Hello, I'm Barry Sample, and I'll be talking to you in this session on drug testing using what we refer to as alternative matrices, and really that's anything other than the what used to be the traditional urine. Starting with the disclosure side, recently retired after 40 plus years in the clinical and forensic toxicology laboratory business, and I'm now a consultant with Barry Sample Consulting, servicing employers, IBD companies, and providing expert witness testimony. So let's start with an outline of what this session will touch on. So we'll talk about testing with the alternative matrices, talk a little bit about the physiology, both with oral fluid and hair, collection process, analysis, interpretation, and relative advantages and disadvantages of utilizing alternative specimens as compared with urine testing. So as a reminder from the laboratory session that we've done, if you look at urine drug testing, long established, it was the first type for many years. It was the only specimen type that was permitted under both the HHS and DOT regulations. It's only recently that other specimen types have been permitted for both. As a result, there's an extensive scientific base. They've been shown to be accurate and reliable. It withstands legal scrutiny and really is a very, very mature technology. But some of the advantages is that if you're looking at urine, it only has a two to three day detection window. Urine is collected in the privacy of a restroom. And even though precautions are taken to try and preclude subversion of the testing process, it's still relatively easy to adulterate because that collection is not an observed collection and there's no dose concentration relationship. So that leads me to some of the potential advantages of alternatives and specimens. It's a less invasive collection procedure. Although some might think that, particularly those with sparse hair, might not view collecting a hair specimen as being minimally invasive. Greater specimen stability, for example, if you're looking at hair. Less biohazards. Easier to ship and store. And one might be able to leverage those differences in windows of detection, depending upon the testing reasons. So, you know, hair, if you're looking for that pattern of repetitive use, might have an advantage for pre-employment testing to ensure you keep drug users out of the workforce. For post-accident, reasonable suspicion types of testing, oral food may be an invitation because it has a shorter window of detection. And both hair and oral food, by the nature of the type of specimen and how they're collected, those are observed collections. So they're far more difficult to subvert the testing process by substituting or adulterating the specimen. However, they're not without some of their potential disadvantages as well. So there's some analytical challenges because concentrations are at a much, much lower level. And, you know, particularly if you're talking about hair, it may require far more sensitive analytical techniques using, for instance, ELISA for screening, or using some sort of fast mass spectrometry for screening as well, and more sensitive confirmation instruments, such as GC-MS or LC-MS-MS. Another difference is compared with urine, at least for certain analytes, is one may be detecting parent drug rather than metabolite, or both parent and metabolite, and that could have some potential impacts on the interpretation of the results. Some specimens, especially hair, may require repetitive use of the substance for detection and achievable cutoff concentrations. And generally, there's less available specimen, particularly with oral food, even to a certain extent with hair, as compared with urine. So if we look at drugs effects and detection periods, and this is really a review, you're talking about intoxication or impairment, that's minutes to hours. Same thing for under the influence. So really, those first three are all very closely related. In blood, you can typically detect a drug for minutes to days after use. Oral fluid, we really call it oral fluid, not saliva. Also minutes to days, urine, hours to days, sweat, weeks, and hair, days to years. And if you look at that graphically, you can see on this slide a graphical representation of those different detection windows. So as laboratories, industries, regulators look at moving to alternative specimens or different specimens for their drug testing programs, some of the things that need to be considered would be the scientific acceptability, court and legal acceptability. Are they going to withstand legal challenge? Is it that testing modality, testing specimen accepted generally by the industry and the community at large? In some cases, FDA clearance or adherence to FDA quality systems regulations or QSR may be required. Need to establish cutoffs, set up stringent quality assurance and performance testing requirements. Because of the differences in technology, differences in detection windows, those all intersect with the cost benefit, and