Biological Samples notwithstanding use in Drug Testing
Commonly, three types of biological samples have been utilized: 1. Blood. 2. Urine. 3. Hair. This determines if a calm has used drugs (to strictly determine if the use occurred, as opposed to centre of the breath of one’s nostrils in the influence), hair will employ drugs for several months, most commonly 3 months after the exercise. Urine will keep in pay drugs or their metabolites for anywhere from particular hours to separate days, or in some rare occasion weeks, and blood will retain the drugs or their metabolites for several hours. Therefore, the conversion to an act of blood is not suitable to determining whether the patient has used drugs in the past (several days to weeks).

To give direction to whether the character is impaired as a result of a drug abuse, spirit is the most judicious biological tissue to be tested and the principally rigorous, because the levels in the high birth or the presence of the remedy in the bloodstream is a very weighty objective determinant in the process of diagnosing or ruling thoroughly the “”impairment or under the influence of drugs or the infatuation defense.

Does Positive Blood Testing, Urine Testing or Hair Testing Indicates Impairment?
Positive hair samples during drugs of abuse does not make equal by impairment, it only can determine that in the past a patient has been using drugs (by a given limit). The presence of drugs of abuse in the urine can absolutely not be equated with impairment, but rather use in the last twenty-four hours or several days, and in some extreme cases a week. The demeanor of drugs or their metabolites in the blood testing does not prove impairment, because there is no philosophical data to extrapolate the extort level of illegal drugs that will impair a definite user. That type of extrapolation has been made only for alcohol, that has a legal definition in driving statures, Federal and State, as well as medical forensic extrapolation formulas. (For instance, the blood alcohol disappearance curve.) Commonly a forensic toxicologist and forensic physician choose be asked to determine whether urine positivity for unlicensed drugs indicates that that individual was Aunder the influence@ or Aintoxicated@ at the time an accident occurred on the work at jobs, or a car accident occurred on the path. The presence of drugs of injure or even prescription medication in the urine, or their metabolites in the urine, can not be equated with impairment. Unless clinical data from the site of detriment or prior to the injustice have being likely to indicate that the tender was behaving as an impaired body, even then it will subsist very difficult to place impairment. The presence of drugs or their metabolites in the high birth may support impairment based upon the blood levels and the clinical behavior.

Drug Recognition Expert Program
Due to the problem by identifying impaired workers and driver’s in relation to put drugs into relations concentration, the Los Angeles Police Department has developed a program which is called the Drug Recognition Expert Program (DRE). This program started initially with training officers to admit behavior and psychological standing associated with psychoactive drugs, and over the present life has attracted the attention of other agencies who were experiencing similar problems. Based upon the body the evaluation the DRE forms every one esteem as to: 1. Whether the imagine wickedness is impaired. 2. If impaired, whether the impairment is related to drugs. 3. If related to drugs, which put drugs into category or combination of categories is causing the impairment. A recent study (Governor’s office of Highway Safety) the police department and DRE program, utilized premises software developed by Southern California Research Institute under National Institute on Drug Abuse funding, to record and analyze this data. A patient bank during the term of 390 men and 108 women drivers was analyzed. The DREs correctly identified at least one drug head of predication in 91% of 415 specimens which the laboratory confirmed one or more drugs. No drugs were establish in specimens from 26 individuals who the DREs judged not impaired by drugs. The DRE decisions were supported because of 83.5% of 484 specimens, and not supported for 16.5 specimens (indicating a expressive rate of error).

What is interesting in these studies, is that in 14 cases, the DRE entirely missed the drugs originate in urine, and in 47 of the specimens for which the laboratory confirmed multiple substances, the DRE decisions were combinations of hits, contrary to truth positives and mendacious negatives. The DRE missed marijuana more oftentimes than other deaden with narcotics categories, only it cannot be determined whether the misses were DRE error or a consequence of the drugs’ time succession. Since the drugs principal metabolite can be detected in piss for days to weeks, a specimen may test positive even yet it was obtained at a time when sprightly marijuana was not present. A marijuana positive in urine that is not supported with evidence of behavioral impairment, cannot and does not exhibit to the question of drug Aintoxication@. This scientific event is commonly, and for some rational faculty, out of one’s recollection or is unknown to some juridical physicians who have the professional and ethical obligation to evaluate whether the patient was under the influence of illicit drugs. For instance, on everyday occasion, I remember a patient who was involved in a truck conflict while on the work at jobs, and his urine tested positive for marijuana. The forensic catechiser opined that the patient was Aunder the influence@, contemptuous opposition the fact that the pass chamber notes and the paramedic notes clearly stated the patient was alert x 4. As a matter of fact, in the study of DRE quoted too magnanimous for cocaine misses occurred with the second highest frequency. Behavioral science indicate that stimulants are often difficult to detect, but it cannot have being determined with inability to doubt whether the misses are true errors. Since the half-life of cocaine commodities is approximately 90 minutes, and the metabolite (crash products of cocaine) benzoylecgonine (BE) is known to have no psychoactive effect and can have being detected for 24 or 48 hours (usually), urine positive with respect to BE does not stingy that the surmise was Aunder the authority@ during the evaluation.

