2021 SC BAR CONVENTION

Family Law Section

Everything You Need to Know About Drug/Alcohol Testing in Family Court

Friday, January 22

SC Supreme Court Commission on CLE Course No. 210742ADO

Friday, January 22, 2021 1:30 – 4:45 p.m. Family Law Section 3.0 MCLE Credit Hours; 3.0 Mandatory JCLE for Circuit Court Judges Supreme Court Commission on CLE Course #: 210742ADO

Everything You Need to Know About Drug/Alcohol Testing in Family Court

Dr. Michelle Bens Clare will provide in-depth information about drug and alcohol testing in the Family Court setting. Specific emphasis will be paid to drug testing in children and how to interpret the results. Additionally, you will get a full legislative update from our esteemed legislators from the Upstate and case law update from the always interesting Judge Timothy H. Pogue!

Agenda

1:30 – 1:50 p.m. Legislative Update Rep. Bruce Bannister Bannister, Wyatt & Stalvey, LLC Greenville, SC Rep. Jason T. Elliott Jason Elliott, Attorney at Law, LLC Greenville, SC 1:50 – 2:15 p.m. Case Law Update The Honorable Timothy H. Pogue S.C. Family Court Marion, SC 2:15 – 2:30 p.m. Break 2:30 – 3:45 p.m. Types of Drug/Alcohol Testing: How they work; Can they be beaten,

tricked or fooled? Dr. Michelle Bens Clare Mount Pleasant, SC 3:45 – 4:45 p.m. Specific Concerns Relating to Testing Children and Interpretation of

Results Dr. Michelle Bens Clare Mount Pleasant, SC

Course Planners/Moderators: Nancy Jo Thomason Thomason & Pracht, LLP Anderson, SC

Family Law Section

SPEAKER BIOGRAPHIES by order of presentation

Dr. Michelle Bens Clare Mt. Pleasant, SC

EDUCATION

Michigan State University College of Osteopathic Medicine 1998-2002 Doctor of Osteopathic

Medicine

University of Michigan 1994-1996 Masters of Public Health in Epidemiology

University of Michigan 1990-1994 Bachelors of Science in Biopsychology

WORK EXPERIENCE

Emergency Room Physician—Colleton Medical Center 2010-present Walterboro, SC

Emergency Room Physician—East Cooper Medical Center 2013-present Mount Pleasant, SC

Emergency Room Physician—Aiken Regional Medical Center 2013-present Aiken, SC

Emergency Room Physican—St. Mary’s of Saginaw 2016-2018 Saginaw, MI

Consultant—Coastal Medical Review 2017-present Mount Pleasant, SC

Emergency Room Physician—Orangeburg Regional 2017-present Orangeburg, SC

Emergency Room Physician—Blessing Hospital 2019-present Quincy, IL

Emergency Room Physician—Oaklawn Hospital 2006-2008, Marshall, MI 2017-2019

Emergency Room Physician—Roper Saint Francis 2008-2010 Charleston, SC

Epidemiologist 1996-1998 Centers for Disease Control, Atlanta, GA • Coordinated

Pneumocystis carinii Pneumonia Project • Facilitated Waterbourne Disease Surveillance in the

United States • Managed data for Cyclospora outbreaks, 1997

CERTIFICATIONS

American Osteopathic Board of Emergency Medicine 2010-2020

American Association of Medical Review Officers 2017-2022

Advanced Trauma Life Support (ATLS) 2017-2021

Advanced Cardiac Life Support (ACLS) 2018-2020

Pediatric Advanced Life Support (PALS) 2018-2020

Basic Life Support (BLS) 2018-2020

Current state licensure in Illinois, Michigan, Missouri, and South Carolina

APPOINTMENTS

Roper-Saint Francis Ethics Committee, 2010

MOA Education Committee, 2002-2004

MOA Past Presidents Committee, 2002-2004

AOA Task Force on Bioterrorism, 2001-2002

AOA Bureau of Interns and Residents Advisory Council, 2002-2003

AOA Council on Health Related Policies, 2002-2003 National Board of Osteopathic Medical

Examiners Liaison Committee, 2001

AOA Basic Documents and Affiliated Organizations Committee, 2001

Delegate, AOA House of Delegates 1999-2004, MOA House of Delegates 2004

Michigan State University Women’s Advisory Committee, 2000

SCHOLARSHIP AND AWARDS

Winner of the Walter Mill Award for Excellence in Surgery, 2002

The Michigan State University College of Osteopathic Medicine Alumni Association Endowed

Scholarship Award, 2001

Winner of the James H. Nakano Citation for an outstanding scientific paper published in 2000

Nominee for the Charles C. Shepard Science Award for demonstrating excellence in science—

Assessment and Epidemiology, 2000

Representative Bruce Bannister Bannister, Wyatt, & Stalvey, LLC

Greenville, SC

Bruce Wyche Bannister is a partner of Bannister, Wyatt, & Stalvey, LLC and a member of the

South Carolina House of Representatives.

Mr. Bannister graduated from Davidson College in 1995 and went on to earn his law degree from

the University of South Carolina in 1998.

Mr. Bannister focuses on Family Law, Eminent Domain, and Real Estate Law. He has tried cases

involving Personal Injury, Premises Liability, Eminent Domain, Education Law, Residential Real

Estate, Commercial Real Estate, Government, Zoning, Planning, and Land Use.

Admitted to the practice of law in South Carolina in 1998, Mr. Bannister was elected as the SC

House District 24 Representative in 2005. He currently serves on the Ways and Means Committee,

where he is Chairman of the Constitutional Agency subcommittee. Mr. Bannister was elected by

his peers to serve as the Assistant Majority leader for the SC House Republican Caucus from 2008-

2012, and served as the House Majority Leader from 2012-2016. He also served as the Chairman

of the South Carolina Bar Lawyer Legislator task force.

Mr. Bannister is a lifelong resident of Greenville. He is a LexisNexis Martindale-Hubbell Peer

Review Rated lawyer, and has also taught as an adjunct professor at Greenville Technical College.

