Variability associated with interpreting drugs within forensic hair analysis: A three-stage interpretation

Delirium in Neurocritical Care: Uncovering Undisclosed Psychotropic Substance and Medication Use and Stress Exposure by Hair Analysis

OBJECTIVE

In intensive care, delirium is frequent, prolongs the stay, increases health care costs, and worsens patient outcome. Several substances and medications as well as stress can impact the risk of delirium; however, assessment of previous exposure to psychotropic agents and stress by self-reports or third-party information is not always reliable. Hair analysis can be used to objectively assess medication and substance use (including chronic alcohol consumption), and allows for the determination of stress-related long-term changes in steroid hormones and endocannabinoids.

METHODS

Consecutive adult patients with acute brain injury admitted to the neurocritical care unit were included. Delirium was diagnosed using the Confusion Assessment Method for the Intensive Care Unit. Liquid chromatography coupled with tandem mass spectrometry was used to investigate psychoactive substances and medications, ethyl glucuronide, steroid hormones, and endocannabinoids in hair samples. Univariable and multivariable analyses were used to reveal any associations with the occurrence of delirium.

RESULTS

Of 50 consecutive patients, 21 (42%) were diagnosed with delirium. Detection of antipsychotics or antidepressants in hair was more frequent in patients with delirium (antidepressants: 43% vs. 14%, p = 0.040; antipsychotics: 29% vs. 0%, p = 0.021). These patients also displayed higher ethyl glucuronide levels (p = 0.049). Anandamide (AEA) concentrations were higher in patients with delirium (p = 0.005), whereas oleoylethanolamide (p = 0.045) and palmitoylethanolamide (PEA) (p = 0.017) concentrations were lower in patients with delirium. Backward stepwise logistic regression analysis revealed antidepressants and AEA/PEA to be independent relevant predictors of delirium.

CONCLUSIONS

Hair analysis provides crucial and otherwise unattainable information regarding chronic stress and the use of psychotropic substances and medications. Undisclosed antidepressant/antipsychotic use or intense chronic alcohol consumption is susceptible to treatment (continuation of medication or provision of low-dose benzodiazepines in case of alcohol). Chronic stress can be evaluated using stress markers and endocannabinoids in hair, potentially allowing for personalized delirium risk stratification and preventive measures.

Outside-in hair contamination by blood containing opiates and opioids

Hair analysis for drugs has become extensively used for forensic investigation in recent years. To best interpret hair drug content in post-mortem conditions, the extent of external contamination by biological fluids, such as blood, must be taken into account to avoid false positive results. The present study evaluated opiates and opioids incorporation into hair from blood containing different concentrations of morphine (MOR), 6-mono-acetyl morphine (6-AM), codeine (COD), dihydrocodeine (DHC), tramadol (TRA), oxycodone (OXY), methadone (MET), 2-ethylidene-1,5-dimethyl-3,3- diphenyl pyrrolidine (EDDP), buprenorphine (BUP) and norbuprenorphine (NBUP). The hair strands contaminated by brief soaking into blood were stored at room temperature (RT) or at 4°C during 6 hours, 1, 3, 7 or 14 days. After decontamination by extensive washing, we show that all opiates and opioids were incorporated into hair within a few hours at RT and 4°C, without significant changes over time. The concentrations of opiates and opioids in hair reached the cut-off levels established by the Society of Hair Testing (SoHT) for therapeutic (MET, COD), or toxic or lethal (all other molecules) blood concentrations. The metabolite to parent drug concentration ratios were determined for NBUP/BUP, MOR/6-AM and EDDP/MET and could be helpful as indicators of blood external contamination.

Evaluation of amphetamines diffusion in hair after contact with amphetamines-containing blood

Amphetamine-type stimulants are the third most widely consumed category of illicit drugs worldwide. Faced with the growing problem of amphetamine-type stimulants, numerous qualitative and quantitative techniques have been developed to detect amphetamine (AMP), methamphetamine (MET), MDMA, MDEA or MDA in biological matrices, including hair. Hair analysis is widely used in forensic medicine, but one of its main drawbacks remains external contamination. In this study, we investigated the possibility of hair contamination through external exposure to blood containing AMP, MET MDMA, MDEA or MDA at 2 ng/mL; 20 ng/mL; 200 ng/mL or 2000 ng/mL after 6 h, 1, 3, 7 or 14 days of contact protected from light at room temperature (RT or 20 °C) or at 4 °C. Dried extracts of hair samples were analyzed by UPLC-MS/MS after extensive washings in several baths of water, methanol and acetone before grounding. At the end of our study, contamination of hair was observed from 6 h of contact with all tested amphetamine-type stimulants. The concentrations found in hair ranged from 3 ± 1 to 1464 ± 10 pg/mg, 5 ± 1 to 5070 ± 160 pg/mg, 3 ± 1 to 1269 ± 60 pg/mg, 4 ± 1 to 1860 ± 113 pg/mg and from 8 ± 1 to 1041 ± 44 pg/mg for AMP, MET, MDMA, MDEA and MDA, respectively. Possibly due to its low polar surface area, MET was the most prone to contaminate. As anticipated, hair contamination was mainly dependent on the concentration of all molecules in the contaminating blood, reaching the SOHT cut-off of 200 pg/mg when amphetamine-type stimulants are at toxic or lethal concentrations in the blood. These observations call for caution in interpreting exposure to these substances in such forensic situations.

