Adulterants in illicit drugs: a review of empirical evidence

Enhancing translation: A need to leverage complex preclinical models of addictive drugs to accelerate substance use treatment options

Preclinical models of addictive drugs have been developed for decades to model aspects of the clinical experience in substance use disorders (SUDs). These include passive exposure as well as volitional intake models across addictive drugs and have been utilized to also measure withdrawal symptomatology and potential neurobehavioral mechanisms underlying relapse to drug seeking or taking. There are a number of Food and Drug Administration (FDA)-approved medications for SUDs, however, many demonstrate low clinical efficacy as well as potential sex differences, and we also note gaps in the continuum of care for certain aspects of clinical experiences in individuals who use drugs. In this review, we provide a comprehensive update on both frequently utilized and novel behavioral models of addiction with a focus on translational value to the clinical experience and highlight the need for preclinical research to follow epidemiological trends in drug use patterns to stay abreast of clinical treatment needs. We then note areas in which models could be improved to enhance the medications development pipeline through efforts to enhance translation of preclinical models. Next, we describe neuroscience efforts that can be leveraged to identify novel biological mechanisms to enhance medications development efforts for SUDs, focusing specifically on advances in brain transcriptomics approaches that can provide comprehensive screening and identification of novel targets. Together, the confluence of this review demonstrates the need for careful selection of behavioral models and methodological parameters that better approximate the clinical experience combined with cutting edge neuroscience techniques to advance the medications development pipeline for SUDs.

Green innovation in analytical chemistry: A sustainable densitometric HPTLC approach for the distinctive separation and quantification of structurally related abused drugs - tramadol, tapentadol, and venlafaxine - in seized pharmaceutical dosage forms

An innovative ecofriendly high-performance thin layer chromatographic (HPTLC) method with spectrophotometric detection for simultaneous determination of Tramadol (TMD), Tapentadol (TAP), and Venlafaxine (VEN) in seized dosage forms was presented. Our method was conducted to achieve separation following the optimal conditions: pre-coated silica gel plates using a green mobile phase (heptane: acetone: ammonia, 7:3:0.5 v/v), with absorbance scanning at 272 nm. The validation of the method was done following International Conference on Harmonization (ICH) guidelines, demonstrates linearity, accuracy, precision, selectivity, robustness, and system suitability. Separation was achieved with a detection limit of 0.34, 0.16, and 0.084 (ug/band) for TMD, TAP, and VEN, respectively, the method successfully analyzes seized samples. Trueness is confirmed through a high degree of similarity between HPTLC and gas chromatography results. The study's ecofriendly approach, simplicity, and selectivity position it as a promising method for efficient, on-site monitoring of seized samples.

Classics in Chemical Neuroscience: Xylazine

Xylazine (also known as "tranq") is a potent nonopioid veterinary sedative that has recently experienced a surge in use as a drug adulterant, most often combined with illicitly manufactured fentanyl. This combination may heighten the risk of fatal overdose. Xylazine has no known antidote approved for use in humans, and age-adjusted overdose deaths involving xylazine were 35 times higher in 2021 than 2018. In April 2023, the Biden Administration declared xylazine-laced fentanyl an emerging drug threat in the United States. In 2022, the Drug Enforcement Agency (DEA) reported nearly a quarter of seized fentanyl powder contained xylazine. This dramatic increase in prevalence has solidified the status of xylazine as an emerging drug of abuse and an evolving threat to public health. The following narrative review outlines the synthesis, pharmacokinetics, pharmacodynamics, and adverse effects of xylazine, as well as the role it may play in the ongoing opioid epidemic.

Application of novel metal organic framework-deep eutectic solvent/molecularly imprinted polymer multiple monolithic fiber for solid phase microextraction of amphetamines and modafinil in unauthorized medicinal supplements with GC-MS

The goal of this research is the development of multiple monolithic fiber-solid phase microextraction (MMF-SPME) using a new integrated fiber for the determination of amphetamine derivatives and modafinil from unauthorized medicinal supplements. For this purpose, a monolithic fiber of metal organic framework MIL-Al (53)-deep eutectic solvent (DES)/molecularly imprinted polymers (MOF-DES/MIP) was synthesized. To find optimum microextraction conditions gas chromatography-mass spectrometer (GC-MS) was used and the influences of effective variables were investigated using one factor at a time method. After that, the significant variables were optimized using a Box-Behnken design (BBD) combined with a desirability function (DF). Under optimized conditions (desorption solvent=1500 µL of 1-octanol, pH=3.5, extraction time=35 min, [NaCl]=0% w/v and stirring rate=600 rpm), calibration graphs of analytes were linear in a concentration range of 0.1-400 μg L-1 with correlation coefficients > 0.9966. Limits of detection and quantification were in the ranges of 0.023-0.033 μg L-1 and 0.088-0.113 μg L-1, respectively. This procedure was successfully employed in determining target analytes in spiked and unspiked unauthorized medicinal supplement samples with recoveries ranging from 95.14 to 104.63%.

Xylazine: A Drug Adulterant of Clinical Concern

PURPOSE OF REVIEW

The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.

RECENT FINDINGS

Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.

The dichotomy between health and drug abuse in bodybuilding

Aim: The aim of the present study was to investigate the expansion and prevalence of anabolic steroid use by examining the divergent effects between health and drug abuse and to create more awareness around the harmful consequences of these drugs when administered at abusive levels. Methods: A focused and concise literature search was conducted, and 101 high-quality articles were included in the review. Results: The findings underscore the adverse health risks of steroid abuse, emphasizing the stark contrast between health and drug abuse. Conclusions: While steroids and other performance-enhancing drugs can yield muscle growth, strength and even fat loss, abusing these substances can lead to adverse health outcomes. Furthermore, within the fitness subculture, particularly in the realm of bodybuilding, steroid abuse fosters an atmosphere of cheating and deception, frequently downplaying or ignoring the negative and sometimes deadly consequences it brings.

Dog and cat exposures to drugs of abuse identified by the California animal health and food safety laboratory system 2013-2023

Introduction

While known animal exposures to human "drugs of abuse" (DA) were previously considered relatively uncommon in veterinary medicine, the trends are changing. Marijuana and amphetamines are among the 20 toxicants most frequently consulted about with the Pet Poison Helpline. When such exposures occur, they are typically considered emergencies.

Methods

This retrospective study describes confirmed cases of DA exposure in pets from the California Animal Health and Food Safety Laboratory System (CAHFS), 2013-2023.

Results

Fifty-seven samples tested positive for DA through liquid chromatography with tandem mass spectrometry analysis (qualitative method). In 75% (43/57) of the DA screen tests, the detected drugs included amphetamine-type stimulants and metabolites (methamphetamine, amphetamine, or both). In 47% (27/57) of cases, a combination of more than one drug group was found. Most cases were diagnosed from a urine specimen. In at least 32% (18/57) of cases, the samples were submitted due to suspicions of animal cruelty, and at least 41% (23/57) of the patients were deceased when the samples were submitted.

