Performance evaluation of on-site oral fluid drug screening devices in normal police procedure in Germany

Probe Electrospray Ionization Tandem Mass Spectrometry for the Detection and Quantification of Benzodiazepines

BACKGROUND

Legally prescribed benzodiazepines (BZDs) and designer BZDs are widely misused and must be determined in multiple contexts (eg, overdose, drug-facilitated sexual assaults, or driving under the influence of drugs). This study aimed to develop a method for measuring serum BZD levels using probe electrospray ionization (PESI) mass spectrometry and an isotope dilution approach.

METHODS

A tandem mass spectrometer equipped with a probe electrospray ionization source in multiple reaction monitoring mode was used. Isotope dilution was applied for quantification using a deuterated internal standard at a fixed concentration for alprazolam, bromazepam, diazepam, nordiazepam, oxazepam, temazepam, zolpidem, and zopiclone. This method included designer BZDs: clonazolam, deschloroetizolam, diclazepam, etizolam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, nifoxipam, and pyrazolam. Sample preparation was done by mixing 10 µL of serum with 500 µL of an ethanol/ammonium formate 0.01 mol/L buffer. Complete validation was performed, and the method was compared with liquid chromatography coupled with mass spectrometry (LC-MS/MS) and immunoassays (IC) by analyzing 40 real samples.

RESULTS

The analysis time for identification and quantification of the 18 molecules was 2.5 minutes. This method was fully validated, and the limits of quantification varied from 5 to 50 mcg/L depending on the molecule. In the 40 real samples, 100% of molecules (n = 89) were detected by both LC-MS/MS and PESI-MS/MS, and regression analysis showed excellent agreement between the 2 methods (r 2 = 0.98). On IC, bromazepam and zolpidem were not detected in 2 and 1 cases, respectively.

CONCLUSIONS

PESI-MS/MS allows serum BZD detection and measurement. Given the isotope dilution approach, a calibration curve was not required, and its performance was similar to that of LC-MS/MS, and its specificity was higher than that of IC.

Detection of Δ9 -tetrahydrocannabinol (THC) in oral fluid using two point-of-collection testing devices following oral administration of a THC and cannabidiol containing oil

Point-of-collection testing (POCT) devices are widely used in roadside and workplace drug testing to identify recent cannabis use by measuring the presence of Δ9 -tetrahydrocannabinol (THC) in oral fluid (OF). However, the performance of POCT devices with oral medicinal cannabis products remains poorly described. In a randomised, double-blinded, crossover trial, adults with insomnia disorder (n = 20) received a single (2 mL) oral dose of oil containing 10 mg THC + 200 mg cannabidiol, or placebo, prior to sleep. Participants were tested with the Securetec DrugWipe® 5S (10 ng/mL THC cut-off) and Dräger DrugTest® 5000 (25 ng/mL THC cut-off) POCT devices at baseline (pre-treatment) and then at 0.5, 10, and 18 h post-treatment. An OF sample, taken at each time point, was also analysed using liquid chromatography-tandem mass spectrometry. Large individual variability in OF THC concentrations was observed 0.5 h post-treatment (range: 0-425 ng/mL; mean (SD) 48.7 (107.5) ng/mL). Both the Securetec DrugWipe® 5S and DrugTest® 5000 demonstrated poor sensitivity to THC at 0.5 h post-treatment (25% and 50%, respectively). At 10 and 18 h post-treatment, all participant OF THC concentrations were below screening cut-offs, and all test results were negative. These findings highlight the relatively poor sensitivity of both devices in detecting recent use of an oral medicinal cannabis product. They also suggest a low probability of obtaining a positive THC result the morning after ('one-off') use. Further research is required to establish the probability of obtaining a positive THC result with regular medicinal cannabis use.

Implementation of the first comprehensive state oral fluid drug testing program for roadside screening and laboratory testing in DUID cases-A 5-year review

Oral fluid (OF) is a valuable specimen for driving under the influence of drugs (DUID) applications. This study demonstrates the implementation of the first comprehensive OF drug testing program in the United States, including approved roadside screening OF devices for law enforcement and validated liquid chromatography-tandem mass spectrometry (LC-MS-MS) confirmation methods. Three roadside OF screening devices were evaluated: the Dräger DrugTest® 5000, Abbott SoToxa®, and Randox Evidence MultiSTAT™. Two qualitative LC-MS-MS confirmation methods were validated per ASB Standard 036. The first method utilized an automated dispersive pipette extraction extraction using Integra and Hamilton STARlet platforms for drugs of abuse. The second method used a liquid-liquid extraction to detect cannabinoids. The prevalence of drugs in blood and OF was monitored over 5 years of casework. Calibration curves were analyzed with each batch to monitor OF concentrations for research purposes. Three roadside OF screening devices were deemed fit for purpose. Devices demonstrated appropriate sensitivity, specificity, positive and negative predictive values, and accuracy above 80% for targeted drugs except for benzodiazepines (DrugTest® 5000) and amphetamine (SoToxa®). The validated LC-MS-MS OF confirmation methods met the National Safety Council-recommended cutoffs for 18/21 (86%) of the targets. Over 5 years of casework, THC and cocaine were detected at a positivity rate of 90% and 97% in OF versus 75% and 44% in blood, respectively. OF:blood ratios exceeded unity for parent drugs. Median concentrations of THC in OF and blood were 31 and 3.5 ng/mL, respectively. OF is a viable alternative or supplemental specimen for DUID investigations. Collecting OF close to the driving event increases the opportunity to identify pharmacologically active substances, and when combined with blood analysis results, an elevated OF:blood ratio provides valuable information for DUID investigation purposes.

Roadside screening tests for cannabis use: A systematic review

As more countries legalize recreational cannabis, roadside screening programs are imperative to detect and deter driving under the influence of cannabis. This systematic review evaluated roadside screening tests for cannabis use. We searched six databases (inception-March 2020) and grey literature sources for primary studies evaluating test characteristics of roadside screening tests for cannabis use compared to laboratory tests for cannabinoids in blood or oral fluid. The synthesis was focused on sensitivity and specificity of delta-9-tetrahydrocannabinol (THC) detection. 101 studies were included. Oral fluid tests were higher in specificity and lower in sensitivity compared to urine tests when evaluated against blood laboratory tests. Oral fluid tests were higher in sensitivity and similar in specificity compared to observational tests when evaluated against blood and oral fluid laboratory tests. Sensitivity was variable among oral fluid tests; two instrumented immunoassays (Draeger DrugTest 5000 [5 ng/mL THC cut-off] and Alere DDS 2 Mobile Test System) appeared to perform best, but definitive conclusions could not be drawn due to imprecise estimates. Specificities were similar. Overall, oral fluid tests showed the most promise for use in roadside screening for blood THC levels over legal limits; their continued development and testing are warranted. Urine tests are generally inadvisable, and observational tests require sensitivity improvements.

