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Substance Clarit y in Toxicolog y | v.7 i.1

The Applications Issue Implementing drug and alcohol testing in child endangerment and drunken driving cases

Winter/Spring

2016

4 The use of ChildGuard速 hair exposure testing in Oregon 8 Wisconsin is the first to test repeat drunken drivers with alcohol biomarkers 14 National positivity rates in fingernail and hair specimens


Letter from the editor

TALKING TESTS: APPLICATIONS Our alternate specimen drug tests are being used in a variety of ways. Here we present two drastically different stories.

I want to start by welcoming our new Managing & Design Editor, Dru Wagner, on board. Dru has been creating the graphics for our newsletters for quite some time but now has the reigns. She will be the main contact for questions and submissions for Substance. Please help me welcome her aboard. I think you will all agree that she has done a great job with this issue, and we continue to look forward to the exciting issues in the future. As you can imagine, we talk about our testing a lot; incorporation, windows of detections, and so on. During these discussions, we realized that there is a larger topic that could be shared with all of you: how people apply our tests. We do testing nationally, so we have a large variety of clients that are using our tests in many different ways. This issue includes guest author Sue Skinner, M.D., FAAP, talking about the use of hair exposure testing in the evaluation of child physical neglect/drug endangerment, and an article previously published by Gannett Wisconsin Media and USA Today by Kate Golden, discussing fingernail and blood testing for Wisconsin repeat drunken drivers. We are always looking for article submissions that would be beneficial to our readers. If you would like to tell your unique story about testing applications and outcomes, please feel free to contact us via editor@usdtl.com. Submissions are not guaranteed to be published. All thoughts are welcome. As always, we hope you find this issue valuable. If so, please consider sharing it online. This helps us reach even more people with our information. This, and past issues, are available under the Resources tab on our website.

Thanks for reading, Michelle Lach, Editor-in-Chief

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Winter/Spring 2016 Substance


Substance

Winter/Spring 2016 volume 7 issue 1 Editor-in-Chief

Michelle Lach, MSIMC Managing & Design Editor

Dru Wagner, MA

Table of Contents

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THE USE OF HAIR EXPOSURE TESTING (CHILDGUARD®) IN THE EVALUATION OF CHILD PHYSICAL NEGLECT/DRUG ENDANGERMENT Sue Skinner, MD, FAAP

Science Advisory Board

Douglas Lewis, D.Sc. Joseph Jones, MS NRCC-TC Adam Negrusz, Ph.D. F-ABFT Substance is a quarterly news magazine of toxicology science, data, and news. It is our mission to distill the technical world of toxicology, drug testing, and addiction science into plain words. If you have suggestions for topics you would like to know more about, let us know. editor@usdtl.com 1700 S. Mount Prospect Rd. Des Plaines, IL, 60018 847.235.2367 © 2016 USDTL All Rights Reserved.

Since 2011, Children’s Center in Oregon has utilized ChildGuard to help identify when a child has been exposed to harmful substances, and determine the next best step toward a healthier life for both child and caretaker.

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WISCONSIN FIRST TO TEST REPEAT DRUNKEN DRIVERS WITH ALCOHOL BIOMARKERS Kate Golden

Fingernail and blood spot testing provide an extensive look back in time and act as an intervention for repeat offenders in multiple Wisconsin counties.

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NATIONAL POSITIVITY RATES Quarterly positivity results for drug and alcohol testing in fingernail and hair specimens.

www.USDTL.com

Images from iStock.

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THE USE OF HAIR EXPOSURE TESTING (CHILDGUARD®) IN THE EVALUATION OF CHILD PHYSICAL NEGLECT/D RUG ENDANGERMENT Since 2011, Children’s Center in Oregon has utilized ChildGuard to help identify when a child has been exposed to harmful substances, and determine the next best step toward a healthier life for both child and caretaker. by Sue Skinner, MD, FAAP Child abuse and neglect remain a public health crisis in the United States. For FFY 2013, there were 679,000 child victims in the U.S., with an overall rate of 9.1 abuse victims per 1,000 children. In other words, nearly 1 in 100 children yearly is a victim of abuse or neglect. By the time a child reaches adulthood, he or she then has a nearly 1 in 5 likelihood of having been a victim of abuse or neglect. Nearly four-fifths of child abuse cases are the result of neglect.1 Although many types of abuse coexist (sexual abuse, physical abuse and psychological abuse), by and large child neglect remains the most significant risk to a child. Frequently, child neglect is not a one-time episode, but rather a pattern of circumstances

