmunoassay cutoff increases true-positiveresults. Clinical Chemistry, 40(5), 729-733.

Huestis, M.A., Mitchell, J.M., & Cone, E.J. (1995).Detection times of marijuana metabolites inurine by immunoassay and gc-ms. Journal ofAnalytical Toxicology, 19(10), 443-449.


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Huestis, M.A., Mitchell, J.M., & Cone, E.J. (1996).Urinary excretion profiles of 11-nor-9-carboxy-∆9-tetrahydrocannabinol in humans after singlesmoked does of marijuana. Journal of AnalyticalToxicology, 20(10), 441-452.

Iten, P.X. (1994). In Fahren untrer Drogen-o-derMedikamenteneinfluss. ForensischeInterpretation und Begutachtung. Zürich: Institutfür Rechtsmedizin der Universtät Zürich.

Johansson, E. & Halldin, M.M. (1989). Urinaryexcretion half-life of ∆1-tetrahydrocannabinol-7-oic acid in heavy marijuana users after smoking.Journal of Analytical Toxicology, 13(7/8), 218-223.

Kouri, E. M., Pope, H. G. Jr., & Lukas, S. E. (1999).Changes in aggressive behavior during with-drawal form long-term marijuana use.Psychopharmacology, 143(3), 302-308.

Niedbala, R.S., Kardos, K.W., Fritch, D.F., Kardos,T.F., & Waga, J. (2001). Detection of marijuanause by oral fluid and urine analysis followingsingle-dose administration of smoked and oral marijuana. Journal of Analytical Toxicology,25(7/8), 289-303.

Reiter, A., Hake, J., Meissner, C., Rohwer, J.,Friedrich, H.J., & Ochmichen, M. (2001). Timeof drug elimination in chronic drug abusers: Casestudy of 52 patients in a “low-step” detoxifica-tion ward. Forensic Science International, 119,248-253.

Schwartz, R.H., Hayden, G. F., & Riddile, M. (1985).Laboratory detection of marijuana use.American Journal of Diseases of Children,139(11), 1093-1096.

Smith-Kielland, A., Skuterud, B., & Morland J.(1999). Urinary excretion of 11-nor-9-carboxy-∆9-tetrahydrocannabinol and cannabinoids infrequent and infrequent drug users. Journal ofAnalytical Toxicology, 23(9), 323-332.

Swatek, R. (1984). Marijuana use: Persistence andurinary elimination. Journal of Substance AbuseTreatment 1(4), 265-270.

Endnotes1. EMIT is a registered trademark of the Dade

Behring/SYVA Company and stands for (EnzymeMultiplied Immunoassay Technique). EMIT is a commercial drug testing product for the analysis of drugs of abuse in urine (d.a.u.).

2. Detoxing from Marijuana (pamphlet). (1992).Marijuana Anonymous: 12-Step Program forMarijuana Addicts, 4. The entire text reads asfollows: “Why do some effects last so long?”“Unlike most other drugs, including alcohol,THC (the active chemical in marijuana) is stored

in the fat cells and therefore takes longer tofully clear the body than with any other commondrug. This means that some parts of the bodystill retain THC even after a couple of months,rather than just the couple of days or weeks forwater soluble drugs.”

3. Website: TeenHealthFX. URL: http://www.teenhealthfx.com/answers/12.html.TeenHealthFX.com is a project funded byAtlantic Health System, a New Jersey hospitalconsortium. The website states that “the professional staff who answer questions fromour vast audience and provide oversight includeclinical social workers, health educators, adolescent medicine physicians, pediatriciansand pediatric subspecialists, psychiatrists, psychologists, nurses, nutritionists, and manyother health professionals.”

QUESTION: “Dear TeenHealthFX,Smoking marijuana can be detected how long?I’ve heard a couple of weeks in urine, a coupleof days in blood, and a couple of years in hair…please clarify! Also, during a routine physical atthe doctor, will they check for marijuana in theblood or urine sample?Signed: Longevity Of Marijuana - How LongDoes It Stay In Your System”

ANSWER: “Dear Longevity Of Marijuana - HowLong Does It Stay In Your System, The chemicalin marijuana, THC, is absorbed by fatty tissues invarious organs. Traces of THC can be detectedby standard urine and blood tests for about 2 days up to 11 weeks depending on the per-son’s metabolism, how much they smoked andhow long they smoked. THC can be detectedfor the life of the hair. Again, the sensitivity ofthe test ranges from person to person dependingon many factors including the amount of bodyfat, differences in metabolism, and how longand how much they smoked.”

Presumably, the 11 week estimate comes fromthe research finding of Ellis, et. al. (1985) whichhas been described earlier.

4. Bureau of Justice Assistance Monograph entitled:Integrating Drug Testing into a Pretrial ServicesSystem: 1999 Update, July 1999, NCJ # 176340.On page 48, Exhibit 5-3 titled; ApproximateDuration of Detectability of Selected Drugs inUrine lists Cannabinoids (marijuana) Chronicheavy use as 21 to 27 days. Source: Adaptedfrom the Journal of the American MedicalAssociation’s Council on Scientific Affairs (1987,p. 3112).