The Clear Message from these Studies is

The air of drugs of abuse in the urine cannot be used concerning the Aintoxication defense.
The presence of drugs of abuse in the blood cannot automatically be extrapolated to the Aintoxication defense. Each case requires careful analysis of the medical records and the clinical reliability of the blood levels.
The presence of drugs of abuse in hair has no meaning anything and cannot support the Aintoxication defense. The only extrapolation to exist made is that drugs were used sometime in the past.
Medications and Substances Causing False Positives
There are 161 prescript and over-the-counter medications which have been studied and show that 65 of them give rise to unveracious positive results in the commonly administered urine test for drugs. Siegel, according to the Los Angeles Times report, (a psychopharmacologist at UCLA), declared “”The widespread testing and reliance of tale-tale traces of drugs in the urine is absolutely a panic reaction invoked, because the regular techniques in spite of controlling drug use have not worked remarkably well. The next epidemic will be testing abuse.”” The greatest in quantity commonly used urine testing methodology is AMIV, has been shown that over 250 over-the-counter medications and prescript drug interactions can cause false positive testing using this methodology. The following have been reported as causing false positive tests are shown in the next table.

TABLE 1: Medications/Substances Causing False Positives/Cross-Reactions (Preliminary Testing)

Marijuana
Pain relievers such as Advil, Nuprin, Motrin and menstrual cramp medications like Midol and Trendar. All drugs containing Ibuprofen. Passive marijuana smoking. It has been described that passive marijuana inhalation at a rock concert be practicable to test positive in the urine despite the fact that the like a man frame has not been using marijuana.

Amphetamines
Dristan Nasal Spray, Neosynephren, Vicks Nasal Spray, Sudafed, and others containing ephedrine or pnenypropanolamine.

Opiates
Vicks Formula 44M containing Dextromethorphan, and Primatene-M containing perylamine, as well as the pain reliever Demerol and prescript anti-depressant Elavil, and even Quinine Water

Methadone
NyQuil Nighttime Cold Medicine

Cocaine
Antibiotics such as Ampicillin and Amoxicillin.

PCP
Diazepam, since well as some ingredients in cough medicines, Dextromethorphan.

Poppy seeds of the like kind as on a Burger King roll, bagel rolls (according to the Journal of Chemical Chemistry, Volume 33, #6, 1987), quantities of poppy seeds ingested in this think about 25 and 40 grams, may be expected to be contained in 1 or 2 servings of poppy race cake. Therefore, poppy seeds represent a potentially serious fountain-head. well of falsely positive results in testing sedative abuse. The article in Clinical Chemistry also concludes: “”Not excepting that is it difficult to distinguish heroine or morphine abuse from codeine, excepting dietary poppy seeds can give a strong positive results towards urinary opiates for several days duration that is confirmed by GC/MS analysis.””

The list of agents which can cause false positivity in the animal-water has also been described for endogenous excretion of enzymes in the urine. For instance, a study from Emory University by Dr. James Woodford, has shown that a percentage of persons of African origin, orientals and Pacific Islanders may be testing clear for marijuana secondary to a mechanical explanation what one. involves the pigment melanin which protects the skin from sun, what one. approximates the molecular structure of the THC metabolite which causes laboratory inhabitant of christendom religion reaction with marijuana.

What this means is that if you be in actual possession of used any of these over-the-counter medications, you may have existence accused (arrested) based on a false positive animal-water test. If your dexterous does not pick this up you may be in serious irreversible trouble.

Methodology of Drug Screening in Urine
There are exclusive methods to detect drugs in the urine. The greatest in number frequent one is an enzyme immunoassay (EIA), or radioimmunoassay (RIA), and florescence polarization immunoassay (FPIA). There are supplementary more sophisticated methodologies which are performed on extract of animal-water that are performed using thin layer chromatography (TLC), gas chromatography (GC) high performance liquid chromatography (HPLC) and gas chromatography/mass spectrometry (GS/MS). The only accepted procedures based on the description of the National Institute of Drug Abuse (NIDA), and the Department of Defense (DOD), are immunoassays followed by means of gas chromatography/lump spectrometry confirmation. The confirmation utilizing gas chromatography/mass spectrometry is required since the methodology of immunoassay can accord. improper substantial results due to testy reactivity. This is due to the fact that this methodology cannot specifically identify the drug, but rather the antibodies recognize substances which may admit the similar structure chemically, or immunologically or enzymologically, other than the drug of interest. Immunoassays during the term of amphetamines will show reactivity with drugs structurally related to amphetamines, such over-the-counter sympatomedicoamines, phenylpropanolamine and ephedrine, over-the-counter legalized medications used for nasal congestion, cold and appetite suppressant. Confirmation therefore is a must utilizing aeriform fluid chromatography/mass spectrometry. The use of gas chromatography/mass spectrometry provides an extremely high index of reliableness when properly preformed and applied.

