Emergency department evaluation of a rapid assay for detection of cocaine metabolites in urine specimens

We evaluated the Abuscreen ONTRAK assay for cocaine metabolites, a rapid immunoassay for the detection of cocaine metabolites in a pediatric emergency department (ED) setting. The ONTRAK uses a cutoff point of 300 micrograms/L for benzoylecgonine (BEC), cocaine's major urinary metabolite. One hundred and thirty-two urine specimens obtained from infants, children, and adolescents whose clinical findings warranted toxicology screening were evaluated. The ONTRAK identified all 15 specimens with BEC values of 300 micrograms/L, but did not detect seven additional specimens positive for cocaine metabolites at concentrations less than 300 micrograms/L. One third of the positive specimens for cocaine metabolite identified by fluorescent polarization immunoassay (FPIA), cutoff point set at 80 micrograms/L, and confirmed by gas chromatography/mass spectrometry (GUMS), cutoff point 50 micrograms/L, were not detected by the ONTRAK. These false negative specimens were seen exclusively in young children, whose concentration of cocaine metabolite was less than the ONTRAK's cutoff value. The test was sensitive to drug concentration at or around the stated cutoff values. The ONTRAK test for cocaine metabolites, although both a sensitive and specific screening test for adolescents who smoke or snort cocaine, lacks the sensitivity to be a useful screening too[ for detecting cocaine metabolites in young children. Limitations of currently performed toxicology screening tests (ie, stated cutoff levels) may cause emergency physicians to miss most young children whose symptoms may he related to cocaine exposure.

[Drug abuse among new draftees]

The aim of the study was to investigate the pattern of the use of drugs among young conscripts by a test screening of their urine. The participants in the investigation also filled in a questionnaire about use of drugs. The urine samples from 916 young recruits were examined for cannabinoids and 429 were also examined for amphetamines, cocaine, opiates and benzodiazepines. We found 68 (7.8%) positive tests for cannabis and a negligible number of positive tests for other drugs. The questionnaire showed a lower statement of use of drugs though 3.3% stated a daily or weekly use of cannabis. Fifty-eight percent of the soldiers admitted that they had tried cannabis. Six percent had used other drugs. The consumption of alcohol is low during weekdays. We concluded that the conscripts did not constitute a population of drug abusers. We recommend that urine test screening (regular or spot test) should be incorporated in the future medical examination in the Danish Army to pinpoint personnel with a moderate use of cannabis.

Enzyme-linked immunosorbent assay and latex agglutination inhibition reaction test for cocaine and benzoylecgonine in urine

An enzyme-linked immunosorbent assay (ELISA) and a latex agglutination inhibition reaction test (LAIRT) for cocaine and benzoylecgonine have been established. In ELISA with polystyrene microtiter wells coated with anti-benzoylecgonine antibody and alkaline phosphatase (ALP)-labeled benzoylecgonine, the activity of antibody-bound ALP was measured with the enzyme cycling method. The range of benzoylecgonine measurable by ELISA was 12 pg-25 ng/well; the analysis time for 96 wells was 90 min. In LAIRT, the agglutination reaction with anti-benzoylecgonine antibody-coated latex and benzoylecgonine-rabbit serum albumin (RSA) conjugate-coated latex was inhibited by 0.1 mu g benzoylecgonine/ml urine; the analysis time for six samples on one glass slide was 20 min. The urine samples of 47 abusers were analyzed by ELISA and LAIRT. From the comparison with results of the enzyme-multiplied immunoassay technique (EMIT) and gas chromatography-mass spectrometry (GC-MS), it was clarified that both ELISA and LAIRT were suitable for the screening method of urine samples.

