Cocaine abuse: dermatologic manifestations and therapeutic approaches

Cocaine affects the cutaneous system and other organ systems. Cocaine use is associated with vasculitides, infectious complications, and numerous dermatologic conditions. It has been associated with formication (ie, tactile hallucinations of insects crawling underneath the skin), which leads to delusions of parasitosis and other psychosis-related dermatologic disorders. When a patient presents to a dermatology clinic with chronic skin lesions, a vague medical history, negative findings from previous evaluations, labile affect, and delusional behavior, drug screening should be performed to identify possible cocaine use.

Detection and quantification of low levels of benzoylecgonine in equine urine

Cocaine (COC) is a highly addictive plant alkaloid expressing strong psychostimulatory effect. It has no medical use in equine veterinary practice. The contamination of the environment with cocaine such as its presence on the US paper currency has been reported few times. There are anecdotal reports of low benzoylecgonine (BE) concentrations (usually much less than 100 ng/mL) being found in urine of race horses. In order to protect horsemen against harsh penalties associated with the presence of trace amounts of BE in horse urine as a result of environmental contamination, in February 2005 the Illinois Racing Board issued new medication rules that established the threshold level of 150 ng/mL for BE in equine urine. The penalties associated with this rule provide for increasing fines ($250, $500, $1000) with successive positive reports against a trainer for levels of BE below 150 ng/mL. A total of 19,315 urine samples were collected over the 2-year period of time from winning horses (both harness and thoroughbred) at race tracks in Illinois for routine drug screening (ELISA). The presence of BE was confirmed by GC/MS in 28 urine samples (0.14%). The concentration range for BE in harness horses (21 detections) was < 5-91 ng/mL, and for thoroughbred (seven detections) was 7-52 ng/mL. To date, the laboratory has not reported concentrations of BE that exceed the established threshold concentration of 150 ng/mL.

Prevalence of psychoactive substances in truck drivers in the Nord-Pas-de-Calais region (France)

A previous study conducted in 1995 showed that psychoactive drug use by workers was higher in safety/security workstations than in the rest of the labour force. In order to verify this finding, we conducted a new study in 2003-2004 in the Nord-Pas-de-Calais region, restricted to truck drivers. The aim of this study was to allow harmonizing the professional practice of the occupational physicians, proposing drug prevention and drug testing policies, validating the analytical methods and the guidelines in case of positive testing results. One thousand truck drivers were studied. Urines were tested for amphetamines, cannabinoids, cocaine, opiates, benzodiazepines, buprenorphine and methadone by immunoassay. Urine ethanol determinations were performed by an ADH method. Positive urines for drugs of abuse, methadone or buprenorphine were then tested by gas chromatography or liquid chromatography coupled to mass spectrometry. Out of the 1000 drivers, cannabinoids were detected in 85 cases, opiates in 41 cases, amphetamines in 3 cases and cocaine in only one case. Buprenorphine was detected in 18 cases, methadone in 5 cases and benzodiazepines in 4 cases. Urine ethanol was positive in 50 cases. We found only one case with 6-monoacetylmorphine. Other positive opiates were metabolites of antitussives. The relatively low number of benzodiazepine positive urines could be explained by the lack of sensitivity of the test we used. All these results confirm those of the previous study for cannabinoids and ethanol in safety/security workstations. Positive results for methadone and buprenorphine are eight times higher than in the general population. In conclusion, the authors think that it will be of a great interest to test urine of truck drivers for other classes of psychoactive drugs, using a liquid chromatography-mass spectrometry method.

Driving under the influence in Greece: A 7-year survey (1998–2004)

Alcohol is one of the main causes of traffic accidents worldwide. Its use decreases significantly the driving ability of an individual increasing in this way the possibilities of their involvement in motor-vehicle accidents. The above possibilities are increased when a psychoactive substance has been taken in combination with alcohol due to their synergistic effect. The Laboratory of Forensic Medicine and Toxicology of the University of Athens is authorized to perform the toxicological investigation of traffic accidents that happen in the southern part of Greece. The objective of the present study was to identify the prevalence of alcohol and other psychoactive substances among drivers involved in road traffic accidents in Greece during the period 1998-2004. Alcohol was detected in the blood of about 37% of the drivers involved in traffic accident during the years 1998-2000. The detection of alcohol was lower (29%) in the years 2001-2004. Cannabis, benzodiazepines, opiates, and cocaine were found in 4%, 4%, 4% and 1% of the total number of cases, respectively. The above values were compared with those of a previous study concerning the period 1995-1997 and the reasons for the reduction of the number of alcohol-related traffic accidents during the last years are discussed.