Suitability of SoToxa® Oral Fluid Screening Over Time: Re-examination of Drugged Driving in Wisconsin

Drug impaired driver detection is a critical element of traffic safety. However, shifting drug use patterns over time and geography may limit long-term reliability of assay-based screening tools. In this work, we compare qualitative results from the Abbott SoToxa® oral fluid (OF) screening device to Quantisal™ OF and whole blood. Our objective was to examine these three qualitative toxicological approaches, scope applicability of OF collection at the roadside, and compare to a previous analysis of SoToxa® in Wisconsin. OF specimens were screened with the SoToxa® for six drugs or drug classes including amphetamine, benzodiazepines, cocaine, methamphetamine, opioids, and tetrahydrocannabinol (THC). OF and blood specimens were collected from 106 participants. Quantisal™ OF and blood specimens were screened for drugs on ultra-performance liquid chromatography coupled to quadrupole time-of-flight high-resolution mass spectrometry (UPLC-QToF-HRMS) using a data independent acquisition mode. UPLC-QToF-HRMS data was compared to comprehensive spectral libraries and drugs were qualitatively identified. Drug Recognition Expert evaluations were performed, and face sheets submitted for 21 participants in this work. In general, the SoToxa® results were consistent with the combined qualitative results observed in Quantisal™ OF specimens and whole blood specimens. Limitations were uncovered for benzodiazepines, opioids, and THC. The SoToxa® benzodiazepine assay has high cutoff concentrations for diazepam and clonazepam, limiting its sensitivity and positive predictive value when considering these drugs. SoToxa® opioid screening did not detect fentanyl, which is increasingly prevalent among drug users. Finally, ∆9-THC and its major metabolite 11-nor-9-carboxy-∆9-THC are lipophilic, limiting partitioning into oral fluid. Despite these limitations, the SoToxa® instrument may be useful in assisting law enforcement with identifying individuals driving under the influence of drugs and establishing probable cause at roadside for making impaired driving arrests. Furthermore, Quantisal™ OF may be useful as screening specimens due to their ease of collection and results consistent with whole blood.

Evaluation of RapidSTAT®, DrugWipe® 6S, DrugScreen® 5TK and DrugScreen® 7TR for on-site drug testing in German police roadside traffic patrol

Driving under the influence of drugs (DUID) remains a subject of concern worldwide, and its increasing trend is likely to continue. Therefore, there is a constant need for reliable on-site drug tests to identify drugged drivers during roadside patrols. Performance and reliability of four on-site drug tests were evaluated among a high number of DUID cases in Germany. Results of oral fluid (OF) (RapidSTAT®, DrugWipe® 6S) and urine (DrugScreen® 5TK and 7TR) test devices were compared with corresponding serum/plasma results obtained by confirmation analyses in consideration of recommended analytical limits for substances pertaining the annex of the German Road Traffic Code ('Straßenverkehrsgesetz', StVG) s. 24a (2). Overall, the screening devices performed well for individual drugs; however, none of the test devices assessed in this study fulfilled the ROSITA-1 criteria (sensitivity, specificity ≥ 90%, and accuracy ≥ 95%) for all substances. Our data demonstrated that both urine tests showed high sensitivities for most compounds. DrugWipe® 6S (94%) and RapidSTAT® (93%) revealed high sensitivities, especially for amphetamine screening. Poor specificities (< 90%) and accuracies (< 95%) were observed for all tests except for low-prevalent substances (e.g. opiates). For drug testing in OF, Δ⁹ -tetrahydrocannabinol (THC) still seems to be a compound of concern due to poor sensitivity (RapidSTAT®, 77%; DrugWipe® 6S, 85%), although the results indicate improvements compared to previously reported data. Although the obtained data indicate reliable detection for some substances, deployment of trained police officers is inevitable to identify DUID suspects by signs of recent use and recognizing impairment.

Emerging trends in point-of-care sensors for illicit drugs analysis

Consumption of illicit narcotic drugs and fatal or criminal activities under their influence has become an utmost concern worldwide. These drugs influence an individual's feelings, perceptions, and emotions by altering the state of consciousness and thus can result in serious safety breaches at critical workplaces. Point-of-care drug-testing devices have become the need-of-the-hour for many sections such as the law enforcement agencies, the workplaces, etc. for safety and security. This review focuses on the recent progress on various electrochemical and optical nanosensors developed for the analysis of the most common illicit drugs (or their metabolites) such as tetrahydrocannabinol (THC), cocaine (COC), opioids (OPs), amphetamines & methamphetamine, and benzodiazepine (BZDs). The paper also highlights the sensitivity and selectivity of various sensing modalities along with evolving parameters such as real-time monitoring and measurement via a smart user interface. An overall outlook of recent technological advances in point of care (POC) devices and guided insights and directions for future research is presented.

Saliva, a bodily fluid with recognized and potential diagnostic applications

Human whole saliva is a bodily fluid that can be obtained easily by noninvasive techniques. Specimens can be collected by the patient also at home in order to monitor health status and variations of several analytes of clinical interest. The contributions to whole saliva include secretions from salivary glands and, among others, from the gingival crevicular fluid that derives from the epithelial mucosa. Therefore, saliva is currently a relevant diagnostic fluid for many substances, including steroids, nonpeptide hormones, therapeutic drugs, and drugs of abuse. This review at first briefly describes the different contributions to whole saliva. A section illustrates the procedures for the collection, handling, and storage of salivary specimens. Another section describes the present use of whole saliva for diagnostic purposes and its specific utilization for the diagnosis of several local and systemic diseases. The final sections illustrate the future opportunities offered by various not conventional techniques with a focus on the most recent –omic investigations. It describes the various issues that have to be taken into account to avoid false positives and negatives, such as the strength of the experimental plan, the adequacy of the number of samples under study, and the proper choice of controls.

Screening major trauma patients for prevalence of illicit drugs

INTRODUCTION

Australasian emergency departments (ED) routinely test patient alcohol levels following major trauma, but assessment for illicit drugs is uncommon.

METHODS

A prospective cross-sectional study of major motor-vehicle-related trauma patients attending both adult major trauma centres in Victoria, Australia. All eligible patients had point-of-care saliva testing to determine the prevalence of common illicit drugs.

RESULTS

Over 12 months, 1411 patients were screened, 36 refused (2.6%) and 63 were excluded. Of the final 1312 cases included, 173 (13.2%; 95% confidence interval 11.5, 15.1) tested positive to at least one illicit substance, with 133 (76.9%; 69.7, 82.8) positive for meth/amphetamines. One in five had more than one illicit substance detected. Patients testing positive were most frequently in motor vehicles (91.9% vs. 85.6%) and least frequently cyclists (2.3% vs. 4.2%) or pedestrians (5.2% vs. 10.3%), compared to those testing negative. They were younger (mean age 35.4 vs. 43.1 years), more likely to arrive overnight (27.2% vs. 12.1%) or after single vehicle crashes (54.3% vs. 42.3%). Although the initial disposition from ED did not differ, those testing positive were more likely to re-present within 28 days (13.9% vs. 5.4%).

DISCUSSION AND CONCLUSIONS

A high prevalence of potentially illicit substances among patients presenting with suspected major trauma supports the need for urgent preventive strategies. The low rate of patient refusal and large numbers screened by ED staff suggests that point-of care testing for illicit substances in major trauma is acceptable and feasible. This study and ongoing surveillance may be used to inform driver education strategies.

