Monitoring substance use in prisons: Assessing the potential value of wastewater analysis

New trends of drug abuse in custodial settings: A systematic review on the misuse of over-the-counter drugs, prescription-only-medications, and new psychoactive substances

The article presents a systematic literature review on the use and the psychiatric implications of over-the-counter drugs (OTC), prescription-only-medications (POM), and new psychoactive substances (NPS) within custodial settings. The searches wer carried out on 2 November 2022 on PubMed, Scopus, and Web of Science in line with PRISMA guidelines. A total of 538 records were identified, of which 37 met the inclusion criteria. Findings showed the most prevalent NPS and OTC and POM classes reported in prisons were synthetic cannabinoids receptor agonists (SCRAs) and opioids, respectively. NPS markets were shown to be in constant evolution following the pace of legislations aimed to reduce their spread. The use of such substances heavily impacts the conditions and rehabilitation of persons in custody, with consequent physical and mental health risks. It is important to raise awareness of the use and misuse of such substances in prisons (i) from an early warning perspective for law enforcement and policy makers (ii) to prompt doctors to cautiously prescribe substances that may be misused (iii) to improve and increase access to treatment provided (iv) to add such substances to routine toxicological screening procedures (v) to improve harm reduction programmes.

Screening for new psychoactive substances in wastewater from educational institutions

Drug (ab)use among young people is a serious issue, negatively impacting their well-being and prospects. The emergence of new psychoactive substances (NPS) further complicates the situation as they are easily accessible (e.g., online), but users are at high risk of intoxication as their chemical identity is often unknown and toxicity poorly understood. While surveys and drug testing are traditionally used in educational institutions to comprehend drug use trends and establish effective prevention programs, they are not without their limitations. Accordingly, we investigated the occurrence of NPS in educational institutions through wastewater analysis and critically evaluated the viability of the approach. The study included eight wastewater samples from primary schools (ages 6-15 years), six from secondary schools (ages 15-19 years), three from institutions for both secondary and higher education (ages 15+), and six from higher educational institutions (ages 19+). Samples were obtained mid-week and evaluated in two Slovenian municipalities; the capital Ljubljana and a smaller one (M1). Samples were screened using liquid chromatography-ion mobility-high-resolution mass spectrometry (LC-IMS-HRMS), and NPS identified at three levels of confidence (Level 1: unequivocal, Level 2: probable, Level 3: tentative) from a suspect list containing over 5600 entries. NPS were identified in all types of educational institutions. Most were synthetic stimulants, with 3-MMC, ephedrine, 4-chloro-α-PPP, and ethcathinone being unequivocally identified. Also, NPS were present in wastewater from all educational institution types revealing potential spatial but no inter-institutional trends. Although specific groups cannot be targeted, the study, as a proof-of-concept, demonstrates that a suspect screening of wastewater employing LC-IMS-HRMS can be used as a radar for NPS in educational institutions and potentially replace invasive drug testing.

Monitoring medication and illicit drug consumption in a prison by wastewater-based epidemiology: Impact of COVID-19 restrictions

Drug consumption in prisons is a concern for the safety of incarcerated people and staff. Typically, drug use prevalence in prisons is estimated through urinalysis and intelligence operations, which can be intrusive and stressful. An alternative approach, wastewater-based epidemiology (WBE), was used in this study to estimate the consumption of licit and illicit drugs for the entire population of a prison in Australia. Wastewater samples were collected from March to December 2020, covering periods of no restrictions and periods when prison access was restricted to prevent the transmission of COVID-19. Target biomarkers were analysed by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The average consumption of common illicit drugs (MDMA, methamphetamine and cocaine) over the sampling period in the prison (0.5 - 4.5 mg/1000 people/day) was two to three orders of magnitude lower than in the community population (254 - 1000 mg/1000 people/day). Comparison of WBE estimates against pharmacy dispensing data suggested potential illicit buprenorphine consumption at the prison. Methamphetamine and buprenorphine use decreased when no visitors were allowed (18% - 72% decrease for methamphetamine; about half decrease for buprenorphine) and increased once these restrictions were eased (22% - 39% increase for methamphetamine; 44% - 67% increase for buprenorphine). The changes in drug use may be attributed in part to a reduction of drug trafficking into the prison from visitors or non-essential staffs and in part to the reduced contribution of urine from staff who used toilets within the prison. This study provided useful information on the scale of illicit drug use and extra-medical use of licit drugs in prison, and its changes under different security conditions.