Identification and quantitation of alkaloids in coca tea

The consumption of coca tea is a common occurrence in many South American countries. The tea is often packaged in individual servings as tea bags which contain approximately 1 g of plant material. The consumption of coca tea leads to ingestion of cocaine and other alkaloids; however, there is little information available regarding the pharmacological or toxicological effects that result from consumption of coca tea. We performed a series of studies with coca tea bags from two South American countries, Peru and Bolivia. The alkaloidal content of the 'coca leaf' in coca tea bags was determined by two different extraction methods: Soxhlet extraction with methanol (exhaustive extraction), and mechanical agitation with methanol. Extracts were purified by solid-phase extraction (SPE) followed by analysis by gas chromatography/mass spectrometry (GC/MS). Coca tea prepared from Peruvian and Bolivian coca tea bags was also analyzed by SPE-GC/MS assay. In addition, urine specimens were analyzed from an individual who consumed one cup of Peruvian coca tea and one cup of Bolivian coca tea on separate occasions. Urine samples were analyzed by immunoassay (TDx) and SPE-GC/MS. Analysis of coca tea bags and coca tea indicated that cocaine, benzoylecgonine, ecgonine methyl ester and trans-cinnamoylcocaine were present in varying quantities. With exhaustive extraction, an average of 5.11 mg, and 4.86 mg of cocaine per tea bag were found in coca leaf from Peru and Bolivia, respectively. The average amounts of benzoylecgonine, ecgonine methyl ester in Peruvian coca leaf were 0.11 and 1.15 mg, and in Bolivian coca leaf were 0.12 and 2.93 mg per tea bag, respectively. trans-cinnamoylcocaine was found in trace amounts in Peruvian tea bags and 0.16 mg/tea bag of Bolivian tea. When tea was prepared, an average of 4.14 mg of cocaine was present in a cup of Peruvian coca tea and 4.29 mg of cocaine was present in Bolivian tea. Following the consumption of a cup of Peruvian tea by one individual, a peak urine benzoylecgonine concentration of 3940 ng/ml occurred 10 h after ingestion. Consumption of Bolivian coca tea resulted in a peak benzoylecgonine concentration of 4979 ng/ml at 3.5 h. The cumulative urinary excretion of benzoylecgonine after approximately 48 h, determined by GC/MS, was 3.11 mg and 2.69 mg after consumption of Peruvian and Bolivian coca tea, respectively. This study demonstrated that coca tea bags and coca tea contain a significant amount of cocaine and cocaine-related alkaloids and the consumption of a single cup of Peruvian or Bolivian coca tea produces positive drug test results for cocaine metabolites.

Toxicology screening in adolescent trauma

We sought to define the prevalence of positive drug screens in adolescent victims of major trauma. The records of 125 consecutive adolescent patients presenting with major trauma to an inner-city trauma center during the last nine months of 1990 were reviewed. Eighty-five (68%) received urine toxicology screens for alcohol and illicit drugs. Twenty-one (25%) of screened patients had a positive urine drug screen. The most commonly detected drugs were alcohol, cocaine, and opiates. Gender, race, mechanism of injury, mental status at presentation, injury severity score, and revised trauma score were not associated with a positive drug screen. We conclude that: 1) 25% of screened adolescent victims of major trauma seen at an inner-city trauma center had positive urine toxicology screens for alcohol or illicit drugs. 2) As none of the study variables was associated with a positive drug screen, selective drug screening cannot be supported.

Traumatic ponto-medullary tear: a case report

The aim of this report is to demonstrate the correlation between an extremely short time acting but strong force leading to incomplete rupture of the ponto-medullary junction (PMJ) accompanied by rupture of the basilar artery. Potential mechanisms involved in a combined hyperextension and axial torsion of the head followed by characteristic lesions at the PMJ are discussed. A 33-year-old male suffered a blunt head injury following a blow to the head, i.e. a head-butt. Resuscitation was performed for 45 min without success. At post mortem, there was a superficial periorbital haematoma on the right and a deep soft tissue bruise in the right fronto-parieto-temporal area, but no evidence of skull or dens axis fracture. A deep tear at the ponto-medullary junction was identified with rupture of the basilar artery, whereas at the tip of the tear, i.e. the floor of the IVth ventricle, only a thin tissue layer of about 2 mm remained intact. In contrast to the severity of these lesions, only mild subarachnoid hemorrhage was observed, but the ventricular system was filled with blood clot resulting from the retrograde flow of subarachnoid hemorrhage.