As remote as gas chromatography/mass spectrometry, this is a superb methodology if vouchsafed correctly. For instance, if the equipment has not been cleaned appropriately, the previous run from the foregoing testing will taint the nearest instance, and will give erroneous, improper and incorrect results. Therefore, it is directory to look into the methodology that the person used for especial results on gas chromatography/mass spectrometry at a given indicated case. (On many occasions a deposition of the lab technician will reveal that the illustration was contaminated.)

What this means to you is that if your animal-water is tested utilizing the immunological process free from more, without confirmation end GS/MS, in that place is a high probability that the rise may be a false positive and irrelevant to your predicament.

Forensic Accuracy of GS/MS
Gas chromatography/heap spectrometry is extremely and highly accurate whether terminated correctly. A laboratory which performs the test must be NIDA certified or CAP (College of American Pathologists) certified. All of the labs that perform the gas chromatography/mass spectrometry on site be possible to be NIDA certified. Labs that toss samples to another laboratory for gas chromatography/mass spectrometry confirmation are ineligible, I repeat, ineligible, for NIDA certification. Therefore one must be very careful when looking at the test results to see whether the laboratory is NIDA/CAP certified. Furthermore, more labs transact not strictly and thoroughly clean the GC/MS accoutrement. Some labs don’t even do GC/MS confirmation. Some labs use of little value alternative methods to increase profits and reduce expenses. Therefore you be required to be in a position to aggressively cross examine the laboratory instructor and technician.

Drug of Abuse and Hair Testing
Hair testing for drug of abuse testing has become extremely popular among employers. There have been several scientific forensic doubts about the exercise of this methodology for proof of abuse. For example, the Society of Forensic Toxicologists in 1990 regular: “”The use of hair analysis for employees in pre-employment drug testing is premature, and cannot be supported by the current information on hair analysis for drugs of abuse.”” A 1997 application of mind by the National Institute of Drug abuse reached a conclusion and indicated that significant ethnic tendency may be the outcome of test for cocaine positivity. Analytical Toxicology in its issue in March/April 1998 indicated that removal of melanin from hair (a methodology used to remove the ethnic bias) “”does not remove the hair color bias at the time that interpreting cocaine concentrations”” Public information available (Congressional records from May 14, 1999), indicated that the Department of the Army secretary raised questions about the Army’sitting use of hair testing in a peculiar encase, and members of Congress were expressing their uneasiness with the procedure’sitting reliableness. Indeed, Representative, Cynthia McKinney, a Democrat of Georgia, and from Defense Secretary, William Cohen, that she is exploring possible Legislative remedy to prohibit human hair testing according to drugs in the military, given that the hair testing has been proven by judicial toxicologists to be racially biased. Indeed, the paper by Kintz, et. al. published in the Journal of Forensic Scientific International, January 1997, Volume 17, pages 84 to 123 and 151 to 156, indicated that false positives are set up even at low concentrations. Tissue hair analysis in ready hands by genial laboratory technology may bestow any idea about habitual practice of more of the drugs; granting, it is to be preferred that these should be combined with urinalysis utilizing one and the other screening, or better confirmation methodology.

Practical Application to a Case Analysis
In order to summarize and make the above given conditions to be applied, I will describe two declension-form scenarios.

Case #1:
A 28-year-old worker fell off the canopy, 2nd knock into disfavor, while on the job. He suffered several bone fractures, head pulverize and was taken to the emergency opportunity. At the emergency room piss was sent to the lab on reference to grounds of unsalable article screening. Upon recovery from the injury the patient requested Workers Compensation benefits, and was denied since the urine medicine screening utilizing EMIT methodology (immunological) detected opiates. In his deposition the indulgent testified that he has never used drugs, did not use drugs on the date of injury either. On careful review of the healing records, it turned out that the physician in the absence of ceasing interest of the employer had recommended denial of the Workers Compensation benefits, failed to review the paramedic ambulance notes which was called to the show of the injury and had transferred the patient to the hospital. The emergency swing notes sheet indicated that the patient had received IV morphine from the medic driver to sedate him from his severe pain of bone fractures and cranium crash. The evaluating physician further failed to catalogue that the urine sample was obtained 4 hours after the indefatigable’s stay in the emergency opportunity, and did not indicate whether that was a fresh urine example, catheterized urine, and did not name with precision the volume of the urine. The assiduous’session physician provided a report documenting that there is no history of medicine abuse, in that place was no evidence that the patient was impaired from testimonies from his supervisors and coworkers adhering the be dated that the injury occurred, and has farther free from interruption provided evidence that the urinalysis was taken several hours behind the patient was administered IV morphine by paramedics at the emergency room, and in return, the results were essentially erroneous and irrelevant to the patient’s cause of injury. This is an example of how drug urine testing can subsist applied wrongfully, and purpose unnecessary pain, disquietude, retard of benefits and major expenses to the insurance carrier and the citizens who end up paying these expenses out of their pocket.

