Urine Creatinine & Sample Tampering

1. Urine Creatinine & Sample Tampering By: Paul L. Cary Toxicology Laboratory University of Missouri

2. The ramifications of a positive drug test (i.e. sanction, program expulsion, imprisonment, etc.) combined with the denial component of substance abuse often create circumstances whereby clients feel the need to “beat the drug test” by tampering with the sample. Sample tampering represents a significant challenge to a the court’s mission and can threaten to undermine the legitimacy of the court’s policies and procedures as well as it’s decisions. It’s a matter of control.

3. Creatinine testing is a specimen validity issue!The most common form of specimen tampering is sample dilution.

4. Why Use Urine for Drug Testing? • generally readily available in large quantities • drug & metabolites are highly concentrated • extensive scientific basis for methodology • results accepted in court • provides both recent and past usage • uniform testing criteria (established cutoffs) • easily tested (laboratory & on-site) • quality assurance practices well-established

5. Problems With Urine as a Specimen: • YUCK factor! • biological waste product • distasteful qualities & invasive collection • NOT QUANTITATIVE – cannot use concentration to evaluate client drug use history • susceptible to tampering • drug concentration influenced by fluid intake • necessities witnessed collection

6. Creatinine & Dilute Samples

7. What is creatinine ? • creatinine is produced as a result of muscle metabolism • creatinine is produced by the body at a relatively constant rate throughout the day • creatinine is a compound that is unique to biological material (i.e. urine, other body fluids) • creatinine measurements can: • determine the “strength” or concentration of a urine sample • ensure the sample being tested IS urine

8. EVERY urine sample used for drug detection should be tested for creatinine!

9. Two Types of Urine Specimen Dilution • pre collection dilution • consumption of large quantities of fluids prior to collection • post collection dilution • adding fluid to specimen post collection

10. Pre-Collection Dilution • high-volume ingestion of fluids (water loading, flushing, hydrating, etc.) • may be in conjunction with products designed to “enhance” drug elimination or removal of drugs (Gold Seal, Clean ‘n Clear, Test-Free, Naturally Klean, etc.) • no evidence these products have any additional effect on drug elimination

11. Water contains no drugs! • easiest, cheapest, simplest • urines with a creatinines of less than 20 mg/dL are considered “dilute” and rarely reflect an accurate picture of recent drug use • dilute samples are more like water than like urine • all drug court/criminal justice samples should be screened for creatinine

12. How are creatinine measurements used ? • normal human creatinine levels will vary during the day based upon fluid intake - healthy individuals will rarely produce urine samples with creatinines of less than 20 mg/dL • incidence of creatinines less than 20 mg/dL in a “normal” population is approximately 1% • urines with a creatinines of less than 20 mg/dL are considered “dilute” and often do not reflect an accurate picture of recent drug use

13. Creatinine Facts • some diseases that produce low urinary creatinines • muscle wasting disease - RARE • some kidney aliments - RARE • low creatinines ARE NOT routinely associated with: • pregnancy • diabetes • obesity • exercise • high-blood pressure • being vegetarian

14. The “Normal” Creatinine • incidence of low creatinines in a population undergoing random drug testing is significantly (up to 10 times) greater than a non-drug tested population • any fluid intake dilutes the concentration of drugs in urine (along with the creatinine) • normal urine creatinine: 2005 study “Urinary Creatinine Concentrations in the U.S. Population” determine the mean (based upon 22,245 participants) was 130 mg/dL • less than 1% below 20 mg/dL • less than 1% greater than 400 mg/dL

15. More Creatinine Issues • rapid ingestion (90 minutes) of 2-4 quarts of fluid will almost always produce low creatinines & negative urine drug tests within one hour • recovery time of urine creatinine and drug concentrations can take up to 10 hours • incidence of drugs in urine of diluted specimens is over 5 times greater than in samples with normal creatinine levels

16. “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 probably could not be detected by the test • positive drug test results from a dilute sample however, are considered valid (donor was not able to dilute the sample sufficiently to deceive the test)

17. The “Inadvertent” Dilute • “My sample is dilute because I work as a roofer, on a black roof, in the middle of August when the temperature is 400˚ F.” • it is possible for a client to achieve a urine creatinine of less than 20 mg/dL under extreme conditions • court needs to develop creative solutions: • collect samples before work • collect samples on days off • use alternative specimens

18. Creatinine Sanctions • no national standard • adjudicate as “tampered” sample - more severely than positive sample • adjudicate as “positive” sample - court utilizes positive sample sanctions • adjudicate as “dilute” sample - unique sanctions • some courts allow one “dilute” sample per phase/quarter • regardless of sanction - court MUST address this issue

19. Two final thoughts about dilute urine samples . . . . . • a creatinine of less than 20 mg/dL (associated with a drug test) is nearly always an attempt by the donor to avoid drug use detection - REGARDLESS of how much liquid was consumed in order to achieve this result • place a dilute sample prohibition in your client contract and sanction for repeat dilute samples

20. On-Site Drug Testing

22. The Creatine Supplement Issue: • creatine is the pre-cursor of creatinine • creatine supplements may increase the amount of creatine in the muscles • muscles may be able to generate more energy or generate energy at a faster rate • creatine supplements (along with training) may improve performance by increasing energy for activities such as sprinting and weightlifting • but that’s NOT why our clients take it!

