Court filing

Sweat Patch Article — USA v. Jittaphol (Dkt. 43-1, D. Mass.)

Summary

Exhibit 43-1 filed 02/12/22 in USA v. Jittaphol, Case 1:21-cr-10270-MLW, in the District of Massachusetts, is a copy of the case report Comparison of urine to sweat patch test results in court ordered testing, by Joseph A. Levisky and co-authors, Forensic Science International 122 (2001) 65-68. The abstract says a former cocaine and methamphetamine abuser was monitored with both sweat patch and urine testing for approximately 6 months, with thirteen sweat patches applied and collected, five positive for cocaine and/or methamphetamine, while all the urine specimens collected were negative at the analytical cut-off levels. The authors discuss the high incidence of false positive sweat patch tests and say the results raise further questions about the preferential use of the sweat patch in detecting new episodes of drug use.

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Filed February 12, 2022 in USA v. Jittaphol; one of 110 filings from this case.

Record facts

Court	U.S. District Court for the District of Massachusetts
Filed	2022-02-12

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“Sweat Patch Article — USA v. Jittaphol (Dkt. 43-1, D. Mass.).” U.S. District Court for the District of Massachusetts, filed 2022-02-12. Archived at Pandemic Darlings, https://pandemicdarlings.com/court-filings/full-docket-aticha-jittaphol-mad-237964/2022-02-12-gov-uscourts-mad-237964-43-1-doc-43-1/, SHA-256 0e724ceacf8c35955c7e5c7d9708bd97cc96bb6946e8b2601253567179c8c6bb.

Full text

Case 1:21-cr-10270-MLW Document 43-1 Filed 02/12/22 Page 1 of 4

Forensic Science International 122 (2001) 65±68

Case report
Comparison of urine to sweat patch test results in
court ordered testing
Joseph A. Leviskya,*, David L. Bowermana, Werner W. Jenkinsa,
Deborah G. Johnsona, John S. Leviskyb, Steven B. Karchc
a
El Paso County Coroner's Of®ce, Colorado Springs, CO 80906, USA
b
Behavioral Science Department, York College of Pennsylvania, York, PA 17405, USA
c
City and County of San Francisco, Hall of Justice, 850 Bryant Street, San Francisco, CA 94103, USA
Received 29 January 2001; accepted 5 February 2001

Abstract

A former cocaine and methamphetamine abuser was continuously monitored with both sweat patch and urine testing for
approximately 6 months. Thirteen sweat patches were applied and collected, ®ve were positive for cocaine and/or
methamphetamine, but all the urine specimens collected were negative at the analytical cut-off levels. The high incidence of
false positive sweat patch tests in relation to the sensitivity, speci®city, and ef®ciency of the sweat patch assay is discussed.
Possible mechanisms, which can lead to false positive results, are presented. The results of our study raise further questions
about the preferential use of the sweat patch in detecting new episodes of drug use in formerly chronic drug users.
# 2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Sweat patch; Cocaine; Methamphetamine; Sensitivity; Speci®city; Ef®ciency; False positive

1. Introduction 2. Case study

Two recent studies from the Addiction Research Center A 35-year-old woman with a history of chronic metham-
assessed the sensitivity, speci®city, and ef®ciency of sweat phetamine and cocaine abuse was ordered by the courts to
patch versus urine testing in a group of 44 methadone undergo drug monitoring. She reported using both drugs
maintenance patients. For the sweat patch detection of interchangeably. When abusing methamphetamine, she con-
concurrent cocaine use, the sensitivity was 97.6%, speci®- sumed, on average, a gram a day. When abusing cocaine, she
city 60.5%, and ef®ciency 77.7%; and, for opiate use, the consumed 2±4 g per day. Her period of heaviest drug use
corresponding values were 68.6, 86.1, and 78.6% [1,2]. The occurred during the 3 months just prior to the commence-
relatively low values for speci®city and ef®ciency raise ment of drug monitoring. The court ordered that she submit
concerns about whether sweat patch testing is the appro- to sweat patch monitoring. However, she also elected to have
priate methodology to be used when false positives can lead observed urine specimens collected and analyzed for com-
to serious or adverse action against the test subject. We parison. Fig. 1 displays the inclusive dates the sweat patch
recently had the opportunity to compare test results of a was worn with test results along with the dates and results of
sequential series of urine specimens and sweat patches of a the urine collections.
probationer, which were collected continuously over a 6 Over a period of 170 days, 104 urine specimens were
month period. Our ®ndings con®rm the low speci®city and collected and analyzed. All specimens were negative for
ef®ciency values reported in the earlier studies. benzoylecgonine and methamphetamine at 300 and 1000 ng/
ml cut-off values, respectively. With the exception of 1 day
during this period, the subject was continuously monitored.
*
Corresponding author. A total of 13 sweat patches were applied. Each patch was
E-mail address: jj.a.levisky@worldnet.att.net (J.A. Levisky). worn a minimum of 10 days, and several as long as 14 days.