that's an analysis that has to be performed. And at the end of the day, all of these tests with any specimen type and the technology you're using must be documented, must be validated to be accurate and reliable. So if we look at the different matrices that have been used for drugs of abuse testing, so there's urine, which is an aqueous matrix. Oral fluid, while it's aqueous, but it also has mucus potential for absorption on the collection device. Sweat is aqueous, but it also relies on the absorption of sweat onto a collection device. And hair is a dry protein complex. So you need to move from a dry matrix to a liquid matrix when dealing with hair in order to do the laboratory testing. So if we take a short walk back through history and looking at the timeline for alternative testing, it was back in 2004, nearly 20 years ago, that HHS first proposed guidelines for hair, oral fluid, and sweat testing. In 2011, HHS's Drug Testing Advisory Board, or DTAB, unanimously recommended adding oral fluid as a permitted specimen type for federal drug testing programs. Also at that time, they recommended adding the prescription opioids, such as oxycodone, hydrocodone, to the federal drug testing program. Shortly thereafter, the SAMHSA administrator accepted DTAB's recommendation. DOT endorsed the opportunity to improve transportation safety by addressing the illicit use of prescription drugs, also by being able to utilize oral fluid, which by its nature is an observed collection. But even with that, it wasn't until 2015, the SAMHSA proposed the Oral Fluid Mandatory Guidelines, or OFMG. Four years later, in 2019, SAMHSA published the final Oral Fluid Mandatory Guidelines. In 2020, SAMHSA proposed the Hair Mandatory Guidelines, again, proposed. And it was in 2023 that DOT published their final rule for oral fluid testing. So there's been a journey here of 19 years just for getting a final rule of final guidelines for oral fluid testing. So the federal regulatory process is sometimes slow and doesn't always adapt as quickly as people may like. So let's talk first about oral fluid. Again, going to our relative advantages and disadvantages, oral fluid is a non-invasive, probably the least invasive procedure of all. It's easy to collect. There's the possibility that drug concentrations may be more closely correlated with impairment. We'll touch on that a little bit later. It can be useful in detecting, I say, very question mark, but very recent drug use. It has a much faster appearance in oral fluid than in specimen, other specimen types. It's an observed collection. It's harder to cheat. And we'll talk a little bit about that as well later on. And a potential advantage, as well as a third-party collection sites, aren't necessarily required. In urine testing, employers generally don't want to do their own urine, manage their own urine collections. Historically, at least in non-regulated testing, they've been more amenable to managing those collections themselves. However, oral fluid does have some disadvantages. It's not all advantages. So there are variations in the rate of saliva production. Just like you can have shy bladder, you can have dry mouth or shy mouth, whereby somebody isn't able to produce an oral fluid specimen. The collection method may affect drug detection and quantification. And oral fluid has a narrower window of detection than urine, and certainly than hair. And that could be an advantage or a disadvantage, depending upon the goal of any specific employer's program. So oral fluid has been utilized for testing for alcohol and drugs of abuse for a number of years. It's been used for diagnostic testing for many years. Again, easy specimen to obtain. It's an observed collection. It's difficult to adulterate or dilute, because it has that observed collection. The DOT, for many years, has allowed saliva screening for alcohol. Again, that's a screen. To make adverse employment decisions, it requires the use of an evidentiary breath testing device. And we'll talk about that as well during the alcohol lectures. But it wasn't until May of 2023 that DOT published the rules authorizing oral fluid drug testing. So sort of a reminder, oral fluid detects recent use, about 24 to 48 hours, we think of the detection window as compared with two to three days in urine. In the case of marijuana, cannabis, America's favorite, at least in most states, illegal drug, but still illegal at the federal level. Detection window is even shorter, probably more on the order of 24 to 36 hours. Oral fluid has an advantage that drugs generally are detected faster in oral fluid than urine, which makes it a really good candidate for doing post-accident reasonable suspicion testing. As I mentioned before, while the presence of the drug may have better correlation with blood concentrations, it cannot be used to determine impairment. There is no recognized standard, i.e., per se limit, for looking at drug concentrations in oral fluid and whether or not somebody is impaired. So cannot emphasize that