Positivity to Cocaine and/or Benzoylecgonine in Confirmation Analyses for On-Road Tests in Spain

We are using real-life data in order to determine the prevalence of driving with the presence of cocaine and/or benzoylecgonine (BZE), their concentrations, and their use in combination with other drugs. This study assessed data on Spanish drivers with confirmed drug-positive results recorded by the Spanish National Traffic Agency from 2011-2016. Frequencies of positivity for cocaine and/or BZE and concentration of such substances were obtained. Comparisons and univariate and multivariate regression analyses were performed. Drivers who tested positive for cocaine and/or BZE accounted for 48.59% of the total positive results for drugs. In positive cases for both cocaine and BZE, other substances were detected in 81.74%: delta-9-tetrahydrocannabinol (THC) (68.19%), opioids (20.78%) and amphetamine-like substances (16.76%). In the multivariate logistic regression analysis, the frequency of cocaine and/or BZE positive cases decreased with age (OR:0.97) and were less likely among women (OR:0.63). Concentrations (ng/mL) of cocaine (249.30) and BZE (137.90) were higher when both substances were detected together than when detected alone. Positivity to cocaine represented an important proportion among Spanish drivers who tested positive for drugs, and polysubstance use was especially observed in more than 8 out of 10 positive cases for cocaine and/or BZE.

Kinetic profile of N,N-dimethyltryptamine and β-carbolines in saliva and serum after oral administration of ayahuasca in a religious context

Ayahuasca is a beverage obtained from Banisteriopsis caapi plus Psychotria viridis. B. caapi contains the β-carbolines harmine, harmaline, and tetrahydroharmine that are monoamine oxidase inhibitors and P. viridis contains N,N-dimethyltryptamine (DMT) that is responsible for the visionary effects of the beverage. Ayahuasca use is becoming a global phenomenon, and the recreational use of DMT and similar alkaloids has also increased in recent years; such uncontrolled use can lead to severe intoxications. In this investigation, liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to study the kinetics of alkaloids over a 24 h period in saliva and serum of 14 volunteers who consumed ayahuasca twice a month in a religious context. We compared the area under the curve (AUC), maximum concentration (C_max ), time to reach C_max (T_max ), mean residence time (MRT), and half-life (t_1/2 ), as well as the serum/saliva ratios of these parameters. DMT and β-carboline concentrations (C_max ) and AUC were higher in saliva than in serum and the MRT was 1.5-3.0 times higher in serum. A generalized estimation equations (GEEs) model suggested that serum concentrations could be predicted by saliva concentrations, despite large individual variability in the saliva and serum alkaloid concentrations. The possibility of using saliva as a biological matrix to detect DMT, β-carbolines, and their derivatives is very interesting because it allows fast noninvasive sample collection and could be useful for detecting similar alkaloids used recreationally that have considerable potential for intoxication.

Amphetamine-type stimulant use among patients admitted to the emergency department behavioural assessment unit: Screening and referral outcomes

Amphetamine-type stimulant use, including methamphetamine, amphetamine, and 3,4-methylenedioxymethamphetamine, is associated with a range of behavioural symptoms. Screening for amphetamine-type stimulant use among people presenting to the emergency department with behavioural disturbance and referral to treatment has not been evaluated. The objective of this study was to determine the prevalence of amphetamine-type stimulant use among patients admitted to a behavioural assessment unit and report referral outcomes. A prospective observational design was used. Individuals who tested positive or self-reported amphetamine-type stimulant use were referred to the alcohol and other drug clinician. We measured the prevalence of amphetamine-type stimulant use in saliva and by self-report along with rates of referral. The setting was a behavioural assessment unit located within an Australian emergency department. Admitted adults were enrolled from July to December 2017. Those who tested positive or self-reported amphetamine-type stimulant use were provided with harm reduction advice and offered referral. Four hundred and seventy-two tests were performed. Fifteen were excluded due to invalid results or redundant enrolment. Of the 457 individuals, 59% were male, with a mean age of 35 years (SD 13). Fifty-three (11.6%, 95% CI: 8.9-15.0) tested positive for amphetamine-type stimulants. Of those with a negative test, 44 (9.6%, 95% CI: 7.3-12.7) self-reported amphetamine-type stimulant use in the previous 24 hours. The prevalence of amphetamine-type stimulant use was 21.2% (95% CI: 17.7-25.2). Most accepted referral to the alcohol and other drug clinician (85.6%, 95% CI 77.2-91.2). The emergency visit represents a window of opportunity for screening for amphetamine-type stimulant use and initiating referrals.

Recent Progresses in Sensitive Determination of Drugs of Abuse by Capillary Electrophoresis

Background:

Today, “drugs of abuse” pose serious social problems such as many crimes, medical treatment costs, and economic repercussions. Several worldwide clinical laboratories use analytical separation methods to analyze their patient samples for drugs and poisons. In this way, they provide qualitative and quantitative data on the substances in various biological matrices (e.g., urine, plasma or serum, saliva, and breath).

Methods:

An extensive review of the published articles indicates that the use of Capillary Electrophoresis (CE) coupled with sensitivity enhancing methods is a very attractive area of interest in the assay of drugs of abuse.

Results:

This review was prepared to have a comprehensive study on applications of sensitivity enhancing methods on the determination of drugs of abuse especially from 2007 to present. The sample preconcentration approaches almost address all methods from online preconcentration (both electrophoretic and chromatographic-based methods) to offline preconcentration. Furthermore, detection system modification and capillary column fabrications were investigated in order to increase the detection sensitivity of complex samples in CE.

Conclusion:

The present review summarizes the most recent developments in the detection of drugs of abuse using CE. Although CE still has a limitation in sensitive detection, several publications in recent years have proposed valuable methods to overcome this problem.

Electrochemical Sensing of Cannabinoids in Biofluids: A Noninvasive Tool for Drug Detection

Cannabinoid sensing in biofluids provides great insight into the effects of medicinal cannabis on the body. The prevalence of cannabis for pain management and illicit drug use necessitates knowledge translation in cannabinoids. In this Review, we provide an overview of the current detection methods of cannabinoids in bodily fluids emphasizing electrochemical sensing. First, we introduce cannabinoids and discuss the structure and metabolism of Δ⁹-THC and its metabolites in relation to blood, urine, saliva, sweat, and breath. Next, we briefly discuss lab based techniques for cannabinoids in biofluids. While these techniques are highly sensitive and specific, roadside safety requires a quick, portable, and cost-effective sensing method. These needs motivated a comprehensive review of advantages, disadvantages, and future directions for electrochemical sensing of cannabinoids. The literature shows the lowest limit of detection to be 3.3 pg of Δ⁹-THC/mL using electrochemical immunosensors, while electrodes fabricated with low cost methods such as screen-printing and carbon paste can detect as little as 25 and 1.26 ng of Δ⁹-THC/mL, respectively. Future research will include nanomaterial modified working electrodes, for simultaneous sensing of multiple cannabinoids. Additionally, there should be an emphasis on selectivity for cannabinoids in the presence of interfering compounds. Sensors should be fully integrated on biocompatible substrates with control electronics and intelligent components for wearable diagnostics. We hope this Review will prove to be the seminal work in the electrochemical sensing of cannabinoids.