Discussion

More studies on the prevalence of illicit drugs in small animals, using confirmatory testing, are warranted to fully understand the significance of this emerging toxicological hazard in veterinary medicine.

Mucocutaneous Manifestations of Recreational Drug Use

Recreational drug use is increasingly common in the dermatology patient population and is often associated with both general and specific mucocutaneous manifestations. Signs of substance use disorder may include changes to general appearance, skin, and mucosal findings associated with particular routes of drug administration (injection, insufflation, or inhalation) or findings specific to a particular drug. In this review article, we provide an overview of the mucocutaneous manifestations of illicit drug use including cocaine, methamphetamine, heroin, hallucinogens, marijuana, and common adulterants to facilitate the identification and improved care of these patients with the goal being to connect this patient population with appropriate resources for treatment.

A novel approach to low-cost, rapid and simultaneous colorimetric detection of multiple analytes using 3D printed microfluidic channels

This research paper presents an inventive technique to swiftly create microfluidic channels on distinct membrane papers, enabling colorimetric drug detection. Using a modified DIY RepRap 3D printer with a syringe pump, microfluidic channels (µPADs) are crafted on a flexible nylon-based substrate. This allows simultaneous detection of four common drugs with a single reagent. An optimized blend of polydimethylsiloxane (PDMS) dissolved in hexane is used to create hydrophobic channels on various filter papers. The PDMS-hexane mixture infiltrates the paper's pores, forming hydrophobic barriers that confine liquids within the channels. These barriers are cured on the printer's hot plate, controlling channel width and preventing spreading. Capillary action drives fluid along these paths without spreading. This novel approach provides a versatile solution for rapid microfluidic channel creation on membrane papers. The DIY RepRap 3D printer integration offers precise control and faster curing. The PDMS-hexane solution accurately forms hydrophobic barriers, containing liquids within desired channels. The resulting microfluidic system holds potential for portable, cost-effective drug detection and various sensing applications.

Distance-based detection of paracetamol in microfluidic paper-based analytical devices for forensic application

Whisky adulteration is a prevalent practice driven by the high cost of these beverages. Counterfeiters commonly dilute whisky with less expensive alcoholic beverages, water, food additives, drugs or pharmaceuticals. Paracetamol (PAR), an analgesic drug that mitigates hangovers and headaches, is commonly used to adulterate whisky. Currently, the primary method for quantifying PAR levels is high-performance liquid chromatography, but this technique is both time consuming and usually generates more residues. In this context, the utilization of miniaturized and portable analytical devices becomes imperative for conducting point-of-care/need analyses. These devices offer several advantages, including portability, user-friendliness, low cost, and minimal material wastage. This study proposes the selective distance-based PAR quantification on whisky samples using a paper-based microfluidic analytical device (μPAD). Colorimetric detection on paper-based platforms offers great benefits such as affordability, portability, and the ability to detect PAR without complicated instrumentation. The optimal detection conditions were achieved by introducing 5 μL of a mixture containing 7.5 mmol L-1 of Fe(III) and K3[Fe(CN)6] into the detection zone, along with 12 μL of whisky samples into the sample zone. The method exhibited linear behavior within the concentration range from 15 to 120 mg L-1, with a determination coefficient of 0.998. PAR was quantified in adulterated samples. The results obtained with the paper-based devices were compared with a referenced method, and no significant differences were observed at a confidence level of 95%. The μPAD allowed to determine ca. 1 drop of pharmaceutical medicine PAR of 200 mg mL-1 in 1 L of solution, demonstrating excellent sensitivity. This method offers cost-effective and rapid analysis, reducing the consumption of samples, reagents, and wastes. Consequently, it could be considered a viable and portable alternative for analyzing beverages at criminal scenes, customs, and police operations, thereby enhancing the field of forensics.

First drug-checking study at an electronic festival and fentanyl detection in the central region of Mexico

BACKGROUND

Perception of drug adulteration has increased in Mexico, but there is little research on adulterants and toxicity. The aim of this study was to identify drug composition in an electronic music outdoor festival nearby Mexico City.

METHODS

The participants completed a questionnaire with demographic data, harm reduction strategies, drug-use patterns, history, and the drug they expected to find. We took a small sample of each substance and prepared it for drug checking. A two-section drug testing station was placed within the grounds of the festival. Interaction with participants occurred at the front part. Drug checking was conducted at the rear part. The service was free of charge, voluntary and confidential. Forty persons aged 22 to 48 years participated (mode = 28), of which 92.5% were male, most (82.5%) were single. Through the Substance Analysis Program of "ReverdeSer Collective," we conducted the testing with the attendants that provided 51 drug samples, following ethical and biosafety protocols. We used colorimetry, Fourier Transform Infrared Spectroscopy, and fentanyl immunoassay strips for sample analysis.

RESULTS

Substances of choice among attendants were psychostimulants (MDMA and other amphetamine-like drugs) and hallucinogens. Most samples contained what the users expected plus adulterants. Main adulterants were methylene-dioxy-ethyl-amphetamine, methylene-dioxy-propyl-amphetamine, hydroxyamphetamine, and the selective serotonin reuptake inhibitor venlafaxine. Fentanyl was present in 2 out of 4 cocaine samples and in 14 of the 22 confirmed MDMA samples.

CONCLUSIONS

Some of the adulterants found pose serious health risks, especially fentanyl, amphetamine-like substances, and venlafaxine. Therefore, it is urgent to monitor these adulterants at electronic music festivals and to implement prevention, treatment, and harm reduction public policies. Naloxone distribution and drug-assisted therapies should be part of government programs in Mexico.

Detection of drugs and hepatitis C virus in used syringes from a needle exchange in Gothenburg, Sweden

People who inject drugs (PWID) are exposed to serious health risks such as lethal overdoses, addiction and infections. The patterns of drug use and the prevalence of hepatitis C virus (HCV) infection vary greatly between and even within countries. Data on drugs used for injection are important to inform PWID of risks and adapt healthcare. This study aimed to determine which substances are injected in Gothenburg, Sweden, and estimate the risk of HCV transmission. A total of 150 syringes handed in at the needle and syringe exchange program (NEP) in Gothenburg over a week in November 2021 were analysed for drug content using liquid chromatography coupled with high-resolution mass spectrometry. Using a dose-adjusted comparison, the main drug(s) injected was distinguished from the impurities in the syringes containing several drugs. HCV RNA was quantified by real-time PCR in an additional set of 150 syringes. Drugs were detected in >99% of analysed syringes, and the most common drugs were amphetamine (81%), followed by buprenorphine (8.0%), heroin (6.7%) and alprazolam (4.6%). Less common findings were testosterone (2.7%), methylphenidate (2.0%), MDMA (0.7%), trenbolone (0.7%) and zopiclone (0.7%). Eleven syringes (7.3%) contained more than one drug. HCV RNA was detected in 13% of the syringes, and one in 10 contained enough to potentially transmit an infection. This study underlines the importance of access to NEPs for PWID to reduce the risks associated with drug injection.

