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Growth of Drug Testing
By the mid-1970s, the field of drug testing had begun to take root, as many young Americans, both military and civilian, experimented with illegal drugs such as marijuana (tetrahydrocannabinol, or THC), lysergic acid diethyl-amide (LSD), and cocaine. Most urine testing for illicit drugs was being done either by forensic laboratories or in methadone treatment programs. In these programs, patients undergoing methadone substitution therapy for heroin addiction were monitored for illicit drug use and compliance with the methadone therapy (4). A modest amount of drug testing was being conducted in the workplace by innovative companies that recognized the productivity value of promoting a drug-free work environment. Then on May 26, 1981, an event occurred that had tremendous repercussions on the drug-testing industry (5). There was a serious and deadly crash involving fighter aircraft on the carrier USS Nimitz, in the Atlantic Fleet.
The Future of Drug Courts
To expand into other specialty courts dealing with issues other than primary substance abuse. Domestic violence, mental health, driving under the influence (DUI), tribal, university campus, child support, and re-entry courts were added to the growing number of adult, juvenile, and family drug courts. With an ever-increasing volume of evaluation data supporting the efficacy of these intensive intervention strategies, the model promises to expand into other special-population areas. Early prison release, prostitution, property offenses, impulse-related violent offenses, and parole or probation violations are all viable arenas for specialty courts. Even though most of these specialty courts do not deal with substance abuse as the primary issue, drug testing is still a very important component. Statistics shows that more than 80 of the crimes committed in the United States each year are drug-related (6).
The eScreen123 Software Runs the eScreen System
The eScreen system consists of a suite of hardware installed at the point of collection. The hardware suite consists of a Windows PC, monitor, eReader (Fig. 2), signature capture device, barcode reader, and laser printer. The PC is connected to the Internet, preferably via a broadband connection, and runs the eScreen123 (eScreen) software platform. The eScreen123 (Fig. 3) software is a Web-based application allowing each of the service providers e.g., the collection site, laboratory, MRO, and administrator to access their respective portion of the drug-testing record in real time throughout the drug-testing process. The collection site portal allows the collector to check in the donor, if not previously scheduled by the employer, based on a set of rules previously established by the system and embedded in the software. Collector screens guide the collector through the specimen-collection process, and require the completion of the custody and control form (CCF) elements.
Diluted Urine A Simple Way to Beat Drug Tests
A negative result for the presence of abused drugs in a urine specimen does not necessarily mean that no drug is present. It is also possible that the amount of drug was below the cut-off values used in the drug-testing protocol. Diluting urine is a simple way to beat an otherwise positive drug test if the original concentrations of drugs in the urine are just slightly above the cut-off values. To counteract this strategy, creatinine analysis in urine is an effective method to detect diluted urine. Neeedleman and Porvaznik considered a creatinine value of less than 10 mg dL as suggestive of replacement of urine specimen largely by water (4). Beck et al. (5) reported that 11 of all urine specimens submitted to their laboratory for DOA testing were diluted. The SAMHSA program currently does not allow analysis of dilute urine specimens at lower screening and confirmation cut-offs.
The Results of the Roadside Drug Testing Assessment Project
The 21-mo Roadside Testing Assessment (ROSITA) project started in January 1999 and included a literature survey of drugs and medicines that have detrimental impacts on road users' performance, an inventory of the available roadside drug-testing equipment for urine, oral fluid, and sweat, an evaluation of the operational, user, and legal requirements for roadside testing equipment in the different European Union countries, and an extensive evaluation of several devices in eight countries. On-site immunoassays were used for the detection of drugs in urine, oral fluid, and or sweat in 2968 subjects. Police officers liked having the tools to detect drivers under the influence of drugs, and they were very creative in finding solutions to the practical and operational problems they encountered. On-site drug testing gave the police confidence, and saved time and money. Police officers had no major obj ections to collecting specimens of body fluids.
