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Drug-Testing Methods and Clinical Interpretations of Test Results
Drug-Testing Methods and Clinical Interpretations of Test Results
Drug-Testing Methods and Clinical Interpretations of Test Results
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Bhushan M Kapur
University of Toronto
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ABSTRACT
In the present paper, major issues related to drug testing are
discussed. For example, drug-testing techniques measure the
presence of a drug but are not sophisticated enough to measure
impairment from drug use. Moreover, it is difficult to determine the
route of drug administration, quantity or frequency, as well as when
the drug was taken, on the basis of the laboratory results.
Introduction
As interest increases in employment-related drug testing, the
technologies and the interpretive skills of analysts continue to
evolve. Although recent literature indicates that significant
refinements and modifications have been made in drug-testing
technology, the complexity of drug effects is so great that many
problems exist in the interpretation of test results. The most
frequent problems that confront the toxicology laboratory are
associated with developing technology that can determine how
much and when a drug was taken, how long after use the tests are
capable of showing positive results, the causes and rates of false
positives and false negatives, and how tests can be "beaten" by
employees. In the present paper, these problems are discussed and
the various laboratory procedures used to combat the problems are
examined.
Some drugs are fat-soluble and are deposited in fat tissues. For
example, 9-tetrahydrocannabinol (THC), the active ingredient in
marijuana, is highly fat-soluble, resulting in a rapid reduction in
levels of THC in the blood as the drug is distributed to the various
tissues [1] . Some studies have shown that THC levels peak and
start to decline in half the time it takes to smoke a marijuana
"joint". Concentrations are known to fall by almost 90 per cent in
the first hour [1] , [2] suggesting that a higher degree of
sophistication in laboratory analysis is needed to detect fat-soluble
drugs. Depending on the amount of drug stored, however, fat-
soluble drugs. Depending on the amount of drug stored, however,
detection in the urine may be possible for as long as 60 days after
last use [3] . Ethanol or ethyl alcohol is the beverage alcohol that is
consumed by people. Alcohol* is not fat-soluble and is distributed in
the total body water [4] . Since blood is mostly made up of water,
the presence of alcohol is more easily detectable than fat-soluble
drugs like THC. The absorption and distribution phases are followed
by an elimination phase. The liver is the major detoxification centre
in the body; drugs are metabolized as blood circulates through the
organ. The metabolites are then excreted into the urine through the
kidneys. At the same time, drugs deposited in fat tissues are also
slowly released into the bloodstream and metabolized.
Table 1.
A. Availability
C. Analytical methods
What should be analysed? Ideally, the parent drug, rather than its
metabolite should be looked for in the analysis, although this may
not always be possible as some drugs are rapidly metabolized (e.g.
heroin metabolism to morphine). The sensitivity of the analytical
procedure should be dictated by the psychoactive pharmacological
properties of the drugs. If the drug is shown to be devoid of abuse
potential, then its detection beyond the time of pharmacological
activity, although important in the clinical management of the
patient, does not necessarily serve a useful purpose in a workplace
drug-screening programme.
Recently, hair samples have been used to detect drug use [14] ,
[15] , [16] . There are a number of technical problems that must be
overcome, however, before hair can be used as definitive proof of
drug use. An advisory committee of the Society of Forensic
Toxicology [17] has recently concluded that, 'because of these
deficiencies, results of hair analysis alone do not constitute
sufficient evidence of drug use for application in the workplace'.
Breath and various body fluids, such as sweat, saliva, blood and
urine, have been used for alcohol analysis. Breath is commonly
used by law enforcement authorities for such analysis. Although a
number of variables [18] can affect the breath-blood ratio, the
2,100:1 alveolar breath-blood conversion ratio has been used and
accepted for the Breathalyser [19] . Breath-testing equipment
calibrated with a blood- breath conversion factor of 2,100
consistently underestimate actual blood alcohol concentrations [20]
. The results of breath analysis may vary depending on the
instruments used and on biological factors [21] , [22] . Potential
errors in breath analysis can also be caused by the presence of
residual alcohol in the mouth. Immediately after drinking, there is
enough alcohol vapour in the mouth to give artificially high
concentrations in breath analysis. Generally, this effect disappears
after 20minutes but high values for as long as 45 minutes have
been reported [23] .
From a positive urine test, the form in which the drug was originally
taken or when and how much was taken cannot be determined. For
example, crack, impure cocaine powder or cocaine paste (which can
be smoked, inhaled, injected or chewed) all give the same result in
a urine test. The consumption of poppy seeds has been reported-to
give positive results for opiate use because some seeds contain
traces of opiates and some have been known to be contaminated
with opium derivatives [12] . Similarly, consumption of herbal cocoa
tea has resulted in positive results for cocaine use. These incidents
clearly illustrate the difficulties involved in measuring impairment
using urine test results.
V. Urine-testing methods
Urine is the most commonly used fluid for drug screening [32] . The
methods most commonly used in toxicology laboratories are as
follows:
1. Immunoassay:
2. Enzyme immunoassay (EIA);
3. Enzyme-multiplied immunoassay technique .(EMIT);
4. Fluorescence polarization
5. Radioimmunoassy (RlA);
6. Chromatography.
7. Thin-layer chromatography (TLC)
8. High-performance liquid chromatography (HPLC);
9. Gas chromatrography (GC.);.
10. Chromatography coupled with mass spectrometry:
11. Gas chromatography coupled with mass spectrometry
(GC/MS);
12. High-performance liquid chromatography coupled with
mass spectrometry (HPLC/MS).
