1. Practicalities of Conducting Biological Assessments for Drug Use Kenzie L. Preston, Ph.D. Chief, Clinical Pharmacology and Therapeutics Research Branch National Institute on Drug Abuse ACTTION/MOST Meeting, March 2015

2. Why Use Biological Measures? Costly Inconvenient Unnecessary? Good evidence that people under report use Adds credibility to results

3. Ideal Drug Testing for Clinical Trials Specimen is: Easily and safely collected Low risk of contamination/adulteration Easily stored/transported (if necessary) Window of detection that matches specimen collection schedule Test is: Good efficiency (sensitivity and specificity) Low cost Quick and easy

4. Drug Testing Workplace: public safety & reduce accidents Roadside: drugged driving Judicial: drug use & crimes Anti-doping: fair competition & promote health Military: deter drug use & ensure fitness for duty Clinical: diagnosis or postmortem Drug treatment: monitor recovery/abstinence Monitor drug use in clinical trials: evaluate treatments for efficacy ScreenConfirmation ? ?

5. Drug Testing and Addiction Sweat Hair Oral FluidBreathDried Blood Spot Urine

6. Survey of Drug Testing in Biological Matrices Major analyte Detection time Detection of recent use/sensitivity to change in rate of use Collection convenient Contamination On site testing? Other Issues

7. Survey of Drug Testing in Biological Matrices Major analyteMetabolite Detection time2-4 days Urine Detection of recent Yes/No - carry over positives can be a problem use/sensitivity to with frequent testing change in rate of use ( Quantitative and frequent testing required) Collection convenient No - Toilet facilities and same-sex observers Contamination Unlikely On site testing? Yes Other Issues Well established concentration cut-offs Well established use as an outcome measure Many laboratories use the same or similar assays

8. Concentration Cutoff Affects Window of Detection Preston, Epstein, Cone Wtsadik, Huestis, Moolchan, JAT 2002 N = 18 cocaine users living on a closed unit No drug administration - monitored excretion of cocaine and metabolites Sample collection - All urine voids (N=953) were collected for up to 14 days. 500450400350300250200150100 24 30 36 42 48 54 60 66 72 78 84 90 Concentration Cutoff for Positive Specimen Hours BE 300 ng/ml cutoff Time to Concentration Cutoff Lower cutoff lengthen window Raise cutoff shorten window

9. 0 2 4 6 8 10 12 ContingentControl Longest Duration of Sustained Abstinence Weeks Responders Nonresponders Clinical Trial - Contingent Reinforcement of Cocaine Abstinence

10. Sequential Urine Specimens Benzoylecgonine Concentration in Urine 50 45 40 35 30 25 20 15 10 5 5 0 0 1 1 100 1000 10000 100000 1000000 ng/mL Specimens were collected M, W, F for 17 weeks.

11. Sequential Urine Specimens Benzoylecgonine Concentration in Urine 50 45 40 35 30 25 20 15 10 5 5 0 0 1 1 100 1000 10000 100000 1000000 ng/mL Cutoff LOQ 11 occasions negative Specimens were collected M, W, F for 17 weeks. SAMHSA

12. Sequential Urine Specimens Benzoylecgonine Concentration in Urine 50 45 40 35 30 25 20 15 10 5 5 0 0 1 1 100 1000 10000 100000 1000000 ng/mL Cutoff LOQ 23 occasions of negative Specimens were collected M, W, F for 17 weeks. Cutoff SAMHSA

13. New Use Rules Purpose: To differentiate urine positives due to carryover from positives due to recent (or new) uses of cocaine

14. Sequential Urine Specimens Benzoylecgonine Concentration in Urine 50 45 40 35 30 25 20 15 10 5 5 0 0 1 1 100 1000 10000 100000 1000000 ng/mL Cutoff LOQ 28 occasions of new use 12 occasions of carry-over 11 occasions of negative Specimens were collected M, W, F for 17 weeks.

15. Comparison of Urine Screen and Self-Report Baseline Intervention

16. Survey of Drug Testing in Biological Matrices Major analyteParent>Metabolite Detection time1 week – months Hair Collection convenient Yes/No (depends of amount and style of hair ContaminationPossible On site testing?No, must be sent to outside lab Other IssuesAffected by hair color & treatments Only matrix with potential for replication Detection of recent No - limited by hair growth rate use/sensitivity to (7-10 days for hair to grow through scalp) change in rate of use Hair grows approximately 1 cm/mo.

17. Admission123456789 Week Scheidweiler, Cone, Moolchan, Huestis. JPET 313, 909-915, 2005 Cocaine and metabolite concentrations in hair N = 10 cocaine users Admission to closed unit 3 week drug washout Week 4 - 3 administrations of 75 mg/70 kg SC cocaine on alternating days Week 7 - 3 administrations of 150 mg/70 kg SC cocaine on alternating days Sample collection - electric razor Head hair shaved on admission Weekly collection of shavings Analysis Liquid chromatography tandem mass spectrometry Representative subject Benzoylecgonine Ecgonine methyl ester Norcocaine Cocaethylene

18. Cocaine - Concordance between hair testing and self-report – 86% Specificity >90%, Sensitivity 65 % Amphetamine - Concordance between hair testing and self-report – 86% Specificity >90%, Sensitivity 24%

19. Baseline and 3-month follow-up

20. Office-based vs. federally licensed narcotic treatment program Hair testing at Baseline and 3- and 6-month follow-ups in addition to self-report and urine toxicology No difference between groups Hair testing identified two additional participants in each group who had used illicit drugs. Positive hair test predicted drug use during the trial.

21. Survey of Drug Testing in Biological Matrices Major analyteParent>Metabolite Detection time3-10 days - usually one week Sweat Other IssuesAllergic reaction possible; patches may fall off Not well established use as outcome measure Currently available from only one company Collection convenient Yes/No (same-sex not needed, but patch may be visible) ContaminationPossible, especially if area not cleaned well On site testing?No, must be sent to outside lab Detection of recent Yes/No - carry over positives can happen use/sensitivity to detection of change limited by length change in rate of use of patch wear

22. BZE 1 1 10 100 1,000 10,000 16 14 12 10 8 8 6 6 4 4 2 2 1 1 100 1,000 10,000 100,000 1,000,000 16 14 12 10 8 8 6 6 4 4 2 2 1 1 100 1,000 10,000 100,000 1,000,000 1 1 10 100 1,000 10,000 Sweat Cocaine Urine Subject C Subject D Sweat Urine Weeks Cocaine BZE ng/mL ELISA Sweat Patch vs. EMIT Urine Results Sensitivity - 97.6% Specificity - 60.5% Preston, Huestis Wong Umbricht, Goldberger, Cone. J Anal Toxicol. 1999. Monitoring Cocaine Use in Sweat Patches ng/mL

23. 63 participants in a buprenorphine trial Applied 536 patches 188 (54%) properly worn, unadulterated patches Agreement between urine and patch results cocaine – 92% opiates – 33%

24. Survey of Drug Testing in Biological Matrices Major analyteParent>Metabolite Detection time1-2 days (depends on cut off and analyte) Oral Fluid Detection of recent Yes use/sensitivity to change in rate of use Collection convenient Yes ContaminationYes/No On site testing?Yes Other IssuesNot established as an outcome measure Affected by flow rate & pH

25. Detection of Cocaine Use in Oral Fluid Cocaine BZE (Cocaine Metabolite) Huestis et al.

26. Potential Areas of Research  Optimize concentration cut-offs/detection windows  Combine different biological matrices to optimize windows of drug detection  Investigate methods to improve adherence to specimen collection  Investigate methods to improve remote collection of specimens

27. Questions?