Adulterants in illicit drugs: a review of empirical evidence

Hair Analysis of Methoxphenidine in a Forensic Chemsex Case

Methoxphenidine (MXP, 2-MeO-diphenidine) is a dissociative anaesthetic drug of the diarylethylamine type, recently introduced for recreational purposes through the online-based sale of new psychoactive substances (NPS). The concentration of MXP in hair has never been reported, either in cases of chemsex use or in fatal cases. A 55-year-old man was found dead at home the morning after a chemsex party. Toxicological analyses indicated high concentrations of MXP in femoral blood (606 µg/L), cardiac blood (254 µg/L), and hair (13 ng/mg). We also identified 3-MMC in femoral blood (traces) and urine (238 µg/L). The concentrations of all other drugs were consistent with living subjects. This case highlights the risk of methoxphenidine poisoning in the context of chemsex and emphasises the importance of including NPS in post-mortem toxicology examinations.

The Lethal Cutting: An Unexpected Cause of Death

Cocaine is among the illicit substances most frequently implicated in deaths related to the use of drugs of abuse both worldwide and in Italy. Cutting agents involved in the adulterations of this substance are many and the process of lacing can take place at various stages of the production of the drug. In this Report we are discussing the case of a 27-year-old woman found death next to her car in a wooded area in the suburban area of Milan. On the crime scene, several specimens of white powder were collected and subsequently analyzed via Q-Exactive Orbitrap with a HPLC system and LC/MS-MS analysis along with biological matrices sampled during autopsy examination. The toxicological analysis revealed that the death could be ascribed to a lethal dose of methomyl, a carbamide pesticide used as cutting agent for cocaine. According to Literature, this is the first time that this substance is used as an adulterant.

Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies

Introduction: Drug checking as a part of drug harm-reduction strategies represents an essential aspect of public health policies. It focuses on rapid identification of drugs that individuals intend to use during night events, in order to implement health-protective behaviors. Chemical drug analysis techniques vary considerably, from simple colorimetric reagents to advanced forensic methods such as gas chromatography/mass spectrometry (GC/MS). Materials and Methods: In 2019, drug-check services were offered at some night events in Umbria (Central Italy). One hundred and twenty attendees directly delivered unidentified substances to a harm-reduction worker, who collected a few milligrams of the substances on ceramic plates and added a drop of colorimetric reagent. Multiple reagents were used to increase the diagnostic capacity of a substance, which may react with a specific drug or a few drugs. Later, a fraction of the samples was analyzed by GC/MS. The concordance of the results obtained using these two methodologies and the intended behaviors of consumers after being informed of the test result was evaluated. Results: We analyzed 120 samples by colorimetric test: 32 MDMA, 25 ketamine, 10 amphetamine, 11 cocaine, 8 heroin, and 4 LSD samples. The results were inconclusive for 29 samples. The GS/MS analysis confirmed MDMA in 84%, ketamine in 78%, amphetamine in 91%, cocaine in 92%, heroin in 88%, and LSD in 100% of the samples. The results of samples with inconclusive results were as follows: 2, MDMA; 7, ketamine; 2, amphetamine; 2, cocaine; 2, heroin; 2, mephedrone; 6, mixes; 1, debris; and 5, adulterants as the main component. Twenty-one of 29 participants reported that they had no intention of consuming the unidentified substance. Discussion: The high percentage of individuals who claimed no intention of consuming the unidentified drugs indicates that drug checking is viable as a part of drug harm-reduction strategies. Overall, colorimetric reagents showed a good performance with regard to samples being unadulterated (LSD) or minimal in quantity, but failed to identify mixtures of substances and the adulterants present in them. Therefore, the use of more discriminatory on-site methods such as Raman or infrared spectrometry is strongly recommended.

Potential Of High-Resolution Mass Spectrometry For The Detection Of Drugs And Metabolites In Hair: Methoxetamine In A Real Forensic Case

The analysis of drugs of abuse in hair and other biological matrices of forensic interest requires great selectivity and sensitivity. This is done traditionally through target analysis, with one or more analytical methods, or with different and specific preanalytical phases, and complex procedures performed by the toxicological laboratories, and there is no exception with ketamine-like compounds, such as methoxetamine, a new psychoactive substance (NPS) whose use has increased in the last decades, and continues to grow quickly year by year. More validated methods of analysis are needed to detect these substances in low concentrations selectively. Reanalyzing the samples of a former case of a polydrug consumer accused of a crime against public health in Spain, five metabolites of methoxetamine (normethoxetamine, O-desmethylmethoxetamine, dehydromethoxetamine, dihydronormethoxetamine and hydroxynormethoxetamine) were tentatively detected using a high-resolution technique that is liquid chromatography coupled to high-resolution mass spectrometry (LC-HR-MS/MS). The most selective analytical LC-HR-MS/MS method together a universal and simpler pretreatment stages has demonstrated to allow faster analysis and more sensitivity than the one performed traditionally at the INTCF laboratories, which was gas chromatography coupled to mass spectrometry (GC-MS).

Analytical findings in used syringes from a syringe exchange program

BACKGROUND

Since it's first implementatation in 1984, Syringe Exchange Programs (SEP) are a critical component of harm reduction interventions among people who inject drugs.. The aim of this work was to use a scientific analytical approach to obtain drug use information through the analysis of the content of used syringes.

METHODS

357 syringes were collected in New York City and submitted to qualitative analysis. Screening analysis was performed by gas chromatography mass spectrometry (GC-MS) and confirmatory analysis by liquid chromatography quadrupole time of flight mass spectrometry (LC-QTOF).

