By Renee DiIulio

One person adds yellow food coloring to water, another spikes his urine with bleach, and yet another carries around a colostomy bag full of someone else’s urine. Weird? Yes, unless one considers that these individuals are substance abusers attempting to fool drug screens. As more employers institute drug-screening programs, a burgeoning industry offers products and advice on cheating these tests. This cottage industry has grown, primarily on the Internet, to combat the efforts of the “bladder cops.” Web sites offer products and procedures to beat any test currently on the market, even hair screens. While not all of the information or products proffered are valid, some do work, and as a result, certified labs have been required for the past few years to conduct testing to verify the validity of a sample.

The testing industry is thus challenged on two fronts: to create screens that can identify cheating and to develop new tests that screen for emerging drugs of abuse. Lab professionals must be able to interpret what the results mean for physicians and other medical personnel—cross-reactions and cutoffs can affect certain results. In some cases, particularly forensic, labs may also need to confirm chain of custody and calibration.

As addiction research continues to delve into changes registered in the brain, the clinical lab may grow to assume a larger role in the management of this disease, but for now, its focus is on screening for drugs as accurately as possible. The result from a certified lab often provides the final word. Don Rothschild, a clinically certified substance abuse professional and addiction counselor, says, “I believe what the test says, not the employee.”

Ronald J. Hunsicker, DMin, FACATA

Dealing With Denial
Most people do not readily admit they have a substance-abuse problem, and it can only be diagnosed and treated with a program that incorporates behavioral study and modification. “There is no one test that will diagnose addiction,” says Ronald J. Hunsicker, DMin, FACATA,  president and CEO of the National Association of Addiction Treatment Providers (NAATP) of Lancaster, Pa. “But the clinical lab can help identify the problem and monitor treatment progress.”

According to Ross Lowe, PhD, research scientist, Intramural Research Program, National Institute on Drug Abuse (NIDA) of Bethesda, Md, when faced with the results of a positive drug screen, an addict may admit use and/or abuse. When monitored during treatment, regular drug testing can provide the incentive needed to stay sober.

Of course, a drug screen can only tell whether or not that drug is present in the patient’s system, not whether the patient regularly abuses substances or whether the metabolite is due to legal use. And everyone who drinks alcohol or uses drugs is not necessarily addicted, but some individuals can develop a problem with their first use, and many are still experimenting. The 2003 National Survey on Drug Use and Health reported an estimated 2.6 million new marijuana users in 2002, 272,000 LSD initiates, 1.1 million persons trying Ecstasy (MDMA), and 2.5 million using pain relievers for the first time.

Incidence of Substance Use and Abuse Steady
Even with the initiates, the study found that the use of alcohol and illicit drugs remained steady over 2002 and 2003. In 2003, an estimated 19.5 million Americans, or 8.2% of the population aged 12 or older, admitted using illicit drugs during the month prior to the survey; in 2002, the same number, representing 8.3% of the population, had also used illicit drugs in the month prior to the survey. The 2003 survey found an estimated 119 million Americans aged 12 or older (50.1% of the population) to be current alcohol drinkers, about 54 million (22.6%) had participated in binge drinking at least once in the 30 days prior to the survey, and 16.1 million (6.8%) were heavy drinkers, figures similar to those reported in 2002. Tobacco use also remained unchanged, with 70.8 million, or 29.8%, of those 12 or older reporting use of a tobacco product in the month prior to the survey.

Marijuana continues to be the most commonly used illicit drug. Its use, as well as that of heroin and cocaine, remained steady while the number of respondents indicating use of Ecstasy, LSD, and methamphetamines decreased. The nonmedical use of pain relievers, however, increased from 29.6 million to 31.2 million. Specific pain relievers with statistically significant increases in lifetime use were Vicodin, Lortab, or Lorcet; Percocet, Percodan, or Tylox; hydrocodone; OxyContin; methadone; and Tramadol.

Of those reporting drug use, an estimated 21.6 million aged 12 or older, or 9.1%, were classified with substance dependence or abuse issues. This figure was similar to the 22 million reported in 2002. Of the 2003 group, 3.1 million abused or depended on both alcohol and illicit drugs, 3.8 million abused illicit drugs alone, and 14.8 million abused solely alcohol. Nearly 77% of adults 18 and older classified with abuse held either part-time or full-time employment.

Costs of Abuse and Efforts to Cheat Increase
The consequences of this abuse have both individual and societal effects, including economic. The Economic Costs of Drug Abuse in the United States, released by the Executive Office of the President (Washington) and the Office of National Drug Control Policy (Rockville, Md) in 2001, found that the overall cost of drug abuse to society between 1992 and 1998 increased at a rate of 5.9% annually. By 1998, the societal cost of drug abuse was $143.3 billion and included productivity, health care, and other expenses, such as those related to the criminal justice system, the war on drugs, and social welfare. The NIDA reports that drug abusers cost their employers about twice as much in medical and workers’ compensation claims as their drug-free coworkers.

