Hello, this is Michael Peat, and in this presentation I'm going to talk to you about specimen validity testing. This is the second part of my laboratory testing presentations, and it deals with identifying specimens that are substituted or adulterated, and we'll talk about what is an invalid specimen in some of the slides that are coming up. This is the same approach as the drug testing protocols. There is an initial test, it's not an immunoassay, it's different from that, but it's still the same concept. It's an initial test to rule out negative specimens, and then there is a quote-unquote confirmation, but in the guidelines they refer to this as a verification, but it's the same protocol. It's a screening test followed by a confirmation that it's a substituted or adulterated specimen. You may find this to be a confusing presentation, particularly if you're a new medical review officer. The concepts behind this are pretty straightforward, but the details can be very difficult to grasp if you have not practiced as an MRO. It will become clearer to you after Dr. Peterson's presentation on practicing as an MRO, and it will become clearer to you, I believe, as you spend time reviewing these slides after my presentation and reviewing his presentation too. All in all, the number of specimens that are determined to be adulterated or substituted are very low. There are more specimens declared invalid, and I will go through why that is in a couple of the slides. In summary, this is an integral part of the drug testing lab's testing protocols. It's called specimen validity testing, and it really determines whether a specimen is adulterated or substituted. My second slide is the definition of validity testing as taken from the HHS guidelines. It's the evaluation of a specimen to determine if it's consistent with normal human urine. The purpose of the validity testing is to determine whether certain adulterants or foreign substances were added to the urine, if the urine was diluted, or if the urine was substituted. Let me go through a few things here about dilution and substitution. Obviously dilution would be diluting the specimen collected with water, and there's obviously protocols in the collection process to avoid that. Substitution means that you might substitute your urine specimen with some other specimen, and we'll go through that on the next slide, because this is where the interesting aspects of this type of testing are. This slide shows three book covers. If you go onto the web and type in urine drug testing, you will come up with a number of hits. Those hits are not the big drug testing labs such as Quest, CRL, and LabCorp, but they are for materials that beat the drug test, either material that you can add after collection or material that you might ingest. The latter, if you buy that material, they generally tell you to drink copious amounts of water, i.e. dilute or hydrate yourself, dilute your urine or hydrate yourself. In the case of the middle book, which was written by Abbie Hoffman, one of the leaders of the protests at the 1968 Democratic Convention, he came to the conclusion that hydrating yourself was the best way to beat the test, that is to lower the concentration of the drug in your urine so that it might fall below the cut-off. That is certainly the way it is, because most of those materials that you ingest really have no other function but to increase urine flow and to hydrate you and dilute your urine. There are also materials that you add to a urine and these might be more effective and we will cover these in a couple of slides. But again, in the protocols that are in place in the urine collection procedures, that should not be allowed, but certainly you can buy belts to put drug-free urine on your body and heat it up with batteries and all sorts of materials that can beat the test. I certainly have been aware of instances where people have catheterized themselves, washed out their urine, inserted urine from a friend into their bladder and gone to give their drug test. Lo and behold, it comes back positive, so you may want to make sure that if you do that, which is very risky of course, you make sure your friend's urine is drug-free before you go off to give your collection. There are many, many products, certainly a mini-industry around how to beat a urine test and as you will hear, there are products that claim to beat an all-fluid test and products that claim to beat a hair test. They'll come up in other parts of the modules in this webinar. So I'm going to move to the next slide, which defines methods to determine a substituted specimen. Substitution testing is based on creatinine and pacific gravity. Obviously creatinine is excreted at a relatively constant rate, pacific gravity measures the density of urine relative to the density of pure water. These are not unusual tests, they are performed routinely in various parts of a clinical lab and certainly a drug testing lab can add these to its menu without any issues. They have to validate them and do all the things that you have to do with other tests for drugs, but they're routinely easy to do and can be done on the automated chemistry analyzers that are used for drug