RESULTS

Of the 357 syringes analyzed, 275 (77.0%) were positive for one or more substances. The most common drug of abuse identified was heroin/related substances (72.0%), followed by cocaine/related substance (34.9%), fentanyl/related substance (13.5%), methamphetamine/related substance (7.6%) and furanylfentanyl (3.6%). Quinine/quinidine (18.5%) was the most common cutting agent detected, followed by levamisole (12.0%), caffeine (11.6%), lidocaine (11.6%), and phenacetin (6.9%).

CONCLUSION

Analysis of samples collected from a drug street scenario allows the identification of new substances being injected and provides information to harm reduction programs to identify strategies to reduce drug abuse.

Paper-Based Electrochemical Devices for the Pharmaceutical Field: State of the Art and Perspectives

The current international pharmaceutical scenario encompasses several steps in drug production, with complex and extremely long procedures. In the last few decades, scientific research has been trying to offer valid and reliable solutions to replace or support conventional techniques, in order to facilitate drug development procedures. These innovative approaches may have extremely positive effects in the production chain, supplying fast, and cost-effective quality as well as safety tests on active pharmaceutical ingredients (APIs) and their excipients. In this context, the exploitation of electrochemical paper-based analytical devices (ePADs) is still in its infancy, but is particularly promising in the detection of APIs and excipients in tablets, capsules, suppositories, and injections, as well as for pharmacokinetic bioanalysis in real samples.

Substances injected at the Sydney supervised injecting facility: A chemical analysis of used injecting equipment and comparison with self-reported drug type

Providing information about substances injected can reduce the negative impact of illicit drug consumption and support people who inject drugs to make informed decisions. In Australia, information about drugs injected relies largely on periodic self-report surveys. For the first time, the analysis of the residual content of used injecting equipment was conducted in a supervised injecting facility (SIF) located in Sydney, Australia. The aim was to gain a better understanding of the substances injected by clients through: (1) chemical analyses of the content of used syringes; (2) comparison of these results with clients' self-reported drug use; and (3) assessing the usefulness of analysing other injecting equipment to detect substances used. During one week in February 2019, syringes and other injecting equipment were collected at the Sydney SIF. Their residual content was analysed by gas-chromatography/mass-spectrometry. Heroin was the most commonly detected substance (present in 51% of syringes), followed by methamphetamine (22%) and oxycodone (10%). In addition to the main psychoactive substance, cutting agents reported in the literature were also detected in used syringes. The main psychoactive substance identified by laboratory analysis reliably corresponded with users' self-reported drug type. Analytical confirmation of substances injected allows for the provision of better targeted harm reduction messaging based on timely and objective data. The approach used is amenable to clients and feasible in the Australian SIF context. Upscaling and wider implementation could be done through Needle and Syringe Programs, and would support the early detection of harmful substances entering drug markets and better inform harm reduction strategies.

Addressing overdose risk among unstably housed women in San Francisco, California: an examination of potential fentanyl contamination of multiple substances

Background

Numerous reports have led to concerns that fentanyl is added to many street drugs as an adulterant, including to stimulants like cocaine and methamphetamine, and could increase risks for negative health outcomes.

Methods

We collected information regarding recent substance use through self-report and urine toxicology (confirmed with mass spectrometry) once a month for up to 6 monthly study visits from a probability sample of 245 women in San Francisco with a history of housing instability (2016-2019). We compared the presence of fentanyl metabolites with (1) the presence of metabolites for other substances and (2) self-reported past week substance use.

Results

Out of 1050 study visits, fentanyl metabolites were detected 35 times (i.e., at 3% of all study visits and among 19/245, or 8% of all women). In most but not all (91%, or 32/35) of these detected cases, heroin or opioid medication use was self-reported. Among women who reported cocaine or methamphetamine use, but did not use heroin or opioid medication, fentanyl was detected in only 1 of 349 cases (0.3%). In adjusted logistic regression, the presence of fentanyl metabolites was independently associated with (1) presence of opiate, heroin, and benzodiazepine metabolites, and (2) self-reported past week use of heroin and opioid medications. Fentanyl metabolite detection was not independently associated with cocaine or methamphetamine use.

Conclusions

The presence of fentanyl metabolites in this population was almost entirely among women who also reported using heroin or opioid pills. These data do not support the hypothesis that fentanyl is being routinely added to stimulants as an adulterant on a large scale in this region.

Discriminative potential of ion mobility spectrometry for the detection of fentanyl and fentanyl analogues relative to confounding environmental interferents

The opioid crisis and emergence of fentanyl, fentanyl analogues, and other synthetic opioids has highlighted the need for sensitive and robust detection for interdiction at screening points, notably vehicles at border crossings and packages at postal facilities. This work investigates the discriminative potential, sensitivity and specificity, of ion mobility spectrometry (IMS) for the detection of fentanyl and fifteen (15) fentanyl-related compounds (analogues, other opioids, and metabolites) relative to confounding environmental interferents. The environmental background interferent levels, frequency and intensity, were derived from over 10 000 screening samples collected from delivery vehicles entering a federal site. A receiver operating characteristic (ROC) curve methodology was employed to quantify the relationship between sensitivity and specificity for these target compounds on two instruments/configurations. These instrument configurations differed in desorption and drift tube temperatures, reactant ion dopant chemistry, and analysis time. This work identified reduced mobility areas of high interference that resulted in increased false positive rates (FPR), effectively reducing sensitivity (true positive rate: TPR) in those regions. Except for a few target compounds on either of the instruments that exhibited elevated FPRs, detection of fentanyl and fentanyl-related species was achieved at single to tens of nanograms with ≥90% TPR and ≤2% FPR. This work established the importance of systematic environmental background characterization at each specific screening setting in evaluating a platform's true performance.

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California

Background: Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). Objectives: This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. Methods: A cross-sectional sample of PWID (N = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Results: Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Conclusion: Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.