Mucocutaneous alterations and complications in amphetamine abusers: a narrative review

Amphetamines are the second most commonly used illicit drug worldwide. Amphetamine use can result in significant cutaneous morbidity. This review highlights the dermatological manifestations of amphetamine abuse.

Naturalistic Psychedelic Use: A World Apart from Clinical Care

Interest in and availability of psychedelics for therapeutic purposes has increased in recent decades. In a large, anonymous, online survey, we investigated patterns of communication with healthcare providers and awareness and utilization of substance testing kits or services among people using psychedelics naturalistically. The sample population included attendees of a psychedelic activism event and users of psychedelic social media forums. Among 1,435 participants, 72.5% never discussed psychedelic use with their primary care provider (PCP). Only 4.4% reported using psychedelics with a therapist and 3% in clinical settings, although 77.8% were very or extremely likely to take psychedelics with a therapist if one were legally available. While 62.6% of participants were aware of substance testing services, 42.6% of these indicated never using them. Regression analyses identified several variables associated with disclosure to PCP and utilization of substance testing services including age, gender, frequency and number of psychedelics used, and likelihood of consuming psychedelics under the guidance of a therapist if one were legally available. Further research is necessary to investigate these findings among other groups. Our findings suggest that relevant training and education for healthcare providers is needed, along with more visible options for substance identity testing.

Electrochemical Rapid Detection of Methamphetamine from Confiscated Samples Using a Graphene-Based Printed Platform

Methamphetamine (MAP) is a highly addictive and illegal stimulant drug that has a significant impact on the central nervous system. Its detection in biological and street samples is crucial for various organizations involved in forensic medicine, anti-drug efforts, and clinical diagnosis. In recent years, nanotechnology and nanomaterials have played a significant role in the development of analytical sensors for MAP detection. In this study, a fast, simple, and cost-effective electrochemical sensor is presented that is used for the sensitive detection of MAP in confiscated street samples with a complex matrix. The optimized screen-printed sensor based on a carbon working electrode modified with graphene demonstrated an excellent limit of detection, good sensitivity, and a wide dynamic range (1-500 μM) for the target illicit drug both for standard solutions and real samples (seized samples, tap water, and wastewater samples). It can detect MAP at concentrations as low as 300 nM in real samples. This limit of detection is suitable for the rapid preliminary screening of suspicious samples in customs, ports, airports, and on the street. Furthermore, the sensor exhibits a good recovery rate, indicating its reliability and repeatability. This quality is crucial for ensuring consistent and accurate results during screening processes.

Opioid cutting agents for use as internal standards in ion mobility spectrometry (IMS)

Opioids have become a serious public health concern over the last decade. These compounds are commonly found mixed, or cut, with safer compounds to make the opioids appear unadulterated while also enhancing the psychoactive effect on the user. Commercial benchtop and handheld IMS devices are capable of detection but published reduced ion mobility (K₀) values, used to identify the target analytes with IMS instrumentation, have shown variability. This lack of agreement, even for compounds used for calibration, is often due to the effects of drift tube temperature, drift gas water vapor levels and the use in-house built instrumentation rather than commercial equipment. Multiple reports exist on assessment of IMS reference standards but a single, consensus universal standard does not exist. Assessment of opioid cutting agents as internal standards is a worthwhile pursuit if precise and accurate K₀ values are obtained. The effects of drift gas water vapor content and drift tube temperature were used to evaluate the cutting agents. The K₀ values of papaverine, a representative opioid with a similar K₀ value to heroin and fentanyl, were calculated with respect to quinine and were in agreement with literature data. The use of quinine as an internal standard also improved precision relative to the instrument standard and shows promise in the application presented here.

Investigating the electrochemical profile of methamphetamine to enable fast on-site detection in forensic analysis

Methamphetamine (MA) is a synthetic psychoactive drug which is consumed both licitly and illicitly. In some countries it is prescribed for attention-deficit and hyperactivity disorder, and short-term treatment of obesity. More often though, it is abused for its psychostimulant properties. Unfortunately, the spread and abuse of this synthetic drug have increased globally, being reported as the most widely consumed synthetic psychoactive drug in the world in 2019. Attempting to overcome the shortcomings of the currently used on-site methods for MA detection in suspected cargos, the present study explores the potential of electrochemical identification of MA by means of square wave voltammetry on disposable graphite screen-printed electrodes. Hence, the analytical characterization of the method was evaluated under optimal conditions exhibiting a linear range between 50 μM and 2.5 mM MA, a LOD of 16.7 μM, a LOQ of 50.0 μM and a sensitivity of 5.3 μA mM^-1. Interestingly, two zones in the potential window were identified for the detection of MA, depending on its concentration in solution. Furthermore, the oxidative pathway of MA was elucidated employing liquid chromatography - mass spectrometry to understand the change in the electrochemical profile. Thereafter, the selectivity of the method towards MA in mixtures with other drugs of abuse as well as common adulterants/cutting agents was evaluated. Finally, the described method was employed for the analysis of MA in confiscated samples and compared with forensic methods, displaying its potential as a fast and easy-to-use method for on-site analysis.

Disruption to Australian heroin, methamphetamine, cocaine and ecstasy markets with the COVID-19 pandemic and associated restrictions

BACKGROUND

Changes to drug markets can affect drug use and related harms. We aimed to describe market trends of heroin, methamphetamine, cocaine and ecstasy in Australia following the introduction of COVID-19 pandemic-associated restrictions.

METHODS

Australians residing in capital cities who regularly inject drugs (n ∼= 900 each year) or regularly use ecstasy and/or other illicit stimulants (n ∼= 800 each year) participated in annual interviews 2014-2022. We used self-reported market indicators (price, availability, and purity) for heroin, crystal methamphetamine, cocaine, and ecstasy crystal to estimate generalised additive models. Observations from the 2014-2019 surveys were used to establish the pre-pandemic trend; 2020, 2021 and 2022 observations were considered immediate, short-term and longer-term changes since the introduction of pandemic restrictions.

RESULTS

Immediate impacts on market indicators were observed for heroin and methamphetamine in 2020 relative to the 2014-2019 trend; price per cap/point increased (β: A$9.69, 95% confidence interval [CI]: 2.25-17.1 and β: A$40.3, 95% CI: 33.1-47.5, respectively), while perceived availability (adjusted odds ratio [aOR] for 'easy'/'very easy' to obtain: 0.38, 95% CI: 0.24-0.59 and aOR: 0.08, 95% CI: 0.03-0.25, respectively) and perceived purity (aOR for 'high' purity: 0.36, 95% CI: 0.23-0.54 and aOR: 0.33, 95% CI: 0.20-0.54, respectively) decreased. There was no longer evidence for change in 2021 or 2022 relative to the 2014-2019 trend. Changes to ecstasy and cocaine markets were most evident in 2022 relative to the pre-pandemic trend: price per gram increased (β: A$92.8, 95% CI: 61.6-124 and β: A$24.3, 95% CI: 7.93-40.6, respectively) and perceived purity decreased (aOR for 'high purity': 0.18, 95% CI: 0.09-0.35 and 0.57, 95% CI: 0.36-0.90, respectively), while ecstasy was also perceived as less easy to obtain (aOR: 0.18, 95% CI: 0.09-0.35).

