A Northwest company in the pursuit of excellence The Seventh Annual Providers Conference Lynnwood Convention Center Lynnwood, WA April 18, 2013

Unraveling the Mysteries of Urine Drug Testing Jim Heit, BS, MT(ASCP) Technical Support Manager STERLING Reference Laboratories

Unraveling the Mysteries of Urine Drug Testing COMMON TOXICOLOGY QUESTIONS

DRUG TESTING How are Drug testing results Obtained? Screening Assays – indicate the presumptive presence of drugs. Confirmation Assays – identify the drug detected in the screening assay

DRUG TESTING Immunoassay Screening tests What are they? How do they work? How accurate are they?

DRUG TESTING U + R = UR Appropriate reagents (Urine) + (Reagent) = (Reaction Product) Appropriate reagents Method for recognizing or measuring the reaction product

DRUG TESTING Screening Tests for Drug Class Enzyme Immunoassay Presumptive Presence of Drugs Indicates the presence of a drug by recognizing that substance’s unique structure. Relatively Inexpensive, easily automated False Positives are Possible Essential to Confirm all POSITIVE Screens False Negatives are Rare

THE QUESTION “Paul’s explanation for his positive THC result of 45 ng/mL was because he was in his friend’s car. He wasn’t smoking but two of his buddies were.”

PASSIVE INHALATION

WEIGHT LOSS?? My client, who is very much over weight, has a history of heavy use of marijuana for many years. He recently started exercising and lost a lot of weight. He claims he tested POSITIVE for THC because THC was released from his fat cells. There is no evidence that rapid weight loss results in release of THC from adipose tissue. 10

CONFIRMATION ASSAYS What are the criteria? Better specificity and sensitivity than the screening test The “Gold Standard” - Gas Chromatography/Mass Spectrometry (GC/MS)

CONFIRMATION TESTING Gas Chromatography/Mass Spectrometry Gold Standard for Confirmation Chemical “Fingerprint” of Drugs Sensitive and Specific Legally Defensible Liquid Chromatography/Tandem Mass Spectrometry (LC/MS/MS) Emerging Standard for Confirmation

Confirmation Testing Quantitative Results ??? The higher the result, the more recent the use or a much larger dose of drug was used. Debate on use of quantitative results. 13

THE EXCUSE My client tested POSITIVE for morphine at 739 ng/mL. He has no history of opiate abuse. He claims that he tested positive because he ate a large poppy seed muffin for breakfast on the morning of the day of the specimen collection. Poppy seeds contain morphine. Morphine levels up to 5,000 ng/mL are possible from ingestion of poppy seeds in baked goods. 14

WINDOW of DETECTION Depends on Drug Class Amphetamines Cocaine Opiates 2 - 3 Days Cocaine 2 - 4 Days, Longer for Chronic Use Opiates 3 - 4 Days PCP 5 – 8 Days THC Less than 2 Weeks most people Heavy, Chronic use, up to 6 – 8 Weeks

Specimen Validity Testing Is the specimen sufficiently concentrated to interpret negative screening results? Has the specimen been tampered with or adulterated in some manner to make negative screening results invalid?

SPECIMEN VALIDITY TESTING Components Visual examination Olfactory examination Chemical Evaluation Creatinine Specific Gravity (S.G.) if creatinine is < 20 mg/dL General oxidant pH

SPECIMEN VALIDITY TESTING Dilution Creatinine <20 mg/dL Inert metabolite from skeletal muscle, concentration dependent on hydration status Most sensitive indicator of dilution Specific Gravity <1.003 Measurement of dissolved solids Determined only if Creatinine <20 mg/dL

SPECIMEN VALIDITY TESTING There is ABSOLUTELY NOTHING that can be taken by mouth, except WATER or other fluids, that will produce a Negative Urine Drug Test. Excessive fluid intake results in Low Creatinine levels. 19

Creatinine Distribution

THE QUESTION So what is the big deal about a dilute specimen? Why should I care that it is dilute?