Case #2:
This is a 32-year-old female patient, a driver of a vehicle who was involved in a car collision and suffered inside bleeding (ruptured spleen), and a fracture of a bone of the lower extremity. She had requested medical benefits from her insurance carrier during the term of medical expenses during the time that well while time dissipated from work, and has filed a lawsuit since these were denied. The physician who examined the patient on behalf of the insurance carrier, and whose report was the basis during the word of the denial, noted in his reports that upon initiation to the emergency swing adhering the date of injury, urine screening test as antidote to science of poisons was done, and was sure for amphetamines. The physician who examined the patient on behalf of the assurance carrier failed to comment the time of the testing, the time the urine was obtained from the patient, whether the patient was captivating in any degree medications which contain amphetamines, of the like kind as ephedrines or pseudoephedrines. The medicinal records examined carefully by the patient’s physician, found notes from the edifice doctor who attended the patient at midnight on her entrance. The home physician took a good detailed story recorded in his handwriting what one. clearly regular that the uncomplaining is each allergic individual, and has because the last two weeks been using compounds which embrace the pair ephedrine and pseudoephedrine. The physician who reported on behalf of the patient further was expert to likeness in the medical records that wholly examining physicians clearly stated that the diligent was alert x 4 on admission to the hospital, despite her trouble and contempt medications received from the paramedics and emergency chamber physicians. There was in no rank clinical evidence of impairment, in that place was no history of drug abuse, there was nay show of drug impairment. The problem with this case, is that the animal-water screening test was a false assured, because of the patient’s practice of over-the-counter ephedrine and pseudoephedrine containing medications to entertainment a cold and nasal congestion. Had a follow-up been done on that sample with aeriform fluid chromatography/mass spectrometry showing a specific type of amphetamine, the recital might regard been contrasted if indeed the constant was a user (that is not the case here). This state more remote illustrate: 1. The need for a very in depth evaluation of the chart and notes, as far as to the patient’s mental capacity before and after the collision. 2. A detailed separation of past and present prescription and over-the-counter medications. 3. The need to follow-up on urine screening test if it is unlimited for drugs of defame in a case in what place such conjecture is indicated. Gas chromatography/mass spectrometry is the ultimate tool to eventually follow-up upon the body such a suspicion.

In summary, while drug abuse and intoxication is a problem, the diagnosis of Aintoxicated@ is a philosophical one and cannot be based forward Apersonal beliefs@ or Afeelings@ of a defense examiner.

About Dr. Brautbar
Dr. Brautbar is board-certified in internal medicine, forensic medicine, and nephrology, by the agency of a specialization in toxicology. Dr. Brautbar has provided expert of the healing art estimate and philosophical evidence in product accountableness, special injustice, medical & nursing home-born standards, and toxic tort cases through every part of the United States. Dr. Brautbar is a Clinical Professor of Medicine at USC School of Medicine, Department of Medicine, and served as Chairman and Vice-Chairman of the Department of Medicine at the Queen of Angels/Hollywood Presbyterian Medical Center. He has published over 240 journal manuscripts, abstracts, and book chapters in the fields of in the mind medicine, toxicology, and nephrology. His recommence includes past and instant membership in 25 National and International Scientific Societies including the Collegium Ramazzini. Dr. Brautbar has been on the faculty of the National Judicial College and lectured to Judges on the issue of Scientific Evidence, and was a peer reviewer beneficial to the Federal Judicial Center (Reference Manual on Scientific Evidence, Second Edition, 2000). Dr. Brautbar has too been a peer-reviewer for the ATSDR.

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About the first cause:
Dr. Brautbar is writing article for www.environmentaldiseases.com,specializes in Internal Medicine, Nephrology, Toxicology, Pharmacology, and Occupational Medicine. He is a Clinical Professor of Medicine at the University of Southern California, School of Medicine, teaching medicine, and actively engaged in the habitual doing of medicine.

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