CONCLUSION

There were distinct disruptions to illicit drug markets in Australia after the COVID-19 pandemic began; the timing and magnitude varied by drug.

Substances from unregulated drug markets - A retrospective data analysis of customer-provided samples from a decade of drug checking service in Zurich (Switzerland)

BACKGROUND

Drug checking services (DCS) are harm reduction interventions for people who consume illicit substances. Unregulated drug markets lead to samples with unexpected and variable contents. A retrospective data analysis of Zurich's DCS was performed to determine the nature of these samples.

METHODS

This study aims to investigate the qualitative and quantitative properties of 16,815 customer-provided psychoactive drug samples analyzed chemically through the DCS in Zurich from 1^st January 2011 to 31^st December 2021. The main analytical method utilized for characterizing these substances was high-performance liquid chromatography and gas chromatography-mass spectrometry. Data sets are summarized using descriptive statistics.

RESULTS

There was a 2.5-fold increase in the number of tested samples over the past decade. An overall proportion of 57.9% (weighted mean) of samples within our database demonstrates unexpected analytical findings and additional low sample contents during the observation period. Substantial differences in quality and quantity between substance groups were detected and an increase of sample quality and content over time was demonstrated.

CONCLUSIONS

Chemical analysis reveals that over half of substances acquired from unregulated drug markets analyzed through DCS in Zurich are with low qualitative and quantitative properties, which may expose users to risks. Based on longitudinal analyses over a decade, this study contributes to the body of evidence that DCS may potentially manipulate unregulated drug markets towards providing better quality substances, as well as may stabilize these markets over time. The necessity for drug policy changes to make this service accessible in further settings was highlighted, as DCS still often take place in legal grey zones.

FUNDING

None to declare.

Xylazine Complicating Opioid Ingestions in Young Children

The authors of this report present 3 cases of synthetic opioid intoxication complicated by the concomitant presence of the additive xylazine, a nonopioid sedative analgesic and muscle relaxant used in veterinary medicine that potentiates respiratory depression associated with the opioid toxidrome. Three exposed children presented with severe signs and symptoms, 2 of whom experienced cardiac arrest, a need for continuous naloxone infusion or multiple naloxone doses, or mechanical ventilation to treat respiratory failure after their exposures. Additives were detected in urine studies only through the performance of specialized toxicology testing. Detection of xylazine among adult overdose deaths has recently increased sharply, particularly across the northeastern United States. Adulteration by xylazine is an emerging public health threat nationally. Our report reveals that pediatricians should be aware of sentinel drug trends among adults, including the emerging types of illicit, synthetic, or counterfeit formulations of recreational substances, because children may be harmed because of accidental or intentional exposure. Children exposed to dangerous substances also need child protection services that may entail safe relocation outside of the home and the referral of affected caregivers to necessary substance use treatment services. Given epidemic drug use among adults, pediatricians should be competent to recognize common toxidromes and be aware that signs and symptoms may be potentiated by synergistic novel additives or polysubstance exposures. Importantly, standard urine drug screens may not detect synthetic opioid derivatives or contributing additives, so that diagnosis will require specialized toxicology testing.

Analysis of umbilical cord tissue as an indicator of in utero exposure to toxic adulterating substances

In utero drug exposure is a significant public health threat to the well-being and normal development of the neonate. Recently, testing of umbilical cord tissue (UCT) has been employed to measure illicit drug exposure, as drugs used by the mother during the third trimester may be retained in the UCT. Focus has also been given to potential adverse health effects among drug users, resulting from exposure to pharmacologically active adulterants and cutting agents in the street drug supply. The in utero effects of these substances have not been well studied in humans, nor has their presence been demonstrated as a means for assessing adverse health effects in the neonate. Here, we describe the application of a novel test method to analyze UCT for the presence of more than 20 common adulterating/cutting substances via LC/Q-TOF. In total, 300 de-identified UCT samples were analyzed-all had previously tested positive for cocaine or opiates. Generally, the positivity rates of individual compounds were similar between the Cocaine and Opiates Subgroups, apart from levamisole, xylazine, dipyrone (metabolites), and promethazine. Many of the adulterants used in the street drug supply do have legitimate medicinal/therapeutic uses, including several of the compounds most frequently detected in this study. Caffeine and lidocaine were the most frequently identified compounds both individually (>70% each) and in combination with each other. Alternatively, levamisole, an adulterant with no legitimate therapeutic use, was present in 12% of cases. Importantly, this data demonstrates that the detection of traditional drugs of abuse may serve as indicators of potential in utero exposure to toxic adulterating substances during gestation. While there is cause for concern with respect to any unintentional drug exposure, illicit drug use during pregnancy, including uncontrolled dosing, poly-adulterant consumption, and the interactions of these drug mixtures, produces a significant public health threat to the neonate which warrants further study.

Lessons Learned From the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Outbreak Response, Minnesota, 2019-2020

OBJECTIVE

Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) is a novel noncommunicable disease with an unknown cause. The objective of this analysis was to describe the Minnesota Department of Health's (MDH's) outbreak response to EVALI, including challenges, successes, and lessons learned.

METHODS

MDH began investigating EVALI cases in August 2019 and quickly coordinated an agencywide response. This response included activating the incident command system; organizing multidisciplinary teams to perform the epidemiologic investigation; laboratory testing of e-cigarette, or vaping, products (EVPs) and clinical specimens; and collaborating with partners to gather information and develop recommendations.

RESULTS

MDH faced numerous investigational challenges during the outbreak response of EVALI, including the need to gather information on unregulated and illicit substances and their use and collecting information from minors and critically ill people. MDH laboratorians faced methodologic challenges in characterizing EVPs. Despite these challenges, MDH epidemiologists successfully collaborated with the MDH public health laboratory, law enforcement, partners with clinical and toxicology expertise, and local and national public health partners.

PRACTICE IMPLICATIONS

Lessons learned included ensuring the state public health agency has legal authority to conduct noncommunicable disease outbreak investigations and the necessity of cultivating and using internal and external partnerships, specifically with laboratories that can analyze clinical specimens and unknown substances. The lessons learned may be useful to public health agencies responding to similar public health emergencies. To improve preparedness for the next outbreak of EVALI or other noncommunicable diseases, we recommend building and maintaining partnerships with internal and external partners.

Pooled Urine Analysis at a Belgian Music Festival: Trends in Alcohol Consumption and Recreational Drug Use

BACKGROUND

Recreational drug use has become more and more accepted in society. Availability and purity are rising and new psychoactive substances (NPS) are popping up.The aim of this study was to provide objective data on illicit drug use at a Belgian festival in order to report on arising trends. This may provide additional information to help develop preventive strategies.