He also holds previous experience as a law clerk to the Honorable Larry R. Patterson, Circuit Court

Judge.

As an active member within the community, Mr. Bannister is a graduate of Leadership Greenville

Class XXVI and a member of Liberty Fellowship’s Class of 2014. He currently serves as a board

member for A Child's Haven and on the Governor’s school for science and math. Mr. Bannister

previously served on the board for the Children’s Museum of the Upstate, the St. Andrews Society

of Greenville, and the Greenville Peace Center. In 2011, Mr. Bannister received the Children’s

Hospital Legislative Advocacy Award for his efforts on behalf of the SC Institute for Child

Success.

Bruce W. Bannister focuses his experience on Family Law, Eminent Domain, and Real Estate

Law. As a practicing family law and real estate lawyer, Mr. Bannister tries cases involving

premises liability, personal injury, education law, zoning, planning, and land use.

Representative Jason T. Elliott Greenville, SC

A proud South Carolina native, Jason attended Wren High School in Anderson County, graduated

with a B.A. in Political Science from Clemson University and received his Juris Doctorate from

the University of South Carolina School of Law. Since opening his law practice in 2004, Jason has

represented hundreds of clients throughout the Upstate of South Carolina.

After law school, Jason served as an Assistant Solicitor for the Tenth Judicial Circuit, prosecuting

misdemeanors and felonies in Anderson and Oconee Counties.

Further serving residents of the Upstate, he worked for then-Congressman Jim DeMint from 1999-

2003 as DeMint’s District Director.

In 2004, Jason opened his own practice, Jason Elliott, Attorney at Law, LLC. During the first year,

he regularly prosecuted DUI and other criminal matters in Greenville County for the Thirteenth

Circuit Solicitor. The firm primarily represents clients in family law and criminal matters. In

private practice, Jason has represented hundreds of clients throughout Upstate South Carolina.

Professional Associations & Memberships

South Carolina Bar Association, 1996 — present

Greenville County Bar Association, 2004 — present (past newsletter editor)

Rotary Club of Greenville, 1999 — present (past president)

Greenville County Legislative Delegation Transportation Committee, 2011 — present

Greenville Tech Charter High School (past board member, past board chairman and vice

chairman)

Clemson University Student Body President, 1992 — 1993

The Honorable Timothy H. Pogue S.C. Family Court

Marion, SC

Judge Timothy H. Pogue was born in DuBois, PA in 1951. His parents are the late Charles E.

Pogue who was an Architect with Federated Department Stores and Betty H. Pogue who was a

public school kindergarten teacher for over thirty years.

He attended public school in Kentucky where he lived most of his childhood years. Upon

graduation from Highlands High School in 1969 he attended the University of Kentucky and

received his BA in History in 1973. Thereafter, he attended and graduated from the University of

Kentucky School of Law with a Juris Doctor in May of 1976. Shortly after graduation, he moved

to Marion, SC where he started as an Associate Attorney in the Law Firm of Derrick and Derrick.

In December of 1978 he became a partner in the Law Office of Derrick and Pogue, P.A. and

continued to work in that firm until September 1985. At that time he opened his sole practice of

law under the name of Law Office of Timothy H. Pogue. He practiced in Marion County as a sole

practitioner until his election to the Bench in February, 2008.

Judge Pogue served as a part-time public defender specializing in juvenile matters from 1978 until

1996. He also was the attorney for Marion County DSS from 1993 until his election and handled

all of the abuse and neglect, adult protective services, and termination of parental rights cases. He

also served as the Marion County Attorney from 1995 until his election to the Bench.

Judge Pogue formerly served on the Marion School District #1 Board of Trustees for over twelve

years and also served as the Chairman for two years. He received the Marion Chamber of

Commerce Public Service Award in 2003 and the SC Bar Pro Bono Services Award in 2002.

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Legislative Update

Rep. Bruce Bannister Rep. Jason T. Elliott

Family Law Section

No Materials Available

Case Law Update

The Honorable Timothy H. Pogue

Family Law Section

No Materials Available

Types of Drug/Alcohol Testing: How they work; Can they be beaten, tricked or fooled?

Dr. Michelle Bens Clare

Family Law Section

TYPES OF DRUG AND ALCOHOL TESTINGMICHELLE BENS CLARE, DO, MPH

TODAY WE WILL LEARN

• Types of drug and alcohol testing

• How they work

• Can they be beaten, tricked, or fooled

• How to interpret results

BASICS OF TESTING: SCREENS VS CONFIRMATIONS

• Screens

• Drug screens are an immunoassays

• Used to obtain a presumptive positive (or negative).

• Screens are “presumptive” because they are prone to false positives, false negatives, and cross-reactivity

• Sensitivity and specificity are relatively low, therefore, for forensic purposes should be followed by a confirmatory test.

BASICS OF TESTING: SCREENS VS CONFIRMATIONS

Confirmations

• Confirmations are performed by GCMS LCMS (Gas or liquid

chromatography combined with mass spectrometry)

• Gold standard for drug testing.

• Very high sensitivity and specificity.

• In layman’s terms, they read the chemical signature of the specific

drug, eliminate cross-reactivity, and can be considered confirmatory

in almost all situations (barring lab error, tampering, or break in

chain of custody)

WHAT IS THE DIFFERENCE BETWEEN SENSITIVITY AND SPECIFICITY?

• Sensitivity—percentage of true positives • Perfect predictor would be 100%, or all sick individuals are

identified• Ruling out a disease if a person is negative• SNout = Sensitivity high, negative result, rule out

• Specificity—percentage of true negatives• How well a test identifies persons without a disease• Perfect predictor would be 100% of persons without a disease• SPin = Specificity high, positive result, rule in

SENSITIVITY VS SPECIFICITY

• In other words:

• A test with high sensitivity tells you that if you have a negative

test, you can likely rule out substance use, as positive samples

are rarely missed

• A test with high specificity tells you that substance use has likely

occurred because negative results are usually correct

TYPES OF TESTING

•Urine

•Hair

•Nails

•Blood

•Sputum

•Sweat

WHAT’S ON THE PANEL?