Excessive Fluid Intake Adequate Fluid Intake Excessive Fluid Intake Kidney Kidney BLADDER

THE QUESTION I received the report that said that the urine was “dilute”. How much water did the person drink?

URINE SPECIMEN DILUTION Pre-Collection Dilution consumption of large quantities of fluids prior to collection Post-Collection Dilution adding fluid to specimen at the time of collection

PRE-COLLECTION DILUTION High-volume ingestion of fluids (water loading, flushing, hydrating, etc.) Flushing or detoxifying products Gold Seal, Clean ‘n Clear, Test-Free, etc No evidence these products have any additional effect on drug elimination

SPECIMEN VALIDITY TESTING Medical Causes for Dilute Urines Diabetes Insipidus Anorexia Nervosa or other muscle wasting syndromes Kidney Disease Diuretics Pharmaceutical Toxicity Lithium, others

SPECIMEN VALIDITY TESTING pH Testing – SAMHSA Guidelines Acceptable pH: 4.5 to 9.0 SAMHSA Guidelines for Adulteration: ≤3.0 or ≥11.0 SAMHSA Guidelines for Invalid Result: >3.0 to <4.5 or >9.00 to <11.00

SPECIMEN VALIDITY TESTING Iodine Producing Adulterants (Urine Luck 6.5) Strong Acid and Fluorine (Urine Luck 6.3 and 6.4) Chromium VI (various formulations of PCC and potassium dichromate) Peroxidase/Peroxide (Stealth) Bleach Nitrite (Klear, Whizzies) NaCl (table salt)

SPECIMEN VALIDITY TESTING Oxidants Hypochlorite (Bleach) Persulfate Fluorine Others Vinegar Sodium Hydroxide (Drano®) Soap

SPECIMEN VALIDITY TESTING pH The uses of Iodine and Fluorine containing compounds results in pH of 2.6 – 5.5 Drano (NaOH) is the only common adulterant that can raise the pH

EXAMPLES Creatinine <2 mg/dL Specific Gravity 1.0005 pH 6.5 Interpretation – Substituted – Creatinine <2.0, S.G. <or= 1.001 Most likely pure water

EXAMPLES Creatinine <2 mg/dL Specific Gravity 1.032 pH 3.2 Interpretation – Substituted/invalid; Creatinine <2.0, S.G. =or> 1.020; pH invalid 3.2 Fruit juice?

EXAMPLES Creatinine <1 mg/dL Specific Gravity 1.011 pH 7.8 Interpretation – Creatinine <2.0, specific gravity acceptable Actual results from an artificial urine encountered frequently in Northern WA

SPECIMEN VALIDITY TESTING Substitution is now more prevalent than adulteration Quick Fix Clear Test Ultra Pure

WHIZZINATOR AD Available in a variety of natural lifelike skin tones Fully adjustable latex belt 4 oz vinyl bag One dehydrated, toxin free urine specimen Four organic heat pads $150.00

SPECIMEN VALIDITY TESTING Synthetic Urine Mimics normal human urine Creatinine Electrolytes (Na ,K, Cl, Ca, Mg) Urea, Phosphate Difficult to detect by standard testing Depends on knowledge and skill of chemist Non-Human Urine Difficult to Detect

SYNTHETIC URINE Is it legal to make or sell synthetic urine? YES Is it Illegal to substitute synthetic urine? In most states NO WA has no statute Illegal in ten states PA, TX, NE, NC, SC, NJ, VA,OR, MD, AL

ARTIFICIAL URINE TEST STERLING has found a unique analyte that is lacking in synthetic urine. Five Synthetic Urines Purchased 12 Components Screened 3 Compounds Studied 1 Analyte Chosen Missing in all synthetic urines studied. Unobserved Employment Urines Screened 5.7% of 567 specimens synthetic urine