METHODS

A cross-sectional study took place during a music festival in the summer of 2019, where 43 samples of pooled urine were collected at four different locations and at different moments of the day. Analysis was performed using gas chromatography with a flame ionization detector (GC-FID) to determine ethanol concentrations. Drugs of abuse were quantified using liquid chromatography-tandem mass spectrometry. A qualitative analysis was performed using high-resolution mass spectrometry.

RESULTS

Median ethanol concentration was 0.88g/L. Cocaine, 3,4-methylenedioxymethamphetamine (MDMA), amphetamines, ketamine, and cannabis were detected in almost every sample and often in high concentrations. Furthermore, two NPS were detected and a variety of over-the-counter medication and adulterants were also found.

DISCUSSION

The findings were largely in-line with trends outlined in the European Drug Report. Striking were the relatively high concentrations of MDMA and ketamine and detection of two synthetic cathinones. Two possible adulterants of cocaine were detected, namely flecainide and amlodipine.

CONCLUSION

Music festivals are considered a high-risk setting for alcohol consumption and illicit drug use. Analysis of pooled urine samples at a festival therefore provides a valuable method to evaluate trends and to screen for new substances. Wide-spread use of classical drugs and identification of two NPS were observed during a major international music festival in Belgium. Results need to be interpreted carefully, taking into account the possibilities and limitations of the used techniques and a standardized sampling is required.

E.P.A.S.S: Electroanalytical Pillbox Assessment Sensor System, A Case Study Using Metformin Hydrochloride

Adulteration of medications is an emerging and significant threat to human health and well-being, even though adulterants are still often not considered seriously in clinical or forensic toxicology. Screening of drug adulterations is a major challenge and concern for regulatory authorities worldwide. Metformin hydrochloride, an important drug to treat diabetes, is found to be adulterated worldwide and a major reason to worry about the health and safety procedure. We have demonstrated a first-of-a-kind electrochemical biomedical device utilizing exfoliated graphene oxide (GO)─Nafion-modified customized gold screen-printed electrodes (spiral electrochemical notification-coupled electrode, SENCE), driven by electrochemical adsorptive stripping voltammetry, to identify the trace level adulteration in metformin. The GO-Nafion-SPE interface has been characterized by powder X-ray diffraction, X-ray photoelectron spectroscopy, scanning electron microscopy, energy-dispersive X-ray analysis, and Fourier transform infrared. Custom-made screen-printed SENCEs have been functionalized with GO nanoparticles (transducer) to obtain a fingerprint signal response of metformin using differential pulse voltammetry. A linear calibrated dose response has been obtained with n = 3 repetitions with a low limit of detection of 10 ppm for metformin. We have used the sensing response as a function of adulteration, and it is extensively supported by rigorous statistical analysis along with the help of the machine learning tool. This is a first-of-its-kind IoT-enabled electrochemical sensor and analysis platform that can detect drug adulteration as a low, medium, and high output.

Comparative study of the analysis of seized samples by GC-MS, 1H NMR and FT-IR spectroscopy within a Night-Time Economy (NTE) setting

Rapid analysis of surrendered or seized drug samples provides important intelligence for health (e.g. treatment or harm reduction), and custodial services. Herein, three in-situ techniques, GC-MS, ¹H NMR and FT-IR spectroscopy, with searchable libraries, are used to analyse 318 samples qualitatively, using technique specific library-based searches, obtained over the period 24th - 29th August 2019. 259 samples were identified as consisting of a single component, of which cocaine was the most prevalent (n = 158). Median match scores for all three techniques were ≥ 0.84 and showed agreement except for metformin (n = 1), oxandrolone (identified as vitamin K by IR (n = 4)), diazepam (identified as zolpidem by FT-IR (n = 2)) and 2-Br-4,5-DMPEA (n = 1), a structural isomer of 2C-B identified as a polymer of cellulose (cardboard) by FT-IR. 51 samples were found to consist of two or more components, of which 49 were adulterated cocaine samples (45 binary and 4 tertiary samples). GC-MS identified all components present in the 49 adulterated cocaine samples, whereas IR identified only cocaine in 88 % of cases (adulterant only = 12 %). The breakdown for ¹H NMR spectroscopy was all components identified (51 %), cocaine only (33 %), adulterant only (10 %), cocaine and one adulterant (tertiary mixtures only, 6 %).

Smartphone as a Portable Detector for Thin-Layer Chromatographic Determination of Some Gastrointestinal Tract Drugs

Thin-layer chromatography (TLC) is an effective and simple technique for screening, evaluating, and quantifying low-quality and counterfeit pharmaceutical products. Smartphones have recently been used as accessible, cheap, and portable detectors that can replace more complicated analytical detectors. In this work, we have developed a simple and sensitive TLC method utilizing a smartphone charged-coupled device (CCD) camera not only to verify and quantify some gastrointestinal tract drugs, namely, loperamide hydrochloride (LOP) and bisacodyl (BIS), but also to detect acetaminophen (ACT) as a counterfeit drug. Both drugs (LOP and BIS) were chromatographed separately on a silica gel 60 F₂₅₄ plate as a stationary phase under previously reported chromatographic conditions, using ethyl acetate:methanol:ammonium hydroxide (24:3:1, by volume) and ethyl acetate:methanol:glacial acetic acid (85:10:5, by volume) as developing systems to determine LOP and BIS, respectively. Universal stains, namely, iodine vapors and vanillin, were used to visualize the spots on the TLC plates to get a visual image using the smartphone camera and a spotlight as an illumination source with no need for a UV illumination source. The spot intensity was calculated using a commercially available smartphone application for quantitative analysis of the studied drugs utilizing ″acetaminophen″ as an example of a counterfeit substance. R_f values were calculated using the recorded images and found to be 0.77, 0.79, and 0.74 for LOP, BIS, and ACT, respectively, providing drug identity. Linear calibration curves using the smartphone-TLC method were obtained between the luminance and the corresponding concentrations over the ranges of 2.00-10.00 μg/mL and 1.00-10.00 μg/mL with limits of detection of 0.57 and 0.10 μg/mL for LOP and BIS, respectively. The suggested method was validated according to the International Conference of Harmonization (ICH) guidelines. The method was then successfully applied for the qualitative and quantitative determination of LOP or BIS as an example for gastrointestinal tract drugs in pure form and in their pharmaceutical dosage formulations. The proposed method is considered as a perfect alternative to traditional reported densitometric methods due to its simplicity, easy application, and inexpensiveness. No previously reported methods utilizing smartphones have been published for the determination of the studied drugs. The developed approach is considered the first TLC method using smartphones for the determination of some gastrointestinal tract drugs in their pure form and in pharmaceutical formulations.

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply

Background

Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl’s dramatic increase in the recreational drug supply over the past decade.

Methods

We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes.

Results

PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers.

Conclusion

PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00659-9.

