The Never-Ending Public Health Issue of Adulterants in Abused Drugs

Xylazine: A Drug Adulterant of Clinical Concern

PURPOSE OF REVIEW

The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.

RECENT FINDINGS

Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.

Strengthening Protocols for Rapid Response to Disruptions in Access to Prescription Opioids: Considerations for State and Territorial Health Agencies

Prescription opioid disruptions pose a danger and lead to adverse health outcomes for patients taking prescription opioids for pain or medication for opioid use disorder. State and territorial health agencies are uniquely positioned to respond to disruptions and potentially prevent risks associated with service disruptions. Responding to disruptions in access to prescription opioids necessitates a multifaceted, collaborative approach that prioritizes care continuity and patient well-being. State and territorial health agencies may benefit from developing and exercising a formal response protocol that outlines roles and activities during these types of events, strengthening capacity to rapidly respond and serve patient needs.

Xylazine and Overdoses: Trends, Concerns, and Recommendations

Xylazine is a nonopioid veterinary anesthetic and sedative that is increasingly detected in the illicit drug supply in the United States. Data indicate a striking prevalence of xylazine among opioid-involved overdose deaths. The emergence of xylazine in the illicit drug supply poses many unknowns and potential risks for people who use drugs. The public health system needs to respond by increasing testing to determine the prevalence of xylazine, identifying its potential toxicity at various exposure levels, and taking mitigating action to prevent harms. Currently, there is little testing capable of identifying xylazine in drug supplies, which limits the possibility of public health intervention, implementation of harm reduction strategies, or development of novel treatment strategies. (Am J Public Health. 2022;112(8):1212-1216. https://doi.org/10.2105/AJPH.2022.306881).

Plastic antioxidants: A family of cocaine cutting agents analyzed by short column gas chromatography-mass spectrometry

Plastic antioxidants (PAOs), which are used in the industry to prevent degradation caused by thermo-mechanical or thermo-oxidative conditions, have been found in cocaine products seized by the Civil Police of the Federal District, Brazil, since 2019. In this study, a 4-meter short column gas chromatography-mass spectrometry (GC-MS) qualitative method was optimized and validated to detect cocaine, PAOs (antioxidant 168, FOS; antioxidant 1076, NOX; and butylated hydroxytoluene, BHT) and 16 other cutting agents in cocaine base and salt. NOX and FOS are high-boiling-point compounds that are not amenable to the standard GC-MS methods. The method uses a 250 °C split mode injection, final temperature of 280 °C, and a total run time of 16.5 min. PAOs were found in 84.2% of the 38 cocaine base samples and in 21.5% of the 65 cocaine salt samples (mainly NOX); 20 samples that did not contain any cocaine also contained PAOs (30% NOX and 25% FOS). Other cutting agents found in the samples included phenacetin, aminopyrine, and lidocaine in cocaine base; lidocaine, tetracaine, and caffeine in cocaine salt. This is the first report of PAOs detected as cocaine cutting agents and shows another important application of the short column GC-MS method in forensic science that can also be applied in other areas involving these compounds.

Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse

Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.

Pharmacotherapeutic strategies for treating cocaine use disorder-what do we have to offer?

BACKGROUND

Cocaine use contines to be a significant public health problem world-wide. However, despite substantial research efforts, no pharmacotherapies are approved for the treatment of cocaine use disorder (CUD).

ARGUMENT

Studies have identified positive signals for a range of medications for treating CUD. These include long-acting amphetamine formulations, modafinil, topiramate, doxazosin and combined topiramate and mixed amphetamine salts extended-release (MAS-ER). However, valid conclusions about a medication's clinical efficacy require nuanced approaches that take into account behavioural phenotypes of the target population (frequency of use, co-abuse of cocaine and other substances, genetic subgroups, psychiatric comorbidity), variables related to the medication (dose, short-/long-acting formulations, titration speed, medication adherence) and other factors that may affect treatment outcomes. Meta-analyses frequently do not account for these co-varying factors, which contributes to a somewhat nihilistic view on pharmacotherapeutic options for CUD. In addition, the predominant focus on abstinence, which is difficult for most patients to achieve, may overshadow more nuanced therapeutic signals.

