Urine Creatinine & Sample Tampering

By: Paul L. CaryBy: Paul L. Cary

Toxicology LaboratoryToxicology Laboratory

University of MissouriUniversity of Missouri

The ramifications of a positive drug test (i.e. sanction, program expulsion, imprisonment, etc.) combined with the denial component of substance abuse often create circumstances

whereby clients feel the need to “beat the drug test” by tampering with the sample. Sample

tampering represents a significant challenge to a the court’s mission and can threaten to

undermine the legitimacy of the court’s policies and procedures as well as it’s decisions. It’s a

matter of control.

Creatinine testing is a specimen validity issue!

The most common form of specimen tampering is sample

dilution.

Why Use Urine for Drug Testing?

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

Problems With Urine as a Specimen:

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

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

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

Creatinine & Dilute Samples

What is creatinine ? creatinine is produced as a result of muscle creatinine is produced as a result of muscle

metabolismmetabolism creatinine is produced by the body at a relatively creatinine is produced by the body at a relatively

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

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

determine the “strength” or concentration of a determine the “strength” or concentration of a urine sampleurine sample

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

EVERY urine sample used for drug detection

should be tested for creatinine!

Two Types of Urine Specimen Dilution

pre collection dilutionpre collection dilution consumption of large consumption of large

quantities of fluids quantities of fluids priorprior to to collectioncollection

post collection dilutionpost collection dilution adding fluid to specimen adding fluid to specimen postpost

collectioncollection

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

loading, flushing, hydrating, etc.) loading, flushing, hydrating, etc.) may be in conjunction with products may be in conjunction with products

designed to “enhance” drug elimination or designed to “enhance” drug elimination or removal of drugs (Gold Seal, Clean ‘n Clear, removal of drugs (Gold Seal, Clean ‘n Clear, Test-Free, Naturally Klean, etc.) Test-Free, Naturally Klean, etc.)

no evidence these products have any no evidence these products have any additional effect on drug elimination additional effect on drug elimination

Water contains no drugs!

easiest, cheapest, simplesteasiest, cheapest, simplest urines with a creatinines of less than 20 urines with a creatinines of less than 20

mg/dL are considered “dilute” and rarely mg/dL are considered “dilute” and rarely reflect an accurate picture of recent drug reflect an accurate picture of recent drug useuse

dilute samples are more like water than like dilute samples are more like water than like urineurine

all drug court/criminal justice samples all drug court/criminal justice samples should be screened for creatinineshould be screened for creatinine

How are creatinine measurements used ? normal human creatinine levels will vary during normal human creatinine levels will vary during

the day based upon fluid intake - healthy the day based upon fluid intake - healthy individuals will rarely produce urine samples individuals will rarely produce urine samples with creatinines of less than 20 mg/dLwith creatinines of less than 20 mg/dL

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

urines with a creatinines of less than 20 mg/dL urines with a creatinines of less than 20 mg/dL are considered “dilute” and often do not reflect are considered “dilute” and often do not reflect an accurate picture of recent drug use an accurate picture of recent drug use

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

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

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

The “Normal” Creatinine

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

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

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

More Creatinine Issues rapid ingestion (90 minutes) of 2-4 quarts of fluid rapid ingestion (90 minutes) of 2-4 quarts of fluid

will almost always produce low creatinines & will almost always produce low creatinines & negative urine drug tests within one hournegative urine drug tests within one hour

recovery time of urine creatinine and drug recovery time of urine creatinine and drug concentrations can take up to 10 hoursconcentrations can take up to 10 hours

incidence of drugs in urine of diluted specimens incidence of drugs in urine of diluted specimens is over 5 times greater than in samples with is over 5 times greater than in samples with normal creatinine levelsnormal creatinine levels

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

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

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

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

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

it is possible for a client to achieve a urine creatinine it is possible for a client to achieve a urine creatinine of less than 20 mg/dL under extreme conditions of less than 20 mg/dL under extreme conditions

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

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

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

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

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

Two final thoughts about dilute urine samples . . . . .

a creatinine of less than 20 mg/dL (associated with a drug test) is nearly always an attempt by the donor to avoid drug use detection - REGARDLESS of how much liquid was consumed in order to achieve this result