enough. There is no correlation with impairment as you look at concentrations of drugs in oral fluid. So talk a little bit about the physiology of oral fluid collection. Something a little different that we do for this lecture than we do for urine. I don't think anyone really has any questions about how urine is produced. But as we're looking at oral food production, there's three glands, the parotid, subvandibular, and sublingual. And there are two types of secreting cells. The serous cells, which secrete water fluid containing electrolytes and amylase, and the mucous cells, which secrete the mucins, mucoproteins, mucopolysaccharides. That's why we really refer to this as being oral fluid, because it's a mix of a variety of constituents. It's not just saliva. Saliva flow varies between a half a liter to one and a half liters per day. And it can be stimulated to a peak flow of approximately 10 milliliters per minute. Oral fluid also has a wide pH range, somewhere in the order of five and a half to 7.9. So how do drugs get into the oral fluid? We're doing an oral fluid drug test. One way is contamination of the oral cavity. A good example of that is smoking. For example, marijuana, heroin, cocaine, and quite frankly, in the case of marijuana, all of the Delta 9 THC that's detected in oral fluid is a result of that oral cavity contamination by somebody smoking or vaporizing or eating an edible. The parent THC compound really doesn't flow from the blood into the oral fluid. Drugs can get into oral fluid via passive diffusion of the free drug, although that could be heavily influenced by the pH of the oral fluid and the pKa of the drug. There's ultrafiltration models where small molecules, alcohol, glycerol, could enter the oral fluid from the blood through active secretion. And some examples of drugs that are actively secreted would include lithium and penicillin. So as I touched on, there are several factors that can influence the transfer of drug into the saliva. Not only pKa and the pH of the oral fluid, but the physical size, the degree of protein binding, drugs that are highly protein-bound, like some of the benzodiazepines, are present in very, very low concentrations in oral fluid, as well as the lipophilicity of the drug. Parent drugs, generally not metabolites, are usually found in oral fluid because they're more lipid-soluble. If you think about metabolism in general, one of the things the body generally does is make them less lipid-soluble as it goes through that metabolic process. Only free drug will diffuse into the oral fluid. So again, protein-bound drugs aren't going to diffuse readily into the oral fluid. And pH plays a very, very critical role in the transport of drugs. So how might oral fluid be stimulated? And really what I'm talking about here is probably more historical in nature on this slide and the subsequent slide. But I think it's useful to understand some of the history. So there have been draining methods from the time we're cheap, moving the lips around, but not providing an external stimulus. Mechanical methods, putting something in the mouth, rubber bands, chewing gum, parafilm, to enhance or to stimulate the production of oral fluid. Gustatory stimulation, just placing lemon drops in the mouth or putting cut lemon in the area where the oral fluid is being collected in order to help stimulate that oral fluid production. And the oral fluid historically has been collected either by spitting, some sort of suctioning, or absorption or swabbing. And really that is the most commonly used method. We'll be talking more about that in a bit. Or some combination of stimulation and collection. And some of the commercial products in the market have used some combination of both stimulation as well as that absorption and swabbing process. I'm really not going to talk much about the paraffin because that's more historical in nature, but those really aren't used today. But what's important here to understand here is that stimulation may change salivary composition. Citric acid stimulation can change the pH and bicarbonate concentration. We talked about pH having an impact on how well drugs are transported from the blood across the mucosal barrier into the oral fluid. Some of the components in the collection device may affect the immunoassay drug test results. An important consideration is post-collection stability, especially if so-called NEAT, that is undiluted oral fluid, is being collected. Some of the commercial products that have been used in the marketplace include Finger Collector, Oral Diffusion Sink, Oralease, OralScreen, Orasure, Intercept, ProFlow Xylometer, Salivet, Quanticell, and Varicell. You'll notice they all seem to have a lot of, most of these have sal or oral somewhere in the name. They've been used when testing for ethanol, steroids, abuse drugs, and many therapeutic drugs historically. So generally speaking, the commercially available oral fluid devices for drugs of abuse testing that are available and common use today involve