Psychosocial functioning and cocaine use during treatment: strength of relationship depends on type of urine-testing method

Although improvement in psychosocial functioning is a common goal in substance-abuse treatment, the primary outcome measure in most cocaine trials is urinalysis-verified cocaine use. However, the relationship between cocaine use and psychosocial outcomes is not well documented. To investigate this relationship and identify the optimal urine-screen method, we retrospectively analyzed data from two 25-week randomized controlled trials of abstinence reinforcement (AR) in 368 cocaine/heroin users maintained on methadone. Cocaine use was measured thrice weekly by qualitative urinalysis, benzoylecgonine concentration (BE), and an estimate of New Uses of cocaine by application of an algorithm to BE. Social adjustment (SAS-SR), current diagnosis of cocaine dependence (DSM-IV criteria), and depression symptoms (Beck Depression Inventory) were determined at study exit. Cocaine use was significantly lower in AR groups than in controls. Across groups, in-treatment cocaine use was significantly associated with worse social adjustment, current cocaine dependence, and depression at exit. Significant differences were detected more frequently with New Uses than qualitative urinalysis or BE. Nevertheless, the amount of variance accounted for by the urine screens was typically <15%. Cocaine use during treatment, especially when measured with New Uses criteria, can predict psychosocial functioning, but cannot substitute for direct measures of psychosocial functioning.

A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release

BACKGROUND

Despite its effectiveness, methadone maintenance is rarely provided in American correctional facilities. This study is the first randomized clinical trial in the US to examine the effectiveness of methadone maintenance treatment provided to prisoners with pre-incarceration heroin addiction.

METHODS

A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred eleven Baltimore pre-release inmates who were heroin dependent during the year prior to incarceration were enrolled in this study. Participants were randomly assigned to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n=70); counseling+transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n=70); and counseling+methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n=71).

RESULTS

Two hundred participants were located for follow-up interviews and included in the current analysis. The percentages of participants in each condition that entered community-based treatment were, respectively, counseling only 7.8%, counseling+transfer 50.0%, and counseling+methadone 68.6%, p<.05. All pairwise comparisons were statistically significant (all ps<.05). The percentage of participants in each condition that tested positive for opioids at 1-month post-release were, respectively, counseling only 62.9%, counseling+transfer 41.0%, and counseling+methadone 27.6%, p<.05, with the counseling only group significantly more likely to test positive than the counseling+methadone group.

CONCLUSIONS

Methadone maintenance initiated prior to or immediately after release from prison appears to have beneficial short-term impact on community treatment entry and heroin use. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.

Parameters for treatment of cocaine-positive patients

PURPOSE

The purpose of this study was to identify the parameters by which oral and maxillofacial surgeons and anesthesiologists make decisions as to the safety for proceeding with surgery and anesthesia in cocaine-positive patients and to determine a national consensus of opinion, if possible.

METHODS

Questionnaires were mailed to all known oral and maxillofacial surgery training programs and anesthesiology training programs in the United States (n = 241). Programs were queried as to screening, testing, parameters, and outcomes.

RESULTS

Of the 241 questionnaires mailed, 114 (47%) were returned. Identification on the returns was optional; therefore, it was impossible to determine the total from each discipline. Only 16% of the programs had a formalized policy for cocaine screening prior to surgery and anesthesia. There was significant variability in the length of delay/time lapse before proceeding with anesthesia and surgery in the face of cocaine positivity.

CONCLUSION

Based on the returned questionnaires and literature searches, the authors propose that patients who test positive for cocaine in their urine may undergo necessary surgical and anesthetic care, after an 8-hour period of discontinuing of cocaine, if the individual is hemodynamically stable.