Cardiovascular effects of cocaine in neonates exposed prenatally

This blinded cross-sectional study was to determine whether chronic cocaine exposure in utero produces abnormalities in left ventricular function (shortening fraction), heart rate, rhythm, and conduction in term neonates. Three groups of neonates were evaluated by two-dimensional echo Doppler and 24 hour Holter monitor, with studies initiated in the first 24 hours of life. Group A (n = 32) neonates had a positive history of chronic maternal cocaine use in pregnancy (MCU+) and a positive neonatal urine cocaine test (NUC+). Group B (n = 23) neonates were MCU+ but NUC-. Group C (n = 32) neonates were MCU- and NUC-. Measured parameters were compared statistically by analysis of variance. p < 0.05 was regarded as significant. Echocardiography showed no significant difference between groups A, B, and C for left ventricular shortening fraction. Holter monitor likewise revealed no significant difference between groups in minimal, maximal, and average heart rate, or in the incidence of supraventricular and ventricular arrhythmias greater than 20 beats/h in the 24-hour period. None of the patients had atrioventricular or bundle branch block. It is possible that the developmental state of the newborn heart makes it less responsive to the adverse effects of cocaine.

Stability of ecgonine methyl ester in postmortem urine specimens

In this study, 25 postmortem urine specimens testing positive, for cocaine and ecogonine methyl ester (EME) by full scan electron impact gas chromatography/mass spectrometry, were used to evaluate the stability of EME in refrigerated and frozen conditions. After an initial quantitation (t = 0), these specimens were split and stored at either 4 degrees C or -20 degrees C. At several intervals, over a six month period, the specimens were tested for cocaine and EME. Twenty-two of the frozen specimens were within 20% of their t = 0 EME concentration after 6 months; 19 of the 25 refrigerated specimens showed similar stability. At least 50% of the EME present was detected in all specimens under both storage conditions. In addition, there was no evidence to suggest that EME concentrations increased over time even though decreases in cocaine concentrations were observed over the same time period. This suggests that the presence of EME in urine specimens indicates in vivo conversion of cocaine and, therefore, use of cocaine.

An automated preconcentration-derivatization system for the determination of cocaine and its metabolites in urine and illicit cocaine samples by gas chromatography/mass spectrometry

Although gas chromatography/mass spectrometry (GC/MS) is the most powerful technique for analysing cocaine and its hydrolysis products (benzoylecgonine, ecgonine methyl ester and ecgonine) in urine, the sample pretreatment required is rather laborious and involves a large number of steps. This paper reports a continuous method for the separation (based on the retention properties of cocaine and its major metabolites on a reversed phase C18 column), preconcentration (evaporation under nitrogen) and derivatization (collection of the residue in a few microlitres of derivatizing reagent) of cocaine and its metabolites in urine samples for subsequent analysis by GC/MS. Calibration graphs are linear from 5 to 3000 ng/mL; the detection limits are 1 ng/mL (cocaine and ecgonine methyl ester), 20 ng/mL (benzoylecgonine) and 200 ng/mL (ecgonine). The method was applied to illicit cocaine samples and to urine from a drug addict.

Urine toxicology screens in drivers suspected of driving while impaired from drugs

OBJECTIVE

Police departments, in conjunction with the National Highway Traffic Safety Administration, have developed a standardized evaluation aimed at identifying drivers impaired by drugs other than ethanol. These evaluations are performed by specially trained police officers known as Drug Recognition Experts.

METHODS

We retrospectively reviewed the evaluations of 242 drivers detained for driving while impaired in the City and County of Denver from January 1, 1988 to June 30, 1990.

RESULTS

All drivers had urine toxicology screens performed, which were positive for a mean 1.2 +/- 0.9 SD (range zero to four) for drugs having the potential for causing driving impairment. The 193/242 urine screens (79.8%) testing positive showed the following drugs: cannabis 162 (66.9%), stimulants (including cocaine metabolites) 80 (33.1%), depressants (benzodiazepines and barbiturates) 24 (9.9%), narcotics 12 (5.0%), inhalants (toluene) 1 (0.4%), hallucinogens (LSD) 1 (0.4%), and other 3 (1.2%). Drug Recognition Experts, based on their initial evaluation, were able to predict correctly some or all of the drugs found on the urine screens in 178/242 (73.6%) of cases. Overall agreement between the Drug Recognition Experts opinions and urine screen results had a kappa value (p < 0.05) of 0.41.

CONCLUSIONS

There was a high rate (79.8%) of positive urine toxicology screens in drivers suspected of nonethanol drug impairment. In most cases, Drug Recognition Experts were able to reliably predict the results of these screens.