Adulterants and altruism: A qualitative investigation of "drug checkers" in North America

BACKGROUND

"Drug checking" has become a common harm reduction method used to test illicit substances, such as ecstasy, for purity and/or the presence of adulterants. Formal drug-checking services have been operating for decades, and the use of personal reagent test kits appears to be relatively common; however, little attention has been devoted to understanding the role and broader experiences of 'drug-checkers' (i.e., people who test their own and/or other people's substances). As such, it remains unknown who is engaging in this practice, their motivations for drug-checking, and what barriers they may experience. We addressed this research gap by interviewing people who check drugs about their experiences, with a goal of better understanding drug checking practices.

METHODS

We conducted in-depth interviews with 32 adults in North America who reported testing drugs. Coding was conducted in an inductive manner and thematic analysis was used to identify relevant themes.

RESULTS

Over half (56.2%) of our sample was affiliated with a drug checking organization. Among non-affiliated checkers (43.8%), the majority (57.1%) tested for friends, 21.4% tested only for themselves, and 21.4% were people who sold drugs and tested for their clients. Motivations were driven largely by altruism, described by checkers as wanting to protect their peers from exposure to adulterants. People interviewed who sold drugs were altruistic in the same manner. Barriers to checking-particularly at nightclubs and festivals-included perceived illegality of test kits and denied approval to test drugs at venues, although many checkers circumvented this barrier by checking drugs without such approval.

CONCLUSIONS

Drug checkers in North America seek to educate people who use drugs about the risk of exposure to unexpected substance types, but they face various barriers. Policy change could help ensure that these potentially life-saving services can be provided without fear of fines and/or criminal prosecution.

Multi-drug cocktails: Impurities in commonly used illicit drugs seized by police in Queensland, Australia

BACKGROUND

Impurities in commonly used illicit drugs raise concerns for unwitting consumers when pharmacologically active adulterants, especially new psychoactive substances (NPS), are used. This study examines impurities detected in illicit drugs seized in one Australian jurisdiction.

METHODS

Queensland Health Forensic and Scientific Services provided analytical data. Data described the chemical composition of 9346 samples of 11 illicit drugs seized by police during 2015-2016. Impurities present in primary drugs were summarized and tabulated. A systematic search for published evidence reporting similar analyses was conducted.

RESULTS

Methamphetamine was the primary drug in 6608 samples, followed by MDMA (1232 samples) and cocaine (516 samples). Purity of primary drugs ranged from ∼30% for cocaine, 2-CB and GHB to >90% for THC, methamphetamine, heroin and MDMA. Methamphetamine and MDMA contained the largest variety of impurities: 22 and 18 variants, respectively. Drug adulteration patterns were broadly similar to those found elsewhere, including NPS, but in some primary drugs impurities were found which had not been reported elsewhere. Psychostimulants were adulterated with each other. Levamisole was a common impurity in cocaine. Psychedelics were adulterated with methamphetamine and NPS. Opioids were quite pure, but some samples contained methamphetamine and synthetic opioids.

CONCLUSIONS

Impurities detected were mostly pharmacologically active adulterants probably added to enhance desired effects or for active bulking. Given the designer nature of these drug cocktails, the effects of the adulterated drugs on users from possible complex multi-drug interactions is unpredictable. Awareness-raising among users, research into complex multi-drug effects and ongoing monitoring is required.

Caffeine as an adulterant of coca paste seized samples: preclinical study on the rat sleep-wake cycle

Caffeine is a common active adulterant found in illicit drugs of abuse, including coca paste (CP). CP is a smokable form of cocaine mainly consumed in South America, produced during the cocaine-extraction process. CP has high abuse liability and its chronic consumption induces severe sleep-wake alterations. However, the effect of CP on the sleep-wake cycle and the effect of the presence of caffeine as an adulterant remain unknown. We studied the effect of an acute intraperitoneal injection of 2.5 and 5 mg/kg of a representative CP sample adulterated with caffeine (CP1) on the rat sleep-wake cycle. Compared with saline, administration of CP1 induced an increase in wakefulness and a decrease in light (light sleep) and slow wave sleep that was larger than the effects produced by equivalent doses of cocaine. Compared with CP1, combined treatment with cocaine (5 mg/kg) and caffeine (2.5 mg/kg), a surrogate of CP1, elicited similar effects. In contrast, a nonadulterated CP sample (CP2) produced an effect that was not different from cocaine. Our data indicate that caffeine produces a significant potentiation of the wakefulness-promoting effect of cocaine, suggesting that caffeine should be explored as a causal agent of clinical symptoms observed in CP users.

When does the cutting of cocaine and heroin occur? The first large-scale study based on the chemical analysis of cocaine and heroin seizures in Switzerland

BACKGROUND

Illicit drug profiling can provide knowledge about illicit drug markets, informing on the level of distribution and its evolution in space and time. Illicit drug profiling is usually limited to impurities originally present in the illicit drug (e.g. alkaloids, co-extracted compounds or by-products). However, the benefit of a comprehensive analysis of cutting agents in drug seizures for law enforcement agencies, intelligence and health policy has not been thoroughly investigated in the literature and is the focus of this research.

AIM

This research aims at assessing when and how cutting (i.e. adulteration and dilution) occurs in the supply chain by analysing cocaine and heroin seizures made between 2006 and 2015 in Switzerland.

METHODS

Cocaine and heroin seizures made along the supply chain by law enforcement agencies in the Western region of Switzerland were investigated for adulteration and dilution. A total number of 7841 cocaine and 3476 heroin specimens coming from 1341 and 721 seizures, respectively, were analysed.