Molecularly Imprinted Nanoparticles Based Sensor for Cocaine Detection

The development of a sensor based on molecularly imprinted polymer nanoparticles (nanoMIPs) and electrochemical impedance spectroscopy (EIS) for the detection of trace levels of cocaine is described in this paper. NanoMIPs for cocaine detection, synthesized using a solid phase, were applied as the sensing element. The nanoMIPs were first characterized by Transmission Electron Microscopy (TEM) and Dynamic Light Scattering and found to be ~148.35 ± 24.69 nm in size, using TEM. The nanoMIPs were then covalently attached to gold screen-printed electrodes and a cocaine direct binding assay was developed and optimized, using EIS as the sensing principle. EIS was recorded at a potential of 0.12 V over the frequency range from 0.1 Hz to 50 kHz, with a modulation voltage of 10 mV. The nanoMIPs sensor was able to detect cocaine in a linear range between 100 pg mL-1 and 50 ng mL-1 (R2 = 0.984; p-value = 0.00001) and with a limit of detection of 0.24 ng mL-1 (0.70 nM). The sensor showed no cross-reactivity toward morphine and a negligible response toward levamisole after optimizing the sensor surface blocking and assay conditions. The developed sensor has the potential to offer a highly sensitive, portable and cost-effective method for cocaine detection.

Benzodiazepines in the oral fluid of Spanish drivers

Background

Driving under the influence of alcohol, illicit drugs and certain medicines is not allowed worldwide. Roadside drug testing is considered an important tool for determining such behavior. In Spain, mandatory roadside oral fluid drug testing is carried out regularly. The aim of this study was to determine the prevalence of benzodiazepines and benzodiazepines in combination with other drugs in drivers, examine benzodiazepine concentrations in drivers, and analyze the association of these factors with age and sex.

Methods

This study assessed data on Spanish drivers with confirmed drug-positive results recorded by the Spanish National Traffic Agency (Dirección General de Tráfico) between 2011 and 2016, accounting for 179,645 tests and 65,244 confirmed drug-positive tests.

Results

Benzodiazepines were confirmed in 4.3% of all positive roadside drug tests. In most of those cases (97.1%), other substances were also detected, particularly cocaine (75.3%) and cannabis (64.0%). The frequency of benzodiazepine-positive drivers (OR, 1.094; 95% CI, 1.088–1.100) increased with age, while the frequency of drivers who tested positive for benzodiazepines in conjunction with other substances, compared with drivers who tested positive for benzodiazepines alone, decreased with age (OR, 0.903; 95% CI, 0.825–0.988). Nordiazepam (54.8%) and alprazolam (46.9%) were the most common benzodiazepines detected.

Conclusion

Concomitant use of benzodiazepines and other psychoactive substances was found to be a common behavior among drivers who tested positive on the road. It is important to raise awareness of all those involved in the consumption of driving-impairing substances (authorities, healthcare providers, patients and their families, etc.): roadside detection of driving-impairing substances is suggested, in addition to promoting the use of fewer driving-impairing medications and the provision of clear information to patients.

Real time detection of amphetamine in oral fluids by MicroNIR/Chemometrics

In this work, a novel coupled approach MicroNIR/Chemometrics based on a miniaturized and portable spectrometer is proposed for the on site detection of amphetamines (AMP) in non pretreated oral fluids. In particular, the coupling of MicroNIR with chemometrics was investigated with the aim of developing a fast and accurate approach able to perform the on-site prediction of AMP abuse. A predictive model to be used in real cases was developed by collecting specimens from volunteers and spiked samples with increasing amounts of AMP were prepared to optimize calibration. Partial Least Square-Discriminant Analysis (PLS-DA) and Partial Least Square regression (PLS) were involved to detect and quantify AMP. Results demonstrated that MicroNIR/Chemometric platform is statistically able to identify AMP abuse in simulated oral fluid samples containing, with the accuracy and sensitivity of the actual proposed official reference methods. The method was checked against false positive and true positive response and results proved to be those required for confirmatory analyses. This method would permit to simplify AMP abuse monitoring for roadside drug testing or workplace surveillance and may be of help at first aid points.

Prevalence of illicit substance use among patients presenting to the emergency department with acute behavioural disturbance: Rapid point-of-care saliva screening

OBJECTIVE

To determine the prevalence of illicit substance use among patients presenting to one ED with acute behavioural disturbance using point-of-care saliva testing.

METHODS

A prospective observational study was conducted. Acute behavioural disturbance was defined as any episode requiring a security response for unarmed threat (Code Grey). The setting was a single ED and tertiary referral centre located in metropolitan Australia. Participants were adults presenting to the ED requiring a Code Grey. Saliva was analysed for meth/amphetamine, cannabis, cocaine and opiates using a rapid point-of-care test. Self-reported drug use was recorded at the time of saliva testing. Data collection occurred between August 2016 and March 2017.

RESULTS

There were 229 valid saliva samples. Participants were, on average, 35 years (range 18-72) and male (168/229; 73%). Forty percent (95% confidence interval 34-47) of samples tested positive, with 20% positive for two or more substances. Meth/amphetamines was detected in 92% of positive samples, 17% of samples tested positive for opiates, 8% for cannabis and 7% for cocaine. Among participants, 19% self-reported current substance use and 20% reported using illicit substances within the past 24 h.

CONCLUSIONS

The prevalence of illicit substance use among this cohort was 40%. Self-reporting was unreliable. Point-of-care saliva testing is feasible. Early identification of harmful drug use may assist clinical decision making in selected or undifferentiated cases and provide an opportunity to implement harm minimisation strategies and make referrals.

MicroNIR/Chemometrics: A new analytical platform for fast and accurate detection of Δ9-Tetrahydrocannabinol (THC) in oral fluids

BACKGROUND

Δ⁹-Tetrahydrocannabinol (THC) is already considered one of the most addictive substances since an increasing number of consumers/abusers of THC and THC based products are observed worldwide. In this work, the capabilities of a novel miniaturized and portable MicroNIR spectrometer were investigated in order to propose a practical and intelligible test allowing the rapid and easy screening of Δ⁹-Tetrahydrocannabinol (THC) oral fluids without any pretreatment.

METHODS

Specimens from volunteers were collected in order to consider any sources of variability in the spectral response and spiked with increasing amount of THC in order to realize predictive models to be used in real cases. Partial Least Square-Discriminant Analysis (PLS-DA) and Partial Least Square regression (PLSr) for the simultaneously detection and quantification of THC, were applied to baseline corrected spectra pre-treated by first derivative transform.

RESULTS

Results demonstrated that MicroNIR/Chemometric platform is statistically able to identify THC abuse in simulated oral fluid samples containing THC from 10 to 100 ng/ml, with a precision and a sensitivity of about 1.51% and 0.1% respectively.

CONCLUSIONS

The coupling MicroNIR/Chemometrics permits to simplify THC abuse monitoring for roadside drug testing or workplace surveillance and provides the rapid interpretation of results, as once the model is assessed, it can be used to process real samples in a "click-on" device.

