Detection of ketamine and its metabolites in urine by ultra high pressure liquid chromatography–tandem mass spectrometry

The metabolic clock of ketamine abuse in rats by a machine learning model

Ketamine has recently become an anesthetic drug used in human and veterinary clinical medicine for illicit abuse worldwide, but the detection of illicit abuse and inference of time intervals following ketamine abuse are challenging issues in forensic toxicological investigations. Here, we developed methods to estimate time intervals since ketamine use is based on significant metabolite changes in rat serum over time after a single intraperitoneal injection of ketamine, and global metabolomics was quantified by ultra-performance liquid chromatography-quadrupole-time-of-flight mass spectrometry (UPLC-Q-TOF-MS). Thirty-five rats were treated with saline (control) or ketamine at 3 doses (30, 60, and 90 mg/kg), and the serum was collected at 21 time points (0 h to 29 d). Time-dependent rather than dose-dependent features were observed. Thirty-nine potential biomarkers were identified, including ketamine and its metabolites, lipids, serotonin and other molecules, which were used for building a random forest model to estimate time intervals up to 29 days after ketamine treatment. The accuracy of the model was 85.37% in the cross-validation set and 58.33% in the validation set. This study provides further understanding of the time-dependent changes in metabolites induced by ketamine abuse.

Acute Dissociation and Ketamine's Antidepressant and Anti-Suicidal Ideation Effects in a Midazolam-Controlled Trial

OBJECTIVE

We sought to explore relationships of acute dissociative effects of intravenous ketamine with change in depression and suicidal ideation and with plasma metabolite levels in a randomized, midazolam-controlled trial.

METHODS

Data from a completed trial in suicidal, depressed participants (n = 40) randomly assigned to ketamine was used to examine relationships between ketamine treatment-emergent dissociative and psychotomimetic symptoms with pre/post-infusion changes in suicidal ideation and depression severity. Nonparametric correlational statistics were used. These methods were also used to explore associations between dissociative or psychotomimetic symptoms and blood levels of ketamine and metabolites in a subset of participants (n = 28) who provided blood samples immediately post-infusion.

RESULTS

Neither acute dissociative nor psychotomimetic effects of ketamine were associated with changes in suicidal ideation or depressive symptoms from pre- to post-infusion. Norketamine had a trend-level, moderate inverse correlation with dissociative symptoms on Day 1 post-injection (P  = .064; P =.013 removing 1 outlier). Dehydronorketamine correlated with Clinician-Administered Dissociative States Scale scores at 40 minutes (P = .034), 230 minutes (P = .014), and Day 1 (P = .012).

CONCLUSION

We did not find evidence that ketamine's acute, transient dissociative, or psychotomimetic effects are associated with its antidepressant or anti-suicidal ideation actions. The correlation of higher plasma norketamine with lower dissociative symptoms on Day 1 post-treatment suggests dissociation may be more an effect of the parent drug.

Design and development of a lanthanide-labeled immunochromatographic strip for simultaneous detection of morphine, methamphetamine and ketamine in hair

Colloidal gold immunoassay is the most widely used method in the field of drug detection. However, this method often has poor quantitative identification ability and low analytical sensitivity, which is not suitable for the analysis of hair poisoning ingredients. In order to solve these limitations, we developed an immunochromatographic test strip for simultaneously screening multiple drugs in this study. This hand-held test strip used fluorescent nanoparticles loaded with lanthanide chelates as the signal carrier of fluorescence reading, and conducted quantitative testing of various drugs based on the competitive immune reaction between the analyte and antigen. Under the optimal conditions, the competition curves of morphine (MOP), methamphetamine (MET) and ketamine (KET) were obtained on a single band. The detection limit (LOD) of this analytical method was 100-1000 times lower than that of colloidal gold test strips. The detection limits of MOP, MET and KET were 0.06 ng mL-1, 0.1 ng mL-1 and 1.0 ng mL-1, respectively. No cross-reaction was observed when morphine, methamphetamine and ketamine were tested simultaneously with this method. And 184 hair samples were tested simultaneously, and the detected amount was very close to the results of LC-MS. The immunochromatographic strip showed good stability in repeated tests, and the coefficient of variation was less than 15%. Fluorescence immunochromatography strips and handheld strip readers have the characteristics of portability, speed, ease of operation and high sensitivity, and may become powerful tools for screening drug abuse in hair in forensic medicine.

Determination of ketamine using melamine-modified gold nanoparticles

Ketamine is used in medicine because of its anaesthetic and antidepressant effects at low doses. Unfortunately, due to its narcotic effect when used at high doses, its abuse among young people is increasing. It is also one of the most common drugs used in rape. Therefore, there is a need for fast and inexpensive tests that can be performed on-site. With the advancement of nanotechnology, nanoparticle-based approaches have found their place in selective analyses as in many fields. In the developed method, firstly gold nanoparticles were modified with melamine (AuNPs@Mel). Under optimized conditions, hydrogen bonds formed between ketamine and AuNPs@Mel cause the red colour of AuNPs@Mel to shift to blue-purple (i.e. aggregation-induced surface plasmon absorption shift). The association between absorbance and concentration produced a calibration line (curve) having a linearity correlation coefficient of 0.9981 for ketamine concentrations ranging from 4.76 to 47.6 mg L-1. The detection limit of the proposed method was 1.5 mg L-1 and the RSD (relative standard deviation) values of concentrations were changed ranging from 5.2% to 8.2%. The intra-assay and inter-assay measurements using the suggested method resulted in coefficients of variation (CVs) of 5.7% and 8.5%, respectively. Scan transmission electron microscopy (STEM), UV-vis spectrophotometry and FTIR spectroscopy were used to characterize the synthesized and modified AuNPs. Additionally, the procedure was successfully carried out with some interference materials and a real sample of fetal bovine serum. Lastly, using the Student t-test and F tests, the suggested technique was compared to and confirmed against an LC-MS/MS procedure previously published.

The clinical toxicology of ketamine

INTRODUCTION

Ketamine is a pharmaceutical drug possessing both analgesic and anaesthetic properties. As an anaesthetic, it induces anaesthesia by producing analgesia with a state of altered consciousness while maintaining airway tone, respiratory drive, and hemodynamic stability. At lower doses, it has psychoactive properties and has gained popularity as a recreational drug.

OBJECTIVES

To review the epidemiology, mechanisms of toxicity, pharmacokinetics, clinical features, diagnosis and management of ketamine toxicity.