5 PANEL URINE TEST

THC

OPIATES

PCP

COCAINE

AMPHETAMINES

10 PANEL URINE TEST

—5 PANEL PLUS

BENZODIAZEPINES

BARBITURATES

METHADONE

PROPOXYPHENE

QUAALUDES

*CAN VARY BY LAB

URINE TESTING

Considered the Gold Standard of drug testing due to ease of collection and reliability

Drop at an appropriate facility• Urine is monitored for pH, temperature, and adulterants• Can be observed or not• Toilet should have blue dye in it to prevent adulterants and

dilution, and sink should be: not present or non-functional• Client should not flush after giving sample

URINE SAMPLES

TAMPER SEALS

TOILET SINK

URINE TESTING--MARIJUANA

Urine Detection Times

Single Use 3 daysModerate use (4x/week) 5-7 daysDaily Use 10-15 daysHeavy Use >30 days

WHAT STATES MADE MARIJUANA LEGAL IN 2020?

• New Jersey

• Arizona

• South Dakota

• Montana

URINE--DRUG DETECTION TIMES

Alcohol 1-12 hoursShort-acting Barbiturates 2 daysLong-acting Barbiturates 1-3 weeksAmphetamines 1-2 daysMethamphetamine 1-2 daysMDMA (ecstasy) 1-2 daysCocaine 2-4 daysShort-acting Benzodiazepines 3 daysLong-acting Benzodiazepines 30 daysPCP 8 days, up to 30 days

*these times are averages, all cases may vary based on use, metabolism, underlying medical conditions, or body habitus

POP QUIZ

WHAT’S THE DIFFERENCE BETWEEN AN OPIATE AND AN OPIOID?

THE DIFFERENCE BETWEEN OPIATES AND OPIOIDS

• Opiates are plant based, from poppies

• Morphine

• Codeine

• Heroin

• Opioids are manufactured

• Oxycontin

• Fentanyl

• Hydrocodone

• Buprenorphine (Suboxone) combo drug with Naloxone

URINE DETECTION TIMES—OPIATES AND OPIOIDS

Codeine (opiates) 2 daysHeroin 48 hoursMorphine 48-72 hours

Methadone 3 days (can be up to weeks in high usage)

*again, detection times vary

PROS AND CONS OF URINE TESTING

Pros of urine testing

•Easy to obtain, cheap

Cons of urine testing

•Synthetic urine or another person’s.

A. Synthetic urine is available online. It can be reconstituted and then kept at

body temp until test time.

B. Often undetectable.

C. For observed collections need same gender

•The Whizzinator can be used to cheat at observed testing. Available online.

THE WHIZZANATOR

DEFEATING THE TEST

• Multiple websites to help clients defeat tests www.nevergetbusted.com, www.vice.com, etc.

• The Whizzinator

POP QUIZ

•What else can you use a shot glass for besides alcohol?

• Fill with synthetic or bought urine, cover with plastic wrap and insert. Slit a hole in the wrap during testing.

HAIR TESTING

Typically tests for amphetamines, methamphetamine, ecstasy, marijuana, cocaine, PCP, opiates (codeine, morphine, heroin), expanded opioid panel (fentanyl, buprenorphine, methadone, tramadol), alcohol (EtG, EtS)

Additional specialized testing panels are available upon request, below is a list of commonly requested testing panels.•Alcohol •Poisons & Toxins •Heavy Metals •Date Rape •Tricyclic Antidepressants

HAIR TESTING

• Need an inch and a half of hair

• Body hair may have a longer window of detection (30-365 days)

PROS AND CONS OF HAIR TESTING

Pros of hair testing

•Window of results is longer — about a 90 day time period

•More difficult to cheat

Cons of hair testing

•Detection times are longer — takes up to 2 weeks after use to show up

•Does not reliably pick up many benzodiazepines

•Some drugs are easily removed by bleaching/alteration. THC is hardest to remove

•Can use hair extensions, wigs to fool results. Not everyone has enough hair.

•More expensive

SWEAT TESTING

•Tests for cocaine, amphetamines, and opiates

•Wear a patch for a week

•Patch has a tamper evident seal

•Non-invasive

•Longer window of drug use

•Only a few labs do this kind of testing

•Sensitive skin will react to the patch

•Subject to external contaminants

•Sweat production dependent

BLOOD TESTING PROS AND CONS

Pros of blood testing

•Good for testing if person is suspected to be immediately under influence.

•Drugs can be tested for within hours of ingestion.

•Most reliable for current alcohol levels

•Nearly impossible to cheat, may test for very comprehensive panels of drugs and toxins

Cons of blood testing

•Brief detection window.

•Often least effective as far as detecting remote use…for example will only detect Valium

for several days whereas urine can detect up to month or more

POP QUIZ

WILL YOUR URINE BE POSITIVE FOR THC (MARIJUANA) IF YOU USE CBD OIL?

NAIL TESTING PROS AND CONS

Pro of nail testing

•Long detection time: 3-6 months

Cons of nail testing

•Like hair, delayed detection post ingestion 1-2 weeks.

•Can detect environmental exposure vs actual ingestion, so may not know if results are valid (e.g. hand sanitizer positive for alcohol)

•People may not have enough nail (need 100 mg). Acrylic nails can affect testing

•Single use may be missed or not detectable

SALIVA TESTING

•Drugs detectable typically 5-48 hours.

•Oral consumption of fluid, food, or other substances can affect results.

•Not typically recognized as reliable as urine or hair

•Easily defeated

FINAL THOUGHTS

RECOGNIZE WHAT YOU ARE TESTING FOR: If unsure, contact the lab!

For example:Opiates: Standard opiate test will recognize codeine, percocet, oxycontin, morphine, and/or dilaudid. Will need expanded opioid panel or specific testing for methadone, suboxone, fentanyl, or tramadol

Amphetamines will be positive for: Vyvanse, Adderall

Ritalin (methylphenidate) requires a specific test, as do some other ADHD drugs.