the utilization of a swab on which the oral fluid is collected. So the swab is left in the mouth, left in the mucal cavity for a defined period of time. Or for some devices that have a sample adequacy indicator that indicates that the collection is complete, generally these swabs collect less than or equal to a milliliter of oral fluid. The swab, after the specimen is collected, is removed from the mouth. That swab is inserted into a tube containing a buffer preservative solution. That collection tube is then closed, sealed, and shipped to the laboratory for testing. I do need to talk a little bit about that specimen collection process, particularly with respect to split collections. So under HHS guidelines for the testing of federal employees, a split collection would include one that utilizes either bilateral, that is a device on either side of the mouth or a single device joined at the hip placed under the tongue, or a simultaneously collected sample where one swab is placed into the mouth, the specimen is collected, and within two minutes a second swab is placed into the mouth to collect the split specimen. So either simultaneous or bilateral is permitted under HHS regulations. However, under DOT rules, the specimen must be subdivided. I won't bore you with all the legal history on that, but let's just say that you know there's obviously there's a difference there between HHS and DOT requirements in terms of what a split specimen collection looks like. And under the DOT rules, it is possible to place two different swabs into the mouth, but they need to be adjacent to one another. So it's sort of like the bilateral, but that's not going to cut it under the DOT rules. So if you have a single device that has two swabs, stick it under the tongue, stick it in the same place in the mouth, and then even if you separate those two swabs and put one swab into one collection tube and the other swab into another collection tube, that meets the DOT requirement of a subdivided specimen. And then the other possibility would be to do a traditional, not maybe not traditional, but to do a neat oral fluid collection where there isn't any dilution with buffer preservative solution. So the oral fluid is collected and then split, or the oral fluid could be collected into a funnel that automatically, you know, by its design, separates that oral fluid into two different collection tubes. So that also meets the definition of a split specimen. So if we look at the federal oral fluid specimen collection requirements, and outside of the definition of split, you need to remember that it's HHS that sets the technical and scientific guidelines for all drug testing, whether it's urine or oral fluid. So there are two types of collections that would be permitted under the federal requirements, a buffer that is diluted or neat. Buffered collection systems do require FDA clearance, and that is an HHS requirement that any buffered collection device needs to have FDA clearance. There's a requirement that at least one milliliter of oral fluid be collected, and that's each for the A and B specimen. That the volume collected must be accurate within plus or minus 10 percent, and you can imagine that's important if you're talking about a buffered collection system, whereby you're diluting that oral fluid into some sort of buffer. If you don't know the exact volume of oral fluid you collected, then you're not going to, after dilution, you're not going to know the exact concentration, and that's going to be hard to, well, you'll know, you'll be able to measure the concentration, but you're not going to be able to have a correctly quantified as compared with a cutoff if you don't know both the amount of oral fluid collected as well as the volume of the buffer. So the HHS also requires that the diluent for buffered systems, that that fill volume be accurate within plus or minus two and a half percent. They require at least 80 percent, that is plus or minus 20 percent, so really between 80 and 120 percent recovery of drug from the collection device. They require stability, again, concentrations within plus or minus 20 percent after storage at room temperature for five days, and that's in addition to whatever the manufacturer's intended shipping and storage instructions conditions are. So the manufacturers don't need to be more stringent than what HHS requires, although generally their devices do have longer stability, but at a minimum those devices must be stable within plus or minus 20 percent for five days. And, oh, by the way, all those items that I just talked about in terms of the volume, verifying collection volume, diluent fill volume, drug recovery, stability, not only does the manufacturer have to document that, each individual HHS or NLCP certified laboratory must also document those aspects. The collection, there's also a requirement that the collection tube or transport vial, you know, that tube that contains the buffer that the swab is put into is sufficiently transparent to assess volume