METHODS

Both OVID MEDLINE (January 1950-April 2023) and Web of Science (1900-April 2023) databases were searched using the term "ketamine" in combination with the keywords "pharmacokinetics", "kinetics", "poisoning", "poison", "toxicity", "ingestion", "adverse effects", "overdose", and "intoxication". Furthermore, bibliographies of identified articles were screened for additional relevant studies. These searches produced 5,268 non-duplicate citations; 185 articles (case reports, case series, pharmacokinetic studies, animal studies pertinent to pharmacology, and reviews) were considered relevant. Those excluded were other animal investigations, therapeutic human clinical investigations, commentaries, editorials, cases with no clinical relevance and post-mortem investigations.

EPIDEMIOLOGY

Following its introduction into medical practice in the early 1970s, ketamine has become a popular recreational drug. Its use has become associated with the dance culture, electronic and dubstep dance events.

MECHANISM OF ACTION

Ketamine acts primarily as a non-competitive antagonist on the glutamate N-methyl-D-aspartate receptor, causing the loss of responsiveness that is associated with clinical ketamine dissociative anaesthesia.

PHARMACOKINETICS

Absorption of ketamine is rapid though the rate of uptake and bioavailability is determined by the route of exposure. Ketamine is metabolized extensively in the liver. Initially, both isomers are metabolized to their major active metabolite, norketamine, by CYP2B6, CYP3A4 and CYP2C9 isoforms. The hydroxylation of the cyclohexan-1-one ring of norketamine to the three positional isomers of hydroxynorketamine occurs by CYP2B6 and CYP2A6. The dehydronorketamine metabolite occurs either by direct dehydrogenation from norketamine via CYP2B6 metabolism or non-enzymatic dehydration of hydroxynorketamine. Norketamine, the dehydronorketamine isomers, and hydroxynorketamine have pharmacological activity. The elimination of ketamine is primarily by the kidneys, though unchanged ketamine accounts for only a small percentage in the urine. The half-life of ketamine in humans is between 1.5 and 5 h.

CLINICAL FEATURES

Acute adverse effects following recreational use are diverse and can include impaired consciousness, dizziness, irrational behaviour, hallucinations, abdominal pain and vomiting. Chronic use can result in impaired verbal information processing, cystitis and cholangiopathy.

DIAGNOSIS

The diagnosis of acute ketamine intoxication is typically made on the basis of the patient's history, clinical features, such as vomiting, sialorrhea, or laryngospasm, along with neuropsychiatric features. Chronic effects of ketamine toxicity can result in cholangiopathy and cystitis, which can be confirmed by endoscopic retrograde cholangiopancreatography and cystoscopy, respectively.

MANAGEMENT

Treatment of acute clinical toxicity is predominantly supportive with empiric management of specific adverse effects. Benzodiazepines are recommended as initial treatment to reduce agitation, excess neuromuscular activity and blood pressure. Management of cystitis is multidisciplinary and multi-tiered, following a stepwise approach of pharmacotherapy and surgery. Management of cholangiopathy may require pain management and, where necessary, biliary stenting to alleviate obstructions. Chronic effects of ketamine toxicity are typically reversible, with management focusing on abstinence.

CONCLUSIONS

Ketamine is a dissociative drug employed predominantly in emergency medicine; it has also become popular as a recreational drug. Its recreational use can result in acute neuropsychiatric effects, whereas chronic use can result in cystitis and cholangiopathy.

Competitive fluorescence immunoassay for the rapid qualitative screening and accurate quantitative analysis of ketamine

In this paper, a sensitive and specific competitive fluorescence immunoassay (CFIA) method was developed for the qualitative and quantitative analysis of ketamine (KET). A novel competitive model in which ketamine hapten (KET-BSA), coated on microporous plates, competed with ketamine antigen (KET-Ag) in actual samples to bind fluorescein isothiocyanate-labeled antibody (KET-Ab) could be used for rapid and indirect quantitative analysis of KET in human urine, blood, or sewage. In the CFIA method, KET concentration in the sample negatively correlated with the detected fluorescence intensity. The linear correlation coefficient of the competitive quantitative equation was 0.992, the linear range was 0.01-0.5 μg mL^-1, and the limit of detection (LOD) was 0.1 pg mL^-1. The specificity results showed that the cross-reaction rate of norketamine was less than 10%. Recoveries of spiked samples at low, medium, and high concentrations ranged from 96% to 117%. The CFIA method and classical gas chromatography-tandem mass spectrometry (GC-MS/MS) were used to detect the actual samples simultaneously. The relative deviation of the quantitative results was less than 10%. The LOD value of KET by CFIA was four orders of magnitude lower than that by GC-MS/MS. Additionally, CFIA had great advantages over GC-MS/MS in terms of sample pretreatment and economic investment. In conclusion, this study provided a targeting detection platform for KET, which achieved a rapid, portable, and sensitive analysis of trace KET in various materials.

Ketamine Induced Bladder Fibrosis Through MTDH/P38 MAPK/EMT Pathway

Purpose: Ketamine is an anesthetic in clinical, but it has also been used as an abusing drug due to its low price and hallucinogenic effects. It is proved that ketamine abusing would cause multiple system damage including the urinary system, which is called ketamine-induced cystitis (KIC). Bladder fibrosis is late stage in KIC and threaten abusers’ life. This study aimed to investigate the molecular mechanism of ketamine-induced bladder fibrosis.

Methods: Female Sprague Dawley (SD) rats were randomly divided into 3 groups. 2 groups were treated with tail vein injection of ketamine (25 mg/kg/day, 50 mg/kg/day ketamine hydrochloride solution, respectively) for 12 weeks, whereas the control group was treated with normal saline solution. In each group, rat bladders were extracted and samples were examined for pathological and morphological alterations via hematoxylin and eosin (HE) staining, Masson’s trichrome staining and immunohistochemistry (IHC). SV-HUC-1 cells were treated with different concentrations of ketamine solution (0, 0.1, 0.5, 1 mmol/L). Rat bladder and SV-HUC-1 cells were extracted protein and RNA for Western blot and RT-PCR detection. Metadherin (MTDH) siRNAs and overexpression plasmids were used to knock down and overexpress the relative genes. P38 mitogen-activated protein kinase (MAPK) inhibitor was utilized to inhibit the MAPK pathway.

Results: Rats in the ketamine group exhibited fibrosis compared to rats of the control group and fibrosis were also markedly upregulated in SV-HUC-1 cells after treated with ketamine, which were ketamine concentration-dependent. After treating with ketamine in SV-HUC-1 cells, there was an increase expression of MTDH, epithelial-mesenchymal transition (EMT) markers, P38 MAPK. MTDH knockdown would suppresses P38 MAPK/EMT pathway to inhibit fibrosis, however, MTDH overexpression could promote the pathway in SV-HUC-1 cells.