ALCOHOL TESTING

WHAT IS HEAVY DRINKING?

•4-6 drinks/day• 1 bottle of wine

• ½ pint (8 oz) hard liquor

• 5 cans of beer

BREATHALYZERS

• Standard for testing while client is suspected to be under the influence• Only effective while client is actively drinking, and during the metabolism

phase of ingested alcohol• Can detect hours after drinking, sometimes next morning/day, depending on

quantity ingested• Typically fairly foolproof, though user error and machine malfunction can

provide false negative

SOBERLINK

• According to their website

• Commonly used in family law courts

• Facial recognition

• Professional grade Breathalyzer

• Tamperproof

• Detection range 0-0.400% BAC and an accuracy level of +/- 0.005 BAC

• Successfully validated in court

BLOOD TESTING ALCOHOL LEVELS

• Gold standard for testing while client is suspected to be under the influence

• Most accurate for alcohol level

• Only effective while client is suspect to currently be under the influence

• Can detect hours after drinking

• With chain of custody, essentially foolproof

THE ALPHABET SOUP OF ALCOHOL TESTING

• ETG

• ETS

• Peth

• %CDT

• %dCDT

• AST/ALT

• GGT

• Gamma%CDT

ETG/ETS (ETHYL GLUCURONIDE AND ETHYL SULFATE)

• Both direct minor metabolites of alcohol• Only produced with alcohol consumption• ETG may be detected if the urine sample ferments (rare)• **does not correlate with the amount or frequency of ingestion or level of

intoxication

ETG—ETHYL GLUCURONIDE

Can be obtained from urine, hair, blood, or fingernail samples

• Urine EtG detects use of alcohol for 24 hrs after 1-2 alcoholic beverages, and up to 2-5 days after heavier use

• Hair EtG detects use of alcohol for the 7 to 90 days prior to testing

• Blood EtG detects use approximately 36 hours after use

• Fingernail EtG detects use of alcohol for up to 90 days prior to testing, detectable about 1 week after use • Toenails superior to fingernails

ETG—ETHYL GLUCURONIDE

• Hair and nails can be influenced by mouthwash, hand sanitizer and other environmental ethanol

• Dilution by drinking water and/or eating can dramatically reduce the level, and the creatinine in urine will still be normal

• EtG should not be used as the only determinant of alcohol use because it can be corrupted by environmental alcohol, but it is reasonable as an abstinence monitoring tool

• EtG level weakly correlates with initial alcohol concentration, lots of false negatives

ETG—ETHYL GLUCURONIDE

• Best for detecting heavy alcohol use

• Lighter consumption may be missed in as little as 24 hours

• Foolproof? No

• Can use fake urine

• Dilution with water

• Heavy metals can corrupt

• Harder to fool in blood, but lower levels may be missed

• Hair is also more difficult to fool (but processing or swimming can alter results)

ETS—ETHYL SULFATE

• Direct ethanol metabolite representing recent alcohol consumption

• Window similar to ETG, but different pathways between the markers in formation and degradation

• Best if used conjointly with ETG for increased sensitivity since some people will be positive for one or the other

• Timeframe of detection similar to ETG = several days

I passed an ETG test 24 hours after drinking a fifth of vodka! Has anyone else passed too?

If I were to consume about 8-12 beers and had an Etg test for alcohol 48-60 hours later what are my chances of passing?

Can I pass an ETG test 60 hours after a 3-day binge?

How do I pass an ETG test?

How long can two drinks take to pass an alcohol EtG test?

I drank lots of wine, What are my chances of passing an etg test in 60 hours?

PETH--PHOSPHATIDYLETHANOL

Obtained from a blood sample

• Detects use of alcohol for 2-3 weeks prior to testing, detectable for up to 2 weeks after abstinence

• Used to differentiate social drinking from alcohol abuse, can be corrupted with hand sanitizer, mouthwash

• Has potential, but further study is needed

• Negative results do correspond to abstinence or light drinking

• Positive results cannot be correlated to rate and level of consumption

PETH

• Baseline level useful, changes in level can indicate changes in use

• Can’t correlate with amount of alcohol consumed

• Can indicate recent use

• Can have false negatives, more frequently in women

• Should be combined with other biomarkers

CDT—CHRONIC USE BIOMARKER

•Best used to look for abstinence

•Or a return to drinking

•Can’t be correlated to the amount of alcohol ingested

%CDT—CARBOHYDRATE-DEFICIENT TRANSFERRIN

• Foolproof?

• Usually from a blood test, so difficult to cheat

• Females have lower sensitivity and specificity than males

• Premenopausal women with high levels of estradiol have significantly higher levels than postmenopausal women or men, or women who take BCP or HRT

• BMI—higher BMI lowers levels

• Smoking—can elevate levels without any drinking

• End stage liver disease—elevates levels

• Glycosylation disorders—test not reliable

%DCDT—DISIALO CARBOHYDRATE-DEFICIENT TRANSFERRIN

—Obtained from a blood sample

• The CDT isoform most specific for heavy alcohol use

• Also detects excessive use of alcohol (5 or more drinks/day) during the previous 2 weeks and can remain elevated for 2 to 6 weeks after stopping drinking

• Chronic heavy drinking sensitivity of 60-80%

• Men more sensitive than women

• Look for a 30% decrease in the baseline level to indicate refraining from alcohol. Similarly if it goes up after a normal baseline, that could indicate binge drinking or a return to heavy use

DIFFERENCE BETWEEN CDT AND DCDT

• CDT looks at the carbohydrate side chains of transferrin (which transfers iron from the intestine to the cells and organs). When someone drinks too much alcohol, the liver cells don’t make transferrin in the normal way and the molecule become deficient in carbohydrates.

• DCDT is the most reproducible isomer of the alcohol biomarker CDT

• DCDT is one of 3 isomers of CDT. Cutoff is different than CDT for a positive result.

