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Conclusions: Clinicians need to be aware of the tampering techniques and the possibility of false-negative urine drug tests. Cognizance of inherent risks involved with using these techniques including psychiatric and/or medical complications is also warranted. The manufacture, sale, and use of these products have little or no regulation by state or federal authorities, making them potentially dangerous and imposing new challenges in testing for abused drugs. The extent of use of these products and techniques is not known at this time and is an area that warrants further research.



An in vivo adulterant is a product that is ingested to change one’s urine specimen in order to avoid detection of recent substance use. Dilution and excretion are the 2 main methods in this technique. Drinking excess water and using diuretic agents are included in this category. There are products available on the market such as Premium Detox, The Stuff, Fizzy Flush, Quick Flush Drug Detox Capsules, and Green Clean Drug Detox Drink. These products contain a mixture of B vitamins and creatine that help avoid detection of recent substance use by specimen integrity tests such as visual inspection and creatinine level check. The products claim to “flush” the body of toxins and to be effective in passing a urine drug screen when used as directed. This mechanism has already been discussed, as it was relevant to our case.


The in vivo adulteration technique carries the most risk among the techniques available, as it requires addition of unregulated chemicals in one’s body. Most of the ingredients in the commercially available products are herbal. The detoxification kit used in the case presented here is unfortunately only one of many herbal products available. Extensive literature has been published on the risks involved in the use of unregulated herbal compounds. Another risk involved with this technique is drinking excess water, which if coupled with insufficient diet can lead to electrolyte abnormalities resulting in adverse effects. 38 The use of diuretic medication without the supervision of a medical professional can pose significant risks as well.

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Table 1.

The manufacturer claims that the product is the “world’s most sophisticated cleansing system.” 5 A thorough literature search of each of the product’s ingredients on PubMed and in the Natural Medicines Comprehensive Database 6 , 7 reveals that many of the ingredients can cause liver dysfunction, notably, cascara sagrada, green tea, uva ursi, milk thistle, guarana, and creatine monohydrate. 6 , 7 Some of these ingredients have dose-dependent hepatotoxicity, but no doses of any of the ingredients are specified on the label. Hence, it is quite possible that Mr A, having had no history of hepatic dysfunction and being on no other medications or supplements, developed abnormal liver function tests associated with the detoxification kit. Also, the liver function tests were normal toward the end of his hospitalization, making the temporal association even stronger. On closer look, the pattern of the liver function tests (AST levels higher than ALT levels by almost 4-fold) does not fit into a drug-induced liver dysfunction pattern; rather, it suggests the presence of alcoholic hepatitis. However, 1 of the ingredients, schisandra, has been documented to lower ALT levels, which might explain the discrepancy. 6 , 7.

1-4 Days After Last Use.




Health & Pre-existing Conditions.


Results: Three commonly used tampering techniques are in vivo adulteration, urine substitution, and in vitro adulteration. Review of the literature regarding the risks involved with use of tampering kits yielded no results. In 1986, an executive order was issued requiring all federal employees to refrain from illicit drug use, and the 1988 Drug-Free Workplace Act precipitated the Substance Abuse and Mental Health Services Administration guidelines and their subsequent revisions. Recently, many states have made regulatory efforts to bring drug test defrauding under the ambit of law.