Ethyl Glucuronide (EtG) – New Strategy for Monitoring Alcohol

Abstinence

By: Paul L. CaryBy: Paul L. Cary

Toxicology LaboratoryToxicology Laboratory

University of MissouriUniversity of Missouri

EtG Discussion Points current approaches to alcohol monitoringcurrent approaches to alcohol monitoring what is ethyl glucuronidewhat is ethyl glucuronide using EtG testing in abstinence monitoringusing EtG testing in abstinence monitoring interpreting EtG testing resultsinterpreting EtG testing results establishing an appropriate EtG cutoffestablishing an appropriate EtG cutoff EtG questions EtG questions client case reportsclient case reports effective use of EtG testing for alcohol effective use of EtG testing for alcohol monitoring monitoring

Current alcohol testing approaches

screening tests specific for ethanol, ethyl screening tests specific for ethanol, ethyl alcoholalcohol

urine, saliva or breathurine, saliva or breath positive results indicate presence alcoholpositive results indicate presence alcohol alcohol is rapidly cleared from the bodyalcohol is rapidly cleared from the body negative results don’t necessarily document negative results don’t necessarily document abstinenceabstinence

detection time = hoursdetection time = hours alternative approaches alcohol can be measured alternative approaches alcohol can be measured transdermally - SCRAM, WristAS transdermally - SCRAM, WristAS

Problems Associated with Monitoring Clients for Alcohol

short detection window (hours)short detection window (hours) current specimens:current specimens:

blood (invasive)blood (invasive) urine (tampering issues)urine (tampering issues) breath/saliva (for best results breath/saliva (for best results requires on-site field visits)requires on-site field visits)

urine - fermentationurine - fermentation

Alcohol is the most commonly abused substance by drug court clients and the most difficult substance to detect in abstinence monitoring.

Characteristics of a Good Alcohol Test:

scientifically valid therapeutically beneficial legally defensible

direct measure of recent alcohol use (specificity)

detection window of several days (sensitivity)

Ethyl Glucuronide

O H

O H

C O O H

O

O

O H

E t

What is ethyl glucuronide?

direct metabolite of alcoholdirect metabolite of alcohol purposed as a breakdown product in 1902purposed as a breakdown product in 1902 isolated in 1952isolated in 1952 less than 0.02% of an ethanol dose is less than 0.02% of an ethanol dose is recovered as ethyl glucuroniderecovered as ethyl glucuronide

unique biological markerunique biological marker can be detected in various body fluids, can be detected in various body fluids, hair and autopsy sampleshair and autopsy samples

non-volatile, water-soluble, and stable in non-volatile, water-soluble, and stable in stored specimensstored specimens

Facts About Ethyl Glucuronide until recently no EtG testing commercially until recently no EtG testing commercially availableavailable

a few hours after beginning of alcohol a few hours after beginning of alcohol consumption, EtG can be detected in urine consumption, EtG can be detected in urine and isand is detectable up to 5 days after the detectable up to 5 days after the complete elimination of alcohol from the complete elimination of alcohol from the body body

so far in > 15,000 serum and urine samples so far in > 15,000 serum and urine samples determined by different groups, no false determined by different groups, no false positives have been reported using the positives have been reported using the recommended testing methodrecommended testing method

E t h y l a l c o h o l

E t h y l g l u c u r o n i d e

T i m e ( d a y s )

Testing for Ethyl Glucuronide

not available as an “on-site” test not available as an “on-site” test - laboratory-based testing only- laboratory-based testing only

scarcity of testing optionsscarcity of testing options recommended analysis LC/MS/MS recommended analysis LC/MS/MS (liquid chromatography/ tandem mass spectroscopy)

testing is highly specific/very sensitive

results/cutoffs in ng/mL

Advantages of Ethyl Glucuronide unique biological marker of alcohol use unique biological marker of alcohol use (no false positives)(no false positives)

direct marker indicating recent usedirect marker indicating recent use longer detection window (up to 5 days)longer detection window (up to 5 days) stable in stored specimens (non-volatile) stable in stored specimens (non-volatile) is not formed by fermentationis not formed by fermentation is not detected in the urine of abstinent is not detected in the urine of abstinent subjectssubjects

may reduce “in the field” BAC testing by may reduce “in the field” BAC testing by staffstaff

