a best practices review of drug detection for court professionals
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A Best Practices Review of Drug Detection for Court Professionals. By: Paul L. Cary Toxicology Laboratory University of Missouri. Volume II ? – Fall 2014. drug testing data/evaluation role of the team ancillary services caseload addendum on legal. Best Practices. - PowerPoint PPT PresentationTRANSCRIPT
A Best Practices Review of Drug
Detection for Court Professionals
By: Paul L. CaryBy: Paul L. Cary
Toxicology LaboratoryToxicology Laboratory
University of MissouriUniversity of Missouri
Volume II ? – Fall 2014 drug testingdrug testing data/evaluationdata/evaluation role of the teamrole of the team ancillary servicesancillary services caseloadcaseload addendum on legaladdendum on legal
Best Practices frequency of testingfrequency of testing random testingrandom testing witness collection & specimen witness collection & specimen
integrityintegrity custody & controlcustody & control accurate results & confirmationaccurate results & confirmation rapid turn-around timerapid turn-around time
The law is not black and white and neither is science.““. . there is a substantial gap between the . . there is a substantial gap between the questions that the legal community would like questions that the legal community would like to have answered by drug testing and the answers to have answered by drug testing and the answers that the scientific community is able to provide. that the scientific community is able to provide. The real danger lies in the legal community’s The real danger lies in the legal community’s failure to “mind the gap” by drawing unwarranted failure to “mind the gap” by drawing unwarranted inferences from drug testing results.” inferences from drug testing results.”
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 maintaining identify 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 accountability provides incentive, support and accountability for participantsfor participants
adjunct to treatment & frames sanction decisionsadjunct to treatment & frames sanction decisions
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 test sweat - patch test saliva - oral fluidssaliva - oral fluids
When to Test? KEEP KEEP ‘‘EM GUESSING !EM GUESSING ! effective drug testing effective drug testing mustmust be be random
unexpected, unannounced, unanticipatedunexpected, unannounced, unanticipated limit time between notification & testinglimit time between notification & testing
test as often as possible - test as often as possible - twice weekly consider use of multiple specimens (hair, consider use of multiple specimens (hair,
saliva, sweat)saliva, sweat) testing frequency remains constant
throughout program participation
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
Drug Testing Reality Check
When developing and administering your When developing and administering your drug testing program drug testing program assumeassume that the that the participants you are testing know participants you are testing know moremore about about urine drug testing than you do!urine drug testing 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 be tested for the presence of drugs in my I will be tested for the presence of drugs in my
system on a random basis according to system on a random basis according to procedures established by the Drug Court procedures established by the Drug Court Team and/or my treatment provider.Team and/or my treatment provider.
I understand that I will be given a location and I understand that I will be given a location and time to report for my drug test.time to report for my drug test.
I understand that it is my responsibility to I understand that it is my responsibility to report to the assigned location at the time report to the assigned location at the time given for the test. given for the test.
The Importance of “Specificity” in a Client
Contract: I understand that if I am late for a test, or miss I understand that if I am late for a test, or miss
a test, it will be considered as a positive test a test, it will be considered as a positive test for drugs/alcohol and that I may be sanctioned. for drugs/alcohol and that I may be sanctioned.
I understand that if I fail to produce a urine I understand that if I fail to produce a urine specimen or if the sample provided is not of specimen or if the sample provided is not of sufficient quantity, it will be considered as a sufficient quantity, it will be considered as a positive test for drugs/alcohol and that I may positive test for drugs/alcohol and that I may be sanctioned.be sanctioned.
I understand that if I produce a dilute urine I understand that if I produce a dilute urine sample it will be considered as a positive test sample it will be considered as a positive test for drugs/alcohol and that I may be sanctioned.for drugs/alcohol and that I may be sanctioned.
The Importance of “Specificity” in a Client
Contract: I have been informed that the ingestion of I have been informed that the ingestion of
excessive amounts of fluids can result in a excessive amounts of fluids can result in a diluted urine sample and I understand that my diluted urine sample and I understand that my urine sample will be tested to ensure the urine sample will be tested to ensure the sample is not dilute. sample is not dilute.
