DRUG TESTING ADVISORY BOARD

Scientific Meeting on:
Drug Testing of Alternative Specimens and Technologies
Day 2

April 1997

Table Of Contents

Internal Quality Control Program Panel 1

Principles and Criteria 4

Saliva Testing 6

Hair Testing 12

Sweat Testing 20

Urine Testing 29

Onsite Testing 41

Questions and Answers 50

Reporting Test Results Panel 86

Principles and Criteria 86

Saliva Testing 90

Sweat Testing 94

Hair Testing 107

Onsite Testing 119

Urine Testing 127 Questions and Answers 137

Interpreting Test Results Panel 161

Principles and Criteria 163

Hair Testing 165

Urine Testing 174

Saliva Testing 180

Onsite Testing 189

Sweat Testing 197

Questions and Answers 209

External Quality Assurance Program Panel 243

Principles and Criteria 245

Urine Testing 248

Hair Testing 257

Onsite Testing 264

Saliva Testing 275

Sweat Testing 282

Questions and Comments 286

P R O C E E D I N G S [8:15 a.m.]

DR. BUSH: Good morning. It is so good to see so many bright, fresh faces at 8:15. I told you yesterday that we have quite a challenging day. Let's see how we all look by about 5:30 this afternoon.

[Discussion off record.]

DR. BUSH: The purpose of this meeting is to provide critical and new information to help the Drug Testing Advisory Board make recommendations to us concerning the use of alternative specimens and technology for drug testing in the workplace. The drug testing advisory board will be working with the information derived from this meeting. We need all of the presenters to provide the best possible responses to the Drug Testing Advisory Board questions.

While it may not be possible for each presenter to provide a full and detailed answer at the time the question is asked, we request that the Drug Testing Advisory Board members keep track of their information needs and make them clearly known to the presenters.

As a follow-up to that, yesterday afternoon we needed one slide one slide from Dr. Armbruster. He gave it to us right there on the spot. Dr. Niedbala provided a couple of slides that somehow, through somebody's oversight or whatever, just did not get included in this group. We want the completeness for the final document. Dr. Kippenburger, and Dr. Baumgartner have agreed to have a transcription of Dr. Baumgartner's presentation prepared with the slides that he presented in order with that presentation so it may be clearer to us some of that information and how everything meshes together. So those needs we believe at this time have been voiced and met. But, please, all of you, work together so that the best possible information can be provided us, provided the Drug Testing Advisory Board to make recommendations to us. We thank you for that.

When I came in here a little earlier, there were three people signed up to make public comments tomorrow. Take the opportunity should you want to do this. This is your arena to do it. So, please sign up should you have comments.

We are going to take a look at internal quality control programs this morning. Dr. Mike Baylor chairs this panel. Dr. Mike Baylor received his Ph.D. degree in pharmacology and toxicology from West Virginia. We read this before, but I do know we have some new people in the audience this morning, so we will go through it again. I am taking some flack on my CV reading resume reading. He immediately began his forensic career in a clinical toxicology post-mortem tox lab in Germany. Since then, he has been involved in over 20 years in various aspects of forensic toxicology and drug testing.

Dr. Baylor was the Director of the U.S. Army Drug Testing Laboratory at Fort Meade, Maryland from 1985 to 1987. For those of you who do not know, he hired me when I came into that laboratory.

In 1987, he left the military to become the Technical Director of one of the largest commercial drug testing laboratories located in Research Triangle Park, North Carolina, testing over 4,500 specimens a day. He has been an active NLCP inspector since 1988.

Dr. Baylor was appointed as a Senior Staff Fellow recipient with the National Institute on Drug Abuse from 1990 to 1993 and has been a special expert with SAMHSA from 1993 to 1994. That is when he worked for me. He played a major role in developing technical policies and procedures for workplace urine drug testing for the NLCP and numerous federal agencies.

Dr. Baylor is currently the senior research forensic toxicologist at the Research Triangle Institute in Research Triangle Park, North Carolina, where he is one of the key staff who are responsible for the operation of the National Lab Certification Program. His primary focus is in the inspection process and remediation. Dr. Baylor has accumulated a wealth of experience and knowledge in workplace drug testing over the past two decades and, hence, he is chairing this session. Dr. Baylor.

Agenda Item: Internal Quality Control Program Panel

DR. BAYLOR: There was a time when I used to say, Dr. Bush, just do it.

[Laughter.]

DR. BAYLOR: And then there was a time when I said, yes ma'am, I will do it.

[Laughter.]

DR. BAYLOR: Times sure change. This morning's session is going to address the forensic and scientific

requirements for internal quality control and assurance. As indicated in Dr. Cone's presentation yesterday, the presenters this morning will address how quality control and assurance are handled in the alternate matrices.

Some of the focuses that should be -- that will be focused on in this morning's presentation are the certified reference standards that are used in the different analyses, appropriate control materials, the use of open controls, as well as blind controls, performance testing, quality assurance, as far as the documentation and review process, in addition to the certification results that would be initiated from the analysis of the specimens.

In keeping on schedule, this morning's first speaker will be Dr. Michael Peat. He joined Lab One in June of 1994 as a Senior Vice President for Toxicology. Since May of 1996, he has served as Executive Vice President of Toxicology. He is responsible for the operation of the Toxicology Laboratory, as well as the Substance Abuse Testing Sales Force and Client Services Department.

Prior to his employment at Lab One, Incorporated, Dr. Peat was Vice President of Toxicology for Roche Biomedical Laboratories, as well as Compuchem Laboratories previous to that.

His previous experience includes appointments at the Metropolitan Police Forensic Sciences Laboratory, near Scotland Yard, London, and the Center for Human Toxicology, the University of Utah, Salt Lake City. He has an undergraduate degree in chemistry, a doctorate in pharmacology, and is certified by the American Board of Forensic Toxicology, where he presently serves as Director.

He is also currently the President of the American Academy of Forensic Sciences, which was left out of his resume yesterday.

Dr. Peat, until October 1994, was a member of NIDA's Drug Testing Advisory Board, with the Department of Health and Human Services, and is a consultant to the Toxicology Resource Committee of the College of American Pathologists. He is the author of more than 40 peerreviewed articles and eight book chapters. Dr. Peat.

Agenda Item: Saliva Testing

DR. PEAT: Thank you, Mike, and good morning.

Before we start, just an historical perspective on quality control. Some of you in the audience, and this will probably date you, may remember the meeting in Toronto where were discussed quality control in the forensic toxicology arena. It is probably at least 10-15 years ago that we had that meeting. At that meeting, a dear, respected toxicologist said: "What do we need accurate quantitation for? All we need to know is whether it is a little, a lot, or a hell of a lot."

[Laughter.]

DR. PEAT: We have come a long way since that time because we now recognize that there is a need for accurate quantitation.

I am going to talk a little bit about saliva. But, before I do, I would like to just mention some of the - what is the basis obviously of an internal quality control program. Certainly, the idea behind that or the mechanism behind that is to ensure accurate and reliable data.

Obviously, it is to ensure accurate and reliable

data. The means by which that is done is obviously the monitoring of the testing data, interpretation of that data, corrective action taken, if that data shows that the assay is out of control or trending to out of control, and then documentation of all of that.

Really, the principles are the same, irrespective of the specimen that you are testing. Certainly, when we talk about saliva, we can very similarly equate that to urine. The urine quality control guidelines have evolved through the inspection process, NLCP inspection process. So that now, on an initial screen, the generally-accepted practice is to run negative controls, 75 and 125 percent controls and to monitor those data for positive and negativity.

On the confirmation, it is to run a control above the cut-off, generally at 125 percent of cut-off and one that is below the cut-off. Certainly, for retest purposes, it is recommended that a 40 percent control be analyzed.

The issue really is, as you look at some of these alternative specimens, can the range of certified labs produce data that are accurately reliable at some of the concentrations that have been discussed. If you take cocaine, metabolite benzoylecgonine, and Tim Rohrig's discussion on saliva yesterday, when you talk about a 40 percent control, you are talking somewhere in the five nanogram per milliliter for benzoylecgonine. That is on a very small volume of fluid. We are not talking of having five mLs or 10 milliliters of fluid available. We are talking of having a half a milliliter or maybe one milliliter available.

So, the question really is can the range of certified lab produce those results accurately and reliably?

The answer probably at this point is that, across-theboard, it would be very difficult for a number of them to do that. Certainly, when you look at THC and other drugs, those concentrations may be in fact lower.

So we certainly have similarities to urine testing as far as saliva is concerned. The analytical protocols are very similar. As I said, lower volumes are available. The mix of immunoassays and MS techniques may differ. There may be a need for more sophisticated MS techniques than we currently use.

Obviously, the applying of QC techniques in a forensic environment have caused some issues in the past, but, generally, those have been resolved through the inspection process at this point.

Certainly, when you look at a lot of statistical data, it is important to bear in mind, as you go down and down in terms of approaching the limit of detection, your confidence level, your degree of confidence in the quantitation is going to broaden and you are going to have more unreliable quantitation results at that particular time.

Do we shift slides there? What are we doing here?

I was in Brazil once and, unbeknownst to me the person in front said -- the projectionist spoke only German and the person in front said when I wave my left hand, move the slides. Well, for those of you who watch me speak on numerous occasions, I wave my left hand a lot.

[Laughter.]

DR. PEAT: We had a movie.

[Laughter.]

DR. PEAT: So, certainly, applying QC techniques in the forensic environment is certainly not a problem these days. It is one that we have learned to live with and certainly one that should be acceptable.

When you look at saliva, it is a different specimen matrix. Does that impact the preparation of the controls? Somewhat. But you also heard yesterday that those pads that are used are put in a preservative fluid. The preparation of control material is relatively straightforward. You just prepare that in the preservative fluid rather than try and prepare that in the spit. You would prepare it in the preservative fluid.

Obviously, as I said, there are a couple of occasions that the specimen volume was less and the target analytes may be different. THC, for example, would be the target analyte for marijuana use. For those of you who have tried to determine THC in bodily fluids, it is a lot more difficult than trying to determine THC acid in bodily fluids. So, again, there will be some changes that come there, as with the target concentrations and the cut-off concentrations will be lower in this fluid.

There are two issues, again, that apply generically to some of these alternative fluids, and they were sort of approached yesterday. The specimen volume is low and there may be an inadequate volume for a retest. There may be also inadequate volumes in one collection for multiple drug determinations. If you have a THC and a cocaine positive, you may not have enough fluid from one saliva collection to go ahead and do both drugs in that saliva fluid.

I asked Sam yesterday, and he was unaware if anybody had tried this, but obviously you can go ahead and do repeatable collections of the pad. You could put that pad in the mouth, collect and then re-collect over a period of time. It is questionable whether there would be significant differences in that, but Sam did not know if anybody had tried that. Certainly, that would be something that would be needed to be tried if you talk about using the saliva fluid in this type of environment, also for the practical purpose of a split collection or a retest at the request of the donor.

The common procedure in urine drug testing is to validate the control material using GC/MS. You obviously could do the same thing with saliva and the preservative fluid. Stability data would be needed, but I have no reason to question that the analytes concerned would in fact be stable. But the degree of difficulty increases dramatically when you are talking about low nanogram per mL determinations and maybe picogram gram per mL determinations of drugs and or metabolites.

Running GC/MS/MS and running LC/MS/MS, running sophisticated techniques such as that are not as straightforward as running mass-selective detectors. For those in the audience who have used them, you will certainly be well aware of that. For those in the audience who have not, you are going to suffer some pain I think when you try to do that. So the degree of difficulty certainly increases.

Yes, it is obviously possible to prepare blind specimens, much the same as you prepare open controls in the preservative fluid and to ship those from the collection sites in the collection devices. That is not a problem with saliva specimens, and certainly it would be very similar in design to the urine blind program that is in place today.

Finally, a summary. The internal QC is similar to

that used in urine programs. The major differences would be with the target analytes and the cut-off concentrations that would be necessary to be targeted with an internal qualitycontrol program. Thank you.

[Applause.]

DR. BAYLOR: Thank you, Dr. Peat. Our next speaker will be Ann Marie Gordon. Ann Marie Gordon received her master's degree in microbiology and immunology from the University of California, at Berkeley. She has more than 10 years of research experience in microbiology and molecular genetics. She has worked as a certifying scientist and expert witness for the U.S. Army Forensic Toxicology Drug Testing Laboratories in both Wiesbaden, Germany, and Fort Meade, Maryland for six years.

For the past three years, Ann Marie has been the Director of Quality Assurance at Psychomedics Corporation in Culver City, California.

She will be addressing internal quality assurance and quality control in the drug testing laboratory.

Agenda Item: Hair Testing

MS. GORDON: I am going to talk this morning about the Internal QA/QC Program at the Psychomedics Drug Testing Laboratory. The procedures that we have in place are not unsimilar to those found in a urine drug testing laboratory, with some exceptions.

We do prepare our standards as working stock solutions and we then spike them into the same matrix as the samples. This is typically intact hair for our screening assays and pooled negative digest for our confirmation assays. We use our standards to calibrate the assays.

We prepare the controls also in working stock solutions and, again, in the same matrix as the samples. And we prepare the controls from a different source or lot number than the standards and we use the stem to verify the assays.

For our negative hair, we do collect hair of any type, of any color, ethnicity, background from a purportedly drug-free population. Typically, we use laboratory employees who are subject to random drug testing. We collect the hair in such a manner as to exclude contamination. That is we do not allow the hair to fall on the floor.

We cut the hair into small segments and mix it thoroughly and then weight aliquots for testing and we store it at room temperature.

To prepare the pooled negative digest, we weigh the negative hair and then we subject it to the same procedures as we do our samples, in that we do an enzymatic digestion. We do a centrifuge to remove the melanin portion of this sample and decant it to remove aliquots for testing, and we store this frozen.

To certify that either the negative hair or the pooled negative digest, we do subject it to both the screening assay and the confirmation assay, the GC/MS of the GC/MS/MS and we should have no signal in any of the assays.

To prepare the RIA standards, we purchase primary

standards in methanol. We prepare the working stock solutions in buffer. We certify them doing RA and crossovers and GC/MS certification, and we recertify every six months.

For the controls, we also start with primary standards and we prepare them independently of the standards. Again, we certify by RA crossovers and GC/MS certification and recertify.

We use our RIA standards to prepare a standard calibration curve. Our controls in RIA are prepared at or near the cut-off. One of the things that i unique to hair is that we do have a predigestion spike which we would term as the recovery and we have a post-digestion spike which we call the assay. This is to control the effect of the digestion on the analytes.

We do track our controls with Levy-Jennings charts.

Our GC/MS standards in controls, again, we start with purchase reference standards. We use different sources and lot numbers of the standards and controls and we prepare these in methanol for the final volume of 100 microliters. We certify the GC/MS standards by GC/MS or GC/MS/MS. We

certify them typically against previously-certified standards and we recertify every six months.

For GC/MS, our standards are -- contain for the cocaine analysis, we include cocaine benzoylecgonine and cocaethylene all at five nanograms, methamphetamine and amphetamine at five and one nanogram respectively, THC acid at .5 picograms, the opiates, morphine, codeine, and 6-acetylmorphine at five nanograms, and for PCP we still use the standard curve, and this is two to 20 nanograms.

For the controls, we use a high and low control. The cocaine, BENC, the low at two and the high at 10, for meth it is two and should be 10 -- or, excuse me, it is five and 10 -- oh, that is a mistake. Oh, I see. The meth is two and 10, and the amp is .5 and five. The codeine, morphine, and 6-acetylmorphine are two and 10. The other are underneath there.

We do, again, track our standards and controls in GC/MS on Levy-Jennings. This is just a composite slide. I think that you saw some of these with Dr. Cairns' presentation yesterday. I will just run through these rather quickly. Here is the benzoylecgonine, and the cocaethylene, and here is our THC acid, the .5 up to 10 picograms.

We do have matrix effects with hair analysis. The exogenous effects that we concern ourselves with are things like preparations being put on their hair, dirt, and smoke.

We usually can remove this by using a dry isopropanol wash prior to our normal wash buffer procedures.

For endogenous effects, this is more important to the RIA assay than to GC/MS. We do minimize those using an optimal digestion concentration of 10 milligrams a hair per one mL of digest.

For the blind quality controls, we used a previously certified negative hair as a blind negative. For positive controls, we do purchase hair from rehabilitation centers or we can prepare a pool of previously certified, previously positive samples after they have been kept in storage for the appropriate length of time.

One of the problems with using user hair is that some of the times the drug concentrations can be quite high.

For quantitative assays, that can result in an excessive amount of time spent on the positive EQCs. Ideally, we want the positive EQCs to be within the linearity of the assays without dilution and exhibit good reproducibility, remembering that these samples are heterogenous.

To prepare them we cut them to approximately two centimeters in length. We mix them thoroughly. We obviously do not have a homogenous mixture, but we do have a pretty good mixture. We aliquot 10 times and then we determine the mean drug concentration by GC/MS.

This is the performance of some BQCs. I am just going to run through these quickly. This is a low-level cocaine with pretty good reproducibility. The CVs are a little -- about 20 to 30 percent for cocaine and BE respectively.

Here is another cocaine. I have been running this one about a year.

Here is a marijuana blind QC, and it is at four picograms with a CV of 12 percent. Here is the same one that I have been running for cocaine. It is also a marijuana positive at one picogram with a CV of 17 percent.

We also have in the hair drug testing lab a unique

opportunity to use retest samples because the drugs are stable in hair over time. We retest samples from anywhere from a week to a year after they originally reported as positives, and they can be evaluated similarly to the QCs.

We have two types of retest samples. We can either retest the original sample or with hair we can recollect a second sample which we termed the safety net.

This is some data showing the retest results of

THC acid where we have the original versus the retest of the same sample, and we get quite good correlation. It is similar with cocaine. We see the same relationship.

The safety net of the newly-collected sample, if it is used to support the original findings, needs to be collected as soon as possible after receiving the positive result.

We do a physical comparison of the two samples.

You would be amazed at how fast some people's hair can grow in two weeks. We compared those test subject's initials and we do some -- we section the safety net if there has been more than 16 days between the two collections just to try to get the similar timeframe.

This is some data showing the original testing results versus the safety net. We do not get quite the same correlation because, again, sometimes there are haircuts and their is time between the two collections. So, we are looking at somewhat of a different timeframe.

Similarly, we see the same pattern with cocaine.

I am going to conclude here with some typical results that we see with some safety net results. These are two samples that were collected approximately two weeks apart. This person did get a haircut. When we retested the sample, we got the same result, but the safety net shows a decrease due to probably cutting off the positive portion of the hair.

Here is another THC result with almost a month between the resection of the sample. We get almost the same results of the sections.

Here are some cocaine results. I have got quite a few of these slides. I am just going to go through them quickly. One of the things I would like you to notice is that we do get very good reproducibility not only on the RIA levels, but the wash kinetics are almost identical from the first sample to the second sample. When there are time differences between the two collections and we do section it, we get pretty much the same result. In this case, there was almost a month between so we did section the sample.

Here is one where we did not section -- although this person seems to have very short hair, and there is some variability in the hair length of the sample. But, again, quite reproducible results with very similar wash kinetics.

This person did get a haircut in the month between. We would have normally tested the safety net at 1.3 to 5.2 centimeters, and you can see that there is a decrease in the drug concentration. That is another sample. We have got methamphetamine results again. We get

the same kind of reproducibility. This is very typical again. We have done about 2,000 safety nets while I have been at Psychomedics. When those are done for the purpose of verifying the original results, we do get quite reproducible results. Here is just another methamphetamine.

Again, the wash kinetics are almost identical. We do also have, for some of -- we do have a blind program -- or a double-blind program where some of our clients can submit samples through William Walsh and Associates, and they can submit samples to -- he submitted samples to them and they submit it to us, and is monitoring us as sort of an external/internal QA program.

Thank you.

[Applause.]

DR. BAYLOR: The next speaker is Dr. Tamara Nichols-St. Claire. Dr. St. Claire oversees all aspects of the PharmChem Laboratories Quality Control Department and reports to the Director of Laboratory Operations. Dr. St. Claire joined Pharmchem in 1995, and supervises a staff of seven individuals and validates all analytical standards and controls for the laboratories.

Dr. St. Claire received a Ph.D. in bio-inorganic chemistry from the University of California-Davis, and a bachelor's of science degree in biochemistry from San Francisco State University.

Prior to joining Pharmchem, Dr. St. Claire was an instructor at Cunsumne's River College, and a chemist at the University of California, San Francisco River Research Laboratory. Dr. St. Claire is a member of the American Chemical Society, and the Association for Women in Science.

Dr. St. Claire.

Agenda Item: Sweat Testing

DR. ST. CLAIRE: The quality control scheme and the evaluation of the quality control materials in the qualitative and the confirmation assays was developed based on widely-approved set-ups using urine testing. Of course, the control levels have been altered appropriately to concentrations associated with the lower cut-offs in sweat testing.

The purpose of the QC program is to ensure consistent and stable performance of assays, or at least the results are only recorded from analytical batches showing acceptable performance.

For screening assays, consistency is judged against performance standards established in the FDA Review Process. The cut-off is determined as a concentration and a calibration range that gave the fewest false-positive and false-negatives resulting in the highest percentage of clinical sensitivity and specificity. So, once we determined the cut-off, we needed to determine the control levels.

The analytical sensitivity of the cut-off was assessed by analyzing in replicate type samples at varying concentrations. For example, I will talk about the amphetamine assay. Despite concentrations of 2.5, five, 10, 12.5, 17.5 and 25 nanogram per mL concentrations, which corresponds with 25 percent, 50, 100, 125, 175 and 250 percent of the cut-off.

The percent positive response is graphed for each concentration. The results yielded the threshold graph shown here in this slide. We chose a concentration that yielded a 95 percent probability of screening positive for our high control and a concentration that yielded a 15 percent probability of screening negative for the level of our negative control. Similar analyses were conducted for each drug assay.

For confirmation assays, performance standards are established in assay validation studies conducted by the laboratory.

There are several points of parallelism in the sweat testing to the urine testing. The first one I would like to talk about is the validation in the quality-control materials.

Calibrators, and controls, and blinds are evaluated in essentially the same manner as the QCs in the urine testing. Purchased ELISA calibrators are verified with the receipt that each new lot by GC/MS and they must quantify within 10 percent of the target concentration to be released for use.

The controls and blinds used in the ELISA assay are validated by GC/MS and ELISA and GC/MS controls are evaluated by GC/MS.

This is the cover sheet for the GC/MS calibrator evaluation. The lot under evaluation is compared to the previous calibrator and the reference material. Typically, the calibrator and the reference material are prepared from drugs purchased from two different vendors. If this is not possible, the stock solutions are prepared from two independent weigh-ins.

The samples are run 10 times and the mean must be within 10 percent of the target concentration and within 10 percent of the expected ratio, compared to the reference in the previous calibrator.

The quality-control scheme in the ELISA sweat testing is essentially the same as in the urine testing. In ELISA there is a drug-free, and negative control, that is a control that is below the cut-off concentration, and a positive control, one that is above the cut-off concentration. For the controls to meet the criteria for acceptability, the negative must have an absorbance that is greater than the cut-off and the positive must have an absorbent that is less than the cut-off. On the calibrators which are run in triplicate, we must have a CD of less than 20 percent.

The GC/MS batches used for confirmation in the sweat testing also mimic urine confirmation batches. These controls must constitute 10 percent of the samples in the batch, and they must qualify as a target drug according to retention times and ion ratio criteria, and must quantitate within 25 percent of the target concentration for the client's specimen data to be reportable.

As you can see in the sweat confirmation batches, there is a calibrator, a non-extracted calibrator on the control, an open control, a carry-over check, and a blank after the carry-over check, as well as an additional QC.

In reference to the blinds, the screening assay has two blind quality control samples per 40 samples. In the parallel to urine testing, if the blind fails, the batch fails.

In terms of trend analysis, GC/MS controls are plotted per batch on the Levy-Jennings plot and reviewed on a weekly basis to evaluate the QC's performance and to allow for us to take corrective actions.

In terms of matrix effects, matrix effects are universal in all drug-testing assays. In fact, we can think of adulteration as matrix effects to such an extreme degree where the tests become susceptible to conditions of the specimen.

With automated analyzers, we have been able to attenuate the effects of temperature, pH, read times, optical conditions, and other things to a degree that we could almost disregard them. This could be illustrated in the immunoassay techniques used in onsite testing devices. I think that Dr. Salamone addressed this just briefly yesterday. We have data that show temperature pH and specific gravity that show remarkable effects when removed from the analyzers.

This is a summary of the data collected with the cocaine device at four different pHs. As you can see, cocaine has an acceptable pH range of greater than two and less than 10 by comparing the expected responses at 450 nanograms per mL. You may be aware that a sample with a pH of 10 at a 450 nanogram per mL concentration would screen positive on an emit analyzer with no problem.

The effect of pH on the THC devices is even more dramatic. As you can see on this slide, they perform up to grades at a clinically-normal pH of five. An acceptable pH range is much narrower in comparison to the cocaine.

After exploring pH, we thought it would be very interesting to look at the effects of temperature. There are three distinct temperatures you can imagine using the testing device sample. One is the void temperature; the second is the room temperature, that is, if you allowed the sample just to sit for a while before you test it; and the third is the refrigeration temperature, that is, if you store the sample to test it for later. We saw dramatic effects.

The cocaine devices provided surprising results at the void temperature compared to the room temperature or that of four degrees.

The THC devices gave the exact opposite results. Refrigerated samples gave false negatives at 75 nanograms per mL.

Let's return to the flat testing. As you can see, nature's effects are universal. So ELISA is really not immune to these effects. No pun intended. In fact, we use methanolic extraction solvents which can be quite severe on the immunoassay. We toyed with several extraction buffers.

In terms of extraction capabilities, we found that a 75 percent methanol, 25 percent .2 molaracetate provided to be very effective. But you can imagine how methanal could denature the antibody as well as strip it from the well.

Well, we have developed two different screening assays for THC. In clinical trials, we have observed that the THC really presents the most effected assay in terms of matrix effects. However, there appears to be some component in sweat that actually interferes with the binding of the drug in the assay, and that gives us a negative bias.

The technique we have incorporated to control for this phenomenon in sweat is by spiking our calibrators onto warm patches. As you can see the calibration curve shifts dramatically. In fact, if you look at the range between 1.5 and 10 nanograms per mL without the shift, we would actually be losing quite a few positives.

In the developmental phase, we worked with RIAs as screening assay. Due to the non-specific binding in this technique, we showed a positive bias. To address this issue, we actually offset the calibration level to compensation for the high bias.

In Dr. Armbruster's presentation, he showed off many of our GC/MS chromatograms. With respect to the GC/MS assay, sweat has actually proven a cleaner matrix and the chromatograms are quite clean, and have afforded us the ability to achieve reliable cut-offs at lower levels required for the sweat testing.

In terms of sample subtypes, there is a lot of data that has shown that hair color and ethnicity play a role in the matrix effects with respect to hair testing, but we really have not explored that arena.

Thank you.

[Applause.]

DR. BAYLOR: The next speaker is Dr. Paula S. Childs. Dr. Childs has worked in the field of toxicology and clinical chemistry for over 20 years. She earned a bachelor's of science degree in chemistry from Nazareth College in Rochester, New York in 1970. She then studied at Tufts University and earned a doctoral degree in chemistry in 1974. Following completion of the doctorate, she completed an additional two years of postdoctoral work at the Medical College of Virginia in clinical chemistry.

At the completion of additional studies in forensic toxicology, Dr. Childs earned recognition as a Diplomate of the American Board of Forensic Toxicology.

Among her employment experiences, she includes a three-year term with the Georgia Bureau of Investigation working in the area of medical examiner, toxicology, and the Driving Under the Influence of Alcohol and Drugs Program.

She moved to the Compuchem Laboratory in 1986 to direct the laboratory's quality control program. She has been interactive in the development of various components of workplace testing programs.

In 1988, Dr. Childs was invited to assist the Department of Health and Human Services in developing the standards for laboratory tests for the Drug-free Workplace Program mandated by President Reagan in 1988.

She was a member of the team of experts who developed criteria for the Laboratory Inspection Program, which is still in use today.

In addition to overseeing laboratory work, Dr. Childs is a member of several professional organizations, including the American Academy of Forensic Sciences, the Society of Forensic Toxicologists, and the American Association for Clinical Chemistry. She has served on a variety of committees for these organizations.

Dr. Childs is recognized as an expert in her profession. She has been qualified as an expert witness in forensic toxicology in more than 100 cases, including homicides, driving under the influence of alcohol and drugs, workplace arbitration, controlled substance abuse and military courts marshal. Her testimony has successfully supported law enforcement programs and workplace testing policies and procedures. Dr. Childs.

Agenda Item: Urine Testing

DR. CHILDS: Good morning. Thank you, Dr. Baylor.

I would like to extend a word of thanks to the Drug Testing Advisory Board for the opportunity to present this information.

I would like to begin with a very basic definition of a quality-control program and that is to be sure that the test systems are producing the right results. Like Nike's, I like to do a play-off on Nike's "Just Do It," and just say let's just do it right.

I am going to focus a little bit, instead of just going through all of the regulatory issues related to definitions of quality control and talk a little bit about the focus of the urine drug testing because that has really become the basis and the foundation of what the other testing matrices and alternate matrices will actually be involved with as their technology is developed.

The QC materials for initial test are often very different from those in terms of target analyses and element composition from the confirmation testing. In addition, the QC requirements for initial test often require just a positive or a negative control response versus in confirmation testing where an actual quantitative value must be obtained.

In addition to that, during the initial testing, there is a requirement that at least one percent of the test batch should be a blind QC with a minimum of at least one and total complement of 10 percent total quality control; whereas, in confirmation testing, there is a quality control component, however, at this time, there is no requirement for a blind quality control to be part of the test batches.

There is some additional information that can be obtained from confirmation testing with respect to 6-acetylmorphine and DL-isomers, as well as evaluation due to rate of internal standards that are part of a good quality-control program.

For definitions, I just want to mention just very briefly that calibrators are solutions of known concentrations used to calibrate a procedure or to compare with a sample response to determine the positive or negative result; a control being defined as a sample used to monitor the status of an analysis to maintain its performance within desired limits; a standard being a reference material of known purity or a solution which contains reference material at a known concentration; and then QC sample is referring to any of those above materials used to evaluate an analytical procedure and whether that procedure is operating within pre-defined tolerance limits; of course, a sample being that of an unknown specimen or a donor specimen.

Analytical runs are defined to contain materials that include negative urine samples. These are materials that have been certified to contain no drug. And initial testing -- also positive controls being defined as those four to five with a drug or metabolite. Often this can be fortifying the negative urine samples to obtain the desired control concentration. And then also concentrations, positive controls have to also include concentrations at or near the threshold cut-off. Often that is defined as plus or minus 25 percent. I was thinking 20 percent with respect to the quantitative recoveries in the GC/MS controls.

Each initial test batch must contain negative samples, positive control four to five with drug, positive controls within 25 percent of the cut-off, and a sufficient number of calibrators to ensure and document the linearity of the assay with a method over time.

For confirmation testing, controls include: B-negative -- negative urine samples, positive calibrators, and positive controls within 25 percent of the cut-off. In addition to that, if a test run includes analysis of limited detection or retest samples, then there is a requirement that there be a control at 40 percent of the cut-off.

For the validation and verification of QCM materials, some very important criteria must be respected. One of those includes the traceability of the drug standard.

This would include documentation of the lot number and the manufacturer. Frequently, manufacturers provide source content. Other pertinent information would perhaps include a full scan of the product as it leaves their facility. They often include material safety data sheets that come along with the standard materials.

The laboratory then would verify with parallel testing, full scan GC/MS and other analytical procedures that might include things like melting point HBLC and so on to perform independent verification from the manufacturer.

There are methods set up to check against the current lot numbers by parallel testing, also being able to use a reference, proficiency test, results from other proficiency programs to determine whether the materials being used in the laboratory are within acceptable tolerance limits.

When there are LOD and LOQ, and actually method validation studies, there are preparation of materials required in order to be able to evaluate things like the limit of detection and the limit of quantitation and upper limit of linearity for each assay.

The one thing that I wanted to mention here is also the evaluation of test results by the certifying scientist. That is part of a good laboratory program and certainly is required under the federally-mandated guidelines. But the certifying scientists play a very critical role in being able to look at the test data, look at the quality control data, and make an assessment of acceptable quality control with respect to each individual test result within a batch that they are certifying.

They are matrix effects. I wanted to talk about the differences between urine or synthetic urine. Many laboratories like to use a synthetic urine matrix that may help eliminate some problems with contamination or different types of materials that are present in donor urines that would be collected. In collecting samples from donors within the laboratory, frequently, a preservative routinely sodium azide is added to the donor samples. It is important to understand that most donor samples coming into the laboratory as unknowns do not contain sodium azide. The typical concentration for sodium azide in the control materials being prepared is approximately one-tenth of one percent.

One of the comments I would like to add in the way that we prepare our pooled controls at our laboratory includes having various donors sign up as part of the donor program. We learned through years of doing this the wrong way first and then trying to get it the right way was that donors often use medications that are not controlled substances. When we were first doing amphetamine, you know, certifying samples to be negative for amphetamine, what we found was that a lot of people, especially during the fall and winter months are taking over-the-counter cold preparations which, by the way, do often interact with screening testing for amphetamines. So we found it necessary when we collected individual donor samples to test those samples before they were mixed in with the larger pool of other samples to verify that each of those individual donor samples were going to screen out the negative cut-off, rather than contributing some cross-reactive substances into the screening testing.

The same is true for GC/MS. Obviously, the GC/MS procedures should overcome many of those, but you want to make sure that there is no baseline effects. If you are going to be adding a fortifying negative urine with other drug, you want to make sure that it is acceptably at the negative level before adding anything else to that or pooling it together.

Just a word on synthetic matrices. I do not have a lot of formulas and recipes. I have not been involved in actually preparing those. We know that some of the quality control manufacturers do use synthetic urine matrices for that. A couple of key things though. One is that synthetic urine is generally considered acceptable to use in a laboratory with the following conditions. One is that there be no matrix effect on the actual assay. That can be evaluated through some parallel testing with normal urine samples. The second is that it should be indistinguishable from human urine. The third thing is that it should be normal ranges for adulteration testing of the synthetic urine matrix issues. The fourth thing that is important to remember is that doing validation studies for the procedures should use human urine as the basis for the evaluation studies and not just a synthetic urine matrix because that can very profoundly affect the recovery and especially in GC/MS procedures.

I want to talk briefly about blind samples. There are basically two kinds of blind samples that laboratories blind. One are internal blinds, and these are generally defined as being blind to the laboratory's analysts. They can be positive or negative materials. On positives it is important to remember, to eliminate carry-over results, unless the procedure that you are using is set up to limit carry-over or to correct for carryover.

A lot of times laboratories want to site blinds to just make sure that they are really going to be positive, so they put very large amounts of drug in the samples. That is, you know, just something to be aware of when preparing blind pools.

Preparation can be to fortify certified negative urine or to purchase materials from outside vendors. It is important to keep the lot numbers of the reagents and do the validations before they are actually introduced into the laboratory testing process.

In terms of introducing blind controls, they can be introduced in coming into the laboratory, along with regular specimens, through the courier systems that a laboratory uses. In that case, they would be coming in in a specimen bottle probably with a chain of custody form, or the laboratory can introduce them into the system during the receiving or aliquoting process.

In terms of external blinds, many laboratories like to have a feel for how other types of testing are happening besides just the analytical components, and external blinds can provide a very valuable source for looking at other administrative issues with regard to laboratory testing.

They should simulate real samples procedurally. The lab then can track and monitor administrative things like turnaround time, follow-up with documentation errors, and other things that are surrounding the mandated programs with respect to chain of custody, and the turnaround time in certifying scientist-related issues.

Generally, the external blinds are not evaluated in real-time along with samples, and the sample results are not held up if an external blind fails its criteria. Mostly that is because most of the people in the laboratory, including perhaps the certifying scientists, are not aware that these are external blind samples. The laboratory director in some audit fashion, would then review the results after the fact and make a determination of corrective action that might be required following a blind QC result. Generally, they are carried through the entire process that includes the initial and confirmation testing, as well as the reporting.

Trend analysis. We saw some very good slides earlier with different types of presentations. Generally, smaller laboratories tend to capture data in a manual manner, and may be able to plot it on a sample by sample or batch by batch basis. Again, it requires review, determination of means, acceptance criteria. With screening data, often the expected result of a quality control is either positive or negative. From a GC/MS perspective, Levy-Jennings often can create a statistical means standard deviations.