%CDT—CARBOHYDRATE-DEFICIENT TRANSFERRIN

Obtained from a blood sample

• Detects excessive use of alcohol

• Can remain elevated for 2 to 6 weeks after stopping drinking.

• Best used as a serial test for changes in alcohol consumption. Need a baseline level

• Can be elevated in other disease states like hepatitis C, certain genetic diseases

• Poor sensitivity, but more specific than GGT

• Best used to look for relapse or abstinence

AST/ALT—ASPERTATE AMINOTRANFERASE AND ALAMINE AMINOTRANSFERASE• Non specific biomarkers

• From blood so difficult to cheat

• Found in the liver, transfer proteins (amino acids) from cell to cell

• Released at higher levels when liver damage is present

• Many false positives and disease states can elevate them

• Damage from drugs (not necessarily illicit) can elevated them (statins)

• Low sensitivity/specificity for alcohol consumption

• AST/ALT ratio 2:1 indicates alcoholic liver damage

GGT-GAMMA-GLUTAMYLTRANSFERASE

—Obtained from a blood sample

• Good for heavy chronic drinking

• Can increase due to illness, obesity, medications (hormones, anticonvulsants), and as we age

• Should be used with %dCDT to get a clearer picture of alcohol use (i.e., if GGT is elevated, but not CDT, the person might have a disease state or take medications that elevate the GGT, not alcohol use)

GAMMA%CDT

• Coming soon, combines GGT and CDT

• Shows less dependence on the liver health

• Research shows more sensitive, but not yet ready for

primetime

COMMON HOUSEHOLD ITEMS THAT CONTAIN ALCOHOL

• Mouth wash• Hand sanitizer• Breath strips• Cough syrup• Nyquil• Rubbing alcohol• Perfume/cologne• Aftershave, mousse, hairspray, some body washes (check the ingredients)• Bug spray• Skin astringents• Nail polish remover• Inhalers• Anti-bacterial soap

COMMON FOODS THAT CONTAIN ALCOHOL • Kombucha• Vanilla and other flavored extracts• Wine is not cooked all the way off in food• Truffles• Grandma’s Rum Cake• Non-alcoholic beer• Burger rolls• Rye bread• Bananas (the riper, the more alcohol)• Pear• Cherry yogurt• Soy sauce• White wine vinegar• Some fruit juice (apple, orange, and grape)• Honeybuns• Hot sauce• Sugarless gum• Energy drinks

HOW SAMPLES ARE OBTAINED

•Court ordered v. Voluntary• Voluntary doesn’t always follow chain of custody

•Unobserved v. Observed • Labs• Doctor’s Offices• Emergency Departments—never observed

•Chain of Custody

PROCESS OF VERIFICATION—CHAIN OF CUSTODY• Observed or unobserved, sometimes filmed (usually only at

methadone/drug clinics)

• Form is filled out and government ID shown

• Sealed in front of client and the client initials the seal

• Sealed again in a bag that the collector initials

• Samples held for a year, but private labs could be different, so call the lab

• GCMS or LCMS verified

• Chain of custody labs are required to keep positive samples for 1 year (DOT requirement)

• Records are stored for a minimum of 2 years

SAMPLE VERIFICATION

• Initial screening sample is an immunoassay, ELISA, easily corrupted, high rate of false positives

• Know whether your sample is GCMS/LCMS (gas chromatography mass spectrometry/liquid chromatography mass spectrometry) verified

• Labs will use one or the other, they are interchangeable

• GCMS/LCMS read the chemical signature of the substance, so it can’t be fooled

• LCMSMS means they ran it twice in tandem (triple/quadruple)

• Very sensitive

SO WHAT SHOULD WE ORDER FOR OUR CLIENTS?

• Know what you’re testing for

• Know what type of testing you need

• If the test doesn’t have numbers, i.e. the amphetamine level is 594, it is likely a screen and not GCMS/LCMS verified

• Call the lab with questions

• Be mindful of drug use trends in your area

REFERENCES

• American Society of Addiction Medicine (ASAM) www.asam.org• Consensus statement—

https://www.asam.org/docs/default-source/quality-

science/appropriate_use_of_drug_testing_in_clinical-1-(7).pdf?sfvrsn=2

Appropriate Use of Drug Testing in Clinical Addiction Medicine

RECAP:

TYPICAL TESTING DETECTION TIMES

• Urine-Gold standard, general detection window from hours to weeks. Easily fooled with tampering (fake urine, whizzinator, substitute samples, dilution, adulteration). High sensitivity and specificity if confirmation test performed

• Blood—minutes to days—very difficult to fool, high sensitivity and specificity but low window of detection

• Saliva—1-48 hours, (some labs report as long as 4 days) may rarely be fooled by adulteration/dilution of oral contents

• Breath—minutes to hours—difficult to fool

• Sweat—hours to weeks, low sensitivity

• Hair—Weeks to months, may test for multiple substances, hair samples can be tampered with by processing with chemicals, can be contaminated from environmental exposure (e.g. study of children of alcoholics all showed measurable levels of etg in their hair, presumably from exposure to parents sweat, etc.)

• Nails—weeks to months, can be contaminated from environmental exposure

CLIENT 1—ALICE

• 35 yo white female• Mother of 3 boys, ages 2, 7, and 8• Occasional daydrinker• Medications—Adderal, Wellbutrin, Synthroid• Heated custody battle, yesterday boys were dropped off and she

was allegedly slurring her words• Emergency hearing in the morning• She says she hasn’t been drinking in a month and takes her

medications as prescribed• How will we find out what she is taking?

ALICE

• Immediate urine testing

•Hair testing with full panel

•Make sure it is GCMS/LCMS verified and donated in chain of custody

CLIENT 2—BILL

•55 year old white male

•Fighting with his brother for control of the family lumbar business

•History of methamphetamine and cocaine use, but swears he’s been clean for 6 months

•His brother would like him declared unfit for executive decisions

•What kind of testing could clear our client?