23. The Creatine Supplement Issue: • consuming over-the-counter creatine can disguise pre-collection hydration and a diluted urine • creatine converted to creatinine will mask the dilution efforts • in reality - very difficult to coordinate the intake timing and volume of creatine and dilution liquid • creatinine greater than 300 mg/dL - increased monitoring • creatinine greater than 400 mg/dL - sanctionable

24. What is Specific Gravity? • measure of total dissolved solids in a liquid • urine SpGr includes creatinine • alternative method of determining sample dilution • introduced in 1988 with federal workplace drug testing • common test performed by “forensic” labs

26. My Advice on Specific Gravity • use creatinine levels only to define “dilute” samples • samples less than 20 mg/dL • science-based approach • very defendable policy • easier to understand & explain to both clients & court professionals than SpGr

27. SUMMARY • TEST FOR CREATININE! • incorporate creatinine guidance in your SOPs and client contract • institute a dilute sample prohibition • understand low urine creatinine levels are NOT normal • dilute samples are nearly always an attempt by the donor to avoid drug use detection • sanction for repeat dilute tests

28. Specimen Tampering

29. Basics of Specimen Tampering - The Three Approaches • dilution • adulteration • substitution

30. Urine Specimen Dilution • most common form of tampering • pre collection dilution (hydration, water loading, diuretics) • post collection dilution • creatinine measurement • dilution detection (validity checks)

31. Urine Specimen Adulteration • addition of foreign substances designed to “mask” drug presence • post-collection tampering • low-tech adulterants that cause “pH shift” (lime, vinegar, bleach, ammonia, lemon, drano) • low-tech adulterants that disrupt testing chemistry (salt, methanol, detergent) • five common “high-tech” adulterants

32. Urinaid, Byrd Laboratories • gluteraldehyde • sterilization chemical • deactivates most screening tests - producing false negative results • can be identified by laboratories employing specimen validity tests • effects can not be reversed

33. Klear & Whizzies • potassium nitrite, sodium nitrite • analytical chemistry • compromises the confirmation (GC/MS) of some drugs, notably carboxy-THC • oxidizes drug and standards • can be identified by laboratories employing specimen validity tests (SVT) • effects can be reversed

34. Urine Luck • pyridinium chlorochromate/dichromate • oxidizing agent in organic synthesis • compromises the confirmation (GC/MS) carboxy-THC and opiates • can also effect screening tests • oxidizes drug and standards • can be identified by laboratories employing specimen validity tests (SVT) • effects can not be reversed

35. Checking for Adulterants • not necessary on all samples • creatinine - YES • suspicious sample collection • unusual sample characteristics • client suspected of relapse who continues to produce negative test results

36. Urine Specimen Substitution • replacing donor urine sample with another drug-free specimen • biological substitution - someone else’s “clean” urine • non-biological substitution - replacing urine with urine “look-a-like” sample (diet Mountain Dew, water with food coloring) • non-biologicals can be detected with creatinine testing

38. Specimen Validity Tests (SVT) • creatinine, UUN • specific gravity • pH • nitrites • gluteraldehyde • pyridine • chromium Request SVT from testing laboratory or use dip-stick SVT products for on-site testing

39. Controlling Specimen Tampering • develop challenging collection strategy - ie. make the testing unannounced and RANDOM! • directly observed collections is the most effective approach to preventing adulteration and substitution • inspect sample - train collection staff • keep abreast of tampering techniques • take temperature measurements (90˚ - 100˚ F) • use laboratory employs specimen validity tests & use with on-site devices

40. Confront Specimen Tampering with Facts: • actively engage clients about tampering issues • illustrates court’s tampering knowledge • discuss specimen tampering in court • prepare a fact-based presentation on the myths of tampering • highlights the futility of tampering • testimony from former clients • constantly reinforce the “honesty” component of drug court

41. Prepare a fact-based presentation on the myths of tampering – what does that mean?

47. Sure Jell/Certo - Reality email • Don't believe in the Certo or Sure Jel method. I tried it...failed all the drug tests I took every time I used it...I was being tested for marijuana for Arkansas Drug Court. Tested me every week...failed all three drug screens...they use a new on site screening machine that spins the sample around...supposedly it can even detect meth for up to 10 days...and can detect adulterants too...I cleaned up rather than try to cover up.

48. Engage clients in an honest discussion regarding tampering!

49. “Witnessed” collection (for urine) • single most important aspect of effective drug testing program • urine collections not witnessed are of little or no assessment value • denial component of substance abuse requires “direct observation” collections of participants