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Hashem-Dabaghian F, Kianbakht S. A randomized controlled trial on the seeds of Sophora alopecuroides var. alopecuroides for the treatment of acute heroin withdrawal syndrome. Complement Ther Clin Pract 2023; 51:101740. [PMID: 36827871 DOI: 10.1016/j.ctcp.2023.101740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND and purpose: The seeds of Sophora alopecuroides var. alopecuroides have attenuated the acute opium withdrawal syndrome in humans. Therefore, the efficacy and safety of a standardized extract of the plant for the treatment of acute heroin withdrawal syndrome was evaluated in abstinent heroin addicts. MATERIALS AND METHODS The patients were randomized to take three 400 mg extract capsules (N = 50) or placebo (N = 50) once per day orally for eight days. The severity of withdrawal syndrome was assessed by the clinical opiate withdrawal scale (COWS) as the primary outcome measure at the baseline and on the days 3 and 8. The hepatic and renal functions and complete blood count were the secondary outcome measures tested at the baseline and end of the study. RESULTS The COWS score decreased in both groups after eight days, but the decrease was significantly higher in the experimental group (p < 0.001); the effect size of the decrease was 2.64. The groups had significant differences in the COWS scores on the days 3 and 8 (p < 0.001 for both). The extract had no significant effect on the other parameters. No side effect was noted. CONCLUSION The extract seems to alleviate acute heroin withdrawal syndrome safely.
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Affiliation(s)
- Fataneh Hashem-Dabaghian
- Department of Traditional Medicine, Institute for Studies in Medical History, Persian and Complementary Medicine, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Kianbakht
- Medicinal Plants Research Center, Institute of Medicinal Plants, ACECR, Karaj, Iran.
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2
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Lappas NT, Lappas CM. Heroin. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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3
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Chen WR, Kong PH, Sauer C, Chen HW, Chan HY, Yang DP, Jair YC, Liu HT, Lin TY, Yen MY, Yen YF, Chang SH, Li LH, George C, Chang YC, Wu YH, Hwa HL, Chen CY, Chen JH, Kicman AT, Maurer HH, Chen PS. A proposed approach to confirm heroin administration - Regional differences in heroin purity is a major factor. Regul Toxicol Pharmacol 2021; 128:105097. [PMID: 34902532 DOI: 10.1016/j.yrtph.2021.105097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 12/04/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022]
Abstract
In forensic toxicology, a marker of street heroin use is urgent especially in the absence of urinary 6-monoacetylmorphine. ATM4G, the Glucuronide of Acetylated product of Thebaine compound 4 Metabolite (ATM4), arising from byproducts of street heroin synthesis has been considered as a useful marker in some European studies. However, whether ATM4G is a universal marker particularly in Southeast Asia due to 'street' heroin with high purity, it's still unclear. To investigate putative markers for different regions, ATM4G and other metabolites including the Acetylated product of Thebaine compound 3 Metabolite (ATM3) and thebaol, also originated from thebaine were detected in 552 urine samples from heroin users in Taiwan. Results were compared with that from samples collected in the UK and Germany. Only a sulfo-conjugate of ATM4, ATM4S, was detected in 28 Taiwanese users using a sensitive MS3 method whilst out of 351 samples from the UK and Germany, ATM4G was present in 91. Thebaol-glucuronide was first time detected in 118. No markers were detected in urine following herbal medicine use or poppy seed ingestion. The presence of ATM4S/ATM4G might be affected by ethnicities and heroin supplied in regions. Thebaol-glucuronide is another putative marker with ATM4G and ATM4S for street heroin use.
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Affiliation(s)
- Wei-Ru Chen
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Po-Hsin Kong
- Department and Graduate Institute of Forensic Medicine, College of Medicine, National Taiwan University, Taiwan
| | - Christoph Sauer
- Department Forensic Toxicology & Drug Analysis, SYNLAB, Weiden, Germany
| | - Huei-Wen Chen
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Hsiang-Yu Chan
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Da-Peng Yang
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Yung-Cheng Jair
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Hsin-Tung Liu
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Tsang-Yaw Lin
- Tsao-Tun Psychiatric Center, Ministry of Health and Welfare, Taiwan
| | - Muh-Yong Yen
- Department of Disease Control and Prevention, Taipei City Hospital, Taiwan
| | - Yung-Feng Yen
- Department of Disease Control and Prevention, Taipei City Hospital, Taiwan
| | | | - Lan-Hui Li
- Department of Disease Control and Prevention, Taipei City Hospital, Taiwan
| | | | - Ya-Chi Chang
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Yi-Hsin Wu
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Hsiao-Lin Hwa
- Department and Graduate Institute of Forensic Medicine, College of Medicine, National Taiwan University, Taiwan; Forensic and Clinical Toxicology Center, National Taiwan University, College of Medicine, National Taiwan University Hospital, Taiwan
| | - Chia-Yang Chen
- Institute of Environmental Health, National Taiwan University, Taiwan
| | - Jung-Hsuan Chen
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan
| | - Andrew T Kicman
- Analytical and Environmental Sciences & Institute of Pharmaceutical Science, King's College London, United Kingdom
| | - Hans H Maurer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Saarland University, Homburg, Germany
| | - Pai-Shan Chen
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taiwan.
