You Can’t Fool the “Bladder Police”

1. You Can’t Fool the “Bladder Police” Effective Use of Urine Drug Screening

2. Why Test? • Accountability • Create and maintain safe treatment environment • Compliance with licensing or policy

3. Collection • Supervised or unsupervised • When to collect • Staff training • Temperature monitored cups • Adulterant testing

4. In-house Testing • Staff training • Staff issues • Client privacy • Cost • Type of test kit • What to test for • When to test

5. Lab Testing • Staff training • Completing forms • Storage and pick up • Prescription • What to test for • When to test

6. Testing – How it Works • Drug Testing Systems • One Test Systems • Use immunoassay (IA) to detect the presence of drugs and • Are most often used for medical purposes in clinical and rehabilitation settings • Two Test Systems • Commonly use immunoassay as an initial test followed by a more specific confirmatory test using a different technology and • Are used for results requiring a high level of certainty John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

7. Testing – How it Works What is an Immunoassay? • An immunoassay is a biochemical test that measures the concentration of a substance in a liquid (a portion of a biological specimen) using the reaction of an antibody or antibodies to its antigen (drug) John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

8. Testing – How it Works What are Antibodies and Antigens? • Antibodies are a type of protein produced by the immune system in response to foreign substances (antigens) • Antibodies bind to the antigen responsible for their production John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

9. Y Common end Testing – How it Works • Antibodies: • Usually harvested from sheep or rabbits • Usually IgG (represented as a “Y”) • Developed against classes of drugs • Recognize antigen (drug) by its shape Immunoassay Principles I Shape recognition end John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

10. Testing – How it Works Immunoassay Principles II • Use Tagged Drug Targets • Indicator (Tag) is bound to the target drug • “Tag” may be • an enzyme • a fluorophore • a particle • Detection is based on competitive binding • Antibodies bind with Drug in Sample OR with Tagged Drug Targets “Tag” Drug John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

11. Testing – How it Works Immunoassay principles • Sample WITH drug in it • Add an antibody • Incubate Y Y Y Y Y Y Y John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

12. Y Y Y Y Y Y Testing – How it Works Immunoassay Principles III • Antibody binds drug in the sample • Add tagged drug target • Little or no antibody binding of the tagged compound • Little or no change in signal John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

13. Testing – How it Works Immunoassay Principles IV • Sample WITHOUT drug in it • Add an antibody • Incubate • Add tagged drug target Y Y Y Y Y Y Y John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

14. Testing – How it Works Immunoassay Principles • Antibody binds with the tagged compound • Binding causes change in signal produced Y Y Y Y Y Y Y John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

15. Testing – How it Works Testing with Immunoassays • Immunoassays are used to screen donor specimens for the possible presence of a drug or a class of drugs • These tests may be conducted on-site as part of the collection process or in a laboratory or other facility • On-site testing is normally conducted with a Point of Collection Test (POCT) device • Most testing is conducted in laboratories which have validated procedures and validated analytical instrumentation • Immunoassays allow some laboratories to test more than 10,000 donor specimens a day John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

16. Testing – How it Works Immunoassay Specificity • Specificity is the affinity of an immunoassay for the target drug • Specificity is measured by cross reactivity: • the response exhibited when an immunoassay reacts with a compound other than the target drug • Specificity limits the conclusions that can be drawn from immunoassay results John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

17. Testing – How it Works Low Specificity • An immunoassay with low specificity will react with many antigens (drugs) with similar structure • Example: One Amphetamine immunoassay with a cutoff of 300 ng/mL of D-Amphetamine gives a positive result with: • D,L-Amphetamine (300 ng/mL), Phentermine (400 ng/mL), Tranylcypromine (500 ng/mL), Methamphetamine (1,000 ng/mL), Ephedrine (1,000 ng/mL), or Phenylpropanolamine (1,000 ng/mL) • Therefore, a positive result from this immunoassay test would not prove use of amphetamine John M. Mitchell Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences

18. Tampering • Diluting • “Doping” • Substitution

19. Tampering • Diluting • Hyper saturating the body with fluids to dilute metabolites possibly below the 50 ng/mL threshold, depending on your metabolism. • AZO • Niacin • Vinegar • Fiber pills • Ready Clean pills • Rapid Cleanse • Detox Tea • Goldenseal • Certo • QCarbo • XXtra Clean • Quick Flush • Terminator Gold • Clear Choice • MC1 • Vale Triple Strength

20. Tampering • “Doping” • Adding different chemicals that defeat immunoglobulin/antigen binding • Bleach (powdered) • Water • Ammonia • Blood • Draino • Goldenseal • Hydrogen Peroxide • Lemon Juice • Liquid Soap • Mary Jane’s SuperClean 13 • Purifyit • Sodium Nitrate • Table Salt • Vinegar • Visine • WD 40

21. Tampering • Substitution • Concealed container • Injection • Catheterization • Cigar containers/droppers

22. Tampering - Countermeasures • Color • Temperature • Creatinine • pH • Specific gravity

23. False Positives

24. False Positives

25. False Positives

26. False Positives

27. False Positives • All positives require clinical intervention • Review clients medications before engaging in a clinical intervention • If a client reports taking a medication that may cause a false positive, a confirmatory test should be completed

28. False Negatives • Time elapsed since use • Improperly obtained or secured specimen • Tampered sample

29. Detection Times

30. Detection Times

31. Detection Times

32. Detection Times

33. Clinical Interventions • Drug testing is a clinical intervention • Upon admission, always explain the role of drug testing • Drug testing may be scheduled, random, or suspicious • Prior to securing the urine, ask the client about changes in medication and if the client has used • Always explain the “why” of a particular drug test • If the drug test is “suspicious,” discuss the behaviors that brought about suspicion • Review test results with client immediately upon receipt, regardless of result

34. Clinical Interventions • Negative drug screen • Congratulate the client • Review what drugs were tested for • Ask the client about use of drugs not tested • Ask about issue/problems when the sample was secured

35. Clinical Interventions • Positive drug screen • Tell the client you have the results and ask if the client has anything to share • Review what drugs were tested for and indicate what was positive • Allow the client time to respond • Ask the client about use of drugs not tested • Ask about when the client used, the circumstances • Review/discuss consequences • If discharge, make appropriate referral • If no discharge, develop relapse prevention plan

36. Resources

37. Resources • Collins, Jennifer. Laboratory Perspective on Additional Drug Testing and Associated Costs. MEDTOX Laboratories, Inc. • Mitchell, John M. Immunoassays as an Initial Test in Drug Testing. Center for Forensic Sciences . RTI International • TROUBLESHOOTING GUIDE DRUGS OF ABUSE. Innovacon, Inc. San Diego, CA • http://www.drug-test-facts.com • http://www.drugabuse.gov/nidahome.html • http://www.drugdetection.net/drug.htm