Urine Drug Test Results Among Adolescents and Young Adults in an Outpatient Office-Based Opioid Treatment Program

PURPOSE

Urine drug testing (UDT) is an important feature of outpatient treatment for opioid use disorder, but associations with patient characteristics among adolescent and young adult patients are unknown. This study assessed UDT results in office-based opioid treatment and characteristics associated with treatment compliance.

METHODS

This was a retrospective study of adolescent and young adult patients enrolled in office-based opioid treatment between January 1, 2009, and December 31, 2020. UDT results were described as positive results or expected and unexpected results. Expected results were negative UDTs for opioids, marijuana (THC [tetrahydrocannabinol]), or cocaine/methamphetamine, or a positive UDT for buprenorphine. Unexpected results were positive UDTs for opioids, THC, or cocaine/methamphetamine, or a negative UDT for buprenorphine. Treatment compliance was defined as ≥75% of UDTs provided being expected results. Counts and percentages described UDT results. Regressions evaluated associations between patient characteristics (retention time, age, sex, race/ethnicity, insurance, and comorbid mental health diagnoses) with treatment compliance, and assessed change of positivity rates for UDTs over time.

RESULTS

A total of 407 patients were included. Overall, 305 patients (74.9%) demonstrated treatment compliance. Rates of expected UDT results increased with longer retention time (p <.001), except for methamphetamine. Buprenorphine expected results ranged from 77.0% to 96.5%. Diagnosis of stimulant use disorder was associated with decreased compliance (p = .04), while diagnoses of depression, anxiety, nicotine use disorder, and post-traumatic stress disorder were associated with increased compliance (p ≤.04).

DISCUSSION

Proportion of expected UDT results increased with retention time. Diagnosis of specific mental health conditions affected treatment compliance. Further research regarding long-term health outcomes is needed.

Fiber spray ionization mass spectrometry in forensic chemistry: A screening of drugs of abuse and direct determination of cocaine in urine

RATIONALE

Ambient mass spectrometry techniques are much required in forensic chemistry to evaluate evidence with low analytical interference, high confidence, and accuracy. However, traditional methodologies, such as paper spray ionization, have been shown to present low sensitivity in the analysis of illicit drugs from biological matrices.

METHODS

Fiber spray ionization mass spectrometry (FSI-MS) was developed using a capillary polypropylene (PP) hollow fiber. Seized samples of drugs, i.e. a tablet, blotter paper, hashish, and cocaine powder, were analyzed. Cocaine was quantified from whole urine by dipping the fiber directly into solution. FSI-MS was tested for the analysis of a sample of urine obtained from a drug abuse suspect.

RESULTS

The FSI(+) analysis showed the detection of different types of synthetic drugs in tablet and blotter paper samples, e.g. amphetamine, cathinones, phenethylamines, and opioids, while pure cocaine and different types of coca alkaloids were identified from cocaine powder with good sensitivity and high mass accuracy. The hashish analysis by FSI(-) revealed signals of cannabinoids, cannabinoid acids, and cannabinoid derivatives, detected mainly as [M - H]^- ions or chlorine adducts [M + Cl]^- . The quantification of cocaine in whole urine showed good sensitivity and precision with limits of detection and quantification of 5.16 and 17.21 ng/mL, respectively, linearity above 0.999, and relative standard deviation below 2.71%. The evaluation of seized sample of urine showed the detection of cocaine with relative ion intensity greater than 36%, as well as the metabolites benzoylecgonine and cocaethylene with a relative intensity of 1.4% and 6%, respectively.

CONCLUSIONS

The developed FSI-MS method has the potential to be applied to forensic sample evaluation as well as to determine illicit drugs from biological matrices in toxicological analysis. The use of a capillary PP fiber has advantages as an extractor agent and ionizing substrate, and also the feature of it being dipped directly into the sample, thus preserving the integrity of the sample, which makes this a very promising ambient mass spectrometry method and relevant to forensic chemistry.