I understand that substituting or altering my I understand that substituting or altering my specimen or trying in any way to modify my specimen or trying in any way to modify my body fluids for the purposes of changing the body fluids for the purposes of changing the drug testing results will be considered as a drug testing results will be considered as a positive test for drugs/alcohol and will result in positive test for drugs/alcohol and will result in sanctioning and may be grounds for sanctioning and may be grounds for immediate termination from drug court.immediate termination from drug court.
Challenging Urine Collection Strategies
The “witnessed” collection (for urine) single most important aspect of single most important aspect of
effective drug testing programeffective drug testing program urine collections not witnessed are of urine collections not witnessed are of
little or no assessment valuelittle or no assessment value denial component of substance abuse denial component of substance abuse
requires “direct observation” requires “direct observation” collections of participantscollections of participants
Sample Collection: pre-collection preparationpre-collection preparation
site selectionsite selection minimize access to water sourcesminimize access to water sources use 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
confirm ID confirm ID removal of outer clothingremoval of outer clothing
Sample Collection: (continued)
wash hands prior to donationwash hands prior to donation ““witness” collectionwitness” collection
additional clothing removaladditional clothing removal body inspectionbody inspection squat and coughsquat and cough
label sample correctlylabel sample correctly 61st District Court - Grand Rapids 61st District Court - Grand Rapids
Sample Collection: (continued)
accept sample & inspectaccept sample & inspect temperature (90-100˚ F)temperature (90-100˚ F) color (no color color (no color diluted ?) diluted ?) odor (bleach, sour apples, odor (bleach, sour apples,
aromatics, vinegar, etc.) aromatics, vinegar, etc.) solids or other unusual particulatessolids or other unusual particulates
store sample properlystore sample properly forensic sample - custody documentsforensic sample - custody documents
Drug Testing Methods
Two-Step Testing ApproachTwo-Step Testing Approach
screening test – designed to separate screening test – designed to separate negative samples from samples that are negative samples from samples that are “presumptively” positive“presumptively” positive
confirmation test – follow-up procedure confirmation test – follow-up procedure designed 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 often based on immunoassay technologytechnology
more drug – more binding - more “color” more drug – more binding - more “color” produced – more instrument detector produced – more instrument detector responseresponse
numerous commercial manufacturersnumerous commercial manufacturers designed for high throughput designed 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 “switch”concept of color “switch” ““dynamic” versus “static” calibration dynamic” versus “static” 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 gas chromatography-mass spectrometry GC/MS or LC/MSspectrometry GC/MS or LC/MS drug molecules separated by physical drug molecules separated by physical
characteristicscharacteristics identified based on chemical “finger-identified based on chemical “finger-
print”print” considered “gold standard”considered “gold standard”
other chromatographic techniquesother chromatographic techniques
Why confirm ? Is it really necessary to confirm drugs Is it really necessary to confirm drugs
that tested positive by initial that tested positive by initial screening tests?screening tests?
Why can’t the court adjudicate cases Why can’t 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 “non-screening tests can and do react to “non-
target” compoundstarget” compounds amphetaminesamphetamines benzodiazepinesbenzodiazepines
obtain list of interfering compounds from obtain list of interfering compounds from lab or on-site test vendorlab or on-site test vendor
initial screening (“instant” tests) may only initial screening (“instant” tests) may only be 60-70% accuratebe 60-70% accurate
confirm positive resultsconfirm positive results
Choosing a Drug Testing Laboratory certifications – SAMHSAcertifications – SAMHSA CAP-FUDT (College of American Pathologists - Forensic CAP-FUDT (College of American Pathologists - Forensic
Urine Drug Testing)Urine Drug Testing) methodology, SOP, staff qualifications, quality methodology, SOP, staff qualifications, quality
assurance, security, etc.assurance, security, etc. turn-around timeturn-around time, result reporting formats, result reporting formats cost - $$$$cost - $$$$ customer service (access to expert advice)customer service (access to expert advice) ease of access - proximity, minimize sample handlingease of access - proximity, minimize sample handling request current customer listrequest current customer list
Choosing an On-Site Testing Device
FDA - approvedFDA - approved CLIA-waived (means nothing)CLIA-waived (means nothing) cost - $$$$ (BUT - you get what you pay cost - $$$$ (BUT - you get what you pay
for)for) ease of useease of use appropriate cutoff levelsappropriate cutoff levels customer service (access to expert advice)customer service (access to expert advice) request current customer listrequest current customer list confirmation required confirmation required
Interpretation ofDrug Test Results
Negative or None Detected Results
indicates that no drugs or breakdown indicates that no drugs or breakdown products (metabolites), tested for, were products (metabolites), tested for, were detected in the sample testeddetected in the sample tested
