Urine Creatinine &Sample Tampering

By: Paul L. CaryBy: Paul L. CaryToxicology LaboratoryToxicology LaboratoryUniversity of MissouriUniversity of Missouri

The ramifications of a positive drug test (i.e. sanction,program expulsion, imprisonment, etc.) combined with the

denial component of substance abuse often createcircumstances whereby clients feel the need to “beat the

drug test” by tampering with the sample. Sampletampering represents a significant challenge to a the court’s

mission and can threaten to undermine the legitimacy ofthe court’s policies and procedures as well as it’s decisions.

It’s a matter of control.

Creatinine testing is a specimenvalidity issue!

The most common form ofspecimen tampering is sample

dilution.

Creatinine Discussion

urine as a specimen of choice for drug testingurine as a specimen of choice for drug testing challenging collection strategieschallenging collection strategies using creatinine for using creatinine for ““dilutedilute”” determination determination court responses to dilute samplescourt responses to dilute samples the the ““inadvertentinadvertent”” dilute dilute creatine supplement issuescreatine supplement issues what is specific gravitywhat is specific gravity

Why Use Urine for Drug Testing? generally readily available in large quantitiesgenerally readily available in large quantities drug & metabolites are highly concentrateddrug & metabolites are highly concentrated extensive scientific basis for methodologyextensive scientific basis for methodology results accepted in courtresults accepted in court provides both recent and past usageprovides both recent and past usage uniform testing criteria (established cutoffs)uniform testing criteria (established cutoffs) easily tested (laboratory & on-site)easily tested (laboratory & on-site) quality assurance practices well-establishedquality assurance practices well-established

Problems With Urine as a Specimen:

YUCK factor!YUCK factor! biological waste productbiological waste product distasteful qualities & invasive collectiondistasteful qualities & invasive collection

NOT QUANTITATIVE NOT QUANTITATIVE –– cannot use concentration cannot use concentrationto evaluate client drug use historyto evaluate client drug use history

susceptible to tamperingsusceptible to tampering drug concentration influenced by fluid intakedrug concentration influenced by fluid intake necessities witnessed collectionnecessities witnessed collection

Creatinine & DiluteSamples

What is creatinine ?

creatinine is produced as a result of muscle metabolismcreatinine is produced as a result of muscle metabolism creatinine is produced by the body at a relativelycreatinine is produced by the body at a relatively

constant rate throughout the dayconstant rate throughout the day creatinine is a compound that is unique to biologicalcreatinine is a compound that is unique to biological

material (i.e. urine, other body fluids)material (i.e. urine, other body fluids) creatinine measurements can:creatinine measurements can:

determine the determine the ““strengthstrength”” or concentration of a urine or concentration of a urinesamplesample

ensure the sample being tested ensure the sample being tested ISIS urine urine

EVERY urine sample usedfor drug detection shouldbe tested for creatinine!

Two Types of Urine SpecimenDilution

pre collection dilutionpre collection dilution consumption of large quantitiesconsumption of large quantities

of fluids of fluids priorprior to collection to collection post collection dilutionpost collection dilution adding fluid to specimen adding fluid to specimen postpost

collectioncollection

Pre-Collection Dilution high-volume ingestion of fluids (water loading,high-volume ingestion of fluids (water loading,

flushing, hydrating, etc.)flushing, hydrating, etc.) may be in conjunction with products designed tomay be in conjunction with products designed to

““enhanceenhance”” drug elimination or removal of drugs drug elimination or removal of drugs(Gold Seal, Clean (Gold Seal, Clean ‘‘n Clear, Test-Free, Naturallyn Clear, Test-Free, NaturallyKlean, etc.)Klean, etc.)

no evidence these products have any additionalno evidence these products have any additionaleffect on drug eliminationeffect on drug elimination

Water contains no drugs!

easiest, cheapest, simplesteasiest, cheapest, simplest urines with a creatinines of less than 20 mg/dLurines with a creatinines of less than 20 mg/dL

are considered are considered ““dilutedilute”” and rarely reflect an and rarely reflect anaccurate picture of recent drug useaccurate picture of recent drug use

dilute samples are more like water than like urinedilute samples are more like water than like urine all drug court/criminal justice samples should beall drug court/criminal justice samples should be

screened for creatininescreened for creatinine

How are creatinine measurements used ?