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

On-Site Drug TestingOn-Site Drug Testing

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

The Creatine Supplement Issue:

creatine is the pre-cursor of creatinine creatine is the pre-cursor of creatinine

creatine supplements may increase the creatine supplements may increase the amount of creatine in the musclesamount of creatine in the muscles

muscles may be able to generate more energy muscles may be able to generate more energy or generate energy at a faster rateor generate energy at a faster rate

creatine supplements (along with training) creatine supplements (along with training) may improve performance by increasing may improve performance by increasing energy for activities such as sprinting and energy for activities such as sprinting and weightliftingweightlifting

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

The Creatine Supplement Issue:

consuming over-the-counter creatine can consuming over-the-counter creatine can disguise pre-collection hydration and a diluted disguise pre-collection hydration and a diluted urineurine

creatine converted to creatinine will mask the creatine converted to creatinine will mask the dilution effortsdilution efforts

in reality - very difficult to coordinate the intake in reality - very difficult to coordinate the intake timing and volume of creatine and dilution liquidtiming and volume of creatine and dilution liquid

creatinine greater than 300 mg/dL - increased creatinine greater than 300 mg/dL - increased monitoringmonitoring

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

What is Specific Gravity?

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

dilution dilution introduced in 1988 with federal workplace introduced in 1988 with federal workplace

drug testingdrug testing common test performed by “forensic” labscommon test performed by “forensic” labs

Specimen Validity Testing Decision Tree

initial immunoassyaliquot ifFirstCreatinine≥20.0mg/dLNOFURTHERCREATININETESTINGISREQUIRED

ifFirstCreatinine≥2.0mg/dLBUT<20.0ANDEITHERSpec.Gravitydeterminationsare>1.0010

NOFURTHERCREATININETESTINGISREQUIRED

Creatinine TEST

FirstCreat.Quant(Jaffe-picricacid)

<2.0mg/dL

ifBOTHcreatininedeterminationsare<2.0mg/dLANDBOTHSpec.GravitydeterminationsareEITHER>1.0010BUT<1.0200-reportasINVALID-INCONSISTENT

SecondCreatinine"fresh"aliquot

iftheSECONDcreatininedeterminationis≥2.0mg/dLBUT<20mg/dLAND

BOTHSpec.Gravitydeterminationsare>1.0010BUT≤1.0029-reportasDILUTED

iftheSECONDcreatininedeterminationis≥2.0mg/dLBUT<20ANDifEITHERSpec.Gravitydeterminations

are>1.0010BUT≥1.0030NOSVTREPORTING

(Jaffe-picricacid)

<20.0mg/dL

ifBOTHcreatininedeterminationsare<2.0mg/dLANDBOTH

Spec.GravitydeterminationsareEITHER≤1.0010OR≥1.0200-reportasSUBSTITUTED

<20.0mg/dL

Specific GravityTEST

First/SecondSpec.Gravity"fresh"aliquots(refractometry)

<1.0200

<1.0030ifBOTHSpec.Gravitydeterminationsare≤1.0010ANDBOTHcreatininedeterminationsare<2.0mg/dL-reportasSUBSTITUTED

≤1.0010

>1.0010

≥1.0200

ifBOTHSpec.Gravitydeterminationsare≤1.0010ANDEITHERORBOTHcreatininedeterminationsare≥2.0mg/dL-reportasINVALID-INCONSISTENT

ifBOTHSpec.Gravitydeterminationsare>1.0010BUT<1.0200ANDBOTHcreatininedeterminationsare<2.0mg/dL-

reportasINVALID-INCONSISTENT

ifEITHERSpec.Gravitydeterminationsare>1.0010BUT≤1.0029ANDBOTHcreatininedeterminationsare≥2.0mg/dLBUT<20mg/dL-

reportasDILUTE

ifBOTHSpec.Gravitydeterminationsare≤1.0029ANDthecreatininedeterminationis≥2.0mg/dL

BUT<20mg/dL-reportasDILUTE

ifEITHERSpec.Gravitydeterminationsare<1.0200BUT>1.0010ANDBOTHcreatininedeterminationsare<2.0mg/dL-reportasINVALID-INCONSISTENT

ifBOTHSpec.Gravitydeterminationsare≥1.0200ANDBOTHcreatininedeterminationsare<2.0mg/dL-reportasSUBSTITUTED

ifEITHERSpec.Gravitydeterminationsare≥1.0030BUT<1.0200ANDtheEITHERcreatininedeterminationsare≥2.0mg/dLNOSVTREPORTING