Most laboratories use a plus or minus 20 percent of acceptability from a target value for the GC/MS expected result. There are West Guard rules that are being used in laboratories. These sometimes provide challenges to the laboratories in terms of determining which points can be eliminated. Again, that should be very clearly laid out in the standard operating procedure.

I want to talk just briefly about corrective actions because often quality control results and failures should result in some type of corrective action. These would be quality control results that do not meet acceptance criteria should be entered into some sort of a problem log to try to determine what went wrong. How did the problem get remediated? Was the batch recalibrated? Were the control materials replaced? Were there samples that were clearly negative released anyway? That documentation is very important. And then the responsible person or laboratory director would analyze the situation and then would develop a program for corrective action, and that should be reviewed by the supervisory staff involved in the set up and evaluation of those programs.

I wanted to just touch briefly on adulterants. We have had some discussions with some of the groups here about different types of adulterant products. It is possible to introduce, through the blind QC programs, different types of adulterants. You can introduce problem samples, be able to substitute, send into the laboratory, for example, Mellow Yellow and see how the staff actually detect that that is Mellow Yellow. Does it look like really urine and so on. It is the same thing with bleach and other types of products that are routinely seen as adulterants.

Again, follow-up with analytical problems would be what happens when there is a failure to recover an internal standard. What process does the laboratory go to to try to overcome that problem? Is there a dilution that is performed? Are there other types of reagents added? And, again, verifying that that is covered in the standard operating procedure. With dilution analysis, that is important to prepare and validate QC materials to be able to provide information on the detection limits and to also verify the reporting requirements. Often, one task, for example, may be that a creatinine is performed and, if it is less than 20, then a reflex to additional testing might take place. Again, QC materials to verify that that reflexing taking place properly.

A couple of special considerations. Preparation of QC materials. Sometimes they are prepared lyophilized and have to be reconstituted. It is important to verify that the volume for reconstitution is providing the correct concentration of the drug after the reconstitution. Integrity in labeling include things like content and concentration, and expiration dates, stability and storage. Are the QC samples being frozen? If so, make sure that they are being thawed and thoroughly mixed before they are introduced into the process.

Last, I just want to also talk about this very briefly, quality assurance issues. Laboratories often set up internal quality assurance programs to audit such things as instrument validations, temperatures, training records, making sure that all of the systems are in compliance, not only for the laboratory standard operating procedure, but with the program guidance that the laboratory is operating under.

Often this results in corrective action and identifying missing or absent information and preparing the corrective action to prevent such recurrence from happening.

Thank you very much.

[Applause.]

DR. BAYLOR: The final speaker on this morning's panel is Dr. Richard Anderson. Dr. Anderson received a doctorate in physical chemistry from the University of California-Davis. Dr. Anderson has 16 years in the development and marketing positions with Miles Laboratories, Hypertech, Incorporated, and Biosite Diagnostics. He has nine years of experience in the development of abused drug immunoassay kits. Currently, Dr. Anderson is the Director of Customer Support with Biosite Diagnostics. Dr. Anderson. Agenda Item: Onsite Testing

DR. ANDERSON: Good morning. I feel a little bit like the congregation trying to give a sermon to the preacher here, as probably a very junior member in the forensic toxicology area. My experience is primarily seat of the pants in the medial diagnostic arena. I have a great deal of experience, however, in making assays, if not necessarily using them.

May I have the house lights a little bit?

I am going to speak on internal quality control as it affects onsite tests. I am going to speak to that topic really as a maker of tests, but attempting to address the issue for users of the test really in the operative mode. The first topic we are going to talk about is verification and evaluation of quality control samples. The first one is calibrators. Calibrators, for most onsite tests, really, the calibration is done at the manufacturing level. That is done by the mechanism that the manufacturer generally unitizes the tests prior to distribution to the users. As a consequence, users really do not have an opportunity to "calibrate" tests, unlike they do perhaps with instrumented methodologies for doing drug tests. Calibration is really only verified by the use of quality control samples. As far as quality-control samples go, external quality controls and known quality-control samples are very much like those used for the standard reference laboratory.

They are generally multi-constituent, in our case, usually liquid controls. They are generally acquired from commercial vendors, not generally manufactured by the user themselves. They are, in some cases, done in that fashion, however.

One slight different wrinkle behind offsite tests that is usually not associated with instrument-based systems is that due to their utilization, they frequently incorporate on board or internal -- so-called internal controls. These control zones are designed to try to help in monitoring aspects such as test procedure, reagent viability and sample integrity. They do not -- these internal test control zones do not function as supplanting external controls. They are designed exclusively as adjuncts, however, they may adjust the frequency with which external controls are used. Their utilization is a topic of much discussion but greater acceptance in the medical community at this point.

Negative control samples are like positive control samples, generally purchased from commercial vendors. They may either be synthetic or natural pools, pools, for instance, from the pediatric patient populations.

Some users of onsite tests may, in fact, product their own negative donor and perhaps produce negative urine pools. Again, as an earlier speaker suggested, you have to be a little bit careful about that in that the negatives need to be verified as truly negative of all drugs, since some over-the-counter and prescription pharmaceuticals can cause problems in the screening exercise.

Onsite tests have a greater -- generally greater exposure to matrix effects, either physiologically-derived or non-physiologically-derived, such as adulterants. The reason for that is has been previously mentioned. Onsite tests generally do not involve any dilution of the sample. The sample usually is neat. And, as a consequence, the test has to survive the onslaught of all objects or items that are within the urine specimen.

I have listed a few items that are usually of greatest significance to onsite testing, such as urine pH, specific gravity, because we new the tests involve filter membranes. Particulate load can be a particular issue. Adulterants, of course, as with regular immunoassays run in a laboratory are an issue, and colorants.

In an onsite testing environment, some of these issues can be addressed by the manufacturer themselves within -- by additions of reagents, particularly large amounts of buffer, for instance, to control physiologic urine pHs.

Specific gravity can sometimes be addressed by either observation followed by centrifugation. Particulate load is generally addressed by the filter at either -- filtering the material out during the course of the assay or occasionally clogging and you will see it in the controls. The one thing that is a little bit different about onsite tests, however, relative to laboratory tests is with regard to adulterants. And that is that the on board controls provide a measure -- not a full measure, but a measure of guard against adulterants because the onsite internal controls have the ability, in some cases, to detect the presence of adulterants. That does not relieve the testing community of the obligation of attempting to determine the presence of adulterants by visual or olfactory detection in the preliminary sample, but it does provide an additional level of protection.

Blind specimens for onsite tests are a little bit more problematic. They are problematic from the perspective that he usual utilization of onsite tests involve the person doing the sample collection being frequently the person who also does the sample testing. In the traditional laboratory environment, the person doing the sample collecting frequently is the one doing the blinding of the specimens unless they are purchased as sample blinds.

This, of course, is a bit of a problem because it requires quite a bit larger number of blinds to be presented if the samples are truly to be blinded to the tester. An issue that I really believe has come up over the last day or so which I think may address a bit of the issue with regard to blind specimens is perhaps retesting a certain fraction of what are effectively blinds, in other words, negative donor samples or samples that are screened negative at the initial onsite screening test, to be sent on to the laboratory for rescreening and verification as negative.

I think that this might address a couple of issues. One would address it or help out on the issue of blinding. Two, it would address, I believe, what has been referred to as the Bubba Syndrome, which is the confrontational component.

If a certain fraction of screened negatives are sent on to the laboratory for rescreening, the mere fact that a sample has been held back, if you will, for additional testing, does not imply that that sample is presumed positive.

In terms of fractions, the question got asked, I believe, yesterday, of what sort of numbers might you add or select for rescreening. I believe that the numbers that were quoted were some that ranged in the range of five to 10 percent. I think it would probably be reasonable that the number of negatives is something of the order of the fraction -- demographic fraction of positives. Positive demographics, of course, tend to run in the range of one to five percent. So, something in the order of the mid-five range would probably be an appropriate number.

I would like to address a little bit about how one might select appropriate concentration for a quality-control sample in the area for onsite tests. One would have to remember that most onsite tests, in fact, all that I am aware of, involved a visual detection of the endpoint. They are not quantitative or numerical in the sense of producing an answer. They produce a yes/no result in that either color indicates present of sample or it may indicate absence of sample. But the change from no signal to signal indicates the difference between positive and negative samples.

Nevertheless, the tests in an internal sense have to act in an analytical relationship to concentrations of the samples. On this graph, what I have attempted to represent is interpretation of what a truly external quality control program burden places on tests, all tests, including onsite tests, for verification of positives or negatives. The red curve, which shows up only really on the left-hand side, represents a simple galcion where we have arbitrary spreads on the basis of standard deviations. The yellow line which has an abrupt transition of about 1.3 SD, represents -- the area under that yellow curve represents 90 percent of the total curve under the red area.

If you refer back to what the requirements are for any laboratory with regard to performance on proficiency testing, what is required is that 90 percent of all samples, at approximately 20 percent above the cut-off for that assay, must be judged positive and, consequently, approximately 10 percent are allowed to be judged negative. If we assign a value of where that abrupt transition is on the yellow curve to the positive/negative transition, in other words, the cut-off for the assay, again, you get 90 percent positives onto the right and 10 percent to the left.

If you calculate what that means in terms of an analytical CV, that allows an assay to have an analytical CV of up to approximately 15 percent and still provide results which would match this external QC requirement. When you translate what that would necessarily would allow for onsite tests or any tests for that matter, it says that, if you had an assay whose CV was on the order of 15 percent and you wished to have a hundred percent of results be positive, which means that you need to be at about three SD positive or to the cut-off, that says that the center point for the QC sample can be as large as approximately 145 percent of 45 percent greater than the cut-off. What we propose to you is that, for onsite tests, for -- eventually for the training purposes, it may need to be as large as that in some cases.

This is not really that out of sorts with some regular manufacturers for laboratory-based tests in which the case -- after having looked at some package inserts, you find that the "near cut-off concentration" or positive controls are, in many cases, as large as 50 or 60 percent greater than the cut-off. We can address the issue of trend analysis. Because onsite tests generally have either a yes or a no final answer, and you are looking for effectively a change of state, not a trend in the general trending sense of a Levy-Jennings plot, you have to structure your sample in such a way that you are going to get all positives for samples which are supposed to be positive and not some fraction of them to be negative, which, of course, can be tolerated in a numerically-based assay when you are evaluating the trending in the context of the numerical result.

For corrective action, I believe it was stated yesterday that -- I believe it was Dr. Armbruster who had mentioned this -- excuse me, it was the military individual -- that corrected action for offsite tests usually focuses on one of three areas: Either assay procedure, which generally because the procedures are relatively simplistic in the number of steps that the operator needs to perform generally boil down to a re-examination of operator training; reagent replacement, either due to a single device failures, which sometimes are hopefully tracked by the internal on board controls; or perhaps full reagent lot replacement, just as happens with laboratory or instrument

based systems; finally, and the one I have actually found to be the most frequent, is that the controls themselves have, in fact, failed because they are probably one of the weakest links in the entire system, given that onsite tests generally involve the utilization of liquid controls which have relatively limited shelf lives once the vial has been opened.

In summary, I would just like to say that the internal quality control systems for onsite tests really mimic what would occur with laboratory-based instrument systems and for the simple fact that the onsite tests systems are simply the instruments compressed down into very small footprints effectively. As a consequence, the methods and issues that we need to address are really one in the same.

Thank you.

[Applause.]

Agenda Item: Questions and Answer DR. BAYLOR: That concludes the formal presentations for the internal quality control program session. I will now open the session to questions from the presenters and the DTAB.

DR. KWONG: Good morning. I have a couple of questions for Dr. Gordon. If I understand correctly, your control material -- what you did was really spiking the digestion mixture.

MS. GORDON: We spike both digest and intact hair, yes. DR. KWONG: But the data you show on the slide was spiking into the digestion mixture.

MS. GORDON: The GC/MS data is spiked digestion, yes.

DR. KWONG: So, you know, if you are not spiking to hair, then what you are really controlling is controlling the recovery or the extraction from the digestion mixture, not from hair.

If, as you said, you have spiked some drug directly into hair, did you show that data there?

MS. GORDON: I had one Levy-Jennings chart which was spiked prior to digestion. That was early on. That was the RA results. We do also carry some of our pre-spiked samples into GC/MS.

DR. KWONG: The question I have really is, if you prepare your standards similarly, by spiking into the matrix or into hair, how do you assess the accuracy of the assay? MS. GORDON: Well, we do also include -- we have the blinds as well, which are -- we have the -- we do have pre-digested -- I mean, pre-spiked samples, and we do have -

DR. KWONG: The pre-spiked sample, how is it spiked?

MS. GORDON: We spike prior to digestion. We do have some intact hair that is spiked prior to digestion.

DR. KWONG: So the drug is spiked into hair?

MS. GORDON: Yes. But most of our standards and controls are done for GC/MS after digestion into pool digest.

DR. KWONG: Okay. The only question I have is your double-blind.

MS. GORDON: Uh-huh. DR. KWONG: What is assay line? What would be your target result for those?

MS. GORDON: For the double-blinds?

DR. KWONG: Right.

MS. GORDON: The ones that are submitted through our clients?

DR. KWONG: Right.

MS. GORDON: I do not know exact targets of those. Sorry.

DR. KWONG: No, no. But my question is what would be your target result, just positive and positive?

MS. GORDON: I am sorry?

DR. KWONG: Yes. How would you assess the result of the double-blind?

MS. GORDON: If -- if they are --

DR. KWONG: What will be -- if it is positive above the cut-off, that will pass? If they were positive, they would be correctly identified. If they were negative blinds that were correctly identified as negative, they would pass, yes.

DR. KWONG: All right. Thank you.

DR. WILKINS: I have several questions. I hope that you will bear with me. The first question I would like to address to Dr. Peat, Ms. Gordon, Dr. St. Claire. Dr. Childs, it may or may not apply to the urine testing program. So, if it is not applicable, yell.

As has been pointed out in the presentations, one of the primary goals of a quality-control program is to ensure reliable and quantitatively accurate results. Certainly that has been a focus of the urine drug testing program for quite some time.

In alternative matrices, our speakers have also pointed out that, unlike traditional urine assays, we need to measure parent drug as well as metabolite. That parent drug is very important for alternative matrix analysis. Therefore, I wondered if each of you could address the following question. I think this is important for reporting above cut-off concentrations. That is how do you control for conversion of heroin to 6-MAM morphine or cocaine to BE in each of your analytical processes? I think that is particularly important for the confirmation procedures.

DR. PEAT: Well, there are obviously standard analytical procedures for monitoring heroin in the presence of MAM monitoring, benzoylecgonine in the presence of cocaine. It is not unusual to do those two drugs simultaneously in a number of biological fluids. I would not see it as a problem.

DR. WILKINS: I just wondered if, in routine practice, do you have a control to monitor for conversion so that you know the number that you get for heroin or 6-MAM morphine that you might be reporting. We have not gotten to the reporting section yet, so this might be a premature question -- that that number that you report is quantitatively accurate. If you do not report quantitative results, then this may not be a critical thing. But it could be if your cut-off is defined by a certain concentration of heroin or a certain concentration of 6-MAM.

That is what I am trying to get at.

DR. PEAT: Well, right now, we just confirm the presence of benzoylecgonine in saliva, so it is not a practical issue at this point for us.

DR. WILKINS: Okay.

MS. GORDON: We do include a hydrolysis control in our sample, so we do measure the amount of hydrolysis in cocaine to benzoylecgonine.

DR. WILKINS: Does that control go through the digestion procedure for confirmation assays?

MS. GORDON: We do have a control that goes -- is, again, we do a pre-digestion and a post-digestion pool.

DR. WILKINS: But, as for RIA?

MS. GORDON: Also for GC/MS. Remember, we do have a hydrolysis control where we do measure the amount of hydrolysis that takes place during the digestion. So we have a spike three digest -- we know what we put in there. We put just cocaine, and we do measure the amount of cocaine converted.

DR. WILKINS: Maybe we will come back to that. Because I think that I have a misconception about the controls and standards that go through the digestion.

MS. GORDON: I did not mention it in my talk.

DR. WILKINS: Okay. So, routinely in GC/MS confirmations, calibrators and controls, the ones that you had spiked on the slide like, for example, cocaine BE, cocaethylene I think it was, five nanograms, five nanograms, five nanograms. Those types of calibrators and controls are spiked to a liquid digest?

MS. GORDON: Yes.

DR. WILKINS: Okay. What additional controls do you have?

MS. GORDON: We have a hundred nanogram cocaine control that we do measure, which is cocaine spiked, and we do measure the amount of hydrolysis.

DR. WILKINS: Okay. Thanks.

DR. ST. CLAIRE: And I am going to defer that to Bob Fogerson. I think he is going to address that in his talk.

DR. WILKINS: Okay. Thank you. My next question is, again, for each of the alternative matrix individuals, and I think this applies also to you, Dr. Anderson, is do you find that there is a large variability in signal response in drug-free matrix from different individuals? That is, if you were to compare saliva, or urine, or sweat, or hair from a large number of individuals, do you find that there is a lot of variability on a blank response? If so, how does this affect your LOD/LOQ and do you routinely report down in that range? What I am trying to get at is how low do you go typically in these assays? Because I think each of the matrixes are very different in what I might expect from a blank response. How do you control for that on a daily basis?

DR. PEAT: I can speak to benzoylecgonine in saliva. There is variation in the saliva specimens, there is no question, from individual to individual. When we do an LOD/LOQ determination with several different specimens, we get values in the range of one to two nanograms per milliliter of fluid and our cut-off is 10-fold higher than that at this point.

DR. WILKINS: Okay.

DR. PEAT: The difficulty -- there is more chemistry involved in the extraction procedure than there is in urine. So you can get lower LODs and LOQs simply by improving the chemistry of the extraction.

DR. WILKINS: Okay. Thanks.

MS. GORDON: We also see more of an effect in the screening assay than we do in the GC/MS because we can do more clean-up in the GC/MS. But, yes, we do have a -- try to separate -- have a fairly good separation between where our cut-off is in the RA assay, as opposed to the matrix variation that we see among the negative samples.

DR. WILKINS: Okay.

DR. ST. CLAIRE: Similarly, I think that our screening assay is more effected. That is why we have not been able to typically go with the 25 percent above and below cut-off. Our GC mass assay is quite clean and we do not see as much of an effect.

DR. WILKINS: I wondered if each of the speakers and, again, I apologize, this does not apply to Dr. Childs or Dr. Anderson, but, if you could clarify for me again the typical precision or percent CVs that you see with fortified standards versus the typical percent CVs that you see in real matrix analyzed samples in general. Mike probably will only comment on DE. What has your experience been? I am just trying to get a flavor for, if I were to look at data as I was looking at whether it is a packet or the literature, what would I expect to find?

DR. PEAT: I think you would expect to find very similar CVs to what you see in urine. I think, with the use of the improved chemistry and due to rated internal standards, and care and attention to the extraction, you are going to get very similar CVs.

MS. GORDON: I think that we have the same experience in that. Particularly in the GC/MS we have quite good CVs. In our blind samples, our CVs are quite a bit larger, but that is because we have a more heterogeneous population. I mean, the mixture is not a homogeneous solution that you would have in urine.

DR. WILKINS: I think it is probably my fault. I can tell that the way the questions are going that I was not specific enough. For example, would you expect that your typical CVs and fortified standards are less than 10 percent and your typical CVs in a true matrix sample are the same. I am looking at approximate percent CV.

DR. PEAT: Certainly I would, yes.

MS. GORDON: We see the same, similar CVs.

DR. WILKINS: Okay. So, yesterday -- I just want

to make sure I am clear -- yesterday we talked about with standards in one of the presentations that typical CVs were between five to six percent, which was what one of the speakers had mentioned. But, on your slides today, it looks like realistically, based on your blind QCs, they are probably about 30 percent?

MS. GORDON: The blinds are higher again.

DR. WILKINS: And those are true matrix samples?

MS. GORDON: Right.

DR. WILKINS: That is what I am just trying to understand is what would I expect to see normally?

MS. GORDON: But I think that is also skewed because we take, you know, several hundred milligrams of hair and mix it up so we do not have -- we may make the blinds. We get quite a bit of hair from these samples.

DR. WILKINS: So you would expect on an unknown patient specimen --

MS. GORDON: On an unknown, I think when you look at the retest data, you can see that we get quite, you know, we get very reproducible results when you retest the same sample when it is the same timeframe. When you take, you know, longer hair and chop it, you do get a larger CV in that mixture than we would in the retest sample.

DR. WILKINS: Okay.

MS. GORDON: There is only so much you can take

off of someone's head.

DR. WILKINS: Okay. Thank you. Dr. St. Claire?

DR. ST. CLAIRE: I just wanted to clarify the

question. You are wondering in repeating tests on client samples what the CB is compared to standards?

DR. WILKINS: If there appears to be a difference.

Because there is not a lot of information about alternative matrices. Does there appear to be a difference between what you see with fortified standards versus what you might see in true patient specimens? That is what I am trying to understand.

DR. ST. CLAIRE: I do not believe there is a huge difference.

DR. WILKINS: Okay. Again, related to QC acceptance ranges, Dr. Childs mentioned in her talk that typically with the urine drug testing labs it is plus or

minus 20 percent or two SDs is what they typically set as an acceptance range for quality-control performance. I wonder for each of the alternative matrix individuals if you might comment. Do you apply the same criteria, slightly modified criteria? What do you typically apply in the -- or what, in general, is typically applied in those settings not necessarily just in your lab, but what people in generally typically --

DR. PEAT: We are going to go in reverse order this time.

DR. WILKINS: Okay.

[Laughter.]

DR. ST. CLAIRE: In terms of our GC/MS assays, the controls have to quantify within 20 percent of the target concentration, similar as urine.

In terms of the screening assay, the negative control has to be above the cut-off and the positive has to be below and the calibrators have to have a CB of 20 percent.

MS. GORDON: We have for the -- the GC/MS controls are plus or minus 25 percent because we have got it at lower trace levels. But in the RA we do have a plus or minus 2ST.

We do that at quantitative.

DR. PEAT: It is the same as we use for urine which is screening controls, negatives -- negative, positive positives and the plus or minus 20 percent.

DR. WILKINS: I have got more. Does anybody else want to go first? Okay. I wondered again, Emory, I have another question for you, I am sorry. How do you -- do you have controls for the wash procedure that you use?

MS. GORDON: Yes.

DR. WILKINS: I wondered if you would just mind explaining it to me because I missed it someplace.

MS. GORDON: I did not include that.

DR. WILKINS: Okay.

MS. GORDON: It was only 15 minutes.

DR. WILKINS: Yes.

MS. GORDON: We do have controls. We do spike because that is a lot easier to do because we spike wash buffer for the controls and we do have similar controls than we do in our assays. We also do analyze the washes of the blinds.

DR. WILKINS: So you have an acceptance criteria or some type of criteria for evaluating this --

MS. GORDON: The quantitative acceptability --

DR. WILKINS: -- performance of the wash?

MS. GORDON: -- of the washes. But our wash evaluation is based upon the ratio of the wash concentrations to what is in the digest. So measuring it, evaluating the quantification that we get from the wash data and then using it to play with.

DR. WILKINS: Okay. One more. Again, this may be covered in the reporting section later. I am not really sure what is going to be covered in which section yet. So, if this is a premature question, just say defer it to later.

For each of the speakers, I wondered if you might comment. How do you routinely establish the linearity of the assay? Is it a pre-established value or do you assign that with each assay based on calibrators? This is for confirmation now. And then, if you have a sample result that exceeds that limit, what happens? I may not have phrased that -- that might have been a confusing question. If you need to report a quantitative result and it exceeds the upper limit of the linearity of your assay, what do you do with that and is that a pre-established value or is it experimentally determined with each assay? This sounds like an inspection doesn't it? I apologize.

[Laughter.]

DR. PEAT: It is getting very familiar.

[Laughter.]

DR. PEAT: Obviously, the way that we do that is identical to the way we handle urine specimens which is every six months we determine linearity of the assay and then any value that is above that upper limit we report as greater than if requested to do so. But generally, in the insurance industry, whether it is testing or performing, they just care if it is positive.

DR. WILKINS: Positive or negative.

DR. PEAT: They do not care how much positive it is.

DR. WILKINS: Okay. Thanks.

MS. GORDON: We do dilute our samples to get them in our linear range.

DR. WILKINS: So you analyze once and then --

MS. GORDON: We do a linearity every six months on our instruments. We do that linearity.

DR. WILKINS: Is that RA or --

MS. GORDON: GC/MS.

DR. ST. CLAIRE: Similarly, we do linearity

studies every six months -- reported greater than linear range.

DR. WILKINS: Okay. Thank you very much.

DR. BAKES-MARTIN: I just wanted to ask a question of Dr. Anderson. You mentioned that some of these systems have on-board internal controls that will detect adulterants. Could you be a little bit more specific about what they are detecting and how they are doing it?

DR. ANDERSON: Well, as you know, most adulterants operate by interfering with the antibody/drug interaction. Some of the systems have part of the controls as an antibody not a used drug interaction. If the adulterant can effect that, of course, it does not do that in all cases, it will trigger that control. In some of the cases, what will happen is you will get the wrong response for that particular control whether that would be the control being on or the control being off, depending on the nature. Some adulterants interact with antibodies in the sense that they actually literally destroy the immunological reagent. Bleach usually operates by actually direct oxidation of the reagent. Again, what you will see or tend to see in many cases is that the adulterant will have destroyed the reagent associated with that control. That control will come up with the wrong result and direction of certain structure if you do not get the correct response for that control to view the assay as invalid. It does not make the sample analyzable by the method. It merely indicates that that sample is probably not going to be analyzable.

It is fair, however, to say that, just as with anything else, the controls are not perfect in that regard and do depend, to a certain degree, on the degree to which the adulterant is present, whether there is a lot, a little or a medium amount.

One place that the onsite test though had a tendency to be a little bit more adulterant-resistant is that the literature -- and I am talking about the lay literature, not the peer-reviewed literature now, the stuff we have got on the Internet for how to avoid drug tests, most of the literature is associated with methods of adulteration which are designed to interact with the generally enzymatic detection space of immunoassays. Most of the onsite tests do not use immuno -- enzymatic detection. Most of them utilize pre-colored particles. As a consequence, that component of the assay because it carries a color that is not directly attackable by things like salt, which is a common one to disrupt enzymes, to that extent, they tend to be somewhat less adulterant-sensitive.

Now, there are some other adulterants that perhaps can be designed that would be more effective for onsite -- effect in the disruption sense, for onsite tests. But the greater share of adulterants have been selected by the delay for the purposes of disrupting the enzyme component of the immunoassay which is generally the weakest link.

DR. HUESTIS: I would really like to compliment you all, everyone on their presentations. They were really nice this morning. First, for onsite testing, since you have had the fewest questions. There is a tremendous controversy going on now that you alluded to with HCFA's decision about the number and amount of controls to run on the onsite tests. I wish you would comment on the amount and type of recommended external quality control -- so, meaning a sample that has a known value that is not included within your device. And how often do you think lots need to be tested, whether it be each lot, each shipment, or onetime per day? What type of recommendations?

DR. ANDERSON: Yes. Part of the FDA's submission for onsite tests, which go through the FDA clearance process, involves some commentary by the manufacturer as to what they think are -- or feel are at least the minimum required external -- additional external controls. In general, the recommendation boils down to still just like the current medical recommendation of some time period. Usually the manufacturer's recommendation is somewhat longer than the current CLIA-mandated timeframe of two per day primarily as a cost savings. Because there is -- someone said yesterday what we need is a 25 cent onsite test, and there are going to be 25 cent onsite tests to date that I am aware of (sic).

Personally, having worked in this area and, as Rosemary will say, battled it out perhaps with the CDC, and HCFA, and others, as we try to work through what does make sense in terms of QC, I think what people have found is that the standard recommendation of things like two a day, if you really evaluate it in the statistical validity sense, is much more of a feel-good and not really nearly as much of a catch for errors as one might like to believe.

When you look at MLSPEC testing requirements, for instance, for how many tests have to be done for the kinds of tests that onsite represent in a unitized sense, generally, you are -- and with knowledge of what the general true device failure rates are which are really quite small, which can be verified at the original manufacturer level, you have come to the disappointing result that, in order to really find the errors, you would nearly have to test an entire batch with QC reagents to find them. Of course, in an operational sense, as a -- for users, that really is just simply not a practical matter.

So, the usual recommendation for manufacturers for onsite tests is the frequencies are on the order of once per week, say once per month. Certainly, every kit shipment, because you need to check for issues that the manufacturer cannot control, namely shipping issues. If -- because most of the users usually buy reagents at frequencies on the order of once a month, and that corresponds to once a shipment typically, those kinds of timeframes are the timeframes that people potentially use external controls something on the order of once a week, once a month, something like that.

DR. HUESTIS: And is that what the Joint Commission accepted? I do not remember the exact--

DR. ANDERSON: Yes, it is.

DR. HUESTIS: -- the once per month?

DR. ANDERSON: At this point in time, the organizations that are utilizing that criteria are HCFA, under their clear regulations via the State Operators Guide, not actually directly under the CLIA regulations. The Joint Commission currently subscribes to that mechanism --

COLA, which is not usually in the hospital laboratory, but certainly affects the physician office laboratory environment.

Probably the largest organization that is resisting this at this point is the College of American Pathologists. However, I will say that just this year, not in the drug testing arena at this point, but in a different arena, namely of electrolyte blood gasses, type devices, the ISTAT device, for instance, for that, electronic QC used in the point of care environment is now an accepted methodology even within the College of American Pathologists. For that matter, onsite drug tests which are used in the point of care, which is relatively uncommon at this point. In fact, under the point of care checklist, under the CAP, alternative QC -- speaking was about alternative samples today -- but alternative QC is a potentially viable route within the College of American Pathologists.

Again, I do not think any of the manufacturers of the onsite methods really would be willing to tell you that do not do extra QC at all. It is really a question of how do you split between internal methods and external methods to kind of get the biggest bang for the buck.

DR. HUESTIS: Okay. Thank you.

For the alternative specimen people again, please. Could you describe for us the batch sizes that you are using? I know a lot of micro titer plates are 96 OLs. But, if you would tell us something about batch sizes. And then I think very importantly is the placement of the quality control within the batch. You all showed us very nice controls, but it makes a difference whether at the beginning of the batch or spread throughout the batch and what kind of CVs you see and how you control for drift across batches.

MS. GORDON: We do -- our screening batches are 300 samples in the batch. And we do have sample controls throughout the batch.

In GC/MS there our batch size can vary up to about 100 samples in a batch and every approximately 10 to 15 samples is a blind -- I mean, is a control.

DR. HUESTIS: So, you have controls throughout the batch? In the screening across the 300 you do not have much problem with drift, with the RIA?

MS. GORDON: Not too much.

DR. PEAT: With the ELISA we have to control every 10 specimens. We do not see hardly any drift across that plate.

DR. ST. CLAIRE: In terms of the GC/MS batches, we have the controls at the beginning and the end of the batch.

In terms of the ELISA, there is -- we use 96, and we also put the controls at the beginning and the end of the batch.

DR. HUESTIS: Okay . Thank you.

DR. ALAN JONES: I am just going to go down the table. I will start over with you, Dr. Anderson, for a question. A concern that is often reflected about all of the whole QAQC is the maintenance of records. What types of things are being done in the onsite arena for the maintenance and storage of QAQC-type records?

DR. ANDERSON: Well, of course, in general, most onsite methods do not generate a paper trail in and of themselves. They are not like instruments with a piece of paper that gets spit out the front. There are a variety of mechanisms for generating the paper trail, generally requiring a transcription of the results to some kind of form. In some of the devices it is possible to xerox or photocopy the device to replicate the results. But, depending on the quality of the photocopies, that may or may not be satisfactory. But, normally, it is done by the mechanism of simply recording the visually-observed results on a standard form.

DR. ALAN JONES: Of course, as we get into litigation procedures and the like, certainly, my experience is more in the urine testing side of it. Many of these types of records are brought into the proceedings. Is it your experience that these are the types of records that are satisfying the queries from the arbitrator, or the courts, or anything?

DR. ANDERSON: Our experience is that that sort of paper trail is not an acceptable mechanism for generating results. It mean, it certainly has the downside that, of course, transcription errors can be introduced into the record, if you will. Most onsite methods, however, do not totally consume the sample. The sample is capable of a split. If there is a challenge to the onsite initial screening results -- and remember that the initial screening result, or the onsite tests are only an initial screening. They are not the sum total of the paper trail.

When the sample has gone on for, as is recommended, for further confirmation at a certified facility, there is a secondary component to the paper trail, which, of course, supports the initial screening results. Should, for some reason, the initial screening result be -- either paper trail or the result itself be challenged, in general, there is a split sample that can be retested or rescreened and confirmed. So it provides enough safeguards I think that generally the results are accepted.

DR. ALAN JONES: But that would not be the case if it were a negative QC and did not go forward?

DR. ANDERSON: If the initial sample is a negative, of course, the results are marked down in part of the paper trail. However, it is generally not going to be the case that negatives go forward for confirmation for onsite, just as negatives do not go on for confirmation at a standard reference lab.

DR. ALAN JONES: Sure.

DR. ANDERSON: However, I think, given some of the feelings with regard to that and the fact that I suspect that, if onsite tests are brought within the Federal workplace programs, that my expectation is actually that a certain fraction of the negatives probably will be included, if for no other reason than to sort of get the program off the ground. There will be a certain fraction of negatives, potentially false-negatives, or probably some fraction will eventually be false-negatives for that. That issue will be addressed.

DR. ALAN JONES: Thank you. Dr. St. Claire, I have one question. Specifically, you showed us a slide talking -- well, I do not know where it was -- talking about bias and the bias of the sample. Is that bias that you have seen uniform across samples or do you get a lot of variation in that bias? Can you expand on that a little bit?

DR. ST. CLAIRE: Are you talking about the THC ELISA assay?

DR. ALAN JONES: Right. And the bias from the -- that you saw from using a patch, a pre-worn patch versus a non-worn patch in the preparation of that? You were talking about matrix bias?

DR. ST. CLAIRE: Right. That bias was only seen in the THC assay. Actually, we did spike the calibrators onto worn patches with the other assays and did not see the similar effect. It was only after doing the THC assay.

DR. ALAN JONES: Only in the THC assay?

DR. ST. CLAIRE: Uh-huh.

DR. ALAN JONES: Is that -- do you have any feel for that? Is that a nature of the antibody or is that -- what is the genesis of that? Do you have any feel for it?

DR. ST. CLAIRE: I suspect -- I mean, like I said before, I think there is just some non-specific binding that is going on.

DR. ALAN JONES: Okay.

DR. ST. CLAIRE: I have a question to Dr. Peat, Ms. Gordon, and Dr. St. Claire. As your particular assay may be moved to another lab that does not have the experience that obviously the three of your facilities have in your given area, what kinds -- and this gets into a little bit more beyond QC, but we do not have a section on validation, so this is a little bit of a validation question I guess. What kinds of challenges would you recommend people consider as you might generate or build QC specimens for validation and looking at ruggedness of the assay? Obviously, you are going to look at the analytes toward which your particular assay is directed, as you have indicated. Are there other things that we should include in these challenges or anything, as another lab might pick up your assay without the experience that you have in your particular arena? Does that make sense?

DR. ST. CLAIRE: Dr. Peat, I would like to defer that to you.

[Laughter.]

DR. PEAT: I am sure you would.

DR. ALAN JONES: Dr. Baylor, would you like to handle that question.

DR. BAYLOR: No, thank you.

DR. PEAT: The biggest challenge, I believe, that other labs are going to face is not necessarily validation protocols. I think they are generally similar to what you would do in the urine program. It may be that the interfering substances may be different.

I mean, for example, doing THC you would have to involve yourself in making sure that other lipids and fatty acids, et cetera, did not interfere with the assays. But I think that the biggest challenge that people are going to face is not in modifying the immunoassays or adapting the immunoassays. They are pretty accepted, commerciallyavailable procedures in both cases, FDA-approved.

I think that the biggest factors are, one, carryover. When you look at alternative fluids, any hint of a carry-over could possibly lead to a positive because you are looking at much lower concentrations. So, carryover, in a sense, has a much greater potential when you are using pipetted diluters in 96 well formats. Then it might attach here on an instrument.