As a result, many companies have decided to implement workplace-related drug-testing programs, and subsequently, many drug users have turned to the Web for advice on how to beat these tests. The Substance Abuse and Mental Health Services Administration (SAMHSA) of Washington, a division of the Department of Health and Human Services (HHS) of Washington, has found that over the past few years, laboratories certified under the National Laboratory Certification Program (NLCP) have received an increased number of adulterated and substituted urine specimens. A recent audit of the 66 NLCP-certified laboratories identified a total of 6,440 adulterated specimens and 2,821 substituted specimens reported to medical review officers (MROs) during the past 2 years. These numbers refer to the approximately 13 million specimens tested under the federal agency workplace drug-testing program and the US Department of Transportation (DOT) of Washington’s federally regulated programs.

Typical Tests
NIDA requires that certain types of employees, particularly those with commercial class driver’s licenses, undergo regular drug testing that screens for five common classes of drugs: cannabinoids (marijuana, hash), cocaine (cocaine, crack, benzoylecognine), amphetamines (amphetamines, methamphetamines, speed), opiates (heroin, opium, codeine, morphine), and phencyclidine (PCP).

Expanded tests may also include screens for barbiturates (phenobarbital, secobarbitol, butalbital), hydrocodone (Lortab, Vicodin), methaqualone (Quaaludes), benzodiazepines (Valium, Xanax, Librium, Serax, Rohypnol), methadone, propoxyphene (Darvon compounds), ethanol (alcohol), and MDMA (Ecstasy).

Tests can also be run to determine the presence of LSD, tryptamines (psilocybin, AMT, DMT, DPT, 5-MeO-DiPT), phenethylamines (mescaline, MDMA, MDA, MDE, 2C-B, 2C-T-7), and inhalents (Toluene, Xylene, Benzene), though these are run infrequently, requiring a specific request. There are also the screens run on athletes to determine use of steroids and other performance enhancers.

Nick Reuter

Labs are challenged to stay ahead of drug users with screens that can identify new drugs of abuse, whether athletic performance enhancers or prescribed pain medication. Nick Reuter, senior health analyst at SAMHSA, says, “Laboratories need to look at the new medications being introduced. OxyContin came out 4 or 5 years ago and quickly became a drug of abuse, but labs trailed in their ability to screen for it. The challenge is to stay ahead.”

Blood, Urine, and Sweat
Drug screens typically use one of five types of media: urine, blood, hair, oral fluids, or sweat. Each varies in its level of invasiveness and ability to detect drug use over time. Urine has been in use the longest and is currently the most trusted. Says Lowe, “I hesitate to suggest that one form of media is better than another, but one type may be more appropriate depending on the application of the test. Urine is a relatively easy collection, is fairly noninvasive, and has a long history.”

Leon Glass, PhD, technical director, United Chemical Technologies of Bristol, Pa, agrees, saying, “Urine is where the body puts the drugs. If you are working with addicts, the treatment physician or counselor wants to see what the patient has done in the recent past. Hair is not as valuable in this regard since it cannot be pulled directly from the follicle, and the evidence found in hair collected 1 or 2 inches from the scalp is a month or two old. When trying to determine whether someone is using drugs at that moment, blood is the best option.”

Louis E. Baxter, Sr, MD, FASAM, executive medical director, Medical Society of New Jersey and a board member of the American Society of Addiction Medicine (ASAM) of Chevy Chase, Md, also trusts urine. “Urine has the longest track record and has been studied more extensively than any other method. Reliable standards have been created and accepted by those in the laboratory industry and the addiction field. Other media may be helpful but are lacking the amount of data available on urine.”

American Bio Medica Corp of Kinderhook, NY, notes that the accuracy of any given drug test is determined by:

  • The technology used in the test, which varies considerably among types of tests
  • The nature of the individual drugs
  • The skills and abilities of the testing organization(s)
  • The protocols used to assure collection integrity and proper processing of samples

Interpreting Test Results
Rothschild relies solely on NLCP-certified laboratories to conduct the drug screens for his clients. “I trust the lab to provide the truth and so use trusted labs,” he says.

Reuter stresses that a laboratory should have procedures and policies in place so it can work with a patient’s challenge. Baxter notes that labs need to perform routine standardization prior to testing. “If an apparatus has not been properly cleaned after use, a specimen can be contaminated by the previous sample, resulting in a false-positive.”

Lowe adds that it’s important for the technical management personnel in the lab to be clearly aware of the capabilities of testing procedures, not only which drugs have been found but what reported levels mean. “Are there any issues specific to a particular test or procedure? What are the limitations of a certain test? What cross-reactivity exists with other drugs? Physicians need to know the possible scenarios for a finding,” he says.