RESULTS

The results show that, for both illicit drugs, adulteration and/or dilution occur before arrival into Switzerland as well as in Switzerland. While cocaine is adulterated and diluted, heroin is only adulterated. Interestingly, the same mixture of adulterants (i.e. caffeine-paracetamol) is used to cut heroin at each step in the supply chain.

CONCLUSION

Gaining knowledge about adulteration and dilution at different stages in the supply chain enhances our understanding of drug markets. It also highlights differences along the supply chain and in the distribution of both drugs in Switzerland.

The future of drugs: recreational drug use and sexual health among gay and other men who have sex with men

There are complex historical connections between sexual minoritisation and desires to chemically alter bodily experience. For gay men, drug and alcohol use can be a creative or experimental response to social marginalisation - and not necessarily a problematic one in every instance. Numerous studies have found that infection with HIV and other sexually transmissible infections (STIs) is more likely among gay and men who have sex with men (MSM) who use recreational drugs than those who do not, but the causal nature of these relations is uncertain. Sexualised drug use is associated with a range of other problems, including dependence, mental health issues, accident and overdose. A growing body of work in the Alcohol and Other Drugs (AOD) field demonstrates the action of drugs and their purported effects to be a product of their relations with various other actors, contexts and practices. Given these contingencies, it is impossible to predict the future of drugs or their effect on the sexual health of gay and MSM with any degree of certainty. This article outlines some of the conditions most likely to mediate such futures in the medium term. Public funding for lesbian, gay, bisexual, transgender and queer drug issues should not remain restricted to questions of HIV prevention and sexual health. It should be expanded to equip sexual health and AOD service providers with the cultural and sexual literacy to mitigate stigma and allow them to respond constructively to drug problems among sexual and gender minorities as a matter of priority.

Label-Free, Visual Detection of Small Molecules Using Highly Target-Responsive Multimodule Split Aptamer Constructs

Colorimetric aptamer-based sensors offer a simple means of on-site or point-of-care analyte detection. However, these sensors are largely incapable of achieving naked-eye detection, because of the poor performance of the target-recognition and signal-reporting elements employed. To address this problem, we report a generalizable strategy for engineering novel multimodule split DNA constructs termed "CBSAzymes" that utilize a cooperative binding split aptamer (CBSA) as a highly target-responsive bioreceptor and a new, highly active split DNAzyme as an efficient signal reporter. CBSAzymes consist of two fragments that remain separate in the absence of target, but effectively assemble in the presence of the target to form a complex that catalyzes the oxidation of 2,2'-azino-bis(3-ethylbenzthiazoline)-6-sulfonic acid, developing a dark green color within 5 min. Such assay enables rapid, sensitive, and visual detection of small molecules, which has not been achieved with any previously reported split-aptamer-DNAzyme conjugates. In an initial demonstration, we generate a cocaine-binding CBSAzyme that enables naked-eye detection of cocaine at concentrations as low as 10 μM. Notably, CBSAzyme engineering is straightforward and generalizable. We demonstrate this by developing a methylenedioxypyrovalerone (MDPV)-binding CBSAzyme for visual detection of MDPV and 10 other synthetic cathinones at low micromolar concentrations, even in biological samples. Given that CBSAzyme-based assays are simple, label-free, rapid, robust, and instrument-free, we believe that such assays should be readily applicable for on-site visual detection of various important small molecules such as illicit drugs, medical biomarkers, and toxins in various sample matrices.

Adulterants in crack cocaine in Brazil

Abstract Introduction Brazil is the world’s biggest consumer of crack cocaine, and dependence is a major public health issue. This is the first study to investigate the prevalence of potentially harmful adulterants present in hair samples from Brazilian patients with crack cocaine dependence. Method We evaluated adulterants in hair samples extracted by convenience from 100 patients admitted at the 48 hour-observation unit of Centro de Referência de Álcool, Tabaco e Outras Drogas (CRATOD), Brazil’s largest center for addiction treatment. A cross-sectional analysis was performed with the data obtained. Results Adulterants were found in 97% of the analyzed hair samples. The most prevalent adulterant was lidocaine (92%), followed by phenacetin (69%) and levamisole (31%). Conclusion Adulterants were widely prevalent in hair samples from crack users treated at CRATOD: at least one adulterant was present in virtually all the hair samples collected. This points to a need to monitor adverse effects in the clinical setting in order to provide this high-risk group of patients with prompt and effective care related to the acute and chronic complications associated with these adulterants.

Titanium dioxide nanoparticles-based colorimetric sensors for determination of hydrogen peroxide and triacetone triperoxide (TATP)

Due to its relatively simple preparation and readily available precursors, determination of triacetone triperoxide (TATP) by portable devices has become important. In this work, two different titanium dioxide nanoparticles (TiO₂NPs)-based colorimetric sensors based on complex formation on the solid surface were developed for determination of H₂O₂ and TATP. The first sensor, (3-aminopropyl)triethoxysilane (APTES) modified-TiO₂NPs-based paper sensor (APTES@TiO₂NPs), exploits peroxo-titanate binary complex formation between APTES@TiO₂NPs and H₂O₂ on chromatographic paper. The second sensor, 4-(2-pyridylazo)-resorcinol-modified-TiO₂NPs-based solid sensor (PAR@TiO₂NPs), relies on the formation of a ternary complex between Ti(IV), PAR and H₂O₂. The developed sensors were also applied to TATP determination after acidic hydrolysis of samples to H₂O₂. The limits of detection (LODs) of APTES@TiO₂NPs-based paper sensor were 3.14 × 10^-4 and 5.13 × 10^-4 mol L^-1 for H₂O₂ and TATP, respectively, whereas the LODs of PAR@TiO₂NPs solid sensor were 6.06 × 10^-7 and 3.54 × 10^-7 mol L^-1 for H₂O₂ and TATP, respectively. Possible interferences of common soil ions, passenger belongings used as camouflage materials during public transport (e.g., detergent, sweetener, acetylsalicylic acid and paracetamol-caffeine based analgesic drugs) and of other explosives were examined. The developed methods were statistically validated using t- and F- tests against the titanyl sulfate (TiOSO₄) colorimetric literature method.