health, safety, and well-being are threatened with harm.3 Child neglect itself is heterogeneous. However, parent or caretaker drug use is a frequent contributor to child neglect, for a variety of reasons. There is the risk of the primary presence of the drug itself, as well as the high-risk environment the child is living in as a caretaker is using and perhaps dealing in drugs. Most importantly, however, the caregiver’s ability to safely and consistently care for their child is impaired. Some professionals emphasize that parental substance abuse is associated with neglect, however, others state more directly that parental substance abuse and/or exposing children to illegal drug activity is itself actually child neglect.3 In The National Alliance for Drug Endangered Children defines fact, 33 states address in their drug-endangered children as those who are at risk of suffering criminal statutes the issue of harm as a result of illegal drug use, possession, exposing children to illegal drug 4 manufacturing, cultivation or distribution. activity. The National Alliance for Drug Endangered Children where the child’s needs are not met by his or her defines drug-endangered children as those who caregivers. Fundamentally, neglect occurs when a are at risk of suffering harm as a result of illegal child’s basic needs are not met.2 More specifically, drug use, possession, manufacturing, cultivation neglect is the failure of a parent or caretaker to or distribution. They may also be children whose provide needed food, clothing, shelter, medical caretaker’s substance misuse interferes with the care, or supervision to the degree that the child’s caretaker’s ability to parent and provide a safe and

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Winter/Spring 2016 Substance


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Diagram 1

Year 1 2011-2012 Total Patients Seen Patients Given ChildGuard速

124

Positive for >1 substance

Year 3 2013-2014 417

447

464

Positive ChildGuard速

Most Common Positive:

Year 2 2012-2013

66

METH

16

METH

15

122

109 69

71

METH & MARIJUANA

21

MARIJUANA

34

67

N/A

22

(25% of all positives)

(23% of all positives)

(30% of all positives)

(49% of all positives)

(32% of all positives)

Positive for 3 substances

2

1

5

8

N/A

Positive for 4 substances

1

0

1

3

N/A

On average:

28%

of all patients were tested with ChildGuard速

55%

nurturing environment.5 In summary, children whose parents are actively abusing drugs, which may or may not include manufacturing or distribution, are also likely being neglected, and are at increased risk of other forms of abuse as well. 2009-2010 Federal data show the state of Oregon is one of the top 10 states for rates of drug-use in several categories (past month illicit use of drugs other than marijuana in persons age 12 and older, also age 18-25, and illicit drug dependence among young adults 18-25). 12.63% of Oregon residents

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Average 438

423 117

136 63

Year 4 2014-2015

of the tests were positive

32%

were positive for more than one substance

reported past-month use of illicit drugs, higher than the national average of 8.82%. Oregon voters legalized medical marijuana in 1998, then legalized recreational marijuana in 2014. 2011 data shows that marijuana is the most commonly cited drug among primary drug treatment admissions in the state.6 DHS data from FFY Oct 2013-Sept 2014 showed there were 6,485 founded (or substantiated) allegations of child abuse and neglect in Oregon, this rate of 12 per 1,000