Use of the USDT flow immunosensor for quantitation of benzoylecgonine in urine

The flow immunosensor works on a principle somewhat distinct from other immunoassay systems in that it performs a displacement immunoassay. Antibody-coated matrices are saturated with fluorescently labeled benzoylecgonine (BE), which is released and measured in the presence of BE-containing urine and measured downstream from the matrix. The same antibody matrix can be used for many samples. A flow immunosensor instrument, built by US Drug Testing, Inc., has recently received "Premarket Notification' (510(K)) from the Food and Drug Administration (FDA) to screen urine for the presence of the cocaine metabolite BE. The performance of the flow immunosensor for screening BE in urine was validated by comparison with results of a blind study using the Syva EMIT, the Abbott TDx and gas chromatography-mass spectroscopy (GC-MS). Potentially interfering drugs were also spiked into urine and evaluated using the flow immunosensor. While the FDA approval is for determining whether the BE concentration is above or below the 300 micrograms/l cutoff recommended by the National Institute of Drug Abuse, we have also shown that the flow immunosensor can be adapted to produce quantitative determinations of the amount of BE in the urine samples. The reliability of the quantitation was confirmed by testing 100 urine samples containing unknown amounts of BE using the flow immunosensor. GC-MS and the Abbott TDx system. Comparison of quantitative data obtained using the immunosensor and GC-MS showed a 97% correlation, compared with a much lower value for data from the TDx and GC-MS.

Neurological correlates of fetal cocaine exposure: transient hypertonia of infancy and early childhood

OBJECTIVE

To assess whether prenatal cocaine exposure has any long-term effects on neurodevelopment.

DESIGN

A prospective cohort study with examiners blind to drug exposure and human immunodeficiency virus (HIV) status.

SUBJECTS

Of 144 high-risk infants enrolled in a perinatal HIV neurodevelopmental study, 119 (83%) infants with both neurological and urine toxicology measures were followed up to age 24 months.

METHODS

Neurological and developmental assessments were analyzed at 6-month intervals grouped according to the presence of cocaine in urine toxicology: 51 infants were cocaine-positive. Adjusted odds ratios (ORs) and 95% confidence interval (CI) were obtained by logistic regression equations that adjusted for perinatal variables, including measures of fetal growth, gestation, HIV status, and infant toxicology results.

SETTING

Harlem Hospital Center from 1988 to 1992.

RESULTS

At age 6 months, 21 of 51 (41%) cocaine-positive children exhibited hypertonia of any type (hypertonic tetraparesis, hypertonic diparesis, and hypertonic hemiparesis) compared with 17 of 68 (25%) cocaine-negative infants (OR = 2.1, CI = 1.0-4.6). Cocaine-positive infants were four times more likely to show hypertonic tetraparesis (HTP) than cocaine-negative infants (OR = 4.0; CI = 1.5-10.8). The association remained significant in multivariate analyses. Hypertonia, consistent with cerebral palsy, diminished over time in both groups. In 97% of affected infants hypertonia resolved by 24 months. Arm hypertonia abated first; leg hypertonia remained in some children up to age 18 months. No differences in development scores between cocaine-positive and cocaine-negative were noted at any age interval. However, among cocaine-positive infants those with early HTP showed significantly lower mean developmental scores at 6 and 12 month compared to infants without HTP.

CONCLUSION

Cocaine positivity urine toxicology at birth is associated with hypertonia during infancy. Such cocaine-induced effects are usually symmetrical, transient, and the majority of exposed children outgrow hypertonia by 24 months of life. Among cocaine-positive infants, HTP may be a marker for later developmental impairments.

Comparison of cocaine and opiate exposures between young urban and suburban children

OBJECTIVE

To determine the prevalence of cocaine and opiate metabolites in the urine of young urban and suburban children.

DESIGN

Survey.

SETTING

Urban and suburban emergency departments and private pediatric practices.

PATIENTS

A convenience sample of 1469 children between 1 and 60 months of age who required a urinalysis for investigation of the chief complaint.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Urine was screened for benzoylecogonine and opiates using an enzyme-multiplied immunoassay technique and a fluorescence-polarization immunoassay, both with a sensitivity of 50 ng/mL.