Health effects from unintentional occupational exposure to opioids among law enforcement officers: Two case investigations

Recent increases in the rate of drug overdose-related deaths, the emergence of potent opioids such as carfentanil, and media reports of incidents have raised concerns about the potential for work-related exposure to a variety of illicit drugs among law enforcement officers (LEOs), other emergency responders, and other workers in the United States. To characterize the risk associated with unintentional occupational exposure to drugs, we retrospectively investigated two incidents that occurred in 2017 and 2018 where LEOs were exposed to opioid and stimulant drugs and experienced health effects. We interviewed five affected LEOs and others. We reviewed records, including emergency department documentation, incident reports, forensic laboratory results, and when available, body camera footage. Multiple drug types, including opioids and nonopioids, were present at each incident. Potential routes of exposure varied among LEOs and were difficult to characterize with certainty. Health effects were not consistent with severe, life-threatening opioid toxicity, but temporarily precluded affected LEOs from performing their essential job duties. While health risks from occupational exposure to drugs during law enforcement activities cannot currently be fully characterized with certainty, steps to prevent such exposures should be implemented now. The creation and implementation of appropriate controls plus education and training are both important to protecting first responders from these hazardous agents. To more fully characterize potential exposures, timely prospective toxicological evaluation of affected responders is recommended.

Atypical Presentation of Chiari I Malformation in a 13-Year-Old Adolescent

In this report, we describe a 13-year-old with opisthotonos as the presenting symptom of Chiari I malformation. This presentation is rare and has previously been reported only in infants. We describe the physical and radiologic findings, literature regarding Chiari malformation, and differential diagnosis of opisthotonos in this patient.

Behavioral economic analysis of the reinforcing effects of "bath salts" mixtures: studies with MDPV, methylone, and caffeine in male Sprague-Dawley rats

RATIONALE

"Bath salts" preparations often contain combinations of synthetic cathinones (e.g., 3,4-methylenedioxymethcathinone [methylone], 3,4-methylenedioxypyrovalerone [MDPV]), and caffeine, and evidence suggests that mixtures of synthetic cathinones and caffeine (e.g., MDPV + caffeine or methylone + caffeine) can be more potent and/or effective reinforcers than predicted for an additive interaction.

OBJECTIVE

To use demand curve analyses to compare the reinforcing effectiveness of MDPV and methylone to mixtures of MDPV + caffeine and methylone + caffeine.

METHODS

Male Sprague-Dawley rats acquired methylone self-administration (0.32 mg/kg/inf) under a fixed ratio (FR) 1 schedule of reinforcement and generated full dose-response curves for methylone (0.01-1 mg/kg/inf) under an FR5 schedule of reinforcement. Demand curves were then obtained for methylone, MDPV, caffeine, and methylone + caffeine and MDPV + caffeine mixtures by increasing the FR across sessions according to the following series: 3, 10, 18, 32, 56, 100, 178, etc. RESULTS: Self-administration of methylone was rapidly acquired by 87.5% of rats and was maintained across a range of doses, producing an inverted U-shaped dose-response curve. Rank order demand for the individual constituents was MDPV > methylone > caffeine. Demand for the 3:1 (but not 10:1) methylone + caffeine mixture was greater than that for methylone alone, and demand for MDPV alone was similar to both MDPV + caffeine mixtures evaluated.

CONCLUSIONS

These studies provide additional evidence that although methylone is an effective reinforcer, combining methylone with caffeine results in an enhanced reinforcing effectiveness compared to methylone alone. Thus, abused "bath salts" preparations containing synthetic cathinones and caffeine may have higher abuse liability than preparations containing only synthetic cathinones.

Caring for Patients With Opioid Use Disorder: What Clinicians Should Know About Comorbid Medical Conditions

Opioid use disorder (OUD) is a growing problem, with opioid‐involved overdose deaths quadrupling since 1999 in the United States. This article reviews comorbid medical conditions related to OUD, starting with complications of behaviors associated with opioid use (e.g., injection drug use), followed by conditions stemming from the direct effects of opioids (e.g., hypogonadism). HIV and hepatitis C virus (HCV) are common infections in people with OUD, and treatment for these conditions can be safely provided regardless of ongoing substance use. Complications of drug injection, such as HIV, HCV, skin and soft tissue infections, and infective endocarditis, may be prevented through provision of sterile syringes and supervised injection facilities. Rare, life‐threatening bacterial infections may present with signs and symptoms that mimic intoxication, such as malaise or stupor, and should be assessed in patients with fever or positive blood cultures. In addition, chronic opioid exposure can lead to hypogonadism, opioid‐induced hyperalgesia, sleep‐disordered breathing, and potentially increased risk of cardiovascular disease and neurocognitive impairment. Pharmacotherapies for OUD (buprenorphine, methadone, and naltrexone) are safe and effective and their adverse opioid effects can be managed in clinical practice. Awareness of OUD‐associated medical conditions and their treatments is an important step in improving the health and wellness of people with OUD.

Safety and tolerability of sauna detoxification for the protracted withdrawal symptoms of substance abuse

Objective

Protracted drug withdrawal symptoms can last months or years after drug cessation, often precipitating a return to substance misuse. We evaluated the safety and preliminary health benefits of a unique chemical exposure regimen based on exercise, sauna and therapeutic nutrients.

Methods

This was a prospective evaluation of 109 individuals sequentially enrolled into a sauna detoxification component of a multi-modal, long-term residential substance abuse treatment centre.