A framework for wastewater sample collection from a sewage cleanout to inform building-scale wastewater-based epidemiology studies

Wastewater-based epidemiology (WBE) is a public health tool utilized for drug surveillance, and more recently, infectious disease monitoring of SARS-CoV-2. Sample collection is historically performed at a wastewater treatment plant, however, at this spatial resolution, much information related to actionable and contextually relevant community health data may be lost. Sampling from within the sewer collection system is now being employed more widely, bringing unique challenges, including health and safety concerns related to sample collection. As proof of concept, we tested the efficacy of sampling at the building-level from a sewer cleanout at an undisclosed location in Greater Phoenix, AZ, USA, to (i) test the feasibility of wastewater sample collection from this alternative access point, (ii) assess the advantages and limitations experienced for both maintenance-hole and cleanout-level sampling, (iii) screen for chemical analytes to evaluate detectability, and (iv) create a sampling framework for future near-source WBE investigations. Results indicate that use of a sewer cleanout compared to a maintenance hole is cost-effective, practical, and safe, while still preserving the anonymity and privacy for the contributing population. Additionally, of the 37 biomarkers screened over two sampling events, 20 were detected that cover a wide range of human behavior, exposure, and activity, indicating use of a sewer cleanout to be entirely feasible for downstream analysis. This reported success of sewer cleanout sampling for WBE and corresponding framework may allow practitioners to isolate specific complexes or buildings of interest, while avoiding challenges that can arise from maintenance hole sampling, thus allowing for widescale implementation of WBE for public health purposes.

Wastewater surveillance for 168 pharmaceuticals and metabolites in a WWTP: Occurrence, temporal variations and feasibility of metabolic biomarkers for intake estimation

Wastewater-based epidemiology (WBE) is amply used for mining information about public health such as the estimation of consumption/intake of certain substances. Yet, proper biomarker selection is critical to obtain reliable data. This study measured a broad range of pharmaceuticals and metabolites in a wastewater treatment plant in Beijing, China, and evaluated their suitability as consumption estimation biomarkers. Wastewater sampling was conducted during a normal week and two holiday weeks to assess the impact of the holiday on population normalized daily mass loads (PNDLs). One hundred and forty-nine out of 168 pharmaceuticals were detected, with 94 analytes being quantified in all sampling events. Moreover, digestive drug cimetidine (<MDL∼672 ng L ^- 1) and anabolic steroid trenbolone (<MDL∼53 ng L ^- 1) were only detected during holiday weeks. PNDLs of some substances showed disparities between weekdays and weekends during the normal week. This study proposed a framework to diagnose whether a parent compound or its metabolite is suitable for intake/prevalence rate estimation. Our results support that not all the metabolites can be employed as biomarkers for back-calculation when the in-sewer stability of these compounds is unclear, such as metoprolol acid and O-desmethyl venlafaxine. Public healthcare data for drug utilization were applied to validate the prevalence of average substance use in this study. As a popular anti-epileptic ranging from hundreds to thousands of ng L ^- 1 in this study, the parent compound levetiracetam is more appropriate to be used in WBE under our framework, referring to public healthcare data. This WBE study illustrates the changes in pharmaceutical use and population lifestyle that stem from holidays and commutes. In addition, it can provide data support for the selection of more suitable biomarkers in WBE studies.

Monitoring and ecological risk of illegal drugs before and after sewage treatment in an area

In this study, the occurrence of illicit drugs and their metabolites in the sewerage systems and in the influent and effluent of wastewater treatment plant (WWTP) in Konya, Turkey, was presented. The drug removal efficiencies of the central WWTP were investigated. Potential ecotoxicological risks for algae, fish, and Daphnia magna in the receiving environments were also evaluated. The highest estimated mean illicit drug use was obtained for cannabis (marijuana) at 280 ± 12 mg/day/1000 inhabitants and 430 ± 20 g/day/1000 inhabitants (15-64 years). Amphetamine was found to be the second most consumed drug of abuse. While cannabis and ecstasy consumption values were higher during the weekend, cocaine use dominated on weekdays. The removal efficiencies for THC-COOH and THC-OH were 100% in the WWTP. The average removal of cocaine, amphetamine, methamphetamine, MDMA, MDA, and methadone varied between 46 ± 7 and 87 ± 3%. The maximum concentration level of MDMA found can pose some low risk for Daphnia magna. The rest of the compounds detected in effluents did not show any toxic effects on fish, Daphnia magna, or algae. However, when the cumulative estimated risk quotient values were evaluated, there might be a low risk for Daphnia magna and algae in the receiving environment.