RESULTS

Benzoylecogonine was identified in the urine of 45 children (3.1%) (95% CI, 2.2% to 3.9%) and opiates in the urine of 38 children (2.6%) (95% CI, 1.8% to 3.4%). No difference was observed between urban and suburban health care facilities in the percentage of patients whose urine tested positive for benzoylecgonine (29 of 1011 vs 16 of 458, P = .6) or opiates (28 of 1011 vs 10 of 458, P = .6).

CONCLUSION

Exposure to illicit drugs, as reflected by urinary metabolites, is similar for urban and suburban children.

False-positive postmortem EMIT drugs-of-abuse assay due to lactate dehydrogenase and lactate in urine

Three cases of multiple false-positive drug tests are described. Postmortem urine specimens were screened using the enzyme-multiplied immunoassay technique. All patients had proteinuria and lactic aciduria. These false-positive reactions were due to the presence of lactate dehydrogenase (LDH), lactic acid, and protein. This finding was confirmed by creating a multiple false-positive sample with a solution of LDH and lactate in 5% bovine serum albumin at pH 6.

Analysis of cocaine and its metabolites from biological specimens using solid-phase extraction and positive ion chemical ionization mass spectrometry

An accurate and reliable gas chromatographic-mass spectrometric method was developed to analyze tissue, whole blood, plasma, and urine samples for cocaine (COC) and its major metabolites. COC, benzoylecgonine (BZE), and ecgonine methyl ester (EME) were isolated from the biological matrix using solid-phase extraction, and the tert-butyldimethylsilyl derivatives of BZE, EME, and their deuterium-labeled internal standards were formed. Separation of the compounds was performed by capillary chromatography, and analysis was performed by positive ion chemical ionization mass spectrometry using methane and ammonia as the reagent gases. The tert-butyldimethylsilyl derivatives of BZE and EME were stable and produced mass spectral ions with higher mass-to-charge ratios than trimethylsilyl derivatives. Recovery of COC and its metabolites exceeded 80% at all three concentrations tested. Linearity of the method was established from 2.5 to 2000 microg/L. Intra-assay precision had a coefficient of variation (CV) of less than 9% for all analytes when tested at 10, 25, 100, and 200 microg/L. Interassay precision also had a CV of less than 9% for COC, BZE, and EME at 25 and 100 microg/L. At 200 microg/L, %CVs for COC, BZE, and EME were 11.5, 12.0, and 12.7, respectively. In addition to the analysis of COC, BZE, and EME, the method was used to quantitate cocaethylene and to identify norcocaine.

ONTRAK TESTCUP: a novel, on-site, multi-analyte screen for the detection of abused drugs

We developed a rapid, sensitive, and simple-to-use multi-analyte diagnostic device for the detection of drugs of abuse in urine: the ONTRAK TESTCUP. No sample or reagent handling is necessary with this device, and the device also serves as the sample collection cup. The TESTCUP contains immunochromatographic reagents that qualitatively and simultaneously detect the presence of benzoylecgonine, morphine, and cannabinoids (delta9-tetrahydrocannabinol [THC] in urine. It is based on the principle of competition between the drug in the sample and membrane- immobilized drug conjugate for antidrug antibodies coated on blue-dyed microparticles. Each drug assay has its own strip, which contains an antibody specific to benzoylecgonine, morphine, or THC. A sample is collected in the TESTCUP, a lid is placed on it, and a chamber at the top of the cup is filled with urine by inverting the cup for 5 s. Urine proceeds down immunochromatographic strips, and the assays are developed. In approximately 3-5 min, the Test Valid bars appear, a decal is removed from the detection window, and the results are interpreted. The appearance of a colored bar at the detection window for each drug indicates a negative result. The absence of color in any specific drug detection window indicates a positive result for that drug. If a positive result is obtained, the same device (cup) can be used for gas chromatographic-mass spectrometric (GC-MS) confirmation. When the precision of the TESTCUP was evaluated, the results obtained were as follows: for urine controls containing drug at 50% of its cutoff concentration, the results were greater than or equal to 96, 98, and 96% negative for benzoylecgonine, morphine, and THC, respectively; for urine controls containing drug at 120% of its cutoff concentration, the results were greater than or equal to 97, 100, and 98% positive for benzoylecgonine, morphine, and THC, respectively. The correlations of clinical sample results using the TESTCUP versus results by GC-MS and the ONTRAK and OnLine assays were assessed. There was 100% agreement between samples prescreened positive by GC-MS and positive by TESTCUP for all three assays. There was 100% agreement between TESTCUP and ONTRAK results and between TESTCUP and OnLine results when testing clinical samples positive and negative for cocaine (benzoylecgonine) or THC. Greater than 99% agreement was observed between TESTCUP and ONTRAK results and between TESTCUP and OnLine results when testing clinical samples positive and negative for morphine. The cross-reactivity of the TESTCUP assay to related drugs and drug metabolites was also determined, and the results were similar to those of the ONTRAK and OnLine assays.