and contents. Because these are medical devices and oftentimes, certainly all the time for the buffered systems, they have this buffer preservative solution that has an outdate. There's an expiration date that's printed on the label on that collection tube, and the TAMP Revenant Seal cannot obscure that expiration date. And then finally, each individual laboratory can only be approved for a specific device. That doesn't mean that they couldn't be approved for device A and device B, but just because a laboratory has HHS certification utilizing device A, that doesn't mean that they can automatically start using device B without having to do all of that validation that we just talked about. It would be interesting to see down the road if laboratories actually go for HHS certification for more than one device, but still too early to tell how that's actually going to play out. So, as a reminder from the laboratory sessions when we first, you know, talked about urine drug testing, the process is the same. Please ignore the pictures here because they still look like yellow urine bottles. I haven't had the opportunity to try and gin up some images for an oral fluid collection tube, but be that as it may, the oral fluid is collected at a collection site, sent by curry to the laboratory where it's accessioned. There is an initial test. Anything that is presumptively positive then has a reflex order to obtain another aliquot of that original specimen, which is subjected to confirmatory testing. And, you know, that would either be reported positive or negative and is reviewed by a laboratory certifying scientist. If it's negative on the initial test, just like urine, goes to a certifying technician and results are reviewed and results reported to the medical review officer. Just like urine, all results, positive or negative, go to a medical review officer because oral fluid does have a certain bit of liability. Oral fluid specimens are stored under frozen storage if they are confirmed positive. And while specimen validity testing really isn't performed on oral fluid, isn't permitted outside of an individualized basis as requested by the medical review officer, you're not likely to have adulterated, substituted, or invalid specimens. Probably just going to be positive for a drug, but any non-negative specimen, for whatever reason, must be stored in the freezer for a year, just like a urine specimen. So let's go through, well, this is actually the certification process. So just like urine, the certifying scientist reviews all of the chain of custody documentation, internal, external, aliquots, specimens, reviews, quality control, there's the same quality control process in terms of calibration, linearity, a minimum of 10% QC, blind controls on the initial test, and then obviously certifying review of initial and confirmatory test data. So as we look at the laboratory processes, things are very, very similar to what is required for the urine testing program. Drug panel components are essentially the same as they are for urine. Two slight exceptions, one a little bit more notable than the other. In the case of marijuana, the target analyte is delta-9-THC, the parent, main psychoactive component of cannabis, not the carboxy-THC as is utilized for urine testing. One other difference is that in testing for the use of cocaine, oral fluid confirmatory analysis requires testing for both cocaine and benzalekamine, and that initial test requires, again, within that plus or minus, you know, at least 80%, you know, plus or minus 20% cross-reactivity for both members of that cocaine class. Generally, and more than generally, cutoffs really are lower for oral fluid as compared to urine, and what's important to remember is that these cutoffs are not designed to be equivalent to urine testing cutoffs. Like urine, HHS established those cutoffs to ensure that only use is detected, not exposure, so that you're not going to have a positive due to environmental contamination or secondhand smoke in the case of marijuana or other drugs, and, you know, as a consequence, windows of detection may be different based on the specific drug and the pattern of use as compared with urine. So, HHS isn't trying to make detection windows exactly the same, just isn't making the cutoffs exactly the same. Either test stands on its own. Again, emphasizing oral fluid positive doesn't establish or correlate to impairment or being under the influence, and another important difference, as I mentioned, is no specimen validity testing is required. It may be authorized only if the specimen is suspect. HHS has specifically said that they may test for a biomarker. It may be possible to test for a biomarker, such as albumin or IgG, or test for a specific adulterant, but in order to do so, they have to follow all of the applicable HHS requirements for any of this additional validity testing. Laboratory has to apply for approval to do that specific validity test, and the NLCP will review the laboratory's procedures and processes