Conclusion: In rats and SV-HUC-1 cells ketamine-treated models, MTDH can regulate EMT through the P38 MAPK pathway to regulate the process of bladder fibrosis.

Family of Structurally Related Bioconjugates Yields Antibodies with Differential Selectivity against Ketamine and 6-Hydroxynorketamine

The dissociative-hypnotic compound ketamine is being used in an increasingly wide range of therapeutic contexts, including anesthesia, adjunctive analgesia, treatment-resistant depression, but it also continues to be a notable substance of abuse. No specific antidotes exist for ketamine intoxication or overdose. Immunopharmacotherapy has demonstrated the ability to offer overdose protection through production of highly specific antibodies that prevent psychoactive drug penetration across the blood-brain barrier, although antiketamine antibodies have not yet been assessed or optimized for use in this approach. Moreover, generation of specific antibodies also provides an opportunity to address the role of 6-hydroxynorketamine metabolites in ketamine's rapid-acting antidepressant effect through selective restriction of metabolite access to the central nervous system. Hapten design is a critical element for tuning immune recognition of small molecules, as it affects the presentation of the target antigen and thus the quality and selectivity of the response. Here, we report the synthesis and optimization of carrier protein and conjugation conditions for an initial hapten, norketamine-N-COOH (NK-N-COOH), to optimize vaccination conditions and assess the functional consequences of such vaccination on ketamine-induced behavioral alterations occurring at dissociative-like (50 mg/kg) doses. Iterating from this initial approach, two additional haptens, ketamine-N-COOH (KET-N-COOH) and 6-hydroxynorketamine-N-COOH (HNK-N-COOH), were synthesized to target either ketamine or 6-hydroxynorketamine with greater selectivity. The ability of these haptens to generate antiketamine, antinorketamine, and anti-6-hydroxynorketamine immune responses in mice was then assessed using enzyme-linked immunosorbent assay (ELISA) and competitive surface plasmon resonance (SPR) methods. All three haptens provoked immune responses in vivo, although the KET-N-COOH and 6-HNK-N-COOH haptens yielded antibodies with 5- to 10-fold improvements in affinity for ketamine and/or 6-hydroxynorketamine, as compared to NK-N-COOH. Regarding selectivity, vaccines bearing a KET-N-COOH hapten yielded an antibody response with approximately equivalent K_d values against ketamine (86.4 ± 3.2 nM) and 6-hydroxynorketamine (74.1 ± 7.8 nM) and a 90-fold weaker K_d against norketamine. Contrastingly, 6-HNK-N-COOH generated the highest affinity and most selective antibody profile, with a 38.3 ± 4.7 nM IC₅₀ against 6-hydroxynorketamine; K_d values for ketamine and norketamine were 33- to 105-fold weaker, at 1290 ± 281.5 and 3971 ± 2175 nM, respectively. Overall, these findings support the use of rational hapten design to generate antibodies capable of distinguishing between structurally related, yet mechanistically distinct, compounds arising from the same precursor molecule. As applied to the production of the first-reported anti-6-hydroxynorketamine antibodies to date, this approach demonstrates a promising path forward for identifying the individual and combinatorial roles of ketamine and its metabolites in supporting rewarding effects and/or rapid-acting antidepressant activity.

Recreational ketamine-related deaths notified to the National Programme on Substance Abuse Deaths, England, 1997-2019

BACKGROUND

Ketamine is a phencyclidine derivative with dissociative anaesthetic properties. Increasing numbers of individuals in England take ketamine recreationally. Information on deaths arising from such use in England is presented.

METHODS

Cases were extracted on 31 January 2020 from the National Programme on Substance Abuse Deaths database, based on text searches of the cause of death, coroner's verdict and positive toxicology results for the terms 'ketamine' or 'norketamine'.

FINDINGS

During 1997-2005, there were <5 deaths p.a. in which ketamine was implicated. Numbers increased until 2009 (21), plateauing until 2016; thereafter, deaths have risen to about 30 p.a. Decedents' characteristics (N = 283): male 84.1%, mean age 31.2 (SD 10.0) years, employed 56.5%, drug use history 79.6% and living with others 60.3%. Ketamine was detected with other substances in most cases. Main (74.6%) underlying cause of death was accidental poisoning. Ketamine may have impaired judgement in other cases.

CONCLUSIONS

Although controlled, recreational ketamine use and related fatalities continue to increase. Consumers need to be more aware of the potentially fatal risks they face.

Estimation of the psychoactive substances consumption within 12 wastewater treatment plants service areas in a certain city of Guangxi, China applying wastewater-based epidemiology

The abuse of psychoactive substances has been increasing dramatically over the last few years, which is becoming a concern for human health and social stability. How to accurately estimate psychoactive substances' total consumption in certain areas is the key to manage such substances. In order to control psychoactive substances, 8 psychoactive substances' consumption within 12 wastewater treatment plants (WWTPs) service areas in a certain city of Guangxi, China was investigated in 2019. Firstly, a solid-phase extraction-liquid chromatography-tandem mass spectrometry method was used to determine the influent concentrations. Morphine (MOR), 3, 4-methylenedioxymethamphetamine (MDMA), methamphetamine (METH), ketamine (KET), and norketamine (NK) were detected, with the concentrations ranging from less than method detection limit (NK, MDMA) to 170.91 (METH) ng/L. Then, the back-estimation of consumption was conducted according to the objective and near real-time wastewater-based epidemiology (WBE). The results demonstrate that KET, MOR, and METH are the most abused psychoactive substances, with the mean consumption of 682.42, 167.81, and 44.56 mg/day/1000 inh, respectively. The psychoactive substance residues of WWTPs influent were analyzed to estimate such substances' consumption in specific areas, so as to provide support for risk prevention and control.

A critical point in chiral chromatography-mass spectrometry analysis of ketamine metabolites

Ketamine is a widely used dissociative drug, whose quantification in plasma and urine can be of pharmacological, toxicological, and clinical interest. Although tandem mass spectrometry allows the reliable determination of ketamine and its metabolites in biological matrices, the structural similarity between norketamine (main active metabolite) and dehydronorketamine (a less relevant metabolite) can represent a critical aspect. These compounds differ exclusively in two hydrogen atoms, but the consequent two‐unit difference in their mass/charge ratio is partially nullified by the isotopic abundance of the chlorine atom present in their structure. This, along with their similar fragmentation pattern, can result in the incorrect identification of the enantiomers of these ketamine metabolites even with triple quadrupole instruments, if shared transitions are monitored after chiral chromatography. The key to prevent norketamine overestimation is therefore observing analyte‐specific MS/MS transitions. Here, we describe in detail how we investigated this issue, during the development of an analytical method for ketamine and norketamine enantiomer determination in plasma.