SALDI Substrate-Based FeNi Magnetic Alloy Nanoparticles for Forensic Analysis of Poisons in Human Serum

In this study, FeNi magnetic alloy nanoparticles (MANPs) were employed for the forensic analysis of four poisons—dimethametryn, napropamide, thiodicarb, and strychnine—using surface-assisted laser desorption/ionization mass spectrometry (SALDI-MS). FeNi MANPs were prepared via coprecipitation using two reducing agents, sodium borohydride (NaBH4) and hydrazine monohydrate (N2H4·H2O), to optimize the prepared MANPs and investigate their effect on the performance of SALDI-MS analysis. Thereafter, SALDI-MS analysis was carried out for the detection of three pesticides and a rodenticide. The prepared substrate offered sensitive detection of the targeted analytes with LOD values of 1 ng/mL, 100 pg/mL, 10 ng/mL, and 200 ng/mL for dimethametryn, napropamide, thiodicarb, and strychnine, respectively. The relative standard deviation (%RSD) values were in the range of 2.30–13.97% for the pesticides and 15–23.81% for strychnine, demonstrating the good spot-to-spot reproducibility of the FeNi substrate. Finally, the MANPs were successfully employed in the analysis of poison-spiked blood serum using a minute quantity of the sample with an LOD of 700 ng/mL dimethametryn and napropamide, 800 ng/mL thiodicarb, and 500 ng/mL strychnine. This study has great potential regarding the analysis of several poisons that may be found in human serum, which is significant in cases of self-harm.

Non-contact Detection of Fentanyl by a Field-portable Ion Mobility Spectrometer

Rapid on-site detection of fentanyl is paramount for the safety of law enforcement and other first responders. Due to the opioid epidemic, death by overdose is at an all-time high with fentanyl adulteration as the main assailant. Providing a user-friendly method for the presumptive detection of fentanyl will increase safety for first responders. Ion mobility spectrometry (IMS) provides a quick, affordable, and accurate method for detecting fentanyl. Currently, most methods for detecting fentanyl requires manipulation or handling of the highly potent substance. A recent comparative analysis study on the headspace of fentanyl determined N-phenylpropanamide (NPPA) a target analyte for fentanyl enabling vapor detection. Here, we demonstrate the development of a handheld IMS method for vapor detection of the target analyte for fentanyl. An alarm was programmed into the handheld IMS device for the detection of NPPA. The system was able to accurately detect NPPA in samples of reference-grade fentanyl and diluted reference-grade fentanyl, as well as 3.67 mg of fentanyl from samples confiscated from the U.S. border. Common adulterants and over-the-counter drugs were tested and resulted in a false alarm rate of 0 for substances sampled. The limit of detection was determined to be as low as 5 ng of NPPA. Overall, the development of this user-friendly, non-contact method has considerable promise for near real-time non-contact detection of fentanyl increasing safety of first responders.

Double Suicide Due to the Ingestion of Levamisole-Adulterated Cocaine: Case Report and Review of the Literature

Suicide is a major public health issue and the risk of attempting and committing suicide increases with age. We present the case of an elderly couple who decided to commit suicide together by self-poisoning using levamisole-adulterated cocaine. The choice of committing a double suicide, the method selected (self-poisoning), the drug self-administered (cocaine), and the route of administration (ingestion) are events rarely encountered in the forensic pathology practice, especially not in combination. In this article, we will review the literature regarding the frequency and features of these methods of suicide. An overview of the effects and mechanism of action of levamisole is also provided, highlighting the importance of including this substance and its metabolites in the routine toxicological analyses for cocaine deaths.

Impurities, adulterants and cutting agents in cocaine as potential candidates for retrospective mining of GC-MS data

Cocaine is one of the most widely used illicit drugs worldwide. Cocaine powders seized by the Police may contain numerous other substances besides the drug itself. These can be impurities originating from the coca plant or the production process, or be purposely added to the drug formulation as adulterants and cutting agents. In forensic laboratories, identification of cocaine is routinely done through GC-MS analysis, but other components are often ignored even if the method allows for their detection. Yet, they can provide valuable insight into the history of a seizure and its potential connection to other samples. To explore this idea, an extensive review of common impurities and adulterants encountered in cocaine is presented. Based on their incidence, concentration in the end product and compatibility with GC-MS methods, their overall usefulness as candidates for the statistical investigation of existing forensic data is evaluated. The impurities cis- and trans-cinnamoylcocaine, tropacocaine, norcocaine and N-benzoylnormethylecgonine as well as the adulterants lidocaine, procaine, tetracaine, benzocaine, caffeine, acetylsalicylic acid, phenacetin, ibuprofen, levamisole, hydroxyzine and diltiazem are promising candidates to provide additional forensic intelligence. Future research on optimized routine GC-MS methods, signal reproducibility, comparison, statistics and databases is suggested to facilitate this concept. Ultimately, such an approach may significantly advance the amount of information that is extracted from routine casework data, elucidate developments in the cocaine markets in the past and facilitate Police work in the future. Preliminary assessment of existing data from the forensic laboratory of the Amsterdam Police has been included to show that the detection of the identified target impurities is feasible, and that small adjustments to the analysis method could significantly increase the detectability of these analytes in prospective drug screenings. Forensic intelligence based on retrospective data mining of cocaine containing casework samples may thus be realized with minimal additional laboratory efforts by using already available instrumentation, samples and data.

Tetanus: A Rare Complication of Black Tar Heroin Use

Tetanus is associated with high morbidity and mortality, although this is rarely encountered in high-income countries. We present a case of tetanus in an unvaccinated patient secondary to black tar heroin use that highlights the importance of considering tetanus in appropriate clinical contexts, harm reduction interventions, and universal tetanus vaccination campaigns.

Strychnine poisoning due to traditional Chinese medicine: a case series

Background: Strychnine poisoning is rare but possibly fatal. The most reported sources of strychnine poisoning include rodenticides and adulterated street heroin. Here we report a case series of an unusual cause of strychnine poisoning – Strychnisemen, a herb known as “maqianzi” in traditional Chinese medicine (TCM).

Methods: All cases of strychnine poisoning confirmed by the Hospital Authority Toxicology Reference Laboratory (HATRL, the highest-level clinical toxicology laboratory in Hong Kong) between May 2005 and May 2018 were reviewed.

Results: Twelve cases of strychnine poisoning were recorded, and Strychni semen was the exclusive source. Ten (83%) patients presented with muscle spasms, and four (33%) developed typical conscious convulsions. The poisoning was severe in two (17%) patients, moderate in three (25%) and mild in eight (58%). No case fatality was recorded. Three (25%) patients were TCM practitioners and two (17%) were laymen who bought the herb themselves without a proper prescription.

Conclusion: The practice of TCM is becoming popular in different parts of the world amid the COVID-19 pandemic. The spectrum of clinical features of strychnine poisoning secondary to Strychni semen are similar to those arising from different origins. Eliciting a history of TCM use, apart from exposure to rodenticides and drugs of abuse, may allow timely diagnosis in patients with compatible clinical features. Enhancement of TCM safety could minimize the hazard.