BILL

•Nail testing would give 6 month window

•Hair could help as well

•Best if both were negative

CLIENT 3--JEN

• 42 year old female surgeon

• Has prescriptions for adderal, xanax

• Urine drug screen at work is positive for amphetamines and benzos

• She says she is taking her medications as prescribed and only uses the xanax when she has to fly

• There is a rumor she has been using street methamphetamine to stay awake during surgery

• How can we know if she is taking her medications as prescribed? Could she be buying them on the street or stealing them?

HOW DO WE KNOW WHAT SHE TOOK?

• The most commonly used urine drug testing approach involves automated immunoassay (IA) either alone as a point-of-care test or as an initial screen for a 2-step testing procedure.

• Results from IA are qualitative (i.e., a drug or its metabolite is denoted either present or absent, without the quantity reported).

• You will get a yes/no answer

• Her urine was positive for amphetamines and benzos

THE NEXT STEP– GET GCMS/LCMS CONFIRMATION

• In the 2-step approach

• Screening IA is followed by confirmatory gas chromatography-mass spectrometry (GC-MS)

• If any substances are positive on the initial IA, a separate quantity of the same sample is then subjected to GC-MS as a confirmatory test for those same substances, with negative results on the IA disregarded.

CAN WE USE GCMS LEVELS TO DETERMINE AMOUNT OF USAGE?

• In a word—No

• GC-MS provides a quantitative result, which can be used to follow serial samples and determine whether the metabolite concentration is rising or falling, which may suggest ongoing use or abstinence, respectively.

• Use caution, as levels may vary with • urine concentration • the amount of drug used• time since last use

• An absolute determination regarding whether use is ongoing is risky

IS JEN ON STREET METH?

• Urine was positive for amphetamine, but negative for methamphetamine

• Methamphetamine metabolizes to amphetamine

• If methamphetamine is positive, you should always be positive for amphetamines

• If methamphetamine is negative, but amphetamine is positive, the client is taking Adderal or Vyvanse

IS JEN ON STREET METH?

• Adderal comes back as amphetamine.

• If you want to tell if the methamphetamine is street, some labs can do an isomer test to look (called methamphetamine d,l isomer test)

• Vicks inhaler causes a positive l methamphetamine isomer test

• d is street form or a prescription appetite suppressant

• In the test, if the d isomer more than 20%, the client is taking either street or prescription meth, not OTC

• Rx methamphetamines – desoxyn (adhd or narcolepsy or weight loss), didrex (benzphetamine)

CONCLUSIONS FOR JEN

• Within reasonable certainty she is taking her adderal

• She is not taking street methamphetamines

• Her positive benzo level should be followed with serial testing, as she states she recently flew on a plane (and can prove it)

• Her level should not be used to tell if she is stealing or diverting it, only that yes, she has it in her system

PEARLS

•Again, there is no specific correlation between GCMS/LCMS levels and amount taken

•That said, it is likely when you get a snapshot, a positive screen indicates that person is a habitual user. But don’t bet the farm on it. Get serial testing.

THANK YOU

SPECIFIC CONCERNS RELATING TO TESTING CHILDREN AND INTERPRETATION OF RESULTSMICHELLE BENS CLARE, DO, MPH

TODAY WE WILL LEARN

• Types of drugs are children exposed to from the womb to adulthood

• What kinds of testing can be done on pregnant women, neonates, children and adolescents

• How age and body size can influence results

• Medicolegal concepts with respect to testing

South Carolina Code §63-7-1660

(F)(1) It is presumed that a newborn child is an abused or neglected child as defined in Section 63- 7-20 and that the child can

(a) a blood or urine test of the child at birth or a blood or urine test of the mother at birth shows the presence of any amount

or

(b) the child has a medical

diagnosis of fetal alcohol syndrome;

and

“the mother has history of testing positive at the birth of another child, another child testing positive at birth, or another child was diagnosed with fetal alcohol syndrome “

AGE DEFINITIONS—CDC.GOV

• Newborn: 0-30 days of age• Infant: 1 month to 1 year• Toddler: 1-3 years• Preschooler: 3-5 years• Child: 5-11 years• Young teen: 12-14 years• Teen: 15-17 years

• Adolescents: 11-21 years of age• Early (11-14)• Middle (15-17)• Late (18-21)

WHAT AGES CAN YOU TEST

•Any age

•Any test

•Type of testing depends on time period you are looking for and ease of obtaining samples

•Urine and hair most common

WHY DO THE TESTING

•10-20% of all babies are exposed prenatally to illicit drugs or alcohol

•1 in 8 children under 17 live in a home where at least one parent has a substance abuse problem

•50% of teens have misused at least one drug in their lifetime

•43% of college students use illicit drugs

•74% of adults in a substance abuse treatment program started using alcohol or drugs before the age of 17

DRUGS COMMONLY ABUSED DURING PREGNANCY

• In order of most common

• Alcohol

• Marijuana

• Opiates

• Then all the rest

FETAL ALCOHOL SYNDROME

• Symptoms vary

• Causes brain damage and growth problems

• Not reversible

• Distinctive facial features• Small eyes• Thin upper lip • Short upturned nose• Deformities of joints, limbs, and fingers• Vision or hearing problems• Small head and brain size• Heart defects• Intellectual disability• Hyperactivity

MARIJUANA AND PREGNANCY

• Most common illicit substance used during pregnancy

• Self-reported prevalence 2-5%, rising to 15-28% for socioeconomically disadvantaged women

• Many smokers (up to 60%) don’t quit while pregnant, believing that it is safer than tobacco and helps with nausea

• Recent study noted that 18.1% of women that use during pregnancy meet the criteria for marijuana abuse or dependence

MARIJUANA AND PREGNANCY

•THC crosses the placenta and produces levels at about 10% of maternal levels, and it goes higher after repeated exposure

•On the rise due to legalization of marijuana

•Can cause impaired neurodevelopment of the fetus

•Plus smoking is bad during pregnancy

OPIOIDS AND PREGNANCY

• Rise of opiate addicted newborns in recent years 300% since 1999

• 7% of women use opioids during pregnancy

• Of those, 20% misuse prescriptions

OPIOIDS AND PREGNANCY

• Neonatal Abstinence Syndrome (NAS)