Effects of time-based administration of abstinence reinforcement targeting opiate and cocaine use

Polydrug use is a common problem among patients in opioid-substitution treatment. Polydrug use has been reduced by administering abstinence-reinforcement contingencies in a sequence, such that a single drug is targeted until abstinence is achieved, and then an additional drug is targeted. The present study examined effects of administering abstinence-reinforcement contingencies sequentially based on time rather than on achieved abstinence. Participants accessed paid work (about $10/hr maximum) in the Therapeutic Workplace by providing urine samples 3 times per week. The urine samples were tested for opiates and cocaine. During an induction period, participants earned maximum pay independent of drug abstinence. Then, maximum pay depended upon urine samples that were negative for opiates. Two weeks later, maximum pay depended upon urine samples that were negative for both opiates and cocaine. Opiate and cocaine abstinence increased following administration of the respective contingencies. The time-based administration of abstinence reinforcement increased opiate and cocaine abstinence.

Evaluation of Trends of Near-Real-Time Urine Drug Test Results for Methamphetamine, Cocaine, Heroin, and Fentanyl

This cross-sectional study uses nationally representative urine drug test data to analyze changes in positivity rates for methamphetamine, cocaine, heroin, and fentanyl.

Does Lidocaine Cause False Positive Results on Cocaine Urine Drug Screen?

BACKGROUND

Individuals who have tested positive for cocaine have claimed that lidocaine, or its primary metabolite, norlidocaine (monoethylglycinexylidide (MEGX)), have caused false positive results for the cocaine metabolite benzoylecgonine (BE) on urinary immunoassay testing.

OBJECTIVE

The goal of the study was to determine if lidocaine exposure from routine medical procedures can result in false positives on a commercially available cocaine immunoassay urine drug screen (UDS).

METHODS

We performed a cross-sectional observational study of patients receiving lidocaine as part of their regular care. Standard immunoassay drug screens and confirmatory liquid chromatography-mass spectrometry (LC-MS) were performed on all urine samples to assess for MEGX and BE.

RESULTS

In total, 168 subjects were enrolled; 121 samples positive for lidocaine were ultimately included for analysis. One hundred fourteen of the 121 were also positive for MEGX. None of the 121 were positive for cocaine/BE on the UDS (95% CI), 0-3.7% for the full sample and 0-3.9% for the 114 who tested positive for MEGX.

CONCLUSION

The present study found no evidence that lidocaine or norlidocaine are capable of producing false positive results on standard cocaine urine immunoassays.

Rate of Fentanyl Positivity Among Urine Drug Test Results Positive for Cocaine or Methamphetamine

IMPORTANCE

Drug overdose deaths continue to increase, despite the leveling off of prescription opioid use and policy changes limiting opioid prescribing. Illicit fentanyl is the leading cause of drug overdose death, and it is important to characterize the emerging combination of other illicit drugs with fentanyl, which increases the risk of overdose.

OBJECTIVE

To determine whether rates of the combination of nonprescribed fentanyl with cocaine or methamphetamine have changed in urine drug test (UDT) results through time.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of UDT results from January 1, 2013, through September 30, 2018, included patient specimens submitted for UDTs by health care professionals as part of routine care. Patients were selected from health care practices across the United States, including substance use disorder treatment centers, pain management practices, primary care practices, behavioral health practices, obstetrics and gynecology practices, and multispecialty groups. The UDT analysis used liquid chromatography-tandem mass spectrometry to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl. Specimens from individuals reported to have been prescribed fentanyl were excluded. A convenience sample approach was used to randomly select 1 million unique patient UDT specimens from Millennium Health's UDT database for further analysis. Each specimen had associated cocaine, methamphetamine, and fentanyl UDT results.

EXPOSURES

Medically necessary UDT to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl, ordered by a health care professional as part of routine patient care.

MAIN OUTCOMES AND MEASURES

Rates of nonprescribed fentanyl positivity among cocaine- or methamphetamine-positive UDT results, quantified through time.