The source material citation is the Journal ofthe American Medical Association. (1987, June)


14

12;257(22):3110-4. The article is titled;“Scientific Issues in Drug Testing—Council onScientific Affairs.” On page 3112, Table 2. titled“Approximate Duration of Detectability ofSelected Drugs in Urine” lists chronic heavysmoker as 21-27 days. The references cited forthis data are Dackis, et. al (1982), and Ellis, et.al. (1985), the potential shortcomings of bothhave been discussed in this article. It is note-worthy and illustrative that this 1999 “updated”publication still relies on research performed in1982 and 1985.

5. Cannabinoid Issues: Passive Inhalation,Excretion Patterns and Retention Times(pamphlet). (1991). Dade Behring, SYVACompany, S-10036. On page 25 in a table titled: “Emit d.a.u. Cannabinoid Assay (20ng/mL)” is listed the following:

All Subjects (n = 86):

First Negative: Mean = 16.0 days Range = 3-46 days

Last Positive:Mean = 27.1 days Range = 3-77 days

Examination of the references associated withthis data indicates the following sources; Ellis,et. al. (1985), Schwartz, Hayden, & Riddile (1985),and Johansson& Halldin (1989). All of these references and their potential study design issueshave been reviewed in this article. This pam-phlet also contains cannabinoid elimination datausing the Emit-st Cannabinoid Assay testingmethod. Given that this assay is no longerbeing manufactured, the data was not included.

6. Website: What You Need to Know. About.comURL: http://experts.about.com/q/1319/718935.htm.This is a popular website for general informationinquiries about almost any subject matter. In asection entitled “About Our Service” the web-site states, “Allexperts, created in early 1998,was the very first large-scale question andanswer service on the net! We have thousandsof volunteers, including top lawyers, doctors,engineers, and scientists, waiting to answeryour questions. All answers are free and mostcome within a day!”

The question submitted to the site was, “Howlong does marijuana stay in your system?” Theexpert response was: “The average time potstays in your system is 30 days. The time maydiffer depending on your metabolism. If youhave a fast metabolism it may be shorter than30 days, if you have a slow metabolism it maybe more. The average though is about 30 days.”Note that in this answer, 30 days is given as anaverage cannabinoid elimination time.

7. Website: Health Choice of New York. URL: http://www.clearchoiceofny.com/drugtestinfo.htm. This website states: “It's One Stop ShoppingFor All Of Your Detoxifying Needs. We Have AllThe Products You Need To Pass A Urine DrugTest.” In a section entitled “Drug ApproximateDetection Time in Urine,” the site provides thefollowing information: “Cannabinoids (THC,Marijuana) 20-90 days.”

8. Website: IPassedMyDrugTest.Com. URL:http://www.ipassedmydrugtest.com/drug_test_faq.asp#detect_time

The following table is provided:

Cannabinoids (THC, Marijuana) Detection Time:1 time only 5-8 days2-4x per month 11-18 days2-4x per week 23-35 days5-6x per week 33-48 daysDaily 49-63 days

9. Website: HealthWorld Online. URL:http://www.healthy.net/clinic/lab/labtest/004.asp.Site’s mission statement; “HealthWorld Onlineis your 24-hour health resource center—a virtualhealth village where you can access informa-tion, products, and services to help create yourwellness-based lifestyle.” In the section called“Detection of Cannabinoids in Urine,” the fol-lowing information is provided: “Cutoff andDetection Post Dose: The initial screening cut-off level is 50 ng/ml. The GC/MS cutoff level is15 ng/ml. The elimination half-life of marijuanaranges from 14-38 hours. At the initial cutoff of50 ng/ml, the daily user will remain positive forperhaps 7 to 30 days after cessation. At theconfirmation level of 15 ng/ml, the frequentuser will be positive for perhaps as long as 15weeks.”

10.Website: Dr. Drew. URL: http://drdrew.com/Office/faq.asp?id=1083&sec-tion=5002

QUESTION: How long does pot (or other drugs)stay in your body? Is there any way to detect it?

ANSWER: Most readily available drug screensare tests of the urine. Blood tests and breathanalyzers are another way substances can bedetected. Pot stays in your body, stored in fattissues, potentially your whole life. However, it is very unusual to be released in sufficientquantities to have an intoxicating effect or bemeasurable in urine screens. Heavy pot smokers,people who have smoked for years on a dailybasis, very commonly have detectable amountsin their urine for at least two weeks.


15

4900 Seminary Road, Suite 320Alexandria, VA 22311

(703) 575-94001-877-507-3229

(703) 575-9402 Faxwww.ndci.org

NATIONALDRUG COURTINSTITUTE

11.Research data indicates that in the terminalphase of cannabinoid elimination, subjects canproduce urine samples with levels below thecutoff concentration (negative results), followedsubsequently by samples with levels slightlyabove the cutoff (positive results) (Huestis, 2002).This fluctuation between positive and negativedid not occur in all subjects and in those thatdid exhibit this pattern, the fluctuation was generally transitory. Based on this eliminationpattern, it is recommended that programs using a cannabinoid cutoff of 50 ng/mL allow an interval of at least three days between thetwo negative result samples to establish theabstinence baseline. It is further recommendedthat programs using the 20 ng/mL cannabinoidcutoff allow an interval of at least five daysbetween the two negative result samples toestablish the abstinence baseline. If a program’stesting frequency is greater than every five days(using the 20 ng/mL cutoff), a total of three ormore negative tests may be required before the five-day interval is achieved.