The methods vary considerably with respect to -their sensitivity and
reliability. TLC is the least expensive and is reliable, GC/MS is
considered nearly perfect, or a "gold standard", [33] ; it requires
highly trained technologists and the most expensive equipment.
A. Immunoassay
Urine drug assay kits have been available in North America for the
past few years. More recently, single- and multiple-test
immunoassay kits designed for home and on-site testing have also
been introduced. Such kits generally carry a cautionary disclaimer
that positive test results must be confirmed by GC/MS, the
reference method. When used in a non-laboratory environment,
they are prone to procedural inaccuracies, poor quality control,
abuse and misinterpretations. Therefore, they are not
recommended for testing in the workplace. The risk of labelling a
person with a false positive is high without confirmatory analysis. In
addition, confirmation analysis is generally expensive when an
individual sample is being tested. The advantages and
disadvantages of immunoassay testing may be summarized as
follows.
1. Advantages:
2. Screening tests can be done quickly because automation and
batch processing are possible;
3. Technologists doing routine clinical chemistry testing can be
easily trained;
4. Detection limits are low and can be tailored to meet the
programmes screening requirements. For example, lower
detection thresholds can be raised to eliminate positives
resulting from passive inhalation of marijuana smoke;
5. Immunoassays are relatively inexpensive, although the
single-test immunoassay kits can be expensive when quality-
assurance and quality-control samples are included;
6. Immunoassays do not require a specialized laboratory. Most
clinical laboratories have automated instruments to do the
procedures;
7. Disadvantages:
8. Although the tests are useful for detecting classes of drugs,
specificity for individual drugs is weak;
9. Since the antibody is generated from laboratory animals,
there can be a lot-to-lot or batch-to-batch variation in the
antibody reagents;
10. Results must be confirmed by another non.-
immunoassay method;-,,
11. A radioactive isotope is used in RIA that requires
compliance with special licensing procedures, use of gamma
counters to measure radioactivity and disposal of the
radioactive waste;
12. Only a single drug can be tested for at one time.
B. Chromatography
1. Thin-layer chromatography
2. Gas chromatography
Given the higher costs associated with GC/MS, urine samples are
usually tested in batches for broad classes of drugs by
immunoassay, and positive screens are later subjected to
confirmation by this more expensive technique. This is the most
common approach used in employment drug- screening
programmes and is the combination recommended by NIDA [13] in
the United States.
1. Advantages:
2. All chromatographic methods: All the chromatographic
methods are specific and sensitive and can screen a large
number of drugs at the same time;
3. TLC: Negligible capital outlay is needed;
4. GC: The procedure can be automated;
5. HPLC:
6. GC/MS:
a. It is regarded as the "gold standard" test; b. Computerized
identification of fingerprint patterns makes identification easy;
c. The procedure can be automated; d. It is currently the
preferred method for defence in the legal system;
7. Disadvantages:
8. All chromatographic methods: All the chromatographic
methods are labour-intensive and require highly trained staff.
Although all the chromatographic methods are specific,
confirmation is still desirable;
9. TLC: Interpretation is subjective, hence training and
experience in interpretation capabilities of the technologist are
crucial;
10. GC or HPLC: Equipment costs are high, ranging between
US$ 25,000 and US$ 60,000, depending on the type of
detector and automation selected;
11. GC/MS:
B. False positives
A false positive occurs if results show that the drug is present when
in fact it is not. False-positive tests are obtained if an interfering
drug -or substance is present in the biological fluid and it cross -
reacts with the reagents. As discussed in the previous section on
immunoassays, an initially positive test based on immunoassay
technique should always be confirmed with a non-immunoassay
method. A confirmed positive finding only implies that the urine
sample contains the detected drug and nothing more.
Tetrahydrocannabinol metabolites a/ 15
Cocaine metabolites b/ 150
Opiates
Morphine 300
Codeine 300
PCP 25
Amphetamines
Amphetamine 500
Methamphetamine 500
Alcohol (mg/100 ml) 10
b/ Benzoylecgonine.
*The protocols and procedures in the present section are based on the
accumulated knowledge of the author in his capacity as Inspector for
the College of American Pathologists (CAP), a certifying agency for
drug-testing laboratories in the United States. In addition,
guidelines suggested by Kwong and others [46] , CAP [47] , NIDA [13]
and the Canadian laboratory standards for drug screening in the
workplace were extensively consulted.
B. Laboratory procedures
Laboratory personnel requirements
3. Receiving specimens
4. Storing specimens
6. Operational guidelines
(a) Laboratory facilities
(b) Inspection
(c) Subcontracting
1. Date received;
2. Date opened or prepared;
3. Expiration date.
When reagents are prepared, the date and the initials of the person
preparing them should be recorded. Control samples should be
labelled with a code allowing the analysts to test them in a blind
manner. The temperature of the refrigerator used for storing the
reagents should be checked and recorded daily. The results for
controls and standards must be recorded along with the date, time
and name of the analyst conducting the test procedure.
7. Review of results
(a) Medical review officer
8. Certification of laboratory
The laboratory must meet all pertinent provisions and guidelines
stated in the present paper. In determining whether to certify a
laboratory or to accept the certification, the following criteria should
be considered: