Analysis of stimulant drugs in the wastewater of five Nordic capitals

Annual incidence of substance-induced psychoses in Scandinavia from 2000 to 2016

BACKGROUND

Substance-induced psychosis (SIP) is a serious condition and may predispose for schizophrenia. We know too little about SIP incidence over time and across countries, including substance-specific SIPs. We estimated annual incidence rate of SIP in Denmark, Norway, and Sweden according to substance, age, gender, and socioeconomic background.

METHODS

Data were drawn from registries covering the whole adult population in the countries. Annual incidence rate per 100 000 persons of SIPs was estimated for Denmark and Sweden from 2000 to 2016 and for Norway from 2010 to 2015.

RESULTS

The annual incidence rate of any SIP fluctuated between 9.3 and 14.1. The most commonly occurring SIPs were those induced by alcohol, cannabis, amphetamines, and multiple substances. There was a steady decrease in the incidence rate of alcohol-induced psychosis from the first to the last year of the observation period in Denmark (from 4.9 to 1.5) and Sweden (from 4.5 to 2.2). The incidence rate of cannabis-induced psychosis increased in all countries, from 2.6 to 5.6 in Denmark, from 0.8 to 2.7 in Sweden, and from 1.8 to 3.0 in Norway. Median age of any SIP decreased in Denmark (from 36 to 29 years) and Sweden (from 41 to 31 years). Incidence rates were higher in men and in individuals on disability pension, and increased more among those with high parental education.

CONCLUSIONS

We found similar and stable incidence rates of any SIP in all Scandinavian countries through the observation period. The incidence of alcohol-induced psychosis decreased. The incidence of cannabis-induced psychosis increased.

Investigation on consumption of psychoactive substances and their ecological risks using wastewater-based epidemiology: a case study on Qinghai-Tibet Plateau

The Qinghai-Tibet Plateau is the third pole of the world, and information on the consumption of psychoactive substances (PSs) in this area is scarce. In this study, we selected Qinghai Province as the research area, and the per capita consumption and prevalence of PSs were investigated using wastewater-based epidemiology. Samples from 17 wastewater treatment plants (WWTPs) in 5 major cities in Qinghai Province were monitored, and 11 PSs were detected by ultra-high performance liquid chromatography-tandem mass spectrometry. Results showed that the target compounds were detected in all samples, with relatively high concentrations of ephedrine (2.1-4825.3 ng/L) and methamphetamine (1.5-295.7 ng/L). The consumption of methamphetamine in Xining City, Haidong City, and Haixi City was up to 78.4, 16.8, and 21.2 mg/1000 inh/d (the PS consumption per 1000 inhabitants in 1 day), respectively, higher than that in the other two cities, which was the result of the different consumption patterns and its relationship with the economic levels of each city. High consumption of methadone (47.9 mg/1000 inh/day) was found in Xining City, which might be related to the methadone maintenance therapy sites in the city. Methamphetamine was the most prevalent drug, with the prevalence ranging from 0.003 (Guoluo) to 0.197% (Xining), and the prevalence of other PSs was low. The ecological risk assessment of PSs in the effluent of WWTPs showed that methadone exerted a low risk to aquatic organisms in three sites, while other substances posed potential risk or no risk. However, the long-term effect of PSs cannot be ignored.

Consumption of common illicit drugs in twenty-one cities in southwest China through wastewater analysis

Wastewater-based epidemiology (WBE) was applied to estimate illicit drugs consumption at a provincial scale in southwest China. A large-scale wastewater sampling campaign was carried out from October to November in 2021 in 156 different wastewater treatment plants (WWTPs). Two 24-h composite influent wastewater samples were collected in each WWTP. Concentrations of 11 illicit drugs or their metabolites were determined using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Benzoylecgonine, cocaine, 6-monoacetylmorphine, norketamine, 3,4-methylenedioxymethamphetamine (MDMA), and MDA were not detected in any of the wastewater samples. Methamphetamine and morphine were detected in >84% of samples, while ketamine was found in about 6% of the samples. The city-specific population-weighted consumption of methamphetamine and ketamine were in the range of 0.6-49.7 and N.D.-7.0 mg 1000 inh^-1 day^-1, respectively, with provincial population-weighted values of 22.6 and 2.4 mg 1000 inh^-1 day^-1 in southwest China. The city-specific load of morphine varied from 3.2 to 10.2 mg 1000 inh^-1 day^-1, with provincial population-weighted load of 6.7 mg 1000 inh^-1 day^-1. Taking into account therapeutic use of morphine and codeine, the provincial heroin consumption was estimated to be 10.3 mg 1000 inh^-1 day^-1, ranging from 1.7 to 18.5 mg 1000 inh^-1 day^-1 in 21 cities. Overall, the patterns of illicit drugs use were similar across southwest China, with high prevalence of methamphetamine and heroin, but relatively low use of ketamine. These findings could provide accurate drugs consumption information for timely identifying potential hotspots of illicit drugs use in southwest China.

Increasing prevalence of illicit drug use among employees at Swedish workplaces over a 25-year period

Background

Reports indicate that the proportion of adults using drugs of abuse has been increasing in recent years in Europe. Although there are various indicators of increased drug use in Sweden over time, few studies could demonstrate an increase in the proportion of adults using drugs. To investigate changes in drug use prevalence over time, drug testing at the workplace has been used for a 25-year period.

Methods

The urine samples of employees sent by occupational health services from all over Sweden during a 25-year period were analyzed. The analyzing capacity increased over time (from 3411 in 1994 to 60 315 samples analyzed in 2019), and the majority of the samples was analyzed for the following drugs: cannabis (tetrahydrocannabinol), amphetamine, opiates, cocaine, and benzodiazepines.

Results

There was an overall increase in the proportion of samples that tested positive for illicit drugs over a 25-year period. This increase seemed to take place step-wise, with phases of linear increases and plateaus that over time became shorter. About 1.3% of samples tested positive for drugs in 1994, whereas 5.6% tested positive in 2019. Since 2007, the rate of positive samples has increased for cannabis and decreased for benzodiazepines. Although the rate of samples tested positive for opiates had remained relatively stable over the last 20 years, this rate had increased for amphetamine and cocaine between 2013 and 2019.

Conclusion

The results indicate that the use of illicit drugs among employees at Swedish workplaces has increased during a 25-year period.

Automatic analytical approach for the determination of 12 illicit drugs and nicotine metabolites in wastewater using on-line SPE-UHPLC-MS/MS

In this study, we developed a novel on-line solid phase extraction (SPE)-ultra-high-performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS)-based analytical method for simultaneously quantifying 12 illicit drugs and metabolites (methamphetamine, amphetamine, morphine, codeine, 6-monoacetylmorphine, benzoylecgonine, 3,4-methylenedioxymethamphetamine, 3,4-methylenedioxyamphetamine, cocaine, ketamine, norketamine, and methcathinone) and cotinine (COT) in wastewater samples. The analysis was performed by loading 2 mL of the sample onto an Oasis hydrophilic-lipophilic balance cartridge and using a cleanup step (5% methanol) to eliminate interference with a total run time of 13 min. The isotope-labeled internal standard method was used to quantify the target substances and correct for unavoidable losses and matrix effects during the on-line SPE process. Typical analytical characteristics used for method validation were sensitivity, linearity, precision, repeatability, recovery, and matrix effects. The limit of detection (LOD) and limit of quantification (LOQ) of each target were set at 0.20 ng/L and 0.50 ng/L, respectively. The linearity was between 0.5 ng/L and 250 ng/L, except for that of COT. The intra- and inter-day precisions were <10.45% and 25.64%, respectively, and the relative recovery ranged from 83.74% to 162.26%. The method was used to analyze various wastewater samples from 33 cities in China, and the results were compared with the experimental results of identical samples analyzed using off-line SPE. The difference rate was between 19.91% and −20.44%, and the error range could be considered acceptable. These findings showed that on-line SPE is a suitable alternative to off-line SPE for the analysis of illicit drugs in samples.

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A new wastewater analysis method based on on-line SPE UHPLC-MS/MS was established.

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The on-line SPE method showed excellent performance compared with off-line SPE.

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High sensitivity and short analysis time were achieved using the on-line SPE method.

Illicit drug use in Reykjavik by wastewater-based epidemiology

Estimation of illicit drug use on a community level by wastewater-based epidemiology (WBE) is both an objective and reliable way to establish near real-time results. Wastewater samples were collected at eleven timepoints in Reykjavik from 2017 to 2020. The use of commonly abused illicit drugs in Iceland (amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), cocaine, and cannabis) was estimated. Solid phase extraction and ultra-high performance liquid chromatography coupled to tandem mass spectrometry was used for analysis. Estimated amphetamine and methamphetamine use showed signs of an increase from 2017 to 2020 with amphetamine being the dominant stimulant on the market. MDMA use remained stable from 2017 to 2020. Results showed a large increase in cocaine use from 2017 to 2019 but interestingly, a marked decrease in 2020 during the COVID-19 pandemic. Cannabis use was stable from 2017 to 2019 but showed signs of an increase during the pandemic in 2020. Results by WBE corresponded with data based on two other indicators of drug use, seizure data and driving under the influence cases. Both temporal and spatial trends in illicit drug use were successfully estimated by using WBE, complimenting other indicators which provided a comprehensive picture of drug abuse in Reykjavik.

Assessment of a wide array of organic micropollutants of emerging concern in wastewater treatment plants in Greece: Occurrence, removals, mass loading and potential risks

Exploring the contamination profile of multi-class emerging contaminants (ECs) in wastewater is highly desirable. To this end, the occurrence, removal, mass loading and risks associated with a large panel of pharmaceuticals and personal care products, illicit drugs, perfluorinated compounds and organophosphate flame retardants in two wastewater treatment plants (WWTPs) in the region of Thessaloniki (Greece) after a survey is illustrated. Influent and effluent wastewaters were submitted to solid phase extraction on Oasis HLB cartridges, followed by ultra-high-performance liquid chromatography Orbitrap high-resolution mass spectrometry (UHPLC-Orbitrap MS). Influent concentrations in both WWTPs were notably higher than effluent, with caffeine, acetaminophen, irbesartan and valsartan being the most ubiquitous compounds, exhibiting elevated concentrations. Average effluent concentrations ranged from below the method quantification limits (<MQL) to remarkably high values (μg L^-1 scale), such as for caffeine, acetaminophen, diclofenac, irbesartan and valsartan, among others. Removal efficiencies ranged between -273% for lamotrigine and 100%, i.e., for the UV filter BP1. Notably, the polar compounds such as cytarabine, methotrexate and capecitabine were removed at a rate >80% in both WWTPs, allowing the correlation between logK_ow and removals. Interesting trends for the illicit drugs were revealed by means of mass loading estimation, as in the case of benzoylecgonine (71.6 mg/day/1000 inhabitants). Ecotoxicological risk assessment was evaluated for both single components and mixture, using three approaches: risk quotient (RQ), risk quotient considering frequency (RQ_f) and toxic units (TU). Irbesartan and telmisartan posed a high risk in all trophic levels, while fish was the most sensitive taxa for diclofenac. This work aspires to intensify the surveillance programs for the receiving water bodies, as well as to motivate the investigation of toxicity to non-target organisms.

Wastewater-based epidemiology for illicit drugs: A critical review on global data

Illicit drug use is complex, hidden and often highly stigmatized behaviour, which brings a vast challenge for drug surveillance systems. Drug consumption can be estimated by measuring human excretion products in untreated wastewater, known as wastewater-based epidemiology (WBE). Over the last decade, the application of wastewater-based epidemiology to monitor illicit drug loads increased and WBE is currently applied on a global scale. Studies from over the globe are evaluated with regard to their sampling method, analytical accuracy and consumption calculation, aiming to further reduce relevant uncertainties in order to make reliable comparisons on a global level. Only a limited number is identified as high-quality studies, so further standardization of the WBE approach for illicit drugs is desired especially with regard to the sampling methodology. Only a fraction of the reviewed papers explicitly reports uncertainty ranges for their consumption data. Studies which had the highest reliability are recently published, indicating an improvement in reporting WBE data. Until now, WBE has not been used in large parts of Africa, nor in the Middle East and Russia. An overview of consumption data across the continents on commonly studied drugs (cocaine, MDMA, amphetamine and methamphetamine) is provided. Overall, high consumption rates are confirmed in the US, especially for cocaine and methamphetamine, while relatively low illicit drug consumption is reported in Asia.

"Waste Not, Want Not" - Leveraging Sewer Systems and Wastewater-Based Epidemiology for Drug Use Trends and Pharmaceutical Monitoring

During the current global COVID-19 pandemic and opioid epidemic, wastewater-based epidemiology (WBE) has emerged as a powerful tool for monitoring public health trends by analysis of biomarkers including drugs, chemicals, and pathogens. Wastewater surveillance downstream at wastewater treatment plants provides large-scale population and regional-scale aggregation while upstream surveillance monitors locations at the neighborhood level with more precise geographic analysis. WBE can provide insights into dynamic drug consumption trends as well as environmental and toxicological contaminants. Applications of WBE include monitoring policy changes with cannabinoid legalization, tracking emerging illicit drugs, and early warning systems for potent fentanyl analogues along with the resurging wave of stimulants (e.g., methamphetamine, cocaine). Beyond drug consumption, WBE can also be used to monitor pharmaceuticals and their metabolites, including antidepressants and antipsychotics. In this manuscript, we describe the basic tenets and techniques of WBE, review its current application among drugs of abuse, and propose methods to scale and develop both monitoring and early warning systems with respect to measurement of illicit drugs and pharmaceuticals. We propose new frontiers in toxicological research with wastewater surveillance including assessment of medication assisted treatment of opioid use disorder (e.g., buprenorphine, methadone) in the context of other social burdens like COVID-19 disease.

Mining chemical information in Swedish wastewaters for simultaneous assessment of population consumption, treatment efficiency and environmental discharge of illicit drugs

Consumption of illicit drugs poses health risks to the public and environment. Knowledge on their usage helps better implementations of intervention strategies to reduce drug-related harms in the society and also policies to limit their releases as emerging contaminants to recipient environments. This study aimed to investigate from the daily consumption to treatment efficiency and subsequent discharge of illicit drugs by the Swedish urban populations based on simultaneous collection and analysis of influent and effluent wastewater. Two different weekly monitoring campaigns showed similar drug prevalence in Stockholm and Uppsala, with amphetamine as the most popular drug. Almost all target drug residues were still measurable in effluent wastewater. High removal efficiencies (> 94%) were observed for amphetamine, cocaine and benzoylecgonine, whereas ketamine, 3,4-methylenedioxymethamphetamine (MDMA), mephedrone and methamphetamine were the least removed substances (< 64%), with the highest discharge observed for MDMA in both catchments (~ 3.0 g/day in Uppsala; ~ 18 g/day in Stockholm). Our study provides new insights into short-term changes in the use and related discharge of illicit drugs by urban populations. Such wastewater monitoring can provide useful information to public health, forensic and environmental authorities in planning future intervention and regulation policies.

Cascade of care during the first 36 months of the treatment as prevention for hepatitis C (TraP HepC) programme in Iceland: a population-based study

BACKGROUND

WHO has set targets to eliminate hepatitis C virus (HCV) infection as a global health threat by 2030 through a 65% reduction in HCV-related deaths and 80% reduction in HCV incidence. To achieve these goals, WHO set service coverage targets of 90% of the infected population being diagnosed and 80% of eligible patients being treated. In February, 2016, Iceland initiated a nationwide HCV elimination programme known as treatment as prevention for hepatitis C (TraP HepC), which aimed to maximise diagnosis and treatment access. This analysis reports on the HCV cascade of care in the first 3 years of the programme.

METHODS

This population-based study was done between Feb 10, 2016, and Feb 10, 2019. Participants aged 18 years or older with permanent residence in Iceland and PCR-confirmed HCV were offered direct-acting antiviral (DAA) therapy. The programme used a multidisciplinary team approach in which people who inject drugs were prioritised. Nationwide awareness campaigns, improved access to testing, and harm reduction services were scaled up simultaneously. The number of infected people in the national HCV registry was used in combination with multiple other data sources, including screening of low-risk groups and high-risk groups, to estimate the total number of HCV infections. The number of people diagnosed, linked to care, initiated on treatment, and cured were recorded during the study. This study is registered with ClinicalTrials.gov, NCT02647879.

FINDINGS

In February, 2016, at the onset of the programme, 760 (95% CI 690-851) individuals were estimated to have HCV infection, with 75 (95% CI 6-166) individuals undiagnosed. 682 individuals were confirmed to be HCV PCR positive. Over the next 3 years, 183 new infections (including 42 reinfections) were diagnosed, for a total of 865 infections in 823 individuals. It was estimated that more than 90% of all domestic HCV infections had been diagnosed as early as January, 2017. During the 3 years, 824 (95·3%) of diagnosed infections were linked to care, and treatment was initiated for 795 (96·5%) of infections linked to care. Cure was achieved for 717 (90·2%) of 795 infections.

INTERPRETATION

By using a multidisciplinary public health approach, involving tight integration with addiction treatment services, the core service coverage targets for 2030 set by WHO have been reached. These achievements position Iceland to be among the first nations to subsequently achieve the WHO goal of eliminating HCV as a public health threat.

FUNDING

The Icelandic Government and Gilead Sciences.

Wastewater analysis of psychoactive drugs: Non-enantioselective vs enantioselective methods for estimation of consumption

The consumption of licit and illicit psychoactive drugs (PAD) is ubiquitous in all communities and a serious public health problem. Measuring drug consumption is difficult but essential for health-care professionals, risk assessment and policymakers. Different sources of information have been used for a comprehensive analysis of drug consumption. Among them, Wastewater based epidemiology (WBE) emerged as an essential and complementary methodology for estimating licit and illicit drugs consumption. This methodology can be used for quantification of unchanged drugs or their human-specific metabolites in wastewater for estimation of consumption or screening of new PAD. Although some limitations are still being pointed out (e.g., estimation of the population size, use of suitable biomarkers or pharmacokinetics studies), the non-invasive and potential for monitoring real-time data on geographical and temporal trends in drug use have been showing its capacity as a routine and complementary tool. Chromatographic methods, both non-enantioselective and enantioselective are the analytical tools used for quantification of PAD in wastewaters and further estimation of consumption. Therefore, this manuscript aims to summarize and critically discuss the works used for wastewater analysis of PAD based on WBE using non-enantioselective and enantioselective methods for estimation of consumption. Non-enantioselective methods are among the most reported including for chiral PAD. Nevertheless, a trend has been seen towards the development of enantioselective methods as most PAD are chiral and determination of the enantiomeric fraction can provide additional information (e.g., distinction between consumption or direct disposal, or manufacture processes) and fulfill some WBE gaps.

The embodiment of wastewater data for the estimation of illicit drug consumption in Spain

Data obtained from wastewater analysis can provide rapid and complementary insights in illicit drug consumption at community level. Within Europe, Spain is an important country of transit of both cocaine and cannabis. The quantity of seized drugs and prevalence of their use rank Spain at the top of Europe. Hence, the implementation of a wastewater monitoring program at national level would help to get better understanding of spatial differences and trends in use of illicit drugs. In this study, a national wastewater campaign was performed for the first time to get more insight on the consumption of illicit drugs within Spain. The 13 Spanish cities monitored cover approximately 6 million inhabitants (12.8% of the Spanish population). Untreated wastewater samples were analyzed for urinary biomarkers of amphetamine, methamphetamine, MDMA, cocaine, and cannabis. In addition, weekend samples were monitored for 17 new psychoactive substances. Cannabis and cocaine are the most consumed drugs in Spain, but geographical variations showed, for instance, comparatively higher levels of methamphetamine in Barcelona and amphetamine in Bilbao, with about 1-fold higher consumption of these two substances in such metropolitan areas. For amphetamine, an enantiomeric profiling was performed in order to assure the results were due to consumption and not to illegal dumping of production residues. Furthermore, different correction factors for the excretion of cannabis were used to compare consumption estimations. All wastewater results were compared with previously reported data, national seizure data and general population survey data, were a reasonable agreement was found. Daily and yearly drug consumption were extrapolated to the entire Spanish population with due precautions because of the uncertainty associated. These data was further used to estimate the retail drug market, where for instance cocaine illicit consumption alone was calculated to contribute to 0.2-0.5% of the Spanish gross domestic product (ca. 3000-6000 million Euro/year).

Occurrence and risk assessment of pharmaceuticals and cocaine around the coastal submarine sewage outfall in Guarujá, São Paulo State, Brazil

The aim of this study was to screen and quantify 23 pharmaceutical compounds (including illicit drugs), at two sampling points near the diffusers of the Guarujá submarine outfall, State of São Paulo, Brazil. Samples were collected in triplicate during the high (January 2018) and low (April 2018) seasons at two different water column depths (surface and bottom). A total of 10 compounds were detected using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Caffeine (42.3-141.0 ng/L), diclofenac (3.6-85.7 ng/L), valsartan (4.7-14.3 ng/L), benzoylecgonine (0.3-1.7 ng/L), and cocaine (0.3-0.6 ng/L) were frequently detected (75% occurrence). Orphenadrine (0.6-3.0 ng/L) and atenolol (0.1-0.3 ng/L), and acetaminophen (1.2-1.4 ng/L) and losartan (0.7-3.4 ng/L), were detected in 50% and 25% of the samples, respectively. Only one sample (12.5%) detected the presence of carbamazepine (< 0.001-0.1 ng/L). Unexpectedly a lower frequency of occurrence and concentration of these compounds occurred during the summer season, suggesting that other factors, such as the oceanographic and hydrodynamic regimes of the study area, besides the population rise, should be taken into account. Caffeine presented concentrations above the surface water safety limits (0.01 μg/L). For almost all compounds, the observed concentrations indicate nonenvironmental risk for the aquatic biota, except for caffeine, diclofenac, and acetaminophen that showed low to moderate ecological risk for the three trophic levels tested.

Comparison of community illicit drug use in 11 cities of Turkey through wastewater-based epidemiology

Wastewater-based epidemiology (WBE) is an ever-increasing discipline that enables researchers to track near-real-time data concerning the recreational use of illicit drugs. Community illicit drug use was estimated in eleven Turkish cities, using eighteen wastewater treatment plants, representing the metropolitan cities and rural areas with different socio-demographic characteristics. In this study, 24-h composite influent wastewater samples were collected for 1 week per season between March 2019 and December 2019. Heroin, amphetamine, methamphetamine, ecstasy, cocaine, and marijuana were covered as illicit drugs in this study. Solid-phase extraction, LC-MS/MS separation, identification, and quantification were used as the analytical methods. Overall results indicate that both cocaine and MDMA usage increased in all cities on weekends. More specifically, it was observed that the average amount of cocaine use regarding 11 cities was 14.7 mg/1000 person/day, while figures for other substances are as follows: 9.5 for amphetamine, 34.5 for methamphetamine, 38.4 for MDMA, 42.2 for heroin, and lastly 5412 mg/1000p/day for marijuana. This study holds the position of being the most comprehensive one conducted, considering spatial and temporal datasets on illicit drug consumption obtained via WBE in Turkey.

Investigation of temporal illicit drugs, alcohol and tobacco trends in Istanbul city: Wastewater analysis of 14 treatment plants

Wastewater-based drug monitoring is a complementary tool that has been used worldwide in recent years, and many cities have periodically reported monitoring results. However, this study is the first to analyze drugs in wastewater in a single city with a high population during four periods simultaneously from 14 treatment plants. The aim was to estimate the consumption of conventional illicit drugs [amphetamine (AMP), methamphetamine (METH), 3,4-methylenedioxymethamphetamine (MDMA), cannabis, cocaine, and heroin], tobacco, and alcohol in 2019 for quarterly periods in Istanbul city, which has a population of almost 20 million, to aid in implementing evidence-based measures. Additionally, the seasonal variations among the 14 wastewater treatment plants and their weekday/weekend comparison of drug use patterns and consumption per substance were examined. Solid phase extraction was followed by liquid chromatography-tandem mass spectrometry and a previously validated method was enhanced by adding new parameters (morphine, cotinine, and ethyl sulfate), and satisfactory results were obtained. In this study, alcohol, nicotine, and cannabis had the highest estimated per capita consumption with mean values of 29655.3 mL/1000 inh/day, 5507.6 mg/1000 inh/day and 3607.0 mg/1000 inh/day, respectively. These results were followed by heroin and cocaine consumption with mean values of 557.0 and 200.9 mg/1000 inh/day, respectively, whereas AMP-type stimulants had the lowest values among the targeted substances. METH and cannabis were also highly consumed drugs when compared with the results of other metropolitan cities, whereas heroin consumption was remarkably high owing to Turkey's location on a possible heroin trafficking route. Because Istanbul is the business center of the country and has the potential to attract tourists in all four seasons, meaningful seasonal consumption differences were not observed for all substances.

Novel multiplex capacitive sensor based on molecularly imprinted polymers: A promising tool for tracing specific amphetamine synthesis markers in sewage water

The development of a sensing system for amphetamine (AMP), N-formyl amphetamine (NFA), and benzyl methyl ketone (BMK) in sewage is a strict requirement for enabling the on-site detection and tracing of the consumption of AMP, and the production and/or transportation of these target analytes. The present research is therefore devoted to the development of an on-site capacitive sensing system, based on molecularly imprinted polymers (MIPs) as recognition elements. To this end, the commercially available CapSenze capacitive sensor system was miniaturized by implementing an application-specific integrated circuit (ASIC), dedicated to the bias and read-out of the chemical sensor. MIPs towards AMP were purchased, whereas the ones towards NFA and BMK were synthesized in house. Gold transducers, consisting of six working electrodes with their corresponding reference electrodes and one common auxiliary electrode, were designed together with a flow cell to enable analyses. The applied water samples were filtered through a 20 micron filter before application in the sensors' flow cell. The limits of detection in filtered sewage water were determined to be 25 μM for NFA and BMK and 50 μM for AMP. The overall performance of the sensing system was tested by analysis of blind-coded sewage samples, provided by legal authorities. To the best of our knowledge, this is the first research presenting multiplex MIP-based detection of amphetamine synthesis markers using a capacitive sensor, miniaturized via ASIC technology. The presented technique is undoubtedly a potential solution for any analysis requiring constant reliable on-site monitoring of a substance of interest.

Alcohol use in severely injured trauma patients

Alcohol is a major risk factor for several types of injuries, and it is associated with almost all types and mechanisms of injury. The focus of the study was to evaluate alcohol use in severely injured trauma patients with New Injury Severity Score (NISS) of 16 or over, and to compare mortality, injury severity scores and mechanisms and patterns of injury between patients with positive and negative blood alcohol levels (BAL). Medical histories of all severely injured trauma patients (n = 347 patients) enrolled prospectively in Trauma Register of Tampere University Hospital (TAUH) between January 2016 to December 2017 were evaluated for alcohol/substance use, injury mechanism, mortality and length of stay in Intensive Care Unit (ICU). A total of 252 of 347 patients (72.6%) were tested for alcohol with either direct blood test (50.1%, 174/347), breathalyser (11.2%, 39/347), or both (11.2%, 39/347). After untested patients were excluded, 53.5% of adult patients (18–64 years), 20.5% of elderly patients (above 65 years) and 13.3% of paediatric patients (0–17 years) tested BAL positive. The mean measured BAL for the study population was 1.9 g/L. The incidence of injuries was elevated in the early evenings and the relative proportion of BAL positive patients was highest (67.7%) during the night. Injury severity scores (ISS or NISS) and length of stay in ICU were not adversely affected by alcohol use. Mortality was higher in patients with negative BAL (18.2% vs. 7.7%, p = 0.0019). Falls from stairs, and assaults were more common in patients with positive BAL (15.4% vs. 5.4% and 8.7% vs. 2.7%, p < 0.006, respectively). There were no notable differences in injury patterns between the two groups. Alcohol use among severely injured trauma patients is common. Injury mechanisms between patients with positive and negative BAL have differences, but alcohol use will not increase mortality or prolong length of stay in ICU. This study supports the previously reported findings that BAL is not a suitable marker to assess patient mortality in trauma setting.