PublisherC. West Huddleston, IIIDirector, National Drug Court Institute

National Drug Court Institute4900 Seminary Road, Suite 320Alexandria, VA 22311703.575.9400 ext. 13703.575.9402 [email protected]

Test your new knowledge. Answerthese true and false questions basedon the Fact Sheet text.

1. The “detection window” meansthe length of time a drug willremain in someone’s system.

2. The choice of testing cutoffhas a profound effect on thecannabinoid detection window.

3. Despite changes in testingmethodologies, detection timesof cannabinoid metabolites inurine monitored by immunoas-say have remained the sameover the past two decades.

4. Chronic users of marijuanacommonly produce a positiveurine drug test result 30 daysafter the last smoking episode.

5. Any positive drug test resultfollowing two successive negative urine drug tests several days apart indicatesnew or recent drug exposure.

6. Since marijuana has such aprolonged elimination period,temporarily suspending drugtesting of a client who testspositive for marijuana is agood money-saving strategy.

FT

FT

FT

FT

FT

FT

FACT SHEET QUIZ: WHAT DID YOU LEARN?

Answers:1. False; 2. True; 3. False; 4. False; 5. True; 6. False

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. 1

PREFACEAs the title implies, the objective of this fact sheet is to provide drug court professionals with a scientifically based justification for discontinuing the interpretation of urine drug levels in an effort to define client drug use behavior. As the premise of this document is not without some controversy, clarificationof its intent seems warranted.

This fact sheet is intended for drug court practitioners who are routinely engagedin the interpretation and evaluation of urine drug testing results for the purpose ofparticipant case adjudication, particularly client sanctioning. Given that most drugcourts do not have routine access to biomedical or pharmacological expertise,this fact sheet recommends that the use of urine drug concentrations be elimi-nated from the court’s decision-making process in order to protect client rightsand ensure that evidentiary standards are maintained.

It is not the intention of this document to prohibit the interpretation of laboratorydata by qualified scientists. Nor is it the objective of this fact sheet to assert thaturine drug levels have no interpretative value. However, drug court practitionersare cautioned that the interpretation of urine drug levels is highly complex andeven under the best of circumstances provides only limited information regardinga participant’s drug use patterns. Further, such interpretations can be a matterof disagreement even between experts with the requisite knowledge and trainingto render such opinions.

It is for these stated reasons that the NDCI strongly encourages drug court pro-grams to utilize the information contained herein to evaluate their drug testingresult interpretation practices. This organization recognizes that the use of urinedrug levels to assess client behavior may be widespread and longstanding.However, because courts rarely have the necessary toxicology expertise, theroutine use of urine drug levels by court personnel in formulating drug courtdecisions is a practice that in most cases would not withstand scientific or judicial scrutiny. It is hoped that this fact sheet will serve as the foundation forthose drug court programs routinely interpreting urine drug levels to transition to a strictly qualitative (positive or negative only) result format. Drug courts arealso encouraged to seek expert toxicology advice when necessary and appropriateto assist in the interpretation of testing data associated with challenging cases.

URINE DRUG CONCENTRATIONS: THE SCIENTIFICRATIONALE FOR ELIMINATING THE USE OF DRUGTEST LEVELS IN DRUG COURT PROCEEDINGSBy Paul L. Cary, M.S.

DRUG COURTPRACTITIONERF A C T S H E E T

INTRODUCTION

While urine drug testing remains the primarystrategy for the abstinence monitoring of drug court participants, interpretation of testresults continues to be problematic for manycourts. The use of urine drug concentrations(numeric values given with positive results)for the purpose of interpretation remainswidespread. Many drug courts utilize urinarydrug levels in an attempt to quantify the druguse behavior and patterns of their client popu-lation. To make matters worse, absolute drugconcentrations are often “interpreted” with-out adjustments for differences in urine watercontent. Increases in absolute drug concentra-tions resulting from changes in urinary outputare often mistakenly interpreted as new druguse rather than carryover from previous drugexposure. Decreases in absolute drug concen-trations, which can also result from urine volume changes, can be misinterpreted asevidence of continued abstinence. Basedupon limited, anecdotal information, urinedrug levels are often arbitrarily assigned quan-titative labels such as “high” or “very high”or “almost negative” in an effort to categorizelaboratory results. Treatment providers monitorfalling urine drug concentrations in an effort to substantiate continued elimination. Manydrug courts utilize urine drug levels in aneffort to define substance abuse behavior and dispense appropriately measured justice.

At best, these interpretation practices aremisguided. At worst, the conclusions reachedregarding drug use behavior and patternsusing urine drug concentrations are just plainwrong! While well intentioned and seeminglylogical, the utilization of urine drug test levels

generally produces interpretations that areinappropriate, factually unsupportable, andwithout scientific foundation. Worst of all forthe court system, these interpretations havelittle, if any, forensic merit.