Winter/Spring 2016 Substance


children demonstrates Oregon's rates of abuse are above the national average.1 Of the child victims (founded assessments), 44.2% were due to neglect, representing the most common type of maltreatment. Alcohol and drug issues represented the largest family stress factor, when child abuse and neglect was present (46.1%). Of the 13 children who died due to abuse and neglect that year, 7 were due solely to neglect. Of children who entered foster care, 45.7% were due to parent drug abuse.7 Oregon’s Child Abuse Intervention Centers (CAIC) were created to minimize trauma for child abuse victims by focusing on the fundamental needs of the child. Currently there are 20 centers which collectively serve Oregon’s 36 counties, and see more than 6,700 children a year.8 By working in partnership with child protective services (DHS), law enforcement and other medical and mental health providers, CAICs have been designed to provide services, based on each child’s needs, in a neutral, child-focused environment and to be a resource for both the child and their caregivers. Each CAIC is uniquely suited to serve the needs of their communities. While services provided vary from county to county, generally services include medically-based evaluations, interviews regarding abuse allegations, mental health treatment and/or referrals.9 Children’s Center is one of the state’s child abuse intervention centers, located in Oregon City. It serves the 400,000 residents of Clackamas County, the third largest county in the state. Since the clinic opened in 2002, many children have been seen for concerns of physical neglect/drug endangerment. When children are seen acutely for concerns of drug exposure/endangerment, urine is frequently sent for drug testing. However, when seeing children for ongoing physical neglect/ drug endangerment concerns, hair testing is more often utilized. Children’s Center began using the ChildGuard® hair exposure test in 2011. Our center sees ∼440 patients annually, of these, 21% are referred for concerns of neglect, which often also includes concerns of drug endangerment.

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Children’s Center is somewhat unique in this approach, as statewide only 12% of children seen at CAICs are referred for concerns of child neglect or drug endangerment.8 Over the past four years, Children’s Center has sent 486 ChildGuard® hair exposure tests, for an average of 122 a year (diagram 1). This means Children’s Center is ordering hair exposure testing on ∼28% of the patients we see. Of the 122 hair tests sent per year, on the average 55% of those are positive. Of those that were positive, 32% were positive for more than one substance. In our evaluation of these children who are referred for physical neglect/drug endangerment, staff have noticed several things. Frequently the children we are seeing have developmental delay, in particular, speech delay. It is also fairly common that a child has dental caries and has never been to the dentist. Children’s Center medical staff note there is often immunization delay and children have not had regular ongoing care by a primary care provider. During comprehensive evaluations, staff are able to do a complete headto-toe exam, including the anogenital exam. Height and weight are documented, as well as the developmental delays and physical findings. In addition, ChildGuard® testing is sent when history suggests drug exposure is a concern. If a child is old enough and has the verbal abilities, he/she will be transitioned to a recorded interview with a forensic interviewer, where the child can be screened for all types of abuse, including neglect. Questions are asked about discipline, drugs and alcohol, domestic violence, guns in home, as well as general questions about who watches the children, who cooks, and where people sleep. At the conclusion of the evaluation, children are referred for a mental health assessment. Where appropriate, they are also referred to a dentist and a consistent primary care provider. If a child is under 5 years old, he/she is referred to Educational Services District (ESD) for a developmental assessment. Recommendations in the completed report address all the risk factors in the child’s life, to include drug and alcohol Continued on page 13, ChildGuard

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WISCONSIN FIRST TO TEST REPEAT DRUNKEN DRIVERS WITH ALCOHOL BIOMARKERS Fingernail and blood spot testing provide an extensive look back in time and act as an intervention for repeat offenders in multiple Wisconsin counties. by Kate Golden

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Winter/Spring 2016 Substance


This article was originally published by the Wisconsin Center of Investigative Journalism and Gannett Wisconsin Media on December 1, 2014. It was also published in USA Today on December 1, 2014. People lie. But their blood and fingernails do not. Wisconsin has a drunken driving problem: More than one-third of the people convicted of operating while intoxicated have been convicted before, according to data analyzed by Gannett Wisconsin Media for its Under the Influence project with the Wisconsin Center for Investigative Journalism. To find out which offenders are at risk of driving drunk again, and help them avoid it, the state

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requires drivers to undergo a drug and alcohol abuse assessment. Essentially, trained professionals ask drivers about their drug and alcohol use. But the answers are unreliable. And alcohol is a pesky little molecule to detect because it fades so quickly from the body. The standard blood test only works for a few hours. In the past several years, a handful of Wisconsin counties became the first nationwide to try a solution European nations have been using for years. They are testing repeat drunken drivers for molecular evidence of heavy drinking in nail or blood samples. Known as alcohol biomarkers, these tests can look back weeks or even months. Researchers say their initial data show that