Testing human hair and urine for anhydroecgonine methyl ester, a pyrolysis product of cocaine

A method using gas chromatography coupled to mass spectrometry for the determination of the cocaine (COC) pyrolysis product, anhydroecgonine methyl ester (AEME), in urine and hair is described. The same procedure allows the simultaneous determination of COC, benzoylecgonine (BZE), ecgonine methyl ester, and cocaethylene. The assay involves acid hydrolysis for hair, deuterated internal standards, a three-step liquid-liquid extraction, and derivatization with N,O-bis(trimethylsilyl) trifluoroacetamide plus 1% trimethylchlorosilane. Detector responses for analytes were linear over the concentration ranges of 0.2-50 ng/mg and 10-2000 ng/mL for hair and urine, respectively. Artifact formation of AEME during the injection was less than 1%. AEME was tested in 65 and 81 cases for hair and urine, respectively, where COC or BZE or both tested positive. Concentrations of AEME ranged from 0.2 to 2.4 ng/mg (n = 7) and from 4 to 226 ng/mL (n = 12) in hair and urine, respectively. Its presence was observed in few cases, clearly indicating that COC smoking is not frequent in France.

Passive inhalation of cocaine

Six healthy male volunteers were exposed to the vapor of 100 and 200 mg freebase cocaine heated to a temperature of 200 degrees C in an unventilated room (12,600-L volume) for a period of 1 h. No pharmacological effects were detected as a result of the exposure. Blood specimens collected immediately following exposure were negative for cocaine and metabolites. Urine specimens analyzed by gas chromatography-mass spectrometry contained peak concentrations of benzoylecgonine that ranged from 22 to 123 ng/mL. The peak excretion time for benzoylecgonine following passive exposure was approximately 5 h. The amount of cocaine inhaled by the subjects during passive exposure was estimated from room air measurements of cocaine to be approximately 0.25 mg. The total amount of cocaine (cocaine plus metabolites) excreted in urine by the six subjects ranged from 0.04 to 0.21 mg. For comparison, the six subjects also received an intravenous injection of 1 mg cocaine hydrochloride. Four of six subjects screened positive (300-ng/mL cutoff concentration) following the injection, indicating that the minimum amount of cocaine in these subjects necessary to produce positive results was approximately 1 mg. A second passive inhalation study was undertaken in which specimens were collected from research staff who assisted in a series of experimental studies with "crack" (freebase cocaine) smokers. The research staff remained in close vicinity while the crack smokers smoked three doses of freebase cocaine (12.5, 25, and 50 mg) over a period of 4 h. As a result, staff members were passively exposed to sidestream smoke from crack pipes and to breath exhalation from the crack smokers. Urine specimens from the staff members contained a maximum of 6 ng/mL benzoylecgonine. Only traces (less than 1 ng/mL) of cocaine were detected in any specimen. Overall, these studies demonstrated that individuals exposed to cocaine smoke under naturalistic or artificial conditions absorbed small amounts of cocaine that were insufficient to produce positive urine specimens at standard Department of Health and Human Services cutoffs. However, passive exposure conditions that would result in absorption of cocaine in amounts exceeding 1 mg could result in the production of cocaine-positive urine specimens.