Simultaneous Determination of Multiple Drugs of Abuse and Relevant Metabolites in Urine by LC-MS-MS

A method was developed for the quantitative analysis of 30 drugs of abuse and their metabolites in urine, including opiates, barbiturates, amphetamines, cocaine, cannabinoids, phencyclidine, methadone, and benzodiazepines. This method uses solid-phase extraction (SPE) on an Oasis HLB column followed by liquid chromatography-tandem mass spectrometry. Analytes were quantified by multiple reaction monitoring with the deuterated analogues as internal standards, using an atmospheric pressure ionization-electrospray interface. The method was validated by examining specificity, precision, accuracy, linearity, recovery, reproducibility, and detection limits. The limits of detection ranged from 9 pg/mL to 2.29 ng/mL in urine depending on the analyte. The SPE procedure was automated on a RapidTrace workstation to increase analytical throughput, and the results obtained via automated SPE were compared to those obtained by manual SPE to examine carryover effect, precision, accuracy, recovery, and reproducibility. To evaluate method performance, 108 urine samples were collected anonymously and tested for the presence of these drugs.

Prevalence of cocaine use in ED patients with severe hypertension

STUDY OBJECTIVE

We prospectively evaluated the prevalence of cocaine use in emergency department patients with elevated diastolic blood pressure greater than 120 mm Hg.

DESIGN

Urine was collected on adult patients with diastolic blood pressure greater than 120 mm Hg. The Institutional Review Board granted a waiver of informed consent based on complete deidentification of the data to prevent selection bias. Spontaneously voided urine specimens were analyzed for the presence of the benzoylecgonine.

RESULTS

Of 107 eligible patients with a diastolic blood pressure equal to or greater than 120 mm Hg, 99 were tested. Of the 99, 13 (13%) tested positive, and of which, 6 (46%) presented with a request for medication refill. Five patients (39%) had cardiovascular and/or pulmonary complaints.

CONCLUSION

Emergency department patients with hypertension who have recently used cocaine may be difficult to differentiate from those who have not. Consideration should be given to the potential for cocaine use when making treatment decisions in patients with hypertension.

Long-term stability of various drugs and metabolites in urine, and preventive measures against their decomposition with special attention to filtration sterilization

The long-term stability of drugs and metabolites of forensic interest in urine, and preventive measures against their decomposition have been investigated, with special attention to filtration sterilization. An aseptic urine collection kit, which was recently developed based on filtration sterilization, was utilized for the aseptic collection and storage of urine samples. For evaluating preservation measures, methamphetamine (MA), amphetamine (AP), nitrazepam (NZ), estazolam (EZ), 7-aminoflunitrazepam (7AF), cocaine (COC), and 6-acetylmorphine (6AM) were spiked into urine at 500 ng/mL each, and were monitored for 6 months at 25, 4, and -20 degrees C, after the addition of NaN(3) and/or filtration sterilization using the aseptic collection kit. In severely contaminated urine with bacteria, there were significant losses of 7AF and NZ, and slight decomposition of MA and AP at 25 degrees C. However, such degradation was successfully suppressed by the use of the kit, though the use of the kit and NaN(3) were preferred for 7AF. The kit was also effective in preventing the hydrolyses of COC and 6AM, while it was suggested that the common preservative NaN(3) can accelerate the hydrolysis of such ester-type drugs and metabolites.

Quantitative analysis of cocaine and its metabolites in whole blood and urine by high-performance liquid chromatography coupled with tandem mass spectrometry

AIM

In forensic toxicology it is important to have specific and sensitive analysis for quantification of illicit drugs in biological matrices. This paper describes a quantitative method for determination of cocaine and its major metabolites (ecgonine methyl ester, benzoylecgonine, norcocaine and ethylene cocaine) in whole blood and urine by liquid chromatography coupled with tandem mass spectrometry LC/MS/MS.