Detection of Δ9 THC in oral fluid following vaporized cannabis with varied cannabidiol (CBD) content: An evaluation of two point-of-collection testing devices

Point‐of‐collection testing (POCT) for Δ⁹‐tetrahydrocannabinol (THC) in oral fluid is increasingly used to detect driving under the influence of cannabis (DUIC). However, previous studies have questioned the reliability and accuracy of two commonly used POCT devices, the Securetec DrugWipe^® 5 s (DW5s) and Dräger DrugTest^® 5000 (DT5000). In the current placebo controlled, double‐blind, crossover study we used liquid chromatography‐tandem mass spectrometry (LC–MS/MS) to accurately quantify cannabinoid concentrations in the oral fluid of 14 participants at various timepoints (10, 60, 120, and 180 minutes) following vaporization of 125 mg of THC‐dominant (11% THC; <1% CBD), THC/CBD equivalent (11% THC; 11% CBD) and placebo (<1% THC; <1% CBD) cannabis. At each timepoint, oral fluid was also screened using the DW5s (10 ng/mL THC cut‐off) and DT5000 (10 ng/mL THC cut‐off). LC–MS/MS analysis showed peak oral fluid THC concentrations at the 10 minute timepoint with a rapid decline thereafter. This trajectory did not differ with THC dominant and THC/CBD equivalent cannabis. With a 10 ng/mL confirmatory cut‐off, 5% of DW5s test results were false positives and 16% false negatives. For the DT5000, 10% of test results were false positives and 9% false negatives. Neither the DW5s nor the DT5000 demonstrated the recommended >80% sensitivity, specificity and accuracy. Accuracy was lowest at 60 minutes, when THC concentrations were often close to the screening cut‐off (10 ng/mL). POCT devices can be useful tools in detecting recent cannabis use; however, limitations should be noted, and confirmatory LC–MS/MS quantification of results is strongly advisable.

Oral Fluid Drug Testing: Analytical Approaches, Issues and Interpretation of Results

With advances in analytical technology and new research informing result interpretation, oral fluid (OF) testing has gained acceptance over the past decades as an alternative biological matrix for detecting drugs in forensic and clinical settings. OF testing offers simple, rapid, non-invasive, observed specimen collection. This article offers a review of the scientific literature covering analytical methods and interpretation published over the past two decades for amphetamines, cannabis, cocaine, opioids, and benzodiazepines. Several analytical methods have been published for individual drug classes and, increasingly, for multiple drug classes. The method of OF collection can have a significant impact on the resultant drug concentration. Drug concentrations for amphetamines, cannabis, cocaine, opioids, and benzodiazepines are reviewed in the context of the dosing condition and the collection method. Time of last detection is evaluated against several agencies' cutoffs, including the proposed Substance Abuse and Mental Health Services Administration, European Workplace Drug Testing Society and Driving Under the Influence of Drugs, Alcohol and Medicines cutoffs. A significant correlation was frequently observed between matrices (i.e., between OF and plasma or blood concentrations); however, high intra-subject and inter-subject variability precludes prediction of blood concentrations from OF concentrations. This article will assist individuals in understanding the relative merits and limitations of various methods of OF collection, analysis and interpretation.

A review of drug abuse in recently reported cases of driving under the influence of drugs (DUID) in Asia, USA, and Europe

Driving Under the Influence of Drugs (DUID) is considered a serious issue related to the abuse of illegal drugs. DUID cases, including deaths, are being continuously reported in Asia, USA, and Europe. This literature review focuses on illegal drug abuse in recent DUID cases reported in Asia, USA, and Europe. To determine illegal drug abuse in DUID suspects, previous studies collected and analyzed biological samples, such as blood, urine, oral fluids, and hair. In addition, there were forensic autopsies and surveys for investigation of illegal drugs in DUID cases and drivers. In previous studies, ketamine, morphine, methamphetamine (MA), and khat were mainly reported in Asia, whereas amphetamine, benzodiazepines (BZDs), and cannabinoids were mainly reported in USA, and synthetic cannabinoids (SCs), opiates, and cocaine were mainly reported in Europe. Since DUID suspects related to illegal drugs have been frequently reported in Asia, USA, and Europe, there is a need to plan for national monitoring for drivers or motor vehicles to regulate and prevent drug abuse and relevant DUID cases.

"Lab-on-Click" Detection of Illicit Drugs in Oral Fluids by MicroNIR-Chemometrics

A novel, entirely automated MicroNIR-chemometric platform was developed for the "lab-on-click" detection of illicit drugs in nonpretreated oral fluids, and a novel tool for the first-level test is proposed. Calibration of the method was achieved by collecting oral-fluid specimens from volunteers, and chemometric analysis was considered for the development of models for prediction for cocaine, amphetamine, and Δ9-tetrahydrocannabinol. In addition, a comprehensive model was optimized for the simultaneous prediction of positive-negative samples and the specific illicit drug used by abusers in a single "click". The detection ability of the method was checked for true-positive and false-positive outcomes, and results were validated by a GC-MS reference official method. The MicroNIR-chemometric platform provided the simultaneous prediction of the three most frequently abused addictive drugs with the sensitivity and accuracy of the confirmatory analyses, offering the advantages of rapidity and simplicity and demonstrating that it is a promising tool for supporting public-health surveillance.

User experience and operational feasibility of four point-of-collection oral fluid drug-testing devices according to Brazilian traffic agents

OBJECTIVE

Traffic fatalities in Brazil still rank among the highest worldwide, with an overall rate of 23.4 deaths/100,000 inhabitants/year. Although alcohol and drug use play an important role in traffic accidents, national data about their relative influence are scarce. Drug screening is not routinely performed by traffic agents because alcohol is the only substance regularly investigated in roadblocks. Therefore, we aimed to describe the initial traffic agent user experience for 4 handheld point-of-collection oral fluid drug testing devices used in routine roadblocks in Brazil, focusing on usage perceptions in hopes of generalizing this approach for other developing countries.

METHODS

Four different oral fluid collection devices were evaluated: The DDS2, the DOA MultiScreen, the Dräger DrugTest 5000, and the Multi-Drug Multi-Line Twist Screen Device. Fourteen trained traffic agents obtained oral fluid from 164 drivers and performed 37 qualitative evaluations of the devices. Traffic agents filled out a questionnaire focusing on 9 feasibility criteria: Overall simplicity for roadside operation; operational success; saliva sample collection time; sample analysis time; ease of sample preparation and analysis; agreement with observed clinical signs; overall hygiene and safety; sufficient operating instructions; and hygiene of saliva collection. These were weighted based on an expert panel and yielded an overall composite device experience score that ranged from 1 (poor) to 100 (excellent).

RESULTS

Ease of use, operational success, and acceptable collection and analysis time were considered the most important criteria by the expert panel. The results ranged from 27.3 to 88.9% for simplicity of use; 45.5 to 100.0% for operational success; 27.3 to 100% for acceptable collection time; and 36.4 to 100.0% for acceptable analysis time. The final device scores, based on the agents' user experiences, ranked as follows: DOA MultiScreen: 49.3/100; Dräger DrugTest 5000: 82.4/100; Multi-Drug Multi-Line Twist Screen Device: 84.3/100; DDS2: 88.4/100.

CONCLUSION

Based on the selected criteria, 3 of the 4 devices were considered useful by traffic agents in routine roadblock operations. The weighted evaluations suggest that their ease of use (handling, sampling analysis, and reliability), as well as their agreement with findings obtained by other means, defined their utility to traffic agents, although such appraisals must be further analyzed in future studies.

Toxicological oral fluid results among Spanish drivers testing positive on on-site drug controls from 2013 to 2015

BACKGROUND

Driving under the influence of drugs (DUID) increases the risk of serious injury or death in traffic accidents. The aim of this study was to provide information about DUID in Spanish drivers.

METHODS

10,064 oral fluid samples were collected from Spanish drivers that tested positive on the roadside using the Dräger DrugTest 5000 (DDT5000) between 2013 and 2015. Samples were collected using Quantisal^™ and analysed by LC-MS/MS at the Toxicology Laboratory of the Institute of Forensic Science of the University of Santiago de Compostela.