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Jakobsson G, Truver MT, Wrobel SA, Gréen H, Kronstrand R. Heroin-Related Compounds and Metabolic Ratios in Postmortem Samples Using LC-MS-MS. J Anal Toxicol 2021; 45:215-225. [PMID: 33031535 PMCID: PMC7953417 DOI: 10.1093/jat/bkaa157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/14/2020] [Accepted: 10/07/2020] [Indexed: 12/02/2022] Open
Abstract
Analysis of postmortem samples with the presence of morphine can sometimes be challenging to interpret. Tolerance complicates interpretation of intoxications and causes of death due to overlap in therapeutic and fatal concentrations. Determination of metabolites and metabolic ratios can potentially differentiate between abstinence, continuous administration, and perhaps time of administration. The purpose of this study was to (a) develop and validate a method for quantitation of morphine-3β-D-glucuronide, morphine-6β-D-glucuronide, normorphine, codeine-6β-D-glucuronide, norcodeine, codeine, 6-acetylmorphine, and ethylmorphine in urine using liquid chromatography–tandem mass spectrometry; (b) apply the method to opiate related deaths; (c) compare metabolic ratios in urine in different causes of death (CoD) and after different drug intakes and (d) compare heroin intoxications in rapid and delayed deaths. Validation parameters such as precision, bias, matrix effects, stability, process efficiency, and dilution integrity were assessed and deemed acceptable. Lower limits of quantitation ranged from 0.01–0.2 μg/mL for all analytes. Autopsy cases (n=135) with paired blood and urine samples were analyzed. Cases were divided into three groups based on CoD; opiate intoxication, intoxication with other drugs than opiates, and other CoD. The cases were classified by intake: codeine (n=42), heroin (n=36), morphine (n=49), and ethylmorphine (n=3). Five cases were classified as mixed intakes and excluded. Heroin intoxications (n=35) were divided into rapid (n=15) or delayed (n=20) deaths. Parent drug groups were compared using metabolic ratio morphine-3β-D-glucuronide/morphine and significant differences were observed between codeine vs morphine (p=0.005) and codeine vs heroin (p≤0.0001). Urine and blood concentrations, and metabolic ratios in rapid and delayed heroin intoxications were compared and determined a significant difference for morphine (p=0.001), codeine (p=0.009), 6-acetylmorphine (p=0.02) in urine, and morphine (p=0.02) in blood, but there was no significant difference (p=0.9) between metabolic ratios. Morphine-3β-D-glucuronide results suggested a period of abstinence prior to death in 25% of the heroin intoxications.
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Affiliation(s)
- Gerd Jakobsson
- *Author to whom correspondence should be addressed. E-mail:
| | - Michael T Truver
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83, Linköping, Sweden
| | - Sonja A Wrobel
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 587 58, Linköping, Sweden
| | - Henrik Gréen
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 587 58, Linköping, Sweden
| | - Robert Kronstrand
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 587 58, Linköping, Sweden
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5
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Kianbakht S, Hajiaghaee R, Akhondzadeh S. Efficacy and safety of
Sophora alopecuroides
var.
alopecuroides
seed extract for opioid detoxification: A randomized, double‐blind, and placebo‐controlled clinical trial. Phytother Res 2019; 34:1108-1113. [DOI: 10.1002/ptr.6578] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Saeed Kianbakht
- Medicinal Plants Research CenterInstitute of Medicinal Plants, ACECR Karaj Iran
| | - Reza Hajiaghaee
- Medicinal Plants Research CenterInstitute of Medicinal Plants, ACECR Karaj Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh HospitalTehran University of Medical Sciences Tehran Iran
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6
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Mallama CA, Trinidad JP, Swain RS, Zhao Y, Woods C, McAninch JK. A comparison of opioid-involved fatalities captured in the National Poison Data System to data derived from US death certificate literal text. Pharmacoepidemiol Drug Saf 2019; 28:1377-1385. [PMID: 31402548 DOI: 10.1002/pds.4869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose of the study is to describe and compare the number and characteristics of opioid-involved fatal cases captured in the National Poison Data System (NPDS) and in US death certificates. METHODS NPDS, which collects data on all calls to US poison control centers, and Drug-Involved Mortality (DIM), which combines information from literal text of US death certificates and National Vital Statistics Systems, were queried for opioid-involved fatal cases from 2010 to 2015. Characteristics of the two case series were compared. RESULTS DIM contained 154 016 opioid-involved overdose deaths, and NPDS contained 2524 fatal opioid exposures, a ratio of 61:1. The number of opioid deaths remained stable in NPDS but increased in DIM over the 6-year period. On average, deaths involving opioids with higher mean dosage strength (in morphine milligram equivalents) per unit among dispensed prescriptions were more likely to be captured in DIM relative to NPDS, as compared with those with a lower mean dosage strength per unit. The increase in fentanyl-related deaths seen in DIM since 2013 was not observed in NPDS. CONCLUSIONS NPDS is a valuable drug safety surveillance resource due to its timeliness and drug specificity. However, it captures only a small fraction of opioid-involved fatal poisonings, and comparisons with data derived from death certificate literal text indicate that caution is warranted in making inferences about opioid-involved fatality trends over time or comparisons across opioids.
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Affiliation(s)
- Celeste A Mallama
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - James P Trinidad
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Richard S Swain
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Yueqin Zhao
- Office of Biostatistics, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Corinne Woods
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Jana K McAninch
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
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7
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Metabolism and metabolomics of opiates: A long way of forensic implications to unravel. J Forensic Leg Med 2019; 61:128-140. [DOI: 10.1016/j.jflm.2018.12.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 12/27/2022]
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8
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Huber D, Bleymaier K, Pellis A, Vielnascher R, Daxbacher A, Greimel KJ, Guebitz GM. Laccase catalyzed elimination of morphine from aqueous systems. N Biotechnol 2018; 42:19-25. [DOI: 10.1016/j.nbt.2018.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 08/29/2017] [Accepted: 01/05/2018] [Indexed: 02/09/2023]
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9
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Sobolesky PM, Smith BE, Pesce AJ, Fitzgerald RL. Interpretation of Pain Management Testing Results Using Case Examples. J Appl Lab Med 2018; 2:610-621. [PMID: 33636894 DOI: 10.1373/jalm.2017.024786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Because of the increasing volume of opiate-related overdoses, clinical testing of urine for drugs and related compounds in pain management clinics has become increasingly important. Interpreting findings of drugs present in urine specimens requires knowledge of pharmacokinetics, metabolism, drug purity, and cutoff concentrations used to report a positive result. CONTENT This case-based mini-review provides examples of how to interpret immunoassay and quantitative confirmatory urine drug-testing results. Particular emphasis is placed on interpretation of opiate and benzodiazepine results, as these drugs have complicated metabolic profiles. SUMMARY Both determining patient medication compliance and identifying the presence of additional drugs provides important information to the treating physician involved in managing pain. Mass spectrometry-based methods are required to identify specific drugs present and can provide important quantitative data for interpreting opiate medication compliance.
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Affiliation(s)
- Philip M Sobolesky
- Department of Pathology, Center for Advanced Laboratory Medicine, University of California, San Diego Health Systems, San Diego, CA
| | - Breland E Smith
- Department of Pathology, Center for Advanced Laboratory Medicine, University of California, San Diego Health Systems, San Diego, CA
| | | | - Robert L Fitzgerald
- Department of Pathology, Center for Advanced Laboratory Medicine, University of California, San Diego Health Systems, San Diego, CA
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10
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Du P, Zhou Z, Bai Y, Xu Z, Gao T, Fu X, Li X. Estimating heroin abuse in major Chinese cities through wastewater-based epidemiology. THE SCIENCE OF THE TOTAL ENVIRONMENT 2017; 605-606:158-165. [PMID: 28666170 DOI: 10.1016/j.scitotenv.2017.05.262] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 06/07/2023]
Abstract
Heroin consumption in major cities across China was estimated for the first time via wastewater-based epidemiology. Influent and effluent wastewater samples were collected from 49 wastewater treatment plants (WWTPs) in 24 major cities that cover all the geographic regions of the country. Concentrations of morphine, 6-acetylmorphine, and codeine were measured. Near complete removal of morphine by wastewater treatment processes was observed, whereas removal rates of codeine were slightly lower. Morphine loads were much higher than codeine loads at most WWTPs in China, a trend opposite to that in many European countries. In addition, morphine and codeine loads were strongly correlated at most WWTPs, indicating morphine and codeine in wastewater were predominantly from the same source, street heroin. At WWTPs in Guangzhou and Shenzhen, codeine loads were considerably higher than morphine loads, consistent with previous reports of codeine abuse (e.g., as cough syrup) among middle and high school students in Guangdong province. Heroin consumption was derived based on morphine loads and taking into account therapeutic use of morphine and codeine, as well as contribution of codeine and acetylcodeine in street heroin. Highest heroin consumption was observed in northwestern and southwestern China. The average heroin consumption of the sampled cities was 64.6±78.7mg/1000inh/d. The nation-wide average heroin consumption was much lower than that of methamphetamine, consistent with seizure data and numbers of registered heroin and methamphetamine users in China.
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Affiliation(s)
- Peng Du
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China
| | - Zilei Zhou
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China
| | - Ya Bai
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China
| | - Zeqiong Xu
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China
| | - Tingting Gao
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China
| | - Xiaofang Fu
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China
| | - Xiqing Li
- Laboratory of Earth Surface Processes, College of Urban and Environmental Sciences, Peking University, 100871 Beijing, China.
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11
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Maas A, Madea B, Hess C. Confirmation of recent heroin abuse: Accepting the challenge. Drug Test Anal 2017; 10:54-71. [DOI: 10.1002/dta.2244] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Alexandra Maas
- Department of Forensic Toxicology; University Bonn, Institute of Forensic Medicine; Bonn Germany
| | - Burkhard Madea
- Department of Forensic Toxicology; University Bonn, Institute of Forensic Medicine; Bonn Germany
| | - Cornelius Hess
- Department of Forensic Toxicology; University Bonn, Institute of Forensic Medicine; Bonn Germany
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12
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Khanjani N, Mousavi M, Dehghanian A, Jahani Y, Soori H. The role of drug and alcohol use and the risk of motor vehicle crashes in Shiraz, Iran, 2014: A case-crossover study. TRAFFIC INJURY PREVENTION 2017; 18:573-576. [PMID: 28095031 DOI: 10.1080/15389588.2017.1279736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/03/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND Traffic accidents and traffic-related injuries and mortality have become a major public health concern in Iran. This study aimed to examine the role of drug and alcohol use in motor vehicle accidents in Iran. METHODS This case-crossover study was conducted on 441 drivers who survived a road traffic crash and were taken to the emergency department of Shahid Rajaee trauma hospital in Shiraz, southern Iran. Data were collected using checklists that included demographic characteristics and drug and alcohol use prior to driving. Alcohol and drug use was identified through self-report, and cannabis, morphine, and methamphetamine urine tests were used to confirm drug abuse among drivers. RESULTS In total 17.9% of drivers reported using drugs (cannabis, opium, or metamphetamine) and 8.84% of drivers reported consuming alcohol prior to the collision. The crude odds ratios (ORs) for having a crash for opium, cannabis, and metamphetamine were 1.94 (95% interval confidence [CI], 1.11-3.38), 2.37 (95% CI, 1.03-5.42), 5.5 (95% CI, 1.21-24.81), respectively, and for all drugs was 3.83 (95% CI, 2.28-6.43). The OR for alcohol was 3.5 (95% CI, 1.73-7.06) based on self-report. CONCLUSION Drug and alcohol use are increasing the risk of traffic crashes in Iran. Risk-reducing programs must be designed and implemented.
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Affiliation(s)
- Narges Khanjani
- a Environmental Health Engineering Research Center , School of Public Health, Kerman University of Medical Sciences , Kerman , Iran
| | - Masoomeh Mousavi
- b Shiraz University of Medical Sciences , Shiraz , Iran
- c Department of Epidemiology and Biostatistics , School of Public Health, Kerman University of Medical Sciences , Kerman , Iran
| | - Amirreza Dehghanian
- d Trauma Research Center , Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences , Shiraz , Iran
- e Department of Pathology , Shiraz Medical School, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Yunes Jahani
- f Department of Biostatistics and Epidemiology , School of Public Health, Kerman University of Medical Sciences , Kerman , Iran
| | - Hamid Soori
- g Safety Promotion and Injury Prevention Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
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13
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Høiseth G, Gottås A, Berg T, Arnestad M, Halvorsen PS, Bachs LC. Urinary Kinetics of Heroin Metabolites in Pigs Shortly After Intake. J Anal Toxicol 2017; 41:451-454. [PMID: 28335030 DOI: 10.1093/jat/bkx017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/13/2017] [Indexed: 11/13/2022] Open
Abstract
In previous experimental studies on heroin metabolites excretion in urine, the first sample was often collected a few hours after intake. In forensic cases, it is sometimes questioned if a positive urine result is expected e.g., 30 min after intake. The aim of this study was to investigate urinary excretion of heroin metabolites (morphine, 6-monoacetylmorphine (6-MAM) and morphine-3-glucuronide (M3G)) every 30 min until 330 min after injection of a 20 mg heroin dose in six pigs. Samples were analyzed using a previously published, fully validated liquid chromatography-tandem mass spectrometry method. All metabolites were detected after 30 min in all pigs. The time to maximum concentration (Tmax) median (range) for 6-MAM and morphine was 30 min (first sample) (30-120), and 90 min (30-330) for M3G. In four of the six pigs, the Tmax of 6-MAM and morphine was reached within 30 min. All analytes were still detectable at the end of study. This study showed that positive results in urine are expected to be seen shortly after use of heroin in pigs. Detection times were longer than previously indicated, especially for 6-MAM, but previous studies used lower doses. As the physiology of these animals resembles that of the humans, transferability to man is expected.
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Affiliation(s)
- Gudrun Høiseth
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway.,Center for psychopharmacology, Diakonhjemmet hospital, Oslo, Norway.,Norwegian Centre for Addiction Research (SERAF), University of Oslo, Oslo, Norway
| | - André Gottås
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway.,Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Thomas Berg
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | - Marianne Arnestad
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | | | - Liliana C Bachs
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
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14
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Andersson M, Björkhem-Bergman L, Beck O. Possible mechanism for inhibition of morphine formation from 6-acetylmorphine after intake of street heroin. Forensic Sci Int 2015; 252:150-6. [DOI: 10.1016/j.forsciint.2015.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/14/2015] [Accepted: 05/03/2015] [Indexed: 12/21/2022]
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15
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Tiscione NB. Comparison of Urine to Oral Fluid and the Recommendation for Routine Drug Analysis for Driving Under the Influence Cases. J Anal Toxicol 2015; 39:330-1. [DOI: 10.1093/jat/bkv005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Abstract
Urine drug screening has become standard of care in many medical practice settings to assess compliance, detect misuse, and/or to provide basis for medical or legal action. The antibody-based enzymatic immunoassays used for qualitative analysis of urine have significant drawbacks that clinicians are often not aware of. Recent literature suggests that there is a lack of understanding of the shortcomings of these assays by clinicians who are ordering and/or interpreting them. This article addresses the state of each of the individual immunoassays that are most commonly used today in order to help the reader become proficient in the interpretation and application of the results. Some literature already exists regarding sources of "false positives" and "false negatives," but none seem to present the material with the practicing clinician in mind. This review aims to avoid overwhelming the reader with structures and analytical chemistry. The reader will be presented relevant clinical knowledge that will facilitate appropriate interpretation of immunoassays regardless of practice settings. Using this review as a learning tool and a reference, clinicians will be able to interpret the results of commonly used immunoassays in an evidence-based, informed manner and minimize the negative impact that misinterpretation has on patient care.
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Affiliation(s)
- Zachary J Nelson
- University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Samuel J Stellpflug
- Region's Hospital Clinical Toxicology, Department of Emergency Medicine, St. Paul, MN, USA
| | - Kristin M Engebretsen
- Region's Hospital Clinical Toxicology, Department of Emergency Medicine, St. Paul, MN, USA
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17
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Smith ML, Nichols DC, Underwood P, Fuller Z, Moser MA, LoDico C, Gorelick DA, Newmeyer MN, Concheiro M, Huestis MA. Morphine and codeine concentrations in human urine following controlled poppy seeds administration of known opiate content. Forensic Sci Int 2014; 241:87-90. [PMID: 24887324 PMCID: PMC4127332 DOI: 10.1016/j.forsciint.2014.04.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 04/28/2014] [Accepted: 04/30/2014] [Indexed: 11/16/2022]
Abstract
Opiates are an important component for drug testing due to their high abuse potential. Proper urine opiate interpretation includes ruling out poppy seed ingestion; however, detailed elimination studies after controlled poppy seed administration with known morphine and codeine doses are not available. Therefore, we investigated urine opiate pharmacokinetics after controlled oral administration of uncooked poppy seeds with known morphine and codeine content. Participants were administered two 45 g oral poppy seed doses 8 h apart, each containing 15.7 mg morphine and 3mg codeine. Urine was collected ad libitum up to 32 h after the first dose. Specimens were analyzed with the Roche Opiates II immunoassay at 2000 and 300 μg/L cutoffs, and the ThermoFisher CEDIA(®) heroin metabolite (6-acetylmorphine, 6-AM) and Lin-Zhi 6-AM immunoassays with 10 μg/L cutoffs to determine if poppy seed ingestion could produce positive results in these heroin marker assays. In addition, all specimens were quantified for morphine and codeine by GC/MS. Participants (N=22) provided 391 urine specimens over 32 h following dosing; 26.6% and 83.4% were positive for morphine at 2000 and 300 μg/L GC/MS cutoffs, respectively. For the 19 subjects who completed the study, morphine concentrations ranged from <300 to 7522 μg/L with a median peak concentration of 5239 μg/L. The median first morphine-positive urine sample at 2000 μg/L cutoff concentration occurred at 6.6 h (1.2-12.1), with the last positive from 2.6 to 18 h after the second dose. No specimens were positive for codeine at a cutoff concentration of 2000 μg/L, but 20.2% exceeded 300 μg/L, with peak concentrations of 658 μg/L (284-1540). The Roche Opiates II immunoassay had efficiencies greater than 96% for the 2000 and 300 μg/L cutoffs. The CEDIA 6-AM immunoassay had a specificity of 91%, while the Lin-Zhi assay had no false positive results. These data provide valuable information for interpreting urine opiate results.
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Affiliation(s)
- Michael L Smith
- U.S. Army Forensic Toxicology Drug Testing Laboratory, Fort Meade, MD, USA
| | - Daniel C Nichols
- U.S. Army Forensic Toxicology Drug Testing Laboratory, Fort Meade, MD, USA
| | - Paula Underwood
- U.S. Army Forensic Toxicology Drug Testing Laboratory, Fort Meade, MD, USA
| | - Zachary Fuller
- U.S. Army Forensic Toxicology Drug Testing Laboratory, Fort Meade, MD, USA
| | - Matthew A Moser
- U.S. Army Forensic Toxicology Drug Testing Laboratory, Fort Meade, MD, USA
| | - Charles LoDico
- Division of Workplace Programs, Substance Abuse Mental Health Services Administration, Department of Health and Human Services, Rockville, MD, USA
| | - David A Gorelick
- Chemistry and Drug Metabolism, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA; Currently at Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew N Newmeyer
- Chemistry and Drug Metabolism, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA; Program in Toxicology, University of Maryland Baltimore, Baltimore, MD, USA
| | - Marta Concheiro
- Chemistry and Drug Metabolism, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA
| | - Marilyn A Huestis
- Chemistry and Drug Metabolism, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA.