“One explanation for a positive finding is that the drug is there. Whether the substance being detected derives from another source, such as a therapeutic prescription or ingestion of foodstuffs, is another issue,” says Lowe,

It is therefore important for the patient being screened to report any substances previously taken, both prescription and over-the-counter (OTC) medication. Cross-reactivities exist for a number of substances. A drug screen may find positive for amphetamines as a result of the use of OTC cold medicines, such as Nyquil and Sudafed; cannabinoids may test positive for users of OTC ibuprofen products, such as Advil; and the presence of morphine may be indicated by the use of prescription codeine.

And then, of course, you have the poppy seed issue made most famous by a particular Seinfeld episode in which one of the characters nearly loses her job for testing positive for opiates as a result of poppy seed intake. “The highest opiate concentration I have ever seen was found in a baker who was eating poppy seed paste directly from the tube. The cross-reactivity of a morphine screen with poppy seeds presented a big hassle for a while, but the decision to raise the cutoff level from 300 ng/mL to 2,000 ng/mL has nearly alleviated this problem,” says Glass.

There is some controversy surrounding the use of cutoffs. “Clinical testing renders a positive result with the presence of a substance, but workplace testing, which is designed to be a deterrent, relies more heavily on cutoffs,” says Baxter.

Therefore, a negative result from a screen that uses the federally mandated cutoffs does not mean that the drug was not present but that it was not present at certain levels. Because drugs are eventually eliminated from the body, this means that a substance could have been used, but enough time has elapsed to allow it to pass through the system.

Robert Lubran

According to Robert Lubran, director, Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, SAMHSA, a drug’s half-life is determined by a number of variables including age, weight, body-fat index, gender, metabolic rate, and the amount of drug consumed. The method of ingestion (for example, snorting versus injection) also affects absorption. A test on his wish list would be one that can specify when and how much of a drug was taken.

Finding the Cheaters
Currently, however, no test can provide this information, although blood is the best medium for determining whether a person is under the influence of a substance at a particular moment and hair can provide information about past use.

That is assuming, of course, that the specimen has not been tampered with. A quick search of the phrase “pass drug test” yields 52,734 matches on AOL, 1,480,000 on Yahoo, and 3,680,000 on Google. If someone wants to beat a drug screen, there are a host of suggestions to try.

Dilution with water reduces the concentration of the drug so that the result may be below the cutoff level. Patients may add household products, such as bleach, hydrogen peroxide, eye washes, or vinegar to mask a substance. Or they may utilize products sold specifically for this purpose, such as Klear or Urinaid.

Fortunately, the testing industry has been aware of this growing field and has developed tests to counteract some of the more popular methods of cheating. In addition to drugs of abuse, the lab can also identify adulteration, the effort to mask the drug or its metabolite by adding a substance to the urine, and substitution, which includes diluting or replacing the specimen.

Labs now routinely test for creatinine levels and specific gravity, which can identify dilution, as well as pH, nitrites, and adulterant analytes, such as bleach. However, as laboratory testing procedures expand, the drug culture develops new methods to fool the screens, and as a result, HHS now includes a list of known adulterants in its monthly Federal Register notice. This notice lists those laboratories that have met the minimum standards for urine drug testing for federal agencies and employers regulated by the DOT.

SAMHSA offers information on an extensive literature review and studies that were used to develop standards for HHS and the DOT that can determine whether a specimen has been tampered with. As part of the project, standards were developed to determine if a specimen was adulterated or substituted. A urine specimen with a creatinine level less than or equal to 5 mg/dL and a specific gravity less than or equal to 1.001 or greater than or equal to 1.020 should be considered substituted. Urine specimens with pH values less than or equal to 4.5 and greater than or equal to 8 are highly suspect for tampering. And a urine specimen with a pH less than or equal to 3 or greater than or equal to 11 has been adulterated.

Products are now available to make this screening easy. One such product is Bioscan Screening Systems Inc’s Intect 7, a dipstick device that detects levels of creatinine, nitrite, glutaraldehyde, pH, specific gravity, bleach, and pyridinium chlorochromate, the presence of which indicates adulteration since it should not be present in untampered urine. Dipping the stick into a separated sample of the specimen and comparing the blocks to a color-coded chart quickly reveals whether the sample is valid.

If a specimen is found to be invalid, rules exist for reporting the findings. If it is valid, then the sample is screened for drugs, and positive findings may be denied by the patient. For this reason, specific guidelines can help verify the accuracy of a finding with standards for collection, chain of custody, and testing. Federal regulations exist and are implemented by certified labs, but SAMHSA is also developing clinical guidelines in a project that will resume next year. Industry professionals are advised to contact the organization to be sure they are on the mailing list to receive the draft and offer input.

Positive drug tests can have serious consequences for users, including job loss or jail, and substance abusers will try anything to avoid claiming responsibility. But with the right protocols, labs can be sure they have busted the abusers.

Renee Dilulio is a contributing writer for Clinical Lab Products.