A global systematic review and meta-analysis on illicit drug consumption rate through wastewater-based epidemiology

Wastewater-based epidemiology (WBE) is a complementary, well-established comprehensive, cost-effective, and rapid technique for monitoring of illicit drugs used in a general population. This systematic review and meta-analysis is the first to estimate the rank and consumption rate of illicit drugs through WBE studies. In the current study, the related investigations regarding the illicit drug consumption rate based on WBE were searched among the international databases including Scopus, PubMed, Science direct, Google scholar, and local database, Magiran from 2012 up to May 2019. The illicit drug consumption rate with 95% confidence intervals was pooled between studies by using random effect model. The heterogeneity was determined using I² statistics. Also, subgroup analyses were conducted to examine the possible effects of year and location of studies on observed heterogeneity. Meta-analysis of 37 articles indicates that the overall rank order of illicit drugs according to their pooled consumption rate can be summarized as tetrahydrocannabinol or cannabis (7417.9 mg/day/1000 people) > cocaine (655.7 mg/day/1000 people) > morphine (384.9 mg/day/1000 people) > methamphetamine (296.2 mg/day/1000 people) > codeine (222.7 mg/day/1000 people) > methadone (200.2 mg/day/1000 people) > 3,4-methylenedioxymethamphetamine (126.3 mg/day/1000 people) > amphetamine (118.2 mg/day/1000 people) > 2-ethylidene-1,5-dimethyl-3, 3-diphenylpyrrolidine (33.7 mg/day/1000 people). The pooled level rate was 190.16 mg/day/1000 people for benzoylecgonine (main urinary cocaine metabolite), 137.9 mg/day/1000 people for 11-nor-9-carboxy-delta9-tetrahydrocannabinol (main metabolite of cannabis), and 33.7 mg/day/1000 people for 2-ethylidene-1,5-dimethyl-3, 3-diphenylpyrrolidine (main metabolite of methadone). The I² values for all selected drugs were 100% (P value < 0.001). The results of year subgroup indicated that the changes of heterogeneity for all selected drugs were nearly negligible. The heterogeneity within studies based on continents subgroup just decreased in America for drugs like 11-nor-9-carboxy-delta9-tetrahydrocannabinol (I² = 24.4%) and benzoylecgonine (I² = 94.1%). The outcome of this meta-analysis can be used for finding the illicit drugs with global serious problem in view of consumption rate (i.e., cannabis and cocaine) and helping authorities to combat them.

Interpol review of controlled substances 2016-2019

This review paper covers the forensic-relevant literature in controlled substances from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20Papers%202019.pdf.

Spatio-temporal assessment of illicit drug use at large scale: evidence from 7 years of international wastewater monitoring

BACKGROUND AND AIMS

Wastewater-based epidemiology is an additional indicator of drug use that is gaining reliability to complement the current established panel of indicators. The aims of this study were to: (i) assess spatial and temporal trends of population-normalized mass loads of benzoylecgonine, amphetamine, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA) in raw wastewater over 7 years (2011-17); (ii) address overall drug use by estimating the average number of combined doses consumed per day in each city; and (iii) compare these with existing prevalence and seizure data.

DESIGN

Analysis of daily raw wastewater composite samples collected over 1 week per year from 2011 to 2017.

SETTING AND PARTICIPANTS

Catchment areas of 143 wastewater treatment plants in 120 cities in 37 countries.

MEASUREMENTS

Parent substances (amphetamine, methamphetamine and MDMA) and the metabolites of cocaine (benzoylecgonine) and of Δ⁹ -tetrahydrocannabinol (11-nor-9-carboxy-Δ⁹ -tetrahydrocannabinol) were measured in wastewater using liquid chromatography-tandem mass spectrometry. Daily mass loads (mg/day) were normalized to catchment population (mg/1000 people/day) and converted to the number of combined doses consumed per day. Spatial differences were assessed world-wide, and temporal trends were discerned at European level by comparing 2011-13 drug loads versus 2014-17 loads.

FINDINGS

Benzoylecgonine was the stimulant metabolite detected at higher loads in southern and western Europe, and amphetamine, MDMA and methamphetamine in East and North-Central Europe. In other continents, methamphetamine showed the highest levels in the United States and Australia and benzoylecgonine in South America. During the reporting period, benzoylecgonine loads increased in general across Europe, amphetamine and methamphetamine levels fluctuated and MDMA underwent an intermittent upsurge.

CONCLUSIONS

The analysis of wastewater to quantify drug loads provides near real-time drug use estimates that globally correspond to prevalence and seizure data.