Association of urinary ketamine and APOA1 levels with bladder dysfunction in ketamine abusers revealed via proteomics and targeted metabolite analyses

Chronic ketamine abuse is associated with bladder dysfunction and cystitis. However, the effects of ketamine abuse on the urinary proteome profile and the correlations among urinary proteins, urinary ketamine (and metabolites) and clinicopathological features of ketamine-induced bladder dysfunction remain to be established. Here, we recruited 56 ketamine abusers (KA) and 40 age-matched healthy controls (HC) and applied the iTRAQ-based proteomics approach to unravel quantitative changes in the urine proteome profile between the two groups. Many of the differentially regulated proteins are involved in the complement and coagulation cascades and/or fibrotic disease. Among them, a significant increase in APOA1 levels in KA relative to control samples (392.1 ± 59.9 ng/ml vs. 13.7 ± 32.6 ng/ml, p < 0.0001) was detected via ELISA. Moreover, urinary ketamine, norketamine and dehydronorketamine contents (measured via LC-SRM-MS) were found to be positively correlated with overactive bladder syndrome score (OABSS) and APOA1 levels with urinary RBC, WBC, OABSS and numeric pain rating scale in KA. Collectively, our results may aid in developing new molecular tool(s) for management of ketamine-induced bladder dysfunction. Moreover, information regarding the differentially regulated proteins in urine of KA provides valuable clues to establish the molecular mechanisms underlying ketamine-induced cystitis.

Ketamine-induced urological toxicity: potential mechanisms and translation for adults with mood disorders receiving ketamine treatment

Intravenous (IV) ketamine has been shown to have rapid and robust antidepressant effects in adults with treatment-resistant depression (TRD). Urological toxicity has been observed in chronic ketamine abusers as evidenced by dysuria, urgency, and hematuria. The foregoing observation provides the basis for evaluating whether ketamine-induced urological toxicity (KIUT) is associated with sub-anesthetic doses of ketamine (0.5-1.0 mg/kg) in adults with mood disorders. The overarching objective of this article is to identify potential mechanisms of KIUT which appears to be dose and frequency dependent. Available research indicates that high-frequency ketamine is associated with disruption of the urothelial barrier as well as direct ketamine toxicity (i.e., decreased expression of junction proteins) in KIUT of the bladder. Chronic and high-frequency ketamine use is also associated with bladder inflammation mediated via neurogenic and IgE inflammation. Other non-mutually exclusive causes are nerve hyperplasia, hypersensitivity, cell apoptosis, microvascular damage, and overexpression of carcinogenic genes. Notwithstanding the evidence of KIUT in ketamine abusers, there is no evidence that ketamine and/or esketamine treatment in adults with mood disorders is associated with KIUT. However, all patients receiving ketamine/esketamine for mood disorder treatment should be queried about genitourinary symptoms during acute and, where applicable, maintenance dosing.

Prolonged Ketamine and Norketamine Excretion Profiles in Urine After Chronic Use: A Case Series

PURPOSE/BACKGROUND

Ketamine (K) is used as a party drug with hallucinogenic properties with a half-life of about 2.5 hours. Data are available with respect to the detection window (ie, when a person is still tested positive for the drug and/or metabolite after use) of K after single use. Nevertheless, no data are available with respect to the detection window of K in urine after chronic use.

METHODS/PROCEDURES

This retrospective case series describes 7 patients with K dependency as their main addiction who have been admitted to an addiction center for K detoxification. Their abstinence-oriented care involved routine urinary screening of K and its metabolites, as well as traditional drugs of abuse, such as cocaine and cannabinoids.

FINDINGS/RESULTS

Urine samples remained positive for all the cases identified after 22 to 96 days. A peak detection period of 61, 40, and 96 days for K, norketamine, and dehydronorketamine, respectively, measured using liquid chromatography-tandem mass spectrometry at a cutoff concentration of 1.0 ng/mL, is defined. The K/norketamine and K/dehydronorketamine ratios varied over time between 0.33 and 3.06, and 0.01 and 0.36 for all patients, respectively, implying a large interindividual variation in K metabolism.

IMPLICATIONS/CONCLUSIONS

Ketamine and its metabolites have a prolonged excretion profile in urine, which requires frequent measurements (at least weekly) to guide abstinence treatment. Further research is needed to develop an algorithm that can differentiate new K use from residual urinary K excretion in urine of chronic daily users.

Aldh2 gene reduces oxidative stress in the bladder by regulating the NF-κB pathway in a mouse model of ketamine-induced cystitis

Aldehyde dehydrogenase 2 (aldh2) serves an important role in the development of organ injury. Therefore, the present study investigated the effects of aldh2 on the oxidative stress response in a mouse model of ketamine-induced cystitis (KIC). A total of 60 8-week-old male Institute of Cancer Research wild-type (WT) mice and 45 aldh2 knock-out (KO) mice were randomized to receive low-dose ketamine (30 mg/kg), high-dose ketamine (60 mg/kg) or normal saline (controls). At 4, 8 and 12 weeks post-injection, bladder tissues were harvested and used to investigate the protective mechanisms of aldh2 on bladder function. The results demonstrated that aldh2 KO mice exhibited significant weight loss following chronic ketamine injection compared with that in WT mice. Furthermore, ketamine treatment increased the urination rate (P<0.05), pathological score (P<0.05), levels of the oxidative stress product malondialdehyde (P<0.05) in addition to reducing the expression of the anti-oxidative stress enzyme superoxide dismutase (P<0.05) and glutathione-SH (P<0.05). Oxidative stress in aldh2 KO mice was also found to significantly enhance the expression of proteins associated with the NF-κB signaling pathway, which promoted the expression of inducible nitric oxide synthase (P<0.05) and cyclooxygenase-2 (P<0.05) further. Finally, aldh2 KO mice demonstrated higher severity of fibrosis in the submucosal and muscular layers of the bladder. In conclusion, the present study suggests that aldh2 serves a protective role in preventing inflammation and fibrosis in KIC.