Results

Data from medical charts, client self-reports and Short Form Health Survey (SF-36) responses indicated that the Hubbard sauna detoxification method was well tolerated, with a 99% completion rate, including one human immunodeficiency virus and nine hepatitis C positive clients. There were no cases of dehydration, overhydration or heat illness. Statistically significant improvements were seen in both mental and physical SF-36 scores at regimen completion, as well as in Addiction Severity Index and Global Appraisal of Individual Needs Short Screener change scores at rehabilitation program discharge, compared with enrolment.

Conclusions

The regimen lacked serious adverse events, had a very low discontinuation rate and high client-reported satisfaction. The SF-36 data indicated improved physical and emotional symptoms. Therefore, broader investigation of this sauna-based treatment regimen is warranted.

Occurrence of bacterial and toxic metals contamination in illegal opioid-like drugs in Iran: a significant health challenge in drug abusers

BACKGROUND

The toxic metals and/or bacterial contaminants in illicit drugs are the main health problems in drug users worldwide. Hence, the potential risks of these contaminants were evaluated in some of the illicit drugs during 2015 and 2016.

METHODS

The metals analysis were performed using graphite furnace atomic absorption spectrophotometry. In addition, all microbiological analysis stages, including handling procedures, dilution, and culture media, were conducted in accordance with the US Pharmacopeia (USP) which are harmonized with the European Pharmacopoeia (EP).

RESULTS

In the present study, the highest lead (Pb; 138.10 ± 75.01 μg/g) and chromium (Cr; 447.38 ± 20.27 μg/g) levels were detected in opium samples. In addition, the highest prevalence of microbial contamination was observed in opium samples, and the lowest was recorded in heroin samples. Clostridium tetani, with about 50% of contaminant, was the most common bacteria in the analyzed samples.

CONCLUSIONS

Our results indicate that Pb exposure as well as bacterial contamination could be the major threats for drug users. Graphical Abstract ᅟ.

Screening of seized cocaine samples using electrophoresis microchips with integrated contactless conductivity detection

This study describes the development of a new analytical method for the separation and detection of cocaine (COC) and its adulterants, or cutting agents, using microchip electrophoresis (ME) devices coupled with capacitively coupled contactless conductivity detection (C⁴ D). All the experiments were carried out using a glass commercial ME device containing two pairs of integrated sensing electrodes. The running buffer composed of 20 mmol/L amino-2-(hydroxymethyl) propane-1,3-diol and 10 mmol/L 3,4-dimethoxycinnamic acid provided the best separation conditions for COC and its adulterants with baseline resolution (R > 1.6), separation efficiencies ranging from (2.9 ± 0.1) to (3.2 ± 0.2) × 10⁵ plates/m, and estimated LOD values between 40 and 150 μmol/L. The quantification of COC was successfully performed in four samples seized by the Brazilian Federal Police Department and all predicted values agree with values estimated by the reference method. Some other interfering species were detected in the seized samples during the screening procedure on ME-C⁴ D devices. While lidocaine was detected in sample 3, the presence of levamisole was observed in samples 2 and 4. However, their concentrations were estimated to be below the LOQ. ME-C⁴ D devices have proved to be quite efficient for the identification and quantification of COC with errors lower than 10% when compared to the data obtained by a reference method. The approach herein reported offers great potential to be used for on-site COC screening in seized samples.

The cost-effectiveness of seven behavioural interventions to prevent drug misuse in vulnerable populations

BACKGROUND

The National Institute for Health and Care Excellence (NICE) developed a guideline on drug misuse prevention in vulnerable populations. Part of the guideline development process involved evaluating cost-effectiveness and determining which interventions represented good value for money.

METHODS

Economic models were developed for seven interventions which aimed to prevent drug use in vulnerable populations. The models compared the costs (to the health and crime sectors) and health benefits (in quality-adjusted life years (QALYs)) of each intervention and its comparator. Sensitivity analysis explored the uncertainty associated with the cost of each intervention and duration of its effect.

RESULTS

The reduction in drug use for each intervention partly offset the costs of the intervention, and improved health outcomes (QALYs). However, with high intervention costs and low QALY gains, none of the interventions were estimated to be cost-effective in the base case. Sensitivity analysis found that some of the interventions could be cost-effective if they could be delivered at a lower cost, or if the effect could be sustained for more than two years.

CONCLUSIONS

For drug misuse prevention to be prioritised by funders, the consequences of drug misuse need to be understood, and interventions need to be shown to be effective and cost-effective. Quantifying the wider harms of drug misuse and wider benefits of prevention interventions poses challenges in evaluating the cost-effectiveness of drug misuse prevention interventions. A greater understanding of the consequences of drug misuse and causal factors could facilitate development of cost-effective interventions to prevent drug misuse.

Identification and Quantification of Cocaine and Active Adulterants in Coca-Paste Seized Samples: Useful Scientific Support to Health Care

Adulteration is a common practice in the illicit drugs market, but the psychoactive and toxic effects provided by adulterants are clinically underestimated. Coca-paste (CP) is a smokable form of cocaine which has an extremely high abuse liability. CP seized samples are sold adulterated; however, qualitative and quantitative data of CP adulteration in forensic literature is still scarce. Besides, it is unknown if adulterants remain stable when CP is heated. This study was designed to report the chemical content of an extensive series of CP seized samples and to demonstrate the stability (i.e., chemical integrity) of the adulterants heated. To achieve this goal, the following strategies were applied: (1) a CP adulterated sample was heated and its fume was chemically analyzed; (2) the vapor of isolated adulterants were analyzed after heating; (3) plasma levels of animals exposed to CP and adulterants were measured. Ninety percent of CP seized samples were adulterated. Adulteration was dominated by phenacetin and caffeine and much less by other compounds (i.e., aminopyrine, levamisole, benzocaine). In the majority of CP analyzed samples, both cocaine and caffeine content was 30%, phenacetin 20% and the combination of these three components reached 90%. Typical cocaine pyrolysis compounds (i.e., BA, CMCHTs, and AEME) were observed in the volatilized cocaine and CP sample but no pyrolysis compounds were found after isolated adulterants heating. Cocaine, phenacetin, and caffeine were detected in plasma. We provide current forensic data about CP seized samples and demonstrated the chemical integrity of their adulterants heated.