testing. So again, not much in this slide except that these are two properties that are used to determine a substituted specimen. So what test does a lab have to do for adulteration and substitution? This is a list of the tests a lab has to do for specimen validity testing. These tests are written into HHS guidelines. The lab will be performance tested on these tests, that is in the NLCP performance testing program they'll be asked to do creatinine, pacific gravity, etc. And certainly that's an important part again of the reliability of this program. So a lab has to determine creatinine concentration on every specimen. If that concentration is less than 20 mg per deciliter, then the lab has to determine the pacific gravity, has to determine pH on every specimen, and then has to do one or more tests for oxidizing adulterants. Well oxidizing adulterants are simply oxidizing agents and they are very effective at destroying the THC acid metabolite of THC. In fact some of them will drive the concentration of that metabolite down to almost zero. They have no impact on the other drugs apart from a very small impact on morphine. So they're really designed to oxidize away from the urine specimen, the THC metabolite. So if a donor has smoked THC and taken some cocaine or amphetamines, then THC acid may well be negative, but the cocaine or amphetamines would be positive. So the lab has to perform tests to detect those adulterants. And then the fifth bullet and the subcategories there are really a catch-all. It needs to perform additional validity tests when the following conditions are observed. Abnormal physical characteristics, maybe an unusual color, response or reactions characteristic of an adulterant. Some adulterants have a fairly characteristic response on some of the immunoassays used. And then possible unidentified interference or adulterant. So these are catch-all phrases. And we'll talk a little more about what types of adulterants are used. So when is a specimen adulterated? This is a list of what is reported to you as adulterated by the lab. So let's just quickly go through these. The pH is less than 4 or greater than or equal to 11. The lab will report that to you as adulterated. Those are obviously strong pHs, strong acids, strong alkali, and would not be produced in normal circumstances. If the nitrite concentration is greater than or equal to 500 micrograms per milliliter, nitrite is a strong oxidizing agent and was one of the first introduced for that purpose. Nitrate is also present in UTIs, but the maximum noted in the UTI has been 125 micrograms per milliliter. So 500 is obviously significantly greater than that 125. The presence of chromium, presence of halogen, chromium or more correctly chromates and halogen compounds are both strong oxidizing agents. Glutaraldehyde has an effect to gel the urine specimen, pyridine is an oxidizing agent, and obviously surfactant is a soap. And then there's a catch-all at the bottom, presence of any other adulterant is verified. I can't emphasize enough how important it is for collection sites to be involved in specimen validity testing. If a collection site notes unusual characteristics of a urine, it has a responsibility obviously to collect a second specimen. They should mark that as 2 of 2, 1 of 2 being the suspect urine specimen, and should note somewhere on one of those chain of custodies that they smelled bleach, they saw soap, and if you shake a urine specimen after collection, it will certainly produce some foam. But if you shake a urine after collection that's been adulterated with soap, then it will be very, very foamy. So those sorts of things, little pointers can be very useful to a lab because as this lab or most of the labs receive hundreds, thousands of specimens a night, please do not expect each receiver of specimens to do a detailed examination. So the collection site is very, very important in this process. The next slide is going to deal with an area where the testing for federal employees and the testing for DOT regulated employees is a little different, and I'm going to go through that on the next few slides. Before I go through the testing criteria, a brief history would be appropriate. In the late 1990s and early 2000s, HHS introduced some rules for specimen validity testing, or more correctly guidelines for the labs to perform that testing. There were a number of situations where flight attendants were defined as substituted simply because their creatinine was less than 5 millicrams per decaliter, and their specific gravity was less than 1.001. Any of you who have flown transatlantic, transpacific flights know that those flight attendants are requested to hydrate themselves by the airline medical director, and many of them drink liters of Avion water. So these flight attendants were transoceanic flight attendants. They genuinely were lightweight, and they generally had creatinines in the 4 milligram per decaliter range. So in 2007, NLCP put on a program, and some of these flight attendants testified to the – well, not testified, spoke to the audience. And they had demonstrated at SAMHSA certified labs, or NLC certified labs, that they could produce urines with a creatinine between 