Clinical and Health Affairs
The Subversion of Urine Drug Testing
Since government and private industry have instituted urine drug testing to ensure a drug-free work force, an industry dedicated to subverting the results of those tests has developed. This article describes that industry, the types of products it markets, and efforts to curb the sale of those products.
In September 2003, toxicologists at the Substance Abuse Mental Health Services Administration (SAMHSA) were contacted by staff from an Ohio nuclear facility and asked if they knew what a product called “Minuteman” was. Evidence of the product had been discovered in a trash can just outside of the site where people applying for jobs at the plant were submitting urine for drug testing. The experts at SAMHSA informed plant officials that Minuteman was a dehydrated drug-free urine product that could be reconstituted, brought up to body temperature, and substituted for the donor’s specimen. The job applicants who had been tested that day were brought back, and new specimens were collected. Nine tested positive for marijuana.
In this case, alert staff prevented a nuclear power plant from hiring candidates who were using marijuana. But in many cases, the medical professionals and others who rely on the results of urine drug tests know little about the methods and means used to subvert them. In fact, few clinicians realize that there is an entire industry devoted to producing products to either dilute drug-tainted urine, substitute “clean” urine for the user’s, or mask evidence of illicit drugs in urine. In some instances, the purveyors of these products are highly sophisticated amateur or professional biochemists and toxicologists whose products work as promised (some even come with a money-back guarantee).
In drug testing, the stakes are high both for those attempting to assure a drug-free workplace and for the habitual user of illicit drugs attempting to avoid detection. Physicians tasked with certifying drug test results of workers applying for or serving in safety-sensitive positions need to be aware that a “negative” drug test does not necessarily guarantee that the test was not subverted. This article describes the history of workplace drug testing, strategies and products used to defeat drug tests, and efforts to curb the sale and use of these products.
History of Drug Testing
Urine drug testing has become a major industry in the United States, as employers have sought assurance that they employ a drug-free workforce. In an effort to deter the demand for illegal drugs and ensure public safety, the federal government’s workplace drug testing program regularly screens about 400,000 employees in “safety-sensitive” fields such as air traffic control and law enforcement. Under separate legal authority through the Omnibus Transportation Employee Testing Act of 1991, the U.S. Department of Transportation (DOT) requires drug testing of workers in aviation, trucking, railroad operation, mass transit, pipeline operation, and other transportation-related industries.Nearly 10 million employees are covered by these DOT regulations, which require pre-employment, random, post-accident, reasonable suspicion, return-to-duty, and follow-up drug testing. According to Minnesota statute 181.951, random drug testing is permitted only for employees in safety-sensitive positions or for professional athletes constrained by a collective bargaining agreement.1 Thus, while the shuttle van driver employed by the hospital may be required under federal and state law to be randomly tested, most health care workers cannot be so tested. Such laws vary from state to state.
Collecting urine for a federal workplace drug test is considered a search under the Fourth Amendment to the Constitution. Challenges to drug-testing programs have been adjudicated by the U.S. Supreme Court. In these cases, the court’s decisions have supported drug-testing programs as representing a legitimate government interest in promoting the safety of the public.
In order to afford workers maximum privacy, specimens are preferably collected in a room that has a single toilet and a full-length privacy door. Specimens also may be collected in a multi-stall restroom in which the stalls have partial-length doors. Some workers take advantage of the privacy granted to them under the Fourth Amendment and cheat rather than pass their drug test legitimately. In cases where there is reason to believe an employee is trying to subvert a drug test, an observer may be present. In all the uniformed military service branches and in many athletic drug-testing programs, urine specimen collection is routinely done in the presence of an observer. In some athletic collection scenarios, “observed” collection means that one’s shirt is tucked under one’s arms and one’s pants and undergarments are on the floor during the collection; such intrusive collection techniques are not at all typical for civilian drug-testing programs.
Five classes of illicit drugs (or their metabolites) are tested for in federally regulated civilian programs. These drugs, which were commonly abused at the time the programs were established in the late 1980s, are marijuana, cocaine, morphine and codeine (with a focus on identifying heroin use), amphetamines (with a focus on identifying methamphetamine use), and phencyclidine.
Both professional and amateur athletes are subjected to screenings for “performance-enhancing drugs” such as designer steroids and erythropoietin. The testing technology as well as the drugs and compounds being screened for have gotten more sophisticated as leagues and federations strive to preserve the integrity of their sports and as athletes continue trying to improve their performance any way they can.
Shortcomings of Testing
As with any laboratory test, both false-positive and false-negative results are possible. Federal programs have a number of safeguards in place in order to minimize laboratory errors. These safeguards are detailed and widely distributed in Federal Register notices. Interpretation of a positive drug test requires special expertise. In the 1980s—the early days of drug testing in the U.S. military—a large group of soldiers tested positive for morphine, which might have indicated heroin use. However, it was determined that the ingestion of sandwiches served on poppy seed rolls was the true cause of these morphine-positive urines. Although the laboratory result was a “true positive,” as a trivial amount of morphine was present in the specimens, it was the result of innocent actions on the part of the soldiers. The military realized then that each positive test needed to be reviewed by an expert in interpreting possible alternative explanations. As a result, the role of the medical review officer was created. Medical review officers receive extensive training in the logistics of drug testing, in the interpretation of the results, and in the limits to the reliability of drug testing.