In vitro model to study cocaine and its contaminants

Cocaine is one of the most popular illicit drug worldwide. Due its great addictive potential, which leads to euphoria and hyperactivity, it is considered a public health concern. At the central nervous system, the drug acts inhibiting catecholamine re-uptake. It is now known that in addition to the toxicity of the drug itself, the contaminants present in the street drug have raised concern about the harmful effects on health. Toxicological in vivo and in vitro studies have demonstrated the toxic effects of cocaine correlated with the generation of reactive oxygen species (ROS), which in turn lead to oxidative damage to the cells. Therefore the aim of this work was to propose an in vitro model that reunites the main parameters of toxicity of the cocaine already observed in the literature so far, and we tested this model using cocaine and seizure cocaine sample (SCS), kindly provided by Federal Police of Brazil. For that, we used a C6 glioblastoma cells and evaluated cell death, oxygen reactive species induction, oxidation of macromolecules as membrane lipids and DNA and loss of mitochondrial membrane potential after cocaine exposure. The results showed that cocaine can decrease cellular viability in a dose-dependent way in the C6 cell immortalized and astrocytes primary culture. Cocaine also induced cellular death by apoptosis. However, in the seizure cocaine sample (SCS), the predominant cell death was due to necrosis. Using dichlorofluorescein (DCF) assay, we confirmed ROS production after cocaine exposition. In agreement with these findings, occurred an increasing in MDA production, as well as increased superoxide dismutase (SOD) and catalase (CAT) activity. The induction of DNA damage was observed after cocaine. Our results demonstrate the occurrence of mitochondrial dysfunction by depolarization of mitochondrial membrane as a consequence of cocaine treatment. In summary, these results demonstrated that cocaine can induce reactive oxygen species formation, leading to oxidative stress. As a consequence of this unbalance, DNA damage, lipidic peroxidation and loss of mitochondrial membrane occurred, which could be an answer to cell death observed.

Heroin in Malaysia and Singapore

Clandestine heroin laboratories have been a feature of the Malaysian illicit drug scene since soon after the abuse of heroin emerged in 1972. The first few clandestine heroin laboratories which synthesised heroin via the acetylation of imported morphine were uncovered in 1973 and 1977. By the mid-1980s, this type of laboratory was replaced by heroin-cutting laboratories whereby imported high-grade heroin was cut to street heroin. This was to meet the rising demand for the drug owing to the rapid escalation of the number of drug users. Over the years, the most significant change in the composition of the street heroin is the decrease in its purity from 30%-50% to 3%-5%. Caffeine has remained the major adulterant and chloroquine is detected in virtually all recent seizures.

Cocaine and Caffeine Effects on the Conditioned Place Preference Test: Concomitant Changes on Early Genes within the Mouse Prefrontal Cortex and Nucleus Accumbens

Caffeine is the world's most popular psychostimulant and is frequently used as an active adulterant in many illicit drugs including cocaine. Previous studies have shown that caffeine can potentiate the stimulant effects of cocaine and cocaine-induced drug seeking behavior. However, little is known about the effects of this drug combination on reward-related learning, a key process in the maintenance of addiction and vulnerability to relapse. The goal of the present study was thus to determine caffeine and cocaine combined effects on the Conditioned Place Preference (CPP) test and to determine potential differential mRNA expression in the Nucleus Accumbens (NAc) and medial prefrontal cortex (mPFC) of immediate-early genes (IEGs) as well as dopamine and adenosine receptor subunits. Mice were treated with caffeine (5 mg/kg, CAF), cocaine (10 mg/kg, COC), or their combination (caffeine 5 mg/kg + cocaine 10 mg/kg, CAF-COC) and trained in the CPP test or treated with repeated injections inside the home cage. NAc and mPFC tissues were dissected immediately after the CPP test, after a single conditioning session or following psychostimulant injection in the home cage for mRNA expression analysis. CAF-COC induced a marked change of preference to the drug conditioned side of the CPP and a significant increase in locomotion compared to COC. Gene expression analysis after CPP test revealed specific up-regulation in the CAF-COC group of Drd1a, cFos, and FosB in the NAc, and cFos, Egr1, and Npas4 in the mPFC. Importantly, none of these changes were observed when animals received same treatments in their home cage. With a single conditioning session, we found similar effects in both CAF and CAF-COC groups: increased Drd1a and decreased cFos in the NAc, and increased expression of Drd1a and Drd2, in the mPFC. Interestingly, we found that cFos and Npas4 gene expression were increased only in the mPFC of the CAF-COC. Our study provides evidence that caffeine acting as an adulterant could potentiate reward-associated memories elicited by cocaine. This is associated with specific changes in IEGs expression that were observed almost exclusively in mice that received the combination of both psychostimulants in the context of CPP memory encoding and retrieval. Our results highlight the potential relevance of caffeine in the maintenance of cocaine addiction which might be mediated by modifying neural plasticity mechanisms that strengthen learning of the association between drug and environment.