normal human creatinine levels will vary during thenormal human creatinine levels will vary during theday based upon fluid intake - healthy individuals willday based upon fluid intake - healthy individuals willrarely produce urine samples with creatinines of lessrarely produce urine samples with creatinines of lessthan 20 mg/dLthan 20 mg/dL

incidence of creatinines less than 20 mg/dL in aincidence of creatinines less than 20 mg/dL in a““normalnormal”” population is approximately 1% population is approximately 1%

urines with a creatinines of less than 20 mg/dL areurines with a creatinines of less than 20 mg/dL areconsidered considered ““dilutedilute”” and often do not reflect an and often do not reflect anaccurate picture of recent drug useaccurate picture of recent drug use

Creatinine Facts some diseases that produce low urinary creatininessome diseases that produce low urinary creatinines

muscle wasting disease - RAREmuscle wasting disease - RARE some kidney aliments - RAREsome kidney aliments - RARE

low creatinines ARE NOT routinely associated with:low creatinines ARE NOT routinely associated with: pregnancypregnancy diabetesdiabetes obesityobesity exerciseexercise high-blood pressurehigh-blood pressure being vegetarianbeing vegetarian

The “Normal” Creatinine

incidence of low creatinines in a population undergoing randomincidence of low creatinines in a population undergoing randomdrug testing is significantly (up to 10 times) greater than a non-drug testing is significantly (up to 10 times) greater than a non-drug tested populationdrug tested population

any fluid intake dilutes the concentration of drugs in urineany fluid intake dilutes the concentration of drugs in urine(along with the creatinine)(along with the creatinine)

normal urine creatinine: 2005 study normal urine creatinine: 2005 study ““Urinary CreatinineUrinary CreatinineConcentrations in the U.S. PopulationConcentrations in the U.S. Population”” determine the mean determine the mean(based upon 22,245 participants) was 130 mg/dL(based upon 22,245 participants) was 130 mg/dL less than 1% below 20 mg/dLless than 1% below 20 mg/dL less than 1%less than 1% greater than 400 mg/dL greater than 400 mg/dL

More Creatinine Issues

rapid ingestion (90 minutes) of 2-4 quarts of fluid willrapid ingestion (90 minutes) of 2-4 quarts of fluid willalmost always produce low creatinines & negativealmost always produce low creatinines & negativeurine drug tests within one hoururine drug tests within one hour

recovery time of urine creatinine and drugrecovery time of urine creatinine and drugconcentrations can take up to 10 hoursconcentrations can take up to 10 hours

incidence of drugs in urine of diluted specimens is overincidence of drugs in urine of diluted specimens is over5 times greater than in samples with normal creatinine5 times greater than in samples with normal creatininelevelslevels

“Dilute” Result Interpretation: negative or none detected results should never be

interpreted as indicating no drug use (abstinence),because if, in fact, drugs were present, they probablycould not be detected by the test

positive drug test results from a dilute samplehowever, are considered valid (donor was not ableto dilute the sample sufficiently to deceive the test)

The “Inadvertent” Dilute ““My sample is dilute because I work as a roofer, onMy sample is dilute because I work as a roofer, on

a black roof, in the middle of August when thea black roof, in the middle of August when thetemperature is 400temperature is 400˚̊ F. F.””

it is possible for a client to achieve a urine creatinineit is possible for a client to achieve a urine creatinineof less than 20 mg/dL under extreme conditionsof less than 20 mg/dL under extreme conditions

court needs to develop creative solutions:court needs to develop creative solutions: collect samples before workcollect samples before work collect samples on days offcollect samples on days off use alternative specimensuse alternative specimens

Creatinine Sanctions no national standardno national standard adjudicate as adjudicate as ““tamperedtampered”” sample - more severely sample - more severely

than positive samplethan positive sample adjudicate as adjudicate as ““positivepositive”” sample - court utilizes sample - court utilizes

positive sample sanctionspositive sample sanctions adjudicate as adjudicate as ““dilutedilute”” sample - unique sanctions sample - unique sanctions some courts allow one some courts allow one ““dilutedilute”” sample per sample per

phase/quarterphase/quarter regardless of sanction - court MUST address thisregardless of sanction - court MUST address this

issueissue

Two final thoughts about diluteurine samples . . . . . a creatinine of less than 20 mg/dL (associated with a

drug test) is nearly always an attempt by the donorto avoid drug use detection - REGARDLESS of howmuch liquid was consumed in order to achieve thisresult

place a dilute sample prohibition in your clientcontract and sanction for repeat dilute samples