to ensure that those results are accurate and reliable. As we continue talking about the laboratory processes, again, general process follows the urine drug testing model. There's initial and confirmatory testing. The technology requirements are the same, immunoassay or alternate technology for the screen. Confirmation requires definitive technology, chromatography, mass spectrometry, so really no differences between the urine and the oral fluid drug testing process in that regard. There are some additional FDA HHS implications in that the HHS mandatory guidelines require the use of FDA-cleared collection devices. I'm really talking about buffer collection systems. Current FDA guidance requires FDA clearance for immunoassay test systems used in federally mandated testing. So, the FDA processes that they clear the test system with a specified collection device. So, if manufacturer A has reagent A and collection device A, it's not possible to mix and match components from a different manufacturer. So, you couldn't as a laboratory, you couldn't use collection device B with immunoassay testing reagents A unless there's also FDA clearance for the use of those two components as a system. As I mentioned earlier, the NLCP also requires laboratories to verify collection volume, dilutable volume of buffer, drug recovery, stability, and laboratories are not permitted to simply rely on the manufacturer's FDA clearance for those components. So, what does this all mean for timing and what's going to be happening in oral fluid testing? So, it's still coming soon to a laboratory. We hope soon to a laboratory near you. At the moment, there's likely only one FDA-cleared buffered collection system that is compliant with the DOT requirements with respect to the definition of a split specimen that can be subdivided. However, that manufacturer is in the process of resubmitting to the FDA. To enable usage with current as well as potential future analytes. Not all of the analytes that that manufacturer has reagents for have FDA clearance at this point. So, there's FDA issues with, I shouldn't say issues, but there's timing implications with respect to the collection device with the FDA, with the reagent systems that are being used with the FDA. So, once the manufacturers have a system that's ready to be used, then laboratories can begin their process of all the validations that they need to do for going through their certification process. So, they have device verification, they need to get the reagents and validate both the screening reagents as well as the confirmatory assays, they have to apply for NLCP certification, they have to go through three PT sets and then also undergo inspection. So, it will be a multi-month process, at least, you know, sitting here in the summer of 2023 before oral fluid testing will be done under the DOT program. Now, it's possible that some labs may opt for NEAT unbuffered systems. So, you know, that might require some more extensive validation, but it might be a faster path. But those types of systems are harder for laboratories to work with. It's referred to as NEAT oral fluid. If you're a laboratorian, you probably don't think there's anything NEAT about what I'll call colloquially raw spit. But that is an avenue that some laboratories may opt to go down. And another thing that impacts DOT readiness for, or readiness for DOT testing, utilizing oral fluid, is that the DOT requires two HHS certified labs prior to implementation of any oral fluid testing. And why is that? If lab A has a confirmed positive, there needs to be a lab B to perform any required reconfirmation utilizing that split specimen. But some questions that I think we're still waiting to have clarified is whether or not lab B must have NLCP certification utilizing the same device. And then, you know, for employers and medical review officers, how are they going to know what devices, what system labs are certified to use? So while the laboratory list will indicate labs that are certified for urine and or oral fluid, it may not indicate, that list may not indicate what device they have been certified with. Next slide is a summary of the various drugs and cutoffs. So as you can see, the drugs are the same as the urine program. In the amphetamines group, you have amphetamine, methamphetamine, MDMA, MDA. Both of those are screened at a cost of 50 nanograms per milliliter. Confirmation is at 25 nanograms per milliliter. Testing for cocaine and benzolecidine, screen is 15. Confirmation is 8 nanograms per mil. All of the opioids, other than 6-acetylmorphine, so codeine morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, screening is at 30 nanograms per ml. Confirmation is at 15 nanograms per ml. And I've broken those out in this way because the, to the extent that immunoassay test systems are used, it's likely that there'll be one set of reagents for codeine morphine, one set of reagents for hydrocodone, hydromorphone, and another set of reagents for oxycodone, oxymorphone, just like in urine testing today. 