no such thing as “zero” tolerance or “drug no such thing as “zero” tolerance or “drug free”free”
negative does not mean NO drugs present negative does not mean NO drugs present
Negative/None Detected Interpretation client is not using a drug that can be detected by the test client is not using a drug that can be detected by the test
Other possible explanationsOther possible explanations client not using enough drugclient not using enough drug client’s drug use is too infrequentclient’s 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 “negative” result need to second-guess every “negative” result notnot suggesting withholding positive reinforcement & rewards suggesting withholding positive reinforcement & rewards
for positive behaviorsfor positive behaviors drug testing is a monitoring tool drug testing is a monitoring tool assess none detected drug testing results in the context of assess none detected drug testing results in the context of
your client’s overall program compliance (or non-compliance) your client’s overall program compliance (or non-compliance) and their life’s skills success (or lack thereof)and their life’s skills success (or lack thereof)
Positive Test Result Interpretation
indicates that drug(s) or breakdown products indicates that drug(s) or breakdown products (metabolites), tested for, were detected in the (metabolites), tested for, were detected in the sample testedsample tested
drug presence is above the “cutoff” leveldrug presence is above the “cutoff” level greatest confidence achieved with confirmationgreatest confidence achieved with confirmation ALWAYS confirm positive results in original ALWAYS confirm positive results in original
samplesample
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 (PCP) * 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 cutoffs are not designed to frustrate CJ
professionalsprofessionals a drug concentration, a drug concentration, administrativelyadministratively
established for a drug test that allows the test to established for a drug test that allows the test to distinguish between negative and positive sample - distinguish between negative and positive sample - “threshold”“threshold”
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
The Issue of UrineDrug Concentrations
Drug Tests are Qualitative
screening/monitoring drug tests are screening/monitoring drug tests are designed to determine the presence designed to determine the presence or absence of drugs - NOT their or absence of drugs - NOT their concentrationconcentration
drug tests are NOT quantitativedrug tests are NOT quantitative
Drug concentrations or levels associated with urine testing are, for the most part, USELESS !
cannabinoidscannabinoids 517 ng/mL517 ng/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
The Twins - urine drug test results
A B
physiological make up
exact amount drug consumed
exact time of ingestion
exact time between drug exposure and urine collection
AND YET . . . . .
The Twins - urine drug test results
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 questions being 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 continued Is 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 no interpretative value. The utilization of urine drug test levels by drug courts generally produces interpretations that are inappropriate, factually unsupportable and without a scientific foundation. Worst of all for the court system, these urine drug level 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 differential elimination of drug
componentscomponents
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 Detection Window
Drug Detection Times - by Drug(this is general guidance!)
amphetamines: up to 4 days amphetamines: 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’s alcohol & cannabinoids . . then there’s alcohol & cannabinoids
Cannabinoid Detection in Urine Conventional wisdom has led to the common
assumption that cannabinoids will remain detectable in urine for 30 days or longer following the 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 exaggerates 30+ day detection window often exaggerates duration 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 useup to 3 days for single event/occasional use up to 10 days for heavy chronic useup 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 useup to 7 days for single event/occasional use up to 21 days for heavy chronic useup to 21 days for heavy chronic use
Recent Cannabinoid Use versus Non-recent use (double sanction issue):
How do drug courts discriminate between How do drug courts discriminate between new drug exposure and continued elimination new drug exposure and continued elimination from previous (chronic) use ?from previous (chronic) use ? an issue only in first phase of programan issue only in first phase of program only drug that poses concern is only drug that poses concern is
cannabinoidscannabinoids ““two negative test” rule – two back-to-back two negative test” rule – 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 synthetic most 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 following detection 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 don’t necessarily document negative results don’t necessarily document
abstinenceabstinence detection time = hoursdetection time = hours example - person intoxicated at 11:00 PM, collect example - person intoxicated at 11:00 PM, collect
second urine sample of next day (11:00 AM), most second urine sample of next day (11:00 AM), most likely test negative for alcohol likely test negative for alcohol
EtG & EtS – Strategy for Monitoring Alcohol
Abstinence
Alcohol is the most commonly abused substance by court clients and the most difficult substance to detect in abstinence monitoring.