Postmortem redistribution of ketamine in ocular matrices: A study of forensic relevance

The present study evaluates the postmortem redistribution of ketamine in ocular matrices, such as vitreous humor, aqueous humor, and ocular tissues in an animal model. To understand the redistribution of ketamine and its metabolite (norketamine) in the ocular matrices, an in vivo study was performed in rabbits. The rabbits were divided into two groups: perimortem and postmortem. The postmortem samples were collected at 17 h after the administration of ketamine (40 mg/kg) intravenously. For a better understanding of the metabolism of ketamine in eyes, an ex vivo study was conducted in goat eyes after administration of ketamine intravitreally. The samples were analyzed by LC-MS/MS and the levels of ketamine and norketamine in these matrices were compared with that of whole blood and plasma. The results of the in vivo study showed a decrease in ketamine levels in whole blood and plasma while an increase in ocular matrices at postmortem. Though, in most cases, this increase/decrease was statistically insignificant. Moreover, there was an increase of norketamine level in ocular matrices. Ex vivo study also shows the presence of norketamine in ocular matrices of goat eyes. The presence of norketamine in goat eyes may be indicative of the metabolism of ketamine in the eyes.

Extracellular vesicles enhance oxidative stress through P38/NF-kB pathway in ketamine-induced ulcerative cystitis

Long‐term abuse of ketamine causes ketamine‐induced cystitis. The functional alterations of bladder epithelial cells in microenvironment during cystitis remain poorly understood. Here, we explored extracellular vesicles (EV) alteration in ketamine‐induced toxicity. To simulate the high‐concentration ketamine environment in vivo, we established an in vitro model of high ketamine using human uroepithelial cells (SV‐HUC‐1). Cell viability and proliferation were assessed to evaluate the effects of various concentrations (0, 0.25, 0.5, 1, 2, 4 and 8 mmol/L) of ketamine on SV‐HUC‐1 cells. The cell supernatant cultured at a concentration (0, 1, 2, 4 mmol/L) of ketamine was selected for EV extraction and identified. Subsequently, we assessed different groups (ketamine, ketamine plus EV blocker, EV, EV plus extracellular vesicles blocker) of oxidative stress and expression of inflammation. Last, luciferase reporter assay was performed to study the transcriptional regulation of EV on the NF‐kB and P38 pathway. The results of our study suggested that treatment with 0, 1, 2 or 4 mmol/L ketamine altered the morphology and secretion capacity of extracellular vesicles. As the concentration of ketamine increased, the average particle size of EV decreased, but the crest size, particle concentration and EV protein increased. Moreover, after the addition of EV blocker, EV secreted at different concentrations were blocked outside the cell membrane, and the degree of oxidative stress decreased. Our study provided evidence that ketamine alters the secretion of EV by directly stimulating cells in inflammation microenvironment and EV play significant roles in intercellular signal communication and the formation of KIC.EV

A revised excretion factor for estimating ketamine consumption by wastewater-based epidemiology - Utilising wastewater and seizure data

The rate of drug excretion (excretion factor) is a critical parameter for monitoring drug consumption in the population by wastewater-based epidemiology (WBE). Previous studies have refined excretion factors for common illicit drugs, such as cocaine, amphetamine, methamphetamine, heroin, to improve the accuracy and reduce uncertainty in back-calculating consumption. Nevertheless, for ketamine, one of the most prevalent psychoactive substances, a careful review of its excretion factors has not been performed due to limited pharmacokinetic data. Here we review WBE studies and seizure data to refine and validate the excretion factors for ketamine and norketamine. The average ketamine/norketamine ratio in wastewater (5.36) was much higher than that found in urine (0.64), which means that the excretion factors derived only from pharmacokinetics data are not appropriate. Based on the comparison of the ratio between estimated consumptions of ketamine and methamphetamine by WBE with their corresponding ratio in official seizure data, a revised WBE excretion factor of 20% was proposed for ketamine following this review and applied to estimate the ketamine consumption in China. The revised estimates of ketamine consumption corresponded well with drug statistics. This suggests that the revised ketamine excretion factor is appropriate for estimating ketamine consumption by WBE. Systematic review of WBE studies is a suitable approach to refine the excretion factors for substances with inadequate pharmacokinetic data.

What urologists need to know about ketamine-induced uropathy: A systematic review

AIMS

Ketamine is a general anesthetic. Dissociative effects and low cost led ketamine becoming an illegal recreational drug in young adults. Ketamine-induced uropathy (KIU) is one of the complications observed in abusers. This study aimed to provide a systematic literature review on KIU clinical presentation, pathophysiology, and treatments.

METHODS

We performed the literature search in PubMed, Web of Science, Scopus, and Embase using the terms ketamine and bladder. English papers on human and animal studies were accepted.

RESULTS

A total of 75 papers were selected. Regular ketamine users complain about severe storage symptoms and pelvic pain. Hydronephrosis may develop in long-term abusers and is correlated to the contracted bladder, ureteral stenosis, or vesicoureteral reflux due to ureteral involvement and/or bladder fibrosis. Cystoscopy shows ulcerative cystitis. Ketamine in urine might exert direct toxicity to the urothelium, disrupting its barrier function and enhancing cell apoptosis. The presence of ketamine/ions in the bladder wall result in neurogenic/IgE-mediated inflammation, stimulation of the inducible nitric oxide synthase-cytokines-cyclooxygenase pathway with persistent inflammation and fibrosis. Abstinence is the first therapeutic step. Anti-inflammatory drugs, analgesics and anticholinergics, intravesical instillation of hyaluronic acid, hydrodistension and intravesical injection of botulin toxin-A were helpful in patients with early-stage KIU. In patients with end-stage disease, the control of intractable symptoms and the increase of bladder capacity were the main recommendations to perform augmentation enterocystoplasty.

CONCLUSIONS

KIU is becoming a worldwide health concern, which should be taken into account in the differential diagnosis of ulcerative cystitis.

Intraperitoneal injection of ketamine enhances apoptosis in urothelium via autophagy in rats

Ketamine abusing is associated with ulcerative cystitis, but the mechanisms remain unclear. This study aimed to investigate the existence of ketamine-induced symptom in a rat model and evaluate the underlining mechanisms. Sprague-Dawley rats were chosen and randomly divided into 12 groups (n = 8), such as the control group, low dose of ketamine (10 mg/kg/day), middle dose of ketamine (30 mg/kg/day) and high dose of ketamine (50 mg/kg/day) groups. The experimental groups were administrated ketamine i.p. daily, whereas the control groups were administrated with saline. After 1, 3, and 6 months of treatment, the bladder tissues were collected. Haematoxylin and eosin (HE) staining and a transferase-mediated dUTP-biotin nick end labeling (TUNEL) assay were used to evaluate the bladder epithelium pathology and urothelial apoptosis, respectively. The protein expression levels of LC3, p62, Beclin1 were assessed by Western blotting. HE staining results of the experimental rats showed the bladder tissue denudation of the urothelial epithelium with edema and congestion compared with the control groups. TUNEL staining showed a significantly higher number of apoptotic cells in experimental groups than in the control groups. The protein LC3 and Beclin1 had significantly higher levels compared with control groups. The protein p62 had lower levels compared with control groups. The expression levels correlated with contraction of ketamine and treatment time. HE staining, TUNEL staining and Western blot results showed dose-dependent, time-dependent autophage in ketamine-treated rats. All the results suggested that autophagy proteins might be involved in inflammatory response in rats.