Internally concealed cocaine: analytical and diagnostic aspects

Thirty persons arrested at Frankfurt airport for smuggling internally concealed cocaine in 1993/1994 were investigated. An X-ray examination (in all 30 cases), immunochemical examination of urine (in 27 cases) and of saliva (in 20 cases) was performed in parallel. An X-ray examination gave positive results in all examined persons. EMIT cocaine metabolite assay (cut off 300 ng benzoylecgonine (BE)/mL) was positive in eight urine samples. After reducing the cut off to 150 ng BE/mL urine, eleven samples were classified as positive. The results were confirmed by means of chromatographic determinations. These findings showed limited role of immunological examination of urine as a screening test in suspected smuggling of internally concealed drugs. All saliva samples showed negative immunochemical results. The number of concealed containers ranged from 44 to 135 per person. The amount of cocaine hydrochloride found in particular cases ranged from 242 to 1050 g net weight, divided into containers weighing from 5.7 to 13.8 g. Drug packages were obviously machine-made. The packages smuggled by a particular person were uniform. However, a distinct interpersonal variability in drug packages was observed, in regard to the number of protective layers (4-7), size, weight, and cocaine purity. This may be helpful for the identification of production site. The leaching of cocaine from selected containers was investigated in a stirring bath and was independent of the conditions applied.

Validation of a rapid urine screening assay for cocaine use among pregnant emergency patients

OBJECTIVES

To determine the accuracy of the OnTrak rapid urine latex agglutination immunoassay (AIA) for testing pregnant ED patients for the cocaine metabolite benzoylecgonine (BE), and to determine the frequency of urine BE in pregnant ED patients and the association of test results with patient demographics.

METHODS

A test performance evaluation was conducted using an inception cohort of pregnant patients at an urban teaching hospital ED. Patients with positive urine chorionic gonadotropin tests who had adequate remaining urine samples were studied. Patient demographics, ED diagnoses, and assay results were recorded without patient identifiers. Urine was tested using the rapid AIA. The first 150 samples were confirmed using a second immunoassay and gas chromatography with a nitrogen phosphorus detector. All positive samples also were confirmed with thin-layer chromatography, and quantification by gas chromatography-mass spectrometry.

RESULTS

Twenty of 342 (5.9%, 95% CI 3.4-8.4%) pregnant patients had urine samples positive by AIA testing for BE. Confirmation testing demonstrated no false-positive or -negative AIA result. Positive test results were not associated with specific patient diagnoses or demographics.

CONCLUSIONS

ED screening for cocaine use among pregnant patients can be accurately performed using the OnTrak AIA for BE. In the ED population screened, 5.9% of the pregnant women had urine samples positive for BE.

Quantitative determination of cocaine, cocaethylene (ethylcocaine), and metabolites in plasma and urine by high-performance liquid chromatography

A sensitive HPLC assay was developed to quantitate the relatively nonpolar compounds cocaine, cocaethylene (ethylcocaine), norcocaine, and norcocaethylene, as well as the relatively polar metabolites benzoylecgonine and benzoylnorecgonine, in rat plasma and urine. The assay in plasma employed two successive liquid-liquid extractions and separate injections onto two different columns (C8 and C18) to separate and quantitate the relatively polar and nonpolar compounds. In urine, the procedure employed a liquid-liquid extraction followed by solid-phase extraction (C18 light-load cartridges) and two separate injections as for plasma. The UV absorbance of the effluent was monitored at 235 nm. Linear standard curves were obtained over the concentration ranges of 25 to 1000 ng/mL and 5 to 250 ng/mL in plasma and urine, respectively. The inter- and intraday coefficients of variation for the assay of all compounds in plasma and urine were < 18% at low concentrations (12.5-100 ng/mL) and < 12% at high concentrations (125-250 ng/mL). There was no degradation of these compounds during the extraction procedure or during 2 months of storage at -20 degrees C. The quantitation limits for the assay of the relatively nonpolar and polar compounds in plasma were 25 (2.5 ng in 0.1 mL) and 50 ng/mL (5 ng in 0.1 mL), respectively. For the assay in urine, the quantitation limits were 5 (2.5 ng in 0.5 mL) and 12.5 ng/mL (6.25 ng in 0.5 mL) for the assay of the relatively nonpolar and polar compounds, respectively. The methods have been applied to quantitate those compounds in rat plasma.