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18
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Abstract
Opioid analgesic misuse has risen significantly over the past two decades, and these drugs now represent the most commonly abused class of prescription medications. They are a major cause of poisoning deaths in the USA exceeding heroin and cocaine. Laboratory testing plays a role in the detection of opioid misuse and the evaluation of patients with opioid intoxication. Laboratories use both immunoassay and chromatographic methods (e.g., liquid chromatography with mass spectrometry detection), often in combination, to yield high detection sensitivity and drug specificity. Testing methods for opioids originated in the workplace-testing arena and focused on detection of illicit heroin use. Analysis for a wide range of opioids is now required in the context of the prescription opioid epidemic. Testing methods have also been primarily based upon urine screening; however, methods for analyzing alternative samples such as saliva, sweat, and hair are available. Application of testing to monitor prescription opioid drug therapy is an increasingly important use of drug testing, and this area of testing introduces new interpretative challenges. In particular, drug metabolism may transform one clinically available opioid into another. The sensitivity of testing methods also varies considerably across the spectrum of opioid drugs. An understanding of opioid metabolism and method sensitivity towards different opioid drugs is therefore essential to effective use of these tests. Improved testing algorithms and more research into the effective use of drug testing in the clinical setting, particularly in pain medicine and substance abuse, are needed.
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19
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Mura P, Saussereau E, Brunet B, Goullé JP. [Workplace testing of drugs of abuse and psychotropic drugs]. ANNALES PHARMACEUTIQUES FRANÇAISES 2012; 70:120-32. [PMID: 22655580 DOI: 10.1016/j.pharma.2012.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 02/20/2012] [Accepted: 03/03/2012] [Indexed: 11/18/2022]
Abstract
In France, workplace testing of drugs of abuse and psychotropic drugs is rarely performed; meanwhile it is a major public health problem. Furthermore, France is the European country that has been associated with the highest increase of the use of drugs of abuse, particularly cannabis. So workplace biological screening of drugs of abuse and of psychotropic drugs exposure is of major concern. New analytical techniques have been developed during the last years. The authors will consider analytical screening of drugs of abuse and particularly the comparison of analytical techniques applied to urine and saliva. The advantages and the disadvantages of these two matrices will be considered. Urinary and blood quantification will be reviewed, but also the interest of hair testing to explore chronic exposure. The research of psychotropic drugs in biological fluids is also a part of this paper. New analytical trends are promising and complete analysis of these substances will be soon routinely possible in blood using a single spot test.
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Affiliation(s)
- P Mura
- Laboratoire de toxicologie et de pharmacocinétique, centre hospitalier universitaire, BP 577, Poitiers cedex, France
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20
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Khan U, Nicell JA. Refined sewer epidemiology mass balances and their application to heroin, cocaine and ecstasy. ENVIRONMENT INTERNATIONAL 2011; 37:1236-1252. [PMID: 21683444 DOI: 10.1016/j.envint.2011.05.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 04/16/2011] [Accepted: 05/13/2011] [Indexed: 05/30/2023]
Abstract
The detection of illicit drugs in environmental matrices may be a cause for concern, both from the perspective of their potential environmental impacts and the fact that their presence in detectable concentrations would be an indicator of significant drug use. The primary goal behind recent studies on this subject has been to use measured influent concentrations of selected illicit drugs or their in vivo metabolites in the environment as a means of estimating the abuse level of these drugs and patterns of consumption. Thus-far, such calculations have hinged on the use of solitary excretion estimates from single studies of limited scope and/or studies of limited applicability. Therefore, the need exists to conduct a comprehensive meta-analysis of metabolic disposition studies to construct excretions profiles for the various illicit drugs and their in vivo metabolites. The constructed excretory profiles should not only provide mean excretion values but also indicate the expected variations in excreted fractions that arise due to differences not only in the metabolic capacity of users but also in the efficiencies of various routes of administration for a given illicit drug. Therefore, the primary goal of the research presented here was to refine sewer epidemiology extrapolation mass balances for various illicit drugs of interest by constructing their excretory profiles segregated by route-of-administration. After conducting such a study with a multi-national scope on illicit drugs including cocaine, heroin and ecstasy, the results obtained clearly indicate that extrapolation factors currently being used in literature for these drugs to enumerate prevalence of abuse required significant refinement to increase their reliability.