EVIDENTIARY STANDARDS

The drug court model is built upon an evidentiaryfoundation that provides maximum flexibilityto team members as they apply innovativetreatment strategies designed to succeedwhere other legal remedies have failed. Whilethis flexibility is an important managementtool, basic evidentiary standards for theadmissibility of scientific data into the pro-ceedings must be maintained. Unfortunately,as drug courts experiment with a variety oftherapeutic interventions and struggle withsanction and incentive decisions, this eviden-tiary foundation sometimes may becomecompromised. This is particularly true whenthe interpretation of drug testing results utilizes urine drug levels.

The fact that urine drug concentrations are of little interpretive value will unfortunatelycome as a surprise to too many drug courtprofessionals. The use of urine drug levels for evaluating patterns of substance abuse is commonplace and has deep roots in thecriminal justice system. Court programs havebeen adjudicating cases based on urine druglevels for years. That fact does not make thepractice any more legitimate. If the use ofurine drug levels cannot be supported scien-tifically, then the validity of decisions basedupon these levels is questionable. Accordingly,the more often a court utilizes drug testresults in a manner that is not scientificallyvalid, the farther it strays from its evidentiaryfoundation – thus undermining the forensicdefensibility of its decisions.

It has even been reported that some jurisdic-tions interpret urine drug levels that fallbelow the testing cutoff point (i.e., samplesthat have tested negative). Presumably, theevaluation of levels under the assay thresholdis an effort to uncover potential covert drug


2

The fact that urine drug concentrationsare of little interpretive value will

unfortunately come as a surprise totoo many drug court professionals.

use. It is further reported that increases inthese levels (still below the testing cutoff) are used to sanction drug court clients. Notonly is the evaluation of urine drug levels in a negative sample the antithesis of the intentof drug testing, but it also violates standardsof evidence admissibility. In short, this practiceis unethical. A negative test result cannot beinterpreted in any other manner than negative.Court-affiliated attorneys, both prosecutionand defense counsel, entrusted with the pro-tection of client rights are obligated to abolishthis practice.

An unambiguous evidentiary foundation thatwill pass scientific and legal scrutiny is crucialfor the continued success of drug courts. Forthose drug courts utilizing urine drug levels to formulate court-related judgments, this factsheet is designed to provide sufficient objec-tive information to support the reevaluation of those result interpretation practices thatallow the introduction of unscientific evidenceinto the courtroom.

LABORATORY/COURT RELATIONSHIP

The controversy associated with urine drugconcentrations is complicated by the relation-ship between drug testing laboratories and thecourts. The reporting of urine drug concentra-tions as part of the drug test result receiveslittle attention within the drug testing industryitself. And if the issue does surface, the discussion often focuses on economic ratherthan scientific or ethical issues.

In performing a drug test, laboratories mustdetermine the concentration of drug in urinein order to differentiate between samples thatare reported as either positive or negative.Testing methodologies require that urine samples producing a drug concentration at or above the cutoff level of the drug test be classified as “positive” and that samplesyielding a drug concentration below the cutoff level of the test be defined as “negative”(or none detected). In other words, the solepurpose for determining a urine drug level is to allow the assignment of a qualitative

result—positive or negative. The dilemma for the laboratory is what to do with thenumeric result (drug concentration) that hasbeen generated during the testing process.

Some laboratories do not report this valueeven if requested, believing that the urinedrug concentration serves no useful purposeor could result in the misapplication of thedata. On the other hand, many drug testinglaboratories do provide the urine drug concen-trations as part of their result report. Whenasked about the practice of reporting urine drugconcentrations, most laboratories admit thatthese values are not useful for interpretationpurposes; however, numerical results continueto be reported because of customer demand.Put another way, laboratories report drug levelsbecause court professionals request thosevalues. Laboratories that report concentrationsroutinely cite customer surveys that indicatethat court programs would be dissatisfied withthe lab services if drug concentrations werenot provided (i.e., not getting their money’sworth). These surveys further suggest thatmerely reporting “positive” or “negative”results would be viewed as insufficient tomeet the court’s needs.

The vicious cycle begins. Regardless of theirnegligible merit, urine drug levels reported tothe court beg for interpretation and many courtsare all too eager to oblige. Courts becomedependent upon the drug levels provided by the laboratories for client adjudication and laboratories feel compelled to provide theconcentrations to avoid the potential adverseeconomic repercussions associated with losingbusiness due to not providing the levels. Thisresults in an apparent institutional reluctance


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An unambiguous evidentiary foundationthat will pass scientific and legalscrutiny is crucial for the continuedsuccess of drug courts.

by both the laboratory industry and the criminaljustice system to change current practices—even in the face of solid scientific evidence.Drug testing laboratories yield to the obviouseconomic forces and drug courts relying onurine drug levels for the dispensation of sanc-tions and rewards are not inclined to changeor find the practice difficult to eliminate.