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biomarker testing during treatment may help repeat offenders stay sober longer, keep them from getting rearrested, and ultimately save counties money. Most approaches to Wisconsin’s repeat drunken drivers have been about “increasing fees, or increasing jail time,” said Pamela Bean, the researcher who initiated the programs and is evaluating them. “This is a different approach.” “The goal is not to catch people. It’s to get them sober, so that they’re not killing someone on the road, and that they actually discover that there’s another life out there,” said Doug Lewis, president and scientific director of United States Drug Testing Laboratories, Inc. in Des Plaines, Illinois, which is analyzing nail and blood samples from several Wisconsin counties. In Dane and Waukesha counties, among the first to try the testing, Bean has found that drivers who tested positive during their year of monitoring were more likely to be rearrested. If biomarker positives turn out to be a red flag for recidivism, counties can target those drivers for extra treatment interventions. In Waukesha, drivers under biomarker monitoring were re-arrested on average a year later than drivers who were not monitored. Bean and Lewis believe more counties and states will be interested in biomarker testing if it is successful. But they say it is too soon to declare that. “This is all data-driven, it’s all new,” Lewis said.

Marques is an advocate for using the tests, which provide a look back in time and assist with treatment, in conjunction with ignition interlocks, which prevent drunk people from driving in the moment. “I look forward to a day when some state has the moxie to do a three-legged program: interlock, alcohol biomarker monitoring, and treatment for those who cannot change behavior on their own,” he said. Bean moved to Wisconsin 17 years ago from California, where she had been working with alcohol biomarkers. She was appalled by a report showing one in three Wisconsin drivers admitted to driving under the influence, and by the frequency of repeat operating-while-intoxicated convictions. “Every time I would see in the newspaper, it was like, this person has been convicted by seventh OWI, eighth, 11, 13! I never saw that anywhere,” she said. “Then I said well, why are we not doing here the same thing that European countries are doing?” In late 2005, she gave a presentation on alcohol biomarkers to a statewide advisory committee looking at new approaches for intoxicated drivers. After the meeting, the state wrote a letter to all 72 counties saying that this new approach was available and permissible under state law. Six counties were interested. Waukesha County was first to try it in 2006. Dane followed in 2010, with some startup funding rounded up by former county In the past several years, a handful of Wisconsin counties became the executive Kathleen Falk. Kenosha came on board, first nationwide to try a solution European nations have been using for adding a suite of tests for years. They are testing repeat drunken drivers for molecular evidence different drugs as well — the of heavy drinking in nail or blood samples. law forbids operating “while intoxicated,” which can include “This is data no one else has really seen before.” other drugs in addition to alcohol. Forest, Vilas and Biomarker expert Paul Marques, senior research Oneida counties received a grant to test for alcohol scientist at Pacific Institute for Research and biomarkers and are looking at testing for drugs as Evaluation in Maryland, said, “If you need to know well. what somebody’s drinking level is and whether it’s a It works like this. A driver, generally with at least public hazard, you need to use something that can three OWI convictions, walks in for the mandatory get you objective information.” alcohol and drug abuse assessment, part of a driver

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Winter/Spring 2016 Substance


safety program required by the state. The assessor will ask the person about his or her substance use, recommend a treatment program, and initiate biomarker testing. The first test is used as a baseline. It tells the assessor whether the driver told the truth — and can admit it, according to Lewis. “The therapist has an enormous history now to break the denial. And that’s what probably is the biggest resistance to treating someone who has a chronic relapsing disease,” Lewis said. The answer also may prompt the assessor to call the driver’s treatment provider and suggest finetuning the plan. The next test comes near the end of treatment, to see if it is working. A driver who tests positive at that point has to come back for more testing the next month. After several months of treatment are up, drivers usually have a gap of several months or a half-year before the driver safety plan ends. That is when data show a person is most at risk of relapsing, Bean said. So drivers are required to submit one final test a month before the driver safety plan is up. The tests seem to serve as a deterrent, Bean said. Waukesha and Dane drivers who tested positive then received a two-minute intervention call giving them the results, suggesting they strengthen their support networks and telling them they would be retested — and 60 to 80 percent of them tested negative the next time around. Cesar is a hotel worker with five OWI convictions. He asked not to be fully identified to avoid embarrassing his employer. At a recent interview, he said he would have his final biomarker test the next day. He hoped it would show that he has been sober for two years. He has something to prove, not just to the judge but to his family. “That I’m not a bad person,” he said. “So that way, I can get my driver’s license and get back to my normal life, like everybody else.” In Dane County, Journey Mental Health Center conducts driver assessments. Assessor Kevin

