Drug Court

MythCannabis levels are really useful in

determining relapse.

Reality

• Basically…not• See the monograph on the NDCI.org

Myth:

The presence of urine sediment (material that settles to the bottom of the collection cup) is a good indicator of sample tampering.

True or False

Urine sediment occurs naturally & is comprised of:

cells - (epithelial, kidney, blood)

casts - (cylindralical particles formed by WBC, RBC, granular material, fat, etc.

crystals -

organisms (bacteria, yeast, fungi)

Myth

Treatment doesn’t work.

Nobody can change.

Myth

Treatment doesn’t work.

Nobody can change.

Myth:

A urine creatinine level of 475 ng/mL is reasonable evidence to indicate specimen tampering.

True or False

Normal Urine Creatinine:

• 2005 study “Urinary Creatinine Concentrations in the U.S. Population” determine the mean (based upon 22,245 participants) was 130 mg/dL– less than 1% below 20 mg/dL– less than 1% greater than 400 mg/dL

• it’s all about patterns

Creatinine Math• healthy adult produces/eliminates approximately 1

mg of creatinine per minute or about 1440 mg in a 24-hour day.

• in order to achieve a urine creatinine level of 475 mg/dL

• the client would only be excreting only about 11.4 ounces of urine in a 24-hour period (or about a cup and a half).

• proof of tampering "beyond a reasonable doubt" - no.

Myth

Methadone/Suboxone are:• Evil• Just another Addiction• Can’t work with Drug Court

ORT Substitutes One Addictive Drug With Another?• ORT uses medication (methadone/Suboxone)

to overcome craving and need for illicit opioids.

• ORT pharmacologic actions differfrom other opioids; not mere substitute.– Orally effective, long acting, cross tolerance

(blockade)• Addictive, opioid-seeking, behaviors cease.• ORT benefits overshadow reliance on

dependency-producing medication.• Consequences of untreated opioid addiction include:

destitution, prison, disease, and/or early death.

MMT Patients Get “High”?• At appropriate and adequate stable

doses, normal function – no lasting euphoria or sedation.

• Adequate methadone dose avoids extremes of intoxication or withdrawal.

• After dosing, some patients may “sense” onset of methadone effects or have vague feelings of “well-being”(soon wears off after blood level peaks).

Taming the Roller Coaster

Adequate methadone smooths peaks & valleys – shifting from opioid intoxication to withdrawal. Patients can live more comfortably

normal lives throughout each day.

ORT Patients Abuse Other Drugs?• ORT not a “cure” for addiction.

– Addresses illicit opioid withdrawaland craving.

• Pharmacologically little effecton alcohol, cocaine, etc.

• With adequate ORT,most patients do eliminate orreduce other drug abuse.

• Ongoing counseling, psychosocial treatment, needed services and self help groups are important.

Benefits to Drug Court

• It can save lives!• The treatment does work

with Drug Court• Fairfield County, Ohio

–62% grad rate with Suboxone–13% grad rate without

Myth

Methadone/Suboxone are:• Evil• Just another Addiction• Can’t work with Drug Court

Myth:

A urine with a negative EtG and an ethyl sulfate (EtS) concentration of 457 ng/mL is inclusive to establish the consumption of alcohol by a client.

True or False

EtS Without EtG

• EtG “discovered” first• large lab testing 2000 samples a month,

incidence of EtS without EtG = 3%• EtG can be “eaten” by bacteria (e. coli)• client with UTI could destroy EtG• reasonable EtS cutoff = 100 ng/mL

using LC/MS/MS

Myth

Poppy seed bagels can cause a positive reaction on a urine test

Myth:

A reasonable “failure to confirm” rate (presumptively positive sample that fails to confirm by GC/MS)is about 25%.

True or False

Failure to confirm rate should be in the low single digits.

Issues to consider:

Failure to Confirm

• discrepant cutoffs• misreading of on-site device

– “Any band, even if faint, partial or broken, indicates a negative result. The absence of color is a presumptive positive result.”

• cross-reactivity - false positive– amphetamines & benzodiazepines

• re-screening at confirmation lab

Myth

Everyone needs residential treatment

Reality

• Some need it• Many/most don’t• Long term residential is expensive• Some jurisdictions don’t have it• Being in the community helps develop

connections: court, judge, self help, etc.• And remember…only a trained treatment

person can determine clinical level of care.

Myth

Everyone needs residential treatment

Myth

A client with diabetes is likely to produce dilute specimens (with urine creatinine levels of less tha 20 mg/mL) because of his/her disease.

True or False

Diabetes & Creatinine

• To the research:– some people with diabetes have slightly lower urinary

creatinine levels– this finding is not universal across all racial/ethnic groups or

even age groups.– non-Hispanic blacks with diabetes had urinary creatinine levels

about 30 mg/dL lower than those without diabetes– no significant differences were observed in other racial/ethnic

groups. – similar variations were observed in different age group

categories– urinary creatinine levels for persons with diabetes 30-39 years

of age were about 40 mg/dL lower than those without diabetes in the same age group.

Diabetes & Creatinine

• how to apply this research to drug court• question is whether diabetes causes dilute

urine samples - the answer is NO!• average urine creatinine level for a non-

Hispanic black participant, 20-49 years of age is 180 mg/dL - subtract 30 mg/dL of creatinine for a diabetic condition, starting with an average urine creatinine level of 150 mg/dL  

Creatinine Facts• some diseases that produce low urinary creatinines

– muscle wasting disease - RARE– some kidney aliments - RARE

• low creatinines ARE NOT routinely associated with: – pregnancy– diabetes– obesity– exercise– high-blood pressure– being vegetarian

Myth

A client with diabetes is likely to produce dilute specimens (with urine creatinine levels of less tha 20 mg/mL) because of his/her disease.

True or False

MythIf taken in large dosages, niacin (vitamin B-3) can be utilized by clients to speed the elimination of THC from their bodies resulting in a shorter detection window for cannabinoids.

True or False

All About Niacin

• niacin - vitamin that affects more than 50 metabolic functions, releasing energy from carbohydrates

• absolutely NO scientific or medical data indicating niacin has ANY effect on a urine drug test

• adds a more intense "yellow" color to the urine• niacin used to disguise diluted samples• niacin overdose is often accompanied by

skin“flushing”

MythIf taken in large dosages, niacin (vitamin B-3) can be utilized by clients to speed the elimination of THC from their bodies resulting in a shorter detection window for cannabinoids.

True or False

MythWell I got my recovery doing it this way so

everyone should do it exactly like me.

Reality

• Everyone has different needs/ experiences

• Show what worked for you, don’t force it• Take what fits and leave the rest

thanks to

• Dave Wallace – Photographer• Meghan Wheeler• Cinderella• The nice popcorn lady• The eventually nice Secret Service