RESULTS

In a sampling of 1 million unique patients' UDT specimens analyzed for cocaine and fentanyl (median [interquartile range] age, 44 [19-69] years; 55.0% women), positivity rates for nonprescribed fentanyl among the cocaine-positive results increased significantly, from 0.9% (n = 84) (95% CI, 0.7%-1.1%) in 2013 to 17.6% (n = 427) (95% CI, 16.1%-19.1%) in 2018, a 1850% increase (τ = 0.78; z = 9.45; P < .001). In the same sampling of 1 million specimens, positivity rates for nonprescribed fentanyl among the methamphetamine-positive results also increased significantly, from 0.9% (n = 29) (95% CI, 0.6%-1.2%) in 2013 to 7.9% (n = 344) (95% CI, 7.1%-8.7%) in 2018, a 798% increase (τ = 0.72; z = 8.75; P < .001).

CONCLUSIONS AND RELEVANCE

An increasing number of UDT results positive for cocaine or methamphetamine were also positive for nonprescribed fentanyl. This provides additional insight into recently reported increases in cocaine- and methamphetamine-related overdoses. Stimulant users who may be opioid naive are at a heightened risk of overdose when exposed to fentanyl. Clinicians need to be aware that patients presenting for treatment of suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.

The effects of extended-release injectable naltrexone and incentives for opiate abstinence in heroin-dependent adults in a model therapeutic workplace: A randomized trial

AIM

To determine whether extended-release injectable naltrexone (XR-NTX), incentives for opiate abstinence, and their combination reduce opiate use compared to a usual care control and whether the combination reduces opiate use compared to either treatment alone.

DESIGN

Randomized 2 × 2 single-site controlled trial conducted from November 2012 through May 2016. After a detoxification and oral naltrexone induction, participants were assigned to a Usual Care, Abstinence Incentives, XR-NTX, or XR-NTX plus Abstinence Incentives group for a six-month intervention period.

SETTING

A model therapeutic workplace where participants could work on automated computer programs that targeted job-skills training for 4 h every weekday for 24 weeks and earn about $10 per hour.

PARTICIPANTS

84 heroin-dependent adults who were unemployed and medically approved for naltrexone. Most participants were male (71.4%), African American (80.1%), and cocaine dependent (71.4%).

MEASUREMENTS

The primary outcome measure was the percentage of urine samples negative for opiates that were collected at once weekly assessments (24 per participant) that were not part of the intervention and for which participants were paid $10 for completing.

INTERVENTION

Participants who attended the workplace provided thrice-weekly urine samples. Abstinence Incentives participants had to provide opiate-free urine samples to maintain maximum pay. XR-NTX participants received one injection every 4 weeks and were required to take injections in order to work and to maintain maximum pay. Usual Care participants were not offered XR-NTX and opiate urinalysis results did not affect pay.

FINDINGS

A large percentage (65 of 149; 43.6%) of individuals failed the induction protocol required for randomization and to be eligible to receive XR-NTX. When missing urine samples were considered positive, there was no significant interaction between XR-NTX and Abstinence Incentives. XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (81.3%, SD 39.0%) than XR-NTX participants (64.5%, SD 47.9%; aOR 10.4, 95% CI 1.3-85.5; P = .030). When urine samples were not replaced, there was a significant interaction between XR-NTX and Abstinence Incentives (aOR 77.0, 95% CI 1.3-4432;P = 0.036); XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (99.6%, SD 0.1%) than XR-NTX participants (85.0%, SD 35.7%; aOR 147.6, 95% CI 6.3-3472; P = 0.002), Abstinence Incentives participants (91.9%, SD 27.3%; aOR 121.7, 95% CI 4.8-3067; P =0.004), and Usual Care participants (78.7%, SD 41.0%; aOR 233.4, 95% CI 9.4-5814; P <.001). No other group differences were significant.