Direct coupling of solid phase microextraction with electrospray ionization mass spectrometry: A Case study for detection of ketamine in urine

Electrospray ionization mass spectrometry (ESI-MS) is a commonly used technique for analysis of various samples. Solid phase microextraction (SPME) is a simple and efficient technique that combines both sampling and sample preparation into one consolidated step, preconcentrating extracted analytes for ultra-sensitive analysis. Historically, SPME has been coupled with chromatography-based techniques for sample separation prior to analysis, however more recently, the chromatographic step has been omitted, with the SPME device directly coupled with the mass spectrometer. In this study, direct coupling of SPME with ESI-MS was developed, and extensively validated to quantitate ketamine from human urine, employing a practical experimental workflow and no extensive hardware modification to the equipment. Among the different fibers evaluated, SPME device coated with C₁₈/benzenesulfonic acid particles was selected for the analysis due to its good selectivity and signal response. Different approaches, including desorption spray, dripping, desorption ESI and nano-ESI were attempted for elution and ionization of the analytes extracted using the SPME fibers. The results showed that the desorption spray and nano-ESI methods offered better signal response and signal duration than the others that were evaluated. The analytical performance of the SPME-nano-ESI-MS setup was excellent, including limit of detection (LOD) of 0.027 ng/mL, limit of quantitation (LOQ) of 0.1 ng/mL, linear range of 0.1-500.0 ng/mL (R² = 0.9995) and recoveries of 90.8-109.4% with RSD 3.4-10.6% for three validation points at 4.0, 40.0 and 400.0 ng/mL, far better than the performance of conventional methods. The results herein presented, demonstrated that the direct coupling of SPME fibers with ESI-MS-based systems allowed for the simple and ultra-sensitive determination of analytes from raw samples such as human urine.

Ketamine and norketamine stability in whole blood at ambient and 4°C conditions

A study was implemented to describe the pharmacokinetics (PK) of ketamine (K) and its metabolite norketamine (NK) in critically ill adults. Conducting studies in these subjects is hindered by the immediate need to process and freeze samples obtained in a busy intensive care setting. The ability to store unprocessed samples at room temperature for an extended time period would overcome this barrier. Stability and blood to plasma partitioning of K and NK were investigated in whole blood for up to 120 h at room temperature and 4°C. Whole blood was spiked with K and NK (1000 ng/mL each). Blood samples were aliquoted at different time points (0-120 h), extracted and analyzed using a validated high-performance liquid chromatography tandem mass spectrometry assay. The study demonstrated the stability of both K and NK in whole blood up to 120 h. These in vitro studies suggest that the concentrations of K and NK measured in the PK samples are reliable. The established stability results were successfully employed to investigate K and NK pharmacology studies in critically ill adults.

Changes to the bladder epithelial barrier are associated with ketamine-induced cystitis

The aim of the present study was to investigate the changes of the bladder epithelial barrier in the pathogenesis of ketamine-induced cystitis (KIC). A total of 60 female mice were randomly allocated into control and ketamine groups, which received daily intraperitoneal injections of saline and ketamine, respectively. Micturition behavior was recorded in 2-h intervals at the end of 4, 8 and 12 weeks, and bladders were harvested for subsequent analyses. Routine hematoxylin and eosin staining was performed on the bladders and histopathological changes were analyzed using light microscopy. The distribution of zonula occludens-1 (ZO-1) protein was determined by immunohistochemical analysis. The ultrastructure of umbrella cells was observed using a transmission electron microscope (TEM). Ketamine-addicted mice exhibited a significantly increased frequency of micturitions following 8 and 12 weeks of ketamine treatment (P<0.05 and P<0.01, respectively). Suburothelial congestion and infiltration of mononuclear cells was observed in ketamine-addicted mice following 8 and 12 weeks of treatment. Immunohistochemical examination demonstrated that there was an increased abnormal distribution of ZO-1 in the bladders of ketamine-treated mice compared with control mice. TEM analysis demonstrated that the surface of bladder urothelium became flattened, the tight junctions between umbrella cells became thinner and the endothelial cells exhibited cell body shrinkage, chromatin condensation and layer denudation in mice treated with ketamine. The present study indicated that the structural and functional changes to the bladder epithelial barrier caused by long-term use of ketamine may be key mechanisms in the development of KIC.

Metabolism and metabolomics of ketamine: a toxicological approach

Ketamine is a phencyclidine derivative and a non-competitive antagonist of N-methyl-D-aspartate (NMDA) receptor for which glutamate is the full agonist. It produces a functional dissociation between the thalamocortical and limbic systems, a state that has been termed as dissociative anaesthesia. Considerable variability in the pharmacokinetics and pharmacodynamics between individuals that can affect dose-response and toxicological profile has been reported. This review aims to discuss pharmacokinetics of ketamine, namely focusing on all major and minor, active and inactive metabolites. Both ketamine optical isomers undergo hepatic biotransformation through the cytochrome P450, specially involving the isoenzymes 3A4 and 2B6. It is first N-demethylated to active metabolite norketamine. Different minor pathways have been described, namely hydroxylation of the cyclohexanone ring of ketamine and norketamine, and further conjugation with glucuronic acid to increase renal excretion. More recently, metabolomics data evidenced the alteration of several biological pathways after ketamine administration such as glycolysis, tricarboxylic acid cycle, amino acids metabolism and mitochondrial β-oxidation of fatty acids. It is expected that knowing the metabolism and metabolomics of ketamine may provide further insights aiming to better characterize ketamine from a clinical and forensic perspective.