RESULTS

Drivers were mainly young men (85.1% male, 29.7 ± 8.1 years old). In 98.5% of cases, LC-MS/MS results confirmed at least one of the positive results detected on the roadside. Cannabis (82.4%) and cocaine (42.1%) were the most commonly detected drugs. Poly-drug use was observed in 42.7% of drivers, mostly for all illicit drugs (>80%) except for cannabis (42.6%). Illicit drug and single-drug use was more frequent among drivers under 35 years old, and medicines and poly-drug use more common among drivers older than 35 years old. The on-site device performance was calculated using both the DDT5000 cut-offs and the LC-MS/MS method LOQs. Sensitivity (>73% vs >58%), specificity [>94% for all the compounds regardless the cut-offs used, except for cannabis (71%)] and accuracy (>87.5% with both cut-offs) fulfilled the DRUID Project requirements in all cases.

CONCLUSION

LC-MS/MS confirmation result was negative in only 1.5% of the cases. The DUID driver profile was a young man, consuming cannabis or a combination of cannabis and cocaine.

Analytical Methods Used for the Detection and Quantification of Benzodiazepines

The prescription of psychotropic drugs, especially benzodiazepines (BZDs), occupies a preponderant place in the management of mental illnesses. Indeed, the BZDs have been used in different therapeutic areas including insomnia, anxiety, seizure disorders, or general anesthesia. Unfortunately, these drugs are present in the illegal street market, leading to a lot of drug abuse amongst some addicted users, road insecurity, and suicide. Hence, it has become essential to analyze the BZDs drugs in human biological specimens for drug abuse in forensic sciences. The present review provides a summary of sample preparation techniques (solid-phase extraction and Liquid-liquid phase extraction) and the methods for the detection and quantification of BZDs molecules in the commonly used biological specimens over the ten last years which may potentially lead to better and accurate evaluation of the physiological state of a given person. The commonly used methods for the detection and quantification of BZDs include nuclear magnetic resonance (NMR), chromatography (GC-MS, HPLC, and TLC), immunoassay (ELISA, RIA, LFA, CEDEA, FPIA, and KIMS), and electroanalytical methods (voltammetry and potentiometry).

Challenges in studying statewide pedestrian injuries and drug involvement

BACKGROUND

Increasing U.S. rates of pedestrian injuries could be attributable in part to changing policies and attitudes towards drugs and associated increases in use, yet drug use has not been investigated widely as a risk factor for pedestrian injury. This study details challenges to investigating drug-involved pedestrian crashes using existing surveillance systems.

METHODS

Using California police reports from 2004 to 2016, we performed simple linear regression with the proportion of data that was missing by year for drug and alcohol use as the outcome of interest. We also explored differences in the relative proportion of missing data across sex, race, and age groups through simple logistic regression. Finally, we compared missing data for alcohol and drug use indicators for pedestrians and drivers.

RESULTS

From 2004 to 2016, 182,278 pedestrians were involved in crashes across California. Only 1.22% (n = 2219) of records indicated drug use, and 98% had missing data for drug use; the proportion of missing data did not change over time (b = - 0.040, p = 0.145, 95% CI = (- 0.095, 0.016)). The proportion of missing values for alcohol use increased each year (b = 0.49, 95% CI = (0.26, 0.72), p = 0.001). Driver drug and alcohol use indictors showed similar data missingness, and missing data did not show significant variation over time. Hispanics were more likely to have missing data for drug use compared to Whites (OR = 0.61, p < 0.001, 95% CI = (0.56, 0.67)), and Blacks were more likely to have missing data for alcohol use compared to Whites (OR = 0.87, p < 0.0001, 95% CI = (0.84, 0.91)).

CONCLUSIONS

Drug use may be a key contributing factor to pedestrian injury, but drug use remains consistently and largely unmeasured in existing surveillance systems. Without better collection of drug and alcohol data, monitoring trends in drug-involved pedestrian injury will not be feasible.

Evaluation of Dräger DrugTest 5000 in a Naturalistic Setting

Reliable field testing devices for psychoactive drugs would be useful tools for the police for detecting drug-impaired drivers. The Norwegian Mobile Police Service (NMPS) started using Dräger DrugTest 5000 (DDT5000) in 2015 as an on-site screening instrument for drugs in samples of oral fluid. The aim of this study was to compare the results of field testing of DDT5000 with drug findings in blood and oral fluid samples taken from drivers suspected for driving under the influence of drugs (DUID). In total, 369 drivers were included in this field testing; blood samples were obtained from all of them, while oral fluid samples were collected with the Intercept device from 301 of them. The median time from field testing with DDT5000 and collection of blood and oral fluid samples was 50 min. The proportions of false positive results with DDT5000 compared to findings in blood samples above the Norwegian legal per se limits were for cannabis 14.5%, amphetamine 23.2%, methamphetamine 38.4%, cocaine 87.1%, opiates 65.9% and benzodiazepines 36.4%. The proportions of false negatives were for cannabis 13.4%, amphetamine 4.9%, methamphetamine 6.1%, cocaine 0.0%, opiates 0.0% and benzodiazepines 18.8%. Among drivers who had drug concentrations above the legal limits in blood, the proportion who tested positive using DDT5000 was 82.9% for THC, 90.8% for amphetamine, 75.7% for methamphetamine, 100.0% for cocaine, 100.0% for opiates and 37.2% for benzodiazepines. In cases with false-positive DDT5000 results compared to blood, traces of drugs were most often found in oral fluid. The DDT5000 did not absolutely correctly identify DUID offenders due to fairly large proportions of false-positive or false-negative results compared to drug concentrations in blood. The police reported that DDT5000 was still a valuable tool in identifying possible DUID offenders, resulting in more than doubling the number of apprehended DUID offenders.

In Situ Determination of Illegal Drugs in Oral Fluid by Portable Capillary Electrophoresis with Deep UV Excited Fluorescence Detection

The present study demonstrates the potential of a portable capillary electrophoresis (CE) instrument, coupled to deep UV fluorescence detector (FD) with a 230-255 nm excitation wavelength range, for the determination of the abuse of illegal drugs in oral fluids in situ. CE was introduced in this study due its exceptional power of separation and resolution, short analysis time, and ability for miniaturization for on-site assessment of different substances. The deep UV fluorescence detector was equipped with five interchangeable emission filters, in the emission wavelength range from 278 to 600 nm, and was successfully employed for determination of natively fluorescing illegal drugs, such as cocaine, cocaethylene, 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxeamphetamine (MDA), 3,4-methylenedioxy- N-ethylamphetamine (MDEA), para-methoxyamphetamine (PMA), para-methoxy- N-methylamphetamine (PMMA), amphetamine (AMP), methamphetamine (METH), tetrahydrocannabinol (THC) and cannabidiol (CBD). The developed FD showed impressive sensitivity. The instrumental detection limit was 0.5 μg/L for MDMA. It also showed broad linearity, up to 50 mg/L for MDMA. The noise CV% was 1.1% for an empty capillary and 0.6% for a capillary filled with acetonitrile. The portable CE-FD with developed electrophoretic methodologies was successfully utilized for the determination of illegal abuse of drugs during "Weekend" 2016 and 2017 Music Festivals (Estonia). Moreover, CE-FD can be employed for detection of other natively fluorescing compounds in the proposed range (e.g., for different phenolic compounds, BTEX, naphthalene derivatives, and others), significantly widening the applicability of developed CE-FD instrument.