CONCLUSION

XR-NTX plus incentives for opiate abstinence increased opiate abstinence, but XR-NTX alone did not. XR-NTX can promote opiate abstinence when it is combined with incentives for opiate abstinence in a model therapeutic workplace.

A Recombinant Humanized Anticocaine Monoclonal Antibody Alters the Urinary Clearance of Cocaine and Its Metabolites in Rats

A recombinant humanized anticocaine monoclonal antibody, h2E2, has shown potential in the preclinical phases for the treatment of cocaine abuse. The standard tests for cocaine usage are the detection of benzoylecgonine (BE) and cocaine in the urine. This includes workplace drug screens as well as in clinical trials for potential treatments of cocaine abuse. By sequestering cocaine into the plasma compartment, h2E2 prevents cocaine from entering the brain. Due to the altered disposition of cocaine in the presence of h2E2, we investigated the effects of h2E2 on cocaine and metabolite levels in the urine of rats to clarify the use of BE as an endpoint measurement for effectiveness in future clinical trials. The urine concentrations of cocaine and metabolites were considerably altered in the presence of h2E2. After a single injection of h2E2 (120 mg/kg) and cocaine hydrochloride (0.56 mg/kg), the concentration of cocaine and BE excreted into the urine of rats decreased by 92% and 91%, respectively, from vehicle controls. Due to the significant decrease in urinary excretion, BE is not an appropriate indicator of cocaine usage in the presence of h2E2. Another endpoint measurement must be selected for the measurement of cocaine usage in the upcoming clinical trials of h2E2. In contrast to the effects on cocaine and BE urinary excretion, there was a 3-fold increase in ecgonine methyl ester (EME) in the presence of h2E2. Therefore, we conclude that EME is a more appropriate measurement of cocaine intake in the presence of h2E2.

Polymer-spray mass spectrometric detection and quantitation of hydrophilic compounds and some narcotics

RATIONALE

High-throughput screening of biofluids is essential in monitoring concentration of a variety of drugs to determine their efficacy and toxicity. Organosiloxane polymers prepared by sol-gel chemistry as sample supports, and electrospray ionization emitters in a single material and as an alternative to paper substrates, is described in this study.

METHODS

Hydrophobic drugs and hydrophilic streptomycin were analyzed by polymer-spray mass spectrometry with an LTQ-Orbitrap mass spectrometer. Drug samples in urine (1-2 μL) were deposited on an OSX polymer, allowed to dry, then electrosprayed from the polymer tip into the mass spectrometer without sample pretreatment. The OSX polymers, whose polarity and porosity can be controlled, were prepared by sol-gel chemistry where methyl-substituted alkoxysilanes were hydrolyzed in the presence of a pore template and an acid catalyst.

RESULTS

Five nanograms each of seven narcotic drugs were detected in <1 min (relative standard deviation (RSD) of response <1% for each drug). Calibration curves of cocaine and streptomycin in urine were used to establish the performance of the polymer. For sample 1 (n = 2), the mean recovery for cocaine was 81% with paper and 90% with polymer. Streptomycin is detected with polymer, not with paper; for samples 1 and 2 (n = 3), mean recovery was 97% and 95%, respectively.

CONCLUSIONS

Organosiloxane polymers achieve more sensitive analysis than paper, allowing for more accurate quantitation of both hydrophobic and hydrophilic drug compounds. The ability to tailor the polymer polarity and porosity allows for the synthesis of a wide range of polymers, and thus opens many possibilities for further development and applications.