Label-Free Phosphoproteomic Approach for Kinase Signaling Analysis

Phosphoproteomics is a powerful platform for the unbiased profiling of kinase-driven signaling pathways. Quantitation of phosphorylation can be performed by means of either labeling or label-free mass spectrometry (MS) methods. Because of their simplicity and universality, label-free methodology is gaining acceptance and popularity in molecular biology research. Analytical workflows for label-free quantification of phosphorylation, however, need to overcome several hurdles for the technique to be accurate and precise. These include the use of biochemical extraction procedures that efficiently and reproducibly isolate phosphopeptides from complex peptide matrices and an analytical strategy that can cope with missing MS/MS phosphopeptide spectra in a subset of the samples being compared. Testing the accuracy of the developed workflows is an essential prerequisite in the analysis of small molecules by MS, and this is achieved by constructing calibration curves to demonstrate linearity of quantification for each analyte. This level of analytical rigor is rarely shown in large-scale quantification of proteins using either label-based or label-free techniques. In this chapter we show an approach to test linearity of quantification of each phosphopeptide quantified by liquid chromatography (LC)-MS without the need to synthesize standards or label proteins. We further describe the appropriate sample handling techniques required for the reproducible recovery of phosphopeptides and explore the essential algorithmic features that enable the handling of missing MS/MS spectra and thus make label-free data suitable for such analyses. The combined technology described in this chapter expands the applicability of phosphoproteomics to questions not previously tractable with other methodologies.

Dose-response characteristics of intravenous ketamine on dissociative stereotypy, locomotion, sensorimotor gating, and nociception in male Sprague-Dawley rats

Clinicians administer subanesthetic intravenous (IV) ketamine infusions for treatment of refractory depression, chronic pain, and post-traumatic stress disorder in humans. However, ketamine is administered via the subcutaneous (SC) or intraperitoneal (IP) routes to rodents in most pre-clinical research, which may limit translational application. The present study characterized the dose-response of a subanesthetic IV ketamine bolus (2 and 5mg/kg) and 1-h infusion (5, 10, and 20mg/kg/h) on dissociative stereotypy, locomotion, sensorimotor gating, and thermal nociception in male Sprague-Dawley rats. The secondary aim was to measure ketamine and norketamine plasma concentrations following IV ketamine bolus at 1, 20, and 50min and at the conclusion of the 1-h infusion using liquid chromatography/mass spectrometry. The results showed that ketamine bolus and infusions produced dose-dependent dissociative stereotypy. Bolus (2 and 5mg/kg) and 20mg/kg/h infusion increased locomotor activity while 5mg/kg/h infusion decreased locomotor activity. Both 10 and 20mg/kg/h infusions reduced the acoustic startle reflex, while 5mg/kg bolus and 20mg/kg/h infusion impaired pre-pulse inhibition. Ketamine 5mg/kg bolus and the 10 and 20mg/kg/h infusions induced significant and prolonged antinociception to the hotplate test. Plasma concentrations of ketamine decreased quickly after bolus while norketamine levels increased from 1 to 20min and plateaued from 20 to 50min. The peak ketamine plasma concentrations [ng/ml] were similar between 5mg/kg bolus [4100] vs. 20mg/kg/h infusion [3900], and 2mg/kg bolus [1700] vs. 10mg/kg/h infusion [1500]. These results support the findings from previous ketamine injection studies and further validate the feasibility of administering subanesthetic doses of IV ketamine infusion to rats for neuropharmacological studies.

Ketamine-Induced Apoptosis in Normal Human Urothelial Cells: A Direct, N-Methyl-d-Aspartate Receptor-Independent Pathway Characterized by Mitochondrial Stress

Recreational abuse of ketamine has been associated with the emergence of a new bladder pain syndrome, ketamine-induced cystitis, characterized by chronic inflammation and urothelial ulceration. We investigated the direct effects of ketamine on normal human urothelium maintained in organ culture or as finite cell lines in vitro. Exposure of urothelium to ketamine resulted in apoptosis, with cytochrome c release from mitochondria and significant subsequent caspase 9 and 3/7 activation. The anesthetic mode-of-action for ketamine is mediated primarily through N-methyl d-aspartate receptor (NMDAR) antagonism; however, normal (nonimmortalized) human urothelial cells were unresponsive to NMDAR agonists or antagonists, and no expression of NMDAR transcript was detected. Exposure to noncytotoxic concentrations of ketamine (≤1 mmol/L) induced rapid release of ATP, which activated purinergic P2Y receptors and stimulated the inositol trisphosphate receptor to provoke transient release of calcium from the endoplasmic reticulum into the cytosol. Ketamine concentrations >1 mmol/L were cytotoxic and provoked a larger-amplitude increase in cytosolic Ca(2+) concentration that was unresolved. The sustained elevation in cytosolic Ca(2+) concentration was associated with pathological mitochondrial oxygen consumption and ATP deficiency. Damage to the urinary barrier initiates bladder pain and, in ketamine-induced cystitis, loss of urothelium from large areas of the bladder wall is a reported feature. This study offers first evidence for a mechanism of direct toxicity of ketamine to urothelial cells by activating the intrinsic apoptotic pathway.

A Rare Urachal Cyst in a Case of Ketamine-induced Cystitis Provides Mechanistic Insights

OBJECTIVE

To establish whether the urothelial ulceration observed in ketamine-induced cystitis is triggered by urinary or systemic factors. This was achieved with a rare case where an urachal cyst was found near the bladder dome in a patient undergoing cystectomy for unremitting pain following ketamine abuse.

METHODS

Clinical investigations included cystoscopy, video urodynamic investigation, and computed tomography of the kidneys, ureters, and bladder. Histological staining was combined with immunoperoxidase labeling for markers of transitional epithelial differentiation.

RESULTS

The urachus found near the dome of the bladder was observed to be a separate cyst, with no evidence of patency found during surgery or video urodynamic investigation. The urachus was lined by a mildly reactive metaplastic epithelium of mixed transitional and columnar morphologies. Evidence of widespread cytokeratin 13, basal p75(NTR), and sparse superficial uroplakin 3a immunoreactivity suggested the urachal epithelium was fundamentally transitional in nature. Near total loss of bladder urothelium was observed from regions in contact with urine, whereas the urachal epithelium (not exposed to urine) remained healthy.

CONCLUSION

This study supports the hypothesis that urinary (and not systemic) factors are the main driver of urothelial ulceration in ketamine-induced cystitis. The most likely excreted factors responsible are ketamine and potentially its metabolites. This study reinforces the importance of complete cessation of ketamine use in patients with ketamine-induced cystitis.

Demonstration of the direct impact of ketamine on urothelium using a tissue engineered bladder model

INTRODUCTION

Ketamine is a common recreational drug. Severe lower urinary tract symptoms associated with its consumption have been reported, but little is known about the involved mechanisms. The effect of ketamine, which is excreted in urine, was evaluated by its application on an in vitro three-dimensional human tissue-engineered bladder model composed of an urothelium and a submucosa.

METHODS

Human urothelial cells were cultured with medium containing various concentrations of ketamine and harvested at different times to obtain growth curves. Using this model, specific activity of caspase-3 was measured to assess the level of apoptosis induced by ketamine. Finally, a human tissue-engineered bladder model was used. Urothelial cells were plated on a stromal layer made of dermal fibroblasts and incubated at the air/liquid interface to allow their differentiation. Ketamine was then put on the mature urothelium using paper or agarose vectors for 48 hours.