Advantages of Ethyl Glucuronide & Ethyl Sulfate unique biological marker of alcohol use (no unique biological marker of alcohol use (no
false positives)false 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 is not detected in the urine of abstinent
subjectssubjects
Extending the detection windowDuration of Detection
0 10 20 30 40 50 60
Urine EtG/EtS
Urine Alcohol
Breath Alcohol
Saliva Alcohol
Blood Alcohol
Specimen Type
Hours After Drinking Cessation
Advantages of Ethyl Glucuronide & Ethyl Sulfate unique biological marker of alcohol use (no unique biological marker of alcohol use (no
false positives)false 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 is not detected in the urine of abstinent
subjectssubjects
Disadvantages of EtG/EtS testing available at relatively few laboratoriestesting available at relatively few laboratories EtG testing more costly than abused drugsEtG testing more costly than abused drugs
expensive LC/MS/MS technologyexpensive LC/MS/MS technology introduction of new testing approachesintroduction of new testing approaches
most significant concern – casual, inadvertent, most significant concern – casual, inadvertent, environmental alcohol exposure causing environmental alcohol exposure causing positive resultspositive results
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., tincture of gingko biloba - memory)herbal/homeopathic medications (i.e., tincture of gingko biloba - memory) foods containing alcohol (such as vanilla extract, baked Alaska, cherries foods containing alcohol (such as vanilla extract, baked Alaska, cherries
jubilee, etc.)jubilee, etc.) ““non-alcoholic” beers (O’Doul’s, Sharps)non-alcoholic” beers (O’Doul’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 test result a definitive indicator of relapse or prohibited drinking?
Is a positive urine EtG/EtS test result sufficient justification for client sanctioning?
Consensus Cutoffs: EtG minimum of 500 ng/mLEtG minimum of 500 ng/mL EtS minimum of 100 ng/mLEtS minimum of 100 ng/mL
Positive EtG Result (500 ng/mL): a result reported as EtG positive in excess of the a result reported as EtG positive in excess of the
500 ng/mL cutoff is consistent with the recent 500 ng/mL cutoff is consistent with the recent ingestion of alcohol-containing products (1-2 days ingestion of alcohol-containing products (1-2 days prior to specimen collection) by a monitored clientprior to specimen collection) by a monitored client
studies examining “incidental” exposure widely studies examining “incidental” exposure widely conclude that results in excess of the 500 ng/mL conclude that results in excess of the 500 ng/mL cutoff are cutoff are notnot associated with inadvertent or associated with inadvertent or environment ethanol sources environment ethanol sources
Negative EtG Result (500 ng/mL): a result reported as EtG negative is a result reported as EtG negative is
indicative of a client who has not ingested indicative of a client who has not ingested beverage alcohol within 1-2 days prior to beverage alcohol within 1-2 days prior to specimen collectionspecimen collection
a negative result is a negative result is notnot proof of abstinence proof of abstinence advertised “80-hour” window of detection advertised “80-hour” window of detection
not “real-world” applicable not “real-world” applicable
EtG/EtS- Specific Contract:
outlines the behavioral requirements and outlines the behavioral requirements and compliance standards necessary for continued compliance standards necessary for continued participation in drug courtparticipation in drug court
educate, alert and advise drug court clients of the educate, alert and advise drug court clients of the potential (incidental) sources of alcohol that could potential (incidental) sources of alcohol that could produce a positive urine EtG/EtS test resultproduce a positive urine EtG/EtS test result
listing the numerous commercial products that listing the numerous commercial products that contain ethyl alcohol and provides a list of contain ethyl alcohol and provides a list of substances to avoid while in a drug court programsubstances to avoid while in a drug court program
Prohibited Items: OTC medications OTC medications non-alcoholic beer & winenon-alcoholic beer & wine foods that contain alcoholfoods that contain alcohol alcohol-based mouthwashesalcohol-based mouthwashes alcohol-based hand sanitizersalcohol-based hand sanitizers alcohol-based hygiene productsalcohol-based hygiene products
When in doubt, don’t use, consume
or apply!