I think that the other challenge people will face is the ability to confirm at very low concentrations with the degree of confidence that these programs require. You know, as I mentioned in my slides, and as I have mentioned before, I think that trying to do sub-10 nanogram per mL determinations with mass selective detectors requires a bit of art. In some days, it probably requires you to kneel on the floor and bow towards HP headquarters.

[Laughter.]

DR. PEAT: That is the biggest challenge I feel that people will have with these alternative technologies. It is not necessarily the validation protocols. They are pretty similar, but just being able to do these assays accurately and reliably day in and day out.

MS. GORDON: I am not sure I can add anything to that. I think I agree with it.

DR. ST. CLAIRE: I think that Dr. Armbruster actually addressed this to some degree yesterday.

DR. PEAT: Right.

DR. ST. CLAIRE: I think we are still somewhat in the infancy in terms of our ELISA assay. I think it would be a wonderful challenge to get to another lab to really try to have controls at the levels that we are able to in the screening, in the urine screening assay, 25 percent above and below the cut-off.

DR. ALAN JONES: Thank you.

DR. CAPLAN: I just had one follow-up question for Dr. Anderson. You were asked earlier about, and maybe Sal might want to comment on this, about how the adulterants might be detected in the various onsite devices. Particularly, I think you made reference to the effects on the assay channel. Some of the devices like I think the one you have, does have a separate channel to validate the process and some other devices only have the assay channel.

Could you comment a little further on whether there is an advantage to a control internal channel for these processes or whether the assay structure themselves would -- how that might detect or deal with the adulterants?

DR. ANDERSON: Yes. I guess -- and this is an issue that those of us who were in the onsite group, as a whole, sort of struggled with -- is that, unlike the other alternate matrices, there really is a single system that we are talking about. The onsite tests are, if you will, a collection of a variety of manufacturers with a variety of tests and the right formats. So the comments, as a consequence, are a little bit generalized in that regard.

Some of the systems -- well, not all of the systems have as many on board controls as some others do. I personally think that, essentially, the more the controls probably the better off you are because they provide -- the different controls can respond to things such as adulterants or other intrusions into the assay procedure in different manners and give you just that more opportunity to trap out errors.

It is true that some of the systems work better with some of the different adulterants. I really have to comment more directly with our own manufactured device. We know that, for instance, some adulterants affect one of the two control zones more directly than they do the other of the two control zones.

Obviously, having only one of the other of the controls would have tended to make your more vulnerable to that specific adulterant. So, I guess, the only way I can answer the question is that the more safeguards you put in the system a little bit, the better off you are. That is really the reason for not taking external controls out of the greater QC environment, but taking advantage of the QC elements that internal controls do provide. I do not know if that answers the question.

DR. CAPLAN: Okay. Well, I guess, the corollary is do you feel a separate control zone in an onsite device would be an essential quality-control component?

DR. ANDERSON: I think it is a very valid component. I mean, you can ask the question in a slightly different fashion. If you think it is a really great idea, then why would you not have it in the instrumented systems?

The reason you do not have it in the instrumented system is because basically it is technically possible to do.

I mean, the difference about onsite devices from say instrumented laboratory-based immunoassays is that it is really impossible to think of each surface area element on the membrane as a separate reaction area. It is really possible to do separate chemistry in the separate zones. So, if you have four, five, seven, eight, however many reaction zones, you really can do four, five, seven, or eight different chemistries. Historically, for the immunoassay systems, while it is possible to do homogeneous systems, such as the FPIA, it has not been possible generally to do multiple homogenous assays inside of this single bottle. People have tried it in some cases with some optical labels where you could measure it one way versus the other in the same tube. But, historically, trying to get that to work has been quite challenging or the assay manufacturers.

Again, I think, the more controls you can add, the more likely you are to be able to trap out errors that a less-sophisticated user might not be able to do.

But when it comes to adulterants and the like, certainly the first wave of defense is not the assay. The first wave of defense is a good collection procedure and good collectors. They are the first ones to touch the sample and the first ones likely to notice that something is obviously awry with the sample, such as strange color, you know, funny temperature, strange odor.

DR. CAPLAN: Okay. Sal, do you have any comment? DR. SALAMONE: Yes. I agree with the immunochromatographic approaches, yes, it is easy to put a control zone in that. But, if you have different types of technology, sometimes it is impossible, just like it would be impossible to put an internal control on an instrumentbased test.

You are familiar with the on-track system. There it is solid -- or it is reagents in the same way that you would use instrument-based reagents. There it would be nearly impossible to put an internal control in the same, while you are running the sample.

DR. WALSH: Just an FYI. I happened to be aware that Stewart Bogum has submitted a very elegant study where he has looked at all of the common adulterants on a number of the onsite, FDA-approved devices that have separate control zones. So you will have to go to Soft this fall to find out the results.

DR. CONE: I know time is getting long here so I will make my questions real quick. I had some onsite testing questions. There is some variability in reading. When we evaluated we had three readers read independently the results and got pretty good concordance usually, around 90 percent. But then there was 10 percent discordance. Do you see a need for more than one reader?

DR. ANDERSON: Our experience is that, in general, that is not a necessity. Certainly, as the concentration of the sample gets near the cut-off, there is variability in the interpretation of the result. That is a natural order event. I mean, in a certain sense, if we take an instrumented system and look at it from sort of the same variability perspective, in the most careful definition of cut-off, which is that the sample essentially will produce 50 percent of the results greater than the numerical value of the cut-off, and 50 percent of the results numerically below the cut-off, in a sense, the instrument has essentially the same problem. And, from what I am aware of, there are no instrumented systems that have effectively a delta function as an error curve for their assay, that occurs over some, if you will, grey zone of interpretability for an instrument perspective.

Certainly, the same thing happens in an onsite system because it produces -- its color change varies to a certain degree over the range, over some concentration range. In most assays, and I am going to mean by that most drug assays, usually the samples do not present themselves very frequently actually at the cut-off. That is perhaps arguable in the case of THC where there are for reasonable numbers.

But most of the samples I think Dr. Peat said earlier, they were either nothing, a lot, or a hell of a lot. And so, as a consequence, most of the results fall in the category of there is, depending on the system, either not much of a signal, a lot of the signal, or a bunch of the signals.

DR. CONE: But you will get samples of the cut-off?

DR. ANDERSON: Oh, yes.

DR. CONE: A related question. You and others have suggested sending out negatives for confirmation. That seems to me to be a good QC check. On the other hand, what do you recommend about if you get the negatives back with a positive result? Should that then be used as a -- this is more of an administrative issue, but it relates to QC. If you implement that procedure, then what do you do with the results?

DR. ANDERSON: Well, I think that is exactly what the issue is going to entail. I mean, certainly, when one goes to select any analytical method, be it drugs of abuse, electrolytes, what have you, one of the goals is to select the most bang for the buck, if you will, the best system you can possibly afford. Certainly, if your decision was that your onsite method was not providing an adequately small fraction of false-negatives, I would suspect that the user of that method would have serious doubts as to whether they would continue on utilizing that approach.

DR. CONE: But that is not answering my question.

What would you do with a negative result that was reported back to you positive?

DR. ANDERSON: You are going -- assuming that that went through a confirmation at that point, you are going to have to assume that that result is positive and act accordingly.

DR. CONE: So, you would think it would be a valid result then and should be reportable --

DR. ANDERSON: Yes. I think that --

DR. CONE: -- even though you have a negative result already established for it?

DR. ANDERSON: Well, let me answer that question in a slightly different fashion. As you know, urinary drug tests are designed to detect urinary metabolites. That is why urinary drug tests are oriented for cocaine, for benzoylecgonine. We all know that quite well. There are many of the urinary metabolites of other drug classes, particularly things like benzodiazepines, where the compound is not benzodiazepine yet. There are quite a number of immunoassays out there right now that are designed to detect pairing, which is not really the compound that you would usually see.

I guess I would ask the same question. What do you do with a test that provides a large false-negative reading in that category. The answer is, if you find it is truly positive, you respond in that way.

DR. CONE: Do you have a recommendation for the local sites in terms of establishment of SOPs and related to the records question originally?

DR. ANDERSON: Our recommendations are essentially that those that fall into the regulatory environment, that the NCCLS protocols for setting up standard operating procedures are good guidelines to follow for facilities in setting up procedure reviews.

DR. CONE: Okay. One quick question for Marie. Have you guys -- do you have any way of producing quality control samples for hair that you are happy with in terms of other than using previously-known drug users' hair? Have you developed any positive control methods for making hair samples that simulate real positive hair samples?

MS. GORDON: I think that Dr. Baumgartner has looked into this. We are not currently using anything like that at this time, but I believe that Dr. Baumgartner could better answer that question.

DR. KWONG: Ms. Gordon, I just wanted to clarify my confusion about the QC data. I am sure that the audience will appreciate a clarification too.

You mentioned that some of your control data were from material that -- hair that the drug has been spiked into hair rather than into the digestion mixture. Is that the IA control recovery and IA control assay, those two slides?

MS. GORDON: The recovery is spiked into hair.

The assay is spiked after, so it is in to digest.

DR. KWONG: So, when you said spike into hair, you mean that you actually incubated a drug in?

MS. GORDON: No. We just added the drug to the intact hair.

DR. KWONG: How long did you leave it with the hair?

MS. GORDON: Just a few minutes before the assay.

It is not subbed in the drug.

DR. KWONG: Okay. So, do you know --

MS. GORDON: And it is also very --

DR. KWONG: -- do you know the entry of the drug into hair in that short timeframe?

MS. GORDON: I beg your pardon?

DR. KWONG: Do you know if the drug will enter into hair in that short time incubation?

MS. GORDON: No, I cannot answer that. I do not know. I doubt it because it is a very short time period. We are not soaking the hair in the drug. It is really adding 100 or 200 microliters.

DR. KWONG: Okay. Thank you.

DR. BAYLOR: I would like to personally thank the members of the panel for their preparation of the presentations. We will now go on break.

The meeting will reconvene at 10:30 with the reporting test results panel. Thank you.

[Applause.]

Agenda Item: Reporting Test Results Panel

DR. BUSH: We would like to begin this next panel.

This panel is entitled reporting test results. Okay. Well, we are going to get started. We have given everyone enough grace period here. Okay. Reporting test results panel. Our moderator is Dr. Reese Jones. Dr. Jones is a Professor of Psychiatry in the School of Medicine at the University of California, San Francisco. For many years, he has been involved in human laboratory studies of the clinical psychopharmacology of cannabis, cocaine, nicotine, methamphetamine, LSD, opiates, and related licit and illicit drugs.

In recent years, he and his associates have been interested in laboratory studies of drug kinetics in hair, saliva, sweat, and skin. He occasionally consults in forensic cases on matters concerned with drug testing.

Dr. Jones.

Agenda Item: Principles and Criteria

DR. REESE JONES: Well, it is really nice and a privilege for a psychiatrist to be invited to something like this. I have had the good fortune of hanging out with real analytic chemists and real clinical pharmacologists. I suppose that is why I am here.

In my mind, the issues around reporting are very simple if everything else that was done that we have heard about in the last day and a half were done well. It is, as I understand it, the essentials are the adequate information for the interpretation of the results. In a way, this session pairs with the next one to follow it on interpretation. The report should be accurate and should be timely. It should be complete. It should be transmitted in a way and formatted in a way that the privacy of the person being tested and reported on is respected. It is not a trivial undertaking in this day of massive databases and the like.

The basic fundamentals I think that we have heard over and over again are it is like reporting the results of a urine test when we -- but these special -- these novel matrices here, sweat, saliva, have some special attributes that I suppose, if one is simply reporting a yes/no or a positive-negative report to an insurance industry company, it is less of a problem though even there, at some level, quantitation does enter into it.

But, if one is reporting to a medical review officer, issues come up that have been hinted at that are very special around saliva, and sweat, and to various degrees to hair, in that the sweat is not simply a simple transudate from plasma. It is not just something that you would get by passing through a membrane. The skin, in its way, is an excretory organ, just as complicated as the kidney. It is not as well studied, and it is not as well characterized. But what appears in a sweat patch is determined by the ambient temperature, whether the person is acclimated to the north or to the south, or racial differences, both genetic and adaptive, environmentallydetermined that interact with what appears in the skin patch.

Now, should those issues somehow be reported or somehow be part of the report or not, I think it is not entirely clear. Certainly, many medical review officers, in terms of trying to make a reasoned decision, would say, at some level, want to take that into consideration.

The same holds for saliva. The fact that parent drug is going to be looked at it sounds like more than metabolite raises certain issues where certainly the amphetamines and cocaine are very dependent on the pH of the sweat and even more so on saliva where you see 10-fold, a hundred-fold differences with relatively small changes in pH.

An anxious patient is producing quite a different kind of saliva and different plasma, different blood --

different saliva levels of the drug, even though the plasma levels may be the same. The highly-anxious patient, for example, at least in our lab, flow rates go down, pH goes down, and saliva concentrations of cocaine or methamphetamine go up enormously with no change in the plasma concentrations.

Should these be part of the report? Well, they are not traditionally part of something which is considered when reporting on urinalysis -- let's see, with the hair analysis.

Quantitation, I think, is, in my mind, the whole main issue around what should be in the report and how. And simply, as an aside perhaps for those of you who do not live in or visit California, the whole issue of quantitation around cannabinoids now may become more relevant in that in our neighborhood the major issue is should the Starbuck's be allowed to build another store to sell coffee or not. That is being fought, but a cannabis store probably will be put in down the block with relatively little discussion.

[Laughter.]

DR. REESE JONES: It is hard to imagine, if you

live back east, that, in California, cannabis, at least in Northern California, is now a legal drug. And so the reporting of simply plus or minus may not be adequate for the poor medical review officer who has to decide whether this is someone who is receiving therapeutic cannabis and certain allowances should be made, et cetera, et cetera. You can see the scenario.

Fortunately, we have a good, experienced group here to discuss reporting. The first speaker is Mike Peat, who needs no introduction, even though he has had three introductions today. I am happy to introduce him. Mike, in some ways, is why I am here, since many years ago, we collaborated on some cannabinboid studies and I learned a lot.

Agenda Item: Saliva Testing

DR. PEAT: Reese mentioned that California is different for the principles of cannabis. But anybody who has been close to Reese's office, also knows that California is different for another reason. Finding Reese in his office is very difficult.

[Laughter.]

DR. PEAT: We have known each other for a number of years.

I am here to talk about reporting. Generally, what I am going to say is going to be very brief. Because, as I have mentioned before in the other talks, the principles of what you do with saliva, or any alternative fluid, is very similar, if not identical to the principle that you now use for urine.

We talk about review and certification of data. And we mention a little bit of this in the quality control presentation earlier. We are talking about reviewing chain of custody documents, both the external and the internal chain of custody documents to see if they have been complete and have been completed correctly. We are talking about reviewing the initial immunoassay data and the quality control that go with that.

We are talking about reviewing the confirmation data and the quality control that go with that. And then we are talking about documenting all of those aspects of the review process for later review by inspection programs or later review in the litigation process. So nothing that we talk about with alternative technologies is any different, in my view, in what we currently use for urine review and certification.

We talk about releasing results. Obviously, there are some changes that have occurred there over the years. That is increasingly an electronic release which obviously requires secure electronic communication, but then, of course, as a follow-up with the certified chain of custody, and to the medical review officer. Again, no change there.

Again, as will be discussed later this afternoon or early this afternoon, the medical review officer review of that information and whether it complies with the prescriptions and therapeutics, et cetera, again, that is no different with the alternative technologies. What may be different is that you may obviously be looking at different target analytes, as, again, we have discussed in various talks throughout the last day and morning.

Obviously, the certification is similar to urine. There are different technologies. We have talked about ELISA RA in hair, hyphenated MS techniques, LCMS, triple quad, et cetera. So we are talking different formats, different techniques, different procedures. But, again, the principles are the same.

There are changes that would be needed to the programs that exist today. We talked about these earlier before the break. You obviously would require further enhancement of laboratory procedures. Those that are in use today may not be, in all likelihood, would not be applicable to the different analytes, and the different cut-offs, and the different mediums that would be used.

You would require further training of the inspectors in these procedures. Not all inspectors today are familiar with LC/MS/MS or GC/MS/MS or even possibly familiar with ELISA technology. They would require further training in these procedures before the certified labs could be inspected appropriately. Obviously, if we apply different technologies such as this, there would be a requirement for capital expenditure by the labs in the new techniques and the new instrumentation that would be necessary.

What would be reported in the case of saliva is obviously the parent drug and/or the metabolite at lower cut-offs in all likelihood, and the presence or absence of IGG to ensure that that is a reliable specimen.

The issue in the debate -- and Ed Cone asked this question yesterday -- is whether you report it as per device, whether you report it as per milliliter of all fluid, or whether you report it, for example, per unit of IGG, rather like some people advocate reporting nanograms per milligrams of creatinine for urine concentrations.

So, there are various options and, obviously, the decision is fraught in that sense because the amount of oral fluid collected, as Reese just mentioned, varies depending upon the state of the individual and other factors.

So, in summary, we would require an enhancement of lab procedures, in my view, to be able to report appropriately alternative specimens, and retraining, and then some research into the detection timeframes and comparison with urine again, which was mentioned yesterday.

Thank you. I told you I was going to be brief.

[Applause.]

DR. REESE JONES: The second speaker is Robert

Fogerson, who will be talking about reporting sweat. Mr. Fogerson joined Pharmchem in 1975, beginning as a laboratory analyst. he served as laboratory supervisor, laboratory manager, director of quality assurance, director of lab operations. So he has more than 20 years' experience in forensic toxicology. He is a member of the American Association of Clinical Chemistry, Past President of the California Association of Toxicologists, member of the Society of Forensic Toxicologists, and the like.

He is responsible for all technical aspects of laboratory operations at Pharmchem. He directs the Methods Development, including the methods for the Pharm-Check Sweat Patch.

He provides also, in his spare time, in-service training of drugs of abuse for Pharmchem customers, and testifies as an expert witness in legal proceedings.

Mr. Fogerson.

Agenda Item: Sweat Testing

MR. FOGERSON: Thank you, Dr. Jones. I would also like to thank the members of the board for giving us the opportunity to go over some of this information. I agree with Dr. Jones. It is a little bit difficult to talk about reporting results in a mechanical sense without verging into the interpretation. I will try not to do that too much, but I will probably fail a little bit. Later on today we can talk about the interpretative things.

But, I think, as we talk through some of just the data and the facts associated with the results that we do report out of sweat testing, you will begin maybe to get a sense of where it might be useful and applicable in a number of environments including workplace testing.

Just about everybody in the alternative matrix group has sort of started out saying that what we do is fundamentally parallel to urine testing. I do not want to break that trend, so I will make the same sort of statement to begin. It is really true in some respects.

We start out receiving the absorption pads and the sweat patch. We dilute it, analyze it. What we are going to initially report to a customer are simply the target analytes, the identified target analytes in the eluate that we receive from the patch.

We do not make any initial report at least in the interpretative commentary about the source of the drug or duration of exposure, intensity of exposure or that sort of thing. So the report is qualitative against an established cut-off in exactly the same sense that we would report a urine drug test result.

The analytical procedure involves a quantitative GC/MS analysis in order to generate that determination of positive or negative means to cut-off. So we do produce quantitative data on the results on each report, and it is available for interpretive use down the road in, again, exactly the same way we would handle a urine test result.

Since quantitation is probably going to be the key note of most of our discussion and interpretation, I think it is probably worth spending a little time telling you how we generate -- well, not so much how we generate quantitative data, but what he data look like in sweat tests and what it is that we know about it from our studies and investigations, and the basis for the interpretations that we think we might be able to make.

My own feeling is that quantitative data in sweat testing is going to have somewhat limited interpretive value. I have the same feeling about quantitation in urine testing. We have talked for years and years about it having no value. I think, in more recent times, we have come to understand that it has some value, but we are all posed with various explanation for a positive result which can be consistent or inconsistent with sort of extreme cases of quantitation. So it does help sometimes.

I know that Dr. Huestis has done some work on generating algorithms for interpreting essential marijuana positive in urine results. This seems very interesting. So

I think there are cases where it will help, but it is going to have a limited application.

In sweat testing, the quantity of the drug that we actually find on the sweat patch is, I think, a function of slightly different things, in some respects, than what we see in urine testing. It is clearly a function of the amount of drug that has been ingested. I want to bring this up because it partly answers the question that was raised yesterday.

A lot of the work we did in developing this technology was based upon a series of controlled-dose administration trials with human subjects. So we did have the opportunity to look at things like dose response, and excretion intervals and that sort of thing. There is a dose response, at least a directional dose response that you do see with sweat testing. The amount of drug we see on the patch is higher when people are given higher amounts of drug. It is a little bit complicated. I will show you some of the data and some slides a little bit later. It is not a terribly precise relationship, but it is there to some extent.

The amount is also going to be, I think, a function of frequency of use. This comes about because of the fact that this device, this collection device, if you want, over an extended period of time. I mean, you really could think about a urine test also being a function of frequency of use, but I think it would not be as natural to think of it that way.

But you could think of a situation where somebody is wearing a device for seven days and they may be using cocaine everyday, every other day, and this device is essentially collecting evidence at each episode of use. You begin, I think, to have to think about it as being a function of not only the amount of any individual use, but the frequency of use. So, all of a sudden, it becomes more complicated.

In some respects, it makes the concentration of drug on the patch less a function of time sense use because you have this additional consideration of how often it has been used over the course of the wear period.

There are some other factors that we have found to influence the amount of drug we see on the patch that I want to mention, although you do not see it in the slide here because, again, it sort of answers some questions of some comments that came up yesterday.

There was one question that was raised about the feasibility of doing split collections perhaps by having two patches worn on different parts of the body. It relates to the degree of variability you might find in the results from two different patches. We do have a fair amount of data on that that was developed in the clinical trials. Our initial interest was in determining where it is one ought to wear a patch. So we had patches applied. As somebody said, there were up to 14 patches on people at various times, and applied on different parts of the body.

Now, statistically, we do not see a great deal of difference between the results we see on patches put on say the upper arm, lower rib, chest, or back. But, if you actually look at the individual variation, they can be significant. So, there are significant variations between the drug level seen in the patch. They do not necessarily rise to the level of a 95 percent statistical demonstration of a fundamental difference in excretion in those areas, but it would be something that you would keep in mind if you are going to interpret a split sample.

So, the location of the patch does have something to do with the amount of drug you see and even the two patches on the same person at a given time. That amount of variation is probably not necessarily much different than say the variation that you might see in doing a urinary retest, especially a cannabinoid retest after a six-month period.

There are a few parts of the body that do seem to produce quite different levels of sweat than others. We have done work with sweat from the palm, for instance. It is not something that we use routinely, but we do have some information that suggests that that level is very much higher. So, this is something that will have to be considered in interpreting the questions.

The question of variation of sweat rates. This one is kind of interesting. I suspect it will have some bearing on the concentration of drug that you find on the patch. It is not entirely clear how it is going to turn out. I think that the answer to the question will be whether or not drug is excreted by sweating or in sweat, whether you think of the excretion being an activity of the skin and sweat providing the fluid for actually carrying away the drug, in the same way you might think of urinary excretion being essentially kidney function, or whether you think of the sweat as being -- the sweat mechanism as being the way that the drug gets carried away.

If you think of it, urinary flow does not have that great an impact on the rate, the daily rate of elimination. It has a great impact on the concentration. So, variations in sweat levels may actually affect the drug concentration in sweat, but because the patch functions to collect this fluid and hold it, it may have less of an impact on the amount of drug we see on the patch itself.

Another variable that I can think of influencing the quantitative level of the drug we might expect to find on the patch will be this duration of wear. This question was raised yesterday. Obviously, if you are testing in an environment where people are using them periodically, it will be some concern of how long the patch is worn. We know, from our clinical trial data, that we need to have the patch on somebody at least 24 hours to detect -- pick up a sufficient signal to reliably detect the positive from a pretty low-level use, I mean, just from doses that you can give to volunteers in a study.

Beyond that, the limiting factor on how long somebody is going to wear a patch sort of derives from the way it sticks onto the skin. If you recall the description of the adhesive of the patch that will be filtrating the epithelial layers of the skin, when those things go the patch comes off. Now, for most people, that is sort of an average of every three weeks. So your range is going to be potentially between 24 hours and something out to three weeks. Our experience has been, and our sort of recommendation has been that the patch functions pretty well within a 24 -- a one-day to seven-day period of time. So, we are going to have to account for where periods kind of span that interval of time fairly commonly, and for amount of drug use that could occur over that period of time. Even within that timeframe, we know a lot more this year say than we did a year ago on where the patch.

Again, going back to a question that was raised yesterday, I am not sure we really have sort of explored fully. There are definitely groups of people for whom the patch does not seem to adhere well. So, this is going to be one consideration in the application of the patch in workplace testing, people whose skin does not seem to support the adhesive very well. There are not very many people who seem to have what we would call allergic or adverse reactions to the patch. That was not an issue. But, once it adheres, it will function fairly well over -- in most environments, in most timeframes over this one to seven-day period.

This slide give you an idea of this effect that we have with the patch, the effects of the quantitation I referred to. This just simply compares with what you might see in urine results over a period of time after a dose, to those you would see in a sweat patch.

This is a single dose on a patch. You actually see the drug level climb fairly close to the timeframe of the urine result. But then the patch essentially holds it. That is really what it is designed to do. It is a collection container that is simply sitting on the skin collecting evidence over a period of time and containing it. This happens to be from a cocaine clinical trial.

I wanted to give you some idea of the sorts of levels we are talking about with select patch. I will give you a couple of sets of data from clinical trials. You can see a little bit of this dose response that I was talking to you about. The methamphetamine dose, 10 milligram dose, 20 milligram dose. You can see the levels that we are seeing in nanograms per mL of patch extract, up to about 200 in the higher dose, and around 80 for the lower dose.

There is similar data for cocaine. The dose response is a little less dramatic, although it is probably because we see this peak here which I do not fully understand. But once the level stabilizes, you see the same sort of effect.

Heroin data is a little bit skimpier. But, from a few subjects, you can see nanogram per mL levels in the patch eluate in the 20 to 50 nanogram range, 6-MAM level, six to 30. This will give you some sort of a sense of what we see at these sorts of dose levels.

Marijuana results. Again, it is similar. Here the dose response is a little more complicated. We actually have people showing higher responses at lower dose levels in some cases.

All of that data were clinical trial data. It has some relevance to real-world data, but I wanted to give you a little bit further information on what we have seen subsequently in patches applied to drug-using populations. So, this gives you some information.

If you look at heroin, we are now up to maybe 400 nanograms per mL in actual users, cocaine, up to 400. PCP.

Some of this data we have generated and some has been generated by other people doing some work with the past.

The units of measures that we actually report when we discuss quantitation are, as has been said before, nanograms per mL after a two and a half milliliter elution of the patch.

Now, I spoke briefly to Dr. Cone about his question yesterday. I will agree with him that using this technique for expressing results is quite different from using a GC/MS number on a native fluid like blood. I do not necessarily agree that it is so different from what we are doing in urine testing in some respects. Once we get to realizing that we have even a variation in urine flow, as Dr. Peat alluded to, we get quite a clinical variation in urine test results quantitatively, depending on what the urinary concentration is. We talked about normalizing that with creatinine, and that is something that can be done, but when we actually went into immunoassay screening for urines, we really jumped into the world of device-specific results anyway. Because, when you think about it, a 50 nanogram TDX cannabinoid result is not clinically the same thing as a 50 nanogram emit cannabinoid result. The cross-reactivity of these devices really do make them device-specific anyway. So I do not know that that that is really all that qualitatively different from what we were doing in sweat in this regard.

The extraction efficiency of the procedure we are using is not very good, so we could very readily convert this nanogram per mL figure into a nanogram per patch figure. Very quick reviews on some things that have been said before on the metabolic profile here. We tend to see parent compounds on the select patch after drug administration. When we see metabolites, they tend to be the more leukophilic of the metabolites. In term of concentration, the more leukophilic of a series tends to be at higher levels.

This is all information you have seen before. Cocaine. You see cocaine EME, BZE.

What I want to get to and show you because I think that it is sort of interesting is a graphic display of these. This is simply a demonstration of the metabolic profile in blood, saliva, urine, sweat, and hair. This happens to be for methamphetamine. These do not look very different. They are sort of very similar profiles.

But when we get to opiates, something like heroin, we do have something very different. You will see a profile on sweat and hair that are quite similar, but quite different from blood.

It is the same thing with cocaine. Sweat and hair look somewhat similar. This is very different from what we see in blood and some of these other fluids.

I agree with Dr. Jones. What we are seeing in sweat is not simply a filtrate of blood. There is something active that goes on in the skin that influences the composition of the -- the profile of the analyses we see in sweat and makes these two look a lot more like each other than they do in the other three.

I think I am running short of time. Our results, again, in a parallel to urine -- our urine testing programs are typically reported to a medical review officer and then gets the enjoyable job of doing the interpretation which we will talk about.

Thank you very much.

[Applause.]

DR. REESE JONES: Thank you. Okay. The third speaker is Carl Selavka. He is Director of the Forensic Services, New York State Division of Criminal Justice Services. He is responsible for coordinating quality assurance activities for all public forensic toxicology and crime laboratories in the State of New York, including implementation of laboratory accreditation standards, training programs, technical assistance for service delivery, et cetera.

Prior to joining the New York position, Dr. Selavka served as Director of Criminalistics at National Medical Services, and before that he was an Operations Officer at the U.S. Army Drug Testing Lab in Hawaii.

In the late 1980s, he received his Bachelor's Degree from Indiana University, with an M.S. and Ph.D. in forensic chemistry from Northeastern University. He is a diplomate of and serves on the board of directors of the American Board of Criminalistics and is a fellow of the American Academy of Forensic Sciences, a member of editorial boards of several forensic science publications and testifies in military and civilian court in civil trials, and cases involving drug testing of urine and hair, et cetera.

Dr. Selavka.

Agenda Item: Hair Testing

DR. SELAVKA: Thank you. It is a pleasure to be part of this august company on the stage today. This whole conference gives us an opportunity to do some things that we do not do very often, and that is to talk about the little fish from time to time.

[Laughter.]

DR. SELAVKA: In addition, this is going to give us enough information perhaps to look outside the box a bit, to think outside the boundaries of our everyday approaches to forensic drug testing in the workplace. I am glad you are getting the joke. Not all audiences do.

[Laughter.]

DR. SELAVKA: I think that some points that have already been brought up that are worth reflecting on is that we have an opportunity here to look at some of the opportunities and the issues as they surround the alternative matrices. I think it will be useful for the board and for all of us who walk away from this to reflect those issues and opportunities on the current paradigm that we use in drug testing. Because a number of the issues that arise in alternative matrices have never been addressed or fully addressed in the current paradigm.

What we hope to do, I think, over time, is to make our paradigm better by improving it, by adding pieces of alternative matrices or other approaches that may come out over the years, to make, overall, the approach to this problem of the drug-free workplace more easily approached.

So, I took a little different tact, I think, than the rest of the speakers with respect to reporting of results for the alternative matrices. What I did is I actually contacted and surveyed the six laboratories that are providing workplace hair drug testing at some extent. Three of the laboratories do a preponderance of it and three others are marginally involved in workplace testing.

I will go over three important aspects of the report itself, what is on the report, to whom reports are transmitted, and how they get transmitted, and then I will talk a little bit about some of the differences in those reports.

The six labs that were surveyed included Psychomedics Corporation, in Culver City, California, PoisonLab, in San Diego California, American Toxicology Institute in Las Vegas, Nevada, Associated Pathologists Laboratory in Las Vegas, Nevada, U.S. Drug Testing Laboratories in Chicago, Illinois, and National Medical Services in Willow Grove, Pennsylvania.

I think it is useful to point out right off the bat that Psychomedics, APL and ATI are predominately offering workplace testing services for those clients who provide hair to them for testing. On the other hand, National Medical Services and Poison -- or National Medical Services predominately provides investigative support in criminal investigations and very limited what we would call secondary hair drug testing for workplace situations, in that it is has already been tested somewhere else and someone merely wants to verify or confirm the original findings. PoisonLab's position for workplace testing is similar to that. U.S. Drug Testing Laboratories is predominately involved in hair drug testing for the purpose of child protection support. PoisonLab does a little bit of that as well.

We have talked a little bit about collection so far in this meeting. We have talked a little bit about the testing involved. Now, we will talk a little bit about the reporting.

[Laughter.]

DR. SELAVKA: There are some similarities among all of the reports that are provided by the laboratories that were surveyed. This includes that confirmed results are the only results which are reported to the submitting units. In addition, a list of specific classes of drugs for which testing was performed is provided on the written report that is supplied to the client.

Following that, the cut-offs that are employed for each drug class that is reported are provided on the written report, and specific analytes that are detected in positive samples are noted as being detected on the reports.

From there, we depart a bit into individual categories of testing for screening and confirmation purposes. And I will talk about some of the differences in reporting after that.

I leave a number of these things out in tabular form. They are a little bit hard on the screen, but you do have them in your notes. So, if you want to reflect upon them later, you will be able to.

In general, most of the laboratories are reporting results for amphetamines, cocaine, opiates, and PCP. Psychomedics, APL and ATI are providing marijuana testing for workplace situations, as is PoisonLab, USDTL, and ATI.

NMS does not report for cannabinoids at this time. Other drug classes are available for testing in three of the laboratories.

The presumptive tests employed among the laboratories that are supporting hair drug testing involve radio immunoassay in a number of laboratories, ELISA, KIMS, EIAs modified for use for hair matrices, and fluorescence polarization immunoassay.

The confirmation tests that are employed in all of the laboratories for all substances other than cannabinoids is conventional YAS chromatography mass spectroscopy, with capillary columns and either SIM-collected quadrapoleequipped instruments or ion traps.

On the other hand, for cannabinoids, you start to get some differences. GC/MS/MS is used in four of the laboratories for confirming cannabinoids. NMS does not offer cannabinoid testing.

ATI approaches this in a very different way than the other laboratories. In essence, when a screen positive for cannabinoids is discovered on a hair submitted for testing to their laboratory, a signal is sent back to the submitting unit and a urine is requested to be collected. The timeframe between the initial collection of hair and the testing, for presumptive purposes, is short enough that they believe that the urine can be collected and give some information revolving the use that might be indicated by the preliminary positive for THC. If that urine is positive for THC, and it is thought to verify the hair result presumptive possible.

The quantitative units used in the laboratories is variable at this time. They all can be normalized, which I do in the slides which follow so that you will be able to compare lab to lab. But, for reporting purposes, on the piece of paper that comes from the lab, they are all a bit different.

Two of the laboratories use the convention of nanograms per 10 milligrams. APL uses picograms per milligram. NMS uses the convention used for all solid human

samples, which is nanograms per gram. PoisonLabs and U.S. Drug Testing Labs use nanograms per milligram. In the ones that follow, I will, again, normalize them.

Two of the laboratories, NMS and PoisonLab, do not report the quantitative value on the report. They would report a substance as positive, but quantitative values are used internally in the laboratory for reporting that positive and are available if needed.

Amphetamine confirmations involve the following analytes for reporting. Psychomedics' computer system, their computer people would tell you, has a feature they would tell you that might have bug and they are working on it. It gives one analyte reporting in all other analytes within a package of analytes for that class that would have to be reported textually on another line. So you will see that reflected throughout these slides.

Methamphetamine and amphetamine are the analytes of interest for all of the laboratories that report, and they give various reporting limits.

You will notice throughout that the U.S. Drug Testing Laboratory's Reporting limits for all substances are one or two orders of magnitude lower than the other laboratories with the exception of cannabinoids.

Cocaine confirmations in the laboratories reflects -- the analytes used for cocaine confirmations reflects the package of analytes available in this matrix. Cocaine, if identified at .5 nanograms per milligram for Psychomedics would lead to the report for cocaine. And, if benzoylecgonine and cocaethylene are available at .1 or higher, they would also be reported; but the cocaine must be available at .5 or greater before the other two analytes are reported.

The other laboratories are variably reporting cocaine and cocaethylene or just benzoylecgonine in the case of ATI. NMS reports all three, as does U.S. Drug Testing Lab, and PoisonLab reports two.

Opiate Confirmation also reflects that package of analytes available for opiate users. Morphine or codeine are reported by Psychomedics' other analytes such as the heroin metabolite. 6-monoacetylmorphine would also be reported textually if present. It is searched for by gas chromatography mass spectrometry.

All of the laboratories seem to be able to report the morphine, codeine. Some report heroin, and some report 6-MAM, in addition to those two analytes.