Magnetic Lateral Flow Strip for the Detection of Cocaine in Urine by Naked Eyes and Smart Phone Camera

Magnetic lateral flow strip (MLFS) based on magnetic bead (MB) and smart phone camera has been developed for quantitative detection of cocaine (CC) in urine samples. CC and CC-bovine serum albumin (CC-BSA) could competitively react with MB-antibody (MB-Ab) of CC on the surface of test line of MLFS. The color of MB-Ab conjugate on the test line relates to the concentration of target in the competition immunoassay format, which can be used as a visual signal. Furthermore, the color density of the MB-Ab conjugate can be transferred into digital signal (gray value) by a smart phone, which can be used as a quantitative signal. The linear detection range for CC is 5–500 ng/mL and the relative standard deviations are under 10%. The visual limit of detection was 5 ng/mL and the whole analysis time was within 10 min. The MLFS has been successfully employed for the detection of CC in urine samples without sample pre-treatment and the result is also agreed to that of enzyme-linked immunosorbent assay (ELISA). With the popularization of smart phone cameras, the MLFS has large potential in the detection of drug residues in virtue of its stability, speediness, and low-cost.

Evaluation of 6 remote First Nations community-based buprenorphine programs in northwestern Ontario: Retrospective study

OBJECTIVE

To evaluate established opioid addiction treatment programs that use traditional healing in combination with buprenorphine-naloxone maintenance treatment in 6 First Nations communities in the Sioux Lookout region of northwestern Ontario.

DESIGN

Retrospective cohort study.

SETTING

Six First Nations communities in northwestern Ontario.

PARTICIPANTS

A total of 526 First Nations participants in opioid-dependence treatment programs.

INTERVENTION

Buprenorphine-naloxone substitution therapy and First Nations healing programming.

MAIN OUTCOME MEASURES

Retention rates and urine drug screening (UDS) results.

RESULTS

Treatment retention rates at 6, 12, and 18 months were 84%, 78%, and 72%, respectively. We estimate that the rate at 24 months will also be more than 70%. The UDS programming varied and was implemented in only 1 community. Initially urine testing was voluntary and it then became mandatory. Screening with either method found the proportion of urine samples with negative results for illicit opioids ranged between 84% and 95%.

CONCLUSION

The program's treatment retention rates and negative UDS results were higher than those reported for most methadone and buprenorphine-naloxone programs, despite a patient population where severe posttraumatic stress disorder is endemic, and despite the programs' lack of resources and addiction expertise. Community-based programs like these overcome the initial challenge of cultural competence. First Nations communities in other provinces should establish their own buprenorphinenaloxone programs, using local primary care physicians as prescribers. Sustainable core funding is needed for programming, long-term aftercare, and trauma recovery for such initiatives.

Sheath flow SERS for chemical profiling in urine

The molecular specificity and sensitivity of surface enhanced Raman scattering (SERS) makes it an attractive method for biomedical diagnostics. Here we present results demonstrating the utility and complications for SERS characterization in urine. The chemical fingerprint characteristics of Raman spectra suggest its use as a label free diagnostic; however, the complex composition of biological fluids presents a tremendous challenge. In particular, the limited number of surface sites and competing absorption tend to mask the presence of analytes in solution, particularly when the solution contains multiple analytes. To address these problems and characterize biological fluids we have demonstrated a sheath-flow interface for SERS detection. This sheath-flow SERS interface uses hydrodynamic focusing to confine analyte molecules eluting out of a column onto a planar SERS substrate where the molecules are detected by their intrinsic SERS signal. In this report we compare the direct detection of benzoylecgonine in urine using DSERS with chemical profiling by capillary zone electrophoresis and sheath-flow SERS detection. The SERS spectrum from the observed migration peaks can identify benzoylecgonine and other distinct spectra are also observed, suggesting improved chemical diagnostics in urine. With over 2000 reported compounds in urine, identification of each of the detected species is an enormous task. Nonetheless, these samples provide a benchmark to establish the potential clinical utility of sheath-flow SERS detection.