DRUG TEST MANUFACTURERS’RECOMMENDATIONS

By way of review, the drug tests used bydrug courts are qualitative. That means thatthe purpose of the test is to determine thepresence or the absence of a drug in a urinesample being tested – period. Either a drugtest is positive (drug presence at or above the cutoff concentration) or negative (nonedetected; drug level below the cutoff concen-tration). These tests were not designed ormarketed to produce quantitative results –how much drug is present in the sample.

The product information materials for themost popular laboratory-based drug testmethod in use in the U.S. (available since1974) states the following:

• “A positive result from the assay indicates the presence of drug but does not indicate or measure intoxication.”

• “Interpretation of results must take intoaccount that urine concentrations can vary extensively with fluid intake and other biological variables.”

• “Immunoassays that produce a single resultin the presence of a drug and its metabolitescannot fully quantitate the concentration ofindividual components.”

• “When the test is used as a qualitative assay, the amount of drugs and metabolitesdetected by the assay in any given specimencannot be estimated. The assay results distinguish between positive and negativespecimens only (Dade Behring, SYVA®, 2003).”

This product information unequivocally estab-lished the qualitative nature of urine drug testing. Similar directives may be found in the product literature of essentially all drugtesting products. The basis for this product

guidance is both technical (issues associatedwith the testing methodologies) and physio-logical (how the human body processes drugs).

TECHNICAL ISSUES AFFECTINGINTERPRETATION OF DRUG LEVELS

First, qualitative drug tests are generally notlinear. That means that the urine drug concen-tration being reported may not be precisebecause the testing instrument’s response tovarying drug concentrations is not a straightline. At high drug concentrations or low drugconcentrations the values produced may notaccurately reflect the actual concentration ofdrug in urine. Qualitative tests are not designedto accurately quantitate drug concentrations;the purpose of these tests is to determinewhether the drug level in urine is greater thanor less than the cutoff – positive or negative.Therefore, at the high concentrations (wellabove the cutoff) or at the low concentrations(significantly below the cutoff) the drug levelsdetermined by the test may be skewed simplydue to the concentration of the drug itself and the inability of the test to measure thatconcentration accurately.

Second, many initial screening tests detectboth the presence of parent drug(s) and theirmetabolites (chemical breakdown products)simultaneously. That means that the numericresult reported represents a total concentrationof the mixture of similar drug components(i.e., total amount of vegetables in a soup).These drug and drug metabolites are detectedby the tests differentially. In other words,each individual component produces a distinctand dissimilar reaction (i.e., the peas in the soupproduce a greater response when countedthan the same number of carrots). With aqualitative test it is impossible to determinewhat portion of the total drug concentrationbeing measured is associated with the primarydrug and what portion is associated with themetabolites (i.e., what portion of the totalmeasured vegetables in the soup is peas andwhat portion is carrots). Therefore, attemptingto evaluate a urine drug level based upon a


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result that measures total drug concentration(of continually changing concentrations of drugand drug metabolites levels) is not possible.

PHYSIOLOGICAL ISSUES AFFECTINGINTERPRETATION OF DRUG LEVELS

Drug concentrations in the urine are presentin proportion to the total amount of liquid. Ifthe urine is diluted, the concentration of thedrug is reduced and when the urine is moreconcentrated the drug concentration isincreased. Urine volume or output is highlyvariable (both from person to person andwithin the same person at different times during the day) and is influenced by a varietyof factors, including: liquid, salt and proteinintake, exercise, and age. The variability ofdrug concentrations due to changes in urinevolume is significant. Drug levels may varywidely within a day or between days evenwith no additional drug exposure as a resultof fluid intake alone. Without some form ofnormalization technique (some drug courtsuse creatinine concentrations to correct forthe variations that occur in urine volume) theinterpretation of urine drug levels is fraughtwith inaccuracy.1

As mentioned in the previous section, initialscreening tests for drugs detect both thepresence of parent drug(s) and their metabo-lites (chemical breakdown products) simulta-neously. As drugs and their breakdown prod-ucts are eliminated from the body they areexcreted at differing rates – those that areless water-soluble are often eliminated moreslowly than those that are more water-soluble.This results in a continually changing ratio ofcompounds that are reacting to the test (i.e.,peas are eliminated more quickly than carrots;subsequent tests measure greater amountsof carrots). Due to the fact that these compo-nents are eliminated from the body at differentrates, thus varying the overall test response,

any attempt to evaluate changing urine druglevels that are based upon a result that meas-ures total drug concentration (drug and drugmetabolites) becomes extremely problematic.

THE BLOOD ALCOHOL MODEL

Judges and courts have relied on quantitative(numeric) testing data for decades in makingsentencing decisions; most notably, the interpretation of blood alcohol levels for thepurposes of establishing intoxication andimpairment. Unfortunately, the interpretationof blood alcohol concentrations cannot serveas a model for evaluating urine drug levels. In fact, the ease with which society legislatesand litigates around BAC’s has likely exacer-bated the problem associated with under-standing the limitations of urine drug levels.The blood alcohol model may have inadvertentlyled to the fallacy that drug levels in any bio-logical fluid can and should be interpreted.