RESULTS

The presence of ketamine increased cells' doubling times from 1.26 days for control to 1.38 days (p = 0.14) and 1.78 days (p < 0.01) for the 0.5 mM and 1.5 mM concentrations, respectively. 5 mM and 10 mM of ketamine led to decline in the major cell population. Exposure to 5 mM ketamine induced apoptosis, confirmed by a 2.5-fold increase in capase-3 specific activity from control (p = 0.03). The structure and cellular cohesion of the urothelium on the three-dimensional model, especially in the intermediate layers, were severely affected in a concentration dependant fashion with both vectors.

CONCLUSION

The presence of ketamine in the bladder directly damages the urothelium through the induction of apoptosis.

Ketamine-induced ulcerative cystitis and bladder apoptosis involve oxidative stress mediated by mitochondria and the endoplasmic reticulum

Ketamine abusers develop severe lower urinary tract symptoms. The major aims of the present study were to elucidate ketamine-induced ulcerative cystitis and bladder apoptosis in association with oxidative stress mediated by mitochondria and the endoplasmic reticulum (ER). Sprague-Dawley rats were distributed into three different groups, which received normal saline or ketamine for a period of 14 or 28 days, respectively. Double-labeled immunofluorescence experiments were performed to investigate tight junction proteins for urothelial barrier functions. A TUNEL assay was performed to evaluate the distribution of apoptotic cells. Western blot analysis was carried out to examine the expressions of urothelial tight junction proteins, ER stress markers, and apoptosis-associated proteins. Antioxidant enzymes, including SOD and catalase, were investigated by real-time PCR and immunofluorescence experiments. Ketamine-treated rats were found to display bladder hyperactivity. This bladder dysfunction was accompanied by disruptions of epithelial cadherin- and tight junction-associated proteins as well as increases in the expressions of apoptosis-associated proteins, which displayed features of mitochondria-dependent apoptotic signals and ER stress markers. Meanwhile, expressions of mitochondria respiratory subunit enzymes were significantly increased in ketamine-treated bladders. Conversely, mRNA expressions of the antioxidant enzymes Mn-SOD (SOD2), Cu/Zn-SOD (SOD1), and catalase were decreased after 28 days of ketamine treatment. These results demonstrate that ketamine enhanced the generation of oxidative stress mediated by mitochondria- and ER-dependent pathways and consequently contributed to bladder apoptosis and urothelial lining defects. Such oxidative stress-enhanced bladder cell apoptosis and urothelial barrier defects are potential factors that may play a crucial role in bladder overactivity and ulceration.

Wastewater analysis to monitor spatial and temporal patterns of use of two synthetic recreational drugs, ketamine and mephedrone, in Italy

Wastewater analysis was applied in a four-year monitoring study to assess temporal and spatial patterns of ketamine and mephedrone use in the general population in Italy. Composite raw wastewater samples were collected from sewage treatment plants (STPs) in 17 cities. Target analytes were measured using a validated method based on solid phase extraction and liquid chromatography coupled to tandem mass spectrometry analysis. Mass loads were use to assess ketamine and mephedrone use and were normalized to the population served by the plants. Ketamine was detected in wastewater in all except one (Palermo) of the cities investigated, while mephedrone was detected only in Bologna and Florence. Ketamine mass loads progressively increased from 2010 to 2013, and in Milan rose from 1 to 1.5 g/day in 2008-2010 to 3.4-3.6 g/day in 2013-2014. Mass loads were higher in north and central Italy than in the south, and in larger rather than small cities. Wastewater analysis was suitable to provide objective and up-to-date information on the use of ketamine in Italy, to identify ketamine spatial and temporal changes, and to confirm the low use of mephedrone. These results can complement information from population surveys which often provide only scant and incomplete figures for these substances.

Illicit and pharmaceutical drug consumption estimated via wastewater analysis. Part A: chemical analysis and drug use estimates

This paper presents, for the first time, community-wide estimation of drug and pharmaceuticals consumption in England using wastewater analysis and a large number of compounds. Among groups of compounds studied were: stimulants, hallucinogens and their metabolites, opioids, morphine derivatives, benzodiazepines, antidepressants and others. Obtained results showed the usefulness of wastewater analysis in order to provide estimates of local community drug consumption. It is noticeable that where target compounds could be compared to NHS prescription statistics, good comparisons were apparent between the two sets of data. These compounds include oxycodone, dihydrocodeine, methadone, tramadol, temazepam and diazepam. Whereas, discrepancies were observed for propoxyphene, codeine, dosulepin and venlafaxine (over-estimations in each case except codeine). Potential reasons for discrepancies include: sales of drugs sold without prescription and not included within NHS data, abuse of a drug with the compound trafficked through illegal sources, different consumption patterns in different areas, direct disposal leading to over estimations when using parent compound as the drug target residue and excretion factors not being representative of the local community. It is noticeable that using a metabolite (and not a parent drug) as a biomarker leads to higher certainty of obtained estimates. With regard to illicit drugs, consistent and logical results were reported. Monitoring of these compounds over a one week period highlighted the expected recreational use of many of these drugs (e.g. cocaine and MDMA) and the more consistent use of others (e.g. methadone).

Determination of ketamine, norketamine and dehydronorketamine in urine by hollow-fiber liquid-phase microextraction using an essential oil as supported liquid membrane

Here, we present a method for the determination of ketamine (KT) and its main metabolites, norketamine (NK) and dehydronorketamine (DHNK) in urine samples by using hollow-fiber liquid-phase microextraction (HF-LPME) in the three-phase mode. The fiber pores were filled with eucalyptus essential oil and a solution of 1.0mol/L of HCl was introduced into the lumen of the fiber (acceptor phase). The fiber was submersed in the alkalinized urine containing 10% NaCl, and the system was submitted to lateral shaking (2400rpm) during 30min. Acceptor phase was withdrawn from the fiber, dried and the residue was then derivatized with trifluoroacetic anhydride (TFAA) for further determination by gas chromatography-mass spectrometry (GC-MS). The calibration curves were linear over the specified range and limits of detection (LoDs) obtained for KT, NK and DHNK were below the cut-off value (1.0ng/mL) recommended by the United Nations Office on Drugs and Crime (UNODC). A totally "green chemistry" approach of the sample extraction was obtained by using essential oil as a supported liquid membrane in HF-LPME. The developed method was successfully validated and applied to urine samples collected from two clinical cases in which KT was suspected to be involved.