Phencyclidine. There is not much to comment on, except that there are some variabilities in the reporting that is used.

For THC acid, Psychomedics reports the acid only. It does not report on THC itself. The report used is .05 picograms per milligram. APL reports at five picograms per milligram for THC, the parent drug itself, and THC acid at .3. ATI, again, uses a urine confirmation, if you will, to verify the hair presumptive positive.

PoisonLab is reporting on the 50 nanograms -- picograms per milligram. I do not think they have an awful lot of experience with that particular substance and, therefore, I have no idea what kind of reporting that might give to the actual users.

U.S. Drug Testing Laboratories uses five picogram per milligram for both THC and THC acid.

Now, to whom are the results reported was another question I queried. All of the three laboratories who do the predominance of the workplace testing can report to MROs or to individual physicians. Human resources departments in some companies are the desired point of reporting. Some clinics receive these reports, and other sites.

NMS tends to be doing criminal investigations, so their reports either go to the criminal investigators or attorneys associated with the investigation. And other laboratories also have either clinical settings that they report to or other settings.

Some or those other settings include child services, third-party administrators, where collections are done and then forwarded to the laboratory that are not the ultimate client, small company owners, legal investigators for a criminal investigation of the Army or the Air Force OSI, and attorneys.

How do results get reported? They may be reported by mail, or UPS. UPS is only used because it has three initials as opposed to FedEx or Airborne.

[Laughter.]

DR. SELAVKA: I mean no offense to the alternative companies out there. Results can be faxed or electronic data interchange may be used for hard printers or on the other line, or phone lines that are dedicated to this purpose of reporting.

Psychomedics does not do any verbal reporting.

The other laboratories may report verbally, with the exception of U.S. Drug Testing Laboratories, when a specific clients desire needs to be met.

General verbal reports are followed by faxed hardcopies.

What makes the reports unique are some of the subtle differences, interpretive comments, and other factors around the certified results that are important. Some labs report with a certifying signature and others do not. All of them have somebody's name on the report and a contact phone number to call in case there is a question about the report.

Some laboratories report the length and/or mass of hair that was tested or received. Some of them specifically state which type of immunoassay and that GC/MS was used as confirmation, as opposed to merely saying the results are -- the positive outcome is a result of two independent examinations. The disposition instructions may or may not be present, such as we will destroy this sample in three months unless we hear from you.

The chain of custody message that may be present on some laboratories' reports is not present on all. For example, the hair was received with seal intact is present on some reports.

There are also interpretative statements on some reports but not on others. Most laboratories will say, for a positive result, this finding means that the analyte identified on the report was identified at a level greater than the cutoff used for that substance. There may be other interpretative statements available depending on the lab.

For those laboratories where a special preparation was needed such as segmented analysis, where long hair is cut into individual portions and those tested segments may then be compared to one another, may also be reflected on those reports for labs that do it that way.

And any caveats for hair colorations that may be indicated during rinsing protocols, many times you will see substances in the rinse that are unusually colored or unusual in appearance. If the hair itself looks unusual, that may lead to a reporting comment that may either inform the donor, the submitter to get more sample from the donor or may at least trigger a phone call to the laboratory.

On balance, the hair/drug testing laboratories are providing similar information, but there are some differences. I think it is useful to reflect back on the initial, the starting stages of urine drug testing to remember that, although they are all zebras, the laboratories still look a little bit different.

If it was to be used -- if an alternative matrix is to be used, whether it is hair or sweat, or saliva, or some other alternative matrix when they come down the blind, it is important to note that, in a snapshot, like I have tried to do today, it is always easy to focus on the differences between the current paradigm and those paradigms that may be useful in the future and among those laboratories who are currently providing services for the alternative matrices. But it is also important to note that they are all in essence laboratories who are capable of doing good quality work and, if provided with a set of standardization protocols of paradigms to use to move forward together, it is possible to bring them together, just as was done with urine drug testing and is being done in post-mortem forensic toxicology labs at this time.

I appreciate the opportunity to be here. I could not have done what I did without an awful lot of support from the laboratories that were involved and by the Drug Testing Advisory Board's Committee who put this together. I appreciate everybody's input into this.

Since there are attorneys in the audience, I thought that I would at least leave you with a disclaimer. [Laughter.]

DR. SELAVKA: Everything I said is my opinion and does not reflect the plan or purport to show you what the actual policies of any lab is. These are my opinions and, again, the outcomes of the survey. Thanks very much.

[Applause.]

DR. REESE JONES: Thank you. The fourth speaker is an attorney, David Evans.

[Laughter.]

DR. REESE JONES: David Evans is Executive Director of the National Onsite Testing Association. NOTA is an advocacy and resource center for onsite drug and alcohol testing.

Mr. Evans is the author of two books, Drug Testing Law, Technology and Practice, and a second book, designing an effective drug-free workplace compliance program. Mr. Evans' law practice concentrates on drug and alcohol-free workplaces and he represents employers, test manufacturers, third-party administrators, MROs, and laboratories. Mr. Evans.

Agenda Item: Onsite Testing

MR. EVANS: Hi, good morning. I would like to tell you a little bit about my past. I went to a state military academy for high school and took chemistry under Colonel Brown, who had worked on the Manhattan Project. I was a rather indifferent chemistry student when I was in chemistry. But I had a different view of how much of the stuff I ought to learn than Colonel Brown did.

[Laughter.]

MR. EVANS: I was such a joy to have in class that Colonel Brown decided that I should take chemistry again.

[Laughter.]

MR. EVANS: A lot of people in this room I am sure when they completed their chemistry studies got cum laude, magna cum laude, well, it was a thank you, laude.

[Laughter.]

MR. EVANS: I wish now that I had listened more to Colonel Brown. I have been sitting here for two days now and understanding maybe about half of what you all are saying. I thought that I knew something about drug testing, however, obviously, I was just scratching the surface.

Let me tell you a little bit about NOTA. We are the National Onsite Testing Association. We are composed of manufacturers of onsite alcohol and drug tests. We are also composed of the users of the tests. We have laboratories who are members of NOTA. There are laboratories now that are marketing onsite tests. We have third-party administrators who are among our membership.

NOTA supports only certain types of onsite tests.

We support the ones that are cleared by the FDA for commercial distribution. As far as the alcohol tests go, the tests would have to meet the DOT requirements as an initial alcohol test. So, when you talk about NOTA and the type of onsite test that we advocate, it does not include the whole range of onsite tests that are available. We are talking about the select group that we feel meet the good scientific standards.

Given my background in chemistry, I was selected to talk about reporting the results because they figured that I could not blow this one. It was so simple and so easy that even I could handle it.

Basically, our position is that, as far as initial screens go, we support, as do the DHHS guidelines, FDAcleared immunoassays. Those are the types of tests that we support. How could the tests results be reported? The same way that they are done under the HHS guidelines.

In terms of verifying a test, again, it is exactly the same. The test can be verified by confirmation of GC/MS and through an MRO if it is a positive drug test result.

As far as the units of measure go, we believe that any onsite test that would be used as part of the federallyregulated system, should meet the HHS cut-off levels. All of our tests can meet the HHS cut-off levels.

As far as parent drug versus metabolite, again, we support the HHS standards. So that is it. That is my presentation. You see, I could do it. I do not know if Colonel Brown is still alive, but I am sure he would be proud of me.

I have a few minutes and I would like to clear up some issues if I may. Yesterday we talked about the Bubba confrontation issue. Donna brought that up in terms of the DOT alcohol tests, that some of the onsite DOT alcohol test collectors were having problems with confronting people when the initial test was positive. Well, part of that is a function of the alcohol test. Because, if the onsite test is positive, then the person usually has to go someplace else to take an evidentiary breath test. In most cases, they do not have it there and you have a short period of time to do that. So you have got to tell the person, hey, you have got to take an additional test.

Well, that does not happen with a drug test. With a drug test, you do not have to tell Bubba the results of the test. You can just say, well, thank you very much. We will get in tough with you. If it is a pre-employment situation, you just say we will call you. We will let you know later on. And you can then give the information to management through the MRO or whatever and make your decision that way. You cannot avoid confrontation though in certain circumstances, even with the laboratory-based tests.

At some point, you have got to tell somebody what happened to their test result. It does not have to be the onsite test collector and test administrator who is the person who does that.

One of the issues that also came up was the admissibility of onsite tests. Well, there is general federal standard of admissibility. This is the new

standard, the Dowberk v. Merrill-Dow Case. It is a U.S. Supreme Court Case, that has overturned the old standard which is the Frye Test. Basically, the Frye Test has been around since the 1920s and it says basically that a scientific technique is admissible in court if a significant portion of the scientific community recognizes it as being valid.

Well, under the new standard, the standard of admissibility is going to be up to the judge. Certainly, any test that is cleared by the FDA is going to be admissible.

Dr. Kaplan spoke yesterday about the -- he was not aware there was any case law upholding onsite tests. Well, if you look at my testimony, it is in your book, you will see that we provided you with case law, both under the federal standards and under the state court rules where onsite tests have been upheld. I am not aware that there have been many legal problems, if any, at all with onsite tests.

Getting back to Bubba. One of the most common reactions that we have with onsite testing is, if you are in a situation where you are going to tell Bubba, is you get an admission right on the spot, you got me. Okay. That is our most common experience. If you will talk to people who administer onsite tests, they will tell you that that is what happens.

As far as also admissibility of onsite tests, we have a number of forms that are available which anybody who is interested, I will be happy to send them to you. They are chain of custody for onsite tests. They are negative result onsite tests reports and positive onsite test reports. And we set them up in a way that the test operator can very carefully document what has happened.

We are also looking at the idea of photographically documenting some onsite test. There are some machines that can take a very quick photograph, like you do when you cash a check or you are at an ATM that could also document the test results. We are looking into the cost factors of that.

Another issue that came up was certification and training of onsite test operators. Are we in favor of that?

Absolutely. We have onsite drug testing bills that are before state legislators right now where we are building into legislation a training process. What we would like to see happen is exactly what is happening now with DOT and the alcohol testing, where the manufacturer will do the training program and certify the technician. The QED product -- I am a certified operator. I received that training certification. DOT thinks that that is fine for onsite alcohol tests. It should be fine also for onsite drug tests.

On the adulteration issues, I think we have covered some of that. That came up. I have just a couple of things that I wanted to add in there. If you have good specimen collection techniques, you are going to cut down on the risk of adulteration. We also have noted that a lot of labs are not doing extensive adulteration testing.

The other thing is I have been told by one of the members of NTS that they are going to be coming out next year with an onsite adulteration test kit. So, I think that that also will add to some of the benefit in that area.

I think that I have covered all of the issues. We have a Scientific Advisory Committee. Everybody who has presented here for onsite testing is a member of that Scientific Advisory Committee. If you have

technical scientific questions about onsite testing, please contact me. I would like to get the information out to you.

We will have our committee review it and we will respond to you in writing. Thanks a lot.

[Applause.]

DR. REESE JONES: Thank you, Mr. Evans. The final speaker on this panel is Daniel Isenschmid, who will be discussing reporting considerations for urine testing. Dr. Isenschmid it currently Chief Toxicologist at Wayne County - Office of the Wayne County, Michigan Medical Examiner, Detroit. He received his M.S. and Ph.D. degrees in pathology and forensic toxicology from the University of Maryland at Baltimore School of Medicine. He was a student of Dr. Kaplan's.

Dr. Isenschmid is a recipient of several educational research awards from the Society of Forensic Toxicologists and the Irvine Sunshine Award from the American Academy of Forensic Sciences for his doctoral research on cocaine.

He has served as the Director of Toxicology at MedPath labs, Supervisor of Forensic Toxicology at the National Center for Forensic Sciences. He has published

papers on such diverse topics as MRO interpretation of urine and drug results, several papers on forensic toxicology of cocaine and marijuana.

He is an inspector for the National Laboratory Certification Program and the College of American Pathologists and Member of the Society for Forensic Toxicologists and a Fellow of the American Academy of Forensic Sciences.

Dr. Isenschmid.

Agenda Item: Urine Testing

DR. ISENSCHMID: Thank you. Good morning. Yesterday we heard about the initial and confirmatory testing procedures for urine drug testing. In order to report a positive urine drug test result, both the initial and the immunoassay, and confirmatory GC/MS result must be positive.

It is important to understand that while both of these tests are used to establish the presence of the drug in the urine, the analytical approach of the two methods should not and are not identical.

Immunoassays are truly screening tests. Depending on the assay, immunoassays may either detect a class of drugs, such as the amphetamines, or opiates, or a specific drug, and/or many of its metabolites. This is the case for benzoylecgonine, cannabinoids, and PCP.

In there case, immunoassays are generally not specific for a single analyte. On the other hand, GC/MS results are specific for single analytes. Because this screening test targets a drug class or a drug and its metabolites, screening thresholds are generally higher than confirmation thresholds. It is the confirmation analyte that is ultimately included as part of the final report.

The choice of the specific analyte to be measured when confirming an initial test, is based on several factors. In selecting an appropriate confirmation analyte, one must consider the biotransformation of the target drug, the relative amount of detection time of the selected confirmation analyte in the urine, the ability to isolate the confirmation analyte from the biological matrix, and the ability of that analyte for the drug targeted -- the selectivity of that analyte for the drug targeted in testing.

For example, when cocaine is metabolized, the primary metabolite detected in the urine is benzoylecgonine and ecgonine methyl ester. Only a small amount of cocaine is cocaine is excreted unchanged. Benzoylecgonine is present in the urine at slightly higher concentration than ecgonine methyl ester and can be detected for a somewhat longer period of time. Thus, benzoylecgonine is an ideal target analyte for screening and confirmation in urine.

Ecgonine, a metabolite arising out of the further breakdown of both benzoylecgonine and ecgonine methyl ester might, at first, seem to be a logical choice, but is not present in sufficient concentration and cannot be readily extracted from the urine because of its amphoteric nature.

Selectivity of the confirmation analyte is also important. Even though morphine is the confirmation and target analyte, its presence does not specifically identify the agent used. Morphine can be present due to heroin use, codeine use, morphine use or poppy seed consumption.

6-acetylmorphine, on the other hand, can only arise out of a result of heroine use. However, the amount of 6-acetylmorphine excreted in the urine is relatively low and its detection time is very short.

The certifying scientist of the testing laboratory is responsible for verifying all aspects of the drug test result forward as reported. First, the certifying scientist must ensure that the confirmation results are consistent with the initial test results. The certifying scientist must be very familiar with what is being tested in both screening and confirmation in order to achieve this. For example, unconfirmed opiate or amphetamine initial test results, frequently occur because the initial tests can detect the presence of opiates or sympathomimetic amines not tested for by the confirmation assays.

On the other hand, some carboxy-THC is usually detected by GC/MS if the initial test for the cannabinoids is positive. However, the ratio of carboxy-THC to other cannabinoids and the extent of its conjugation vary so that the relative response of the initial immunoassay test will not necessarily predict a carboxy THC concentration determined in confirmation.

The cocaine metabolite immunoassay is relatively selective for benzoylecgonine so that its initial immunoassay response is much more predictive of the amount of benzoylecgonine that will be measured in the confirmation assay.

The initial test for PCP is fairly specific for PCP, but will also detect PCP metabolites and some phencyclidine drugs, if present. Thus, unconfirmed PCP immunoassay results can also occur.

In addition, the certifying scientist must also review all internal and external chain of custodies for completeness. Any correctable deficiencies must be accompanied by an affidavit or memorandum for record resolving the issue.

The scientific review also requires a review of all of the screening data. This should include calibration, open and blind quality controls, and the patient result.

The absorbance values of the patient result should be examined to ensure consistency with normal human urine. The review of the confirmatory test results should include verification that all required quality assurance procedures have been adhered to, including chromatographic criteria. All calibration and QRC results must be carefully checked.

If there are multiple positives in a single specimen, all confirmatory testing must be reviewed by a single certifying scientist before the results may be reported. After the certifying scientist has reviewed all of these items and signed the federal chain of custody and control form or initialed it in the case of DOT negatives, the result can be reported to the MRO along with any memoranda for the record which may have been generated as a result of correctable collection site problem.

Of course, if the problem could not be corrected or if a memorandum for a record could not be obtained, the test result must be reported as test not performed with an explanation on the remarks line.

The results may only be sent to the MRO. Test results may never be sent to the client or individual.

The certified second original of the federal chain of custody and control form must be sent to the MRO. This is the only official report on which patient results should be based. Some laboratories generate an additional report from their internal computer system.

The results on the laboratory-generated computer reports should be verified either onscreen or by hardcopy by the certifying scientist before they are released. A hardcopy of this report is often sent to the MRO with a chain of custody and control form. Many laboratories also utilize their computer-generated reports to send results to the MRO by facsimile or a remote printer. However, computer-generated reports are not a substitute for the official report, which is the federal chain of custody and control form.

For security purposes, absolutely no telephone reporting of urine drug test results are allowed. If the MRO chooses to have a remote printer or a fax machine, a letter must be obtained from the medical review officer maintained by the laboratory in which the MRO certifies that the printer and/or fax machine are maintained in a secure location.

In addition, it is in the laboratory's best interest to maintain a record of the transmission sent to the remote sites. Again, the certified federal chain of custody and control form must follow up any electronic report and is the only official report.

Only the analytes authorized by the HHS guidelines may be reported when a federal drug test is performed. Cutoff concentrations for these analytes were discussed yesterday. Results are reported qualitatively, however, the MRO may request blanket quantitative results for all opiatepositive.

In addition, if only morphine is reported positive, the MRO may, by individual written request, obtain quantitation for codeine, even if it is below the cut-off, providing all other reporting criteria have been met.

The quantitative results for other analytes must be requested by the MRO individually. At present, the optional assays, amphetamines, steroids (sic) immersion, 6acetylmorphine, do not have to be performed by the testing laboratory and may be sent to another certified laboratory for testing.

A blanket request from the MRO to perform these assays whenever a positive amphetamine and/or opiate result is reported is allowed. However, the laboratory cannot perform these assays unless they are requested by the medical review officer.

These results may be reported to the MRO on a supplemental report that contains all of the appropriate specimen identification criteria or can be included on the federal chain of custody and control form by checking off the other box and indicating the results.

Currently, there are no specific reporting requirements for the optional analytes, other than the requirement from the appropriate forensically-valid GC/MS procedure.

For 6-acetylmorphine, many laboratories currently use a 10 nanogram per milliliter cut-off, as this is consistent with the proposed revisions to the HHS guidelines.

The results for the stereoisomer assays of amphetamines are usually reported as percent D and percent L. Although there are no specific requirements for resolution limits between these isomers, most laboratories appear to be able to detect 10 percent of one isomer in the presence of 90 percent of another.

The mandatory guidelines are deliberately vague in addressing laboratory procedures for reporting adulterated specimens and diluted specimens. New adulterants are constantly appearing on the market and are causing new problems for laboratories which need to be addressed on a timely basis.

The choice of whether a laboratory tests for a specific dilution or adulteration is their own and is usually precipitated by client demands. If dilution or adulteration testing is performed, the following guidelines have been established by the Department of Transportation for reporting the results.

If a specimen is determined to be diluted, the result should be reported, whether positive or negative and a comment added in the remarks line stating the specific gravity was less than 1.003 and that the creatinine was less than 20 milligrams per deciliter.

The actual numeric specific gravity and creatinine results should not be reported nor should there be any attempt, on the part of the laboratory, to interpret the results on the report. HHS requirements for reporting are the same as DOT in this case.

A specimen may be unsuitable for analysis if a valid result cannot be obtained. Examples of this may include unusually low immunoassay absorbance readings, as with glutaraldehyde, unusually high immunoassay absorbance readings as with talectine, or failed recovery of internal standard and confirmation testing as with clear in a carboxy-THC assays.

The laboratory may, of course, attempt to perform these assays by using alternate procedures or send a specimen to another certified laboratory, however, their SOP dictates.

If, however, a valid result cannot be obtained, the result must be reported as test not performed with the comment specimen not suitable on the remarks line.

HHS guidelines are consistent with DOT guidelines, however, the laboratory may decide the appropriate comment for the remarks line.

Finally, a laboratory may, although it is not required to, identify the adulterant in a specimen using a forensically defensible analytical procedure. If an adulterant has been unequivocally identified, the laboratory may indicate on the remarks line that the specimen was adulterated and what the adulterant identified was. If a valid result was not obtained as a result of adulteration, the test must be reported as test not performed.

The MRO, at the request of the patient, may request that a split specimen be sent to another certified laboratory for a reconfirmation of positive results.

For a retest, only confirmation testing by GC/MS can be performed and all cut-offs are waived, including the requirement for amphetamine to be present in the presence of methamphetamine.

Laboratory program documents require that a laboratory be able to reconfirm the presence of any analyte tested at 40 percent of the original cut-off concentration.

All quality control and quality assurance criteria must be met at that concentration.

The laboratories may reconfirm any analyte at lower concentrations, provided that the results are forensically defensible. The results are qualitatively reported as wither reconfirmed for a given analyte or failed to reconfirm. If a particular analyte is believed to be present by the laboratory performing the reconfirmation testing, but quality assurance criteria cannot be met, they can then send it to yet another laboratory. The laboratory performing the initial reconfirmation must report the result as test not performed.

In summary, we have talked about the factors in selecting a confirmation analyte, the role of the certifying scientist in reporting, reporting the results to the MRO, security in reporting, analytes reported, reporting of adulterated and/or diluted specimens, and reporting of test results.

I thank you for the opportunity to speak with you today.

[Applause.]

Agenda Item: Questions and Comments

DR. REESE JONES: Well, this panel will be happy to receive questions or comments.

DR. ALAN JONES: I have a question to you first, Mr. Evans. We are always -- in the onsite testing arena, we hear the issue of the disgruntled employee that was raised earlier. But could you comment on your feelings about what kinds of actions a company should take or the employer should take on a presumptive positive on an onsite test, not necessarily with a disgruntled employee? Are there any risks or liabilities? Where does the case law lead us in that and what is the situation at present?

MR. EVANS: Okay. Well, I will answer that question in two parts. First of all, this forum today deals with federally-regulated drug testing. The federal drug testing program was set up in this way, in large part, because of the fourth amendment. The U.S. Supreme Court has decided that a drug test is a search. Before a search can take place, it has to be justified in its inception, which means that it has to be a good idea for the search, and in its scope. You cannot search beyond what you are entitled to search for. That is where test accuracy comes into play because that provides the proper scope.

So, in federally-regulated drug testing and in government-regulated drug testing where people have access to a whole array of rights under the Bill of Rights in the Constitution, I would not recommend taking any employment action that could be termed government action against somebody unless the test was confirmed. Okay. So I want to make that clear.

However, most of the country is and most of the drug testing that is going on in the United States is by private employers, and there is a whole different standard when it comes to a private employer. In most states, we have employment at will, which means that an employer can set the terms and conditions of employment. If the person does not want to adhere to those terms and conditions, they do not have to work there. So, in that case -- and listen very carefully -- I am not taking this position -- but I am saying that it is legal to take any employment action you want to based on presumptive onsite testing.

I do not recommend that. I do not think that NOTA would recommend that. We certainly recommend that tests be confirmed. It is in the package insert that we have.

Now, the question is what actions could be taken even under federally-regulated drug testing using a presumptive onsite positive. You can certainly assign somebody, temporarily take them offline pending the confirmation. I would think that, in a safety context, not only can you do that, but you have a duty to do so. If you know that somebody is potentially under the influence of drugs, you have the duty to do so.

DOT has no problem with that. DOT takes the position -- there have been a couple of cases on this right now -- that under the employer's policy, an employer can reassign an employee, can fire an employee, or can do whatever they want, but you just cannot apply federal sanctions to that person unless you have a confirmed result.

So, for a driver, for example, you could not take their commercial driver's license away based on a presumptive onsite test. But you could say to them you are not driving that truck today. I am concerned about Bubba's rights, and I am also concerned about the victim of Bubba when he crashes that truck or crashes that plane, or crashes that train. So they have to be taken care of also.

DR. ALAN JONES: Thank you very much for clarifying that. I have a question to the three alternative matrices spokesmen. Do any of you have any experience with the alternative matrices in doing similar reporting of specimen unsuitable, specimen adulterated with, et cetera, in your particular matrices. If you do, could you expand on that briefly? If you do not have such reporting criteria, what would -- I would appreciate your comments on a movement toward establishing those types of reporting criteria in your particular matrices.

I realize, Dr. Peat, you are talking about one analyte where the predominance of the experience is also. DR. PEAT: Well, it is not the analyte per see.

In the absence of IgG, we do report that specimen as not being saliva or oral fluid.

DR. ALAN JONES: But, is that the only case that you have?

DR. PEAT: Yes.

DR. ALAN JONES: You do not have adulterant testing?

DR. PEAT: Yes. That is the only case that we will report other than the presence or absence of cocaine metabolites.

MR. FOGERSON: We have a bit of experience there.

We will get patches in that are obviously visually adulterated with something that are just a strange color. Those will simply be reported as contaminated and not tested.

Some are not so obviously contaminated. We had a case recently where we were -- there was a suspicion that a bleach had been added under a patch in an attempt to influence the test.

Now, we get a little detection advantage there because it typically blisters or causes a fairly noticeable skin reaction, so that is actually the triggering event. We did a little analysis to establish the chloride level on the patch, which was way beyond what you would expect from the wear. So we do some of that, yes.

DR. SELAVKA: For hair, I think I mentioned a little bit in the presentation, but there are some standard tests that give you data through the rinsing protocol that allows you to understand whether or not a hair may have been chemically-treated. Hair that is from alternate body sources, other than the head, often has some unusual features to it morphologically. You may need to use a microscope to examine them.

There are tests for dye intake, for hair porosity and fracture that can lead to comments on a report that says another sample is suggested to be collected in this particular case.

One of the things that does happen with some frequency is the QNS. Hair is too short a length. It does not completely fill the little boxes that are supplied by some of the laboratories for filling. So, in those cases, you would get quantity not sufficients. Those are the kinds of comments you can get.

DR. ALAN JONES: What about the DL-isomer resolution? Are those processes available, those techniques available to the alternate matrices?

DR. PEAT: I see no reason why. But, obviously,

the levels may be lower after you improved the technology somewhat.

MR. FOGERSON: The same answer really.

DR. SELAVKA: Yes.

DR. ALAN JONES: Are either of you doing or have any experience with doing that DL resolution in either the hair or the sweat?

DR. SELAVKA: Yes. NMS had done testing for DNL isomers.

MR. FOGERSON: We have not actually done any. We do know that the L-isomer will appear in a sweat patch. We have some data on the levels. The technology is not very different from what we use in the urine test.

DR. ALAN JONES: Thank you.

DR. ROLLINS: I am going to be the moderator of this afternoon for the interpretation section. I have a couple of questions for Dr. Selavka about the -- his presentation. First, I would like to thank Carl for providing us with an unbiased survey of the state of hair test reporting in the U.S. I have got a couple of questions. First, you indicated one of the laboratories was reporting a presumptive positive that was subsequently confirmed in the urine. I wonder if you could elaborate on that and maybe give us some insight as to why you thought they might be doing this particularly when a urine has already been shown to be negative and the hair could be positive for months, weeks and months later.

DR. SELAVKA: I think the -- I cannot read their minds or their policies, and you have to recognize in a telephonic survey, as Dr. Huestis well knows, after having done one last year or a couple of years ago for hair/drug testing, they have an immunoassay which is able to, they believe, segregate those who may be positive for cannabinoids from those who are not.

They do not currently have the technological or methodological capabilities of confirming that instrumentally. So they are using, in essence, a biomarker verification. Because the timeframe is short enough in their test collection and preliminary testing of hair to allow them to go back to the same subject and provide for a urine collection at that point, they believe that that verification gives the same kind of information about drug use history for cannabinoids. And it might be unique only to cannabinoids because you do have a relatively extended excretion profile in urine. They tell me that their confirmation rate, if you will, of presumptive positives in hair and being verified by confirmed positives in urine, is upwards of 70 percent.

Alternatively when the sources ask for a urine sample and they call in the previous hair donor to ask them for a urine sample, many times they will get a, well, I used the drug, in fact, and do not then provide a urine sample for testing.

DR. ROLLINS: And you may have presented this, Carl, and I just simply missed it. Are any of the labs providing their clients only screen-positive hair results?

DR. SELAVKA: No. As I stated very early in the talk, only confirmed analyses are reported. I wanted to use the biomarker confirmation by ATI, who is, I think, following this same paradigm.

DR. HUESTIS: I have one question for Mr. Evans about onsite testing and the specimen not suitable. What is your organization or specific companies, if you know, recommend when you have -- we have heard about some of the internal quality control checks, and they could indicate that there is a possible problem either with the testing, you know, the individual who is testing or with possible adulterants. What do they recommend testing on another device, send to the confirmation lab?

MR. EVANS: Let me see if I understand your question. If we run an onsite test on somebody and the test indicates that the test is not working --

DR. HUESTIS: Uh-huh. Correct.

MR. EVANS: -- what would be the recommendation?

I would like to defer to the members of our scientific advisory panel. But I would think that one thing we do is just run the test again and see if the problem kept occurring because then it might mean that there was some problem with the matrix or something like that.

Does anybody want to take a shot at that?

DR. HUESTIS: Dr. Anderson or Mike?

MR. EVANS: I am sorry, Rick, in the back. Rick will --

DR. ANDERSON: Normally, the recommendation within the package insert is when one of the internal controls fails to operate normally. The test samples should just be repeated on another device under the assumption that the failure is related to a unitary failure of the reagent cartridge.

On secondary failure, the normal recommendation is that either a second sample be collected because the presumption is that the sample has something wrong with it or merely contact the technical services group for additional information. But it is rare that device cartridges fail twice in a row for device reasons. Usually, if the failure is twice in a row, it is usually related to the sample somehow.

DR. HUESTIS: I think that is an important point both from the point of view of the individual. If you have multiple tests with urine testing, you know, we cannot just keep on testing and get different results. That raises a lot of miles. But, also, the fact that, if you come up with not suitable, the fact that you are going to go get a different sample and not further evaluate that particular one may be a question too especially if it is due to an adulterant.

MR. EVANS: What is normally done in the laboratory when that happens on an initial immunoassay screening?

DR. HUESTIS: I will let Dan answer that one. DR. ISENSCHMID: If the specimen is not suitable for testing, there are a number of different things that can be done. If it is a problem with a particular immunoassay, one can try to reanalyze that specimen using an alternate immunoassay methodology, send it to another lab, a certified laboratory that has alternate immunoassay methodology if the primary laboratory does not have it, or alternatively, simply report it as tests not performed or tests not suitable.

MR. EVANS: Right. And certainly some of those options are available for onsite testing. Especially, if we took a split specimen, we would be able to have the specimen sent on someplace else.

DR. PINDER: I too have a question for Mr. Evans.

I think that he stated or implied that because the device is FDA-approved that it is almost more likely to be accepted in court as an acceptable device. I wonder if you have data on what is required for FDA approval of such a device and, in your opinion, why the court should accept that device as forensic evidence.

MR. EVANS: Okay. I will give you my response to that. Again, I would like one of our scientific members to handle that. But my understanding of the FDA clearance process -- and I have been trained not to say approval, but it is clearance, they have been cleared for marketing -- is that you do have to present evidence that the test is save, that it is effective, that it is shown that it is the equivalent of a known reference standard, a standard that has already been established. I believe that is the CV MET, if I am correct. Again, if I am incorrect, I hope that someone will explain it better than I have.

So, what you are doing is showing that the test can meet basic scientific standards, that the test operator can operate it, and the manufacturer has to submit data showing that. And you are matching it up to a known reference standard. If it is the CV MET, I mean, there are probably hundreds of cases, at this point, of holding CV MET, and of holding immunoassay technology in general, and either that it has been upheld and confirmed with GC/MS, or standing alone. Immunoassays standing alone have also been upheld by the courts in numerous cases.

So, if somebody can explain it better than I did --- Sal?

DR. SALAMONE: It is the information that is contained in the package insert. All of that has to be backed up by hardcore data. So you have a correlation with a previously-approved immunoassay, whether it is SIVA, MIT, RIA, KIMS, or some assay that has already been approved. You also have to make comparisons with GC/MS and clinical positives. You have to show that the test works with negatives and that the false positive rate is low, and you have to show cross-reactivity with related compounds and unrelated compounds, and you also have to show recovery and things like that.

And so when you pick up the package insert, all of the information there is backed up by packets of data that you submit to the government. And the government requires certain information.

MR. EVANS: And this has already been incorporated into the SAMHSA guidelines. The SAMHSA guidelines already require that the initial immunoassay test be FDA-cleared. So that is already built into the law. The U.S. Supreme Court has already looked at this issue in NTEU v. Longrock.

And the Court looked at the federal guidelines and specifically stated that an initial immunoassay test supported by GC/MS meets all federal admissibility and legal standards. So that is why we make reference to that. Because I would think that, even under the old Frye Rule of admissibility, that a substantial or some portion of the scientific community has to recognize it. It has been recognized by the FDA. I think it meets that standard. The new Dow -- Merrill-Dow standard is even a lower standard

than that of admissibility under the federal rules. So that is why I would feel very confident.

The courts that have looked at it and supplied you with the cases have admitted it into evidence.

DR. PEAT: Here comes the inspector again.

DR. WILKINS: Oh, no. I am even going to ask inspector-type questions. How is that? I have a couple of questions. The first one would be for our sweat and saliva representatives. The question will pertain not to just what you do specifically in your lab, but in the saliva or sweat testing arena in general for the limited number of labs that are doing it. That is do you routinely or do laboratories routinely measure the pH of sweat or saliva and report that to the MRO or whoever in order to assist in interpretation of drug concentrations?

MR. FOGERSON: No, we cannot. We do not actually receive sweat. We receive a dry piece of blotter paper.

DR. WILKINS: I am asking in general. Those that collect liquid sweat, are there facilities collecting liquid sweat?

MR. FOGERSON: I do not know that there is anybody who does that.

DR. WILKINS: Okay.

DR. PEAT: Generally, the collection devices for saliva contain a buffer, so the pH would be the same no matter what specimen is submitted.

DR. WILKINS: So, in general, this is just for my information, in general, collection devices that collect liquid sweat are not routinely used at this point in time; is that correct?

MR. FOGERSON: To the best of my knowledge that is correct.

DR. WILKINS: Okay. Also, for actually everybody

on the board on the panel, with the exception of Mr. Evans probably, what is -- what do you estimate the average length of time between submission of a specimen and reporting of results for negative and positive specimens? I am trying to get a feel for how does that compare to what we typically see in the urine drug testing industry? Is it comparable? Is it weeks later, months later? What kind of turnaround time could we expect for this type of testing to be implemented?

MR. FOGERSON: It is comparable. The transportation techniques are the same. We actually -- it is a little bit easier with a sweat patch than a urine bottle because it is a very small piece of paper that is being mailed in. They are typically sent in by an overnight courier. The negatives are due out in 24 hours. Positives are -- the confirmation technology is a little more complicated. A positive is typically 48 to 72 hours.

DR. WILKINS: Okay.

DR. PEAT: That is the same.

DR. WILKINS: Okay.

DR. SELAVKA: For the higher-volume laboratories it is the same, for the smaller-volume laboratories, they are batching them per week for confirmations, for example. A NMS runs two batches a week for a screening and then whatever confirmations are needed thereafter.

DR. WILKINS: So --

DR. SELAVKA: The investigative purposes to which their tests are put though are quite different than the workplace purposes for which we are mostly discussing the science today.

MR. FOGERSON: And ours are a couple of minutes. [Laughter.]

DR. WILKINS: Dan, just for other people in the audience who may not have an idea what a typical turnaround time for urine is.

DR. ISENSCHMID: Currently, the client demands generally require that urine specimens screening negative are reported the same day they come in, for the most part, and positives are then 24 to 48 hours.

DR. WILKINS: Okay. I have another question for Dr. Selavka. You mentioned in your talk, one of the slides, that some of the laboratories provide additional caveats on their report for hair-coloring or other treatments. I wondered if you could expand on that a little bit. I was not clear if what you meant was that additional statements were on the report to indicate a problem with the specimen.

Because to me hair-coloring or chemical treatments would not necessarily imply that the specimen was inadequate. I was not quite sure what you meant there.