Cocaethylene (ethylcocaine) detection during toxicological screening of a university medical center patient population

Cocaethylene (ethylcocaine) (CE) was incorporated into this laboratory's urine toxicological screening protocol more than 1 year ago. During a 1-year period, 451 urine specimens tested positive for benzoylecgonine (BE) and/or cocaine (COC) and/or CE using a combination of thin-layer chromatography with enzyme immunoassay confirmation. CE was detected in 57 urine specimens. Blood ethanol (EtOH) analysis was available for 37 of these cases, and the mean concentration (1320 mg/L) was significantly higher than that found in 117 blood EtOH assays performed for the CE-negative patients (630 mg/L) (p < .01). In two instances, CE was noted in urine in the absence of EtOH in the corresponding blood. Without exception, CE, when present in urine, was always detected with both BE and COC. Most of the time, no other drugs were found. In one instance, CE was present in the urine of a neonate but was not detected in that of its mother. Demographic and analytical findings are presented for both CE-positive and CE-negative cases.

Fatal injuries after cocaine use as a leading cause of death among young adults in New York City

BACKGROUND

Cocaine intoxication can lead to fatal cardiovascular and cerebrovascular events. In addition, the neurobehavioral effects of cocaine may increase the likelihood that a user will receive violent fatal injuries. Since New York City is a center for the importation and distribution of cocaine, we sought to determine the extent of cocaine use among city residents with fatal injuries.

METHODS

Among a total of 14,843 residents of New York City who received fatal injuries from 1990 through 1992, we determined the proportion who used cocaine shortly before their deaths. We also determined the population-based rates of fatal injuries that were known to follow cocaine use and the proportion of all deaths of New York City residents that was represented by these cases for each demographic stratum. For adults 15 to 44 years of age, fatal injury after cocaine use was ranked with other causes of death as though it was a separate cause.

RESULTS

Cocaine use, as measured by the detection of the metabolite benzoylecgonine in urine or blood, was found in 26.7 percent of all New York City residents receiving fatal injuries; free cocaine was detected in 18.3 percent. Approximately one third of deaths after cocaine use were the result of drug intoxication, but two thirds involved traumatic injuries resulting from homicides, suicides, traffic accidents, and falls. If fatal injury after cocaine use was considered as a separate cause of death, it would rank among the five leading causes of death among those 15 to 44 years of age in New York City.

CONCLUSIONS

Fatal injuries among cocaine users account for a substantial proportion of all deaths among young adults in New York City.

Detection of cocaine and its polar transformation products and metabolites in human urine

This paper describes a method for the analysis of thermal degradation compounds generated from cocaine during the smoking process, together with chemical and enzymatic biotransformation products which, by virtue of their polarity, are not recovered by existing analytical procedures. The method employs cation exchange solid phase extraction coupled with gas chromatography/mass spectrometry. Compounds identified in urine from subjects of cocaine-related death included cocaine, benzoylecgonine, ecgonine methyl ester and ecgonine, which were measured quantitatively, and ecgonidine, ecgonidine methyl ester, ecgonine ethyl ester, ethyl benzoylecgonine, norcocaine, benzoylnorecgonine, cinnamoylcocaine, and cinnamoylecgonine. The concentrations of ecgonine (0-104 micrograms/ml) and ecgonine methyl ester (0-177 micrograms/ml) were substantial and averaged about one tenth the concentrations of benzoylecgonine (0-1074 micrograms/ml) and cocaine (0-1221 micrograms/ml). These and several of the other compounds identified will be valuable markers for cocaine use, in degraded samples and for indicating the route of administration.

Occult cocaine and opiate exposure in children and associated physical findings

We determined the prevalence of cocaine and opiate exposure and the association of exposure with objective physical findings in children presenting to an urban pediatric emergency department. The study included 942 children between one and 60 months of age who required urinalysis for investigation of their chief complaint. Anonymously and without informed consent, urine was screened for benzoylecgonine (BE) and opiates, using an enzyme multiplied immunoassay technique (EMIT) with sensitivity of 50 ng/ml. EMIT-positive samples were rescreened using a fluorescence polarization immunoassay (FPIA). Specimens positive by both EMIT and FPIA were confirmed by gas chromatography/mass spectrometry (GC/MS) if sufficient quantity of urine was available. BE was identified in 41 (4.4%) and opiates in 46 (4.9%) patients by both EMIT and FPIA. The presence of BE or opiate was confirmed by GC/MS in all 34 cases where sufficient urine was available. The age- and sex-adjusted systolic and diastolic blood pressure percentiles were greater, and head circumference and weight percentiles were lower in BE-positive patients compared to those with negative drug screens. There were no associations between opiate exposure and any of these variables. We conclude that occult postnatal cocaine exposure is associated with measurable physical and physiologic differences.