On-Site Drug TestingOn-Site Drug Testing

The Creatine Supplement Issue: creatine is the pre-cursor of creatininecreatine is the pre-cursor of creatinine

creatine supplements may increase the amount ofcreatine supplements may increase the amount ofcreatine in the musclescreatine in the muscles

muscles may be able to generate more energy ormuscles may be able to generate more energy orgenerate energy at a faster rategenerate energy at a faster rate

creatine supplements (along with training) maycreatine supplements (along with training) mayimprove performance bimprove performance by increasing energy fory increasing energy foractivities such as sprinting and weightliftingactivities such as sprinting and weightlifting

but thatbut that’’s NOT why our clients take it!s NOT why our clients take it!

The Creatine Supplement Issue:

consuming over-the-counter creatine can disguiseconsuming over-the-counter creatine can disguisepre-collection hydration and a diluted urinepre-collection hydration and a diluted urine

creatine converted to creatinine will mask thecreatine converted to creatinine will mask thedilution effortsdilution efforts

in reality - very difficult to coordinate the intakein reality - very difficult to coordinate the intaketiming and volume of creatine and dilution liquidtiming and volume of creatine and dilution liquid

creatinine greater than 300 mg/dL - increasedcreatinine greater than 300 mg/dL - increasedmonitoringmonitoring

creatinine greater than 400 mg/dL - sanctionablecreatinine greater than 400 mg/dL - sanctionable

What is Specific Gravity?

measure of total dissolved solids in a liquidmeasure of total dissolved solids in a liquid urine SpGr includes creatinineurine SpGr includes creatinine alternative method of determining samplealternative method of determining sample

dilutiondilution introduced in 1988 with federal workplace drugintroduced in 1988 with federal workplace drug

testingtesting common test performed by common test performed by ““forensicforensic”” labs labs

My Advice on Specific Gravity

use creatinine levels only to define use creatinine levels only to define ““dilutedilute””samplessamples samples less than 20 mg/dLsamples less than 20 mg/dL science-based approachscience-based approach very defendable policyvery defendable policy easier to understand & explain to both clientseasier to understand & explain to both clients

& court professionals than SpGr& court professionals than SpGr

SUMMARY TEST FOR CREATININE!TEST FOR CREATININE! incorporate creatinine guidance in your SOPs andincorporate creatinine guidance in your SOPs and

client contractclient contract institute a dilute sample prohibition understand low urine creatinine levels are NOTunderstand low urine creatinine levels are NOT

normalnormal dilute dilute samples are nearly always an attempt by the

donor to avoid drug use detection sanction for repeat dilute tests

Specimen Tampering

Basics of Specimen Tampering -The Three Approaches

dilutiondilution adulterationadulteration substitutionsubstitution

Urine Specimen Dilution

most common form of tamperingmost common form of tampering pre collection dilution (hydration,pre collection dilution (hydration,

water loading, diuretics)water loading, diuretics) post collection dilutionpost collection dilution creatinine measurementcreatinine measurement dilution detection (validity checks)dilution detection (validity checks)

Urine Specimen Adulteration

addition of foreign substances designed to addition of foreign substances designed to ““maskmask””drug presencedrug presence

post-collection tamperingpost-collection tampering low-tech adulterants that cause low-tech adulterants that cause ““pH shiftpH shift”” (lime, (lime,

vinegar, bleach, ammonia, lemon, drano)vinegar, bleach, ammonia, lemon, drano) low-tech adulterants that disrupt testing chemistrylow-tech adulterants that disrupt testing chemistry

(salt, methanol, detergent)(salt, methanol, detergent) five common five common ““high-techhigh-tech”” adulterants adulterants

Urinaid, Byrd Laboratories

gluteraldehydegluteraldehyde sterilization chemicalsterilization chemical deactivates most screening tests -deactivates most screening tests -

producing false negative resultsproducing false negative results can be identified by laboratoriescan be identified by laboratories

employing specimen validity testsemploying specimen validity tests effects can not be reversedeffects can not be reversed

Klear & Whizzies

potassium nitrite, sodium nitritepotassium nitrite, sodium nitrite analytical chemistryanalytical chemistry compromises the confirmation (GC/MS) ofcompromises the confirmation (GC/MS) of

some drugs, notably carboxy-THCsome drugs, notably carboxy-THC oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories employingcan be identified by laboratories employing

specimen validity tests (SVT)specimen validity tests (SVT) effects can be reversedeffects can be reversed