Sample Adulteration in Urine DOA Testing
The instant DOA testing procedures are instituted, opposing forces are at work to develop methods to avoid detection of drug use. Initially, common household chemicals such as laundry bleach, table salt, toilet-bowl cleaner, hand soap, and vinegar were used. More recently, a variety of products became commercially available, which can be ordered through Internet sites and tollfree telephone numbers. Commercially available adulteration products can be classified into two broad categories. The first category consists of specific fluids or tablets, which when taken along with plenty of water, serve to flush out drugs and metabolites, resulting in diluted urine and reduced concentrations of drugs or metabolites. Examples of products in this category include Absolute Detox XXL drink, Absolute Carbo Drinks, Ready Clean Drug Detox Drink, Fast Flush Capsules, and Ready Clean Gel Capsules. All products are available from Internet sites.
Changeable Bar Code Prelude to Digital Drug Testing
Confirmation laboratory can positively identify the drug. Removing the drug names from the cassette means that if all the color lines are present, as is the case with most strips, no drugs are detected in the specimen (i.e., the result is negative). If one or more color lines are absent from the series, the result is presumptively positive. It does not matter which drug is detected, because in every case, the outcome is the same. The specimen must be sent to a confirmation laboratory for further testing. From the bar code prospective, this argument presents a unique opportunity to translate the lines and spaces on the LFDOA test strips into a digital code, or a series of 0s and 1s. Consider the presence of a target line as indicated by a 1 and a space by a 0, then a five-drug test with one control line would be translated by a barcode reader into 10101010101 (six lines and five spaces) when the sample is negative and all six lines appear.
The eCup
The eCup (eScreen) (Fig. 1) is a specimen-collecting device with an internal aliquoting pump to sequester an aliquot when the lid is closed onto the cup. The aliquot pump is a double-walled syringe designed to pump the sample aliquot up onto the two LFDOA test strips and adulteration strips. Adulteration strips (see Chapters 13 and 14), which contain tests for pH, creatinine, and nitrite, reside in the eCup lid in a third test-strip slot. The eCup has a unique patented lid label with an integrated tamper-evident seal. The label and seal are bar-coded with a unique specimen number. This is the specimen number used to create the electronic custody and control form, and to track the specimen and result throughout the testing process. Additional barcodes appear on the label to direct the eReader (eScreen) (discussed later) to decode certain coded information from the test-strip configurations, as well as lot numbers of cups and test strips.
The eScreen System
In view of the deficiencies associated with the conventional POCT and the perception that a digital drug test could be created, a system known as eScreen was developed. eScreen combines the benefits of point-of-collection specimen collection with recent advances in information technologies to create an instrumented POCT system. eScreen monitored the progress of LFDOA development closely. LFDOA clearly led the market as the analytical method of choice. Easy-to-use, low-cost, highly sensitive lateral-flow test strips could do everything that the lab-based immunoassay could do. eScreen did not compete in the manufacturing of LFDOA devices, but realized that commoditization would likely develop as tests got better and cheaper. eScreen uses the current Federal drug testing standards as a starting point, extracts the immunoassay screening procedure from the centralized laboratory, and shifts it to the point of collection.
Peroxidase Activities in Urine Adulteration
Stealth is an adulterant advertised as an effective way to beat a urine drug test. Stealth consists of two vials, one containing a powder (peroxidase) and a second one containing a liquid (peroxide). Combining the contents of both vials results in a strong oxidizing potential capable of oxidizing several drugs and metabolites. Stealth can mask detection of marijuana metabolite, LSD, and opiate (morphine) at 125-150 of cut-off values assayed by Roche OnLine and Microgenic's CEDIA immunoassay (16). Low concentration of morphine (2500 ng mL) could be effectively masked by Stealth, but not higher concentrations (6000 ng mL). Stealth also affects the GC-MS confirmation step. Cody et al. (17) reported that results of GC-MS analysis of Stealth-adulterated urine using standard procedures proved unsuccessful in several cases, and in 4 out of 12 cases, neither the drug nor the internal standard was recovered.
Glutaraldehyde As a Urine Adulterant
Glutaraldehyde has also been used as an adulterant to mask urine drug tests (18). This product is available under the trade name of UrinAid. Each kit contains 4-5 mL solution of glutaraldehyde, which is to be added to 50-60 mL of urine. Glutaraldehyde solutions are readily available in hospitals and clinics as a cleaning and sterilizing agent. A 10 solution of glutaraldehyde is also available from pharmacies as over-the-counter medication for treatment of warts. The addition of glutaraldehyde at a concentration of 0.75 volume to urine can lead to false-negative drug-screening results for cannabinoid tests using EMIT II immunoassays. Amphetamine, methadone, benzodiazepine, opiate, and cocaine metabolite tests can be affected at glutaraldehyde concentrations of between 1 and 2 using the EMIT screen. At a glutaraldehyde concentration of 2 by volume, Braith-waite (18) found that the assay of cocaine metabolite was significantly affected, with an apparent loss of 90 of assay sensitivity.