DR. SELAVKA: In those situations that the laboratory feels the detected substances on the hair, the detected differences of the hair from what hair normally looks like or acts like under the conditions of the testing, the laboratory may not be able to get valid results from either the immunoassay or the confirmation and, therefore, may be precluded from reporting a result in those cases where you cannot provide a result that you feel is forensically defensible and you feel that the person should be -- the donor should be either asked for another sample or that at least the submitter should be notified that there was a problem. You want to give them some feel for what kind of problem you experienced That could be that the hair seems to have been treated in some way that precludes our being able to successfully test it.

DR. WILKINS: So then, just to clarify for me. So then typically what would happen at the current time is for laboratories who do that, an individual who had a chemical treatment, or a hair coloring, which we are all aware of, probably occurs quite frequently in the population independently of whether they are a drug user or not. Those people would typically be required to have another specimen submitted?

DR. SELAVKA: Not at all. I do not mean to mislead.

DR. WILKINS: Okay. I just wanted to make sure I was clear on that.

DR. SELAVKA: No. Those for whom their treatment has now interfered with the testing, yes, the great majority of the population, one-half of the population, the hair donors provide treated hair.

DR. WILKINS: Would fall into that? Okay.

DR. SELAVKA: And for the rest of us, Rogaine-

treated hair.

[Laughter.]

DR. SELAVKA: Only if it interferes with the testing would that caveat be there.

DR. WILKINS: Okay. Thank you.

[Laughter.]

DR. WILKINS: A quick question for Mr. Evans. I do not want him to feel left-out. One of the essential components of the current drug-testing programs that we have in the Federal workplace is, as we have all alluded to, inspection and oversight of the particular facility. I wondered if you might kind of comment or speculate on how you see that occurring for onsite?

Currently, we do not have the authority for example, to inspect or provide oversight for collection facilities. How do you see that portion of the program expanding to the use of onsite devices?

MR. EVANS: Well, I do not know. I do not think we have developed a real carefully thought out policy on that, but I will give you some ideas on it. It is something that we are going to address. We are a new organization and we just have not taken care of everything yet. But some of the things that we are doing -- for example, there is an onsite drug testing bill in Oregon right now that we have authored that would require that onsite testing be monitored by the state health division. They are the people responsible for clinical laboratory services. So, you would have to register, you would have to supply a certification to be subject to an inspection on the local level. So that is one way that it could be done. So, you have to say upfront that you are going to be doing it. You have got to show that you are going to be doing it according to manufacturer's instructions, that your people are going to be trained, and you will be subject to an inspection and you have to pay a fee, okay, all of that. So that is one way of ensuring that it could be done.

Under the federal program, right now, you are not certifying collection sites, however, we just made a presentation to the National Association of Collection Sites about a week ago, and we told them that this would be -- they would be perfect for doing onsite testing because they are people who are already trained and following the federal guidelines on specimen collection and chain of custody. So we would have to do very little training. There are people who are already on board with that.

There are laboratories who are going to be doing onsite testing. Laboratories can oversee, including the SAMHSA-approved laboratories, can oversee onsight testing. We have SAMHSA-approved labs that are doing that now. So that would be another way.

It could also be done under state law. Most of the states now have got clinical laboratory offices that could provide some type of oversight on that issue.

So those are some of the ways it could be done. Again, this is something that we need to work on and come out with a more carefully thought-out policy on that.

DR. WILKINS: Okay. Thank you all.

DR. REESE JONES: Are there any other questions or comments?

DR. KWONG: Dr. Jones, if we are short on time, I can delay my question until after lunch.

DR. REESE JONES: No. We are scheduled to go to 12:30.

DR. KWONG: I have a question for Dr. Peat and Dr. Fogerson. In urine testing, if the specimen collected, if the volume is less than the minimum requirement, the receiving staff or the assessment staff will need to know and appropriate action taken and reported back to the appropriate people.

Now, in saliva, in some of the saliva-collection devices and also in the patch, if the analysis and the result is based on the specimen collected per device, how do you know that there is a sufficient amount of saliva or sweat that has been collected for analysis? In other words, the negative result is not because there is not enough saliva or sweat?

MR. FOGERSON: Well, the only thing we can measure from the documentation that we have received with the specimen is the period of time that the patch was worn. That is the reason that we were concerned in our clinical trials to establish a minimum wear period from which we would have a reasonable expectation of a positive result from the fairly modest doses that were given in those trials.

It was about a 24-hour period. So, if we had a patch that was worn for less than 24 hours, we would not consider that to be an adequate specimen to establish a negative. I mean, if it were positive, that would be a different matter -- to look for at least a 24-hour wear period to establish a baseline sensitivity, if you will, or clinical sensitivity.

DR. PEAT: The way that you could do that with saliva is to determine the amount of IgG present and see if that was below a minimum amount, above a minimum. That is not currently done, but you could certainly do it.

DR. KWONG: So you are going to have to establish what would be the minimum requirement?

DR. PEAT: Yes.

DR. REESE JONES: Is there anything further? If not, we will --

DR. ALAN JONES: I have one.

DR. REESE JONES: I am sorry. Sure. Of course, of course.

[Laughter.]

DR. ALAN JONES: I thank you, Dr. Jones. My one quick question to the three alternative matrices. As we have heard earlier and as you are aware, in reconfirmation testing certainly in the urine arena for reconfirmation it goes to the presence of, or that is the legal definition that is being used. We typically drop down to some LOQ, which is often well below the cut-off for the confirmation procedure. Where are we in doing that with these alternative matrices? Of course, as Dr. Peat has already referred to and as we have heard from other speakers, these concentrations are very low. Should we progress to the presence of concept or should we reapply the cut-off that has been originally imposed upon that specimen in a reconfirmation situation? I would appreciate your comments on that.

MR. FOGERSON: We are already operating sort of on the assumption that we will use the presence of rule. I mean, as we mentioned earlier, each mass spec batch contains a control at about 40 to 50 percent of the cut-offs. So we know that we have got reasonable operation of that level. Our LODs are actually quite below that. So there is no reason we could not use the same procedure that we have now.

DR. PEAT: We certainly do the same. The applicant for the insurance policy requests a retest, and we use the presence of concept.

DR. SELAVKA: This was not a question that I queried the labs on -- and I notice you have heard a little bit about the safety net procedure that Psychomedics uses. I believe that the safety net does have a lower threshold because it may not include the same time period, but I believe their retesting of the same sample may or may not apply different cut-offs. At NMS, we were able to apply limited detection and limited quantitation applications just like you would with a blood or a urine.

DR. REESE JONES: Is there anything more?

[No response.]

DR. REESE JONES: Then there will be an announcement.

DR. BUSH: Okay. We are 15 minutes early actually is what we are. Now, there is a choice here. We can still allot the amount of time -- we can come back on schedule at 1:45 if you would like 15 minutes tacked on to your lunch or we can come back 15 minutes early and probably get out a little earlier tonight.

[Simultaneous discussion off the record.]

DR. BUSH: I gave you two choices, and I did not give you a way to respond, right?

Okay. How many want to have a longer lunch?

[Show of hands.]

DR. BUSH: How many want to leave early?

[Show of hands.]

DR. BUSH: Okay. I guess we are going to come back then at 1:30 instead of 1:45 and starting again. [Discussion off record.]

[Whereupon, at 12:13 p.m. the meeting was recessed for lunch, to reconvene at 1:30 p.m. this same day.]

A F T E R N O O N S E S S I O N [1:30 p.m.] Agenda Item: Interpreting Test Results Panel

DR. BUSH: I want to tell you that I honestly do not know anyone by the name of Bubba. When Donna Smith was Chief of the Compliance Program over at DOT, she and I many times traveled on the road together to present to medical review officers, from my perspective, all of the technical detail in interpreting urine drug test results and understanding forensic stuff to begin with. And Donna Smith would have to follow that with a bitter pill of DOG regulations for these medical doctors. So we would always choose the name Bubba when we talked about a donor individual. That is because I did not want to pick Frank, you know, like my dad's name, or Walt, like my most able assistant's name, or Joe, my bosses name, so we chose -- or Lauren Bush from NRC, although, Lauren, it was thought about, but so we went to Bubba. So, now, I guess we have defined a syndrome. Gosh, whatever happens at these meetings. So I just want to express to you -- I knew I was going to make a contribution, but I really never thought about that being one of them.

Anyway, thank you for joining us back at this meeting of the Drug Testing Advisory Board. We are back after lunch for a very interesting panel on interpreting test results. This panel will be moderated by Dr. Doug Rollins. Dr. Doug Rollins is a Professor of Pharmacology and Toxicology, and Director of the Center for Human Toxicology at the University of Utah, Salt Lake City. He received a B.S. Degree in Pharmacy from Ohio State University and M.D. and Ph.D. in Pharmacology from the University of Utah.

After receiving his degrees, Dr. Rollins received training in internal medicine at the University of Kansas, Pharmacology at the National Institutes of Health, and Clinical Pharmacology at the Karolinska Institute, Stockholm, Sweden. In 1978, he joined the faculty of the School of Medicine at the University of Kansas and, in 1980, he returned to the University of Utah where he joined the faculty of the Department of Medicine and the Department of Pharmacology and Toxicology.

In 1983, Dr. Rollins became the Director of the Center for Human Toxicology. Dr. Rollins is also Medical Director of the Utah Poison Control Center and Professor of Pharmacology and Toxicology at the University of Utah. Dr. Rollins is a Medical Review Officer for the State of Utah Drug Testing Program.

Dr. Rollins' research interests include: The disposition and metabolism of drugs of abuse, as well as downhill skiing. He has been specifically interested in the disposition of drugs of abuse and to care. Dr. Rollins.

Agenda Item: Principles and Criteria DR. ROLLINS: Thank you, Donna. We are going to have a very interesting beginning to the afternoon, where we are going to talk about interpreting test results. We have a very illustrious panel. I would like to begin by making an announcement of my own, sort of a commercial, if you will. The SOFT Meeting, the Society of Forensic Toxicology Meeting, is going to be held in Salt Lake City this fall, October 5 through 9. If you want to see me and give me your address, I will see that you get information or you can look up the SOFT Website and get the information off of that. Unfortunately, I do not know the HTML, but I could send it to any of you if you needed it or somebody else here may know that Website.

I want to make another observation. There are several people in this room who have done research into hair testing. Myself, Dr. Ed Cone, and Dr. Reese Jones are among three of us who are very interested in hair testing. Although we do not have a lot in common, you may notice that we do have one thing in common.

[Laughter.]

DR. ROLLINS: I would say that this might be a criteria for getting into hair research or, at least, after you have been in it for a while.

In addition, I have made a request of each of our speakers of the alternate matrices, not urine and not the onsite tests, and I have asked them what are the data that the matrix that they are going to discuss has been pharmacologically validated as discussed by Dr. Cone in his first talk, i.e. dose response studies, for example. Number two, what are the factors that confound the pharmacologic validity of the matrix, i.e., for example, with hair, you might talk, be concerned about hair growth, or the amount of sweat that is produced. Some of these things have already been discussed, but I think that they need to be discussed in terms of interpreting results.

Finally, for your matrix that you are discussing, are the data interpreted only qualitatively or can they also be interpreted quantitatively? And I know the answer to that. But what are the data for quantitatively accurate results? I do not just mean tell me that they ar quantitatively accurate. I would like some discussion, if possible, of the data that is available to show that they are quantitatively accurate. I realize that they may not have the answers to all of these questions, but, at least they can try to focus on these questions in their talk.

Our first speaker on hair testing is Dr. Baumgartner. Dr. Baumgartner was introduced yesterday. Although he does not really fit the phenotypic profile of a hair researcher, he has certainly been a pioneer in the field and he is now and has been the founder of Psychomedics Corporation and is its current Scientific Director.

Dr. Baumgartner.

Agenda Item: Hair Testing

DR. BAUMGARTNER: I have been tearing out my hair.

I do not know what is going to happen.

[Laughter.]

DR. BAUMGARTNER: The key question that we face with hair analysis is how to interpret our data to establish with the highest degree of certainty, that a positive result is due to drug use and not due to external contamination.

At Psychomedics, we do this by evaluating the efficiency of our wash procedures through the determination of three wash kinetic criteria or kinetic parameters. Why do we do this? We do it because different hair act differently to key contamination procedures.

In addition, we use metabolite criteria to differentiate between external contamination and use. This gives us additional certainty.

Before we go into these criteria, I have to cover a little bit of some fundamental properties of hair to explain the rationale for our procedure. This his a very well-established property that I am going to talk about that is called the three-domain properties of hair. In the drugs of abuse area, I have used the term accessible, semiaccessible, and inaccessible domain. But, as you will see, as I am proceeding, this is a well-established property. If you look at C.R. Robbins' excellent book called the Chemical and Physical Behavior of Human Hair, Springer Froelich, 1988, you will see many examples.

What does this diagram here represent? If you look at the blue curve, if you take a hair sample from a drug user, and you wash it with a non-hair swelling solvent like isopropanol, you go from zero to point B. In other words, you reach a plateau. It is a cumulative removal of drug on the Y axis, and the X axis is simply a time of washing.

There comes a point where you can no longer remove any material with a non-hair-swelling solvent. Now, when you identify a hair-swelling solvent like water or methanol, you, again, keep -- they get more material out until you reach again a near flatter (sic) at three.

When -- in order to remove the remaining drug now from the hair, you have to dissolve the hair. We will use some very drastic acid-based procedures and you get a big bolus which goes from C to D. This is called the inaccessible domain. Why is it called inaccessible? Because water cannot remove things from this domain.

The second we call semi-accessible domain. It is successful with the first wash, which is near the surface. This is a typical profile that you would see when you would try to extract lipids from there. In other words, you would get the same thing. It is very well established.

Now, what happens when you contaminate hair? The experiments that we have done, we have taken non-drug-user's hair, soaked it for an hour in solution and then proceeded, took it out of the solution, dried it. Hair picks up 30 percent of its wait in water, which is very significant. Hair quickly dries in about 15 minutes. You then applied this wash procedure.

So, when you applied a non-hair-swelling solvent, isopropanol, you go from zero to H, point H (sic), and, again, you reach this plateau. Then you go and use the hair-swelling solvent, and you from H to E. This access is expressed as a hundred percent of drug present. And then when you do a digestion, you would find nothing. So, this is, as I said, a well-established property and how we make use of this.

Now, we apply two kinds of wash procedures. I am apologizing that this slide is not in your notes. But you can communicate it verbally, and I will send it into you on Thursday.

The first procedure to be used for the truncated wash procedure, we do the 15-minute isopropanol wash. The reason why it is isopropanol, we remove grease, and other perhaps large amounts of drugs. We do not want to contaminate the wash solution, the aqueous wash solution and so on. We could talk about at some length, but I do not think that we have the time.

So, this is then followed by three 13-minute phosphate washes with a pH of 5.5, shaking, 38 degrees centigrade. And then we apply wash kinetic criteria, which I will discuss in a minute.

If the hair sample fails the wash kinetic criteria, we then apply a second procedure. We go back, get another sample against another 15-minute isopropanol wash,

three times 30 minutes phosphate buffer washes, and then two times 60 minute phosphate buffer washes, and we apply wash kinetic criteria. If it fails, then the hair is contaminated at zero it is a negative.

Now, we have developed three kind of wash kinetic criteria. One is called the curvature ratio. What we do -- the curvature ratio is simply defined as the amount of drug per 10 milligram of hair in the three phosphate buffer washers, divided by three times the amount of drug per 10 milligram of hair on the last wash.

What this tells you is that if there is a linear, if the -- if little curvature has occurred in the wash kinetics, in other words, if you are nowhere near plateau, you would get a value of one. And, obviously, you know, that is not where you want to be. So what we did do, we had a population of middle drug users. We measured this particular kinetic criterion, and we see those for the cocaine, opiates, PCP, and methamphetamine. We decided, you know, on the pivotal grounds (sic), that 1.3 was the cut-off level. That is the minimum curvature we will tolerate. We will see, however, that enormous curvature can occur between five and 10 and that most of them are between two and five, 50 percent in cocaine. So, this defines basically the profile of users. So this is one criteria.

If we wash the hair, anything less than 1.3, and it is rejected, and all three wash kinetic criteria have to be met simultaneously.

The second criteria is called -- incidently, this figure that I showed first is your figure four in your book.

If you now go to figure two, this is the extended wash ratio. This is simply defined by the amount of drug contained in the digest divided by the amount of drug contained in the last phosphate buffer wash. The cut-off for this is 10. What this ratio really means is that we have mathematically extended the wash procedure by 10 washes and that the 10 washes -- we assume that it is linear because the last wash is multiplied by 10. Of course, we know that it is not linear, it is incurring. But the ten times the last wash has to be less than what is in the digest, otherwise, we would say, in principle, you could have washed it all out. It is obviously an approximation. But, so this is a criterion that has to be met that is not met when you do the normal wash.

The final parameter, we call this the safety zone ratio. This simply is the amount of drug per 10 milligram of hair in the digest divided by the amount of drug per 10 milligram of hair on all phosphate buffered washes. We are just simply putting a limit to what we allow phosphate to remove from hair. And .3, you know, that is certainly -- you know, it makes up a very small percentage of the population.

When we go below .3, what we do is we look at the hair. We do a stain and evaluate whether this hair has been excessively treated. Because our wash procedure, as you know, is very, very aggressive. If that is treated, then we make adjustments based also on the metabolite criteria.

Now, in addition, we measure drug metabolites in here. Of course, the cocaethylene is the best. If you find cocaethylene, then no matter what some of the criteria look like, cocaethylene just overrides it. Benzoylecgonine, you know, we have hydrolysis control.

I will talk about MAM a little bit later. That is an interesting thing.

Of course, the carboxy-THC, although we wash the hair of all of the one -- we do not do wash kinetic criteria because the picogram level is the MS/MS. First, it was not

defined because carboxy-THC is not found in smoke. This has been determined incorrectly. And before Dr. Cairns joined us, we had done extensive examination of smoke.

Now, I would like to briefly discuss some misunderstandings in this field. There has been a very nice paper by Dr. Henderson Hokey and Dr. Reese Jones which dealt with the tracking of deuterated cocaine in hair. Samples of most of their data show that deuterated cocaine traveled in the pulse (sic). But some of -- maybe three or four subjects had this deuterated cocaine smeared all over the hair. Now, European investigators not -- Henderson, Harkin and Cone, and Dr. Reese Jones, have misinterpreted this. They feel that, you know, a material moves in hair. Now, what is happening is that the semi-accessible domain has been accessed by perspiration. Henderson and Harkin are doing this one-dose study and were somewhat reluctant to apply very aggressive wash procedures. They used essentially 10 one-minute washes and just did not clean it out. The semi-accessible domain, which can be accessed by sweat.

What I did not say, for instance, is that the inaccessible domain -- the term for inaccessible is inaccessible to water washes. But the inaccessible domain, as I said, is also highly resistant to penetration. Because otherwise, these contamination experiments would not work. So it is very important that you wash aggressively when you do segmental analysis.

Here is a study that we did with MAM. With MAM, we soaked hair in a solution and we washed it with alcohol, and then with water, and then we did the digest, and we found nothing at the end. However, if we look at a druguser's hair, we find MAM after doing the extensive washing.

So, merely finding MAM is not enough. It has to meet wash kinetic criteria. Because, if you have heroin contamination on the surface of the hair, MAM is easy to produce by water from heroin. But, if you find it in an inaccessible domain, you know that this person is a heroin user. I have certainly discussed with NIDA and SAMHSA the idea that, you know, since 90 percent of urines are being overturned in the opiate positives, opiate-positive urines are overturned -- that such overturned urines ought to be investigated by hair analysis.

Segmental analysis in dormant hair effects is no problem. We find that there is a very rapid drop in the use -- I mean, in the level of drugs due to dormant hair and to will very quickly drop below the cut-off level. Of course, this is only true, again, if you do washes. Excessive washing and days of study is too little to see is too little to see, which demonstrates that this is a shade of study that has absolutely no problem with respect to dormant hair.

The results have been accepted in the courts. They have been interpreted in the courts, and largely due to the consensus in Europe on drug testing and 400 publications. Thank you.

[Applause.]

DR. ROLLINS: Our next speaker, who does not fit the hair research profile either, is Dr. Ian MacDonald, who is going to talk about urine testing. As a founder, Chairman, and CEO of Employee Health Programs, Inc., since 1989, Dr. MacDonald and his staff provide programs designed to reduce the use and consequence of alcohol and drugs in the workplace.

As a former director of the White House Drug Abuse Policy and Administrator of the Federal Alcohol Drug Abuse and Mental Health Administration, Dr. MacDonald supervised all block grant and research activities of the National

Institute on Alcohol Abuse and Alcoholism and the National Institute on Mental Health.

His tenure as a public health administrator, also included his position as assistant surgeon general to the U.S. Public Health Service from 1984 to 1989. As a physician, Dr. MacDonald practiced pediatrics from 1962 to 1984 and authored numerous publications for professional and lay readers including the book Drugs, Drinking and Adolescents. Dr. MacDonald.

Agenda Item: Urine Testing

DR. MACDONALD: Thank you, Doug. I absolutely hate it when you say I started that stuff in 1962. You could have fudged a little. 1982 would have been better.

[Laughter.]

DR. MACDONALD: This talk that I am going to give is what my -- my mother-in-law would describe it the way that she described it to me. This is going to be the safe and boring talk of the afternoon. I am sort of the control group to all of the exciting experiments that are going on around me.

[Laughter.]

DR. MACDONALD: I hope you will see it that way.

I am not going to talk about the long window of patch and hair, and I am not going to talk about the quick turnaround of onsite. I am going to talk about good, old, boring urine testing.

It is interesting though just for a backdrop and thinking with David Evans looking at me and thinking about the court, in hearings over the last year or so, and we go to a lot of those, the issue of the laboratory is almost non-existent. The grievance is not that the laboratory made a mistake. They do not often ask the laboratory to be there anymore. That is how far this science or this perception of science has come ahead. The cases now involve the collection procedure, was the employee appropriately tested under a random pool and all sorts of procedural issues. But, for the MRO, he knows that going to these hearings, defending the laboratory is not a part of the 1997 business.

PCP, of course, is the easiest. I just put this here to remind us that what an MRO does is he checks the ID, he mirandizes, he informs the individual, tells him about retest and split rights and, in some cases, informs him that he has got a right to a substance abuse professional, and then tells him he is going to call the test positive. That is a very, very easy interpretation for the MRO. Cocaine, not a whole lot harder, any E.R. visit, dental work. I know that cocaine does not last a month. That is just my routine, because when I am asking the question I do not always have the date of the collection. So, the one or two-day window of a topical anesthetic I will worry about later. Very, very easy interpretation for the MRO. I oftentimes explain that lidocaine and ponocaine, and all of those other guys are not related and putting that in writing for our clients.

Marijuana, a little harder, not from the technical standpoint. We ask are they on any prescription medications, and specifically we will mention Marinol, Dronabinol. Marijuana brownies and seedy sweeties are an interpretative issue we believe, as evidence shows that they are indeed causes of positive tests. But we pretty much follow the DOT guidance to say that is not a legitimate medical explanation. And we will be glad to assist the individual with the company explaining that that is possible, but it is not part of what we do.

In our fairly large MRO practice, we have not yet had the California/Arizona challenge of marijuana as a medicine, but we know that will come and we will deal with it when it gets here.

Passive ventilation for us is pretty much covered by the cut-off levels of the drugs as they are presently set and is not a great interpretation. So this is another drug that we handle rather routinely and have very little interpretation troubles.

Amphetamines are legal for a number of things. We ask about prescription use. Obviously, when we have an amphetamine positive, all sorts of drugs containing amphetamine, and I put "and others" on the bottom. Maybe that is the most significant as we move into NAFTA and acceptance of the fact that people travel a lot. We are going to find amphetamine prescriptions or non-prescriptions that come from places that we have never heard of with names that we have never heard of, and the MRO is part of his responsibility to track those down. Once it metabolizes to methamphetamine or amphetamine, this and, again, others, a long list of medications that the MRO has to be aware of and indeed an investigation, do the history of medication use -- contain dextromethamphetamine and others.

Methamphetamine. I guess the trivia question, for those of you who do not read the New England Journal, in last week's issue, Selegiline picked up a new indication, apparently effective as a slowing down the process of Alzheimer's. I do not think we see much Alzheimer's in the workplace or hope not, but it sounds like the kind of question that they will ask on one of these MRO certification exams. So I just throw that in as another indication for selegiline.

This one is a problem for us. It will get better when Joe Autry, and HHS, and the rest of those guys get the and proposed opiate regulations off so we are not dealing with morphine levels of 540 and codeine levels very well.

The friends and foreign prescription really is not an interpretative issue. It is a decision issue. Do we follow the guidance as given to us by DOT this year or the guidance as given to us by DOT last year. It is somewhere in that mix of MROs interpreting how best do we handle those things. But, again, it is not an interpretation of the test itself, it is an interpretation of evidence around the issue.

MROs also look at non-HRS panels. How do we interpret benzodiazepines and barbiturates and alcohol? Alcohol is, as you know, in the federal program, is not MROreviewed, but we are dealing with clients that ask us questions about it all of the time. Urine alcohol when properly done with a weight window of 30 minutes and understanding of the fact that glucose and yeast make alcohol is not a bad test, and, indeed, we see it in return to work profiles, where people are not supposed to have any form of alcohol, and follow-up testing in treatment programs.

Other issues. Shy bladder. I noticed at the break that this group has no shy bladder cases.

[Laughter.]

DR. MACDONALD: And there is no such thing as shy hair, except maybe Doug is getting close to that.

[Laughter.]

DR. ROLLINS: Your time is up.

[Laughter.]

DR. MACDONALD: I knew that. Dilute urine. I do not want to say anything about dilute hair or my time will really be up. Trap door -- you know, that is a problem with urine, as you are well aware, and how best to deal with that and interpret it is something for us.

Interfering substances. We like it better when the laboratories get a little closer to really telling us what is going on rather than that this is unsuitable for testing. So I like Mike Peat -- I asked Doug is this a valid panel? Mike Peat is not up here. He said, well, I guess not. But, Mike Peat has assured me that if he finds high levels of nitrite and interference with his internal marijuana standard, he is going to call it an adulterated specimen. That is the sort of stuff that we like as MROs when something has no specific gravity that is measurable, 1-0-0-0 and no pre-admin. We like Mike Peat because he is going to call it water, but that is his issue.

So, anyway, these are issues that we deal with and need to be aware of as medical review officers looking at urine.

The intoxication issue. The trap for the MRO is to take the level of one of these metabolites or analytes and try to equate that to intoxication. The trap is set for us by many attorneys asking us how drunk was he, or not so much how drunk was he but how stoned.

Some evidence perhaps that if you control for creatinine, that there is some value to that. But, for us, we stay away from it almost completely. It is the same about frequency of use, although we are aware of the fact that the more you use, the more likely your test is to be positive. That is another place that the MRO does not go in testimony.

Time of detection. It is relatively short for all of these, as you know, a day or two or three. The Huestis/Cone paper last year I think opened a lot of eyes about the single-dose use of marijuana saying do not give us this three-week, four-week stuff. It is a relatively short detection period also.

We see benzodiazepines longer and PCP longer, but not a long detection window for urine testing. That is all that I have to see.

Doug, I had one more comment, but I am not going to make it.

[Laughter.]

[Applause.]

DR. ROLLINS: Thank you. Our next speaker is Dr. Sam Niedbala, who is going to talk to us about saliva testing. He is Executive -- I am not going to go through all of his bio again, but he is Executive Vice President and Founder of STC Technologies, Inc. in Bethlehem, Pennsylvania. Since Dr. Niedbala is also one of us who is folicularly challenged, I think that he might want to consider a career change.

[Laughter.]

Agenda Item: Saliva Testing

DR. NIEDBALA: This crowd is getting brutal.

[Laughter.]

DR. NIEDBALA: You guys could not see this before, but when this was all first starting, Carl is in the audience going you are one of them, you are one of them.

[Laughter.]

DR. NIEDBALA: So, I have this feeling when I get home that I am supposed to start up a whole program in hair now, and so at the next conference perhaps I will join. My term was anatomically challenged. It covers a lot.

Let me get started. By far, as the meeting has gone on, we are degrading here. Coming back to interpretation with saliva. Now, yesterday, we heard the classic spit happens. But, really, when it comes down to brass tacks, as far as interpretation, saliva definitely is a challenge, and I use that word sincerely.

Just to reiterate, this is a slide you have from yesterday, but I felt it important to bring it back up. As we look at the requirements for immunoassays for alternative fluids, again, we have to keep in mind that it has to have the appropriate cross-reactivity with the analytes and metabolites found in the specimen we are targeting. We need to have GC mass spec as the gold standard for the presence, for confirming the presence of the drug. We need to then set cut-offs against the best sensitivity, specificity, and efficiency as conducted through both controlled dose and randomized studies, and then it needs to relate, in terms of predictive value, to the relevant population. Obviously, there can be variations in the hit rate that you will find.

As we examine saliva, I think that the algorithm for testing is pretty much the same. I add one step in here because GC mass spec being the most expensive portion of the analysis usually. Samples arrive at the lab for analysis. You have heard all about chain of custody, sample integrity, et cetera. We tested qualitatively using the immunoassay. Of course, if it is negative, we are complete. If it is positive, generally, there is a repeat of the immunoassay. Just in case there has been any mispipetting or anything else that affected things through the process. Of course, if it does repeat, then it is confirmed.

Now, that is a very simple algorithm which many of you follow. Those of you doing alternative fluids, it has been talked about over and over. But the real nuts and bolts of interpretation, again, is what happens when you see specimens. So the slides which you have on the overhead are not intended to scare you. They are real-life for saliva. So, what I have tried to do is pick a few other analytes, other than cocaine because saliva -- we have just talked about cocaine because of its relevance in the insurance industry.

So here are a few other analytes, just to give us a flavor for where this is headed. There are lots of additional studies that are being conducted at this point. Some of them are randomized, some have controlled-dose subjects. Before we go through the specimens, I also wanted to add a little bit of information. It is nice to be able to get a second shot to add a little bit of additional data.

I think that Marilyn had asked yesterday about some of the adulterants tested with these specimens. Just to give you a little bit more specific, we have looked at some of the collection devices with things like sugar water, toothpaste, cranberry juice, baking soda, orange juice, Coca-Cola, not Pepsi, cough syrup, antiseptic washes, meaning Listerine, in this particular case, and just copious amounts of water. So, we have tried some of this with both negatives as well as spikes, and I will come back to that. I think the heterogeneous format of the assays we are using right now contribute to that not having an effect. Obviously, I think, if we are in a homogeneous format, there would be some of the things we have noted earlier about its effect on the enzymes in particular.

So, with that having been said, these are from controlled dose studies in heroin. What you see is that there is, again, a very quick window of detection. This is a 12-milligram dose given IV. If we compare that and superimpose that onto the urine, you can see the magnitude of detection and the windows are very different. That should not be a surprise. It holds through for the expected metabolism for this particular drug using saliva. Now, that does not mean we cannot confidentially detect in the zone. We just have to understand that it gives us different information. From my perspective, this is the kind of information that would be communicated to a user through a package insert through publications so that they understand what the real, what the product, what the fluid will do for them in clinical interpretations.

Here is another patient. These were random patients. Some of them I selected because there is more of a story. Heroin is actually pretty boring. It comes out the same throughout for the most part. The window here overlapped a little bit. But, again, you see we are going basically offscale when you see this on some of the slides.

These are just drawn point to point. There is not necessarily clean lines coming across. We are just connecting the dots as we look at the different time points.

If we switch to a different analyte, again, not been talked about at all, THC. This one I find very interesting. Now, these are from marijuana cigarettes and these are two doses. Here is dose one, here is dose two, and you can see this very short window of detection in the buckle cavity. It is not unexpected again from what we know in the literature. Someday it would be nice to see one done intravenously and then compare it to see if there is any partitioning. We would not expect it, but it would be nice in terms of buttoning up what we know about the data and interpreting.

We now look at some of the urines that were collected matching these, and we see our spikes. What is interesting here is that I would have expected the drop-off to be much slower in terms of the absorption back out of the buckled cavity into the blood stream. They are very sharp peaks.

And then urine we have coming out several hours later and continuing for quite some period in time. But there is a difference in terms of when it appears in urine versus when it appears in the saliva, even with the multiple doses.

Let me give you a different viewpoint. In this one, there is a mistake in this slide. I did not realize it until after I got here and saw it. This should be coming back down basically in the hour or so that you saw in the others back down to zero versus staying up. So we can make that correction, Donna, and I will make sure that that is done.

If we superimpose that onto the urine, what you see is -- now, this is only one marijuana cigarette, followed by a placebo which had no effect or no drug obviously seen and there you get one nice peak, and the urine coming down over hours. The saliva would have been over here and, again, it ties out single dose versus multiple doses of marijuana.

Cocaine is a little bit different in terms of the dosing that was done with these particular patients. These were subjects who are in a repeat dose study, and so there is a time course here where you are watching them get doses of the drug. What we are doing is catching a window of time here where they are getting their next dose and in the saliva it is a zero, and then you can see it last for much longer here. And this is real. This has been retested. We are not quite sure why that is that far out. It does not hold true for many other subjects, but it is an interesting one.

If we superimposed the urine, you can see there is a baseline level in the urine. Again we think of urine as a reservoir, potentially holding some of the metabolite for a longer period of time. And then here are the peaks we discussed just one slide ago. You can see the urine concentrations of benzoylecgonine being much higher than in saliva.

The last patient to look at here is with cocaine.

You see the very quick peak. Again, coming back down, a little bit of an elevation here, but it pretty holds true to what I would expect, which is rounding back down towards zero over a relatively short time when we compare that to urine.

Now, this patient had been previously dosed with drug and you can see in urine they are way up here. This is the new injection that is occurring. So, in Saliva, we see our window, and then they are dropping actually, and then it starts to come back up with this particular dose.

So, as far as interpretation, I may be confusing, but I wanted to say that there is a challenge and there is an opportunity. My glass is always half-way full, if you know me. So, I sort of look at this as saying that it is different information. It can be used differently and, in terms of interpretation, we will pick up those that had been dosed with these various drugs, but the time, the concentrations, all of those things will be different.

So, in conclusion, again, it is nothing that we have not heard over and over at this meeting, that the selection of the screening cut-off is critical, again, based on your window and, as publications occur, as more and more specimens are looked at in both controlled dose as well as chronic doses, we will get an idea of what is the appropriate cut-off. We have to be aware of this window of detection. I think that we can tell the users what that is going to be. We have to relieve the immunoassay specificity to the GC/MS mass spec confirmation. I am not going through because we only have the 15 minutes basically looking at each analyte to compare what I would recommend in saliva looking at GC mass spec versus the immunoassay and what metabolites or parent compounds it picks up.

Finally, I think, in the state of current technology, we need to devise a prioritization for confirmation. I think that Dr. Peat and Dr. Rohrig, et al. talked about this either in relation to HIV or with the drugs in general. I know that there is new technology that is being tried that will multiplex and basically look for different drugs all at the same time. So, I think, as you look at these fluids where we are going to have smaller amounts to collect and test, microminiaturization is all over the place in terms of testing and biotechnology in general. I think that this is one of the places that it is going to be used. As a matter of fact, I think you can look forward to that.

So, that was where I want to end it. Was that okay?

DR. ROLLINS: You are fine.

DR. NIEDBALA: Even among the challenged.

[Applause.]

DR. ROLLINS: Next, we are going to have an interpretation of onsite test results by Dr. Kenneth Steiner. Dr. Steiner received his M.D. degree from the University of Tennessee in 1979 and was board-certified by the National Board of Medical Examiners. He served as a clinical fellow in the Department of Medicine at Harvard Medical School, went on to be come the Associate Director of emergency services at the Lincoln Hospital, Bronx, New York, and received a special citation from the emergency medical services of New York City.

In 1992, Dr. Steiner became board-certified by the American Board of Emergency Medicine and was elected a fellow of the American Academy of Emergency Medicine. He was certified by the American Academy of Emergency Medicine.

He was certified by the American Association of Medical Review Officers in 1992 and has served many fortune 500 firms as an MRO.

Additionally, Dr. Steiner has been designated as an FAA medical examiner. During the past year, Dr. Steiner has devoted much of his time as a consultant to American Biomedica Corporation of Ancromdale, New York. Thank you. Dr. Steiner.

Agenda Item: Onsite Testing

DR. STEINER: Okay. It is time to get back to the mainstream a little bit. Our talk today is trying to incorporate onsite drug testing into the mainstream of the programs as we know them over the past years.

Basically, I want to give you an MRO's perspective to drug testing and its relationship to new onsite tests that we all have been presented with over the last day or two.