ALCOHOL TESTING Blood or Breath Alcohol Urine Alcohol Gold Standard Legally Defined Limit of Impairment 12 Hour Window of Detection Urine Alcohol Does not correlate with Blood Alcohol 14 Hour Window of Detection Fermentation is Potential Problem

ALCOHOL TESTING Ethylglucuronide Direct Bio-Marker of Ethanol Exposure Stable, Water Soluble Minor Metabolite of Ethanol Synthesis in Liver EtOH +glucuronic acid = EtG Window of Detection 72 – 96 Hours Dependent on amount and frequency of consumption No False Positives Fermentation NOT a Factor

ETHYLGLUCURONIDE Not a marker of impairment Does not correlate with BAC Not a marker for amount of alcohol consumption

ETHYLGLUCURONIDE: ANALYSIS Screening Assays LC/MS/MS Immunoassay Confirmation Assays EtS Detected and Quantified No False Positives Legally Defensible

ETHYLGLUCURONIDE Voluntary Exposure to Ethanol Voluntary consumption of alcoholic beverage Incidental Exposure to Ethanol Alcohol exposure without intent Not a FALSE POSITIVE Result Alcohol exposure in both situations

ETHYLGLUCURONIDE SAMHSA Advisory Analytical Methods are Valid! What are Appropriate Cut-Offs? Interpretation of Low Positive Results? Incidental Exposure?

Ethylglucuronide-Incidental Exposure 10% 26.9% 62% 35% 0.2 - 0.8 % 14% 0.5% 3 – 6 %

Ethylglucuronide

Ethylglucuronide

THE EXCUSE “My job requires me to wash dirty car parts in denatured alcohol. Every 20 – 30 minutes I have my hands in the alcohol. That is why my EtG level was 2600 ng/mL”

ETHYLGLUCURONIDE CUT-OFFS Common Positive Cut-Off Values 100 ng/mL Used in “zero tolerance” programs Susceptible to incidental exposure 250 ng/mL Used in most programs Less susceptible to incidental exposure 500 ng/mL Used in more “liberal/tolerant” programs Least susceptible to incidental exposure

Alternate Matrices Hair Oral Fluid On Site Devices 51

HAIR ADVANTAGES Provides a longer estimate of time of drug use Observed collection Ease of obtaining, storing, and shipping specimens Second specimen can be obtained from original source 52

HAIR Recent use not detected Casual user may not be detected DISADVANTAGES Recent use not detected Casual user may not be detected Possible hair type biases Possible false positives from external contamination Expensive 53

ORAL FLUID ADVANTAGES Gender neutral collections Non-invasive collection Detects recent use Possible correlation with state of impairment 54

ORAL FLUID DISADVANTAGES Short window of detection Quality of specimen is collection device dependent Specimen recovery from stimulant abusers difficult Drug recovery, especially cocaine, is pH dependent Limited test menu 55

Onsite Devices Advantages Instant Results Ability to confront donor May be cheaper Disadvantages Qualitative results and subjective interpretation No accurate cut-offs High false positive rate Specimen validity tests unreliable 56

Others Sweat Patches Finger/toe nails Skin scrapings Meconium

SPICE

SPICE and BATH SALTS Calls to Poison Control Centers SPICE BATH SALTS 2010-- 2,870 calls about spice Jan. 2011-- 385 calls 2011 Projected = 4,620 2011 6,890 actual calls BATH SALTS 2010-- 236 calls about bath salts Jan. 2011--251 calls 2011 Projected = 3,012 2011 6072 actual calls

SPICE: Synthetic Cannabinoids Synthetic cannabinoids started out as legitimate scientific endeavors. More than 250 synthetic cannabinoids synthesized.