METHOD

The sample pre-treatment (0.20 g) consisted of acid precipitation, followed by centrifugation and solid phase extraction of supernatant using mixed mode sorbent columns (SPEC MP1 Ansys Diag. Inc.). Chromatographic separation was performed at 30 degrees C on a reverse phase Zorbax C18 column with a gradient system consisting of formic acid, water and acetonitrile. The analysis was performed by positive electrospray ionisation with a triple quadropole mass spectrometer operating in multiple reaction monitoring (MRM) mode. Two MRM transitions of each analyte were established and identification criteria were set up based on the retention time and the ion ratio. The quantification was performed using deuterated internal analytes of cocaine, benzoylecgonine and ecgonine methyl ester. The calibration curves of extracted standards were linear over a working range of 0.001-2.00 mg/kg whole blood for all analytes. The limit of quantification was 0.008 mg/kg; the interday precision (measured by relative standard deviation-%RSD) was less than 10% and the accuracy (BIAS) less than 12% for all analytes in whole blood. Urine samples were estimated semi-quantitatively at a cut-off level of 0.15 mg/kg with an interday precision of 15%.

CONCLUSION

A liquid chromatography mass spectrometric (LC/MS/MS) method has been developed for confirmation and quantification of cocaine and its metabolites (ecgonine methyl ester, benzoylecgonine, norcocaine and ethylene cocaine) in whole blood and semi-quantitative in urine. The method is specific and sensitive and offers thereby an excellent alternative to other methods such as GC-MS that involves derivatisation.

Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients

Underreporting of drug use is common and influenced by multiple factors. Cannabis (THC) use nonreporting and its relationship to heroin and cocaine use were investigated in 690 patients enrolled in 25- to 29-week clinical trials of contingency management plus methadone maintenance. Urine specimens and self-reports of drug use were collected 3 times/week. Potential predictors of THC use nonreporting were analyzed by multiple logistic regression; relationships between THC use nonreporting and % cocaine- and opiate-positive urines were analyzed by multiple regression. Compared to non-THC users (n=317), patients with THC-positive urines (n=373) were more likely to be male and have more years of THC use, but were not different on other characteristics. Nonreporting to user ratios were: THC 191/373 (51.2%); opiates 17/686 (2.5%); cocaine 21/681 (3.1%). Predictors of THC use nonreporting were low rate of THC-positive urines during treatment, fewer days of THC use in the last 30 before treatment, African-American race, and absence of antisocial personality disorder. Nonreporting of THC use was associated with significantly greater opiate and cocaine use. Contingency management decreased cocaine use in THC nonreporters to the level of reporters. Nonreporting of THC use is a significant predictor of greater cocaine and heroin use. This association can be eliminated with contingency management therapy.

"Excessive tears": a diagnostic sign for cocaine-induced mood disorder?

OBJECTIVE

This study aims to investigate excessive tearfulness as a sign to help determine the etiology of depressive symptoms.

METHODS

Clinicians were instructed to document the occurrence of excessive tearfulness in all patients seen in the Psychiatric Emergency Service. Excessive tearfulness was defined as crying to the severity that at least 1 tear drops off the face. A comparison group was formed from the general population of the Psychiatric Emergency Service.

RESULTS

Excessive tearfulness was documented in 36 different patients. The prevalence of the sign in the general population was 1.9%. Patients with excessive tearfulness were more likely to have cocaine in their urine (P < .0001, chi(2) test), receive a substance-related primary diagnosis (P < .0001, chi(2) test), and be admitted for psychiatric hospitalization (P < .001 chi(2) test). Patients with excessive tearfulness had significantly shorter voluntary hospital stays (P < .05, t test).

CONCLUSION

Excessive tearfulness could be a useful clinical sign of cocaine-induced depression.

Unusual finding on bronchoscopy: trauma patient identified as a body stuffer

We present the case of a trauma patient whose persistently abnormal chest radiography led to exploratory bronchoscopy. After the discovery of a foreign body in the right lower lobe bronchus, an attempted retrieval resulted in accidental perforation of a cocaine bag and release of the drug, which may have been the cause of the patient's subsequent pneumonitis.