4 and 5 milligrams per decaliter by drinking copious amounts of water. So at that point DOT introduced some, my correction, HHS introduced some rules for a specimen to be defined as substituted and these were introduced for federal employees only because HHS covers federal employees. So under those rules a urine specimen is reported as substituted when the creatinine concentration is less than 2, specific gravity is less than or equal to 0010, note the four significant figures, or greater than or equal to 0200. That is the HHS definition of a substituted specimen and that is used for federal employees. As a MRO you are unlikely to be an MRO for federal employees so this may serve as an information item for you but certainly if you are taking the MRO exam this might be an important piece of information. So the next slide shows what is a dilute specimen and we'll talk about that in this over the next slide. This is the definition of a dilute specimen for federal employees. A dilute specimen has a creatinine between 2 and 20 and a specific gravity between 0010 and less than 0030. This is information, you cannot interview the donor or do any of those actions around these results, it's information only and certainly might be important information in some situations but these would be very very rare. So this is an information only item for you but you will see it on the lab report. This slide covers a very important topic which is an invalid specimen. In general an invalid specimen can be one where we cannot get a consistent result or get not get a result at all and certainly there are many many circumstances that could happen none of which are very common but certainly there are many circumstances. This is one that relates to specimen validity testing and the reporting of creatinine and specific gravity results and the reporting of pH. The first bullet covers the creatinine and specific gravity results. If they are inconsistent and some examples are given here then the lab would report that as invalid to you as the MRO. An invalid result to you as an MRO requires you to immediately contact the company or the DER and have that donor provide a specimen immediately under direct observation because these results are inconsistent with each other and therefore they're suspicious. The same applies to pH. The pH is greater than or equal to 4 but less than 4.5 or greater than or equal to 9 but less than 11. Again those pHs are rare and would not normally be produced by the body and therefore this is also reported as invalid and again the donor is required to provide a specimen under direct observation. You can obviously imagine some questions on an exam that have numbers like these in them and my recommendation to you when you take the exam around the topic and have questions around creatinine and specific gravity to make sure you count the zeros. It can be somewhat confusing if you're a little bit pressured to define 0010 etc so read carefully and count the zeros. This is a list, a second list of conditions under which a specimen would be reported in as invalid. A little history here. In the early days of specimen validity testing a lab may have done a colorimetric test for an oxidizing agent and then repeated that test on a different aliquot of the urine and reported that test as that urine being positive for an oxidizing agent. That of course does not follow the same guidelines that are in use for drug testing where one does a screening test and then a confirmation test the latter of which uses a different chemical principle or technique. So DOT and HHS in their requirements for specimen validity testing required labs to have a different chemical test to confirm the presence of an oxidizing agent. For labs that will be an expensive process given that they only do that test once or twice a year and they would then have to quality control validate performance test that confirmation test for the oxidizing agent. So the agencies allowed the reporting of possible presence chromium etc in this list and that keys the MRO to requesting a directly observed collection of the donor. Again a condition that's described as invalid. So the list is fairly self-explanatory. If you see the possible presence of then that requires a directly observed recollection and nitrite is a concentration range higher than you would expect in a UTI but less than the cutoff of 500 micrograms per milliliter. The three lower bullets talk about interferences. Interferences with immunoassays or GC-MS or any MS confirmation results would result in no drug being able to be detected and again that would be reported as invalid. The bottom one physical experience of the specimen is such it might damage the lab's instruments. Not sure what that means. Maybe it means bubbling or thick or acidic or smoking. I in fact have never seen that and never seen a report with that on it. So this is specimen validity testing and my next slide is going to cover the differences between DOT and HHS. Okay these are the DOT covered employees rule requirements. Certainly there is some consistency here. The specific gravity has to be 0010 or less for a specimen to be reported as substituted. If the creatinine is less than 