When it comes to the testing of urine, it mayseem logical to make the assumption that drugconcentrations are related to either a specificphysiological response or that urine drug levelscorrelate with drug usage patterns. But thecorrelation between blood (as a specimen)and alcohol (as a drug) from an interpretationperspective could not be more different fromthe interpretation of urine drug testing results.The interpretation of blood alcohol concentra-tions is relatively straightforward because: (1) alcohol is a simple molecule, (2) blood is thebiological specimen most closely associatedwith the site of drug action (receptor), and (3) the study of alcohol levels and their effectson humans spans nearly 100 years. By contrast:(1) abused drugs have very complex chemicalstructures, (2) urine is a waste specimen notassociated with the pharmacological activityof the drug, and (3) research associated withabused drug concentrations and physiologicalresponse is in its infancy (compared to alco-


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1. For additional information on the use of creatinine to normalize results, see also: “The Use Creatinine-Normalized Cannabinoid Resultsto Determine Continued Abstinence or to Differentiate Between New Marijuana Use and Continuing Drug Excretion From PreviousExposure”, Drug Court Review, Volume IV, Issue 1, Summer 2002, pages 83-103.

hol). It is for these reasons that eleven notedtoxicologists, in a consensus report regardingthe interpretation of urine drug testing resultsin a forensic context, wrote:“Testing of drugs or drug metabolites in urine isonly of qualitative value in indicating some priorexposure to specific drugs. Inferences regardingthe presence or systemic concentration of thedrug at the time of driving or impairment fromdrug use are generally unwarranted (ConsensusDevelopment Panel, 1985).”

Few outside the scientific community realizethat even when measuring drugs in blood (asopposed to urine), that many of the abuseddrug levels commonly quantitated areextremely difficult to interpret or even to cor-relate with specific physiological responses.Not surprisingly, scientists generally agree thatthere is no correlation between urine drug levels and pharmacological action. Since thereis no recognized correlation between urinedrug levels and drug action, it is not difficultto understand why attempting to interpreturine drug levels is not scientifically valid.

A urine drug level does not indicate whetherthe drug has been used frequently or only asingle time. Levels do not indicate the strengthof the drug being used or when the drug waslast used. Urine drug levels do not indicatewhether a person was under the influence or intoxicated by the drug at the time of thesample collection. Urine drug concentrationscannot tell the drug court whether new druguse has occurred or the value is associatedwith continued elimination from a previousexposure. Numeric results do not accuratelydiscriminate between whether a participant’soverall drug level is increasing or decreasing –

even if compared to previous urine drug concentrations from the same client, for thesame drug. (This excludes those courts thathave adjusted drug levels based upon urinecreatinine concentrations.) Without extensivestudy under controlled conditions, no singleurine drug test can reliably answer any ofthese questions.

WHAT INFORMATION CAN BE OBTAINEDFROM A URINE DRUG TEST? A positive drug test indicates prior exposureto the drug detected. A negative drug testindicates either the specimen does not containthe drug or the drug is present in concentrationsbelow the cutoff level of the assay. Repeattesting of clients at regular intervals canimprove the interpretation of positive results.Multiple positives over a period of time rein-force that an individual may be regularly usingthe drug(s) being detected. For individualsknown to have chronically used drugs prior to the start of urine drug testing, collection ofmultiple urine samples over a period of timerequires special attention. While continueddrug excretion from previous exposure is afactor in multiple positive tests, this explanationis only valid until such time as the drug beingdetected should have been eliminated fromthe body. Accordingly, continuing positivedrug test results cannot be related to drugexcretion from previous exposure indefinitely.Multiple negative or “none detected” resultsprovide evidence that an individual is main-taining abstinence and not using drugs on aregular basis. As mentioned earlier, the use of creatinine-normalized urine results mayenhance interpretation. For cannabinoids, thisapproach allows the differentiation betweennew marijuana use and positive test resultsassociated with continued drug excretionfrom previous marijuana exposure.

ELIMINATING DRUG LEVELS

Has the urine drug level increased or decreasedsince the last test? How positive is he/she?Does this level indicate relapse? The level


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The blood alcohol model may haveinadvertently led to the fallacy that

drug levels in any biological fluid can and should be interpreted.

continues dropping so that indicates continuedelimination, correct? If any of these questionsare being asked within the drug court setting,it is almost certain that urine drug levels arebeing used inappropriately in the court’s deci-sion-making processes. For those court pro-grams that use urine drug concentrations tomake sentencing decisions, the transition to anon-numerical drug report format (i.e., resultssimply reported as positive or negative) maybe difficult. However, there are benefits. Firstand foremost, the court moves forwardsecure in the knowledge that its rulings havea strong scientific basis and are forensicallysound. Second, the court no longer has toattempt to interpret data that is not inter-pretable. Third, courts that have eliminatedthe use of urine drug concentrations havereported greater confidence in their decision-making process. Making decisions basedentirely on either positive or negative reportsremoves the judicial ambiguity associated withmanipulating numbers that few individuals, ifany, in the court environment are trained tounderstand. Lastly, the use of urine drug testresults that do not rely on concentrations addsadditional fairness and equity to the rewardsand sanctions process of the drug court. Byremoving the unpredictable urine drug levelsfrom the decision-making equation, courtseliminate the unsupportable foundation onwhich these interpretations are based.