CONCLUSION

While there is an emphasis on finding new medications with novel mechanisms of action for treating CUD, currently available medications deserve further investigation based on the existing literature. Evaluating refined metrics of treatment success in well-defined subgroups of patients, and further exploring combination therapies and their synergy with behavioural/psychosocial interventions, are promising avenues to establishing effective therapies for CUD.

The Increasing Prevalence of Fentanyl: A Urinalysis-Based Study Among Individuals With Opioid Use Disorder in New York City

BACKGROUND AND OBJECTIVES

Opioid-related overdose deaths in North America have increased drastically, partially due to the increased prevalence of illicitly manufactured fentanyl. The current study sought to assess the prevalence and intentionality of fentanyl use among individuals with opioid use disorder (OUD).

METHODS

For this secondary analysis (study 1) we screened a total of 1118 urine samples from 316 participants with OUD from 2016 to 2019. Fentanyl knowledge and intentionality of use were assessed in a separate OUD sample (study 2; N = 33).

RESULTS

In study 1, 34.6% of all urine samples tested positive for fentanyl. Overall, 149 (47.2%) participants provided more than or equal to one urine sample that tested fentanyl-positive, and 93 (29.4%) provided more than or equal to two fentanyl-positive samples. The number of fentanyl-positive samples, relative to the number of samples tested each year, increased by 330% from year 1 to 3. Study 2 found all participants had pre-existing knowledge that drugs may be adulterated with fentanyl, yet 67% were surprised by their own fentanyl-positive test result.

DISCUSSION AND CONCLUSIONS

Like previous studies, our data indicate the high prevalence of fentanyl exposure and low perception of fentanyl-related risk among individuals with OUD, respectively, suggesting that opioid overdose harm reduction efforts may need to focus more on drug users' understanding of risks related to fentanyl use and adulteration of drugs.

SCIENTIFIC SIGNIFICANCE

The current studies provide longitudinal data on fentanyl exposure prevalence and risk perception that is uniquely granular by assessing OUD treatment status, and by identifying potential associations between fentanyl exposure with the presence of other drug use and nonfatal overdose. (Am J Addict 2021;30:65-71).

Sleep- and Wake-Promoting Drugs: Where Are They Being Sourced, and What Is Their Impact?

Background: Recent decades have seen both an increased number of shift workers in order to deliver services 24/7, and increased potential for social interactions at all hours of the day. People have sought to engage in strategies, which either promote vigilance or facilitate sleep, with the use of sleep- and wake-promoting drugs representing one strategy. Methods: We investigated use of sleep- and wake-promoting drugs in participants (n = 377) who completed a survey investigating the type and source of sleep- and wake-promoting drugs, and their impact on sleep and performance outcomes. Results: The most commonly reported wake-promoting drugs were amphetamine and dextroamphetamin salts, modafinil, and illicit substances including methamphetamine and cocaine, while the most commonly reported sleep-promoting drugs were benzodiazepines and antihistamines. Use of a sleep-promoting drug in the past month was associated with higher odds of having poorer sleep quality (OR = 3.15) and moderate-high insomnia (OR = 3.30), while use of a wake-promoting drug was associated with poor sleep quality (OR = 3.76), or making a fatigue-related error (OR = 2.65). Conclusions: These findings represent novel data on the use and source of sleep- and wake-promoting- drugs, and suggest that despite their use, poor sleep and performance outcomes persist, likely representing individuals struggling to keep up with the 24/7 world.