6-acetylmorphine is tested at a screening cutoff of 4 nanograms per milliliter. Confirmation at 2. The parent, delta-9-THC, is tested at 4 and confirmed at 2 nanograms per milliliter. And the screening cutoff and confirmation cutoff is the same for PCP at 10 nanograms per ml. As a reminder, if a laboratory is using alternate technology for screening, they have to use a confirmatory cutoff from performing those screening tests, just as they would with urine testing. So some of the differences from the urine guidelines. Again, no specimen validity testing is required. There is no amphetamine rule, as there is with urine testing for the reporting of a positive methamphetamine. And there's a similar positive without cutoff for codeine morphine positives without medical explanation at a concentration of 150 nanograms per ml. So what are some of the issues for MROs? As we look at marijuana, CBD is probably one of the larger ones. What I can tell you is that laboratory analysis does not confuse CBD and THC. Just as urine testing doesn't confuse carboxy-CBD with carboxy-THC, parent compounds in oral fluid testing are not confused. They're two distinct compounds with different chromatographic and mass spectrometric characteristics. However, THC may be a contaminant in CBD products, and you'll hear more about that during the MRO lectures. And something else that may come up for you as a MRO, more so in the non-regulated arena than in the regulated testing arena, is other cannabinoids, such as Delta-8-THC, which may be legal or not legal depending upon a particular state's laws. So we could talk a long time about Delta-8, but it is important to remember that Delta-8 is not a part of the federal program. However, you may have to deal with Delta-8 as you're doing reviews of non-federally regulated drug testing. If we look at the opioids, poppy seeds may cause a morphine positive above that 15 ng per ml cutoff level. Just like in urine, poppy seeds may cause a positive over the 2000 ng per ml level. So similar to what has occurred in urine testing, in oral fluid testing, the MRO uses that 150 ng per ml level as a burden of proof level. And that cutoff of 150 is well higher than level C one hour post-consumption of either raw poppy seeds or products that contain poppy seeds. So that clearly provides a very large safety zone. Another important thing for you to remember as a medical review officer is that while body metabolism remains the same, what you find in oral fluid as compared to urine is very different. When any of the morphome, hydromorphone, oxymorphone products are used, or if hydrocodone or oxycodone is used, very little hydromorphone or oxymorphone is found in oral fluid, which really underscores that like urine, it's important not to try and rely on parent metabolite ratios. Again, you'll hear more about this during the MRO lectures. So the fatal flaws under the oral fluid testing program are essentially the same. For those of you who are paying attention, there's nine fatal flaws here, not eight. So there's a ninth one that's been added, and I've italicized it here, is that because for buffered collection systems, they have an expiration date. If a specimen is collected using an expired device that is collected after the device expiration date, not necessarily received at the laboratory and tested, but if a specimen is collected after the device expiration date, the laboratory is required to reject that specimen for testing because an expired device was used. But otherwise, all of the same collector name and signature, specimen ID mismatches, no specimen, et cetera. All of those fatal flaws remain the same in both the urine and oral fluid testing program. So while I said that there's likely only one testing system that is going to meet collection testing system that's going to meet DOT requirements, you may run across some of these others in HHS testing and certainly in non-regulated testing. So the three main commercially available oral fluid collection and testing systems in the marketplace, at least today, are Intercept, Oral-Ease, and Quanticell. Although one of those Oral-Ease, I believe, is being phased out. So one may start to see less of that later this year or in 2024. So this is a very busy slide, really more for your reference, but this lists the cutoffs for the various devices. But of these, only one of them, the Quanticell manufactured volume analysis, has all the necessary analytes and at the necessary cutoffs as required under the federal program. But these other devices are used broadly in non-regulated testing, so you may run across those. And this gives you a little handy reference of comparison between the various devices. And the other note I would make is that not all of the individual analytes offered by these manufacturers have FDA clearance. Some are, some aren't, and some others, some of those that aren't are in the process of going through that FDA clearance process. So let's switch gears a little bit and look at