Short-term efficacy of Disulfiram or Naltrexone in reducing positive urinalysis for both cocaine and cocaethylene in cocaine abusers: A pilot study

Cocaine abusers frequently report taking the drug in association with alcohol. This combined intake leads to the synthesis of cocaethylene, an active metabolite with effects similar to those of cocaine, but more prolonged. Since pharmacological effects of cocaethylene may partially account for the habit of cocaine abusers to take the drug in combination with ethanol, a main therapeutic goal in these patients should be making body fluids negative for cocaethylene. This randomized controlled open study conducted on 12 subjects co-abusers of cocaine and alcohol, evaluates the efficacy of a 12-week pharmacological treatment with Disulfiram (DIS) 400mg daily or Naltrexone (NTX) 50mg daily associated with Cognitive Behaviour Therapy (CBT), as compared to CBT alone, in terms of: (i) stay in treatment; (ii) drug-free urinalyses for cocaine and cocaethylene; (iii) reduction of alcohol and cocaine craving. Data presented in this study are restricted to the first 4 weeks of treatment when all the enrolled subjects were still available for examination. In fact, of the 12 subjects enrolled in the study only 4 (33%) completed the 12-week treatment. Of these, three were in the CBT group and one in the NTX/CBT group. Results show that CBT treated subjects remained in treatment longer than those assigned to either DIS/CBT or NTX/CBT therapies. However, during the first 4 weeks of treatment, CBT-group urine tested positive almost always for both cocaine and cocaethylene. In contrast, both DIS/CBT and NTX/CBT treatments were associated to a statistically significant reduction, of positive urinalysis for both cocaine and cocaethylene, with respect to CBT alone. Moreover, across the first 4 weeks of treatment DIS/CBT and NTX/CBT treated subjects maintained lower scores at Visual Analogue Scales (VAS) for both cocaine and alcohol craving than subjects receiving CBT alone. This pilot study suggests that the transient efficacy of pharmacological treatments in maintaining subjects drug free, does not add to the capability of CBT to retain them in treatment.

[Epidemiological analysis of cases with confirmed presence of amphetamine and THC in the material of Department of Analytical Toxicology and Drug Monitoring UJ CM]

The aim of this paper is epidemiological analysis of poisonings with amphetamine and tetrahydrocanabinols (THC), particularly in three aspects: (1) co-occurrence of other substances (mixed poisonings); (2) factors shaping dynamics in number of poisonings and 3) average age of patients. The data this paper is based on come from the data set "Duch" which is run by the Department of Analytical Toxicology and Drug Monitoring UJ CM in Kraków. The data were collected between 1 Dec. 2001 and 28 Feb. 2005 (1186 days). Amphetamine and THC were determined in patient's urine in semi-quantitative manner by means of EMIT and FPIA methods.

RESULTS

Amphetamine: In the studied period amphetamine was confirmed in 493 patients. Other substances were confirmed in 57.6% of patients: opiates--28.6% THC--14.2%, opiates and THC--5.9%. Since the beginning of the studied period till mid Aug 2003 daily number of cases showed increasing trend (0.062% per day), then the tendency was reversed (-0.074% per day). We observed more males than females (3.24:1). Most cases were poisoned on Mondays, less during the week and least on weekends. At the beginning of the studied period males were older than females (27 vs. 20 years). As the time progressed average age of males was stable but in women average age was increasing at the rate 0.004 year per day. As a consequence of this trend in winter 2004/2005 average age of both sexes was equal. THC: We observed 410 cases with confirmed presence of THC in urine. Other substances were confirmed in 40.2% of patients: amphetamine 17.1% amphetamine and opiates 7.1, opiates 7.1%. There were 17 various substances accompanying THC. In our material the sex ratio was biased toward males (7.8 to 1). Weekly dynamics of poisonings with THC have the same pattern as the one observed in amphetamine. At the beginning of the studied period males were older than females (28 vs. 20 years). Changes in averages followed the same pattern as in amphetamine.

Microwave assisted extraction of drugs of abuse from human urine

Microwave assisted extraction (MAE) was used to extract drugs of abuse from urine samples for the simultaneous determination of morphine, codeine, 6-acetylmorphine (6AM), cocaine, cocaethylene, benzoylecgonine (BEG), methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) by high performance liquid chromatography with diode array detector (HPLC-DAD). The working wavelengths used were 285 nm for morphine, codeine and 6AM; 233 nm for cocaine, cocaethylene and BEG; and 292 nm for methadone and EDDP. The mobile phase was a gradient of acetonitrile and phosphate buffer at pH 6.5. A full factorial design was used to identify the most suitable extraction conditions as regards pH, solvent and time of extraction. The optimum conditions thus established provided analyte recoveries from 61% to 109%. The detector response was linear over the drug concentration range 0.1-4.0 microg ml(-1) in urine. The within- and between-day precision and accuracy were less than 8% and 6.5%, respectively. The method was applied successfully to samples obtained from Galician hospitals and courts.