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McConeghey said Cesar’s desire for proof is part of why biomarker tests are helpful. These are people who have tried quitting before. People in their lives have a tendency not to believe them. “What this does is it reinforces the natural pride that a person would have in being sober. And it allows them to take a little more ownership of what they’re doing to stay sober,” McConeghey said.

"This is all

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At United States Drug Testing Laboratories, Inc., which analyzes samples for Kenosha, Forest, Vilas and Oneida counties, Doug Lewis walked a reporter through the analysis. Clipping nails may be easy, but finding alcohol in them requires a tall machine that costs a half a million dollars. It is called a triple quadrupole mass spectrometer, “and it’s one of the more data-driven, it's all new," Lewis said. "This is data no one sensitive instruments that else has really seen before." you can buy in the analytical chemistry world,” Lewis said. Dane and Waukesha are testing for what are Drivers pay about $100 for each test, and they known as indirect markers. need at least three — so many counties are hesitant Their program, called EDAC, is a suite of 20 to lay such costs on people who are rarely flush. routine blood tests, for instance cholesterol and Bean is trying to get the costs down. But she says liver enzymes. The results are statistically analyzed even at $300 for a three-test regimen, the tests will for the likelihood that a person was heavily save counties money if they keep people out of drinking in the past month. prison. They are not perfect; there is a small chance that “In one year, it’s $30,000. So you do the math. other conditions can cause the same test results. It’s 100-fold less expensive to test this person with But they have an advantage: They show the damage biomarkers than to put him in jail.” that alcohol has done to a person’s body. Andrew MacGillis is serving time at Fox Lake If the liver enzyme comes back high, for example, Correctional Institution for his seventh drunken the client can learn “right away that their drinking driving offense. He believes he has changed his is having an effect on their liver,” McConeghey said. ways — and says he would be happy to pay to prove “And a lot of studies show that immediate feedback it. He’s corresponded with Bean, who has come to about health effects of drinking have a significant visit him. effect as long as five years later on the client’s “That’s pretty cheap for an inmate to pay for drinking.” that,” MacGillis said. “Yeah, I would definitely want The fingernail and blood-spot tests used in to be in the program.” Kenosha, Forest, Vilas and Oneida counties do The nonprofit Wisconsin Center for Investigative not provide that kind of information. Those tests Journalism (www.WisconsinWatch.org) are looking for direct biomarkers, which are the collaborates with Wisconsin Public Radio, byproducts of alcohol itself. Wisconsin Public Television, other news media Among their advantages is that they are easy to and the UW-Madison School of Journalism and collect, requiring just a clipping. Mass Communication. This report was prepared in They can be used as forensic evidence in court, collaboration with Gannett Wisconsin Media for because only alcohol can create their signature its “Under the Influence” series. results. And the samples can also be used to find other drugs, as Kenosha County is doing. Wisconsin’s heroin epidemic has prompted extra interest in testing for other drugs, Bean said. But for all the markers being used, there are costs.

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ChildGuard, continued from page 7.