2 then that is a substituted specimen. However DOT has said that donors with creatinines between 2 and 5 and specific gravities of 0010 or less are so unusual and that they are suspicious and therefore they require that donor to undergo an immediate recollection under direct observation. These are very few situations are very few and far between but Dr. Peterson and Dr. Smith call the specimens hyper dilute. DOT does not but I think hyper dilute is certainly a good description of them. So again creatinine between 2 and 5, specific gravity of 0010 or less DOT requires immediate recollection under direct observation. From a lab perspective we will provide you the creatinine and specific gravity numbers for these specimens and report to the MRO as negative dilute or positive dilute. So you need to be aware or your staff need to be aware of this rule so it does not these specimens don't slip through the cracks. I'm sure that the large MRO groups have procedures in place and I'm sure these are so unusual that you would notice them instantly. So this is the difference the only difference between a DOT rule and an HHS rule here in this definition of substitution or hyper dilutes as Dr. Smith and Dr. Peterson calls them. So let's talk a little bit about retest on the next slide. So let's talk about retesting of split specimens. There's a difference here from retesting for drug or drug metabolites. A retest for adulterants or a retest for substitution must use the same criteria as the initial test. For the retest for a substituted specimen the creatinine must be less than 2, specific gravity must be less than 1.0010 or greater than 1.0200. So the retest criteria are the same. If the lab performing testing on the split cannot perform those tests they can send them to another HHS certified lab if necessary. That's a rule put in there for example if you lab A have a positive cocaine with a positive adulterant like an oxidizing agent and send it to lab B if lab B cannot do that oxidizing agent test it can send that specimen on to lab C. Very rare and very academic in a way but it does allow that to occur if necessary. So I'm now going to talk a little bit about types of adult. So there are many many types of adulterants certainly traditional household chemicals bleach, soap, salt etc. In the case of salt somebody might put that under their fingernails and urinate over it. That's not effective today in canceling out the immunoassay kit results but it used to be in the old days so to put it. But these are still commonly used people add them and they're very usually very easily detectable. And then there's some designer adulterants glutaraldehyde which actually sort of clogs the urine it forms a gel over time. Oxidizing agents and I've listed some there and are the ones that are most effective in destroying the THC metabolite and the ones that most people use obviously because THC is the most common drug detected. And then there are interferences with the immunoassays or confirmations. These are not as frequent as they used to be. The immunoassays have been re-engineered in some cases to avoid interference and the confirmation assay should be certainly rugged enough to avoid that. And of course the most effective ones are the ones that are unknown. There could be compounds out there that the labs haven't encountered. That's unlikely given that ones unknown would be over the would be available over the internet and I would imagine would be detected in one of the tests that the labs do to detect adulterants. But I do want in my last slide to show you something that would beat the testing protocols. This is a compound called stealth and two things of note here. You can see how small those tubes are. They're probably maybe five centimeters long and a centimeter wide and very small. Therefore they can be hidden at the point of collection and would not be detected at the collection site. They contain hydrogen peroxide and peroxidase. Hydrogen peroxide is a very strong oxidizing agent and will destroy THC acid very quickly because of its strength as an oxidizing agent. And obviously peroxidase is an enzyme that destroys hydrogen peroxide. So in normal circumstances say a 12 to 24 hour period to get the urine to the lab if it's been adulterated with stealth the hydrogen peroxide would have destroyed the THC acid metabolite and the peroxidase would have destroyed the hydrogen peroxide. This is very effective and as I define it it's better living through chemistry and sometimes the dragon wins. These programs are not meant to be detection programs. They're meant to be deterrence programs and even though this compound might be effective the fact that there's checks and balances in place in the collection in the lab and occasionally in the MRO review process the program is an effective deterrent of drug use in the regulated federal workplace. Thank you for your attention and I look forward to talking to you in some other presentations but I believe I've covered effectively the laboratory testing parts of this program. Thank you.

specimen validity testing

substituted specimens

adulterated specimens

drug testing protocols

medical review officers

creatinine concentration