Concerns About Necessity of Specimen Aliquoting
Manually performed DOA tests introduce several complications to the standard model of laboratory-centric testing. The first complication in the process of testing for drugs at the point of collection is aliquoting the specimen. Although aliquoting the specimen is standard procedure in the laboratory, there are standard operating procedures (SOP) and supervisory controls to reduce the potential for contamination of the forensic specimens. In the decentralized, point-of-collection model of DOA testing, there is little standardization in the method and procedures for aliquoting or handling of the original specimen. The sealed specimen must have its tamper-evident seal broken, and the specimen exposed to allow for the introduction of the aliquoting device. The introduction of a foreign object, such as a pipet, to obtain the aliquot in an uncontrolled environment, creates a potential legal challenge to the integrity of the specimen.
Drug Testing Technologies and Applications
Over the past few decades, a remarkable gamut of increasingly sophisticated technologies has been employed for the development of drug-testing applications. Recent advancements in analytical instrumentation and computer technologies have further expanded the capabilities and dimensions for drug testing and toxicological analysis. Technologies of different chemical principles can be used sequentially or in combination to accomplish the specific goals and requirements of the drug analysis programs. Ligand-binding assays such as immunoassays are commonly used for screening. Separation techniques such as chromatography or electrophoresis, as well as their coupling with powerful detectors such as mass spectrometry, can be effectively used for confirmatory testing of preliminary positive results or systematic analysis of generally unknown toxic compounds. Each of these technology categories can be further broken down into multiple selections for instrumentations and methodologies.
Household Chemicals as Urine Adulterants
Simple household chemicals are found to be effective adulterants of urine drug tests. These include table salt, vinegar, liquid laundry bleach, concentrated lemon juice, and Visine eye drops (8,9). The effectiveness of these chemicals on specific drug tests is summarized below. Amphetamines sodium chloride at a concentration of 75 gm L of urine caused a false-negative drug test in a urine specimen containing 1420 ng mL of amphetamine. Similarly, Drano (bleach SC Johnson & Son) at a concentration of 18 mL L masked a urine specimen containing 1800 ng mL of amphetamines by EMIT assay. Benzodiazepines Visine, hand soap, and Drano caused false-negative tests with benzodiazepines at concentrations less than 6500 ng mL. authors tested these adulterating agents at 10 by volume concentration of urine.
Pyridinium Chlorochromate As a Urine Adulterant
Besides simple household chemicals, more sophisticated substances are advertised commercially as adulterants for urine drug tests. Wu et al. (13) reported that the active ingredient of Urine Luck is 200 mmol L of pyridinium chlorochromate (PCC). The authors reported that Urine Luck caused a decrease in response rate for all EMIT II drug screens and for the Abuscreen morphine and THC assays. In contrast, Abuscreen amphetamine assay produced a higher response rate, and no effect was observed on the results of BE and PCP. This adulteration of urine did not alter GC-MS confirmation of methamphetamine, BE, and PCP. However, apparent concentrations of opiates and THC were reduced.
Oral Fluid and Saliva Tests
In the 2003 European Workplace Drug Testing Society (EWDTS) Symposium, held in Barcelona, the merits of oral fluid, oral mucosal transudate, and saliva as DAT matrices were debated. Although the use of oral fluid-based assays remains low, their demand is definitely on the increase in Europe (4). For example, the original British Rail Alcohol and Drug Policy recommended use of urine tests for standard DOA screening. However, at least one rail operator has already switched to using oral fluids instead, because it is more acceptable among its staff. Less invasive and intrusive than either blood or urine, testing of oral fluid may be performed under direct visual supervision. Furthermore, by eliminating the need to send the sample for laboratory analysis, less time is taken to obtain the results (12). Presence of DOA in oral-fluid samples is also more indicative of recent consumption.