0379-0738/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 3 7 9 - 0 7 3 8 ( 0 1 ) 0 0 4 4 3 - 1
Case 1:21-cr-10270-MLW Document 43-1 Filed 02/12/22 Page 2 of 4

66 J.A. Levisky et al. / Forensic Science International 122 (2001) 65±68

Fig. 1. Schedule and results of sweat patch and urine testing.

Of the 13 patches, ®ve were considered positive: three for and tested on the day before and the day after each patch was
cocaine, one for methamphetamine, and one for cocaine, placed plus all weekdays while the patch was worn. The
benzoylecgonine, and methamphetamine. Excluding the overlay presented in Fig. 2 compares the protocol used to test
period from 14 to 24 January, urine samples were collected this subject and the protocols used in previous clinical studies.

Fig. 2. Comparison of testing protocol of court subject to reference protocol.
Case 1:21-cr-10270-MLW Document 43-1 Filed 02/12/22 Page 3 of 4

J.A. Levisky et al. / Forensic Science International 122 (2001) 65±68 67

3. Discussion test with the highest speci®city is desired when the occur-
rence of a single False Positive test can lead to serious and
The concepts of sensitivity, speci®city, and ef®ciency are adverse action against the test subject. By this de®nition, all
widely used in clinical medicine to estimate how accurately the positive sweat patches reported for this subject were not
a test result will predict the presence or absence of disease true positives, but in fact were false positives.
[3]. When these terms are applied to forensic drug testing,
the de®nitions remain the same, but the implications are very 3.3. Ef®ciency
different, and these differences have led to some confusion
in the courts, even among toxicologists. The ef®ciency of a test is de®ned as the percent of all
results that are true results, whether positive or negative, or
3.1. Sensitivity
TP TN
Efficiency 100
N
The term sensitivity is de®ned as the incidence of true
positive results obtained when a test is applied to patients where N is the total number of tests.
known to have the disease, or If a test is 100% ef®cient, the test represents the true
condition all the time. An ef®ciency of <80%, as was the case
TP
Sensitivity 100 in the clinical studies for cocaine and opiate detection [1,2],
TP FN
suggests the assay represents true results <80% of the time. A
where TP is true positive, and FN is false negative.
test with the highest ef®ciency is desired when both false posi-
In previous publications on sweat patch testing [2], the
tiveandfalsenegativeresultsareequallyseriousanddamaging.
term false negative was used to indicate that a negative sweat
False positives and false negatives present something of a
patch test result had been obtained, even though a urine
conundrum, False Positive tests damage the probationer, while
specimen tested positive while the patch was being worn.
False Negative tests can be said to damage the justice system by
Thus, during the period of 28 February±9 March, a false
allowing drug users to go free, in spite of the courts orders.
negative patch test result was recorded when the subject was
Sweat patch proponents argue that, in the case of cocaine
given opiates during oral surgery. She did have a positive
abuse, the test has a 97.6% sensitivity, which means that the
urine test, but her sweat patch test result was negative,
test can be relied upon to detect drug use when drug use
consistent with the low sensitivity of the sweat patch test
occurs. However, should a test for cocaine detection with a
for opiates. A sensitivity of 100% means that if drugs are
speci®city of 60.5% and a 21.1% false positive rate [1] be
used while the patch is being worn, a positive sweat patch test
acceptable? In monitoring opiate use, Huestis et al. [2]
is always accompanied by at least, one positive urine test. The
reported a false positive rate of as high as 7.9%. Of 44
higher the sensitivity, the more likely it is that drug use will be
monitored subjects, 15 subjects had positive sweat patches
detected. By de®nition, a False Positive Test result does not
during weeks when all corresponding urine tests were nega-
alter the sensitivity value of a test. That means then, that a test
tive. During the course of the study, one of the test subjects
with a very high degree of sensitivity is not always desirable,
had six positive sweat patches associated with all negative
especially when a false positive may result in incarceration
urine tests, and >30% of the participants had at least, one
or loss of child custody for the person being tested.
false positive sweat patch at some times during the study.
There are several possible mechanisms that might explain
3.2. Speci®city
the high incidence of false positive sweat patch tests. Licit
and illicit drugs are readily identi®ed in skin and adipose
The speci®city of a test characterizes the incidence of true
tissues of cadavers, and their presence is a function of
negative results when a test is applied to subjects known to
antemortem deposition, not postmortem redistribution
be free of disease, or
[4,5]. Jufer et al. [6] reported that chronic cocaine users
TN exhibit prolonged terminal urine half-lives for cocaine and
Specificity 100
TN FP metabolites and suggested that cocaine might accumulate in
where TN is true negative and FP is false positive. the fatty tissues of the body. Slow release from these tissues
Unlike sensitivity, speci®city is greatly in¯uenced by the might account for the prolonged elimination. Subjects who
number of false positives. A positive sweat patch test in undergo court ordered drug testing undergo testing for a
relation to all negative urine tests while the patch is being reason, and the reason is usually that they are chronic drug
worn is de®ned as a false positive [1,2]. A speci®city of users. The time it takes to clear all residual drug from their
100% means that if drugs are not used while the sweat patch bodies has never been studied and is not known.
is being worn, both the sweat patch test and the urine tests There is also evidence to suggest that drugs can migrate
will always be negative. As the number of false positives from adipose tissues to the skin surface via extra-circulatory
increases, the speci®city of the test decreases. Compared to routes [4,7]. Others have suggested that skin-to-skin contact
urine testing, the speci®city of sweat patch tests for cocaine is another possible mechanism of drug deposition on the
detection is reported to be between 60.5 and 62.9% [1]. A sweat patch. Kidwell [8] demonstrated that drugs applied to
Case 1:21-cr-10270-MLW Document 43-1 Filed 02/12/22 Page 4 of 4