Investigation of drugs of abuse in educational institutions using wastewater analysis

Wastewater analysis was used to investigate drug prevalence in primary and secondary schools and institutes of higher education located in urban and non-urban areas of six municipalities in Slovenia. Seven-hour composite raw wastewater samples from 44 educational institutions, including 19 primary schools (6-15 yrs.), ten secondary schools (15-19 yrs.), nine higher education institutions (19+ yrs.) and six mixed secondary and higher education institutions (15+ yrs.), were collected at the end of the 2018/2019 academic year. Metabolic residues of licit drugs (nicotine and alcohol), medications of abuse (morphine, codeine and methadone) and illicit drugs (cannabis, cocaine, amphetamine, methamphetamine, ecstasy and heroin) were targeted in the study. The analysis was carried out using solid-phase extraction and direct injection combined ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Biomarkers of nicotine, alcohol and cannabis intake were the most frequently detected, indicating a high prevalence of these drugs. Morphine and codeine were also detected, while among the stimulants, benzoylecgonine had the highest detection frequency. Drug differences were found between different levels of educational institution, geographic location (inter-municipality comparison) and degree of urbanization. However, t-distributed stochastic neighbour embedding (t-SNE) revealed that the level of educational institution was the main factor influencing the differences in drug prevalence. Although a good agreement between data from this study and other studies implementing wastewater analysis was observed, there was a discrepancy with Slovenian epidemiological survey data. Finally, despite certain drawbacks of the method, its application to detect drug residues in educational institutions provides a non-invasive insight into drug use trends.

Patterns of Drug Use and Related Factors Among Prisoners in Iran: Results from the National Survey in 2015

Drug use by prisoners is one of the world's most important problems. We sought to determine the pattern of drug use behavior and related factors among prisoners of Iran in 2015. This cross-sectional study was part of the bio-behavioral surveillance survey conducted among 6200 prisoners in 26 prison sites in Iran who were selected through multi-stage sampling. Data were collected through questionnaires and interviews which inquired about participants' demographics and drug use behaviors. We analyzed study data using descriptive statistics, and crude and adjusted logistic regressions, in STATA-12. Of all prisoners, 74.0% had a history of lifetime drug use, and 16.6% of drug users had a history of lifetime injection drug use (IDU). According to the results of a multivariate logistic regression, male sex, being between the ages of 24 and 45, having a history of imprisonment, and having a history of lifetime high-risk sexual behavior were significant risk factors for lifetime drug use. Also, male sex, single status, and a history of previous imprisonment were significant risk factors for lifetime IDU. The prevalence of drug use in Iran's prison population is high and alarming. There is a continuing need for harm reduction programs, including the methadone maintenance treatment, among imprisoned drug users and IDUs.

Air monitoring for synthetic cannabinoids in a UK prison: Application of personal air sampling and fixed sequential sampling with thermal desorption two-dimensional gas chromatography coupled to time-of-flight mass spectrometry

In recent years, there have been increasing complaints from staff working in UK prisons of secondary exposure to psychoactive drug fumes, often believed to be synthetic cannabinoids. Our pilot study aimed to provide an initial evidence base for this issue and reveal compounds of interest within indoor prison air. Here, we present a new method for the detection of synthetic cannabinoids in air and demonstrate its application in a UK prison. Air sampling was conducted using a fixed sequential sampler, alongside personal air sampling units worn by prison officers within an English prison. Air samples were collected onto thermal desorption (TD) tubes and analysed via comprehensive two-dimensional gas chromatography coupled to time-of-flight mass spectrometry (GC × GC-TOF MS). This study is the first of its kind in a prison setting, and the approach is of importance to analytical scientists, policy makers and public health employees tasked with the health and safety of prison staff. GC × GC-TOF MS analysis was able to separate and identify a range of compounds present in the prison air samples. Analysis of the TD tubes did not reveal any synthetic cannabinoids from the fixed pump air samples or the personal pump samples worn by prison officers. Air monitoring in prisons presents a challenge of logistics and science. Fixed sequential air sampling combined with personal air monitoring devices allowed air from multiple locations within a prison to be collected, providing a comprehensive approach to evaluating the air that prison staff is exposed to during a fixed time period.

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.

Refining the excretion factors of methadone and codeine for wastewater analysis - Combining data from pharmacokinetic and wastewater studies

Analysing drug residues in wastewater (wastewater analysis) to monitor the consumption of those drugs in the population has become a complementary method to epidemiological surveys. In this method, the excretion factor of a drug (or the percentage of drug metabolites excreted through urine) is a critical parameter for the back-estimation of the consumption of a drug. However, this parameter is usually derived from a small database of human pharmacokinetic studies. This is true for methadone and codeine, the two most commonly used opioids and also common substances of abuse. Therefore, we aimed to refine the current excretion factors used for estimating methadone and codeine by analysing published data from the literature on the excretion of methadone, its main metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), and codeine. Our review included both human drug pharmacokinetic studies and wastewater analysis studies. We found that while the commonly used excretion factor of methadone (~27.5%) was relatively accurate, the excretion factor of EDDP, a better biomarker for methadone consumption in sewer epidemiology, should be twice that of methadone (i.e. 55%) instead of the current equal or half values. For codeine, the excretion factor should be ~30% instead of 63.5% or 10% as previously used in wastewater analysis studies. Data from wastewater analysis studies could be used in this way to refine the excretion factors of the drugs of interest.