≥1.0030ifBOTHSpec.Gravity

determinationsare≥1.0200ANDEITHERcreatininedeterminationsare≥2.0mg/dL-NOSVTREPORTING

ifBOTHSpec.Gravitydeterminationsare<1.0200BUT>1.0010ANDEITHERcreatininedeterminationsare≥2.0mg/dL-NOSVTREPORTING

ifEITHERCreatinine≥2.0mg/dLBUT<20.0ANDBOTHSpec.Gravitydeterminationsare≤1.0010reportasINVALID-INCONSISTENT

My Advice on Specific Gravity

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

clients & court professionals than SpGrclients & court professionals than SpGr

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

and client contractand client contract institute a dilute sample prohibition understand low urine creatinine levels are understand low urine creatinine levels are

NOT normalNOT normal dilute dilute samples are nearly always an attempt

by the donor to avoid drug use detection sanction for repeat dilute tests

Specimen Tampering

Basics of Specimen Tampering - The Three Approaches

dilutiondilution adulterationadulteration substitutionsubstitution

Urine Specimen Dilution

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

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

checks)checks)

Urine Specimen Adulteration addition of foreign substances designed to addition of foreign substances designed to

“mask” drug presence“mask” drug presence post-collection tamperingpost-collection tampering low-tech adulterants that cause “pH shift” low-tech adulterants that cause “pH shift”

(lime, vinegar, bleach, ammonia, lemon, drano)(lime, vinegar, bleach, ammonia, lemon, drano) low-tech adulterants that disrupt testing low-tech adulterants that disrupt testing

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

Urinaid, Byrd Laboratories

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

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

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

Klear & Whizzies

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

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

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

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

and opiatesand opiates can also effect screening testscan also effect screening tests oxidizes drug and standardsoxidizes drug and standards can be identified by laboratories employing specimen can be identified by laboratories employing specimen

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

Checking for Adulterants

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

continues to produce negative test continues to produce negative test resultsresults

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

drug-free specimen drug-free specimen biological substitution - someone else’s “clean” biological substitution - someone else’s “clean”

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

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

non-biologicals can be detected with creatinine non-biologicals can be detected with creatinine testingtesting

Specimen Validity Tests Specimen Validity Tests (SVT)(SVT)

creatinine, UUNcreatinine, UUN specific gravityspecific gravity pHpH nitritesnitrites gluteraldehydegluteraldehyde pyridinepyridine chromium chromium

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

Controlling Specimen Tampering

develop challenging collection strategy - ie. make the develop challenging collection strategy - ie. make the testing unannounced and RANDOM!testing unannounced and RANDOM!

directly observed collections is the most effective directly observed collections is the most effective approach to preventing adulteration and substitutionapproach to preventing adulteration and substitution

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

with on-site devices with on-site devices

Confront Specimen Tampering with Facts:

actively engage clients about tampering issuesactively engage clients about tampering issues illustrates court’s tampering knowledgeillustrates court’s tampering knowledge

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

tamperingtampering highlights the futility of tamperinghighlights the futility of tampering

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

drug courtdrug court

Prepare a fact-based presentation on the myths of tampering – what does

that mean?

Don't believe in the Certo or Sure Jel method. I Don't believe in the Certo or Sure Jel method. I tried it...failed all the drug tests I took every time tried it...failed all the drug tests I took every time I used it...I was being tested for marijuana for I used it...I was being tested for marijuana for Arkansas Drug Court. Tested me every Arkansas Drug Court. Tested me every week...failed all three drug screens...they use a week...failed all three drug screens...they use a new on site screening machine that spins the new on site screening machine that spins the sample around...supposedly it can even detect sample around...supposedly it can even detect meth for up to 10 days...and can detect meth for up to 10 days...and can detect adulterants too...I cleaned up rather than try to adulterants too...I cleaned up rather than try to cover up.cover up.

Sure Jell/Certo - Reality email

Engage clients in an honest discussion regarding

tampering!

“Witnessed” collection (for urine)

single most important aspect of single most important aspect of effective drug testing programeffective drug testing program

urine collections not witnessed are of urine collections not witnessed are of little or no assessment valuelittle or no assessment value

denial component of substance abuse denial component of substance abuse requires “direct observation” requires “direct observation” collections of participantscollections of participants

email address: carypl@health.missouri.educarypl@health.missouri.edu