Defeating Urine Drug Testing
Sadly, a number of highly motivated and capable individuals wish to avoid detection of their use of banned substances. Drug use and abuse, particularly marijuana use, remain common in our culture. In addition, some athletes trying to gain a competitive edge seek to use banned substances without detection, as evidenced in recent years when world-class bicycle racer Floyd Landis and Olympic track and field star Marion Jones confessed to using performance-enhancing substances and trying to subvert testing that might have identified this use. A brief Internet search on “how to beat a drug test” reveals a host of techniques and strategies for avoiding detection of illicit drug use. These range from the simple to the highly sophisticated and from the ineffective to the highly effective. The three strategies most often used to defeat urine drug testing are dilution, substitution, and adulteration.
The simplest strategies rely on dilution of the sample to lower the concentration of the drug in the urine specimen to a level below what it takes for a test to be reported as positive. Specimen collection strategies have evolved to limit the opportunity to simply dilute the sample with water from the toilet bowl or with tap water. In vivo dilution resulting from heavy ingestion of water before testing or by diuretic use is another strategy for which countermeasures have been developed. Although government-mandated tests look only at creatinine concentration in the urine as a marker of dilution, the more comprehensive testing panel used in athletic drug testing programs also screens for diuretic use. Diuretics are considered banned substances for athletes not because they themselves improve performance but rather because they can mask evidence of performance-enhancing drugs in urine drug screens.
One of the downsides of unobserved specimen collection is that it is possible for the donor to substitute his or her own urine with another individual’s “clean” urine. Multiple products are available on the Internet including freeze dried clean urine that can be reconstituted. Devices such as the Urinator allow these products to be quickly reconstituted and warmed to body temperature for delivery by a tube hidden in the clothing of both male and female donors. These can be hidden during casually observed collection. The Whizzinator (Figure 1) includes a lifelike prosthetic penis (available in five different skin tones) that can be used to falsify a more closely observed collection. In one extreme case, a donor evacuated his own bladder, catheterized himself, and instilled someone else’s clean urine into his bladder in the minutes between being summoned for witnessed testing and the collection. Clearly, some highly motivated individuals will go to extreme lengths to not be caught by a drug test.
Several companies market easily concealable products such as Urine Luck that, when added to a urine specimen in the privacy of a testing stall, promise to render illicit drugs undetectable (Figure 2). Although many of these products are frauds, several are produced by companies that possess a sophisticated knowledge of current drug-testing technology and are able to supply agents that do, in fact, result in a negative drug test. As part of their surveillance program, toxicologists at SAMHSA purchase such products, test them to see if they actually work, and analyze those that are effective in order to ascertain their chemical components.
Stopping Subversion of Screening
To learn more about urine drug testing and efforts to subvert workplace drug tests, read the Handbook of Workplace Drug Testing, second edition, by Jeri D. Ropero-Miller and Bruce A. Goldberger, eds. Chapter 5 deals with subversion techniques such as adulteration and substitution. The book is available from AACCPress, 1850 K Street NW, Suite 625, Washington, DC 20006-2213.
As of 2005, 14 states had laws outlawing efforts to obstruct or interfere with drug tests. (Minnesota does not have such a law.) Generally, these laws prohibit the advertising, selling of, or possession of substitute specimens, devices, or products intended to defeat a drug test. Although offenders can face fines and possible imprisonment, it is not clear whether the states that have such laws actually enforce them. Congress has also taken an interest in these products. In May 2005 and November 2007, a U.S. House of Representatives subcommittee held hearings on the subversion of drug testing. To date, no federal law has been enacted that would make these products illegal to advertise, manufacture, sell, possess, or use to beat a drug test.
Federal district courts have, however, taken up fraud and conspiracy cases involving individuals conspiring to sell products to defeat drug testing. In 2008, the U.S. Attorney’s Office in the Western District of Pennsylvania charged the two co-owners of Puck Technology Inc. with defrauding SAMHSA and conspiracy to sell drug paraphernalia by marketing the Whizzinator and another product, Number 1. Undercover federal agents bought these products as part of their investigation. As part of the case, the government seized all of the company’s assets, as well as its Internet domain names. The two men pleaded guilty and are serving prison time or probation for their crimes. In another case that went before the same federal court, a Florida pilot pleaded guilty to conspiring to sell a powdered drink mix over the Internet to help fellow pilots, truck drivers, and train engineers beat federally mandated drug tests. The pilot, who still retains his license, is scheduled for sentencing in September.
Although workplace drug testing has been shown to decrease the prevalence of illicit drug use among employees subjected to such testing, it is clear that it is vulnerable to subversion by highly motivated drug users who wish to continue their drug use without detection. Therefore, health care providers who base clinical decisions on such tests must bear in mind that results might not reflect the clinical facts. MM
Keith Berge is a consultant in anesthesiology at Mayo Clinic. Donna Bush is a forensic toxicologist in the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration’s division of workplace programs.