Disappearance of codeine, morphine and 6-MAM in hair after cessation of abuse

Research on the determination of drugs of abuse in hair has established that drugs can be detected in hair even long after cessation of use. The purpose of this study was to analyze hair samples from chronic opioid users who were beginning a controlled drug cessation program. The study population (n = 15) is involved in a drug rehabilitation program in Santiago de Compostela, Spain. Over a 6-month period, subjects provided hair samples at 2-month intervals, with the first sample collected on the day they began the program. Codeine, morphine, and 6-MAM were analyzed by GC/MS (LOQ = 0.2 ng/mg). Hair tresses were divided into 1 cm segments and analyzed for all analytes 0-1 cm corresponding to the proximal portion to the scalp Following cessation of opioid use, traces of codeine, morphine, and 6-MAM still remained in the newly growing hair segments for a specified period. After 2 months, still 27 % of the users tested positive, and at 4 months, 20 % were positive but only for 6-MAM. However, after 6 months of abstinence, the results were negative for all analytes.

Hair glucocorticoids are not a historical marker of stress - Exploring the time-scale of corticosterone incorporation into hairs in a rat model

Hair glucocorticoids are increasingly popular biomarkers, used across numerous research fields, and studied species, as a measure of stress. Although they are suggested to be a proxy of the average HPA axis activity spanning a period of weeks or months into the past, this theory has never been tested. In the present study, adrenalectomized rats with no endogenous (adrenal) glucocorticoid production were used to study how circulating glucocorticoid levels would be reflected in the glucocorticoid levels found in hair samples. By dosing the animals daily with high levels of corticosterone for seven days, while sampling hairs before, during, and after treatments, a timeline for glucocorticoid uptake into hairs was constructed. This kinetic profile was compared to two hypothetical models, and the theory that hair glucocorticoids are a record of historical stress had to be rejected. Corticosterone concentrations in hairs were found to increase within three hours of the first injection, the highest concentrations were found on the seventh day of treatments, and the decrease in concentrations post-treatment suggests rapid elimination. We speculate that hair glucocorticoid levels can only be used to characterize a stress-response for a few days following a postulated stressor. An updated model, where glucocorticoids diffuse into, along, and out of hairs needs to be adopted to reconcile the experimentally obtained data. The inescapable consequence of this updated model is that hair glucocorticoids become a marker of - and can only be used to study - recent, or ongoing, stress, as opposed to historical events, weeks or months in the past.

The MPRINT Hub Data, Model, Knowledge and Research Coordination Center: Bridging the gap in maternal-pediatric therapeutics research through data integration and pharmacometrics

Maternal and pediatric populations have historically been considered "therapeutic orphans" due to their limited inclusion in clinical trials. Physiologic changes during pregnancy and lactation and growth and maturation of children alter pharmacokinetics (PK) and pharmacodynamics (PD) of drugs. Precision therapy in these populations requires knowledge of these effects. Efforts to enhance maternal and pediatric participation in clinical studies have increased over the past few decades. However, studies supporting precision therapeutics in these populations are often small and, in isolation, may have limited impact. Integration of data from various studies, for example through physiologically based pharmacokinetic/pharmacodynamic (PBPK/PD) modeling or bioinformatics approaches, can augment the value of data from these studies, and help identify gaps in understanding. To catalyze research in maternal and pediatric precision therapeutics, the Obstetric and Pediatric Pharmacology and Therapeutics Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) established the Maternal and Pediatric Precision in Therapeutics (MPRINT) Hub. Herein, we provide an overview of the status of maternal-pediatric therapeutics research and introduce the Indiana University-Ohio State University MPRINT Hub Data, Model, Knowledge and Research Coordination Center (DMKRCC), which aims to facilitate research in maternal and pediatric precision therapeutics through the integration and assessment of existing knowledge, supporting pharmacometrics and clinical trials design, development of new real-world evidence resources, educational initiatives, and building collaborations among public and private partners, including other NICHD-funded networks. By fostering use of existing data and resources, the DMKRCC will identify critical gaps in knowledge and support efforts to overcome these gaps to enhance maternal-pediatric precision therapeutics.