Disadvantages of Ethyl Glucuronide testing available at very few laboratoriestesting available at very few laboratories uses highly sophisticated technology uses highly sophisticated technology (LC/MS/MS)(LC/MS/MS)

testing rather costly ($25.00 - $90.00)testing rather costly ($25.00 - $90.00) detection window decreases as cutoff level detection window decreases as cutoff level is increasedis increased

casual, inadvertent, environmental alcohol casual, inadvertent, environmental alcohol exposure could result in positive resultsexposure could result in positive results

EtG production is variably between EtG production is variably between subjects subjects

Interpretation of EtG Results in Urine

Concentration Range of Urine EtG Testing

using LC/MS/MSusing LC/MS/MS linear range = 50 - 10,000 ng/mLlinear range = 50 - 10,000 ng/mL

Urine EtG Concentrations Following Alcohol Consumption:

one 3.2% beerone 3.2% beer > 3800 ng/mL @ 4 hours > 3800 ng/mL @ 4 hours detection up to 24 hours detection up to 24 hours

(alcohol - 90 minutes)(alcohol - 90 minutes)

three 3.2% beersthree 3.2% beers detection up to 48 hours detection up to 48 hours (alcohol - 3.5 hours)(alcohol - 3.5 hours)

Urine EtG Concentrations Following “Incidental” Alcohol Exposure:

0.5 teaspoon of0.5 teaspoon of 75 ng/mL @ 9 75 ng/mL @ 9 hours communion winehours communion wine

Purell handPurell hand > 40 ng/mL @ 3 > 40 ng/mL @ 3 hours sanitizerhours sanitizer

Other Consumer Products that Pose Incidental Exposure Concerns:

over the counter medications (Nyquil)over the counter medications (Nyquil) mouthwashes (Listermint)mouthwashes (Listermint) tincture of gingko biloba (herbal - memory)tincture of gingko biloba (herbal - memory) foods containing alcohol (such as vanilla foods containing alcohol (such as vanilla extract, baked Alaska, cherries jubilee, etc.)extract, baked Alaska, cherries jubilee, etc.)

““non-alcoholic” beers (O’Doul’s)non-alcoholic” beers (O’Doul’s)

AVERAGE ALCOHOL AND CALORIE CONTENT OF REGULAR, LIGHT, AND NON-ALCOHOLIC BEER

Product No. % AlcoholCalories samples per 100 ml------------------------------------------------------------------------------------------------------------

Regular 163 5.0 [2.0-9.5] 43 [26-83]

Light 26 4.1 [2.4-5.4] 32 [19-43] Non- 13 0.3 [0.1-0.7]0.3 [0.1-0.7] 17 [13-30]alcoholic

------------------------------------------------------------------------------------------------------------

Alcohol in Food - Cook’s Illustrated Study (2005) “A Few Sobering Thoughts” beef burgundy - three hours in oven, lid beef burgundy - three hours in oven, lid on, 40% alcohol retainedon, 40% alcohol retained

flambflambé recipes - igniting brandy over high heat 29% alcohol retained - igniting brandy in cold pan 57% alcohol retained

As a result of “incidental” exposure issues, if ethyl glucuronide testing is to be used in drug court client alcohol abstinence monitoring, it is important to delineate in client agreements/ contracts those products that are expressly prohibited.

term - “innocent positive”; no alcoholic beverage use - truly accidental

Establishing an Appropriate EtG Cutoff:

detection time is significantly impacted by amount of detection time is significantly impacted by amount of alcohol consumedalcohol consumed

as the cutoff concentration of the EtG test is as the cutoff concentration of the EtG test is increased, the detection window (length of time EtG will increased, the detection window (length of time EtG will be detected in urine) decreasesbe detected in urine) decreases

when monitoring for abstinence, interpretation of low when monitoring for abstinence, interpretation of low EtG levels is criticalEtG levels is critical

similar to “passive” inhalation or poppy seed issuessimilar to “passive” inhalation or poppy seed issues

@ 500 ng/mL = 8 hours detection

@ 250 ng/mL = 16 hours detection

@ 100 ng/mL = 25 hours detection

QuickTime™ and aPhoto - JPEG decompressor

are needed to see this picture.

all subjects + @ 2.5 days

only one subject excluded @ 3 days

only three subjects excluded @ 4 days

17 still positive for EtG @ 4 days

500 ng/mL cutoff

250 ng/mL cutoff

20 “Detox” Patients:

What EtG cutoff to use?