iMStrong: Deployment of a Biosensor System to Detect Cocaine Use

Biosensor systems are increasingly promoted for use in behavioral interventions. Portable biosensors might offer advancement over self-report use and can provide improved opportunity for detection and intervention in patients undergoing drug treatment programs. Fifteen participants wore a biosensor wristband capable of detecting multiple physiologic markers of sympathetic nervous system (SNS) arousal for 30 days. Urine drug screening and drug use self-report were obtained twice per week. A parameter trajectory description method was applied to capture abrupt changes in magnitude of three measures of SNS activity: Electrodermal activity (EDA), skin temperature and motion. Drug use events detected by the biosensor were verified using a triad of parameters: the biosensor data, urine drug screens, and patient self-report of substance use. Twelve positive cocaine urine screens were identified. Thirteen self-reported episodes of cocaine use were recorded. Distinct episodes with biometric parameters consistent with cocaine use were identified on biosensor data. Eleven potential cocaine use episodes were identified by biosensors that were missed by both self-report and drug screening. Study participants found mobile biosensors to be acceptable, and compliance with the protocol was high. Episodes of cocaine use, as measured by supraphysiologic changes in biophysiometric parameters, were detected by analysis of biosensor data in instances when self-report or drug screening or both failed. Biosensors have substantial potential in detecting substance abuse, in understanding the context of use in real time, and in evaluating the efficacy of behavioral interventions for drug abuse.

[Uniform analyzes of drugs in urine needed for rule of law]

Drugs of abuse testing is used in various areas of society for detection and follow-up of drug use. In routine laboratory drug testing, immunoassays are employed for initial screening of specimens to indicate the presence of drugs. To confirm a positive screening test, a secondary analysis by mass spectrometry is performed. The "cut-off" is the pre-defined concentration threshold of a drug or drug metabolite above which the sample is considered positive. A reading below this level implies a negative test result. Swedish drug testing laboratories currently employ varying cut-offs to distinguish between a positive and a negative test result. Because a positive drug test may have serious legal consequences to the individual, it is of importance that testing is performed and judged equally, regardless of where it is performed. A national harmonization of cut-offs is therefore warranted. Based on data from four major Swedish drug testing laboratories, and considering the recommendations in international guidelines, a proposal for national harmonization of urine cut-offs for the most common set of drugs of abuse is presented.

Association between travel length and drug use among Brazilian truck drivers

OBJECTIVE

To investigate whether the use of the stimulants amphetamines and cocaine by truck drivers in Brazil was related to travel length.

METHODS

Truck drivers were randomly stopped by the Federal Highway Police on interstate roads in Sao Paulo State during morning hours from 2008 to 2011 and invited to participate in the project "Comandos de Saúde nas Rodovias" (Health Commands on the Roads). Participants were asked about the use of drugs, travel distance, and age, and gender was recorded. Samples of urine were collected and analyzed for amphetamine, benzoylecgonine (a metabolite of cocaine), and carboxytetrahydrocannabinol (THC-COOH; a metabolite of cannabis) by immunological screening and quantification by gas chromatography-mass spectroscopy.

RESULTS

Current use of amphetamine, cocaine, and cannabis was reported by 5.7%, 0.7%, and 0.3% of the truck drivers, respectively. Amphetamine, benzoylecgonine, and THC-COOH were found in urine samples from 5.4%, 2.6,% and in 1.0% of the drivers, respectively. There was a significant association between the positive cases for amphetamine and reported travel length; 9.9% of urine samples from drivers who reported travel length of more than 270 km were positive for amphetamine, and 10.9% of those drivers reported current use of amphetamines. In most cases, appetite suppressants containing amphetamines had been used, but the purpose was most often to stay awake and alert while driving. Truck drivers with travel length of more than 270 km had significantly higher odds ratio (OR) for having a urine sample that was positive for amphetamine when adjusted for age as confounding factor (OR = 9.41, 95% confidence interval [CI], 3.97-22.26). No significant association was found between the use of cocaine or cannabis and travel length.

CONCLUSION

Truck drivers who reported driving more than 270 km had significantly higher frequencies of urine samples positive for amphetamine and reported significantly more frequent current use of amphetamines than those who reported shorter driving distances.