positivity rates with the different specimen types. Now, you know, this data is from the Quest Diagnostics Drug Testing Index. This is a full year report that was released in May of this year. And remember that I said earlier that oral fluid has a shorter detection window than urine. One might expect if oral fluid has a shorter detection window that you'd have lower positivity rates with oral fluid than with urine. But as you can see here, since at least 2007, the results of the oral fluid tests were showing a higher positivity rate in oral fluid specimens than in urine specimens. And that has been consistent over time, and actually with the delta, the separation between those two kept going up. And to me, this speaks volumes about the power of that observed collection. A lot of this positivity, and we'll see that in just a second, was driven by marijuana. But the striking difference in these positivity rates, I think, suggests that perhaps what you might be missing at the back end based on window detection when utilizing oral fluid is more than made up for by what you were able to do by detecting people that otherwise might have tried to subvert the testing process. The comment I would make about the 2021-2022 data, where you see oral fluid positivity dropping significantly, that was a result of the removal from many of those oral fluid tests, including marijuana in the testing panel. And because 50%, certainly in urine testing, more so in oral fluid testing of all the positives are due to marijuana, if employers are taking marijuana out of the testing panel, it's not surprising that positivity rates are going down. So, as we look at marijuana now, that's the main driver in that overall positivity numbers. You can really see those striking differences. To me, what's even more striking is that up until 2022, the positivity rate in oral fluid for marijuana was far higher than it was in hair. And hair detects this pattern of repetitive use. We think of it as a lifestyle test. So, to me, that's quite striking as you look at those marijuana positivity rates in oral fluid. And here you can see the other drugs. This doesn't compare the various specimen types, but you see the positivity rates. And clearly, the bulk of the positives in oral fluid testing are related to marijuana, less so the other drugs. But the comment I made about generally having higher positivity rates in oral fluid than in urine also holds true for these other drugs. So, I'll spend a little bit of time on some potential interpretive issues just as we're looking at environmental passive exposure to THC, exposure to secondhand smoke. So, there have been several studies that have performed that have, you know, looked at the interpretation of THC in oral fluid. So, one of the things that's important to note here is that when radiolabeled THC was injected intravenously, no radioactivity was detected in oral fluid. THC metabolites don't diffuse from the plasma into the oral fluid. Well, THC and metabolites. So, very small amount of metabolites present in very, very low concentration, but effectively not likely to find carboxy-THC in oral fluid in the majority of cases. People taking Marinol, they don't have THC in their oral fluid either. Again, THC does not cross from the blood into the oral cavity. The THC that is detected in oral fluid drug testing really is a result of contamination of the oral cavity with the delta-9-THC product. So, a couple of studies that looked at passive exposure, referencing here two studies that were conducted to determine if extreme, and by extreme I mean the individuals participating in the study needed to wear goggles or masks in order to protect their mucous membranes. So, first study, four passive subjects sat alongside four active smokers in a closed vehicle. The second study, four passive subjects sat alongside four active smokers who smoked a single THC cigarette. The difference being that in that first study, the oral fluid collection from the passive smokers was collected in that smoke-filled van. They were stored in the smoke-filled van, and the second study collection was performed outside of the vehicle. So, in the first study, even under those conditions, THC concentrations declined to negative levels in 30 to 45 minutes, and it was found that environmentally contaminated exposed collectors, but the individual just the exposed collectors contained as much as 3 to 14 nanograms per ml of THC. So, in that second study where potential contamination during collection was eliminated, all of the passive subjects were negative at initial and confirmatory test levels. So, if an individual is claiming that they were in the proverbial smoke-filled van or at a concert, the data does not support at these cutoffs of four for the screen and two for the confirmation of somebody being reported as positive due to secondhand smoke.

drug testing

alternative matrices

oral fluid

hair testing

urine testing

specimen collection

detection window

sensitive analysis

positivity rates