Driving under the influence of cocaine: Quantitative determination of basic drugs in oral fluid obtained during roadside controls and a controlled study with cocaine users

Using the Belgian Drugs and Driving procedure, 36% of the cocaine-positive oral fluid (OF) screening results were not confirmed in plasma. This study investigates the impact of the choice of screening devices and confirmation matrix on the detection of cocaine use. An ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method quantifying cocaine, benzoylecgonine (BZE), and other basic drugs in OF was developed and validated. This method monitored OF samples obtained either from a roadside (n = 12) or a double-blind controlled study with cocaine users (n = 10) who were given either a capsule containing 300 mg of cocaine-HCl or a placebo. The OF data were compared to plasma concentrations to obtain concentration-time profiles. In addition, the sensitivity and accuracy of the Drugwipe5S® was assessed. A significant difference between the OF volume collected at baseline/placebo (median 0.93 mL [range 0.43-1.92 mL]) or after cocaine-HCL intake (0.79 mL [0.30-1.21 mL]) was observed. The median OF/Plasma at the 3 collection time points were 10.7, 13.8, 6.7 for cocaine and 0.8, 1.7, 0.8 for BZE, respectively. The Drugwipe5S® detected cocaine use until at least 4 hours after intake. When applying the Belgian legal confirmation decision limit of 10 ng/mL in OF, an accuracy of 75%-98% was observed, depending on the study setting. Cocaine concentrations in OF were much higher and were detected longer as compared to plasma, when applying the same decision limit. From a toxicological viewpoint, the longer detection window with the higher sensitivity of Cocaine and BZE is beneficial to detect drivers in the crash/fatigue phase.

Correlation between Blood and Oral Fluid Psychoactive Drug Concentrations and Cognitive Impairment in Driving under the Influence of Drugs

BACKGROUND

The effects of drugs on driving performance should be checked with drug concentration in the brain and at the same time with the evaluation of both the behavioural and neurophysiological effects. The best accessible indicator of this information is the concentration of the drug and/or metabolites in blood and, to a certain extent, oral fluid. We sought to review international studies on correlation between blood and oral fluid drug concentrations, neurological correlates and cognitive impairment in driving under the influence of drugs.

METHODS

Relevant scientific articles were identified from PubMed, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE up to April 2017.

RESULTS

Up to 2010, no epidemiological studies were available on this matter and International scientists suggested that even minimal amounts of parent drugs in blood and oral fluid could affect driving impairment. More recently, epidemiological data, systematic reviews and meta-analysis on drugged drivers allowed the suggestion of impairment concentration limits for the most common illicit drugs. These values were obtained comparing driving disability induced by psychotropic drugs with that of established blood alcohol limits. Differently from ethyl alcohol where both detection methods and concentration limits have been well established even with inhomogeneity of ranges within different countries, in case of drugs of abuse no official cut-offs have yet been established, nor any standardized analytical protocols.

CONCLUSION

Multiple aspects of driving performance can be differently affected by illicit drugs, and even if for few of them some dose/concentration dependent impairment has been reported, a wider knowledge on concentration/impairment relationship is still missing.

Oral Fluid Testing for Cocaine: Analytical Evaluation of Two Point-of-Collection Drug Screening Devices

The use of point-of-collection testing (POCT) devices for drugs of abuse in oral fluid (OF) is an advantageous tool that has been used for different purposes-particularly traffic enforcement. However, even with the widespread report of cocaine consumption, the reliability of POCT devices has been reported in different magnitudes. This study evaluated the reliability of two POCT devices for the detection of cocaine in OF samples of 110 cocaine users: (i) the DDS2™ (cutoff = 30 ng/mL) and (ii) the Multi-Drugs Multi-Line-Twist Screen Test Device™ (MDML) (cutoff = 20 ng/mL). Results of the screening tests were compared with a Liquid Chromatography-Mass Spectrometry (LC-MS) assay. Sensitivity, specificity and accuracy of DDS2™ were 100, 77.77 and 80% when compared with LC-MS with a cutoff of 30 ng/mL, and 88.89, 89.15 and 89.09% with a cutoff of 10 ng/mL. The MDML™ device achieved sensitivity, specificity and accuracy of 100, 65.6 and 70.9% when compared with LC-MS with a cutoff of 20 ng/mL, and 92.6, 71.1 and 76.6% with a cutoff of 10 ng/mL. When compared with a 10 ng/mL cutoff, the DDS2™ achieved reliability parameters higher than 80%. On the other hand, the MDML™ device did not achieve the minimal recommendation of 80% for all parameters at the same time. Taking into consideration the reliability results showed here, the authors believe that the use of these POCT devices seems to be suitable for cocaine detection in forensic tests only if all positive specimens are further confirmed by a validated method.

Saliva: a reliable sample matrix in bioanalytics

Saliva is gaining increasing attention as a bioanalytical sample matrix. Mostly because of the easy and noninvasive collection, it is not only beneficial in endocrinological and behavioral science, but also in pediatrics. Saliva also has the advantage of being the only body fluid which can be collected even during physical exercise, for example, during sportive activities, and there are physiological characteristics that make it superior to serum/plasma or urine for specific scientific questions. This review provides an insight into the physiology of saliva formation, explaining how certain compounds enter this bodily fluid, and gives advice for collection, storage and analytical methods. Finally, it presents a number of reliable and proven applications for saliva analysis from scientific fields including endocrinology, sports medicine, forensics and immunology.

Reliability of point-of-collection testing devices for drugs of abuse in oral fluid: A systematic review and meta-analysis

Point-of-collection testing (POCT) devices for drugs of abuse are used to screen for the presence of psychoactive substances (PAS) in different types of settings and environments. However, these quick and advantageous tools also present disadvantages, including low-reliability measures in comparison to chromatographic assays. Therefore, this article presents a systematic review and meta-analysis of studies evaluating the reliability of measurements of PAS detection in oral fluid using POCT devices. The reliability measures for detection of the five most important drug classes - cocaine, amphetamines, benzodiazepines, cannabinoids and opioids, are reported. The article also presents a subgroup analysis considering the reliability estimates for the different POCT devices that were evaluated by the studies contemplated in the review. A discussion considering the strengths and limitations of POCT techniques was performed in order to guide policymakers, traffic agents and other professionals who also conduct such tests. The use of POCT devices often involves legal and moral aspects of the subjects tested, which demands critical evaluation of these devices before they are implemented in different settings.

Cannabis Edibles: Blood and Oral Fluid Cannabinoid Pharmacokinetics and Evaluation of Oral Fluid Screening Devices for Predicting Δ9-Tetrahydrocannabinol in Blood and Oral Fluid following Cannabis Brownie Administration

BACKGROUND

Roadside oral fluid (OF) Δ9-tetrahydrocannabinol (THC) detection indicates recent cannabis intake. OF and blood THC pharmacokinetic data are limited and there are no on-site OF screening performance evaluations after controlled edible cannabis.

CONTENT

We reviewed OF and blood cannabinoid pharmacokinetics and performance evaluations of the Draeger DrugTest®5000 (DT5000) and Alere™ DDS®2 (DDS2) on-site OF screening devices. We also present data from a controlled oral cannabis administration session.