100 ng/mL cutoff - 100 ng/mL cutoff - most sensitivity, longest most sensitivity, longest detection period (up to 5 days), for programs with strong detection period (up to 5 days), for programs with strong client supervision, solid treatment support, need to client supervision, solid treatment support, need to establish absolute alcohol prohibition establish absolute alcohol prohibition

250 ng/mL cutoff - 250 ng/mL cutoff - balance between reasonable balance between reasonable detection window and exclusion of “incidental” exposure, detection window and exclusion of “incidental” exposure, detection period 2-3 days, for programs monitoring detection period 2-3 days, for programs monitoring abstinenceabstinence

500 ng/mL cutoff500 ng/mL cutoff - - most conservative, shortest most conservative, shortest detection period (1-2 days), for programs without detailed detection period (1-2 days), for programs without detailed client contracts; limited client tracking; without access client contracts; limited client tracking; without access to toxicology/clinical expertise or who want to avoid risk to toxicology/clinical expertise or who want to avoid risk

Positive EtG Result:

any result reported as positive (using any result reported as positive (using LC/MS/MS) in excess of either the 250 or 500 LC/MS/MS) in excess of either the 250 or 500 ng/mL cutoff is consistent with the recent use ng/mL cutoff is consistent with the recent use of alcohol-containing products by a monitored of alcohol-containing products by a monitored clientclient

studies examining “incidental” exposure using studies examining “incidental” exposure using huge amounts of mouthwash yielded EtG results huge amounts of mouthwash yielded EtG results < 300 ng/mL & alcohol-based hand disinfectants < 300 ng/mL & alcohol-based hand disinfectants < 100 ng/mL< 100 ng/mL

Ethyl Glucuronide Questions

Can alcohol based hand sanitizers result in positive EtG results?

YES!YES! Purrell Gel is 70% ethyl alcoholPurrell Gel is 70% ethyl alcohol anti-bacterial effect primarily due to anti-bacterial effect primarily due to alcoholalcohol

dermal absorption of alcohol well-dermal absorption of alcohol well-documented documented

studies indicate urine EtG levels as studies indicate urine EtG levels as high as 50 ng/ml with total detection high as 50 ng/ml with total detection time approximately 90 minutes time approximately 90 minutes

Does hot weather cause EtG to breakdown during shipment?

NO!NO! experiments in heating samples to the experiments in heating samples to the boiling point demonstrates no boiling point demonstrates no breakdown of EtG breakdown of EtG

nitrites and blood in urine can cause nitrites and blood in urine can cause EtG deteriorationEtG deterioration

Are EtG results reliable enough for client

sanctioning purposes? YES!YES! using LC/MS/MS technologyusing LC/MS/MS technology EtG is highly specific for alcohol EtG is highly specific for alcohol useuse

direct metabolite only present direct metabolite only present following recent alcohol following recent alcohol consumption consumption

Are there any medications that could produce a positive EtG result?

YES!YES! while no false-positive tests for EtG while no false-positive tests for EtG reported reported

only ethyl alcohol produces EtGonly ethyl alcohol produces EtG many liquid medications (& gel-cap) many liquid medications (& gel-cap) include ethanol as a solvent (cough include ethanol as a solvent (cough syrup, etc.) syrup, etc.)

medications containing ethanol will medications containing ethanol will result in low levels of EtG (100 ng/mL) result in low levels of EtG (100 ng/mL)

Case Reports

Dilute Urine Case:

client with a negative drug screen client with a negative drug screen & negative urine alcohol but & negative urine alcohol but dilute sample - creatinine = 11 dilute sample - creatinine = 11 mg/dL; behavioral indicators mg/dL; behavioral indicators mixed; urine EtG ordered and mixed; urine EtG ordered and returned with a result of 5300 returned with a result of 5300 ng/mL; client subsequently ng/mL; client subsequently admitted drinking on weekendsadmitted drinking on weekends

Missed Screen Post New Year’s Eve:

client missed a random January 2nd client missed a random January 2nd drug test; on January 12th a drug test; on January 12th a standard urine screen was negative standard urine screen was negative for alcohol and other drugs; for alcohol and other drugs; sample analyzed for EtG with sample analyzed for EtG with results indicating > 10,000 ng/mL; results indicating > 10,000 ng/mL; client admitted partying on New client admitted partying on New Year’s Eve and having a “few” Year’s Eve and having a “few” drinks drinks