exposure, domestic violence, physical punishment and storage of weapons. The report stresses that adult caretakers should be both physically present and not mentally impaired, in order to best safely parent their children. Children’s Center sees a real value to assessing children for concerns of physical neglect/drug endangerment, and this is evidenced by the fact that it is 21% of our referrals. National and state data, as well as medical literature indicate this is the most common type of abuse; families often have a long standing history and there are farreaching effects on the health and well-being of the child, if not addressed. Data obtained through the Adverse Childhood Experiences (ACE) Study, clearly demonstrates a strong relationship between household dysfunction and abuse, and multiple risk factors for leading causes of death in adults.10 Studies show that parental substance abuse is associated with a more than twofold increase in the risk of physical and sexual abuse.11 Community partners who refer to Children’s Center (law enforcement, DHS, medical providers & therapists) see the value in these assessments as well, given that they make the majority of the referrals. A comprehensive evaluation for drug endangerment/physical neglect, including the ChildGuard hair exposure testing provides valuable documentation and test results to best allow work with families and other caretakers, and to engage parents in treatment they otherwise may be reluctant to address. Children’s Center data has shown that positive test results on the ChildGuard hair exposure test were associated with an increased number of founded DHS referrals, as well as improved outcomes in Dependency Court.12 The bottom line - at Children’s Center we consider what is best for the children, as well as their adult caretakers. Child neglect, left unchecked and unidentified, has lifelong physical and emotional consequences for children. It is imperative that advocacy centers address the needs of children in homes where illegal drug

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activity is taking place. Best practice includes a comprehensive medical assessment, a forensically sound interview, and lab testing, to include the ChildGuard hair exposure testing. Appropriate referrals upon completion will provide the best chance at identifying all challenges present within the family unit and hopefully moving toward a healthier and safer life for each child. References 1. http://www.acf.hhs.gov/sites/default/files/cb/ cm2013.pdf#page=20 2. Dubowitz, Howard, H. Neglect in children. NIHPublic Access Author Manuscript, Pediatric Annals. 2013 April: 42(4): 73-77. 3. https://www.childwelfare.gov/pubPDFs/define.pdf 4. https://www.childwelfare.gov/pubPDFs/drugexposed. pdf 5. http://www.nationaldec.org 6. https://www.whitehouse.gov/sites/default/files/docs/ state_profile_-_oregon_0.pdf 7. http://www.oregon.gov/dhs/children/child-abuse/ Documents/2014%20Data%20Book.pdf 8. Oregon Network of Child Abuse Intervention Centers, Statewide Statistical Data July 2014-June 2015. 9. http://www.childabuseintervention.org 10. Felitti, Vincent et al. Relationship of Childhood abuse & household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998 14(4): 245-258. 11. Walsh, Christine et al. The relationship between parental substance abuse and child maltreatment: findings from the Ontario Health Supplement. Child Abuse & Neglect 27 (2003): 1409-1425. 12. Unpublished data, CC poster presentation, APSAC national conference 2013.

Dr. Sue Skinner is the Medical Director for Children’s Center in Oregon City, Oregon. She is board certified in both General Pediatrics & Child Abuse Pediatrics. She has been working in the field of child abuse & neglect for more than 20 years. Children’s Center is a private, non-profit child abuse intervention center. For more information, visit http://www.childrenscenter.cc.

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USDTL NATIONAL POSITIVITY RATES* * These data report national positivity rates for forensic toxicology tests conducted by USDTL on behalf of external clients and are not reflective of systematic research results.

Fingernail Specimens

Amphetamines | 15.1% Cocaine | 4.2% Opiates | 8.3%

Cannabinoids | 23.9% Barbiturates | 0.6% Methadone | 0.8% Benzodiazepines | 2.1% Oxycodone | 4.8% Tramadol | 2.2% Fentanyl | 0.0% Buprenorphine | 23.5% Ketamine | 5.7% Ethyl Glucuronide | 20.4%

Not shown: Meperidine 0.0%, Phencyclidine 0.0%, Propoxyphene 0.0%

30

14

20

10

0

Winter/Spring 2016 Substance


Report date range: October 1, 2015 – December 31, 2015

Hair Specimens

Amphetamines | 17.8

%

Cocaine | 7.1% Opiates | 13.5% Cannabinoids | 19.7% Barbiturates | 0.7% Methadone | 2.2% Benzodiazepines | 2.9% Oxycodone | 11.5% Tramadol | 3.5% Fentanyl | 0.8% Buprenorphine | 47.0% Ketamine | 3.8% Ethyl Glucuronide | 15.3%

Not shown: Meperidine 0.3%, Phencyclidine 0.2%, Propoxyphene 0.0%

0

USDTL

10

20

50

15


®

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