Coca tea consumption causes positive urine cocaine assay

BACKGROUND

Coca tea, derived from the same plant that is used to synthesize cocaine, is commonly consumed in South America and easily obtained in the United States.

OBJECTIVES

To determine whether consumption of coca tea would result in a positive urine toxicology screen for cocaine metabolites.

METHODS

Five healthy adult volunteers consumed coca tea and underwent serial quantitative urine testing for cocaine metabolites by fluorescence polarization immunoassay. The cutoff for a positive assay was chosen at 300 ng/ml, the National Institute on Drug Abuse standard.

RESULTS

Each participant's urine cocaine assay was positive (level exceeding 300 ng/ml) by 2 h after ingestion. Three out of five participants' samples remained positive at 36 h. Mean urine benzoylecgonine concentrations in all postconsumption samples was 1777 ng/ml (95% confidence interval: 1060-2495).

CONCLUSIONS

Coca tea ingestion resulted in a positive urine assay for cocaine metabolite. Healthcare professionals should consider a history of coca tea ingestion when interpreting urine toxicology results.

Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases

Toxicologic analysis is an integral component in the investigation of suicide and requires correlation with a detailed scene inspection, with an extensive exploration into the decedent's medical and social background to uncover suicidal ideation or intent and a postmortem examination of the body. In this review, the authors analyzed 2864 cases classified as suicide upon autopsy and toxicologic examinations between 1993 and 2002 in the Kentucky Division of Medical Examiner's Services. Blood and urine were collected in 95.0% and 72.3% of cases, respectively. A total of 32.5% of the victims had negative blood toxicologic results, and 52.7% of urine toxicology screens yielded no drugs. Analysis of the data indicated that 3 times as many women had taken antidepressants and more than twice as many had consumed opioids. Drug toxicity ("overdose") ranked as the third (9.9%) leading cause of suicide after firearm injury (67.5%) and hanging (13.7%). Women succumbed to drug toxicity more than men (27.5% versus 5.9%). Of the overdose deaths, 66.5% had a negative blood alcohol concentration (BAC), while antidepressants, opioids, and benzodiazepines were detected in blood in 54.4%, 37.4%, and 29.2% of the subjects, respectively. The collection of these data serves the goals of public health and clinicians in devising strategies for suicide prevention.

A double-blind, placebo-controlled trial of amantadine, propranolol, and their combination for the treatment of cocaine dependence in patients with severe cocaine withdrawal symptoms

BACKGROUND

This trial evaluated the efficacy of amantadine, propranolol and their combination in cocaine dependent patients with severe cocaine withdrawal symptoms.

METHODS

Cocaine withdrawal symptom severity was measured by the cocaine selective severity assessment (CSSA). One hundred and ninety-nine patients with high scores on the CSSA participated in a 10-week double-blind trial. Patients were randomly assigned to receive amantadine (300 mg/day), propranolol (100mg/day), a combination of amantadine (300 mg/day) and propranolol (100mg/day) or matching placebo capsules. The primary outcome measure was cocaine abstinence.

RESULTS

In the intent-to-treat sample, there were no significant differences between the four medication groups in treatment retention. The odds of cocaine abstinence showed a marginally significant increase over time in the propranolol group (p=0.06) but not in the other three groups. In highly medication-adherent patients, treatment retention was significantly better in the propranolol group compared to the placebo group (p=0.01) and the odds of cocaine abstinence increased significantly over time in the propranolol group but not in the other three groups.

CONCLUSION

In the intent-to-treat sample, none of the three active treatments (propranolol, amantadine or their combination) was significantly more effective than placebo in promoting abstinence from cocaine among patients who entered treatment with more severe cocaine withdrawal symptoms. Among patients highly adherent to study medication, propranolol treatment was associated with better treatment retention and higher rates of cocaine abstinence compared to placebo.