Drug Testing Methodologies and Technology
As a result of the above-mentioned issues of cost and immediacy, drug courts have experimented with most of the testing methodologies in an effort to discover the most efficient means to achieve their testing agenda. Based upon the high concentration of drug metabolites present in urine, the basic ease of urine sample collection, the accuracy of urine testing, and the relatively low cost of testing a urine sample, urinalysis has become the primary choice of most drug courts. Drug courts have experimented with other matrices, such as hair, saliva, sweat, breath, and ocular scans. All of these methodologies have specific, limited value within a typical drug court. Because courts test multiple times per week and are concerned about new use, long-term methods such as sweat patches and hair testing have only minimal relevance in specific situations. Untimeliness of results, lack of long-term validity studies, and high cost have minimized the acceptance of saliva tests.
Pharmacokinetics and Pharmacodynamics
Nephron should still be able to cause a response. Alternatively, the finding of negligible amounts of these drugs in urine might simply mean that an as yet unidentified metabolite is the active species, and it behaves like the other loop diuretics with a lumen site of action, albeit with a more prolonged duration of effect. This appears to be the case with muzolimine. This drug has been withdrawn from study because of severe adverse neurologic effects.
Immediate and Long Term Roles for Medicinal Chemistry
Figure 2.5 Future drug discovery and development paradigm. This model portrays interactions with U.S. regulatory agencies and uses terms related to those interactions for steps 11 to 17. Future implies about 50 to 75 years into the new millennium. The most striking feature of this paradigm compared to Figs. 2.1 and 2.2 is the considerable number of decisions that will be made from virtual constructs rather than from experimental results. Confidence in the virtual decisions will be directly proportional to the level of knowledge that is learned from the huge amounts of drug screening data being amassed during the first 25 to 50 years of the new millennium, coupled with the overall ability to predict clinical outcomes.
Nuclear Receptors As Transcriptional Regulators Of Bile Acid Homeostasis
Receptor that typically utilizes drugs and xenobiotics as its ligands.66 In response to these ligands, PXR induces the expression of genes encoding proteins involved in drug detoxification and elimination pathways. In addition to xenobiotics, certain bile acids, such as the highly toxic LCA, can serve as agonistic ligands for PXR.67 -68 Indeed, activation of PXR can protect mouse livers against LCA-mediated injury.67 Doubleknockout mice lacking both FXR and PXR exhibit more severe disturbances of bile acid metabolism than mice lacking only one of the nuclear receptors, demonstrating that both contribute to bile acid homeostasis.69 PXR is a master regulator of the gene encoding the CYP3A4 enzyme,70 which, in addition to its role in detoxifying xeno-biotics, also metabolizes bile acids to less toxic and more easily excreted derivatives.
Raphael C Wong
Oral fluids have been generating increased interest as a matrix for abused drug testing. The present chapter describes an oral-fluid on-site detection device, Oratect , which screens for six drugs simultaneously. Oratect integrates collection, testing, and confirmation sampling into a single device. The collection process is simple, and test results can be obtained within 5 to 6 min. The data collected so far suggest that it is a viable screening test. Recently, the testing has been extended to alcohol, so that a simultaneous determination of drugs and alcohol is possible. Oral fluids offer an attractive alternative matrix for drug testing as a result of several factors including (a) reduced chances for adulteration (b) accessibility (c) non-invasiveness and (d) better correlation with serum drug levels compared to urine. These factors contribute to the increasing acceptability of oral-fluid drug testing as a valid indicator of drug usage (1-3).
Amitava Dasgupta
Persons abusing drugs attempt to adulterate urine specimens in order to beat drug testing. Dilution of urine in vivo by consuming excess fluid and various detoxifying agents available through the Internet is a common practice. Household chemicals such as bleach, acid, table salt, laundry detergent, toilet-bowl cleaner, vinegar, lemon juice, and Visine (Pfizer) eye drops are also used for adulterating urine specimens. Most of these adulterants except Visine eye drops can be detected by routine specimen integrity tests (creatinine, pH, temperature, and specific gravity). However, certain adulterants, such as Klear , Whizzies, Urine Luck , and Stealth , cannot be detected by using routine specimen integrity testing. These adulterants can successfully mask drug testing if the concentrations of certain abused drugs are moderate. Several spot tests have been described in the literature to detect the presence of such adulterants in urine.
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