Best Practices for EtG/EtS Testing:
provide those being monitored with an provide those being monitored with an alcohol use advisory document - EtG/EtS alcohol use advisory document - EtG/EtS specific contract - specific contract - mandatorymandatory
use appropriate cutoffs:use appropriate cutoffs: EtG - 500 ng/mLEtG - 500 ng/mL EtS - 100 ng/mLEtS - 100 ng/mL
test for EtS (ethyl sulfate) - biomarker of test for EtS (ethyl sulfate) - biomarker of choicechoice
EtG/EtS Admissibility? are EtG/EtS results legally admissibleare EtG/EtS results legally admissible Kelly-Frye, Daubert, Rule 703 Kelly-Frye, Daubert, Rule 703 use of proper cutoffs 500/100 ng/mLuse of proper cutoffs 500/100 ng/mL use of appropriate methodologies use of appropriate methodologies
(LC/MS/MS for confirmation of positives)(LC/MS/MS for confirmation of positives) use client contractuse client contract interpret results correctlyinterpret results correctly YES!YES!
Why Courts Should Use EtG/EtS
Prescription Drugs
Challenge with Challenge with PrescriptionPrescription
DrugsDrugs therapeutic use versus
abuseQuickTime™ and a
TIFF (Uncompressed) decompressorare needed to see this picture.
therapeuticuse
abusevarious stages of misuse
Drug testing is an excellent tool for the abstinence monitoring of court clients, however it provides limited information for the differentiation between the appropriate therapeutic use of prescribed medications and the misuse/abuse of those same drugs - regardless of the specimen tested.
Client Signed Releases
doctorsdoctors dentistsdentists other healthcare professionalsother healthcare professionals pharmaciespharmacies
Healthcare Contact Form
form used by clients to document contact with healthcare form used by clients to document contact with healthcare professionalsprofessionals
clients required to use contact form for each visit where clients required to use contact form for each visit where medications are being used during a procedure or prescribed for medications are being used during a procedure or prescribed for useuse
sanction for failure to use formsanction for failure to use form place requirement in client contractplace requirement in client contract client seek prior permission to see doctorclient seek prior permission to see doctor
I (client name), am a participant in drug court. This program is a court monitored recovery program for addicts. As a result, I am subject to frequent and random drug testing. Therefore, I must report to the court my visit today. As I am in recovery, I would respectfully request that you take this into consideration and offer non-narcotic medications, if possible, when drugs are necessary for my medical treatment.
Physician (Name) ______________________________________ Physician (Signature) _______________________________________
If you have any questions or concerns, please feel free to call the court and talk to my case specialists. If this patient fails to present this form to the nurse and physician prior to receiving medication or a prescription for medication, please notify the court.
Please list the medications prescribed today:
Other Control Strategies
search & seizure (client contract)search & seizure (client contract) car, home, possessions car, home, possessions
pill countspill counts no out-of-state prescriptionsno out-of-state prescriptions use of specified pharmaciesuse of specified pharmacies loss of completion credits/time while on certain loss of completion credits/time while on certain
prescription medsprescription meds
Ten Principles of Drug Testing 1. Design an effective drug detection program, place the
policies and procedures into written form & communicate to court staff and clients alike.
2. Develop a client contract that clearly enumerates the responsibilities and expectations of the
court’s drug detection program.
3. Select a drug testing specimen & testing methodology that provides results that are scientifically valid, forensically defensible and therapeutically beneficial.
Ten Principles of Drug Testing 4. Ensure that the sample collection process supports
effective abstinence monitoring practices; (random/unannounced selection & witnessed/direct observation sample collection)
5. Confirm of all positive screening results using alternative testing methods.
6. Determine the creatinine concentrations of all urine samples to identify tampering.
7. Eliminate of the use of urine levels for the interpretation of client drug use behavior.
Ten Principles of Drug Testing 8. Establish drug testing result interpretation
guidelines that have a sound scientific foundation and that meet a strong evidentiary standard.
9. In response to drug testing results, develop therapeutic invention strategies that promote behavioral change and support recovery.
10. Understand that drug detection represents only a single supervision strategy in an overall abstinence
monitoring program.
email address: [email protected]@health.missouri.edu