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Affiliation(s)
- Usman Khan
- Department of Civil Engineering & Applied Mechanics, McGill University, 817 Sherbrooke St. West, Montreal, Quebec, Canada
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21
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Abstract
Urine toxicology screening testing is an important standard of care in the addiction and pain treatment setting, offering a reproducible, unbiased, and accurate laboratory test to monitor patients and provide objective support for clinical observations. It has been shown that physicians do not have proficiency in the ordering or interpretation of these tests. This article is an attempt to respond to that need. Current antibody-based enzymatic immunoassays (EIAs) used for urine toxicology screening are useful to detect classes of drugs (ex., opiate) but cannot determine which specific drug (ex., morphine) is present. Gas chromatography and mass spectroscopy can determine exactly which drugs are present, allowing prescribed (or illicit) opiates and benzodiazepines to be identified. This article will discuss principles and details of opiate and benzodiazepine EIA and gas chromatography and mass spectroscopy urine toxicology testing. The approach to detecting patients attributing positive opiate EIAs to prescription opiates who are using heroin or other opioids will be reviewed. Cases of controlled prescription drugs that do not produce the expected positive urine tests (ex., oxycodone producing negative opiate screening tests) will be discussed. How to differentiate codeine from heroin and the role of poppy seeds in toxicology will be examined. The case of an anti-depressant drug that produces false-positive benzodiazepine results and antibiotics that cause positive opiate urine toxicology results will be reviewed. Common benzodiazepines (ex., clonazepam and lorazepam) that do not reliably produce positive benzodiazepine EIAs will be discussed. The approach to detection and management of all these types of toxicology cases will be reviewed, and it is hoped that the analyses presented will impart an adequate information base to medical providers and staff members of drug treatment and pain centers, enabling them to order and interpret these tests in the clinic more effectively as an integrated part of whole patient care.
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Affiliation(s)
- Peter L Tenore
- Wellness Center atWaters Place, 1510Waters Place, Bronx, NY 10461, USA.
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22
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Abstract
The interpretation of toxicological findings is critical for the thorough investigation of the use and abuse of psychoactive substances. A positive analytical result for a sample taken could usually result in criminal proceedings and a punitive outcome for the defendant whose sample was analysed. The detection of markers of illicit opiate misuse is important both in the management of substance misuse and in the postmortem identification of illicit opiate use. The aim of this study was to emphasise the role of opiate biomarkers available at the laboratory and in the clinical environment. Urine remains the biological tool of choice for qualitative detection of illicit drug use in a clinical setting, while quantitative accuracy remains strictly the domain of blood. Accurate interpretation of the screening tests within a clinical setting alongside other relevant information remains the key to the usefulness of any test. Moreover, the finding of a morphine/codeine concentration ratio in blood exceeding unity is a strong evidence that the person had used heroin, as opposed to having taken a prescription analgesic drug containing codeine.
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Affiliation(s)
- M Stefanidou
- Department of Forensic Medicine and Toxicology, Medical School, University of Athens, Athens, Greece.
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23
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Krasowski MD, Pizon AF, Siam MG, Giannoutsos S, Iyer M, Ekins S. Using molecular similarity to highlight the challenges of routine immunoassay-based drug of abuse/toxicology screening in emergency medicine. BMC Emerg Med 2009; 9:5. [PMID: 19400959 PMCID: PMC2688477 DOI: 10.1186/1471-227x-9-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Accepted: 04/28/2009] [Indexed: 11/10/2022] Open
Abstract
Background Laboratory tests for routine drug of abuse and toxicology (DOA/Tox) screening, often used in emergency medicine, generally utilize antibody-based tests (immunoassays) to detect classes of drugs such as amphetamines, barbiturates, benzodiazepines, opiates, and tricyclic antidepressants, or individual drugs such as cocaine, methadone, and phencyclidine. A key factor in assay sensitivity and specificity is the drugs or drug metabolites that were used as antigenic targets to generate the assay antibodies. All DOA/Tox screening immunoassays can be limited by false positives caused by cross-reactivity from structurally related compounds. For immunoassays targeted at a particular class of drugs, there can also be false negatives if there is failure to detect some drugs or their metabolites within that class. Methods Molecular similarity analysis, a computational method commonly used in drug discovery, was used to calculate structural similarity of a wide range of clinically relevant compounds (prescription and over-the-counter medications, illicit drugs, and clinically significant metabolites) to the target ('antigenic') molecules of DOA/Tox screening tests. These results were compared with cross-reactivity data in the package inserts of immunoassays marketed for clinical testing. The causes for false positives for phencyclidine and tricyclic antidepressant screening immunoassays were investigated at the authors' medical center using gas chromatography/mass spectrometry as a confirmatory method. Results The results illustrate three major challenges for routine DOA/Tox screening immunoassays used in emergency medicine. First, for some classes of drugs, the structural diversity of common drugs within each class has been increasing, thereby making it difficult for a single assay to detect all compounds without compromising specificity. Second, for some screening assays, common 'out-of-class' drugs may be structurally similar to the target compound so that they account for a high frequency of false positives. Illustrating this point, at the authors' medical center, the majority of positive screening results for phencyclidine and tricyclic antidepressants assays were explained by out-of-class drugs. Third, different manufacturers have adopted varying approaches to marketed immunoassays, leading to substantial inter-assay variability. Conclusion The expanding structural diversity of drugs presents a difficult challenge for routine DOA/Tox screening that limit the clinical utility of these tests in the emergency medicine setting.