Poor Compliance - Communion Wine Excuse:

client with multiple relapses client with multiple relapses tests positive for EtG at 860 tests positive for EtG at 860 ng/mL; when confronted, claims ng/mL; when confronted, claims communion wine consumption several communion wine consumption several times per week; referred for times per week; referred for increased treatment; within a increased treatment; within a month arrested for drunkenness and month arrested for drunkenness and admits to several months of admits to several months of clandestine alcohol use clandestine alcohol use

Positive Urine Alcohol/Alcohol Use Denied:

a client’s routine urine drug test a client’s routine urine drug test returns positive for alcohol; returns positive for alcohol; client denies use; all behavioral client denies use; all behavioral indicators positive; urine EtG indicators positive; urine EtG performed and results are performed and results are negative; determined urine alcohol negative; determined urine alcohol presence due to fermentation post presence due to fermentation post collection.collection.

Effective Use of EtG Testing

too costly for widespread use in all too costly for widespread use in all drug court clients drug court clients

verify positive urine alcohol results; verify positive urine alcohol results; rule out false positive urine alcohol rule out false positive urine alcohol (in vitro fermentation) (in vitro fermentation)

surprise testing for suspicion of surprise testing for suspicion of relapserelapse

selective random testing in high risk selective random testing in high risk individualsindividuals

evaluating dilute urinesevaluating dilute urines

Final Thoughts:

EtG testing more effectively EtG testing more effectively detects clandestine alcohol use in detects clandestine alcohol use in recovering clientsrecovering clients

EtG testing added to monitoring EtG testing added to monitoring panels may enhance deterrent effect panels may enhance deterrent effect and discourage alcohol relapseand discourage alcohol relapse

surreptitious alcohol use by surreptitious alcohol use by clients likely more common than clients likely more common than previously thoughtpreviously thought

Psychiatric Hospital Study (2002)

35 forensic psychiatric inpatients -12 35 forensic psychiatric inpatients -12 months (alcohol related crimes)months (alcohol related crimes)

samples collected following reentry/ samples collected following reentry/ resocialization visitsresocialization visits

146 urine samples collected, 14 tested 146 urine samples collected, 14 tested positive for EtGpositive for EtG

in all 14 cases, patients reported in all 14 cases, patients reported alcohol consumption of alcohol alcohol consumption of alcohol equivalent to 3 - 15 standard drinks in equivalent to 3 - 15 standard drinks in the 12 - 60 hours prior to sample the 12 - 60 hours prior to sample collectioncollection

Health Professionals Study (2003) 100 sequential urines from health 100 sequential urines from health professionals under contract for professionals under contract for abstinence monitoring abstinence monitoring

all samples tested negative for all samples tested negative for drugs and alcoholdrugs and alcohol

7 were positive for EtG7 were positive for EtG 8 out 8 positive for EtG in “for 8 out 8 positive for EtG in “for cause” testingcause” testing

www.ethylglucuronide.com

Laboratory Recommendations

use a facility employing use a facility employing LC/MS/MSLC/MS/MS

establish a reasonable EtG establish a reasonable EtG cutoff (500 ng/mL)cutoff (500 ng/mL)

carefully evaluate laboratories carefully evaluate laboratories using EtG “screening” testsusing EtG “screening” tests

evaluate lab’s testing track evaluate lab’s testing track recordrecord

Summary of Ethyl Glucuronide (EtG)

EtG is a reliable bio-marker for recent alcohol EtG is a reliable bio-marker for recent alcohol usageusage

EtG remains detectable for up to five daysEtG remains detectable for up to five days two days - single drink five days - heavy drinkingtwo days - single drink five days - heavy drinking

diagnostically & therapeutically usefuldiagnostically & therapeutically useful enhanced deterrentenhanced deterrent more definitive relapse indicatormore definitive relapse indicator

more costly than alcohol testingmore costly than alcohol testing available only from select laboratoriesavailable only from select laboratories becoming increasingly popular testing approach for becoming increasingly popular testing approach for determining continued abstinence determining continued abstinence

Ethyl Glucuronide

O H

O H

C O O H

O

O

O H

E t