Fate of environmental pollutants

This annual review covers the literature published in 2018 on topics related to the occurrence and fate of environmental pollutants in wastewater. Due to the vast amount of literature published on this topic, we have discussed only a portion of the quality research publications, due to the limitation of space. The abstract search was carried out using Web of Science, and the abstracts were selected based on their relevance. In a few cases, full-text articles were referred to understand new findings better. This review is divided into the following sections: antibiotic-resistant bacteria (ARBs) and antibiotic-resistant genes (ARGs), disinfection by-products (DBPs), drugs of abuse (DoAs), estrogens, heavy metals, microplastics, per- and polyfluoroalkyl compounds (PFAS), pesticides, and pharmaceuticals and personal care products (PPCPs), with the addition of two new classes of pollutants to previous years (DoAs and PFAS).

Alarming attitudinal barriers to help-seeking in drug-related emergency situations: Results from a Swedish online survey

Background

New troublesome drug trends constitute a challenge for public health. Sweden has the second highest drug-related mortality rate in Europe. This calls for an investigation into the help-seeking attitudes of young adults to early middle-aged individuals asking how they would act in acute drug-related emergency or overdose situations.

Methods

In total, 1232 individuals completed an online survey promoted on Sweden's largest discussion forum Flashback.org. Their free-text responses were analysed according to inductively generated categories.

Results

Around 60% of the sample would act as expected and contact emergency care without hesitation. However, approximately 32% of the sample showed palpable resistance and would put off seeking help and use emergency care only as a last resort due to, for example, fear of legal repercussions and stigma. Moreover, 8% displayed a total lack of confidence in public healthcare and would avoid it at all costs or entirely disregard it as an option due to the alleged risk of negative consequences and experienced restrictions on their personal freedom.

Conclusions

While the inevitable criminalisation and stigmatisation associated with Sweden's "zero tolerance" drug policy putatively serve as deterrents to drug use, our results demonstrate that these measures may also contribute to attitudes which discourage help-seeking. Such attitudes may at least partly explain the growing and comparatively high number of drug-induced deaths. Therefore, attitudinal and structural barriers to acute help-seeking in drug-related emergency situations should be acknowledged and investigated further in order to minimise harm.

Wastewater analysis for nicotine, cocaine, amphetamines, opioids and cannabis in New York City

According to current surveys and overdoses data, there is a drug crisis in the USA. Wastewater-based epidemiology (WBE) is an evolving discipline that analyses wastewater samples to detect drugs and metabolites to estimate drug consumption in a certain community. This study demonstrates how drug relative presence could be tracked by testing wastewater, providing real-time results, in different boroughs in New York City throughout 1 year. We developed and fully validated two analytical methods, one for 21 drugs and metabolites, including nicotine, cocaine, amphetamines, opioids and cannabis markers; and another for the normalization factor creatinine. Both methods were performed by liquid chromatography tandem mass spectrometry (LC-MS/MS) using positive electrospray ionization, achieving a limit of quantification of 5–10 ng/L for drugs and metabolites, and 0.01 mg/L for creatinine. These methods were applied to 48 one-time grab wastewater samples collected from six wastewater treatment plants in New York City (Manhattan, The Bronx, Queens and Brooklyn), eight different times throughout 2016, before and after major holidays, including Memorial Day, 4th of July, Labour Day and New Year’s. In this study, the drug group normalized concentrations present in the wastewater samples, in decreasing order, were cocaine, nicotine, opioids, cannabis and amphetamines. When looking at individual compounds, the one with the highest normalized concentration was benzoylecgonine (BE), followed by cotinine, morphine and 11-nor-9-carboxy-tetrahydrocannabinol (THCCOOH). To estimate community use, these concentrations were multiplied by the corresponding correction factor, and the most present were THCCOOH, followed by BE, cotinine and morphine. When comparing the treatment plants by drug group (nicotine, cocaine, amphetamines, opioids and cannabis), samples collected from The Bronx had the highest normalized concentrations for nicotine, cocaine and opioids; The Bronx and Manhattan for cannabis; and Manhattan and Queens for amphetamines. In most of the cases, no effect due to holiday was observed. This study provides the first snapshot of drug use in New York City and how that changes between key calendar dates employing wastewater analysis.

Profiling cocaine residues and pyrolytic products in wastewater by mixed-mode liquid chromatography-tandem mass spectrometry

This work provides a new analytical method for the determination of cocaine, its metabolites benzoylecgonine and cocaethylene, the pyrolytic products anhydroecgonine and anhydroecgonine methyl ester, and the pharmaceutical levamisole in wastewater. Samples were solid-phase extracted and extracts analyzed by liquid chromatography-tandem mass spectrometry using, for the first time in the illicit drug field, a stationary phase that combines reversed-phase and weak cation-exchange functionalities. The overall method performance was satisfactory, with limits of detection below 1 ng/L, relative standard deviations below 21%, and percentages of recovery between 93% and 121%. Analysis of 24-hour composite raw wastewater samples collected in Santiago de Compostela (Spain) and Brasilia (Brazil) highlighted benzoylecgonine as the compound showing the highest population-normalized mass loads (300-1000 mg/day/1000 inhabitants). In Brasilia, cocaine and levamisole loads underwent an upsurge on Sunday, indicating a high consumption, and likely a direct disposal, of cocaine powder on this day. Conversely, the pyrolytic product resulting from the smoke of crack, anhydroecgonine methyl ester, and its metabolite anhydroecgonine were relatively stable over the four days, agreeing with a non-recreational-associated use of crack.