Fast Quantitative LC-MS/MS Determination of Illicit Substances in Solid and Liquid Unknown Seized Samples

Narcotic and psychotropic substances are natural, synthetic, or semisynthetic compounds that are present in both solid and liquid illicit products. The alterations effects on the central nervous system related to their use can be psycholeptic, psychoanaleptic, or psychodiseptic and are able to generate tolerance, addiction, or dependence phenomena, creating social and public order problems. In this scenario, the analytical evaluations that aim to determine these analytes in seized nonbiological samples, and which assume the character of judicial evidence, must meet high analytical requirements of reliability, transparency, and procedures uniformity at a national level. For the first time in the literature, the herein validated method is able to provide the simultaneous quantitative determination of 37 of the most common narcotic substances as well as the most commonly used excipients/adulterants found in seized illicit material. Additionally, the validated method can process both solid and liquid samples maintaining the precision and trueness levels (intraday and interday) in accordance with the U.S. Food and Drug Administration and European Medicines Agency international guidelines (<14.31 and <13.41%, respectively). Furthermore, it provides a simple and fast procedure for sample preparation using the dilute and shoot approach, exploiting the sensitivity and selectivity of the LC-MS/MS instrument configuration used and the signal acquisition in multiple reaction monitoring (MRM) mode (both positive and negative polarization modes).

A Membrane-Modulated Centrifugal Microdevice for Enzyme-Linked Immunosorbent Assay-Based Detection of Illicit and Misused Drugs

Increased opioid use and misuse have imposed large analytical demands across clinical and forensic sectors. Due to the absence of affordable, accurate, and simple on-site tests (e.g., point of interdiction and bedside), analysis is primarily conducted in centralized laboratories via time-consuming, labor-intensive methods. Many healthcare facilities do not have such analytical capabilities and must send samples to commercial laboratories, increasing turnaround time and care costs, as well as delaying public health warnings regarding the emergence of specific substances. Enzyme-linked immunosorbent assays (ELISAs) are used ubiquitously, despite lengthy workflows that require substantial manual intervention. Faster, reliable analytics are desperately needed to mitigate the mortality and morbidity associated with the current substance use epidemic. We describe one such alternative─a portable centrifugal microfluidic ELISA system that supplants repetitive pipetting with rotationally controlled fluidics. Embedded cellulosic membranes act as microvalves, permitting flow only when centrifugally generated hydraulic pressure exceeds their liquid entry pressure. These features enable stepwise reagent introduction, incubation, and removal simply by tuning rotational frequency. We demonstrate the success of this platform through sensitive, specific colorimetric detection of opiates, a subclass of opioids naturally derived from the opium poppy. Objective image analysis eliminated subjectivity in human color perception and permitted reliable detection of opiates in buffer and artificial urine at the ng/μL range. Opiates were clearly differentiated from other drug classes without interference from common adulterants known to cause false positive results in current colorimetric field tests. Eight samples were simultaneously analyzed in under 1 h, a marked reduction from the traditional multiday timeline. This approach could permit rapid, automatable ELISA-based drug detection outside of traditional laboratories by nontechnical personnel.

Purity of street-level cocaine across Denmark from 2006 to 2019: Analysis of seized cocaine

Cocaine-related emergency department admissions are increasing, and cocaine seizures are at an all-time high in Europe. Our aim was to investigate the trends in purity and adulterants over time in cocaine available to cocaine users at street level in Denmark. We used a representative sample of cocaine seized at street level and analyzed by the national departments of forensic medicine between 2006 and 2019 (n = 1460). Latent profile analysis was used to classify the samples based on cocaine, levamisole, and phenacetin content. Low purity cocaine comprised most of the cocaine seizures in early years, but its share began to decline in 2013, and from 2016 to 2019, the high purity profile was dominant. While the total number of samples containing adulterants decreased, levamisole remained a common and dangerous adulterant. The findings underline the need to inform the public, medical doctors, and service providers for people with drug use disorders about the higher potency of street cocaine.

Biosurveillance of Drug Overdoses and Substance Misuse Treated in Selected Emergency Departments in Minnesota, 2017-2020

OBJECTIVES

Increasing knowledge about the toxicology of drug overdose and substance misuse (DOSM) is important in improving our understanding of the epidemic. We describe the Minnesota Drug Overdose and Substance Use Pilot Surveillance Activity, which started collecting data on emergency department (ED) visits attributable to DOSM in 2017, with a focus on the toxicology results of a subset of clinical encounters.

METHODS

From November 1, 2017, through January 30, 2020, we collected near-real-time data on DOSM-related ED encounters. The Minnesota Department of Health Public Health Laboratory tested leftover clinical specimens (blood and/or urine) for the presence of various substances for patients who died, were hospitalized, had an atypical clinical presentation, or were part of a local drug overdose cluster. Testing looked for >250 drugs or their metabolites, including those commonly misused (eg, methamphetamine, cocaine), prescription medications, synthetic cannabinoids and cathinones, and opioids. We describe characteristics of the overall group and a subgroup of clinical encounters with toxicology results.

RESULTS

Specimens submitted from 6 EDs during the study period represented 239 clinical encounters. Methamphetamine was the most frequently detected substance (67.4%) but was suspected in only 45.6% of encounters. At least 1 opioid was detected in 42.5% of encounters but suspected in only 29.7%. Testing also detected potential adulterants and additives (eg, fentanyl, fentanyl analogues, levamisole) and showed frequent patient exposure to substances not reported by patients or suspected by clinicians. Nearly half (44.4%) of clinical encounters had >1 substance detected.

CONCLUSIONS

ED surveillance for DOSM encounters, enhanced by toxicology testing, can provide local situational awareness on overdoses, prevent potential mischaracterization of the true drug overdose epidemic, and inform harm reduction and drug overdose prevention efforts.

Gastrointestinal manifestations of synthetic cannabinoids: a retrospective cohort study

BACKGROUND

Synthetic cannabinoids (SC) are chemical substances which activate cannabinoid receptors similarly to tetrahydrocannabinol, but with a higher efficacy. These substances are used as illicit recreational drugs, often smoked as herbal mixtures. The continuing availability and rapid evolution of SC is an ongoing health risk. The adverse effects of SC are wide ranging, and span from mild behavioral changes to death. Knowledge regarding gastrointestinal (GI) manifestations of SC use is sparse.

METHODS

Single tertiary-care referral medical center retrospective study.

RESULTS

The medical records of patients presented to hospital emergency care due to SC use between January 2014 and February 2018 were retrieved from Hadassah Mount Scopus Hospital's computerized database. The records were reviewed for clinical outcomes and laboratory tests. Fifty-five (55) patients were identified with a hospital presentation due to SC use. Twenty-one (21) out of 55 patients (38%) reported gastrointestinal complaints. The most common complaints were abdominal pain and vomiting. Of those, 28% had recurrent emergency department presentations due to abdominal pain and 66% presented with leukocytosis. Serum lactate was elevated in 66% of patients with GI manifestations. One patient had an abnormal computerized tomography (CT) abdominal angiography scan, which was compatible with intestinal ischemia.