Amphetamine, methamphetamine, and MDMA in hair samples from a rehabilitation facility: Validation and applicability of HF-LPME-GC-MS

INTRODUCTION

It is known that drug abuse jeopardizes economic and social development. Toxicological analyses can guide prevention and treatment strategies in rehabilitation facilities. The current greatest challenge is finding easily adaptable and less costly sensitive methods that meet the principles of green chemistry. Hair, as a biological matrix, has several advantages, and its ability to detect consumption for longer periods keeping the matrix stable and unaltered stands out. This manuscript addresses the use of a miniaturized technique in an alternative matrix, by making use of a reduced amount of solvents to quantify amphetamines, aiming to guide prevention and treatment strategies in rehabilitation facilities.

METHODS

A Hollow Fiber Liquid-phase Microextraction (HF-LPME) technique for extracting amphetamines from hair samples with Gas Chromatography-Mass Spectrometry (CG-MS) was validated, adapted, and applied to ten samples from patients of a rehabilitation facility.

RESULTS

The technique proved to be sensitive, accurate, precise, and not affected by interference from the biological matrix and the linear range for the analytes was 0.2 to 20 ng mg ^-1. The three analytes were quantified in the samples analyzed. It is worth stressing that the patients were young.

CONCLUSION

The HF-LPME-GC-MS technique complied with the principles of green chemistry, and proved to be a sensitive technique, adaptable to the routine of common laboratories. Validation in the analysis phase with authentic samples, thus, showed that it can be an important tool for preventing and controlling drug addiction.

Evaluation of extraction parameters in authentic hair reference material using statistical design of experiments

Optimal methods for forensic hair analysis are often debated, especially regarding extraction parameters that include incubation time, temperature, and size of extracted hair particles. To assess hair pretreatment parameters for analysis of drugs of abuse, the statistical technique known as Design of Experiments (DoE) is useful. DoE evaluates both the individual roles and the combinatorial associations between multiple variables and overall drug extraction efficiency. Previous reports have focused on incorporated hair reference material (HRM), which is prepared in the lab at a specified drug concentration. In contrast, authentic HRM, which is prepared by diluting hair from drug users with blank hair to achieve specific drug concentrations, is an effective matrix for standardization of forensic hair testing, since the drug is incorporated into the hair matrix via uptake from systemic distribution. In the present study, extraction parameters for authentic HRM samples containing multiple drugs (diazepam, alprazolam, cocaine, methamphetamine, oxycodone, hydrocodone, and morphine) and metabolites (nordiazepam, cocaethylene, norcocaine, hydroxycocaine, and 6-monoacetylmorphine) were optimized based on recovery using a 2³ full factorial DoE matrix. The factors evaluated included extraction solvent volume/sample weight ratio (12.5 or 25 μL/mg), particle size (pulverized or cut into 1 mm snippets), and extraction time (2 or 24 h) using solvent swelling. DoE analysis revealed significant differences in the optimal combinations of extraction parameters for maximum recovery. However, for the majority of drugs and metabolites, the most effective extraction method consisted of pulverizing hair prior to a 2-h extraction with a 12.5 μL/mg extraction solvent volume/sample weight ratio.

Unlocking the potential of forensic traces: Analytical approaches to generate investigative leads

Forensic investigation involves gathering the information necessary to understand the criminal events as well as linking objects or individuals to an item, location or other individual(s) for investigative purposes. For years techniques such as presumptive chemical tests, DNA profiling or fingermark analysis have been of great value to this process. However, these techniques have their limitations, whether it is a lack of confidence in the results obtained due to cross-reactivity, subjectivity and low sensitivity; or because they are dependent on holding reference samples in a pre-existing database. There is currently a need to devise new ways to gather as much information as possible from a single trace, particularly from biological traces commonly encountered in forensic casework. This review outlines the most recent advancements in the forensic analysis of biological fluids, fingermarks and hair. Special emphasis is placed on analytical methods that can expand the information obtained from the trace beyond what is achieved in the usual practices. Special attention is paid to those methods that accurately determine the nature of the sample, as well as how long it has been at the crime scene, along with individualising information regarding the donor source of the trace.

A strange New Year's Eve: triggers in Kleine-Levin syndrome

NONE

Kleine-Levin syndrome is a rare neurological disease of unknown cause beginning typically during adolescence, characterized by remittent-relapsing episodes of severe hypersomnia associated with cognitive and behavioral disturbances. Triggering factors at Kleine-Levin syndrome onset include infection, sleep deprivation, as well as alcohol, drug, and substance intake. A young woman had 6 episodes over 2 years, including hypersomnia, confusion, derealization, cognitive impairment, anxiety, feeling of being scrutinized, anorexia (and sweet craving once) but no hypersexuality. The first episode started after a party where she experienced a complete, 4-hour-long blackout despite moderate alcohol intake. The patient suspected having been poisoned. Twenty-five months after the party, when Kleine-Levin syndrome was eventually diagnosed, her long hair was analyzed and exogenous γ-hydroxybutyrate was found in the tips (corresponding to the party time). This case illustrates the interest of looking for γ-hydroxybutyrate in the hair when Kleine-Levin syndrome starts after a party.