Naltrexone and buprenorphine combination in the treatment of opioid dependence

Naltrexone treatment has demonstrated some advantages for special populations of heroin addicted individuals, but patients' compliance seems to be very poor, with a low adherence and low retention rate. Kappa-opioid system overdrive seems to contribute to opioid protracted abstinence syndrome, with dysphoria and psychosomatic symptoms during naltrexone treatment. The objective of this observational study was to determine the effectiveness of a functional k antagonist in improving naltrexone treatment outcome. A partial mu agonist/kappa antagonist (buprenorphine) and a mu antagonist (naltrexone) were combined during a 12 weeks protocol, theoretically leaving k antagonism as the major medication effect. Sixty patients were submitted to outpatient rapid detoxification utilizing buprenorphine and opioid antagonists. Starting on the fifth day, 30 patients (group A) received naltrexone alone. Alternatively, 30 patients (group B) received naltrexone (50mg oral dose) plus buprenorphine (4 mg sublingual) for the 12 weeks of the observational study. The endpoints of the study were: retention in treatment, negative urinalyses, changes in psychological symptoms (Symptom Checklist-90 Revised: SCL-90) and craving scores (visual analysis scale (VAS)). Thirty-four subjects (56.67%) completed the 12 weeks study. Twenty-one patients (35.0%) had all urine samples negative for opiates and cocaine. nine subjects (15.0%) had urine samples negative for cocaine and opiates for the last 4 weeks of the study. five subjects (8.3%) continued to use cocaine during the 12 weeks of the study. No significant change in pupillary diameter after buprenorphine administration was evidenced during clinical observations from baseline across the weekly measurements. Retention rates in group A (naltrexone) and group B (naltrexone + buprenorphine) at week 12 were respectively 40% (12 patients) and 73.33% (22 patients), with a significant difference in favour of group B (p= 0.018). Patients treated with naltrexone in combination with buprenorphine (B patients) showed a significantly lower rate of positive urines for morphine (4.45%) and cocaine metabolites (9.09%) than those treated with naltrexone alone (A) (25%, morphine; 33.33% cocaine) (p< 0.05; p< 0.05). Irritability, depression, tiredness, psychosomatic symptoms and craving scores decreased significantly less in Group A patients than in group B patients. The dysfunction of opioid system with kappa receptors hyper-activation provoked by heroin exposure, probably underlying dysphoric and psychosomatic symptoms during naltrexone treatment, seems to be counteracted, at least in part, by buprenorphine. The combination of buprenorphine and naltrexone may significantly improve the outcome of opioid antagonists treatment in terms of retention, negative urinalyses, and reduced dysphoria, mood symptoms and craving.

Rapid Analysis of Benzoylecgonine in Urine by Fast Gas Chromatography-Mass Spectrometry

A novel fast gas chromatography-mass spectrometry (FGC-MS) analytical method for benzoylecgonine (BZE) has been developed to improve the efficiency of specimen analysis without diminishing the reliability of metabolite identification and quantification. Urine specimens were spiked with deuterated internal standard (BZE-d8), subjected to solid-phase extraction, and derivatized with pentafluoropropionic anhydride (PFPA) and pentafluoropropanol (PFPOH). The pentafluoropropyl ester derivative of BZE was identified and quantified using both a standard GC-MS method and the newly developed FGC-MS method. Shorter GC analyte retention times were made possible in the FGC-MS method by employing a 220-volt GC oven controller, which allowed an increased temperature ramp rate. The FGC-MS method was linear between 25 and 10,000 ng/mL of BZE yielding a correlation coefficient of 0.9994. The intra-assay precision of a 100 ng/mL BZE standard (n=15) yielded an average concentration of 99.7 ng/mL and a coefficient of variation of 1.2%. The interassay precision of 21 sets of 50, 100, and 125 ng/mL BZE controls was found to be acceptable, with coefficients of variation less than 2.4%. No interference was observed when the FGC-MS method was challenged with cocaine, ecgonine, ecgonine methyl ester, and nine other drugs of abuse. Analysis of presumptively positive specimens (n=146) by both analytical methods yielded comparable results with a correlation coefficient of 0.996. The FGC-MS method, when compared with a standard GC-MS method, reduces total assay time by approximately 50% while demonstrating comparable reliability.