• Withdrawal from Opioids after birth most common

• Also could be from Barbiturates and Benzos

• Can cause low birth weight, jaundice, seizures, SIDS

• Long term effects: developmental delay, behavioral problems, speech delay, vision problems, ear infections, and sleep problems

TESTING OF PREGNANT WOMEN

• Pregnant women not routinely tested unless there is suspicion

• During prenatal visit, asked questions about drug and alcohol use

• Abstinence encouraged

• Consent form gives permission, but mothers will be told if there will be drug screening

• After viability (24 weeks), if there is a positive test, social work and DSS are involved

• If 2 positives, mom will have to take a class and may need help with the baby

• Mandated reporting by physicians if mother admits to doing drugs in the presence of the baby

REPORTING OF DRUG USE WHILE PREGNANT

• Only 5% of women admit to using illicit substances, so underreporting is high

• Drug testing can be a barrier to care, so it isn’t done without medical necessity

• Women don’t get help because they fear losing their newborns

• In South Carolina women who have taken drugs while pregnant have been charged with child abuse

FERGUSON V. CITY OF CHARLESTON

• Case filed in 1989. Went before the Supreme Court in 2001

• At MUSC, urine tested positive for cocaine

• No consent to test had been obtained

• They were arrested and prosecuted for child abuse

• 10 women filed suit

• Case found to violate 4th amendment

• The first case before the Supreme Court to address maternal-fetal conflict in terms of warrantless searches

ISSUES WITH DRUG SCREENING IN PREGNANCY

• Few validated and standardized tests for screening

• Uncertainty as to when testing should occur, which tests should be used, and how testing should be done

• Results between types of material and five drug classes found highly discordant results

• Legal issues with consent

• American Society of Addiction Medicine and American College of Obstetricians and Gynecologists state that all women should be screened using a validated screening test and not biochemical measures

TESTING NEWBORNS FOR PRENATAL EXPOSURE

• In 90-95% of babies who are exposed to drugs in utero, exposure was not detected at birth

• Drug use in utero puts the fetus at risk of premature delivery, physical, and cognitive delay, and increases risk of neonatal mortality

• What is tested?• Same as with adults—typical 5 panel (THC, Opiates, PCP, Cocaine,

Amphetamines)

• Does DSS have to be notified?• Yes, mandatory reporting

TYPES OF MATERNAL/FETAL TESTING

• Urine• Saliva • Sweat• Hair• Breath• Blood• Meconium• Placenta• Cord Blood

• Urine, Saliva, Hair, Breath, and Blood tests reviewed in the first lecture

• All different types of tissue have their advantages and disadvantages

TYPES OF TESTING

•Maternal hair, urine, and blood can be screened prior to birth

•Placenta, meconium, and cord blood can be tested after

•Prenatal urine testing is easy and accessible•Urine only validates recent usage by the pregnant woman•Alcohol, amphetamines, Benzos, marijuana, and cocaine

can be tested

•High rate of false positives

MECONIUM

• First bowel movement of the fetus

• Forms in the beginning of the second trimester (once the fetus can swallow)

• Factors can make it difficult to collect, like low birth weight or time to first BM

• Must be collected 2-3 days after birth, so only useful if the newborn is admitted to the NICU

• Tests alcohol, cocaine, marijuana, opiates, barbiturates, benzos, amphetamines and PCP during pregnancy

• Most useful for long term drug use

• Gold standard of newborn testing, though it can’t test for first trimester exposure

MATERNAL OR NEONATAL HAIR

•Easy to collect

•Long window of detection

•Neonatal hair begins to grow at the beginning of the third trimester

•Limited amount of neonatal hair can cause problems

•Useful if you want to know now, and not wait for meconium

PLACENTA

•Non invasive and simple, placenta usually discarded after birth

•Large sample available

•No standardized procedure for sample preparation

•Accuracy not verified

UMBILICAL CORD BLOOD

• Short window of detection

• Readily available (it’s considered medical waste), routinely collected after birth

• Completely on the fetal side of the vascular organ, so better represents fetal exposure

• Drug levels lower than matched meconium

• Marijuana fairly sensitive, other drugs, not as much

• Commercial test for detection of opioids available

• Rarely used clinically

• Not tested for substances unless there is suspicion

Specific Concerns Relating to Testing Children and Interpretation of Results

Dr. Michelle Bens Clare

Family Law Section

TESTING IN CHILDREN

SPECIFIC CONCERNS BASED ON AGE

• Pharmacokinetics refers to the processes of drug absorption, distribution, metabolism, and elimination

• In general, the younger the child, the less reliable the pharmacokinetics

• The body changes rapidly during the first year of life

• Adolescents are even more complex—changes based on age, gender, and body size

SPECIFIC CONCERNS BASED ON AGE

• Stomach flora acts differently based on age

• Absorption of oral drugs is affected by changes in gastric pH

• Decreased during infancy, reaches adult values by 2 years of age

• Reduced stomach acid increases bioavailability of acid-labile drugs (Penicillin) and decreases weakly acidic drugs

• The younger the child, the faster the transit time through the gut

• Reduced bile salt formation decreases bioavailability of lipophilic drugs (diazepam)

• Under 3 months of age, delayed gastric emptying

METABOLISM IN CHILDREN

• Injectable drugs are often erratically absorbed because of

• Variability of chemical characteristics• Differences in muscle mass among children• Illness• Variability of depth of injection

• Transdermal drug absorption varies by age

• Infants and small children have less fat and thinner skin so more drug is absorbed

METABOLISM IN CHILDREN

• Metabolism—as children mature, liver enzymes effectively metabolize most drugs, because the basal metabolic rate is higher in children than adults

• Dosages of drugs relative to body rate may need to be higher for children than adults

• Water soluble drugs tend to need higher dosages because the percentage of water is higher

• Childhood obesity can influence fat soluble drugs

• The net result is that at younger ages, increased drug concentrations, greater pharmacologic effects, and higher frequency of adverse effects at lower drug concentrations can be found

CHANGES IN BODY COMPOSITION WITH GROWTH AND AGING

WHAT DOES ALL THIS MEAN FOR TEST RESULTS?