68 J.A. Levisky et al. / Forensic Science International 122 (2001) 65±68

the skin surface remain on the skin surface for days and that [2] M.A. Huestis, E.J. Cone, C.J. Wong, A. Umbricht, K.L.
simple cleansing does not remove all the drug. Joseph et al. Preston, Monitoring opiate use in substance abuse treatment
[9] showed that cocaine persists for several weeks in the patients with sweat and urine drug testing, J. Anal. Toxicol. 24
stratum corneum (the outer layer of the skin) in chronic drug (2000) 509±521.
[3] R.S. Galen, S.R. Gambino, Beyond Normality. The Predictive
users. Individuals who must wear sweat patches have hus-
Value and Ef®ciency of Medical Diagnoses, Wiley, New York,
bands, live-in lovers, and friends who may continue to use 1975.
drugs. It is not surprising that the sweat patch wearer may [4] J.A. Levisky, D.L. Bowerman, W.W. Jenkins, S.B. Karch,
unknowingly be exposed to these drug sources. Drugs deposition in adipose tissue and skin: evidence for an
Whether one or all of these mechanisms contribute to alternative source of positive sweat patch tests, For. Sci. Int.
the problem is not known, and will never be known until the 111 (2000) 35±46.
appropriate studies are undertaken. Until such studies are [5] J.A. Levisky, D.L. Bowerman, W.W. Jenkins, D.G. Johnson,
undertaken the appropriateness of the sweat patch metho- S.B. Karch, Drugs in postmortem adipose tissues: evidence of
dology, at least for use by the courts, remains in doubt. antemortem deposition, For. Science Int., in press.
[6] R.A. Jufer, A. Wstadik, S.L. Walsh, B.S. Levine, E.J. Cone,
Elimination of cocaine and metabolites in plasma, saliva, and
Acknowledgements urine following repeated oral administration to human
volunteers, J. Anal. Toxicol. 24 (7) (2000) 467±477.
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J. Chromatog. B. Biomed. Sci. Appl. 721 (2) (1999) 333),
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