A TEST FOR ALCOHOL -- AND ITS FLAWS

A New Screen Detects Sunday's Gin in Monday's Urine but It May Be
Ensnaring Some Innocent People Too

HARRISBURG, Pa. -- The state of Pennsylvania this year suspended
Nancy Clark's nursing license, saying the recovering addict violated
her agreement to remain free of alcohol. Its evidence: a new type of
urine test that Ms. Clark flunked.

The new analysis "is the gold standard of testing," Shawn E. Smith, a
lawyer for the state, argued during a June 7 hearing here on Ms. Clark's fate.

Ms. Clark counters: "I didn't drink."

Throughout history, few questions have prompted more lies than, "Have
you been drinking?" For decades, the truth has been obtainable
through urine tests and breathalyzers. But since alcohol dissipates
from the system in a matter of hours, that truth always has been as
fleeting as drunkenness itself. Whether a person is drunk this moment
can be documented. But how about last weekend?

Now comes a test that can answer that question. Known as EtG, the
test is being administered by the industry that searches the urine of
millions of Americans annually for illicit drugs. Because alcohol is
legal, EtG testing is being performed only within a hidden society of
people who aren't supposed to drink at all -- and are required to
provide regular urine samples to prove it.

A breakthrough for the $4 billion-a-year urine-testing industry, the
new test doesn't screen for alcohol. It screens for ethyl
glucuronide, or EtG, a byproduct of the metabolization of alcohol,
which remains in the system for about 80 hours. Now that Sunday's gin
can be detected in Monday's urine, about 10% of people who had been
passing conventional urine screens are testing positive for alcohol,
say administrators of the test.

About 20,000 urine samples a month are now being tested for EtG,
which was introduced about two years ago, and that growth is
continuing exponentially. At $25 -- compared with about $7 for a
standard drug screen -- EtG represents an important new source of
revenue for the urine-testing industry, whose largest players include
Quest Diagnostics Inc. and National Medical Services.

Little advertised, though, is that EtG can detect alcohol even in
people who didn't drink. Any trace of alcohol may register, even that
ingested or inhaled through food, medicine, personal-care products or
hand sanitizer.

The test "can't distinguish between beer and Purell" hand sanitizer,
says H. Westley Clark, director of the federal Substance Abuse and
Mental Health Services Administration's center for substance-abuse
treatment. His office intends to study EtG and issue a statement on
its use in the fall. "When you're looking at loss of job, loss of
child, loss of privileges, you want to make sure" the test is right, he says.

Because EtG is simply a molecule that any laboratory can identify,
nobody owns the test. Urine-testing companies are marketing it to
courts, which increasingly demand abstinence from drunk-driving
defendants. The test is also being marketed to boards or companies
that license workers in health care, aviation, law and other
professions. These boards routinely require urine monitoring of
professionals who are recovering addicts. About 4,500 physicians
alone in the U.S. are subject to urine monitoring.

The urine-testing industry doesn't need federal approval for tests
that aren't used to monitor federal employees and aren't sold over
the counter. Testing firms say it is up to their clients -- the
courts and licensing boards -- to decide how to use the results.

"It's a powerful tool," says Doug Lewis, president of United States
Drug Testing Laboratories Inc. near Chicago. "But it's only a tool."

Some in sobriety enforcement contend any alcohol, however ingested,
could trigger a relapse in recovering addicts. "They must abstain
from alcohol in any form," says Kevin Knipe, manager of a
Pennsylvania state program for monitoring physicians, nurses,
pharmacists and others.

Yet critics worry that growing acceptance of the EtG test is
punishing those who haven't relapsed or aren't problem drinkers. They
argue it's unfair to demand addicts produce urine free of any trace
of alcohol because there is no comprehensive list of products that
contain it. Mouthwash and cold medicine are sources of alcohol. It
can also be found in pastries, perfume, salad dressing, insecticide,
ripe fruit, lunch meat, vanilla extract, ice cream and automotive fuel.

Such critics have gained an unusual ally: the physician who pioneered
EtG testing in America. "Use of this screen has gotten ahead of the
science," says Gregory Skipper, an Alabama addiction specialist and
recovering addict. He says he has received about $10,000 in
consulting fees, mostly from urine-testing firms, in connection with the test.

An unfair monitoring test could dissuade addicts from entering
monitoring programs voluntarily. After Ms. Clark, the Pennsylvania
nurse, confessed her addiction to her supervisor, she entered a
state-monitored program, requiring attendance at two 12-step meetings
a week. On average, she has attended three a week, her sponsor says.
She also has to phone a toll-free number each weekday morning to find
out whether a urine sample is required that day.

In five years, she has never failed to call or submit a specimen,
according to court testimony. She pays the $120-a-month cost of
monitoring. According to testimony, after getting sober, Ms. Clark
joined a church, entered its ministerial program, started a program
to entertain patients and raised three children.

