a best practices review of drug detection for court professionals

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: carypl@health.missouri.educarypl@health.missouri.edu