It is noteworthy that in the federal workplacedrug testing programs (DOT, DOE, DOD, etc.),the routine reporting of urine drug levels isnever permitted. Federally certified laborato-ries are never allowed to report the numericalvalues generated from initial screening proce-dures. These protections that are provided tofederally regulated employees should serve to further illustrate the validity concerns asso-ciated with using urine drug concentrations in the drug court environment.

FINAL THOUGHTS

Mark Stevens and James Addison may havesaid it best. In an article entitled, “Interface ofScience and Law in Drug Testing” they wrote:

“In short, there is a substantial gap between the questions that the legal community wouldlike to have answered by drug testing and theanswers that the scientific community is ableto provide. The real danger lies in the legalcommunity’s failure to “mind the gap” bydrawing unwarranted inferences from drugtesting results (1999).”

When a drug court uses urine drug concentra-tions as the evidentiary basis in support of aruling (a practice that likely would not with-stand a serious legal or scientific challenge),the interpretation is performed by court pro-fessionals who generally lack background ortraining in pharmacology, toxicology, or fieldsrelated to drug testing. Accordingly, the courtcannot be expected to fully comprehend andapply the many physiological variables associ-ated with the pharmacology of abused drugsin the human body or the scientific and tech-nical issues of detecting those drugs in bio-logical fluids. However, by using urine drugconcentrations in a forensic context, the drugcourt assumes and accepts the responsibili-ties (and liabilities) associated with that scien-tific knowledge – its use and misuse. Therefore,it is incumbent upon each court to determinethe appropriateness of its use of drug testsresults in the dispensing of justice. Drug courtshave been portrayed as models of effectiveand appropriate jurisprudence. However, the continued use of urine drug levels in thedetermination of sentencing decisions repre-sents a practice that is ultimately detrimentalto the process of justice.

Urine drug testing is qualitative – the purposeof a drug test is to determine the presence orabsence of a drug in a urine sample – nothingmore! Eliminating drug levels will not make


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Making decisions based entirely oneither positive or negative reportsremoves the judicial ambiguity associated with manipulating numbers

urine drug testing results any less reliable oruseful. However, the continued use of urinedrug levels by drug courts in an attempt tointerpret drug test results will likely result inboth inappropriate and unfair rewards andsanctions for participants. Attempting toextract information from a drug test result in order to develop conclusions about urinedrug concentrations, however well-intentioned,cannot be supported by the science and represents an adjudication practice that issimply not forensically defensible.

Paul L. Cary, M.S. is the Director of the Toxicology & Drug Monitoring laboratory, University of MissouriHospital and Health Care System, Columbia, Missouri;and NDCI Faculty Resident Expert on drug testing issues.Mr. Cary can be reached at [email protected].

This document was published with support from theOffice of National Drug Control Policy, Executive Office of the President and the Bureau of Justice Assistance,U.S. Department of Justice.

References

Cary, P.L. (2002). The use of creatinine-normalized cannabinoid results to determine continuedabstinence or to differentiate between newmarijuana use and continuing drug excretionfrom previous exposure. Drug court review,4(1), 83-103.

Consensus Development Panel. (1985, November 8).Consensus report: Drug concentrations anddriving impairment. Journal of the Americanmedical association, 254(18).

Dade Behring, SYVA®. (2003, July, Revised). Emit® II Plus Enzyme Immunoassay product informationsheet. Cupertino, CA: SYVA Company.

Stevens, M.P., & Addison, J.R. (1999, December). Interface of science and law in drug testing. The Champion, 23(10), 18-24.

Publisher

C. West Huddleston, III

Director, National Drug Court Institute

National Drug Court Institute

4900 Seminary Road, Suite 320Alexandria, VA 22311703.575.9400 ext. 13703.575.9402 [email protected]

Test your new knowledge. Answerthese true and false questions basedon the Fact Sheet text.

1. Urine drug levels are similar to blood alcohol concentrationsin that they may be used todetermine the impairment or intoxication status of the individual being tested.

2. In addressing the complexitiesassociated with various sanctionand incentive options, cocaineurine levels may be utilized inthe decision making process.

3. Any fluid intake changes an individual’s urine drug level.

4. Laboratories will not reportdrug testing results without a numerical value becausetesting manufacturers haveindicated in their product literature that such measure-ments are important to resultinterpretation.

5. Certified laboratories are neverallowed to report the numericalvalues produced by screeningprocedures for drug tests per-formed on federally regulatedemployees.

6. Evidence admissibility standardsfor drug courts are less restric-tive because in many courtsthe participants have alreadypleaded guilty.

FT

FT

FT

FT

FT

FT

FACT SHEET QUIZ: WHAT DID YOU LEARN?