What happens in treatment doesn't stay in treatment: cocaine abstinence during treatment is associated with fewer problems at follow-up

OBJECTIVE

Cocaine users often present to treatment with a multitude of problems typically considered addiction related; however, there is little evidence that reductions in cocaine use are followed by reductions in these problems. This study evaluated the relationship between rates of cocaine use during treatment and the level of non-cocaine life problems experienced during a 12-month period following treatment in a pooled sample of 434 cocaine-dependent individuals participating in 1 of 5 randomized controlled trials.

METHOD

Structural equation modeling and latent growth curve modeling were used to evaluate the relationship between frequency of cocaine use within treatment (8 or 12 weeks) and a latent construct of global problems indicated by the days of problems reported on the Addiction Severity Index across follow-up time points (1, 3, 6, and 12 months after treatment).

RESULTS

Both a continuous latent cocaine use outcome measure (percent days abstinent, percent positive urines, and maximum days of consecutive abstinence) and a dichotomous measure of cocaine use (≥21 consecutive days of abstinence) during the treatment period were associated with frequency of cocaine use and global problems during follow-up. Overall, results indicated that greater cocaine abstinence during the treatment period was associated with higher rates of abstinence and fewer global problems experienced following treatment.

CONCLUSION

This is one of the first studies to support a model that suggests addiction-related problems decrease in accordance with achieving abstinence from cocaine, thereby providing evidence that within-treatment cocaine abstinence has benefits that extend beyond the frequency of drug use.

Acute morphine and cocaine related death after trimethoprim-adultered cocaine abuse

Over the last few decades, cocaine and morphine (heroin) have been among the primary causes of deaths related to drug abuse. Cocaine is frequently altered by dilution, substitution, contamination, and adulteration. Trimethoprim has never been identified in the powders of cocaine, making this the first post-mortem case report in which the presence of this compound is described. The case reported here is that of a 46-year-old woman with a history of cocaine and morphine abuse who was found dead inside her bathroom. The police found the corpse next to a syringe, with a telephone card containing trace of cocaine on the sink. Toxicological analysis was performed, and drug levels were measured by means of gas chromatography/mass spectrometry. In addition to the presence of cocaine and smaller alkaloids, trimethoprim was also detected on the syringe and telephone card and in the woman's nasal mucosa. Trimethoprim analysis is very quick and easy and can be added to the routine analysis of drugs of abuse seized on the illicit market to obtain more information.

Use of illicit drugs by truck drivers arriving at Paranaguá port terminal, Brazil

OBJECTIVE

The purpose of this study was to estimate the prevalence of recent use of illicit drugs among truck drivers who had parked their vehicles at the terminal port in Paranaguá City at Paraná State, southern Brazil.

METHODS

This cross-sectional study was part of a larger research project conducted among drivers at a regional Brazilian port. Data on professional characteristics, involvement in road traffic injuries, sleep, and use of alcohol and illicit drugs were collected using a questionnaire. Urine samples were collected and analyzed for amphetamines, cocaine, and cannabis using gas chromatography with mass spectrometric detection.

RESULTS

Sixty-two drivers were included in the study. Toxicological analyses showed that 8.1 percent (95% confidence interval [CI], 2.7-17.8%) of the urine samples were positive for drugs (4.8% for cocaine, 1.6% for amphetamine, and 1.6% for both); 8.1 percent reported drug use during the preceding 30 days in the questionnaire and only one tested positive for the drug in the urine sample. No sample was positive for cannabinoids. In total, at least 14.5 percent (95% CI, 6.9-25.8%) had used illicit drugs during the preceding 30 days based on self-reports and urine testing. Drivers who reported involvement in traffic injuries the year before more often tested positive for drugs in biological samples (P <.05).

CONCLUSIONS

This research provides preliminary evidence that the use of illicit stimulants was common among professional truck drivers transporting grain loads. Thus, actions are needed to reduce drug use among truck drivers in order to prevent drug-related road traffic injuries.