In 2004, the state of Pennsylvania introduced the EtG test. After
flunking it, she says she read the label of every imaginable product
- -- edible and inedible -- only to flunk it again. "I don't know what
else I could have done," says Ms. Clark, 49, who has practiced
nursing since 1978. She recently passed a polygraph test asking
whether she has drunk alcohol.

In January, the state suspended her license, costing Ms. Clark her
job of eight years as an assessor of patient care in a hospital. She
is spending thousands of dollars to fight her suspension. Her
witnesses include her boss at the hospital, who describes Ms. Clark
as indispensable, and Dr. Skipper, who doesn't believe her positive
EtG scores represent proof of drinking.

The purpose of urine monitoring has always been to prevent -- or
provide early warning of -- relapse. Preliminary evidence suggests
monitoring programs may increase success: Addicted physicians subject
to urine monitoring relapse at a rate of 25% over five years, studies
show, compared with a rate among the general population of 75% in a
single year. No comparison exists for unmonitored physicians.

Despite innocent positives, some courts and licensing boards are
digging in their heels. They are arguing that a participant "must
produce a negative urine" sample, says Mr. Lewis, the drug-testing
company president. "Trying to argue that you're an innocent victim --
good luck."

Indeed, the state of Pennsylvania isn't saying that Nancy Clark
drank, only that she failed to produce clean urine. "This case is not
about relapse," said Mr. Smith, the lawyer for the state, in the June
argument against her appeal.

Until the EtG test, a determined drinker could deceive monitors,
because, unlike illicit drugs, alcohol dissipates from the system in
a matter of hours. Recovering alcoholics say they could easily drink
weekends -- when random tests typically aren't required -- and could
also drink weekdays if they stopped early enough.

Sobriety monitors say their main responsibility is to protect the
public. "I had one physician walk into my office with a [low-level
EtG score] and he said he didn't drink," says Martha Brown, a
University of South Florida psychiatrist who monitors addicted
professionals. "He looked great. I believed him." Six months later,
he admitted he had been drinking all along, she says.

Catching such drinkers wasn't the primary interest of Dr. Skipper
when he set about searching for a better screen for alcohol. As
director of Alabama's monitoring-and-assistance program for addicted
physicians, he wanted to find more convincing proof of sobriety. [etg]

Dr. Skipper, a 56-year-old internist, had a personal interest in such
a test: He is a recovering narcotics addict. After entering a
chemical-dependency program in 1981, he underwent additional
training, received a certification in addiction medicine, and began
caring for others. He had a relapse in 1990, and confessed to
stealing painkillers from the medical facility where he worked. His
license was suspended for a year.

Dr. Skipper says he has been clean and sober since Nov. 16, 1990. He
continues submitting voluntary urine samples, and advises other
recovering physicians to do the same.

One physician in Alabama's monitoring program says he has been sober
14 years, yet continues submitting urine specimens, expressly for his
malpractice insurer. "The only proof of my sobriety is my urine,"
says James, a gynecologist who asked that his last name not be used.

In 2001, Dr. Skipper attended a conference in Europe and heard a
lecture about ethyl glucuronide. It had been discovered nearly a
century earlier, but only now was its use as a possible marker of
alcohol consumption being explored. Dr. Skipper and the lecturer, a
Swiss psychiatrist named Friedrich Wurst, eventually conducted
research together. Their studies revealed a powerful connection
between alcohol consumption and creation of EtG.

The publication of these results generated much interest among U.S.
urine-testing laboratories and their clients.

Lacking funds, Dr. Skipper and colleagues conducted only limited
research, most of it focused on this issue: Could drinkers somehow
avoid producing EtG? Except for rare cases, the answer was no.
Whether alcohol derived from other sources could show up in the test
wasn't a central focus of their research.

With all published research on EtG having examined about 1,500
specimens, Dr. Skipper expressed the belief that any level of EtG
above 100 nanograms per milliliter of urine -- an infinitesimal
amount -- represented proof of drinking.

Some in the urine-testing industry went a step further, saying any
EtG is evidence of drinking. A news release from Quest Diagnostics's
Northwest Toxicology unit asserted: "EtG is not detectable in urine
unless an alcoholic beverage has been consumed." A spokeswoman for
Quest says, "That was the best information we had at the time."
Before introducing the test, a Quest scientist says that the company
"evaluated it on some people here at the lab."

Statements about the infallibility of the test bewildered Lorie
Garlick, a California pharmacist who says she is in recovery from
narcotics addiction. To comply with an agreement with the California
Board of Pharmacy, she says she attended 12-step meetings and avoided
drugs and alcohol. When her urine tested positive -- twice -- for EtG
in 2005, she went online and discovered the new screen was touted as
definitive proof of drinking.

"The first thing that went through my head was that there must have
been a mix-up at the lab -- my urine got swapped with somebody
else's," says Ms. Garlick, who says she never drank. Her license has
been suspended and she hasn't worked in more than a year. The
California Board of Pharmacy didn't return phone calls.

She found a Web site with a chat room for addicts claiming to have
been victimized by EtG. Its founder: Dr. Skipper. "I'd been hearing
from people saying they were innocent, and I wanted to research that," he says.

