Drug Court
Myth
Cannabis 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 differ
from 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 withdrawal
and craving.
• Pharmacologically little effect
on alcohol, cocaine, etc.
• With adequate ORT,
most patients do eliminate or
reduce 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
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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 nonHispanic 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
Myth
If 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”
Myth
If 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
Myth
Well 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
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Dave Wallace – Photographer
Meghan Wheeler
Cinderella
The nice popcorn lady
The eventually nice Secret Service