Urine Luck pyridinium chlorochromate/dichromatepyridinium chlorochromate/dichromate oxidizing agent in organic synthesisoxidizing agent in organic synthesis compromises the confirmation (GC/MS)compromises the confirmation (GC/MS)

carboxy-THC and opiatescarboxy-THC and opiates can also effect screening testscan also effect screening tests oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories employingcan be identified by laboratories employing

specimen validity tests (SVT)specimen validity tests (SVT) effects can not be reversedeffects can not be reversed

Latest Update: New Adulterants Bake N Shake (sodium persulfate)Bake N Shake (sodium persulfate) Urine Luck 6.8 (hydrofluoric acid)Urine Luck 6.8 (hydrofluoric acid) Clear-X (potassium nitrite)Clear-X (potassium nitrite) Diamond Purifier (unknown)Diamond Purifier (unknown) Eradicator (probably chromate)Eradicator (probably chromate) NuKlear (unknown)NuKlear (unknown) Purafyzit (probably chromate)Purafyzit (probably chromate) Randomizer (unknown)Randomizer (unknown)

Checking for Adulterants

not necessary on all samplesnot necessary on all samples creatinine - YEScreatinine - YES suspicious sample collectionsuspicious sample collection unusual sample characteristicsunusual sample characteristics client suspected of relapse who continuesclient suspected of relapse who continues

to produce negative test resultsto produce negative test results

Urine Specimen Substitution replacing donor urine sample with anotherreplacing donor urine sample with another

drug-free specimendrug-free specimen biological substitution - someone elsebiological substitution - someone else’’s s ““cleanclean””

urineurine non-biological substitution - replacing urinenon-biological substitution - replacing urine

with urine with urine ““look-a-likelook-a-like”” sample (diet sample (dietMountain Dew, water with food coloring)Mountain Dew, water with food coloring)

non-biologicals can be detected with creatininenon-biologicals can be detected with creatininetestingtesting

Specimen Validity Tests (SVT)Specimen Validity Tests (SVT) creatinine, UUNcreatinine, UUN specific gravityspecific gravity pHpH nitritesnitrites gluteraldehydegluteraldehyde pyridinepyridine chromiumchromium

Request SVT from testing laboratory or usedip-stick SVT products for on-site testing

Controlling Specimen Tampering develop challenging collection strategy - ie. make thedevelop challenging collection strategy - ie. make the

testing unannounced and RANDOM!testing unannounced and RANDOM! directly observed collections is the most effectivedirectly observed collections is the most effective

approach to preventing adulteration and substitutionapproach to preventing adulteration and substitution inspect sample - train collection staffinspect sample - train collection staff keep abreast of tampering techniqueskeep abreast of tampering techniques take temperature measurements (90take temperature measurements (90˚̊ - 100 - 100˚̊ F) F) use laboratory employs specimen validity tests &use laboratory employs specimen validity tests &

use with on-site devicesuse with on-site devices

Confront Specimen Tamperingwith Facts: actively engage clients about tampering issuesactively engage clients about tampering issues

illustrates courtillustrates court’’s tampering knowledges tampering knowledge

discuss specimen tampering in courtdiscuss specimen tampering in court prepare a fact-based presentation on the myths ofprepare a fact-based presentation on the myths of

tamperingtampering highlights the futility of tamperinghighlights the futility of tampering

testimony from former clientstestimony from former clients constantly reinforce the constantly reinforce the ““honestyhonesty”” component of component of

drug courtdrug court

Prepare a fact-basedpresentation on the myths oftampering – what does that

mean?

Don't believe in the Don't believe in the Certo Certo or Sure or Sure Jel Jel method. I triedmethod. I triedit...failed all the drug tests I took every time I used it...Iit...failed all the drug tests I took every time I used it...Iwas being tested for marijuana for Arkansas Drugwas being tested for marijuana for Arkansas DrugCourt. Tested me every week...failed all three drugCourt. Tested me every week...failed all three drugscreens...they use a new on site screscreens...they use a new on site screening machine thatening machine thatspins the sample around...supposedly it can even detectspins the sample around...supposedly it can even detectmeth meth for up to 10 days...and can detect adulterantsfor up to 10 days...and can detect adulterantstoo...too...I cleaned up rather than try to cover up.I cleaned up rather than try to cover up.

Sure Jell/Certo - Reality email

Engage clients in an honestdiscussion regarding tampering!

email address:carypl@healthcarypl@health..missourimissouri..eduedu