Music festivals and drugs: Wastewater analysis

Drug consumption in individual cities, regions, and at various music events and festivals across the EU has generally been monitored via questionnaires, patients' medical data, and police reports. However, an overview of drug consumption obtained from these methods can be negatively affected by various subjective factors. We aimed to investigate an association between levels of target drugs in wastewater, music genres, and festival courses. The occurrence of illicit drugs, their metabolites, and psychoactive compounds was investigated in the influent of six wastewater treatment plants in the Czech and Slovak Republic during seven large-scale music festivals from different music genres: metal, rock, pop, country and folk, ethnic, multi-genre, dance, and trance. The total number of participants included >130,000 active festival attendees. The association between music genre and illicit drug and/or psychoactive pharmaceutical consumptions is discussed on the basis of the results obtained through wastewater analyses. The observed trend was similar to worldwide published data with a specific local phenomenon of methamphetamine prevalence that did not significantly change between music events. Increased specific loads of cocaine (measured as its metabolite benzoylecgonine) and Ecstasy, along with some cannabis, were mainly observed during pop/rock and dance music festivals. However, there was no significant increase observed in the specific loads of all monitored psychoactive pharmaceuticals. This study demonstrates that the abuse of some illicit drugs is closely associated with specific music preferences.

Wastewater-based monitoring of illicit drug consumption in Istanbul: Preliminary results from two districts

Wastewater-based epidemiology is a well-established and complementary approach for monitoring illicit drug use in the general population. In this study, amphetamine (AMP), methamphetamine (METH), 3,4-methylenedioxymethamphetamine (MDMA), cocaine (COC) (from benzoylecgonine), and cannabis (from THC-COOH) consumption levels were investigated for the first time in Turkey (Istanbul). A solid-phase extraction method was applied to influent wastewater samples collected from two districts, Beyoglu and Catalca. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis was conducted with electrospray ionization in positive mode. Calibration curves were acquired in linear form with >0.999 correlation coefficients. Limit of detection levels were measured as 0.91-151 ng/L, and limit of quantitation levels were in the range of 3 to 500 ng/L. Solid-phase extraction recovery and repeatability experiments were achieved by spiking the mix solution to different concentrations (50, 250, 750 ng/L) in 50 mL tap water and wastewater (500, 1000 ng/L) samples in six replicates. The method was optimized, and recoveries were found to be over 80% for all six substances with up to 11.9% relative standard deviation. According to the real sample results, cannabis was found to be the most abused illicit substance among the analytes. The mean consumptions of the two districts, including seven consecutive days for AMP, METH, MDMA, COC, and cannabis, were found to be 27.2, 322, 331, 385, and 1224 mg/day/1000 inhabitants, respectively. In this presented study, all targeted compounds were analyzed simultaneously with the same analytical conditions. To the best of our knowledge, this report is the first to present illicit drug consumption data from Istanbul.

Reduction in methamphetamine consumption trends from 2015 to 2018 detected by wastewater-based epidemiology in Dalian, China

BACKGROUND

Wastewater-based epidemiology (WBE) has become a useful tool in long-term or short-term continuous monitoring of illicit drugs consumption over the world.

METHODS

We investigated the trend of methamphetamine (METH) use between 2015 and 2018 through WBE in Dalian, a typical Chinese city. Samples were collected in 11 municipal wastewater treatment plants (WWTPs). An analytical method, solid-phase extraction combined with trifluoroacetic anhydride derivatization prior to gas chromatography-mass spectrometry (GC-MS) analysis was applied to detect METH concentrations.

RESULTS

During the sampling period, the METH concentrations increased slowly from 315 ± 243 ng/L in 2015 to 523 ± 549 ng/L in 2016, followed by a significant decrease with the concentrations 188 ± 187 ng/L in 2017 and 54.6 ± 42.9 ng/L in 2018. Ammonium nitrogen (NH₄-N) was applied to estimate population size. The average coefficient of variation for population in 11 WWTPs was 35.3 ± 8.9%, reflecting the dynamic variations of population effectively. For METH consumption, there was a gradual increase from 2015 (231 mg/day/1000 people) to 2016 (414 mg/day/1000 people) and a significant linear decrease to 2017 (206 mg/day/1000 people) and 2018 (53.9 mg/day/1000 people). The prevalence of METH increased from 2015 (0.78%) to 2016 (1.06%), then decreased to 2017 (0.55%) and 2018 (0.17%), showed similar trends with the consumption.

CONCLUSIONS

The obvious reduction trends of METH consumption via WBE over the period in Dalian provides objective evidence for declined METH consumption in local population. The reduction is probably due to the severe crack-down of illicit drugs by the government.

Association between purity of drug seizures and illicit drug loads measured in wastewater in a South East Queensland catchment over a six year period

This study aimed to examine associations between the annual average purity of seized illicit drugs and their corresponding load measured in wastewater. Daily loads (averaging 81 samples/year) and purity of seized methamphetamine (average 287 samples/year), cocaine (50/year) and MDMA (70/year) were collected from a catchment that serviced approximately 220,000 persons in Queensland, Australia during 2010-2015. Using regression models for mass load and purity data, we found a strong linear increase in the mass load of methamphetamine detected across study years (363-1126 mg/1000 people/day, R² = 0.89). Strong linear increases in methamphetamine purity were also apparent (19-69%), and were closely correlated with detected mass load (r > 0.9). When differences in purity were controlled for, the linear trend in mass load over time was no longer significant (p > 0.27). For cocaine and MDMA there were no statistically significant trends in either mass load or drug purity over the study period. Our study demonstrates that purity changes may have accounted for a substantial proportion of increases of methamphetamine load measured in wastewater of the studied catchment. Wherever possible, when examining temporal trends in drug loads, or when making comparisons between geographic regions, purity trends should also be examined, as this can aid appropriate interpretation of findings by stakeholders and policy makers.