SUMMARY

OF THC maximum concentrations (Cmax) were similar in frequent as compared to occasional smokers, while blood THC Cmax were higher in frequent [mean (range) 17.7 (8.0–36.1) μg/L] smokers compared to occasional [8.2 (3.2–14.3) μg/L] smokers. Minor cannabinoids Δ9-tetrahydrocannabivarin and cannabigerol were never detected in blood, and not in OF by 5 or 8 h, respectively, with 0.3 μg/L cutoffs. Recommended performance (analytical sensitivity, specificity, and efficiency) criteria for screening devices of ≥80% are difficult to meet when maximizing true positive (TP) results with confirmation cutoffs below the screening cutoff. TPs were greatest with OF confirmation cutoffs of THC ≥1 and ≥2 μg/L, but analytical sensitivities were &lt;80% due to false negative tests arising from confirmation cutoffs below the DT5000 and DDS2 screening cutoffs; all criteria were &gt;80% with an OF THC ≥5 μg/L cutoff. Performance criteria also were &gt;80% with a blood THC ≥5 μg/L confirmation cutoff; however, positive OF screening results might not confirm due to the time required to collect blood after a crash or police stop. OF confirmation is recommended for roadside OF screening.

ClinicalTrials.gov identification number: NCT02177513

Long-term stability of cannabinoids in oral fluid after controlled cannabis administration

Cannabinoid stability in oral fluid (OF) is important for assuring accurate results since OF has become a valid alternative matrix of choice for drug testing. We previously published OF cannabinoid stability studies using Quantisal™, Oral-Eze®, and StatSure™ devices stored at room temperature for 1 week, 4 °C for up to 4 weeks, and at -20 °C up to 24 weeks. Extending refrigerated stability up to 3 months would be helpful for clinical and forensic testing, for re-analysis of OF samples and for batching research analyses. Individual authentic OF pools were prepared after controlled smoking of a 6.9% ∆⁹ -tetrahydracannabinol cannabis cigarette; the Quantisal™ device was utilized for OF collection. Fifteen healthy volunteers participated in the Institutional Review Board-approved study. Stability for THC, 11-nor-9-carboxy-THC (THCCOOH), ∆⁹ -tetrahydrocannabivarin (THCV), cannabidiol (CBD), and cannabigerol (CBG) were determined after storage at 4 °C for 1, 2, and 3 months. Results within ±20% of baseline concentrations were considered stable. All analytes were stable for up to 2 months at 4 °C for all participants with positive baseline concentrations. Baseline concentrations were highly variable. In total, THC, THCCOOH, THCV, CBD, and CBG were stable for 3 months at 4 °C for pooled positive specimens from 14 of 15, 8 of 9, 7 of 8, 8 of 9, and 9 of 10 participants, respectively. In conclusion, Quantisal™-collected OF specimens should be stored at 4 °C for no more than two months to assure accurate THC, THCCOOH, THCV, CBD, and CBG quantitative results; only one participant's OF was unstable at three months. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Quantitative determination of methamphetamine in oral fluid by liquid-liquid extraction and gas chromatography/mass spectrometry

Methamphetamine abuse is one of the most medical and social problems many countries face. In spite of the ban on the use of methamphetamine, it is widely available in Iran's drug black market. There are many analytical methods for the detection of methamphetamine in biological specimen. Oral fluid has become a popular specimen to test for the presence of methamphetamine. The purpose of the present study was to develop a method for the extraction and detection of methamphetamine in oral fluid samples using liquid-liquid extraction (LLE) and gas chromatography/mass spectrometry (GC/MS) methods. An analytical study was designed in that blank and 50 authentic oral fluid samples were collected to be first extracted by LLE and subsequently analysed by GC/MS. The method was fully validated and showed an excellent intra- and inter-assay precision (reflex sympathetic dystrophy ˂ 10%) for external quality control samples. Recovery with LLE methods was 96%. Limit of detection and limit of quantitation were 5 and 15 ng/mL, respectively. The method showed high selectivity, no additional peak due to interfering substances in samples was observed. The introduced method was sensitive, accurate and precise enough for the extraction of methamphetamine from oral fluid samples in forensic toxicology laboratories.

Techniques and technologies for the bioanalysis of Sativex®, metabolites and related compounds

Sativex® is an oromucosal spray indicated for the treatment of moderate-to-severe spasticity in multiple sclerosis and is also an effective analgesic for advanced cancer patients. Sativex contains Δ9-tetrahydrocannabinol (THC) and cannabidiol in an approximately 1:1 ratio. The increasing prevalence of medicinal cannabis products highlights the importance of reliable bioanalysis and re-evaluation of the interpretation of positive test results for THC, as legal implications may arise in workplace, roadside and sports drug testing situations. This article summarizes published research on the bioanalysis of THC and cannabidiol, with particular focus on Sativex. Common screening and confirmatory testing of blood, urine, oral fluid and hair samples are outlined. Correlations between matrices and current analytical pitfalls are also addressed.

Oral fluid drug analysis in the age of new psychoactive substances

Oral fluid has become an important matrix for drugs of abuse analysis. These days the applicability is challenged by the fact that an increasing number of new psychoactive drugs are coming on the market. Synthetic cannabinoids and synthetic cathinones have been the main drug classes, but the diversity is increasing and other drugs like piperazines, phenethylamines, tryptamines, designer opioids and designer benzodiazepines are becoming more prevalent. Many of the substances are very potent, and low doses ingested will lead to low concentrations in biological media, including oral fluid. This review will highlight the phenomenon of new psychoactive substances and review methods for oral fluid drug testing analysis using on-site tests, immunoassays and chromatographic methods.

Cocaine and benzoylecgonine oral fluid on-site screening and confirmation

Accurate on-site devices to screen for drug intake are critical for establishing whether an individual is driving under the influence of drugs (DUID); however, on-site oral fluid (OF) cocaine device performance is variable. We evaluated the performance of a newly developed benzoylecgonine (BE) test-strip for the Draeger® DrugTest 5000 device (20 µg/L cut-off) with equivalent cross reactivity for cocaine and BE. Ten cocaine users provided OF, collected with the Draeger cassette and Oral-Eze® and StatSure Saliva Sampler(TM) devices, up to 69 h following 25 mg intravenous cocaine administration. All screening results were confirmed by a validated two-dimensional-gas chromatography-mass spectrometry (2D-GC-MS) method for cocaine and/or BE. Cocaine test-strip median Tlast for screening only results was 6.5 h, and 6.5 h with Oral-Eze® and 4 h for StatSure OF confirmation for cocaine and/or BE at 1, 8, and 10 µg/L; sensitivity, specificity, and efficiency ranged from 85.5 to 100% and 83.3 to 100% for cocaine only confirmation at 8 and 10 µg/L. For the BE test-strip, median Tlast was 12.5 h for screening only and confirmation for cocaine and/or BE at all three cut-offs; sensitivity, specificity, and efficiency ranged from 85.5 to 97.5% and 78.4 to 97.4% with cocaine and/or BE confirmation at 8 and 10 µg/L cut-offs, respectively. The Draeger cocaine test-strip with cocaine only confirmation offers a useful option for monitoring the acute intoxication phase of DUID; additionally the BE test-strip with cocaine and/or BE confirmation increases the length of detection of cocaine intake for workplace drug testing, drug court, parole, pain management, drug treatment programs and both the acute cocaine intoxication and cocaine crash/fatigue phase of DUID. Copyright © 2016 John Wiley & Sons, Ltd.