What I can say emphatically is that the MRO's position, whether it be using onsite tests or whether it be using the classical lab test is no different. So that the role of the MRO, as we have these onsite tests introduced, does not change. The MRO, by any standard, has to confirm all positives by the laboratory. So, whether he gets a positive in the field with the lab test being a field test or in the lab, it has to be confirmed, and he is not able, on the federal level, to discuss any results of any applicant until he has a confirmed positive.

The advantages of onsite testing is that it allows immediate action for a negative test. So that, if you have someone who is looking for employment or wants to get back driving his true, or what have you, or has to pass a random drug screen, he is able to go right back to work if he has a negative screen with an onsite test.

It also provides for early intervention and further evaluation of the client. What I mean by that is that many times, if you have a positive field test and you are sending it off to the lab, it gives you that extra window to talk with the applicant.

We had one who filled out his form saying that he was not taking any over-the-counter drugs at all and, as he is talking to us, he is spraying his nose with Vick's Inhaler. These situations can be cleared up. If you find a positive, you can make that extra effort to interview the applicant on-the-spot and see if you can bring forth some relevant materials that would help you in evaluating a positive laboratory test. It is also a therapeutic deterrent. When folks come and they know that you are going to find out on the spot that they are going to be positive, we seem to feel that this has a major deterrent effect on the clients. Also, it lets you make an on-the-spot determination as far as the fellow's ability to -- as far as having fitness for work and suitability for a job safety position.

There are really four reasons to verify a positive laboratory result as negative. A legally-prescribed drug is the main reason that most MROs immediately call a positive a negative. That includes pharm prescriptions now as well. As it was discussed earlier with NAFTA and everything else, we are seeing a lot of prescriptions coming up from Mexico these days, a lot of the MROs on the border towns. As long as someone can produce a legitimate prescription for a legitimate illness, most MROs will sign-off on that as being negative.

Also, their injection of legal substances, mainly, the poppy seed scenario we have heard a lot about and we all know about. That we can call negative if indeed the lab criteria can satisfy this. Also, most people when you speak with them and interview them, and have the question what did you eat that day, many of them will probably remember that they had something with poppy seeds on it.

When there is a chain of custody of control labs, that is an indication to call the test negative. I do not think that anyone would argue with that. Also, any errors that may occur under any technical analyses which are extremely rare today.

Going drug by drug real quickly, cocaine, as was discussed earlier, has uses mostly in the emergency setting and certainly surgeries that involve the ear, nose, and throat-type surgeries. Many times you will have a client come and they will say that they have taken lidocaine, or one of the related caines, and structurally, I think that most of us understand that none of them are related to cocaine in any way.

The opiates are the big problem for most of us.

So, with 6-MAM in the lab getting that reading, we can designate whether they are heroin users or not. HHS Drug Testing Advisory Board recently was recommending increasing cut-off levels of opiates to 2,000 to reduce the falsepositives that we are seeing, and also requiring 6-MAM testing.

PCP has no therapeutic role in the United States today. Years ago, it was used in veterinarian medicine and as an anesthetic or sedative. It is totally illegal today in the United States. It is rarely used overseas. PCP does not occur in nature.

THC -- that is becoming a hot one these days. Medical uses -- the FDA approved it in 1993 for anorexia associated with AIDS. There are certain compassionate bases for this, but I have yet to hear of anyone who has been drug-tested positive who has a legal prescription for marijuana. Okay. My understanding is, under the federal guidelines, any class I drug, even if there is a prescription for it, is still called a positive.

Amphetamines, which are a schedule II drug, are use for attention deficit disorder with hyperactivity, exogenous obesity, and narcolepsy. Its legal use, even if someone has a legitimate use or it, should raise many safety concerns for the MRO. Many times the MRO will call the est negative, however, they will inform the employer that this person should not be placed in a safety-sensitive position.

We all know about DN antomers of DNL forms, L being the peripheral forms, and D being the centrally-active forms, and the ones of abuse mostly falling into the D forms.

The classic one I just mentioned earlier is the Vick's Vapor Inhaler, which will produce the L forms. We have heard about some other ones, Selegiline. Many of the phenylalanine, phenylamines, ephedrine in high doses can cause a false-positive pseudoephedrine, and some of the Mexican diet pills. However, as well as the other drug classes, as long as someone has a legitimate prescription and use for the medication, the MRO has to call the lab positive test negative on the result.

Now, there are other non-medical situations that we would like to discuss. Passive ventilation is absolutely not an alternative medical explanation for having a positive THC. We have heard stories. I think there is a book out, A Funny Thing Happened on the Way to the Urinal. We have heard stories of intentional contamination of coworkers' and foreign use of prescriptions, and prescription drug abuse. Basically, it is the MRO's position that any THC that is found is positive.

There is no medical explanation at all for cocaine other than the surgeries that were talked about.

PCP. There is no non-medical explanation. Amphetamines. The prenylamines, again, can interfere. There have been new directives to the lab that I understand that, if amphetamines are present, you also have to prove that -- I mean, rather, if the methamphetamine is present, you have to prove that amphetamines are present as well.

That is helpful to clarify the situation right now. Opiates, the poppy seeds have been proven to show positive on drug screens. Basically, what we are seeing with the opiates is that they are able to cause very high levels of positives for morphine and codeine.

This is the structure of the metabolism, if anyone would like to review it real quick of the opiate metabolism. You can see that the 6-MAM only comes from heroin, and you cannot go from morphine back to codeine. So, if you have 6-MAM in there, for sure you have a heroin user, and most MROs today are requesting that.

The main issue here is onsite screening for negative results. This raises certain new issues for the MRO. Right now, under the federal guidelines, most of us get reports from the federal programs of negative reports. This is not usually done outside of the federal programs. But there needs to be a standardization of the reporting system.

There is a possible situation in which someone could be discriminated against. Let's say we are at a truck stop, and we have two applicants, and you are doing an onsite test, and one has a positive, but it is a falsepositive, and the other has a negative and they are applying for one position. The person with the positive is at a kind of a disadvantage because he is waiting for it to be confirmed, and he may even have a legitimate explanation for it, and he may not get the job that day. These issues have to be addressed.

Also, an accurate, reliable reporting system for onsite screening, as far as standard reporting, has to be developed.

And the issue of quality-control, which was discussed earlier, has to be implemented.

In summary, the role of the MRO utilizing onsite testing does not change. The MRO still waits for a confirmation before he can call any test positive. However, it does give the window of early intervention which we discussed, and facilitates negatives more rapidly, which is a great cost-savings and convenience to the client, as well as to the employer.

And, as we stated earlier, it is an excellent therapeutic deterrent.

All right. Thank you for letting me talk.

[Applause.]

DR. ROLLINS: Our final speaker in this panel to talk about the interpretation of sweat testing results is Bob Fogerson. Bob has already been introduced and his bio has been read. You will remember that he is Vice President and Laboratory Technical Director of PharmChem Laboratories, Inc., Menlo Park, California. Bob.

Agenda Item: Sweat Testing

MR. FOGERSON: Thank you very much. I guess I will continue on with some of the things I was getting into a bit in the earlier discussion about just what it is that we report out of select tests and then try to tell you a little bit about some of the things that we know or think we know about what interpretations we can apply to those results or what some of the limitations on interpretation exists.

These sorts of questions come up all of the time in the context of just about any drug testing program that I am aware of. Again, this is nothing really qualitatively different from the urine testing program. I want to make some comments about these sorts of things.

One might get asked to comment on the source of a drug. We detect heroin with benzoylecgonine in a select sample. What can we say about where that came from? What sort of allowance do we have to make it a possibility that passive inhalation is a cause of a positive result or passive exposure, if you will, to a drug? Where do we worry about contamination? What are the test techniques that are susceptible to contamination? What sort of information can we get about the frequency of drug use from a sweat result or in a related question, how long is somebody going to be positive after a given episode of drug use?

I will talk a little bit about what are the limitations of interpretation when one is addressing the question of the source of the drug that we find in sweat. These are sometimes described as alternative medical explanations for a positive result. Here what we see in sweat testing is really quite similar to urine testing.

Prescription medications certainly will appear in sweat. We did a lot of our clinical trial work with schedule I drugs and schedule II drugs, but we did quite a lot with, say, codeine, as well as heroin in our opiate investigations, and codeine will appear in sweat. So it will be necessary to take a prescription history into account in interpreting test results.

There are some interesting differences though in the sweat test for codeine and the urine test for codeine, sort of along the felicity scale that you mentioned earlier.

Sweat testing seems to be a little less sensitive about it, maybe quite sensitive to codeine than urine testing is. Some of our real patient populations being simultaneously tested by urine and by sweat when we assessed the relative detection deficiency of the two techniques, sweat does not do as well in detecting codeine as urine testing does as compared to some of the other drugs that we have compared. I will mention a little bit more on that later.

Over-the-counter medications, again, are an issue, things like phenylpropanolamine, L-desoxyephedrine will appear in sweat. We have determined that experimentally.

As I mentioned earlier, I think that the solution to that is going to be the same as the solution we applied in the urine result. We will use GC/MS to resolve the methamphetamine issues, and the appropriate techniques to resolve other over-the-counter compounds from the analytes that we are concerned about in our testing programs.

Poppy seeds we all know to be a source of morphine. We did actually do some experiments that were sort of interesting with the sweat patch where we did administer poppy seeds and did not get any positives in the patch, but I do not think that to be too definitive because the urine samples we collected from those guys tended to be at best almost positive. So I would suspect that it is a thing we have to take into account. But, similar to codeine, I do not think that the sweat technology is quite as sensitive and as capable of detecting that compound as it would be say heroin, which is somewhat useful.

On the other side of the coin, I think we do know some things hat are sort of interpretative strengths of the sweat matrix, as compared to urine tests. As I have said before, in the case of heroin use, what we will detect on the patch in the sweat is primarily heroin and then, in sort of decreasing orders of concentration, 6-acetylmorphine and some morphine and, in some very extreme cases, a little bit of codeine. That allows us to unequivocally identify heroin use in a substantial fraction of the samples that we do see.

In some of this parallel urine sweat testing, we are able to identify clear cases of heroin ingestion in a very large fraction of the urine opiate positive, none of which really had a profile that would have made me comfortable interpreting them as clearly as heroin cases.

So, I think that that sort of suggests an application for sweat testing in a couple of arenas, clearly, in treatment programs this would be very useful. It might be very useful in resolving the MRO's dilemma. The application of sweat testing might be a more purposeful response to a urinary opiate positive than is currently available, and a fairly practical one as well.

Cocaine positives I think will give a little bit of additional useful information out of sweat than we did with urine because of the fact that we do see cocaine, ecgonine methyl ester, and benzoylecgonine.

Dr. Cone's point about contamination I think is, to some extent, addressed by that in cases where we see a substantial amount of DME. I think it is less likely that we would be concerned that we had an environmental contamination problem. I also addresses the issue that has been raised in the military system as well about the fact that benzoylecgonine is relatively passively produced from cocaine or can be.

With respect to the susceptibility to passive inhalation, there are a couple of ways you can think about that. Obviously, in the case of marijuana, one can think about a positive due to actually inhalation of the smoke. Can somebody in a passive environment inhale enough smoke to produce a positive?

The way you would think about it in a urine test, given that the patch is worn externally, you could also think about the possibility that smoke itself would deposit on the patch and produce a positive result.

We did an experiment to test the possibility of inhalation of smoke in a room. That does not appear to occur. We did not get any signal at all in the experiments that we did in that respect.

In terms of the possibility of the smoke itself depositing, that has been sort of empirically and theoretically ruled out, as nearly as I can tell from the data. If you think a little bit about what this device is or think back to it, we have a collection pad that is held against the skin by a plastic film. That film is intended to allow the passage of small molecules, vapor-phase molecules something on the order of the size of a single water molecule, maybe a drug water molecule. Anything much bigger than that just will not go through the pores in that membrane. So this membrane actually represents a fairly sturdy mechanical barrier to a molecule as big as a drug molecule.

In the passive exposure experiments, we actually did put patches in the room to see if smoke would deposit on them and be detectable, and it does not happen. So, the patch itself provides some considerable protection from that sort of a possibility of a positive result passively.

The issue of contamination was raised in a couple of questions yesterday. I can think of a couple of different types. One of mine describes environmental contamination, the likelihood that a subject wearing a patch might encounter drug in his daily life that would then be

picked up as a positive, the other being the sort of contamination that might occur in a laboratory.

I think that the first kind, again, is unlikely because of the basic functioning of the patch. As long as that film stays intact, the adhesive is infiltrating the skin cells, and that barrier is in place, you can pour cocaine solution on a patch, and we have one this, and you cannot detect the drug on the pad underneath once you have removed it and prepare it for testing.

Obviously, if you think a bit about the cut-offs that we are using here, it does not take very much drug on a patch to produce a positive. So the possibility for what I call laboratory or I suppose collection site contamination is a real one and that is something that we do have to contend with and take into account.

In some respects, the laboratory might be the more problematic partner or possibility because, in the laboratory, we will typically have drug materials around in some form. Collection sites, I think, are probably a little less likely for that to be the case. But the point of vulnerability is when that collection pad is not protected by the plastic film. That is going to be at the point of application, the point of removal and any handling of the pad in the laboratory.

The detection period of drugs in sweat is something that we know a fair bit about because we did have the opportunity to do clinical trials. One of the things that we would do is provide a dose and then, at day zero, day one, day two, to day three, actually apply new patches and remove them.

For the compounds that we have done work with, a period of about two to three days seems to be a typical period of time over which that dose is excreted through the skin. If you put a patch on a day three or day four after dose, and we do not typically see a positive result. So the actual excretion period through the skin does not seem to be all that different from what we have typically experienced in urine testing, given the test methods and sensitivities that we are using now.

Some of the most interesting interpretative questions that we have been faced with to date come about I guess really because this is a new technology. Most of the people looking at it are not simply grabbing it and replacing their urine testing programs with sweat testing. The typical investigatory technique is to start it in parallel sweat and urine testing. So we end up with fairly large bodies of data on people who are subject to both sweat testing and urine testing. Today, these have primarily been in criminal justice agencies.

So we have the two possibilities. We have the concordant results and then we have cases where we get different results. The question that arises immediately when they are different is whether or not the difference in the test results suggest that a conclusion of drug use is wrong; but whether it is just a difference in the nature of the test to administrate.

I wanted to show a couple of cases that we have seen. First of all, I wanted to give you some idea of the magnitude of this effect. There are a lot of numbers on these couple of slides, and they are all in your handouts, so you do not need to focus on them necessarily now. But this is one early study that we did. If you look at cocaine, this is a population of a thousand subjects over a six-month period. If you look at a number of users that we picked up as individuals -- picked up 61 individuals as cocaine users in our sweat testing, only 15 of these guys showed a positive with urine testing. So, in certain cases, cocaine being the extreme case, we see quite a large discrepancy in these results, and that was a bit alarming actually at first.

We tried to explain them and begin to investigate them in detail. We see a couple of different reasons for these discrepancies. I think that these will be important to understand if sweat testing is used in parallel with urine testing.

One is what I call timelines, the sort of difference in the detection intervals or detection windows in these technologies. There is a different sort of discrepancy that occurs because of the difference in the cut-offs that we apply in urine testing and the cut-offs with the sweat testing. And then I think there are some differences that simply reflect the relative success that people have at least to date in evading detection with a urine test versus a sweat test. In some respects, I think that we just put the users about 10 or 15 years back in their skill set as far as how to evade detection to a test.

Let me show you some examples of what I mean. When we tried to relate urine tests results and patch test results, we looked at a time window that might reflect something like this. We have a patch that you would put on at day zero and remove at day seven. Given that drug may be excreted through the skin for a period of about two to three days from our clinical data, we would generally consider that any urine taken maybe up to two days prior to patch application could influence what we get on this patch. There could be enough drug coming out three days later to give you a positive. Similarly, given that I have to have about 24 hours of wear with the patch to get a positive, the drug taken in here might not show in the patch, but might give me a urine test result. It would kind of extend the window out a couple of days on either side to match the urine and test results where people are being tested in parallel.

So, you can see that, in some cases, we would expect to see some differences. I could get a urine negative here, a drug use episode here, a positive on this patch that may be worn over a period of time. As I mentioned earlier, we get a drug use occurring right in here. There is not enough time of patch to show a positive, and plenty of time to show a positive urine down there. So some of it is just phrenology. You have to work with these dates.

Some of it could easily be these cut-offs. I suppose there is really no point in spending time working through these when we are all familiar with what these cutoffs are and they have been described a little bit. You can see that they are quite different.

We clearly have some cases, I will show you one of them here, where we had some discrepant data on one particular patient. This individual is being tested. We have three patch results over a period of two weeks. These are reasonably substantial cocaine levels in the sweat patch. This guy was doing a very good job of staying -- these are the emit results on his urine samples. You see that he has actually been tested very frequently. He is a cocaine user who is being tested every two or three days in here. He is skating. I mean, he has really got it figured out. He is consistently just a few units under the emit cut-off.

Now, clearly, we could make these concordant results if we were testing a lower urine cut-off. But this sort of thing occurred several times. This suggests to me that there are some people who get fairly skilled at typewriting the doses, calculating the testing intervals, whatever it is that they do. This guy was doing a really good job of getting by. So that, I think, will explain some of the discrepant results. That is fairly easy to see if you analyze the data in detail.

Some of the others are just tougher to tell. This may be a guy with a different evasion technique. I am not sure. Again, we had two patch results, a cocaine positive, well above the cut-off using the 10-nanogram cut-off here.

These -- it is not obvious here -- but these are zero drug level emit. Again, he is being tested fairly often, every three days. You would expect to catch this guy if he is using cocaine. I really do not know what he explanation for this is. It is hard to imagine cases where you would have consecutive patches on somebody two weeks apart being contamination issues. I think that, in some cases, there are detection or evasion techniques that we do not see, and maybe some reasons that we do not yet understand why this technology works a little better on this particular drug.

That is the last slide I have and probably all of the time I have. Thank you.

[Applause.]

Agenda Item: Questions and Answers DR. ROLLINS: That is the end of the

presentations. We will answer -- I am sure the panel would be willing to answer questions.

I would like to take the prerogative of the moderator and ask the first question of Dr. Baumgartner. As you look out across the audience here, it is evident that a number of people have gray hair, including yourself, which I just noticed. Take, for example, Mr. Bush here in the second row, who has quite gray hair, and the person next to him, Dr. Kwong, who has very dark hair. Would you recommend, do you recommend or would you recommend that there be a difference in the interpretation of a drug concentration between these two individuals?

DR. BAUMGARTNER: No. The reason is very simple.

Biochemical individuality creates enough scatter and, in the studies that I have done with the different types of hair shows biochemical individuality is a more dominant factor. And then we do not know of any mechanism whereby melanin features in drug uptakes when you spin it down. I can perhaps make this point perhaps clearer because yesterday I did not make it perhaps so sharp because I was trying to solve Dr. Cone's problem as well as answer a question. I think that we will have a discussion with Dr. Cone tomorrow. When melanin shows a high affinity for a drug, it has a high equilibrium constant and it simply sticks, it just sticks to melanin when we spin it out -- should -- should melanin have such a property, but we have not seen one in 44 or 45 drugs.

DR. ROLLINS: Of course, Mr. Bush has no melanin in his hair, and Dr. Kwong has a lot. So you would spin down a lot in his hair.

DR. BAUMGARTNER: I mean, if there was such a property, if the five drugs were showing a predisposition, our studies show that they do not. Medications -- the reason why the melanin issue came up at all was a Japanese study with haloperidol. But, you know, I do not know anything about haloperidol, but that it is antipsychotic agent.

So, what I am saying is that biochemical individuality factors are the ones that are shifting things around. Now, of course, gray hair is thicker than other hair, and, you know, weight basis. You have to quantitate it on a weight basis and so on.

DR. ROLLINS: Are there other questions? Mike? DR. WALSH: Just to follow up on that example there, Dr. Baumgartner, if -- and I know that this would never happen, but, if Mr. Bush and Dr. Kwong were sharing a joint --

[Laughter.]

DR. WALSH: -- and they each smoked precisely the same amount, they took in the same dose, would there be a difference in the probability of detection of a positive for Dr. Kwong and Mr. Bush?

DR. BAUMGARTNER: The date -- you know, Mitch Clowsky's data, you know, clearly shows that the 1,200 people that we do not see any such effect. I do not know why people keep ignoring Mitch Clowsky's data. It is in the literature. There are 1,200 cases -- as if it was not there. You know, that is the first thing.

Secondly, as I said before, in my own studies which are also published, when NIDA gets around to publishing general two, it very clearly shows that we do not see hair color effects.

DR. WALSH: Well, I will just respond to that.

One of the reasons that I do not cite Mitch Clowsky is because I asked Dr. Mitch Clowsky on several of his studies why he does not do any control samples through the system, why he does not send blind controls to your laboratory when he runs these studies, and he told me that he does not have to do that.

DR. BAUMGARTNER: I do not think that blind controls have anything to do with the data he is presenting anyway.

DR. WILKINS: Somebody said inspection as I was walking up here. No, this is not going to be an inspection question. Actually, I am going to follow up on the pigment issue again.

One of the questions I have is the Japanese study that you cited, Dr. Nakahara's work with haloperidol, is not the only study that is in the literature right now with control dosing situations where the dose is known definitively, not a self-report assessment of drug intake or a self-assessment report, even if that were -- even if we believed that self-report is always totally accurate. On a street drug, you do not know what the purity is of that and how much of a dose they are really getting at any one time.

So I think that people are reluctant somewhat to totally base their interpretation of potential pigmentation effects on drug incorporation on that data because they do not know what the dose is or the purity of the street drug preparation. So there is some hesitation to take that as the definitive study on pigmentation.

Certainly, the Japanese study is a control-dosing situation where they have looked at pigmentation effects. There were several of those recently. One came out with cocaine, looking at graying here versus pigmented hair, I believe. I think that is Ralston Reed who did that with cocaine, and found a significant difference between cocaine in BE concentrations and in pigmented and non-pigmented hair. Again, that was in the human subjects studies. The list can go on.

There are several controlled-dosing studies both in human subjects and in animals that seem to support that pigmentation can be an important factor, and perhaps that may relate to the type of analytical process that you do. You are alluding to the fact that you remove the melanin and that that overcomes that potential bias. There may be other analytical approaches to hair testing that may not remove that bias.

I would like to explore with you a little bit more about the possibility that when you are testing a hair sample, let's say a pigmented hair sample, I noticed in the particular wash protocol that you are using, you have isopropyl alcohol, and then you are following that with a buffer at pH 5.5. In my mind, it seems that, depending on the drug, the type of drug, and how tightly that drug may be bound to let's say melanin in this situation, you may or may not be able to physically remove drug from the melanin pellet during that process. I would think that it would not be consistent in all subjects for all drugs. And, therefore, I would think that there might be a difference between pigmented and nonpigmented individuals. Do you see what I am getting at?

DR. BAUMGARTNER: Yes, sure.

DR. WILKINS: Yes. Have you looked at the effect

of the pH of the buffer solution on this process? Are you extracting drug from the hair as well as washing it off from the exterior of the hair?

DR. BAUMGARTNER: Yes. I will give you a very specific example. I ran out of time when I was discussing the Henderson and Harkey study. It is all methodologydependent. There is no doubt about it. If you do not wash rigorously, if you do not clean the semi-accessible domain, and if you do not digest the hair so that you get it out of the inaccessible domain, and then remove the melanin, if melanin -- you know -- I have data which you saw yesterday where melanin picked up only as much drug in proportion to its weight, which was five percent.

But, in the case of the Henderson and Harkey study, where the deuterated drug was spread over the hair, not the others which gave the clear-cut bolus, that happened to be non-Caucasian hair, and it gave rise to some suggestion in various quarters -- and these are erroneous suggestions -- that these four cases represent a racial bias.

DR. WILKINS: But I am not implying -- I was not trying to address racial bias in this instance. I was trying to limit it strictly to pigmentation.

DR. BAUMGARTNER: It was a hair color. You know, we are talking about hair color now. Racial bias, hair color, they all finally go down to the melanin. Very few people talk about structure.

DR. WILKINS: So do you have evidence that melanin -- that the type of melanin present in hair is different between ethnic groups? Is that what you are saying?

DR. BAUMGARTNER: No. The point that I am making is that in Henderson and Harkey, with the 10 one-minute washes, did not decontaminate. Maybe these people -- you know, I do not know the history -- they know it. They went -- whatever the sports activity was or whatever, what was contaminated. And these also gave very high values. You see, not only did they not fit the pattern. Because the thing spreads out and it is not, in anyway correlated with the dose. There is something wrong. So not only did the wash -- did not do sufficient washes, they did not follow wash kinetics. I understand why they did not do it, because it was a one-dose thing. I could not persuade them, you know, at the time, to use our approach.

DR. WILKINS: So, let me just follow up a minute.

I asked -- somewhere in my question I asked about have you looked at the effect of various pHs of the wash procedure that you use on different drugs? Is there a difference in

how much is recovered from the samples?

DR. BAUMGARTNER: No. It is timed. It various so much from individual to individual. You know, the plateaus -- you know, ultimately, what you are trying to achieve is the plateau condition so that you have cleaned out the accessible and semi-accessible domain. Because you must remember the semi-accessible domain is where endogenous drugs and exogenous drugs overlap. You must get rid of that.

DR. WILKINS: Okay. So, just to clarify for me. So, if an individual is truly exposed to drug, whether it is an IV route, an IM route, subcutaneous, oral ingestion, all of the drug that they ingest, in some manner, is distributed solely into the inaccessible domain?

DR. BAUMGARTNER: No. The accessible and semi-accessible domains contain endogenous drugs. The only problem is that these domains -- the pools of the drug overlap with the exogenous source. So, in order to separate --

DR. WILKINS: So, if you wash and remove from the semi-accessible domain, you could be removing drug that actually came from a true exposure?

DR. BAUMGARTNER: Not could, absolutely certainly. DR. WILKINS: Absolutely.

DR. BAUMGARTNER: Certainly it will do it.

DR. WILKINS: Okay.

DR. BAUMGARTNER: And, yes, and I would rather like to call abuse people who use drugs rather than being exposed to drugs.

DR. WILKINS: Thank you. I have one more question, and then I get to move on to the next group. You briefly showed a slide on a dormant hair study for cocaine.

DR. BAUMGARTNER: Yes.

DR. WILKINS: I wondered if you might elaborate on that a little bit. How was that done? Was that cut hair? If so, how did you determine that it was dormant hair versus actively-growing hair?

DR. BAUMGARTNER: Yes.

DR. WILKINS: Because that was the first time I had seen that so I am kind of curious.

DR. BAUMGARTNER: Yes. Well, you know, 15 percent of hair is, you know, in the dormant phase. The slide, the last slide which had so much data on it which could not be read was a study that showed all of the people who came in were in a drug-free environment, and we did segmental analysis, you see. So the way we interpret this segmental analysis is that the first segment after, you know, when people stop using drugs, which is 15 percent of the previous segment where they were using drugs, that is viewed, this is a negative, scored as a negative. This is a period of no drug use. But, in the next month --

DR. WILKINS: But it was not a -- I just wanted to make sure I understood the study. It was not a study comparing actively growing hair and dormant, non-growing hair?

DR. BAUMGARTNER: No, no, no. It is -- no.

DR. WILKINS: The word dormant in that --

DR. BAUMGARTNER: Right. No.

DR. WILKINS: -- did not imply that the hair was not growing and did not incorporate drug?

DR. BAUMGARTNER: We did not make an effort to collect dormant hair. It is simply the pattern that is typical of people who are in a guaranteed drug-free environment. But it drops very quickly down to below the cut-off level. But the first segment, you know, is interpreted as negative. It is 15 percent of the -- that is how we interpret our data.

DR. WILKINS: Okay. Thank you.

Now, I have two questions for Dr. Niedbala, if I may. Just a quick one. In your THC study that you showed, you showed several slides. I just wondered, did you measure actually parent THC in saliva and urine or was it parent THC in the saliva and carboxy-THC in the urine?

DR. NIEDBALA: Actually, it is both. In terms of the immunoassay?

DR. WILKINS: Yes, for the immunoassay results.

DR. NIEDBALA: Yes. It will detect both.

DR. WILKINS: It will?

DR. NIEDBALA: Yes.

DR. WILKINS: Okay. So it is a total. Okay.

Thank you. That was easy. And, finally, do you know is the morphine that you measure and that you showed on your slides excreted directly into the saliva as morphine or is some of that produced in the specimen. Do you see what I am getting at? I just wondered -- the pH is, I am assuming somewhere - and I could be wrong -- is somewhere around five-ish, and that could vary quite a bit. Just for my own information, do you have any data on where it actually is coming from?

DR. NIEDBALA: Well, the specimen collected is actually put into a phosphate buffered solution, so it is 7.2.

DR. WILKINS: Thank you. That is what I wanted to know.

Finally, I hope people will forgive me if I make a comment just to clarify something that came out in one of the talks earlier. One of the speakers mentioned that one of the reasons that the opiate cut-offs were going to be raised was because of false-positive. I just wanted to point out for those of you who are not familiar with the urine drug testing arena at least as in-depth as perhaps we all are here, I do not know -- the reason the cut-off concentrations were increased was not because the laboratories had a high rate of false-positives. The laboratories are very, very good and quite accurate at detecting and truly identifying and quantitating opiates in urine specimens. The reason the cut-off concentrations are considering -- that we are considering raising those or the recommendations were made is because most opiate positive results are overturned. They are not reported out as positives. And what happens is that -- and I just wanted to clarify that they are true positives from a laboratory analytical perspective, but, in terms of reporting, they were frequently overturned.

Also, for those of you unfamiliar with the area, with respect to ephedrine and pseudoephedrine as reasons for, again, false analytical positives, I think about three years ago -- I might be wrong on that one -- I will have to refer to RTI's program documents -- but about three years ago probably many of you are familiar with the problems of potential false-positives with a particular derivative in the amphetamine assays. That was the carboxy -- the CBderivative. That problem has been, to my knowledge, eliminated virtually by changes in the analytical procedures. I think, again, ephedrine and pseudoephedrine would not currently be put into the category of causing false-positives on amphetamine testing results. The laboratories are required to demonstrate that they can accurately quantitate and chromatographically resolve amphetamine and methamphetamine in the presence of ephedrine and pseudoephedrine and distinguish between those. I hope that that clarifies it for you.

DR. BUSH: I would just like to remind Dr. Wilkins that time flies when you are having fun. Diana, that happened in September of 1990. So it is a little more than three years, Diana.

I would also like to clarify one more time, for those of you who are not familiar with our proposed changes to the guidelines, we also, in a confirmation assay, would require analysis for 6-monoacetylmorphine, 6-acetylmorphine at a cut-off of 10 nanograms per mL. This entire effort is undertaken to reduce the number of laboratory positives that were reported to medical review officers who, following their interview and discussion with the specimen donor, determined, in fact, and more than 80 percent of the time, there was a legitimate alternative medical explanation mostly Tylenol Number Three or a codeine-containing medical prescription. So, we are focusing back on the guidelines and the deterrent nature of this program, the deterrent scope to deter federal employees from the use of illegal substances either on or off of the job. Hence, we have focused back to heroin, looking at morphine and codeine and 6-acetylmorphine.

DR. CAIRNS: Since this subject has come up, my question is for Dr. MacDonald. If you could share with us, Dr MacDonald, your decision tree when you do get a morphinepositive urine? Specifically, do you accept the poppy seed defense if it is a certain level? If you do order another test for 6-MAM, are you aware that it may be the short halflife. It is not detected. How do you view increasing the cut-off level to the 2,000 mark? Will we miss genuine heroin users because of this elevation of cut-off level?

DR. MACDONALD: The first part of the question is a little tempered by the fact that in the regulations that we follow, codeine and morphine, unlike all of the other analytes that are measured, we must present clinical evidence, in addition to the drug test, unless we have a 6AM positive. So that, if somebody does not present clinical evidence and there is no 6-AM positive, and there is no suggestion that they used somebody else's prescription, and they have no needle tracks, we accept the poppy seed defense. In fact, there is no reason to really ask about the poppy seed. It contributes nothing to the decisionmaking whether they tell you they have had poppy seed bagels or not poppy seed bagels because they do not have to prove anything. The burden is entirely on the MRO.

What will happen when we raise the levels? Well, we have seen positive 6-AMs at 1,200. We have seen positives at 1,500. So there is no question that we will miss some by raising this level to 2,000, 2,500, or whatever it is. But, in terms of the great majority of what we see, we are going to let a few people go undetected, but simplify the system tremendously by not bothering, worrying, causing consternation in many, many, many more who did have a poppy seed bagel or whatever. So, I am in favor or raising the levels. I do not think that I would go quite as high. I would have been at 1,500. That is not the issue.

DR. CAIRNS: The other question I have, and forgive me if I might sound a little naive on this issue, being new to drug testing, but I have heard the declarations that perhaps hair and some of the other matrices are biased with either hair color or gender. I have never heard those accusations thrown against urine. Do they potentially exist? Is there a database that excludes urine from the same scrutiny as perhaps the ultimate technologies that they are now being scrutinized under?

DR. MACDONALD: To my knowledge, there is no database suggesting that there is a hair color difference in urine, in other words, melanin in skin, or hair, or wherever that affects the urine results. So it has not, in my judgment, but I am not the ultimate expert -- seen anything that would ask the same questions of urine testing.

DR. CAIRNS: But it could potentially exist? DR. MACDONALD: Possibly.

DR. CAIRNS: Thank you.

DR. ROLLINS: I think that that issue was raised a number of years ago. I do not know exactly how it was studied. I do not know the extent to which it was studied, but it was looked at and studied, and I think that the decision was that it was not an issue in urine.

DR. ARMBRUSTER: The Woodward defense that came out of the military in Europe, and was totally discredited, if I recall correctly.

I have two questions, one for Dr. Niedbala. I always thought that saliva was an interesting alternate specimen, and I was struck by the relatively short half-life of drugs in saliva, especially as it compares to the urine.

So I was curious to know if you think it would be a logical specimen to look at in a workplace drug testing program because of that short half-life. I imagine that it would be longer if you have a chronic user or if there was some other arena where you think that an oral fluid specimen would be better suited.

DR. NIEDBALA: I think that there are a couple of answers for that. As you said, a chronic users needs to be looked at to see what would happen. Also, these are very low doses that we are looking at, so they really are substreet doses. So I do not know overall what would be the effect if we took a single use that way in a larger concentration. I think that that will come out over time.

If I look at sort of the empirical evidence and, again, I can only use cocaine as the analyte, and cocaine to some extent, although not considered among the normal panel of drugs of abuse, as we look at the matched urines with the saliva specimens, we really see that, in almost all cases, they agree. Again, these are randoms. We do have some history on what these people do and their drug habits. For those who have a problem, the specimen seems to work very well. So, in a workplace testing environment, I think that it comes down to sort of convenience of using saliva. In the end, as more specimens are tested, I think that it will play out to what its true utility is.

DR. ARMBRUSTER: My second question is for Drs. MacDonald and Steiner. Dr. MacDonald, I do not think you addressed PCP, Dr. Steiner, you did. I am always curious how many PCP-positives do you see as MROs?

DR. MACDONALD: Actually, I did have some slides on it. It is the easiest to do because there is no excuse.

We see PCP. In our office today, we may have one or two positives.

DR. ARMBRUSTER: Over what course of time?

DR. MACDONALD: That is today.

DR. ARMBRUSTER: Okay. On a daily basis.

DR. NIEDBALA: It is in Rockville, actually.

[Laughter.]

DR. MACDONALD: I am not sure that is true, but that is -- yes, we see some. It is around.

DR. STEINER: In my experience, years ago, we used to see a lot of it around the New York City area and in the urban centers, but now we do not see nearly as much, and it is rare that we see it up in the northeast there.

DR. BAUMGARTNER: Could I make a comment on this too? We studied the PCP in patients taken into psychiatric wards and state hospitals in California. We came up with 20 percent positives. These were people who came in to be diagnosed for toxic psychosis. They were not picked up by urine because their use was -- in fact, it was not an emergency visit.

DR. ROLLINS: While you are walking up here, Ed, I have got a questions for Dr. Steiner.

You talked, I think, briefly, about the effect of possibly raising the opiate cut-offs on the onsite. I wonder if you would reiterate that in light of the question that was asked just a few minutes ago.