Answers:1. False; 2. False; 3. True; 4. False; 5. True; 6. False

Example EtG/EtS Drug Court Client Contract The following document is an example client contract for use with drug court participants undergoing alcohol abstinence monitoring that employs the laboratory test for ethyl glucuronide (EtG). As with any client contract, the primary purpose is to outline the behavioral requirements and compliance standards necessary for continued participation in drug court. In addition, this client contract serves to educate, alert and advise drug court participants to the potential (incidental) sources of alcohol that could produce a positive urine EtG test result. This contract is designed to inform drug court clients of the numerous commercial products that contain ethyl alcohol and to provide them with a list of substances to avoid while in a drug court program. Courts utilizing EtG testing should consider this contract as a tool for advising participants on inadvertent sources of alcohol. This contract may also be useful in the sanctioning of drug court clients when used in combination with a positive EtG test result. Programs should revise this example contract as needed to conform to specific program goals and objectives. URINE ABSTINENCE TESTING AND INCIDENTAL ALCOHOL EXPOSURE CONTRACT Recent advances in the science of alcohol detection in urine have greatly increased the ability to detect even trace amounts of alcohol consumption. In addition, these tests are capable of detecting alcohol ingestion for significantly longer periods of time after a drinking episode. Because these tests are sensitive, in rare circumstances, exposure to non-beverage alcohol sources can result in detectible levels of alcohol (or its breakdown products). In order to preserve the integrity of the Drug Court testing program, it has become necessary for us to restrict and/or advise Drug Court participants regarding the use of certain alcohol-containing products. It is YOUR responsibility to limit your exposure to the products and substances detailed below that contain ethyl alcohol. It is YOUR responsibility to read product labels, to know what is contained in the products you use and consume and to stop and inspect these products BEFORE you use them. Use of the products detailed below in violation of this contract will NOT be allowed as an excuse for a positive test result. When in doubt, don’t use, consume or apply. Cough syrups and other liquid medications: Drug Court participants have always been prohibited from using alcohol-containing cough/cold syrups, such as Nyquil®. Other cough syrup brands and numerous other liquid medications, rely upon ethyl alcohol as a solvent. Drug Court participants are required to read product labels carefully to determine if they contain ethyl alcohol (ethanol). All prescription and over-the-counter medications should be reviewed with your case manager before use. Information on the composition of prescription medications should be available upon request from your pharmacist. Non-alcohol containing cough and cold remedies are readily available at most pharmacies and major retail stores. Non-Alcoholic Beer and Wine: Although legally considered non-alcoholic, NA beers (e.g. O’Douls®, Sharps®) do contain a residual amount of alcohol that may result in a positive test result for alcohol, if consumed. Drug Court participants are not permitted to ingest NA beer or NA wine. Food and Other Ingestible Products: There are numerous other consumable products that contain ethyl alcohol that could result in a positive test for alcohol. Flavoring extracts, such as vanilla or almond extract, and liquid herbal extracts (such as Ginko Biloba), could result in a positive screen for alcohol or its breakdown products. Communion wine, food cooked with wine, and flambé dishes (alcohol poured over a food and ignited such as cherries jubilee, baked Alaska) must be avoided. Read carefully the labels on any liquid herbal or homeopathic remedy and do not ingest without approval from your case manager. Mouthwash and Breath Strips: Most mouthwashes (Listermint®, Cepacol®, etc.) and other breath cleansing products contain ethyl alcohol. The use of mouthwashes containing ethyl alcohol can produce a positive test result. Drug Court participants are required to read product labels and educate themselves as to whether a mouthwash product contains ethyl alcohol. Use of ethyl alcohol-containing mouthwashes and breath strips by Drug Court participants is not permitted. Non-alcohol mouthwashes are readily available and are an acceptable alternative. If you have questions about a particular product, bring it in to discuss with your case manager.

Hand sanitizers: Hand sanitizers (e.g. Purell®, Germex®, etc.) and other antiseptic gels and foams used to disinfect hands contain up to 70% ethyl alcohol. Excessive, unnecessary or repeated use of these products could result in a positive urine test. Hand washing with soap and water are just as effective for killing germs. Hygiene Products: Aftershaves and colognes, hair sprays and mousse, astringents, insecticides (bug sprays such as Off®) and some body washes contain ethyl alcohol. While it is unlikely that limited use of these products would result in a positive test for alcohol (or its breakdown products) excessive, unnecessary or repeated use of these products could affect test results. Participants must use such products sparingly to avoid reaching detection levels. Just as the court requires Drug Court participants to regulate their fluid intake to avoid dilute urine samples, it is likewise incumbent upon each participant to limit their use of topically applied (on the skin) products containing ethyl alcohol. Solvents and Lacquers. Many solvents, lacquers and surface preparation products used in industry, construction, and the home, contain ethyl alcohol. Both excessive inhalation of vapors, and topical exposure to such products, can potentially cause a positive test result for alcohol. As with the products noted above, Drug Court participants must educate themselves as to the ingredients in the products they are using. There are alternatives to nearly any item containing ethyl alcohol. Frequency of use and duration of exposure to such products should be kept to a minimum. A positive test result will not be excused by reference to use of an alcohol-based solvent. If you are in employment where contact with such products cannot be avoided, you need to discuss this with your Case Manager. Do not wait for a positive test result to do so. Remember! When in doubt, don’t use, consume or apply. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES: ___________________________ _________________________ PARTICIPANT DATE Paul Cary would like to thank Michael Hollenbeck and Ron Michaelson of the Dearborn, MI Drug Court program for the concept of this contract and the original draft used to produce this example.

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