CONCLUSIONS

The clinical spectrum of gastrointestinal manifestations in SC intoxication ranges from mild symptoms, such as abdominal pain and vomiting, to even more severe symptoms suggestive of intestinal ischemia. Clinicians should be aware that abdominal pain and other gastrointestinal complaints can be associated with SC use.

3D-printing for forensic chemistry: voltammetric determination of cocaine on additively manufactured graphene-polylactic acid electrodes

Cocaine is probably one of the most trafficked illicit drugs in the world. For this reason, police forces require fast, selective, and sensitive methods for cocaine detection at crime scenes. Taking benefit of additive manufacturing, we demonstrate that 3D-printed graphene-polylactic acid (G-PLA) electrodes using the affordable fused deposition modelling technique can identify and quantify cocaine in seized drugs. The detection of cocaine based on its electrochemical oxidation on such electrodes was dramatically improved after an electrochemical surface treatment that generates reduced graphene oxide (anodic followed by a cathodic treatment). Square-wave voltammetric determination of cocaine was achieved in the concentration range between 20 and 100 μmol L-1, with a detection limit of 6 μmol L-1, and free from the interference of paracetamol, caffeine, phenacetin, lidocaine, benzocaine and levamisole, which are common adulterants found in seized drugs. The analytical characteristics obtained using 3D-printed G-PLA electrodes were comparable with those of previously reported electrochemical sensors, but presented the inherent advantages of the 3D-printing technology that enables low-cost, reproducible, and large-scale production of such electrodes in remote areas combined with the use of an environmentally-friendly biopolymer.

A cluster of lysergic acid diethylamide (LSD) poisonings following insufflation of a white powder sold as cocaine

OBJECTIVE

Adulteration, substitution or contamination of illicit substances can have clinically significant implications when other illicit substances are included. Such circumstances can present as clusters of poisonings, including severe toxicity and death following exposure to unexpected illicit substances. We report a cluster of laboratory-confirmed lysergic acid diethylamide (LSD) in a powder that was sold as cocaine and used recreationally.

METHODS

The Prescription, Recreational and Illicit Substance Evaluation (PRISE) program established by the New South Wales Ministry of Health includes State-based hospital toxicology services, Poisons Information Centre, Forensic & Analytical Science Service and emergency services to identify clusters of severe and unusual toxicity associated with substance use. PRISE criteria include a known cluster (geographically or situationally related) of people with acute severe toxicity, especially when accompanied by a toxidrome that is inconsistent with the history of exposure. A timely comprehensive drug screen and quantification is performed in eligible cases and the results are related to the clinical features. The need for a public health response is then considered. Four individuals inhaled a white powder that was sold as cocaine and developed severe toxicity that was not consistent with cocaine which prompted transfer to hospital for further management.

RESULTS

LSD was confirmed in four subjects, and the concentrations in 3 of the individuals were 0.04-0.06 mg/L which are among the highest reported in the literature. Common clinical features were hallucinations, agitation, vomiting, sedation, hypertension, and mydriasis. One subject required intubation and admission to the intensive care unit, two required overnight admission, and the fourth was discharged following oral diazepam after observation. No subject suffered persistent injury.

CONCLUSIONS

A close working relationship between pre-hospital emergency services, hospital-based clinical services, public health authorities, and analytical laboratories appears to be advantageous. Favourable clinical outcomes are observed from LSD poisoning despite high exposures with good supportive care.

Electrochemical Fingerprints of Illicit Drugs on Graphene and Multi-Walled Carbon Nanotubes

Illicit drugs use and abuse remains an increasing challenge for worldwide authorities and, therefore, it is important to have accurate methods to detect them in seized samples, biological fluids and wastewaters. They are recently classified as the latest group of emerging pollutants as their consumption increased tremendously in recent years. Nanomaterials have gained much attention over the last decade in the development of sensors for a myriad of applications. The applicability of these nanomaterials, functionalized or not, significantly increases and it is therefore highly suitable for use in the detection of illicit drugs. We have assessed the suitability of various nanoplatforms, such as graphene (GPH), multi-walled carbon nanotubes (MWCNTs), gold nanoparticles (AuNPs) and platinum nanoparticles (PtNPs) for the electrochemical detection of illicit drugs. GPH and MWCNTs were chosen as the most suitable platforms and cocaine, 3,4-methylendioxymethamfetamine (MDMA), 3-methylmethcathinone (MMC) and α-pyrrolidinovalerophenone (PVP) were tested. Due to the hydrophobicity of the nanomaterials-based platforms which led to low signals, two strategies were followed namely, pretreatment of the electrodes in sulfuric acid by cyclic voltammetry and addition of Tween 20 to the detection buffer. Both strategies led to an increase in the oxidation signal of illicit drugs. Binary mixtures of illicit drugs with common adulterants found in street samples were also investigated. The proposed strategies allowed the sensitive detection of illicit drugs in the presence of most adulterants. The suitability of the proposed sensors for the detection of illicit drugs in spiked wastewaters was finally assessed.

Interactions between reinforcement history and drug-primed reinstatement: Studies with MDPV and mixtures of MDPV and caffeine

Many drugs of abuse are mixed with other psychoactive substances (e.g., caffeine) prior to their sale or use. Synthetic cathinones (e.g., 3,4-methylenedioxypyrovalerone [MDPV]) are commonly mixed with caffeine or other cathinones (e.g., 3,4-methylenedioxy-N-methylcathinone [methylone]), and these "bath salts" mixtures (e.g., MDPV + caffeine) can exhibit supra-additive interactions with regard to their reinforcing and discriminative stimulus properties. However, little is known about relapse-related effects of drug mixtures. In these studies, male Sprague-Dawley rats self-administered 0.032 mg/kg/inf MDPV or a mixture of MDPV + caffeine (0.029 + 0.66 mg/kg/inf, respectively) and then underwent multiple rounds of extinction and reinstatement testing to evaluate the influence of reinforcement history and drug-associated stimuli on the effectiveness of saline (drug-paired stimuli alone), MDPV (0.032-1.0 mg/kg), caffeine (1.0-32 mg/kg), and mixtures of MDPV:caffeine (in 3:1, 1:1, and 1:3 ratios, relative to each drug's ED₅₀ ) to reinstate responding. Dose-addition analyses were used to determine the nature of the drug-drug interaction for each mixture. MDPV and caffeine dose-dependently reinstated responding and were equally effective, regardless of reinforcement history. Most fixed ratio mixtures of MDPV + caffeine exhibited supra-additive interactions, reinstating responding to levels greater than was observed with caffeine and/or MDPV alone. Drug-associated stimuli also played a key role in reinstating responding, especially for caffeine. Together, these results demonstrate that the composition of drug mixtures can impact relapse-related effects of drug mixtures, and "bath salts" mixtures (MDPV + caffeine) may be more effective at promoting relapse-related behaviors than the constituents alone. Further research is needed to determine how other polysubstance reinforcement histories can impact relapse-related behaviors.