DR. STEINER: Basically, the problem with opiates right now is we are getting too many positives that turn out to be negative. What we want to do is cut down on that whole experience. The way we do that, as has been suggested, is to raise the cut-off levels so that the true abusers, rather than the people who have prescriptions for it, are identified. The abusers seem to have very high levels. So, if we can segment them out of this whole situation, which we do by raising the levels, then we would probably not have this turnaround rate of over 80 percent being called negative, and we would get more validation on the process.

DR. ROLLINS: What will be the impact on the onsite drug-testing industry physically? I mean, will we have to get new kits?

DR. STEINER: I think we will see probably 90 percent or about 80 percent not bothering with it, not even recalled for a second interview and follow-up. It would be a tremendous cost-savings for labs, as well as clients and employers.

DR. ROLLINS: Dr. Cone?

DR. CONE: I had a question for Dr. Steiner related to the same issues. I think that you mentioned in your talk that the initial positives for, I guess, people looking for a job were difficult to deal with, in the sense that I am sure -- I guess you send them all for confirmation. But I think you mentioned that they may still not get the job.

DR. STEINER: Yes. Well, the situation that was brought up was, if you had two applicants at a truck stop let's say at an employer who had a truck stop, and he needed an immediate hire, and one had a negative screen and one had a false-positive there, let's say, then you would have the fellow being discriminated against who was really a falsepositive, and yet, you know, he loses his opportunity to get the job that day. So that is a possible issue.

DR. CONE: Well, I guess, I wanted to follow up on that then. It sounded to me like you are suggesting that we -- that is a reality that we have to live with.

DR. STEINER: Well, that is probably. There could be policy directed towards that. I am just throwing it out there as a possible policy situation that we have to address.

DR. CONE: It seems to me like we still owe people a fair shake, and that is not a fair shake.

DR. STEINER: Right. But, you know, it is reality right now. But we could try to make it better.

DR. CONE: Okay. I guess I need to ask Dr. Baumgartner, since he did not solve my problem yesterday. I wanted to revisit the issue, if I could, the issue of drug binding to melanin. There is an overwhelming number of studies that have been reported now in peer-reviewed literature that does not come from my laboratory that find differences. Usually they almost always consistently find much greater concentrations of drug in dark hair versus the light hair. And the best one that has recently been shown was the one that Diana Wilkins cited where they tested rizzled hair from cocaine subjects who had both dark and light hair. So, they served as their own control. The amount of cocaine in the dark hair was much higher than in the light hair.

I am trying to understand -- and I am not against hair testing, believe me. I am very much for understanding what hair testing can do for us. I can tell you that we are doing a controlled dosing study now at great expense so that we can find out what this means. But I want information from you because you offer it out to the public as facts. The facts that you present relate to your contention that drug binding to melanin stays bound to melanin when you spin it down in your enzyme digestion step.

For all of the number of times that I have heard you say that, I have never seen any data from your lab or from any other lab that supports this contention.

DR. BAUMGARTNER: Good. So we can have our discussion on physical chemistry now. We, I think, agree, Ed, that, if melanin is a binding site, right, just like an antibody, we would define it by an equilibrium constant. If this equilibrium constant is very high, like, for instance, the antibody, 10 to the 10, anything that binds to melanin stays on it when you spin it down.

It is quite different -- your study, the study that you mentioned -- I want to start on that one. You took hair powder, if I remember correctly -- I have not got your paper here. You ground up the powder, and you put in some cocaine. And we know that anything sticks to anything. And, you know, you call something specific binding. Of course, it was not really specific in the sense of antibodies. It is just that you did not have an equilibrium constant. You simply said it is stuck, and they said, yes, things stick. But then you digested it, and yes, it came off, just like if you had washed it without even having digested it it would have come off.

So that is the principle that I am defending. It is a straight-forward physical chemistry principle that, if you have a closed system, the thing just sticks to it just like with an antibody and it needs to come down if you spin it down.

Then, of course, some of the other studies, you know, we are talking about methodology, you know. So, you know, it is a matter of, you know, how well they washed it, and how -- whether they digested it, you know, and how you treat the melanin.

So, I mean, I am not having a particular, you know, problem, except, you know, we have to all obey the laws of physics and chemistry. If you have a high-affinity binding, it sticks to it when you spin it down.

DR. CONE: No.

DR. BAUMGARTNER: If you do not have the highaffinity, then there is no reason for things to accumulate in melanin. Now, there may be other mechanisms that people have discussed, but they may be correlated to them, you know.

When you say the grizzly hair, for instance, black and white hair, these hair differ. They are quite different, and you need to look at the extraction efficiencies. Many people use extraction methods. They do not do kinetics on it. They do not know how much they got out. They do not know what domain, they do not know what washes.

So those are interesting issues. But I do not have a principle to opposing that this happens. I am just simply saying when the data is of the quality that I would like to see, then, you know, we take the data and, more importantly, you can do a very simple correction for it with hair. It is not that I have a problem with it. We have some slides -- you just -- you know, you go two different distributions and you have two different cut-off levels. But, once you see the data and once you have the right methods for the methods, then you just simply apply a correction. But I have not seen the data, nor have I seen the methods. I am very open-minded on it.

DR. CONE: If I could just respond?

DR. BAUMGARTNER: Please.

DR. CONE: Binding has been characterized so many times by so many people, and we know a lot about the physical chemistry of substances binding to receptors, to surfaces and so forth. In all of the literature that I am familiar with, only covalent bonding sites that drugs bind through covalent bonds to those sites does binding become irreversible. All of the other types of binding that I am familiar with are reversible regardless of the affinity. It is an equilibrium phenomenon. It is a reversible process.

DR. BAUMGARTNER: Ed, everything is reversible.

There are labile bonds and there are not so labile bonds. It is well known. But the point is in the test tube you are not washing. It is a closed system. It is a closed equilibrium system.

I am not saying that you cannot wash this thing off, but we are talking about a closed system. In a closed system, you get an equilibrium. If the equilibrium moves toward melanin, if there are these drugs -- and I am sure there are drugs like that, then, down you go. But I fully agree that any binding has some degree of reversibility, but that is not in a closed system that I am working in when I am digesting the hair. It is a closed system.

DR. CONE: One more response, and I will quit. It seems like it is a totally circuitous argument to say that you can wash off drug that is bound to hair, but then when you digest it, that you cannot wash off the drug that is bound to melanin.

DR. BAUMGARTNER: But that is not what we are doing. We are not -- I am not saying that. I am not saying that I am not washing it off. I am saying I am letting it sit where it is and spin it down. It is a closed system. It is a different -- we are looking at a -- yes, it is a good thing to just think a little bit about the system. I will describe to you exactly the experimental conditions so that you can see. You know, it is like having the antibody and there it grabs it. But, yes, you can wash the thing off of the antibody. But we are not washing. We are not washing. We are digested -- the washing has occurred. We are talking the melanin -- we are not even touching the melanin in the inaccessible domain.

DR. CONE: I guess I would still repeat my first question and I will leave. I will not prolong it. Do you have any data to support your contention?

DR. BAUMGARTNER: The data is that I have done binding studies, and you can -- in fact, Nakahara's paper on that presented it. You can see that I have done binding studies on melanin in mice. It turns out that it has nothing to do with what happens to humans. His paper, our paper is going to come out. Yes, I have done binding studies.

DR. ALAN JONES: I have two short questions. One is to Dr. Baumgartner and one to Mr. Fogerson. Do you have -- you come to us with a lot of experience in hair testing and you do a lot. Do you have any recommendations to the individuals whom you serve, the clients, as to the maximum

lengths of hair that you would recommend they test? I mean, many people have different lengths of hair, short, and long, et cetera. What guidance do you give to those people?

DR. BAUMGARTNER: Yes. We have done about a million tests, over a million now. And the standard length is a three-month window, which is one and a half inches.

DR. ALAN JONES: I thought that is what it was. I just wanted to clarify it. You had mentioned that yesterday. Okay.

DR. BAUMGARTNER: Right.

DR. ALAN JONES: Okay. Thank you.

Mr. Fogerson, you had talked a little bit about contamination, environmental contamination. We have seen in the urine drug testing arena where topically applied or topical exposure can result in sufficient amounts particularly of cocaine, of benzoylecgonine appearing in the urine. Do you have any data in your test system that would parallel that or refute that where topically-applied cocaine could appear in this patch as either cocaine or its metabolite?

MR. FOGERSON: We do not have any direct data from a study of that sort. I mean, the best we would be able to do would be to sort of model the efficiency with which you would get transport across the skin, and then compare that to the percentage of positives we get in the clinical trials for a low cocaine dose. If the low cocaine does is even at 24 hours exposure, as I recall, we were getting something like 77 percent of the cases being positive. So, it would take more than a few milligrams of topical exposure to have a sweat patch positive.

DR. ALAN JONES: Thank you.

DR. HUESTIS: First for Mr. Fogerson. When your selection -- I noticed for cocaine and opiates that you had a screening and a confirmation cut-off of 10 nanograms per mL for both portions of the assay. Was that based on analytical limitations of the GC mass confirmations or was that based on the ROC curve analysis of the controlled clinical dosing?

MR. FOGERSON: The screening cut-off is based on ROC analysis. That actually was done subsequent to the GC/MS cut-off. The history of this development project was initially -- it was intended to be based on GC/MS data alone. The cut-off was set at 10 nanograms for a quantitative assay with an extension down to about two for nanogram for an LOD. That has not been adjusted relative to the screening cut-off. Probably one of the things that would make sense would be to adjust the confirmation cut-off relative to that 10 nanogram screening cut-off. Because the screening assay does combine the response to cocaine in BZE and EME. It would probably be sensible to actually be running a confirmation cut-off slightly lower than 10.

DR. HUESTIS: Yes. Because having just looked at some data, that is the same impression that I have.

MR. FOGERSON: Right.

DR. HUESTIS: And, also, your 10 nanogram per mL cut-off for confirmation is for each analyte, not a combination of the analytes?

MR. FOGERSON: Correct. The current practice is separately identified.

DR. HUESTIS: Okay. This is for Dr. Niedbala.

You had mentioned that the saliva and the urine data that you presented was in response to both THC and Carboxy-THC. What is the cross-reactivity in your assay to THC and Carboxy-THC?

DR. NIEDBALA: In the THC, this is developmental work that we are experimenting with different antibodies. I am trying to remember the exact numbers. But, in this particular case, it is a mix, so it is pretty much equivalent, but I do not remember the exact numbers off of the top.

DR. HUESTIS: We looked at saliva following control dosing. Your data, the initial test data looked very similar to our RIA data that we had previously tested which was just specific for THC, and we were unable to find any Carboxy-THC in the saliva. The saliva really looks like it is THC, but you are saying in the urine you think it is reactive with both?

DR. NIEDBALA: Yes. And, you know, again, this data is going to be developed over time and we will make decisions as to what looks best, again, based on ROC and larger studies, both with the random as well as the controlled doses.

DR. HUESTIS: For Dr. Steiner, in urine drug testing, we have a situation where we try and separate the medical review officers' role from the laboratory role in order not to have any conflict of interest. Especially in many cases, we do not want the MRO to have a vested interest in the laboratory. In test MRO work, are you actually employed by the employer? I mean, if you are right there doing this testing, do you have control over the onsite testing lab? Are you employed by the employer? How does that work?

DR. STEINER: Okay. Well, most MROs are employed by the employer. So, it would be no different than if you were to perform the onsite test as well, and then he would pass along those costs to the employer. So I think ethically it is the same situation as you have now, whether he performs the test onsite or whether he performs it through a laboratory. The same ethical questions are at play.

DR. HUESTIS: Okay. But, in this case, you actually are involved with the onsite testing, as well as a review of the results?

DR. STEINER: Right. You are closer to the situation, in that you have a vested interest in the laboratory test itself. So, yes, now it is double-jeopardy in that sense. That issue, you know, is potentially addressed right now. I think it is a new point and it is good that you brought it up. I think that a lot of MROs would jump at onsite testing because it could be an additional revenue screen to have the screening test done in their offices. So I think that that issue has to be addressed as well.

DR. HUESTIS: Okay. And just one other comment about the amphetamine problem.

DR. STEINER: That is a little bit out of context.

I took it for onsite testing. Maybe I did not make it clear. That is why we send them to the lab to confirm that.

DR. HUESTIS: Yes. I was not talking in relation to you. But we have heard a lot about the CV-derivative. But I think, my understanding is that it occurred with more than just the CV-derivative.

DR. STEINER: Yes. Basically, to clarify that issue, the phenethylamines, generally, the amines, the ephedrines, the pseudoephedrines, in very high doses, can trigger, in some of the over-the-counter, or some of the onsite testing, can trigger positives, and those need to be sent on to the lab.

DR. ROLLINS: Mike.

DR. WALSH: I just wanted to follow up on Ed Cone's question before about the fairness of two applicants being tested onsite, one testing negative, and the other one is presumptive positive, sent out of the lab, and the guy who tested negative gets the job.

One of the things that we struggle a lot with in writing the guidelines was trying to somehow deal with the fairness issue there. Initially, all of the results of a batch of specimens sent to the lab were supposed to be reported out at the same time. I think that the reality of the situation is today that, with all of the advanced management information systems, and voice-actuated responses, that employers can call in and download responses by various electronic means.

It is my impression that the negatives are generally available in the 24 to 36-hour timeframe, and the positives may be delayed two, three, four, five days, depending on how long it takes for the lab to report out to the MRO and the MRO to actually find the individual, run it through the system and get it reported out. So, I think, if somebody needs somebody on the job, as soon as possible, if they get a negative result back in 24 hours, the reality is that they are likely to hire that person and not wait for the negative that may be coming down the road.

I guess that another thing that we struggle with, and Mac may remember this, it was a very significant event for me, a meeting where we had all of the health agency heads, the head of NIH, and CDC, and HCFA, and so on, trying to decide who should be an MRO. Should he be a licensed physician? Could a nurse do this job? Could a physician's assistant, and so on? How do we set this whole thing up? I think, at the time we envisioned really a face-to-face evaluation, especially on this opiate issue of looking for clinical signs. I think that the reality today where the SAMHSA-certified labs are processing 60,000 to 70,000 specimens a day, face-to-face visits with the MRO are I think pretty rare. I think that that is sort of the reality of the situation that we have to sort of, as we begin to look at where we are with this program now 11 years down the road from where we started -- a lot of the issues about the accuracy and reliability of the technology, and a lot of the court cases have settled those issues, and there is an opportunity now to begin to look at new ways to make the program more efficient and cost-effective.

One of the things that does get confused in the discussion here is that the Drug Testing Advisory Board advises Dr. Autry on federal employee drug testing, which is a very, very limited scope. I think -- but, as we all have seen over the last 10 years, the gold standard obviously expands out to cover most of the testing in this country. So, you need to look at ways in which to improve the overall efficiency of the system, while not sacrificing any of the integrity of the program.

DR. ROLLINS: Thank you. Are there any further questions?

DR. KWONG: I have one.

DR. ROLLINS: Oh, sorry.

DR. KWONG: I have a question for the speakers.

For an individual who is on a pretty hefty maintenance dose of medication who has a strong anti-cholinergic activity, do you anticipate or do you foresee any problem in the sweat testing system or the saliva testing system?

MR. FOGERSON: I do not really have any data to answer that. The range of activity levels of the people who were involved in our trials was pretty great. There was no clear difficulty in detecting a given dose at lower ranges of activity. So, to the extent that you are looking at a function of sweat rate, unless you are talking about totally shutting down the sweating mechanism for a seven-day period, which I do not think is typically going to happen, I do not expect that they will be a tremendous problem. But it something that we ought to look at experimentally at some point.

DR. NIEDBALA: My answer kind of follows Bob's, in that, for some of the randoms we have looked at, I have not come across any situations where this has come up with a reason for weird results or unexplainable results. I mean, if I look at some of the lifestyles of people, unfortunately, who are addicted to drugs, you know, their activity is not a problem for them, in part, because of the types of drugs that, in many cases, we have tested so far. It is stimulating them to do all kinds of things.

DR. KWONG: If you anticipate that that might have some effect on your testing system, I think, you know, based on -- I do not think you can fish that out of what is your past experience because you would not know what to look for and you would not know what the outcome is. So, probably there will have to be a design study to see if there is any -- thank you.

DR. ROLLINS: Further questions?

[No response.]

DR. ROLLINS: If not, I would like to thank the panel. It is 3:35. We will come back in 15 minutes.

[Recess.]

Agenda Item: External Quality Assurance Program Panel

DR. BUSH: It is time to reconvene. We will be starting. I would like to convene the last panel for the afternoon, entitled External Quality Assurance Program. This panel will be moderated by Mr. Kenneth Davis.

I would like to talk a little bit about Ken, in the form of a bio sketch. Mr. Kenneth Davis, Jr. received his bachelor's degree in chemistry from North Carolina State University. Upon graduation, he accepted a position as a junior chemist with Dr. Mongrel Wall, of the Research Triangle Institute.

His early experience was in the synthetic chemistry and isolation and identification of anti-tumor agents from plants. In 1968, he began work on the isolation and identification of cannabinoids from marijuana sponsored by NIDA.

Over the next 20 years, his work included studies on the pyrolysis and smoking dynamics of marijuana and expanded to include a number of other abused drugs. Mr. Davis was instrumental in developing several dosage forms of synthetic cannabinoids including THC capsules. In 1983, Mr. Davis began working on the preparation and distribution of proficiency testing materials.

He developed methods for spiking drugs and metabolites such as the THC metabolites into urine, blood, and plasma.

In 1986, he performed a pilot proficiency testing study of urine drug testing laboratories for DHHS. This study was the forerunner of the National Laboratory Certification Program's current proficiency testing activity.

Mr. Davis and his coworkers routinely prepare double-blind proficiency testing materials for external quality assurance programs.

In 1987, Mr. Davis led a team of RTI staff and consultants which developed the external implementation aspects of the National Lab Certification Program for DHHS.

Mr. Davis continues to serve as the RTI Director for this program which has certified approximately 120 drug testing laboratories.

Over its nine-year life, the National Lab Certification Program has distributed more than 25,000 single-blind PT samples to applicant and certified laboratories, implemented effective procedures to prevent sample identification errors, refined methods for computerized scoring of laboratory PT results and performed approximately 1,200 inspections of laboratories.

I do not really think I can say anymore. At this time, I will turn the panel over to Mr. Davis.

Agenda Item: Principles and Criteria

MR. DAVIS: Good afternoon and welcome to this final panel discussion of this meeting. You know, I had a thought that could be important to some of you and I thought I would share it with you, in light of recent events. There are people in this world who would like to find this big a collection of drug testers in one place.

[Laughter.]

MR. DAVIS: This afternoon's subject is external quality assurance. Our speakers will be considering facets of external quality assurances that are applied in each drug-testing area, with respect to established principles and criteria for external quality assurance. The mandatory guidelines for workplace drug testing mandate performance testing and periodic inspections. I am sure that our speakers will be addressing those issues. In addition, they may also address other facets of external quality control, such as double-blind testing, and their remediation of testing facility errors.

Our first speaker of the afternoon is Dr. John M. Mitchell, who will speak on aspects of external quality assurance in urine/drug testing facilities. That Pepsi Cola did not do me much good. John has 15 years of experience in forensic urine drug testing. For 10 years he worked in the Navy's drug testing program, serving as Laboratory Director of the Navy's Laboratories in Norfolk, Virginia, and Jacksonville, Florida. During his tenure at these laboratories, he worked cooperatively with the addiction research center, in their studies concerning the excretion of cocaine, opiate, and marijuana metabolites in urine.

Dr. Mitchell is co-author of articles detailing the excretion of drug metabolites in urine as well as new methods for the analysis of drugs that would be used in urine.

Dr. Mitchell has done a number of the national laboratory certification programs for staff at the Research Triangle Institute since 1992. He serves as the Assistant Program Director, and is responsible for pre-inspection activities.

He is also responsible for the NLCP Performance Testing Program, which includes formulation and production of PT samples, shipment of PT samples to certified and candidate laboratories, scoring of the results recorded by laboratories, and remediation of errors reported by participant laboratories.

He is also responsible for reviewing and approving new laboratory applications for acceptance into the NLCP, review and acceptance of candidates for the position of responsible persons in a certified laboratory, and the scheduling, staffing, and implementation of inspections for laboratories certified by HHS to provide testing services for federal workplace programs.

He is also responsible at RTI for the performance testing program for the Canadian Accreditation program, which is known as LAPSA.

Dr. Mitchell will address external quality assurance in forensic urine drug testing laboratories. I might just share with you that all of us who are at RTI have received various nicknames. John is very affectionately known as old-Navy.

[Laughter.]

MR. DAVIS: In saying that, I just have to let you know that, in that same arena, they call me the grinch.

[Laughter.]

MR. DAVIS: John.

DR. MITCHELL: Actually, Ken, they call me Softy. [Laughter.]

Agenda Item: Urine Testing

DR. MITCHELL: Today, I am going to address my talk primarily to the forensic urine drug testing in federal workplace programs as it occurs under the National Laboratory Certification Program. I am not addressing the other forensic urine drug testing that is conducted outside of this organization. So, with that, I would like to have the first slide please.

External quality assurance in forensic urine drug testing. Provisions for external quality assurance have been an integral part of forensic urine drug testing in federal workplace programs since their implementation. These provisions were first published as part of the Department of Health and Human Services' mandatory guidelines in 1988 and have been retained through subsequent revisions. These guidelines have incorporated external quality assurance into all activities concerning the initial certification and maintenance of certification for laboratories that perform forensic urine drug testing for federal programs.

Quality testing must be functional prior to HHS certification. The three phases of the initial certification process, application, initial PT, and initial inspection, are designed to support that goal.

The candidate laboratories' application must document the status of the laboratory and its preparation for testing under HHS guidelines. It must document the laboratory's understanding and compliance with program requirements by providing evidence of a complete SOP, procedures for processing and testing specimens, procedures for recording specimen results, adequate facilities, appropriate equipment, trained and qualified personnel, and adequate chain of custody, security, and quality control.

The initial certification PT exercise consists of three sets of 20 samples, spiked with varying levels of the required analytes and also compounds that have the potential to cross react or interfere with the testing methodologies.

These samples are designed to verify the performance of the laboratory's test procedures at the level expected of a certified laboratory.

A laboratory will be disqualified from further consideration for certification if it produces a falsepositive result, if it fails to identify 90 percent of the total analyte challenges, fails to quantitate 80 percent of the total challenges within 20 percent of the reference mean, fails to quantitate any analyte challenge within 50 percent of the referenced mean, or fails to identify and quantitate 50 percent of the drug challenges for any analyte within 20 percent of the referenced mean.

After successful completion of initial PT and concurrent with the third set of PT samples, candidate laboratories undergo their initial certification inspection.

An inspection team comprised of two inspectors evaluate whether or not the laboratory has met the requirement of the mandatory guidelines, as well as other guidance documents found in such as the NLCP Guidance document for laboratories and inspectors, and the NLCP Program documents.

Items to be evaluated are contained in the NLCP inspection report, which is completed by each inspector. All procedures, security, documents, personnel, facilities, equipment, reagent, quality-control and methodologies to be utilized by the laboratory in testing and reporting of regulated specimens are reviewed to ensure that they meet HHS guideline requirements and forensic standards.

Initial inspections have one of two outcomes, even though three are listed here on the slide. They are acceptable or fail. Acceptable laboratories are required, prior to being recommended for certification, they are required to enter into a remedial process to complete any issues which are found deficient during the initial inspection. After they have successfully completed the corrective actions, they are recommended for certification to HHS.

Laboratories that fail the inspection because they are found to have numerous minor, easy-correctable deficiencies, and that would be failed one, can be certified after entering and successfully completing a remedial process. They are required to develop a plan of action within five days for the correction of the deficiencies and complete those corrective actions within 30 days. After successful completion of those corrective actions, the laboratory will be recommended for certification.

Under the fail two category, laboratories which fail with major deficiencies or numerous minor not easily correctable deficiencies will be allowed to re-enter the initial certification process after completion of extensive remediation. Then, if the laboratory successfully completes an additional set of PT samples, successfully reanalyzes the PT samples from three previous cycles, and successfully completes an initial certification inspection and any additional corrective actions resulting from that inspection, it will be recommended for certification by HHS.

Once certified, testing quality is monitored by quarterly PT challenges, semi-annual inspections, blind quality control samples, and re-test of specimens previously reported positive for drugs of abuse.

Certified laboratories are required to maintain the minimum performance standards states in the mandatory guidelines and participate in remediation concerning PT errors.

Now, the minimum standards that are required of the laboratories are those that were previously stated for a laboratory to meet in the PT area prior to becoming certified.

The quarterly PT samples consist of a set of 15 samples designed to challenge each testing methodology utilized to report a specimen positive for the authorized analytes. These samples will, over the course of 12 months, challenge the specificity and cut-off accuracy of the laboratory's initial test procedure. They will define the ruggedness of the laboratory's GC mass spec procedure, test its ability to identify and quantitate the analytes of interest over a wide range of analyte concentrations, evaluate the effectiveness of the laboratory's carry-over procedures, and assess the specificity and accuracy of the confirmation procedure and the presence of compounds known to interfere or have the potential to produce technical false-positives.

After each set of PT samples, the laboratory is notified of its performance to include the score for the most recent PT cycle, the cumulative score over the most recent two PT cycles, and the identify of any errors. The laboratory is also notified of major errors in other incidents (sic) identified by the PT process which require corrective action.

Remedial action required due to errors, problems, or program issues identified by the PT process is monitored and reviewed by the NLCP staff at RTI. Implementation of the corrective action resulting from the remedial process is reviewed by the inspectors during the laboratory's next maintenance inspection.

Minor problems require corrective action and notification of the NLCP when that action has been completed.

Major errors require the laboratory to formulate an action plan within five days of notification and completion of the corrective action within 30 days. In addition, the laboratory with a major error may be required to audit and/or retest previously reported positives. It may be suspended from testing for one or more drug classes, and also it may face suspension and/or revocation of its certification, depending on the seriousness of the problem uncovered by the PT section.

Semi-annual certification maintenance inspections review the laboratory's implementation of guideline requirements and corrective actions required as a result of prior inspections and maintenance PT. These inspections last for two or three days and involve two, three, or four inspectors. The number of inspectors and the number of days onsite are determined by factors in the laboratory which impact upon the resources required to conduct the inspection.

The NLCP Laboratory Inspection Report is utilized by each inspector to determine their findings and evaluate the laboratory. These reports are synthesized by NLCP staff into a single critique listing comments and observations resulting from the inspection.

Based upon the review of the report submitted by the inspectors, the inspection outcome will fall into one of four categories: Acceptable, minimally-acceptable, unacceptable, and failed.

Laboratories not receiving an acceptable outcome will be required to complete remedial action. These laboratories must successfully complete the corrective action in order to remain certified.

Issues from a failed outcome are evaluated to determine their impact on the quality of results reported by that laboratory. If it is determined that continued testing could result in inaccurate results being reported, HHS will proceed with suspension and revocation proceedings as outlined in the guidelines.

In the absence of imminent harm, the failed laboratory will be given three months to correct the deficiencies and undergo reinspection.

Outside of the NLCP, we also have a blind-folded control program. HHS, DOT, and NRC guidelines require that employers of individuals whose specimens are submitted to certified laboratories as a result of federal mandate, must also submit blind QC samples to those laboratories. The results reported for these samples must be monitored by the employer or agency. The rules governing acceptable performance on these blind samples are the same as those for PT samples.

The problems identified from the results reported by the laboratory are investigated by the cognizant agency and will, in the event of a major error, also involve HHS and the NLCP, with the consequences that were previously

listed for PT sample major errors.

Specimens which have been reported as positive are subject to retest at the request of the donor. These retests are conducted at a laboratory other than the laboratory that originally reported the result. Retest results will be reported to the cognizant agency by the MRO when the retest fails to reconfirm the original result.

Each instance is investigated by HHS. If it is determined that one of the laboratories is responsible for the failure to reconfirm, the laboratory will be required to undergo remedial action to prevent a recurrence of the error. The laboratory could also face suspension and/or revocation of the certification.

In summary, external quality assurance and forensic urine drug testing for federal workplace programs begins when a laboratory submits an application and is continued in the initial and certification maintenance processes. Integrated into these processes are inspections and performance testing which provide checks to ensure that quality is present and maintained. Other quality checks, such as blind QC program, and retest of previously reported positive specimens, challenge the system as it operates on a day-to-day basis.

The certification maintenance process is further strengthened by the regulatory portion of the guidelines which require successful completion of corrective action on problems or potential problems are identified and suspension and/or revocation of certification when a laboratory fails to meet the program requirements.

Thank you.

[Applause.]

MR. DAVIS: Our next speaker is Dr. Hans Sachs.

Dr. Sachs received his Ph.D. in physical chemistry after his dissertation about paramagnetic resonance examinations of the manganese tuon (sic) in tetrahydronal environments.

Beginning in 1977, he was the forensic toxicologist in the Institute of Legal Medicine in Muenster, Germany. From 1981 to 1995, he was head of the Forensic Toxicological Laboratories in Olm, and Vice Director of the Department of Legal Medicine from 1993 to 1995. He is a member of Legal Medicine, Chemistry, and Forensic Toxicology Societies in Germany, and a member of the International Association of Forensic Toxicologists.

He has more than 40 publications about blood alcohol, forensic toxicology, and especially hair analysis, including the first determination by GC/MS of morphine and codeine in human hair in 1985. This work made it possible, for the first time, to distinguish between regular heroin abuse and consumption of codeine-containing drugs. He is President and a founding member of the Society of Hair Testing in Stasburg, France.

Dr. Sachs will speak to us about external quality assurance in hair testing. Dr. Sachs.

Agenda Item: Hair testing

DR. SACHS: Thank you, Mr. Davis. Also, I thank the Drug Advisory Board for having the Opportunity to present our external quality control system on hair analysis. You may wonder at the end that you have so many slides printed in the manual which are not shown here. The reason is a misunderstanding about what I had to talk about which was so firmly in the last days (sic). I will give the correct copy of the slides to the organizers.

After each of the conferences dealing with hair analysis in Abudabi, Tampa. Strasburg, and two times in Genua, in the final discussions, it was stated that proficiency tests would be needed.

In the early 1990s, there were only three groups providing external quality control. NIS started with soap tests, trans, and changed later to drug users' hair. The change was to find out the positive of acetylmorphine, morphine, cocaine, and benzoylecgonine. Sometimes the challenge was to recognize the contamination. The results of the participants matched better with every new exercise.

There were about four exercises until 1995. A recently organized study included one specimen spiked with amphetamine and methamphetamine.

In Europe, we had two groups providing interlaboratory comparisons. The Institute of Legal Medicine in Munich and Hamburg, which worked together and the Paschal in Strasburg (sic). Some European labs participated in the NIS study until, in 1995, a NIS representative announced that they were going to stop the program because of lack of money.

That led to the formation of the Society of Hair Testing and the German and French groups decided to have one program. In the meantime, some other groups prepared their own studies like, in Florida, Dr. Goldbagger has also contacted some laboratories in Europe to play a role as reference labs.

The study begins with a production of several hair proofs. In contrast to urine and blood analysis, we have to face one problem. In spiked powdered hair samples -- in spiked hair samples, the added substance together with the internal standard, lies on the surface of the surface of the blind hair and can easily be washed away from that surface and will be present in the extract without telling us. But the challenge is to measure the quantity of the incorporated substance, and finally, to answer the question do the participants detect the right mark, and what are the deviations in quantitative results?

Three sorts of hair pools are usually provided by the organizer of inter-laboratory studies: Hair free of drugs, hair spiked with drugs, hair with incorporated drugs.

While the first two sorts of pools can easily be produced by using negative hair, we have to take the hair for addicts to prepare a hair pool with the incorporated drugs. Most of the hair samples come from the autopsy cases after fatal drug intoxication.

At first, one hair strand is examined to detect whether it was really a regular drug consumer and whether he consumed opiates or cocaine. The samples are never used in one pool, but are divided in opiate and cocaine positive samples. This was one simple reason. If we will put them all in one pool, a cocaine-positive but opiate-negative sample will decrease the opiate concentration and the other way around. Finally, cocaine and opiate hair pools are separately homogenized in a bowl.

The next step is to control the homogeneity. This is controlled by a ten quantitative analysis in the same run in the reference labs. The homogenizing procedure has to be repeated and samples are analyzed again by the reference lab. If the standard deviation of the new analysis is smaller than the first one, the homogenization procedure has to be repeated until the standard deviation no longer changes. These hair pools can be used for internal quality control and inter-laboratory comparisons.

One of the difficulties in evaluating inter-laboratory comparisons is to fix a limit or range of acceptable results. While NIS uses the mean and the standard deviation of the participants to find any outliers, in our program, three reference labs are involved. According to the guidelines of clinical chemists in Germany, each reference lab has to determine each component in 10 different days. All will be taken to calculate the standard deviation of the referenced labs.

The possible procedure known from the external quality control of the determination of drugs in blood of drivers in Germany is to affix a limit of three standard deviations of the referenced labs.

In the last study, before the foundation of the Society, the participants had to analyze five hair samples.

In one of these samples, 6-acetylmorphine, morphine, and codeine had to be determined quantitatively. In the other one, cocaine, benzoylecgonine -- and benzoylecgonine (sic) had to be determined quantitatively.

To give an example, the results of acetylmorphine are listed in the table. The range of the results of the referenced labs lay between 3.2 and 4.3, and the range of the participants between 1.2 and 6.3.

Traces of opiates in samples with high cocaine concentrations and traces of cocaine sampled with high opiate concentrations were not always identified with all correct reports about the negative sample.

In this slide, the numbers of the labs which would have passed the test are given. While 13 out of 18 labs found an acceptable result of acetylmorphine, but there were only nine of 22 with correct cocaine results.

The proof samples for the first test of the Society in December 1996 were prepared in the Institute of Legal Medicine in Munich. The homogeneity was tested by the Institute of Legal Medicine in Strasburg and in Hamburg.

The referenced labs for the Institutes were in Strasburg, Hamburg and Paris.

The challenge was to determine acetylmorphine, morphine, codeine, cocaine, benzoylecgonine and cocaethylene quantitatively in two samples and to report negative or positive results after the examination of four further samples.

Most of the participating labs in Germany and Italy were Institutes of Legal Medicine, like in Geneva, Berlin, Frankfurt, Milan, and Rome.

The Institut de Investigacion in Barcelona is an International Olympic Committee-accredited laboratory led by Dr. Segua. For example, the Bavarian State Crime Lab is the biggest crime lab in Germany.

The Laboratour de Toxicologi in Luxembourg is the lab of the T.F. President.

The National Institutes of Health Science is the Lab of Dr. Nakahara, who is well-known as a hair analysis scientist.

You know probably much better than I do the labs from the -- the participating labs from the United State and Canada. There was even one participant from Santiago de Chile.

The certification will only testify that the results of a special compound lay in the range of three standard deviations of the control laboratories and that there were no false-positive results examining negative pool hair and no false-negatives with a cut-off of 0.5.

The data have been evaluated last week and the participants are not yet informed about their results, but we can already say that they were much better than in the test of 1995. There were six false-positive and one falsenegative, but only two labs were involved in these faults according to the criteria of three labs -- of the criteria, only three labs failed the test.

The aim of these studies was to control only the quantitative determination of the laboratories for a proficiency test that is worthwhile to include the sample preparation and washing procedures. But, for this purpose, we would need homogeneous hair proofs containing strands with longer hair which are difficult to produce if it is possible at all.

In future exercises, specimens of drug users containing amphetamine and cannabinoids will be added. The published results of the study organized by Dr. Kents concerning amphetamines were not satisfying.

Also, it is well-known that some laboratories may be using MSD and GC/MS NCI find higher values of Carboxy-THC than others using GC/MS/MS. These problems have to be solved by future comparisons. These exercises will be continued, if possible, twice a year.

That was all I could say concerning the proficiency testing program.

The report about laboratory inspection programs is very short. To my knowledge, there does not exist one.

[Laughter.]

DR. SACHS: They need money, they need experienced inspectors, and guidelines, and we have neither one nor the other.

At last, at least in Europe, it will be hard to find someone to sponsor such a program.

Thank you very much.

[Applause.]

MR. DAVIS: Thank you, Dr. Sachs. Our next presenter is Dr. Richard Anderson. Dr. Anderson has his doctorate in physical chemistry from the University of California-Davis. He has 16 years in development and marketing positions with Miles Laboratories, Hybertech, Inc., and biosite diagnostics. He has nine years' experience in development of abused drug immunoassays. He is currently the Director of Customer Support with Biosite Diagnostics.