SPICE: HISTORY 2004 First Appearance in Europe 2008 Wide Spread use in Europe 2008 First Appearance in United States 2008 First Analysis of SPICE at University of Freiburg, Germany 2009 Wide Use in United States 2010 Laboratory Testing of Spice Available

SPICE: Preparation Botanical Material Herbal Incense Synthetic cannabinoids sprayed on herbs, allowed to dry Residual solvent No quality control Batches inconsistent Expensive compared to marijuana Caveat emptor

SPICE: Pharmacology Euphoria (“high”) similar to Marijuana Relaxation Altered state of consciousness Distortion of sensory experiences Impaired motor control Increased reaction time Decreased cognition NO effect on appetite

SPICE: Adverse Side Effects Elevated Blood Pressure Increased Heart Rate Hyperventilation Anxiety and Agitation Paranoia Seizures Vomiting Death (unsubstantiated media reports)

SPICE: International Legal Status All or some Synthetic Cannabinoids Banned Australia Austria France Germany Japan New Zealand Poland Romania Russia Slovak Republic South Korea Switzerland United Kingdom

SPICE: Legal Status in U.S. States Some or all Synthetic Cannabinoids Banned Alabama Arkansas Georgia Illinois Iowa Kansas Kentucky Louisiana Michigan Missouri Nevada (?) New Hampshire New Mexico Oklahoma Oregon Tennessee Utah (?) Washington West Virginia

SPICE: Legal Status U.S. Military Banned in All Branches of Military U.S. Army U.S. Air Force U.S. Coast Guard U.S. Marine Corps U.S. Navy

SPICE: Legal Status U.S. Federal Schedule Status November 24, 2010 DEA published in Federal Register intent to place five synthetic cannabinoids on Schedule 1 of CSA. March 1, 2011 final rule published. STATUS: Schedule 1, therefore ILLEGAL

SPICE: Laboratory Testing Synthetic Cannabinoids not detected in THC screening immunoassays or THC confirmatory GC/MS testing. Immunoassays now available. On-Site screening tests now available, but high cutoff severely limits usefulness. LC/MS/MS technology available. Few labs perform testing. Expensive $30 - $100 per sample

SPICE: Lab testing Current Metabolites STERLING screens for: JWH018 (2 metabolites) JWH019 (1 metabolite) JWH073 (2 metabolites) JWH250 (2 metabolites) AM2201 (1 metabolite)

SPICE: ANALYSIS Future of Spice Testing Alternative Matrix More compounds to be tested as SPICE formula evolves. New metabolites. Alternative Matrix Blood Measure Parent Drug Oral Fluid Hair Enhanced Window of Detection

DESIGNER DRUGS: BATH SALTS

CATHINONES Fresh leaves chewed or consumed as tea Originated in Ethiopia Causes release of dopamine from brain areas Sale of Khat legal in - Australia by permit Oman Yemen United Kingdom

DESIGNER DRUGS: Bath Salts Central Nervous System Stimulants Similar in action to methamphetamine Thought to be highly addictive MDPV is 5–8x potency of methylphenidate Available as research chemical in 2007 Popular in Europe and Australia Legal Banned in Louisiana and Florida Jan. 2011

BATH SALTS: Adverse Side Effects Elevated Heart Rate and Blood Pressure Anxiety and agitation Hallucinations Extreme Paranoia Delusions Seizures Nausea and Vomiting Death

PREVALENCE: Urine MDPV 88.0% Methylone 20.7% Mephedrone 3.1% Butylone 1.2%

BATH SALTS: ANALYSIS Bath Salts are not detected in Amphetamine Screening Immunoassays or Confirmatory GC/MS assays Immunoassays available, but expensive. Rapid On-Site Tests not available LC- or GC/MS assays available for MDPV and Others Available at STERLING March 1, 2011

SPICE and BATH SALTS FUTURE OF DESIGNER DRUGS They are here to stay. The problem will get worse long before it gets better. DEMAND = SUPPLY Analytical Labs Will Always Lag Behind the Synthetic Chemists

Contact Information QUESTIONS??? jheit@regtox.com dbaker@regtox.com dricketts@regtox.com certifying@regtox.com