[Recurrent neutropenia due to adulterated cocaine]

BACKGROUND

Since 2009, a warning has been issued about cocaine that has been adulterated with levamisole, mainly in the USA and Canada. Agranulocytosis occurs as an idiosyncratic reaction in 3-10% of patients exposed to levamisole.

CASE DESCRIPTION

A 36-year-old man was referred to our hospital because of an episode of high fever and infections on his hands, mouth and ears. Laboratory testing showed neutropenia. The infections were treated successfully with antibiotics. The neutropenia disappeared, but returned with recurrence of the infections. Upon presentation at the emergency care unit, the patient had signs of intoxication. This patient's urine contained metabolites of cocaine (benzoylecgonine and ecgonine methyl ester), whereupon additional testing showed levamisole to be present in serum. The patient discontinued cocaine use. Following treatment of the infections, the neutropenia fully resolved and did not recur.

CONCLUSION

This patient had acquired agranulocytosis, due to the use of cocaine adulterated with levamisole.

Extending the dynamic range of the ion trap by differential mobility filtration

A miniature, planar, differential ion mobility spectrometer (DMS) was interfaced to an LCQ classic ion trap to conduct selective ion filtration prior to mass analysis in order to extend the dynamic range of the trap. Space charge effects are known to limit the functional ion storage capacity of ion trap mass analyzers and this, in turn, can affect the quality of the mass spectral data generated. This problem is further exacerbated in the analysis of mixtures where the indiscriminate introduction of matrix ions results in premature trap saturation with non-targeted species, thereby reducing the number of parent ions that may be used to conduct MS/MS experiments for quantitation or other diagnostic studies. We show that conducting differential mobility-based separations prior to mass analysis allows the isolation of targeted analytes from electrosprayed mixtures preventing the indiscriminate introduction of matrix ions and premature trap saturation with analytically unrelated species. Coupling these two analytical techniques is shown to enhance the detection of a targeted drug metabolite from a biological matrix. In its capacity as a selective ion filter, the DMS can improve the analytical performance of analyzers such as quadrupole (3D or linear) and ion cyclotron resonance (FT-ICR) ion traps that depend on ion accumulation.

Sweat testing to monitor drug exposure

It may be advantageous to use sweat, rather than blood or urine, to monitor individuals' drug exposure for the purposes of drug treatment programs, employment initiatives, and forensic investigations. Forty-eight patients receiving methadone at the Public Service for the Treatment of Drug Dependence of Perugia (Italy) were monitored for 14 days by the analysis of methadone and cocaine present in two sweat patches, each worn for 7 days. The results were compared to those from the analysis of urine samples collected at the beginning of the study and after 7 days, as well as those from the analysis of hair collected on the fourteenth day. Sweat patch analysis was positive for methadone and its metabolite EDDP in 100% of patients. Some individuals were positive for cocaine in urine, sweat, and hair while others were positive for cocaine in only one of those samples. Results suggest analysis of a sweat patch indicates an individual's drug use or drug washout for the previous week, and provides an alternative to blood or urine analyses.

Retrospective study of outcomes, for patients admitted to a drug treatment centre board

Retrospective study of urinary heroin outcomes of a cohort (123) of patients commenced on a methadone treatment program. Significantly poorer outcomes were associated with urines positive for cocaine (OR 0.69 CI 0.59-0.81) benzodiazepines (OR 0.7 CI 0.53-0.93) with prescribing of low dose methadone (OR 0.65 CI 0.48-0.87), with urines positive for heroin at time of admission (OR 0.74 CI 0.56-0.97) and with behavioural sanctions (OR 0.8, CI 0.65-0.98). Improved outcomes were associated with granting of take away methadone (OR 1.34 CI 1.1-1.62). with an indication of improved outcomes associated with alcohol positive urines (OR 1.34 CI 0.95-1.9) and increased duration of clinic attendance (OR 1.21 CI 0.99-1.47). On multiple regression analysis low dose methadone (0.07 CI 0.01-0.33) prescribing remained negatively associated with urine heroin outcomes.