He became convinced that so-called incidental exposure to alcohol
could create higher levels of EtG than he had imagined. His suspicion
fell on a product that has been sweeping the halls of health care:
hand sanitizers.

The federal Centers for Disease Control and Prevention recommends the
use of alcohol-based sanitizers in hospitals, schools and day-care
centers. Whether alcohol in these sanitizers could be absorbed
doesn't appear to have been deeply studied, says physician John
Boyce, who served as chairman of the CDC's hand-hygiene task force.
The question also remains uninvestigated by Pfizer Inc., owner of the
dominant brand, Purell, the company says.

A small study of 24 people that Dr. Skipper helped perform found that
use of Purell could result in EtG showing up in urine. It concluded
alcohol in the sanitizer can enter the body through inhalation,
rather than through the skin. That study, presented in May at the
scientific conference of the American Society of Addiction Medicine,
hasn't been published or peer-reviewed.

At Dr. Skipper's suggestion, Ms. Garlick, 43, entered a treatment
center in California and stayed two days under the supervision of
counselors instructed to search her and her belongings for any
products containing alcohol. Each morning, she provided a urine
sample that tested negative for EtG. Then she washed her hands
repeatedly during the day with Purell -- and her urine that night had
an EtG score of 770. That was more than seven times the cutoff that
Dr. Skipper originally thought represented proof of drinking. By
contrast, a single drink would produce a peak EtG level of perhaps
6,000 nanograms.

To Dr. Skipper, this finding didn't diminish the value of the test.
After all, a negative EtG score provided definitive proof of
sobriety. He says he has always believed a low-level score should be
regarded as a red flag rather than grounds for prosecution. In his
experience, most secret drinkers offered no defense when confronted
with EtG scores.

Worried that states are treating low EtG scores as grounds for
suspension, Dr. Skipper felt "a moral obligation" to speak out. Last
August, he wrote an open letter to state boards that monitor
health-care workers, urging them "to refrain from taking action
against an employee or licensee based on urine EtG testing alone." He
said he now believes incidental exposure to alcohol could create EtG
levels as high as 1,500 nanograms -- far above the level that was
costing many addicts their professional licenses.

His warning has gone largely unheeded. Licensing boards and other
sobriety monitors continue punishing recovering addicts for producing
positive EtG scores.

Most laboratories are now recommending cutoff levels of 250 or 500
nanograms. But they say it is up to their clients to decide whether a
level above that amount represents proof of drinking or some other
exposure to alcohol.

"The industry needs to do some population studies to get a sense of
what a reasonable cutoff is," says Dr. Clark of the federal
substance-abuse office.

He notes that after an opiate screen was introduced about 20 years
ago, some people who tested positive protested they hadn't used
opiates. When observers speculated that poppy seeds -- a baking
ingredient which is also a source of opiates -- might be the
explanation, "labs were saying that poppy seeds could not produce a
positive for morphine at the cutoffs used," Dr. Clark says. "A few
empirical tests later proved this to be false."

Establishing an EtG cutoff high enough to spare the innocent may
involve allowing the guilty occasionally to slip through, concedes
Dr. Clark. But the only ethical option is "to err on the side of due
process," he says, noting that a true addict will get caught soon
enough anyway.

Not everyone being monitored for sobriety is an addict or alcoholic.
Tina Schroeder, a home-health nurse in Wichita, Kan., made what she
calls the mistake of her life last year. At a going-away party for a
colleague, she drank a martini -- even though she had a patient yet
to visit. The smell of alcohol on her breath caught the attention
either of the patient or a fellow nurse. She promptly found herself
seated before her boss, to whom she confessed.

Referred to the state disciplinary board, Ms. Schroeder learned that
to keep her license she had to attend 12-step meetings, visit an
addiction specialist, abstain from alcohol and submit to random urine testing.

Ms. Schroeder says she has never had a problem with alcohol. Her
ex-husband, Craig Schroeder, agrees. He says he never saw her consume
more than two drinks at a sitting -- and that would happen once or
twice a year. Her boss, Ed Cornejo, says he has seen her at many
social functions but never with a drink. He believes the martini was
an isolated incident. "In my opinion, she did not have a drinking
problem," says Mr. Cornejo, general manager of Interim Healthcare of
Wichita. "She's responsible and loyal -- an excellent nurse."

It looked as though she would gain early release from the monitoring
program -- until her urine tested positive for EtG. "I didn't drink," she says.

That result meant Ms. Schroeder would remain in the program. It also
prompted a letter warning that a second such score would result in
immediate suspension.

"Please be aware that [over-the-counter] medications that contain
alcohol can cause a positive alcohol screen," wrote Mary Carder,
executive director of the Kansas Nurses Assistance Program, which
oversees monitored nurses in Kansas. "You should also be cautious of
any foods, sauces, pastries etc. that may have alcohol."

Ms. Schroeder says she's in such fear of getting suspended for a
positive EtG test that she plans to return to school in the fall to
pursue another career.