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24
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Høiseth G, Bernard JP, Karinen R, Johnsen L, Helander A, Christophersen AS, Mørland J. A pharmacokinetic study of ethyl glucuronide in blood and urine: Applications to forensic toxicology. Forensic Sci Int 2007; 172:119-24. [PMID: 17306943 DOI: 10.1016/j.forsciint.2007.01.005] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/05/2007] [Accepted: 01/06/2007] [Indexed: 10/23/2022]
Abstract
This pharmacokinetic study investigated the kinetics of ethanol and its metabolite ethyl glucuronide (EtG) in blood and urine during the whole time course of absorption and elimination. There are few previous studies on the kinetics of EtG in blood, and we wanted to evaluate whether such knowledge could yield valuable information regarding the time of ethanol ingestion in forensic cases, such as, for instance, drunk driving. Ten male volunteers consumed ethanol at a fixed dose of 0.5 g/kg body weight in a fasted state. Blood samples were collected for 14 h and urine samples were collected for 45-50 h after the start of drinking. EtG reached its maximum concentration (C(max)) in blood after a median of 4 h (range 3.5-5), a median of 3 h (range 2-4.5) after C(max) for ethanol. The ethanol-to-EtG ratios in blood (ethanol in g/L, EtG in mg/L) were >1 only for the first median 3.5 h (range 2.5-3.5) after drinking. EtG elimination occurred with a median half-life of 2.2 h (range 1.7-3.1 h), and the renal clearance was 8.32 L/h (median, range 5.25-20.86). The concentrations of EtG were always much higher in urine than in blood. The total amount of EtG excreted in the urine was median 30 mg (range 21.5-39.7), representing 0.017% (median, range 0.013-0.022) of the ethanol given, on a molar basis. The information from the present study may be a valuable supplement to determine the time of ethanol ingestion. For this purpose, two subsequent increasing EtG values and a high ethanol-to-EtG ratio in blood would support information of recent drinking.
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Affiliation(s)
- Gudrun Høiseth
- Norwegian Institute of Public Health, Division of Forensic Toxicology and Drug Abuse, Nydalen, Oslo, Norway
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25
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Maurer HH, Sauer C, Theobald DS. Toxicokinetics of drugs of abuse: current knowledge of the isoenzymes involved in the human metabolism of tetrahydrocannabinol, cocaine, heroin, morphine, and codeine. Ther Drug Monit 2006; 28:447-53. [PMID: 16778732 DOI: 10.1097/01.ftd.0000211812.27558.6e] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This review summarizes the major metabolic pathways of the drugs of abuse, tetrahydrocannabinol, cocaine, heroin, morphine, and codeine, in humans including the involvement of isoenzymes. This knowledge may be important for predicting their possible interactions with other xenobiotics, understanding pharmaco-/toxicokinetic and pharmacogenetic variations, toxicological risk assessment, developing suitable toxicological analysis procedures, and finally for understanding certain pitfalls in drug testing. The detection times of these drugs and/or their metabolites in biological samples are summarized and the implications of the presented data on the possible interactions of drugs of abuse with other xenobiotics, ie, inhibition or induction of individual polymorphic and nonpolymorphic isoenzymes, discussed.
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Affiliation(s)
- Hans H Maurer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, University of Saarland, D-66421 Homburg (Saar), Germany.
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26
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Abstract
Data on the detection times of drugs of abuse are based on studies of controlled administration to volunteers or on the analysis of biologic samples of subjects who are forced to stop their (often chronic) use of drugs of abuse, eg, because of imprisonment or detoxification. The detection times depend mainly on the dose and sensitivity of the method used and also on the preparation and route of administration, the duration of use (acute or chronic), the matrix that is analyzed, the molecule or metabolite that is looked for, the pH and concentration of the matrix (urine, oral fluid), and the interindividual variation in metabolic and renal clearance. In general, the detection time is longest in hair, followed by urine, sweat, oral fluid, and blood. In blood or plasma, most drugs of abuse can be detected at the low nanogram per milliliter level for 1 or 2 days. In urine the detection time of a single dose is 1.5 to 4 days. In chronic users, drugs of abuse can be detected in urine for approximately 1 week after last use, and in extreme cases even longer in cocaine and cannabis users. In oral fluid, drugs of abuse can be detected for 5-48 hours at a low nanogram per milliliter level. The duration of detection of GHB is much shorter. After a single dose of 1 or 2 ng of flunitrazepam, the most sensitive methods can detect 7-aminoflunitrazepam for up to 4 weeks in urine.
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Affiliation(s)
- Alain G Verstraete
- Clinical Biology Laboratory, Ghent University Hospital, B-9000 Ghent, Belgium.
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27
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Affiliation(s)
- T A Brettell
- Forensic Science Laboratory Bureau, New Jersey State Police, Box 7068, West Trenton, New Jersey 08628-0068, USA
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