Drug checking as a potential strategic overdose response in the fentanyl era

Adulteration of illicit drug supplies with synthetic opioids such as fentanyl has contributed to a dramatic rise in overdose morbidity and mortality in North America. One promising response to this crisis is the implementation of "drug checking" services. Drug checking encompasses a range of interventions used to assess the constituents of illicit drug samples, such as colour-spot testing, gas or liquid chromatography, and various methods of spectroscopy. Testing may be performed on-site at events or harm reduction service locales, performed independently by consumers, or sent to a centralized lab for analysis. This information may then serve to inform individual decision-making, enhance harm reduction efforts and strengthen public health surveillance and response strategies to prevent harms associated with illicit drug use. Historical examples of drug checking services that emerged with the 1990s synthetic "party drug" movement in Europe provide a theoretical and practical basis for the adaptation of these services for use in context of the current opioid overdose crisis. Potential harm reduction benefits of drug checking for synthetic opioid adulterants include individuals being more likely to use drugs more safely or to dispose of drugs found to contain harmful adulterants. Public health benefits of drug checking may also include negative feedback on the illicit drug supply with decreased availability or consumption of drugs from sources adulterated with synthetic opioids following public health warning campaigns. As part of the response to the current synthetic opioid epidemic in BC, pilot efforts are being undertaken in Vancouver to determine the feasibility and effectiveness of drug checking as an overdose response strategy. Models of drug checking service delivery and comparison of differing technologies, including unique challenges and potential solutions related to access to these services, legal obstacles, and sensitivity and specificity of testing technologies, are explored, alongside suggestions for future research and directions.

Recent Trends in Analytical Methods to Determine New Psychoactive Substances in Hair

New Psychoactive Substances (NPS) belong to several chemical classes, including phenethylamines, piperazines, synthetic cathinones and synthetic cannabinoids. Development and validation of analytical methods for the determination of NPS both in traditional and alternative matrices is of crucial importance to study drug metabolism and to associate consumption to clinical outcomes and eventual intoxication symptoms. Among different biological matrices, hair is the one with the widest time window to investigate drug-related history and demonstrate past intake.

The aim of this paper was to overview the trends of the rapidly evolving analytical methods for the determination of NPS in hair and the usefulness of these methods when applied to real cases.

A number of rapid and sensitive methods for the determination of NPS in hair matrix has been recently published, most of them using liquid chromatography coupled to mass spectrometry. Hair digestion and subsequent solid phase extraction or liquid-liquid extraction were described as well as extraction in organic solvents. For most of the methods limits of quantification at picogram per milligram hair were obtained. The measured concentrations for most of the NPS in real samples were in the range of picograms of drug per milligram of hair. Interpretation of the results and lack of cut-off values for the discrimination between chronic consumption and occasional use or external contamination are still challenging.

Methods for the determination of NPS in hair are continually emerging to include as many NPS as possible due to the great demand for their detection.

New psychoactive substances: Purchasing and supply patterns in Australia

OBJECTIVE

To examine the purchasing and supply patterns of new psychoactive substance (NPS) consumers in Australia.

METHOD

Data were obtained from a self-selected sample of 296 past-year NPS consumers, with comparisons made across dimethyltryptamine (n = 104), 2C-x (n = 59), NBOMe (n = 27), and synthetic cannabinoid (n = 22) users.

RESULTS

Most consumers (58%) nominated a friend as their main NPS source, and almost half (46%) reported that they had supplied NPS to others in the past year (predominantly "social supply"). However, when comparisons were made across NPS, NBOMe users were more likely to nominate a dealer (30%) or online marketplace (22%) as their main source and to report: supplying NPS to others (63%); supplying to strangers (29%) and acquaintances (24%); and supplying NPS for cash profit (29%). Similarly, NPS consumers who nominated online markets as their main NPS source (9%; n = 26) were more likely to have supplied NPS to others (risk ratio [RR] 1.57); supplied to strangers (RR 6.05) and acquaintances (RR 12.11); sold NPS for cash profit (RR 4.36); and to have exchanged NPS for something else (RR 3.27) than those who reported alternative primary sources.

CONCLUSION

NBOMe consumers and those who nominated online markets as their main NPS source reported greater engagement with for-profit supply; it is unclear if these individuals have "drifted" into dealing or if they were already engaged in such activities.

Purity and adulterant analysis of some recent drug seizures in Italy

The data collected in this study describe an initial attempt to systematically introduce the qualitative and quantitative analysis of adulterants present in seized street drugs in Italy with the aim of improving surveillance and data sharing and for this purpose, the implementation of validated and standardized procedures are essential.