• Test results are processed similar to adults, in that a positive is a positive

• Reference ranges vary by age

• Get a 5 panel or 10 panel depending on what you are looking for

• Positive results should be confirmed with GC/MS

• Hair gives the best long term information

• A study that looked at children in homes where methamphetamines were known to be used found good correlation with testing

• —Greatest correlation in children under 3

WHAT’S ON THE PANEL?

5 PANEL URINE TEST

THC

OPIATES

PCP

COCAINE

AMPHETAMINES

10 PANEL URINE TEST

—5 PANEL PLUS

BENZODIAZEPINES

BARBITURATES

METHADONE

PROPOXYPHENE

QUAALUDES

*CAN VARY BY LAB

CONSENT IN ADOLESCENTS

• Parents will bring their unruly teens to the Emergency Department for drug or alcohol testing

SECTION 63-5-340. Minor's consent to health services.

Any minor who has reached the age of sixteen years may consent to any health services from a person

authorized by law to render the particular health service for himself and the consent of no other person shall

be necessary unless such involves an operation which shall be performed only if such is essential to the

health or life of such child in the opinion of the performing physician and a consultant physician if one is

available.

Drug and alcohol treatment not specifically addressed, unlike some states (in California, a minor can get

treatment/testing as early as age 12)

CONSENT IN ADOLESCENTS

• The American Academy of Pediatrics (AAP) advises that testing can be a breach of trust and may damage the relationship between parent and child

• Physicians can order testing if it is medically necessary or by a court order• If the child can consent, then HIPAA applies, and results not to be given to the

parents unless the patient consents

CONSENT IN ADOLESCENTS

•If the child is altered, do what you need to treat the patient, otherwise follow the law

•For example, if it is not an emergency to find out the child’s blood alcohol level, then don’t do it

•Best not to risk assault and battery of a minor and stay within the law

IS RANDOM DRUG TESTING IN SCHOOLS LEGAL

• Yes according to the Supreme Court in 2002, for children in competitive extracurricular activities

1. Vernonia School District 47J v Acton, 115 SCt 2386 (1995)

2. Board of Education v Earls, 536 US 822 (2002)

• AAP opposes random drug testing of adolescents because of lack of scientific evidence of their effectiveness

• Numbers of positives were low• Number one abused substance in this age group is alcohol, which is not

tested for• Breech of privacy (HIPPA) because medications may be detected

COMMON DRUGS OF ABUSE IN TEENS

• Why do we care?

RATES OF DRUG USE AMONG TEENS

• Marijuana use on the rise

• Second most commonly used drug in America• 13% 8th graders• 29% 10th graders• 36% 12th graders have ever used THC• Use has doubled in last few years (all age groups)

• 10 years ago it was illegal across the United States• Legal for medicinal purposes in 36 states• Legal for recreational use 15 states

• Most other drugs stabilized or on the decline

ADVERSE EFFECTS OF DRUG USE IN CHILDHOOD

• Earlier use linked to less likely school completion and enrollment in postsecondary education

• Greater risk of being unemployed at age 36

• Is it a gateway drug?

AGE OF FIRST TIME USE OF ILLICIT SUBSTANCES

• Cigarettes• Alcohol• Marijuana• Other drugs

• Depends of race/ethnicity, research on non-whites is scarce

Race/Ethnicity Wave 1 Sample Size

Average Sample Age of First Use / Percent Who Have Ever Used

Cigarette Alcohol Marijuana

White (N= 10,487) 14.3 (79.1%) 14.9 (84.1%) 15.8 (58.5%)

Black (N= 4,391) 15.7 (60.3%) 15.7 (65.6%) 15.5 (46.9%)

Hispanic (N= 611) 14.5 (63.7%) 15.2 (66.0%) 14.7 (45.7%)

Asian (N= 1,321) 15.8 (61.9%) 16.1 (67.9%) 16.8 (38.8%)

American Indian (N= 148) 13.7 (81.1%) 13.9 (76.4%) 13.5 (64.2%)

White-Black (N= 135) 14.8 (75.6%) 15.0 (80.0%) 16.0 (65.9%)

White-Hispanic (N= 2,202) 15.2 (68.4%) 15.2 (74.6%) 15.6 (48.2%)

White-Asian (N= 145) 14.6 (73.1%) 14.9 (78.6%) 15.2 (64.8%)

White-American Indian (N= 312) 13.5 (85.3%) 14.3 (81.4%) 15.4 (64.4%)

Black-Hispanic (N= 154) 15.0 (69.5%) 15.6 (73.4%) 15.7 (51.3%)

Black-Asian (N= 26) 16.3 (69.2%) 16.2 (73.1%) 14.9 (57.7%)

Black-American Indian (N= 85) 15.1 (63.5%) 15.4 (62.4%) 15.1 (52.9%)

Hispanic-Asian (N= 121) 15.0 (67.8%) 15.3 (67.8%) 15.3 (49.6%)

Hispanic-American Indian (N= 355) 15.1 (73.8%) 15.3 (75.2%) 14.5 (55.8%)

Multi/Other (N= 250) 15.0 (72.0%) 14.5 (70.8%) 15.1 (54.4%)

PARENTAL INFLUENCE

•A close parent-child relationship is significantly associated with the age of first use of substances

•Close relationships with one parent or both more frequently never used illicit substances

•Extremely important to delay substance use onset

• Impacts school completion and future employment

EFFECTS ON HEALTH

• Brain development continues until the mid 20s

• Substances can impact the brain permanently

• Delayed onset of substance use minimizes potential negative impact

• Initiating substance use in adolescence increases the risk of developing chronic substance use disorder later

• Initiating alcohol use at a younger age is linked to alcoholism

• Early adolescent onset of substance use linked to mental illness

• Higher risk for truancy, declining grades, and dropping out

THANK YOU