Dr. Anderson will speak to us about the external quality assurance and onsite testing. Dr. Anderson.

Agenda Item: Onsite Testing

DR. ANDERSON: Well, let me say good afternoon, after having my chance earlier to say good morning. I am going to speak about external quality assurance with regard to onsite. My talk is going to be split into two halves. One part is going to be a little bit on the theoretical what probably should happen in order to use onsite tests, and the second is going to cheat a little bit and change gears from the forensic area to the medical to give real-life examples of what is possible.

In terms of the issues associated with onsite tests, they are, of course, the same as done currently in forensic labs, and that is, of course, that you need a laboratory test site inspection of some form. I think the issues for onsite we should really focus on, of course, because the onsite testing is going to be done primarily in the location of collection, is to focus on issues associated with that, in other words, sample collection, testing, and storage facilities for the samples. Obviously, that is to guarantee the integrity of the samples, as well as the test results. It does have an implication for exactly how confrontational the sample testing would be. Because, in my own personal viewpoint, the testing actually will be done outside the view of the sample donor.

In terms of quality assurance and quality control, both of those, of course, are important. I think that the testing facilities certainly can follow things like the CCLS guidelines, like CP282, for procedures on how to do testing that have certainly been applied in the medical arena.

As far as inspection program goes, our suggestion from NOTA is that the thought process for inspecting testing sites for onsite be -- onsite drug testing be -- follow along the sorts of protocols that are currently in place for the onsite alcohol, non-evidential alcohol tests.

Certainly, there are a couple of issues with regard to onsite that are a little bit unique relative to the current forensic laboratories. Probably the biggest one has to do with the mere fact that there was no expectation at this point that onsite testing facilities will be doing confirmation. Relative to the in-place federal guidelines, that is probably one of the biggest places where there is a need for a change in the guidelines as written down, mainly that testing is allowed to occur at physically separate facilities.

I think that the inspection process certainly will focus heavily on the chain of custody and collections since, quite frankly, if you do not have good quality sample collection, in the first place, really the process, as a whole, begins to break down.

Again, the inspection program probably should mirror that of a non-evidential saliva alcohol.

Okay. Now, I am going to change gears a little bit and focus a little bit on reality. I saw a funny thing the other day on television. I have a 10 year-old, and, of course, they are hooked on Nickelodeon. Nickelodeon had an interesting thing, of course, with kids these days, games, particularly computer games, which are generally thought of as virtual reality, and Nickelodeon was pushing the concept on children that actual reality had some validity. So, I would like to shift gears here a little bit to actual reality on proficiency testing programs.

Really, again, the issue with onsite is that it is not going to use -- would not utilize probably the sorts of proficiency testing programs that have been traditionally used simply because the sites are not going to be doing the full spectrum of testing. They are not going to be doing confirmation as well as screening.

So, what I have on this slide is a list of sort of complementary programs that are currently in place mostly from the medical side. The first one is the College of American Pathologists. They have a very nice survey, the urine drug screening survey. That is sort of a complement of their forensic-oriented proficiency testing program for the UDC or urine drug confirmation.

New York has a complementary set of programs in a similar sense. There is an emergency toxicology program, which sort of parallels the forensic toxicology. Again, the focus being on the screening component, and not the confirmation component.

The last one on the list here is the American Association of Bioanalysts. They have a program much like the CAP, although, typically, the sample challenges tend to be not quite as challenging as the CAP urine drug screening program.

I kind of like this slide because it took me a long time to finally get the graphs to behave it turns out in power point. I like this slide because it really, again, illustrates the issue of the fact that even within the proficiency testing programs, there is really an acceptance of the concept that you are going to get the wrong answer some fraction of the time. You are not allowed to get the wrong answer a lot of the time, but there is an understanding that depending upon where the sample challenge is placed relative to the sample cut-off, you can expect some fraction of the labs, on a normal statistically-based analysis, to provide, if you will, the wrong answer. That is illustrated in this slide, again, by a zero being the fraction of the cut-off, this particular challenge being at 20 percent of the cut-off and the expectation that there is an allowance for surveyed laboratories approximately 10 percent of the time to provide a negative for what is ostensibly a positive sample.

I know a little bit earlier today there was a question about interpretability as with respect to the ability of assays to resolve samples one from the other. I am going to have to apologize to the Advisory Board. I am going to have to provide you with a new handout for this page. I noticed today, as I was looking at the handout, that the onsite graph is displaced, which was an error when I transferred the slide from color to black and white for better printing. I will provide you with an improved slide.

What you see on the yellow solid line are genuine results for an onsite method screening, visually screening cocaine samples at a selected group of points. In red is a more theoretical curve calculated from the stated precision data for one of the laboratory methods. What you see is that certainly there are zones within the concentration in the vicinity of the cut-off that essentially each assay makes an error. The sample concentration either is negative or positive.

In the strictest analytical sense relative to the cut-off in the assay methods, provide incorrect answers either in that they are not all positive or not all negative. But what I think is important to realize is that the width of the grey zone or the width of the resolution zone is approximately the same in both methods. So, it is not that you do not get the wrong answer some of the time, but you get the wrong answer some of the time with both methods, and you get it at roughly the same rates.

Now, this slide, what I had taken of it, there is a little bit of a slight of hand on this particular slide because not all of the data is easily extractable from the CAPs, urine drug screening/urine toxicology surveys. But there is enough information contained within their final critiques published over the last five years, that you can extract approximate fractions of users on those surveys for a variety of methods, EIA, FPIA and, more recently, the onsite method.

What I really want to point out is, while the absolute values may be a little bit in error, the relative values are definitively as laid out in this particular graph. What you should note is that the approximate number or fraction, if you will, of the total of the onsite providers are about half of the total. In fact, it actually sums up to about the same number as the two primary reference lab methods sum together.

What I think is important about that is that medical labs have to go through a certification process just as the forensic labs do. Rosemarie is nodding her head on that. They suffer decertification just about as readily as the forensic labs do. I can easily assure you -- I get enough phone calls myself as in charge of customer support, that laboratories which have suffered, if you will, damage during the course of a proficiency survey, are not reticent in informing me of that fact, as an example, the fact that they are having trouble. We do not get a lot of phone calls of that nature. That is the reason why you see the onsite methods as widely adopted.

The other aspect that I think is important to recognize on the medical side is that it is a little bit of a quirk in the medical law that laboratories, of course, can use more than one testing method for a particular analyte. In the drug testing methods, you may find labs who at least use one of the other EIA and onsite -- in conjunction with onsite. However, what is required within the medical community in terms of efficiency testing is you must test with your primary method for the purposes of reporting to the proficiencies. So, again, you need to realize that about half of all of the medical labs testing within the CAP proficiency testing program are using onsite methods as their primary method.

Secondarily, it is important to realize that most, unlike the forensic side, and you may disagree with this operationally, but, nevertheless, this is how they do it.

On the medical side, laboratories do not generally confirm. Actually, the medical folks operate a little more loosely than the forensic side do. In fact, they depend much more heavily on their screening results because that is really the only result analytically that they have. They combine those obviously with attending physician diagnoses of medical conditions. So they really depend on these results quite heavily.

Now, this is the other one of the major agencies, the American Association of Bioanalysts. I show this graph only because it is boringly similar to the graph that precedes it. Again, the approximate fraction of users using onsite methods is about half of the total and it is about equal to the number of the sum of the numbers that people are using EIA and FPIA methods.

The last couple of slides. I would just like to take a couple of quotes relative to, if you will, testimonials, although unsolicited somewhat from final critiques written up by the CAP's toxicology community when evaluating results for CAP surveys. They were very kind in doing that.

The first one is that they note that, for the respondents on the CAP -- let me just note that the approximate number of labs participating in that is about 2,200 -- that essentially all of the labs participating basically got the right answers. So, again, if onsite methods were producing wrong answers at a high rate, you would not see that 99 percent of all of the labs were basically producing correct answers.

The second quote from this particular survey, which was at about the middle of last year, is that, while there are errors made in the surveys, quite naturally, it turns out that the errors, in general, are roughly equally spread against the testing methods being used. They do not necessarily focus on one method specifically.

I have just a couple of quotes from the last survey from last year again. They noted that pretty much participation or performance by labs participating in the survey was quite good. Some, again, 99 percent of the participating facilities correctly identified the challenges.

I think another issue -- I picked this quote simply because it was on the other side of the coin from false-negatives, which was false-positives. Again, remember that the laboratories on the medical side are depending upon the screening results to give their one and only answer as to what is wrong with that person presumably down in the E.D. That fact was that, at least within the challenges that were presented to the labs within this particular survey, the false-positive rate was noted as being extremely low.

The summary that I would like to leave you with is that I really cannot present this sort of information on the forensic side because, obviously, the participation of onsite methods in the forensic area at this point is really heavily delimited. That is part of the purpose for this conference.

But I do want to leave you with the thought that, on the medical side, some -- at this point, oh, of the order of about 2,500-plus medical labs in the U.S., onsite methods are used. They are used a lot, and they are used pretty much as the primary method. In fact, for any of you who might have an opportunity, at some point in time, to visit an E.D., post an accident, a car accident or something where an attending physician applies a drug test to you for whatever reason, chances are about 50 percent that the drug testing method that they will use on you in a hospital laboratory will be an onsite method.

With that, I would like to say thank you.

[Applause.]

DR. MITCHELL: Thank you, sir. Our next speaker is Tim Rohrig, who has already been introduced to you during the course of these proceedings, so I am going to abbreviate this a bit. Dr. Rohrig is currently the Vice President and Director of Toxicology of Osborne Laboratories. Prior to joining Osborne, he was Chief Toxicologist and Laboratory Director for the Office of the Chief Medical Examiner in the State of Oklahoma.

His previous positions include Toxicologist for the Office of the Chief Medical Examiner, the State of West Virginia, the Chief Toxicologist for the Kansas Bureau of Investigation's Forensic Science Laboratory. He has also held academic appointments at the University of Oklahoma and Rockhurst College.

Dr. Rohrig also serves as a consultant on medical/legal issues related to post-mortem and human performance toxicology. He has authored 15 peer-reviewed articles and given numerous scientific oral presentations in the field of toxicology.

Dr. Rohrig will speak to us about external quality assurance issues and saliva testing.

Agenda Item: Saliva Testing

DR. ROHRIG: Thank you, Ken. I was glad to hear you were going to abbreviate the introduction. I hate to have the introduction run longer than the actual presentation.

[Laughter.]

DR. ROHRIG: External quality assurance for an oral fluid drug testing program. As we heard earlier today and the day before, as far as an external QA program, there are essentially three components: Inspection, proficiency testing, and remedial action, that all relate to a QA program for a production laboratory.

As we heard yesterday, and as we have heard already today, for the alternate fluids or the alternate matrices, there is not an inspection program. We really do not have external proficiency programs for the alternative fluids, oral fluid, for instance. Since Mike Peat, and Sam, and I, and the production areas do not make mistakes, we do not have to worry about remedial actions.

[Laughter.]

DR. ROHRIG: I wish it was that simple though.

The one thing, though, that is in the industry that uses oral fluid in a high-production basis, that is the insurance industry -- quality assurance is a concern to these people. They are paying money, a lot of business decisions are being made on these laboratory results. So, one way they approach this problem is many of the companies who submit samples will actually split -- and I do not mean

split the applicant's specimen, but, you know, Mike's lab may get half of the specimens collected for a company, and our laboratory may get the other. What they do is they monitor the hit rate, the number of positives and using that as at least a gross loose measure of how the laboratories are performing at least compared to each other. Now, if they are both doing a terrible job, it will be unknown to them. But, if there is a significant difference between the number of HIV hits or the number of cocaine hits, or whatever, that is an indicator that there may be a problem with the laboratory.

As far as certification inspection process, the production laboratories that are doing the oral fluid testing now were not operating in a vacuum, in the sense that our sole purpose in life is not to test spit for drugs.

We do a lot of other testing which we are either forced or because of market pressures, we must be inspected, we must be regulated, as far as just overall quality science in the laboratory. CLIA, for instance, will extend its arms into our laboratory and make sure that our overall production, overall laboratory testing meets the requirements of CLIA88. Now, under those guidelines, they do specifically exempt forensic testing. But then, a lot of times, the inspector will come in and they will say, well, saliva, oral fluid is not workplace testing. It is not a crime lab, so we are going to look at it. Other inspectors may not want to look specifically at the cocaine testing, for instance. But, in the same laboratory, we may do HIV testing. So there is still concern about the qualification of the people doing the testing. Are the pipettes calibrated? Do we have the charts on the refrigerators to monitor temperature? Are all of the reagents within the proper expiration date? Are they labeled appropriately?

So there is some inspection process in the production laboratories that are doing oral fluid testing today.

CAP is another certification program. Mike's lab and our lab are also inspected and certified by CAP. They will come in and they look at all aspects of the laboratory testing. So the program is not specifically aimed towards oral fluid testing, but they are looking at the laboratories overall and making sure that at least the quality of science coming out of these laboratories meet at least the established minimal guidelines.

NLCP does not come into our laboratory. When they go into the other laboratories they focus in on the urine drug testing. But this is something that, if they choose to use oral fluid for workplace testing, through proper training of the inspectors so they understand the nature of the oral fluid test, is something that they could easily expand into.

External proficiency programs. It is a must.

Like I said, we really do not have one right now. So one of the issues is, if we want to come up with an external proficiency program, we need to keep a couple of things in consideration. One is we have what I call here the liquid samples, or the spit samples, or you expectorate into a cup.

Is the external quality control sample, the proficiency sample that is submitted to the laboratory for testing, is it going to be in that fashion? Well, at least in the insurance industry we do not get saliva samples, oral fluid samples in this fashion. We get saliva samples, oral fluid samples on oral fluid collection devices. I have it pluralized up here because I want everybody to understand that there is not just one device out there. There are several devices out there.

One issue that came up is, well, how do you know if the sample collected was enough? Well, some of the devices actually have what they call an adequacy indicator on there. What it does is it loosely measures the volume of oral fluid that is soaked up on this pad. Another approach, which we do for our HIV testing, is we actually measure is there a minimal amount of IgG or IgA on that sample, and also we determine if it is human or not to make sure that we are not testing Rover.

Then the other issue that comes up with proficiency testing is what compounds are we going to put in here. I have the stuff up for cocaine, but this could apply to opiate testing. Are you going to put heroin? Are you going to put morphine? Are you going to put codeine? Are you going do put 6-MAM? Are you going to put all of these compounds on there?

What do we know about the stability of these compounds in these various devices? Some oral fluid devices are just a dry pad. Other oral fluid devices have a buffer around 6.5. So what is the stability of heroin, for instance, in an oral fluid device that is buffered at 6.5 over several months that will go to several different laboratories?

The same thing would apply to cocaine or cocaethylene. What is the stability of this compound on there?

And, also, what is the utility? Are we using this as a surveillance tool? Some of the data I showed yesterday shows that cocaine, and this was from Dr. Cone's one study, cocaine drops off very vastly, but, in a chronic user, you will see some build-up of benzoylecgonine, or the metabolite in oral fluid. We have kind of borne this out by comparing oral fluid samples to our urine samples, as far as -- we get about the equivalent hit rate. So what actual target compound are we going to zero in on in this proficiency program?

The last comment that I would like to make on this is Dr. Peat raised an issue yesterday, and a very valid one, which was, if we are trying to use oral fluid to match the surveillance window of the detection window as urine, we have to get down to very, very low concentrations. He threw out the number of 10 nanograms per mL. With normal GC/MS and the electron impact mode, that is a challenge. We have very, very small sample sizes to test. I can only share with you some of our data.

Yesterday, I showed you a chromatogram showing an eight nanogram per device control. This was our below cutoff control, our 10-day CVs, and also CVs over like a month period or something run generally below 10 percent. So it is a challenge. But, even at that low concentration, with routine laboratory equipment, one can get down to levels that at least we found in our laboratory and also I would suspect, since I have not heard the contrary, in Dr. Peat's laboratory, that our saliva hit rate will mimic what we are seeing on urine samples and at least is usable in the industry that we are testing for, and that is the insurance industry.

Thank you very much.

[Applause.]

DR. MITCHELL: Thank you, Dr. Rohrig. Neil

Fortner has also spoken to us during the course of this meeting, and I will also abbreviate his introduction with his permission.

Mr. Fortner joined Pharmchem in 1991 and has served as Director and Vice President of Laboratory Operations. Prior to joining Pharmchem, he served as the director of toxicology at a certified forensic drug testing laboratory. Mr. Fortner has more than 15 years' experience in forensic toxicology. He is the designated responsible person for Pharmchem's forensic drug testing laboratory. He is a DHHS and CAP laboratory inspector, and a member of the American Association of Clinical Chemistry, the Society of Forensic Toxicologists, and the American Academy of Forensic Sciences.

Mr. Fortner is also a member of the American Board of Forensic examiners. As Vice President and Laboratory Scientific Director, he is responsible for the technical quality and reliability of the test results. Mr. Fortner will address the external quality assurance in the sweat testing laboratory.

Agenda Item: Sweat Testing

MR. FORTNER: Thank you, Ken. Maybe to reflect on Tim's comment, the introduction may exceed the length of the presentation. Although I have the unique opportunity, and you should welcome my appearance because I am the last speaker here today.

[Applause.]

MR. FORTNER: When Walt called and asked if we would be interested in participating in the Drug Testing Advisory Board Panel, we certainly welcomed that as an opportunity. As we sat and looked through the criteria that we wanted to address, things went along fairly well until we got to this last section. When you go and look at the infancy of sweat testing, and, as you leaf through the presentation already, I will cut to the chase and say, at this point in time, there is no quality, external quality assurance or laboratory onsite inspection program that exists for sweat testing.

If you look at the analytical data that is presented in the last few days by Dr. Armbruster,

Dr. St. Clair, and Bob Fogerson, you realize that this testing, in many ways, mimics the urine testing programs that are very well-established under HHS. And, in fact, what I would submit to you is that we go through and talk about the development of quality assurance, external proficiency, onsite inspection, you will see that those programs would lend themselves quite well in the adaptation.

Now, certainly, we are talking about in alternative fluids slightly different analytical approaches.

We have already seen the screening applications, like the HHS Mandatory Workplace Program. These are done using FDAapproved immunoassay. They follow a very similar scheme in terms of the calibration and quality control requirements. I think that if you were to take a number of the colleagues who are in the audience today who serve as SAMHSA inspectors, you would be able to go through a slightly different orientation program just to familiarize them with the types of data that are released from ELISA assays, get them used to looking at nanogram cut-offs of 10 nanograms per mL, as opposed to 50 or a hundred or 300. The inspection process would lend itself quite well.

Similarly, because all of the confirmations of hatch technology are done using GC/MS, it is at slightly different levels, but also using derivatives, salt-phase extractions, that are very common in the urine application programs, again, application development of an onsite inspection program I think does lend itself quite readily.

Now, you could follow the two guidelines that are currently out there for forensic urine drug testing. Either one of these programs I think would fit quite well. There are many similarities in there. Certainly, all of the aspects in terms of internal quality control from the specimen collection, from the initial receipt, certification, security, initial testing, certification of those reagents, temperature-dependent instruments, heating blocks, pipettes, are all integral parts of that inspection program.

Now, the program, you know, both under SAMHSA, and under the College of American Pathologists, Forensic Urine Drug Testing, if you were to just change the name and say sweat, and change a couple of the inspection checklist questions, you could probably go right down through and do that type of approach. So it does lend itself quite well.

The Test Site Proficiency Program. There is currently one that has been developed that has not been implemented at this point in time. Most of the sweat testing that is done today is done in the criminal justice arena. Several of our large clients have worked with Dr. Roulette, at DOL Research, and he has developed an onsite or a proficiency testing program designed around the sweat patch. How do you do that? Well, it is fairly easy to go do because, in the same way that we run both open and blind controls, we take patches that have been worn by individuals and spike them. Now, you can spike them in lots and do replicate analysis to determine the mean, and then submit those in either as open or blind proficiency samples. So, very similar to the way that the SAMHSA Program or the CAP/UDC programs work, in which you are sent four or five materials or sent materials that contain no drug, would lend itself, again, to this particular application.

It is relatively easy to do. The drugs, once spiked on the patches, do have some very good stability primarily because they do exist in a dry form. They could be then mocked up on chain of custodies and mailed into the laboratories either as open or blind approaches. Then, after that, the results, very similar to the way the federal program or the CAP program runs, will be sent back overnight.

As I say, this is a unique opportunity, but, more importantly, it is the last one of the day. I will end it with a short and sweet presentation from me.

Thank you.

[Applause.]

Agenda Item: Questions and Answers

DR. MITCHELL: As you said, that is the last presentation of this panel and of the day. The floor is open for question for the panel members from the Drug Testing Advisory Board and from participants.

DR. ALAN JONES: Dr. Sachs, thank you for sharing with us the data from Europe. It is certainly very interesting. I anxiously look forward to seeing some data that Dr. Fortner referred to there of that proficiency testing program. Certainly, we look forward to seeing some types of stuff out of the other testing programs also in their infancy here in the states. But, Dr. Sachs, I do have a couple of questions I would ask you.

DR. SACHS: Please start with the simple ones.

[Laughter.]

DR. ALAN JONES: Okay. You presented us with some of your round robin data there. Given the results of those, would you recommend that testing be used -- that hair testing be used in workplace programs where that result, as we do with our urine testing program here in the states, of a single test, has such an impact upon the individual? You know, it can say that he is not going to be hired, he is going to be fired, she has to go to rehabilitation, et cetera.

DR. SACHS: Well, we do not use it in Germany in that case. But we have totally different systems in that way. When we have positive data, we confirm it by other things. To test it as a single -- it is your decision. I cannot say.

DR. ALAN JONES: You do not use any of that in Europe, as I understand it, in that arena?

DR. SACHS: No, we do not.

DR. ALAN JONES: Okay. One follow-up to that from you and your European colleagues. I may be asking Dr. Cone's question. But do you or your colleagues have any data that you can share with us concerning some of the questions that have already been raised, and that is drug concentrations related to hair color, gender, donor, et cetera? Do you have any data on that arena that you might share with us?

DR. SACHS: Well, I do not have that especially. But, from the literature, we know that most of the literature says that dark hair has higher concentrations than without melanin. But there are some other studies there. But I must confirm that most of the literature says that melanin -- that is why it is such a high concentration in dark hair.

DR. ALAN JONES: Thank you.

DR. CAPLAN: I just had one general question since there seems to be, I think, you would center PT as an integral part to any program or process, excluding John and the current urine program. What barriers do you think -- some of you mentioned and some did not, which is why I was asking the question -- to develop this kind of cornerstone process, what barriers do you think there are in implementation of the process? Could those of you who are not laboratory-based and the ones that are laboratory-based comment on whether you think there should be a difference in frequency of PT in the process in order to achieve an equitable outcome?

DR. SACHS: To me?

DR. CAPLAN: Well, yes. You just mentioned some.

DR. SACHS: No, I was just noticing the question. DR. CAPLAN: What things can we do? What is preventing us from establishing a proficiency testing program? What things are needed in order to do that for the various different fluids or materials? You discussed round cases there. You discussed the round robin. But, obviously, the preparation of adequate specimens, and the source of them --

DR. SACHS: The special difficulty in analysis is the homogeneity of the sample. In fact, you can homogenize only powdered sample. You will not be able to homogenize hair strands, total hair stands. You would need a kilogram of hair, and you would have to stir it four a half a year or so.

[Laughter.]

DR. SACHS: So, probably you would not succeed in that.

DR. CAPLAN: You would need a really bit bowl,

room size.

[Laughter.]

DR. CAPLAN: But, I mean, is there something that you can recommend that might overcome that?

DR. SACHS: I hope so.

[Laughter.]

DR. ANDERSON: I will address that or onsite.

There really are not any barriers for I think implementing PT for onsite testing. It is effectively an extension of what is currently being done in the medical laboratory. The practical realities generally are, first of all, an instruction that folks who would probably be doing testing for the first time, that there is such a thing as PT testing, and you do have to pay for it. The second thing is that, depending upon the numbers of people who would suddenly apply, it might prove to be a little bit of a logistics burden for the folks who are currently PT providers to be able to satisfy the additional demand for samples.

DR. CAPLAN: What about frequency? Since onsite is substantially different in a laboratory base, would you think -- what type of frequency would you recommend?

DR. ANDERSON: Well, I do not know. My understanding is that, in the current forensic environment, it is four times a year. Right now, on the medical side, it is three. So there is really not a lot of difference in that timing sense.

I think that that is a debatable point that the folks really who set the PT program up might be better set up to answer. Three to four times a year seems fairly reasonable to me.

DR. ROHRIG: Well, I would not characterize it as a barrier, but as a challenge. One overwhelming consideration is marketplace demand. The marketplace, as it exists today, A, is not demanding that they have a specialized program. But, I think a more important challenge to consider is, right now, for instance, my laboratory has to support assays for five different oral fluid devices. So that, basically, if you are going to challenge the system with what we are doing right now, you are going to have to have five different types of devices coming in if you want to assess the different collection modalities.

Another issue that I already alluded to is what drugs and at what concentrations that we put on this thing?

I think, you know, any lab in the world, you put a thousand nanograms of benzoylecgonine or cocaine on an oral fluid device, they are going to find it. But, in the real world, I think I would maybe see one at that concentration in the hundreds of thousands of samples that we would run. So, getting down to a more usable, reasonable level, there has to be a concurrence in with the users as to what drug, what concentration we are going to look at and what kind of device, or are we going to put it in just a tube as a liquid spit sample? So I think that those are some of the challenges. That just deals with cocaine. Many of the other drugs I do not think have been fully characterized to help us even answer those two different challenges, that is, what analyte, what concentration?

DR. CAPLAN: Neil, I cannot resist this. But how can you control sweat in a sweat shop?

[Laughter.]

MR. FORTNER: Where do you think we generate our batches from? We have to have some way.

[Laughter.]

DR. CAPLAN: The negative controls, right?

MR. FORTNER: Oh, negative controls. I am sorry. [Laughter.]

MR. FORTNER: Well, I think that the programs that are currently in place, if you want to model after the existing inspection program, would lend itself quite readily. You could debate on what levels should be used. Currently, the technology to screen and confirm, using and FDA-approved immunoassay, GC/MS confirmation I think are fairly straight-forward.

You have an extensive group of people in the inspection program that are qualified and certainly, with minimal training, could step in to do that. I would hesitate to probably think that the frequency of proficiency samples might go back to what it was in the early days of the program, maybe on an alternate month at one time just because it is a new technology. We will look at the challenges that come out there. And then the program eventually backed off and went to a quarterly with more sample per quarter. So I think that that is something that could be looked at and determined.

DR. CAPLAN: Okay. Thanks.

DR. CONE: I think I would like to ask a question of the alternate matrices people. As sort of a general overview now, we were talking about proficiency testing, and we have heard a lot about the difficulties of designing the appropriate controls, the need for further information about stability, which analytes should be added, how should they be added, and so forth. Are we at a stage with any of the bile fluids or tissues that we should go forward with developing proficiency test programs?

MR. FORTNER: Well, I think, with the sweat-type testing patch, that has already been in existence and certainly lends itself quite easily to preparation of proficiency samples. We know what drugs we are testing for.

We know about what levels we want to look at. We know how to spike them in and submit it for batch analysis and submit it then to several laboratories. Because there are laboratories other than us that have been involved in analysis of the pathogen.

DR. CONE: Despite the fact that you may not know how stable heroin is in the patch over the period of a week or --

MR. FORTNER: Well, no. Actually, in the FDA filings, there were requirements to do stability on the patch itself. So there is data generated for all of those drugs. And spiking, they were from spike samples, and then looked at stability over a period of weeks.

DR. ROHRIG: Well, I think absolutely. Right now, since this is somewhat for oral fluid is in its infancy and that the major analyte that Mike and I have been talking about is only cocaine, and we are only testing for BE, I think that that would be a good place to start. Now, whether a vendor wants to develop a program and sell it to the marketplace, that is a different challenge. But I think that it would add even more credibility to an oral fluid testing program. If it ever did emerge out into the workplace testing, it would make it appear more acceptable to people being tested.

DR. CONE: Hans, you have done incredible and important work in the development of PT program. How do you feel about implementing a PT program? Should we implement one here in the states for workplace testing? Do we have enough experience now to implement one?

DR. SACHS: Well, if you use it, you should try to establish a PT proficiency test. That is quite important. But, if you really need it, I can really make no decision.

DR. CONE: John, are you keeping notes? Thank

you.

DR. MITCHELL: Absolutely.

DR. WILKINS: I wondered if I could address a question to each of our panel members? This might help summarize for the board and perhaps members of the audience a lot of what has gone on over the last two days, and that is, if each l the panel members could identify for me what you personally, based on your own experience, are the top two strengths of the matrix that you are using right now and the top two limitations that you would identify as being the most important at this point in time or would need to be addressed? I will start with Neil.

MR. FORTNER: All right. Two advantages. One is certainly an extended detection period to be able to pick up drug use, and the fact that you can detect parent drug in patch. I mean, it was very revealing when we first did it or Dr. Cone actually was involved in heroin dosing studies.

So I think those are two very significant advantages.

The disadvantages. I think that one of the limitations of the patch, given the fact that you suspend it in two and a half mLs of an eluate and then recover about 2 mLs, is you are going to have some limitations in retest or poly-drug positives. So you may not be able to confirm multiple drug positives that are in there. Currently, in one of the presentations, I think it was maybe for saliva, there was a recommendation to develop a hierarchy in terms of which drugs do you confirm first. So I think that those are two of the limitations.

DR. WILKINS: Thank you.

DR. ROHRIG: Advantages. Actually, I would say it is more a perception, ease of collection, but more specifically directly-observed collections. You can actually watch the individual place the device in his mouth, collect the oral fluid and place it into the container. You can have that same individual seal the container. So there is little question of him pouring something into his urine sample or doctoring it up because you give him the clean lollipop that goes into his mouth/her mouth, and it goes right back into the container which they seal up.

There is at least a perception of decreased risk of infection or disease to the collector. This is a big spin-off on HIV collecting. This is one of the reasons why it evolved as a good device for collecting samples for HIV testing is you can avoid the blood.

Now, in comparing urine and saliva, as far as that type of exposure, I would equate them as essentially the same. But, still, I think, at least in some people's mind, it is at least my experience that spit is a little bit cleaner than urine. Few baseball players seem to think that.

[Laughter.]

DR. ROHRIG: Disadvantages. You are dealing with a small sample, so repeat testing, QNS's, you are going to have a lot higher experience of QNS's.

The testing is less automated so it is a little more labor intensive, so you are testing costs are going to be somewhat increased. Also, I will put three. You have a limited menu because of that smaller sample size, especially if you have multi-positives on that.

DR. WILKINS: Thank you. Dr. Anderson.

DR. ANDERSON: For onsite testing, probably its greatest strength is the speed of result. It is pretty instantaneous for negatives. It is a little bit faster for positives. It is not much, but significantly faster for negatives which represent 95 to 98 percent of all of the results that you get back in a normal demographic workplace.

The second greatest strength is that it is probably the smallest displacement from what the laboratory does now since it is really, again, the same immunoassays, in most cases effectively just being done in a different location.

It is also one of its biggest disadvantages I think is the perception that it is putting too much power in the hands of perhaps people who are not that sophisticated in a forensic toxicology sense. The analogy I always like to think of is -- and I am old enough to remember this from my first employment, that the people who ran the big computer did not like those little tiny computers on people's desk because that is not proper. They are not supposed to have that kind of desktop power. Obviously, we have gotten past that point with PCs. We have not quite gotten past that point in all cases with urine drug testing.

I guess that the other disadvantage is a little bit tongue in cheek. I have to go back to a particular event when I went out with a particular pathologist with regard to doing our particular product, but onsite tests as a whole. It is the Federal Express version of what is the issue. People are going to use it too much. It is true that it is not really necessarily the best method for all testing when you have 5,000 samples to do and a bunch, onsite tests are generally not well developed for large batch-type methods. But the phrase that sometimes comes around is abuse of convenience. People have a tendency to gravitate towards what is easy to do and do not necessarily focus on necessarily what is most appropriate or cost-effective in all cases.

DR. WILKINS: Thank you. Dr. Sachs.

DR. SACHS: Well, the strength is quite obvious. You have a period of a possible consumption even the risk of that. And you give maybe months or even two years.

The disadvantage, I cannot see any.

[Laughter.]

DR. WILKINS: Okay.

DR. SACHS: Of course, the disadvantage, the possibility of contamination, the possibility of washing out, the substance is washed out. Then perhaps the handling of the sample, because a liquid is quite obvious that a liquid is much easier to handle and the procedure is much easier to neutralize than with an air sample.

DR. WILKINS: So, you mean the solid matrix is more difficult to deal with in most cases maybe?

DR. SACHS: Of course, yes.

DR. WILKINS: Okay. Thank you. Dr. Mitchell. DR. MITCHELL: I think that the advantages of urine are, one, that you can obtain relatively large amounts of it that you can work with in the laboratory for analysis and also that the methodologies are pretty standard now that -- at least since 1981-1982 there has been a push for development of methodologies for detection of drugs in urine that have been fairly well worked out. And many of the problem which have occurred, they are well-defined at this point in time.

The disadvantages are, one, the collection process because it is -- culturally it causes some problems among people and also it, in the unobserved state, it is readily - it can be readily subverted by the addition of adulterants.

I think that is the major problem with urine, at this point in time, besides the smell.

[Laughter.]

DR. WILKINS: Well, in that case, thank you very much.

DR. CAIRNS: I have questions for Professor Sachs.

Can you tell us in Europe what hair analysis is used primarily for?

DR. SACHS: To test the general ability of driving. That is one part of it, or half of it, and the other is to test the credibility of drug, of dealers, or drug users. It is not so much used only to test to detect drug consumption because they will not be punished and nobody wants to know that. But to get your license back

when they lose their license because of drug consumption, to get that back, they are tested by hair analysis.

DR. CAIRNS: So the European Governments demand a hair test to have a driver's license reinstated?

DR. SACHS: Yes.

DR. CAIRNS: Thank you.

DR. SACHS: Sometimes they can choose the -- they will go to a medical/psychological examination and they decide whether they want a urine test, especially people with short hair will be tested by urine samples, or you can choose through hair analysis.

DR. CAIRNS: But the preferred choice for matrix would be hair?

DR. SACHS: Yes, of course, because you would want to be sure of that period. You need a period of one year free of drug consumption. You can prove that by about 12 centimeters of hair. But, if you would have to prove that by hair analysis, you will -- by urine sample, you would -- I did not calculate that, but a lot of urine samples are -

DR. CAIRNS: The other thing is we were pleased to see the consensus statement from the Society for Hair Testing published.

Would you care to highlight the major points of that consensus?

DR. SACHS: Well, I am not prepared to do that because yesterday they said that we should not talk about consensus and guidelines.

[Laughter.]

DR. SACHS: So, I would like to avoid that now and perhaps do that tomorrow.

DR. CAIRNS: Thank you.

MR. DAVIS: If that is it for questions, I would like to, on behalf of the Drug Testing Advisory Board, extend thanks to these speakers and for the hard work they have put into their presentations.

[Applause.]

DR. BUSH: Okay. Thank you all. It was a profitable day even though it was very long in length. We got a lot of information. We are out at 5:30. This is good. We resume again at 8:30.

When I came in we had 13 speakers signed up, members of the public who wanted to present questions. I have gotten a couple of cards from individuals who will not be present but who wish a comment or a question. We have got about 15 so far. There are probably more to come.

We will be a bit flexible tomorrow. Come early. Get a seat here if you can because I do not believe we are going to have the auditorium, the amphitheater next door tomorrow. We are losing a lot of people this afternoon. Some people are going back. So we do not believe this is going to be a problem. But, if it is, the earlier we know, the easier it will be for us to take care of by obtaining another room.

I am not sure if the meeting tomorrow is going to take the entire day. I guess we will play that by ear, Dr. Autry, Board Chair. Yes. We will play that by ear because I am not sure exactly how long the comments and questions from these 15 so far individuals will take. I am certainly not sure how long the discussion and clarification of issues by the Drug Testing Advisory Board Members will take. But, I am betting it is going to go until after lunch.

So, we will play that by ear tomorrow. We will see you hear at 8:30.

Anything else? Board members, we would like to

see you for a few moments here. Thank you.

[Whereupon, the meeting was adjourned at 5:25 p.m.]