Levamisole in Illicit Trafficking Cocaine Seized: A One-Year Study

Cocaine use is increasing around the world and its purity is frequently altered through dilution, substitution, contamination, and adulteration. Sugars, talc, starch, and carbonates represent the principal diluents of cocaine, while phenacetin, levamisole, caffeine, and lidocaine are its major adulterants in Europe. Levamisole is used because it is an odorless powder, with physical properties similar to cocaine, and it has reasonable cost and availability, being widely used in veterinary medicine. For this study, we analyzed 88 cocaine samples. The seized cocaine analyzed showed an average purity of 55% and the most frequent adulterants identified were: levamisole (31.8%), caffeine (6.8%), lidocaine (2.3%), acetaminophen (2.3%), and phenacetin (1.1%). Our aim is the study of the presence of levamisole, over other adulterants in seized cocaine samples, due to its recognized human toxicity. The chronic use of levamisole-adulterated cocaine represents a serious public health issue because it may be responsible for side-effects such as dermal vasculopathy, leukoencephalopathy, leukopenia, agranulocytosis, pulmonary hemorrhage, multiple emboli, and several other effects. Moreover, aminorex can cause idiopathic pulmonary hypertension, presenting another harmful and mostly lethal side-effect from cocaine cut with levamisole. In conclusion, levamisole determination should be performed in routine toxicological analysis in deaths due to cocaine use.

Cocaine adulteration

Cocaine is a naturally occurring and illicitly used psychostimulant drug. Cocaine acts at monoaminergic neurotransmitter transporters to block uptake of the monoamines, dopamine, serotonin and norepinephrine. The resulting increase of monoamines in the extracellular space underlies the positively reinforcing effects that cocaine users seek. In turn, this increase in monoamines underlies the development of addiction, and can also result in a number of severe side effects. Currently, cocaine is one of the most common illicit drugs available on the European market. However, cocaine is increasingly sold in impure forms. This trend is driven by cocaine dealers seeking to increase their profit margin by mixing ("cutting") cocaine with numerous other compounds ("adulterants"). Importantly, these undeclared compounds put cocaine consumers at risk, because consumers are not aware of the additional potential threats to their health. This review describes adulterants that have been identified in cocaine sold on the street market. Their typical pharmacological profile and possible reasons why these compounds can be used as cutting agents will be discussed. Since a subset of these adulterants has been found to exert effects similar to cocaine itself, we will discuss levamisole, the most frequently used cocaine cutting agent today, and its metabolite aminorex.

Global cocaine intoxication research trends during 1975-2015: a bibliometric analysis of Web of Science publications

BACKGROUND

Cocaine is subject to recreational abuse as a stimulant and psychoactive agent, which poses a major worldwide health problem. The aim of the present study was to perform a bibliometric analysis of publication related to cocaine intoxication an insight of the research trends at a global level to enable recommendations for future research strategies in this field.

METHODS

Publications about cocaine intoxication were retrieved from the Web of Science (WoS) Core Collection database on December 28, 2016, and analysed regarding the following bibliometric indicators: research trends, document types, languages, countries/territories with their h-index, collaboration patterns, journals with their impact factors (IF), and institutions.

RESULTS

In total, 2,902 scientific publications from 1975 to 2015 were retrieved from the WoS database. The annual number of publications related to cocaine toxicity increased slightly after 1990 and reached a peak of 148 in 1992, with an average of 103 publications per year. The USA outranked other countries/territories with 2,089 publications, of which 1,927 arose exclusively from the USA and 162 involved international collaborations. The h-index for all publications related to cocaine was 212, and the h-index for all publications related to cocaine intoxication was 99. Moreover, the USA had the highest h-index of 95, followed by Spain with h-index of 24, and Canada with h-index of 24. The main research topics were consistently reproductive toxicity, clinical management of acute cocaine exposure, laboratory methods for detection of exposure to cocaine, cocaine metabolism, and cocaine toxicity in animals.

CONCLUSIONS

This is the first bibliometric approach to examining research related to cocaine toxicity and shows that research activity has become more global and extensive since 1990. The USA remains the leading country regarding published literature, the highest h-index, and greatest role in international collaborations.

Purity and adulterant analysis of some recent drug seizures in Italy

The data collected in this study describe an initial attempt to systematically introduce the qualitative and quantitative analysis of adulterants present in seized street drugs in Italy with the aim of improving surveillance and data sharing and for this purpose, the implementation of validated and standardized procedures are essential.

Caffeine Induces a Stimulant Effect and Increases Dopamine Release in the Nucleus Accumbens Shell Through the Pulmonary Inhalation Route of Administration in Rats

Oral, intraperitoneal, or intravenous have been the common routes of administration used to study the behavioral and neurochemical pharmacology of caffeine, one of the most widely used psychoactive substances worldwide. We have reported that caffeine is an active adulterant frequently found in coca-paste (CP)-seized samples, a highly addictive form of smokable cocaine. The role of caffeine in the psychostimulant and neurochemical effects induced by CP remains under study. No preclinical animal studies have been performed so far to characterize the effects of caffeine when it is administered through the pulmonary inhalation route. Caffeine (10, 25, and 50 mg) was volatilized and rats were exposed to one inhalation session of its vapor. The stimulant effect was automatically recorded and plasmatic levels of caffeine were measured. Caffeine capability (50 mg) to increase extracellular dopamine (DA) levels in nucleus accumbens shell was also studied by in vivo microdialysis in non-anesthetized animals. A dose-dependent stimulant effect induced by volatilized caffeine was observed and this effect was directly related with caffeine plasmatic levels. A significant increase in the extracellular DA was achieved after 50 mg of volatilized caffeine exposure. This is the first report showing pharmacological acute effects of caffeine through the pulmonary inhalation route of administration and suggests that this could be a condition under which caffeine can elevate its weak reinforcing effect and even enhance the psychostimulant effect and abuse liability of smokable adulterated psychostimulant drugs.