Concomitant drug abuse of opioid dependent patients in maintenance treatment detected with a multi-target screening of oral fluid

Trends in polysubstance use among patients in methadone maintenance treatment in Ireland: Evidence from urine drug testing 2010-2020

INTRODUCTION

The benefits of methadone maintenance treatment (MMT) may be compromised by the continued use of other substances during treatment. Polysubstance use has been identified as a major contributing factor to treatment discontinuation, a known risk factor for drug overdose. We examined trends in immunoassay drug positivity rates for amphetamines, benzodiazepines, cannabis, cocaine and opioids, and (2) trends in polysubstance positivity rates for drug combinations associated with increased risk of drug overdose among patients attending the national drug treatment centre in Ireland for MMT between 2010 and 2020.

METHODS

Repeated cross-sectional study of patients attending the national drug treatment centre (NDTC) for MMT (total N = 1942) between 2010 and 2020, focused on urine drug samples provided for testing to the NDTC clinical testing laboratory (n = 221,564). Samples were analysed using immunoassay during the study period. Mixed-effects logistic regression models evaluate time trends in drug positivity. A random intercept accounts for repeat testing of individual patients. The study reports Adjusted Odds Ratios (AOR) for time (per year) with 95 % Confidence Intervals (95 % CI).

RESULTS

Drug positivity rates increased over time for benzodiazepines (AOR 1.02, 95 % CI 1.01-1.03, p < .0001), cannabis (AOR 1.06, 95 % CI 1.05-1.08, p < .0001) and cocaine (AOR 1.28, 95 % CI 1.27-1.29, p < .0001), with decreasing trends for opioids (AOR 0.91, 95 % CI 0.91-0.92, p < .0001). Methadone and benzodiazepines were co-detected in over two-thirds of all samples during the study period. Co-detection of methadone and benzodiazepines with cocaine was also found to be increasing (AOR 1.24, 95 % CI 1.23-1.25, p < .0001), with weighted polysubstance positivity rates reaching 29.2 % in 2020. The co-detection of methadone and benzodiazepines with opioids decreased over the study period (AOR 0.92, 95 % CI 0.91-0.92, p < .0001), ranging from 36.7 % in 2010 to 26.9 % in 2020.

CONCLUSION

Interventions are needed to target the persistently high use of benzodiazepines among patients in receipt of methadone due to their synergistic effects with opioids on respiratory depression, enhancing the risk of overdose. The growing use of cocaine among people in MMT also needs to be addressed.

A Human Oral Fluid Assay for D- and L- Isomer Detection of Amphetamine and Methamphetamine Using Liquid-Liquid Extraction

Medical providers are increasingly confronted with clinical decision-making that involves (meth)amphetamines. And clinical laboratories need a sensitive, efficient assay for routine assessment of D- and L-isomers to determine the probable source of these potentially illicit analytes. This paper presents a validated method of D- and L-isomer detection in human oral fluid from an extract used for determination of a large oral fluid assay (63 analytes) on an older AB SCIEX 4000 instrument. Taken from the positive extract, D- and L-analytes were added. The method for extraction included addition of internal standard and a 2-step liquid-liquid extraction and dry-down step to concentrate and clean the samples. The samples were suspended in 50% MeOH in water, diluted with mobile phase, with separation and detection accomplished using LC-MS/MS to determine analyte concentration. Once samples were confirmed positive for (meth)amphetamine from the large oral fluid assay, they were further examined for the enantiomeric forms with 50 μl aliquots of the standards and samples of interest combined with 450 μl of D- and L-assay mobile phase, then analyzed using chiral column separation, and LC-MS/MS detection with standard curve spanning the range from 2.5 to 1000 ng/mL. The result is a sensitive and accurate detection of D- and L-isomers of amphetamine and methamphetamine in human oral fluid performed on an older model mass spectrometer (AB SCIEX 4000). The novelty of this assay is twofold (a) the 2-step liquid-liquid extraction and dry-down step to concentrate and clean the samples, and (b) its adoption characteristics as a reflex test from a large ODT panel without the need to invest in newer or expensive LC-MS/MS instruments. Finally, this assay also has potential to add a valuable option to high-throughput laboratories seeking a D- and L-testing alternative to urine drug testing methods.

Specific polysubstance use patterns predict relapse among patients entering opioid use disorder treatment

Introduction

While polysubstance use has consistently been associated with higher rates of relapse, few studies have examined subgroups with specific combinations and time course of polysubstance use (i.e., polysubstance use patterns). This study aimed to classify and compare polysubstance use patterns, and their associations with relapse to regular opioid use in 2637 participants in three large opioid use disorder (OUD) treatment trials.

Methods

We explored the daily patterns of self-reported substance use in the 28 days prior to treatment entry. Market basket analysis (MBA) and repeated measure latent class analysis (RMLCA) were used to examine the subgroups of polysubstance use patterns, and multiple logistic regression was used to examine associations between identified classes and relapse.

Results

MBA and RMLCA identified 34 "associations rules " and 6 classes, respectively. Specific combinations of polysubstance use and time course (high baseline use and rapid decrease of use prior to initiation) predicts a worse relapse outcome. MBA showed individuals who co-used cocaine, heroin, prescription opioids, and cannabis had a higher risk for relapse (OR = 2.82, 95%CI = 1.13, 7.03). In RMLCA, higher risk of relapse was observed in individuals who presented with high baseline prescription opioid (OR = 1.9, 95% CI = 1.3, 2.76) or heroin use (OR = 3.54, 95%CI = 1.86, 6.72), although use decreased in both cases prior to treatment initiation.

Conclusions

Our analyses identified subgroups with distinct patterns of polysubstance use. Different patterns of polysubstance use differentially predict relapse outcomes. Interventions tailored to these individuals with specific polysubstance use patterns prior to treatment initiation may increase the effectiveness of relapse prevention.

Science of interdisciplinary salivary bioscience: history and future directions

Salivary bioscience is noteworthy in its history, as well as in the breadth and scope of its impact. The minimally invasive nature of sampling oral fluid allows for evaluation of individual and intra-individual change in biological processes in ways and settings not possible with traditional biospecimens. The range of measurements is expansive (e.g., DNA, hormones, cytokines, antibodies) and modern technologies enable simultaneous multisystem assessment from a singlet specimen. Used in combination with modern multivariate analytical models, the capacity to repeatedly assess multisystem and level measurements collected from the same individual over time enable operationalization, testing and refinement of complex biobehavioral models. This review describes the emerging narrative of salivary bioscience, and aims to inform and reveal opportunity for innovation and discovery.

Hydromorphone and codeine concentrations in oral fluid specimens from patients receiving substitution therapy with Substitol™ (morphine sulfate)

This study aimed to determine whether hydromorphone and codeine can be detected in oral fluid specimens following administration of Substitol™, a slow-release formulation of morphine. This is of interest for those monitoring treatment compliance using drug testing. Oral fluid specimens collected for compliance assessment in routine clinical practice or as part of a clinical trial were subjected to quantitative analysis of hydromorphone, morphine, codeine, and 6-acetylmorphine using highly sensitive mass spectrometric methods. Oral fluid was collected using a Greiner Bio-One saliva collection system. Patients undergoing substitution treatment with Substitol™, methadone, or buprenorphine were included, together with patients undergoing pain treatment with hydromorphone. Hydromorphone was detected in 642 of the 663 (97%) samples from substitol-treated patients. Concentrations were not higher in methadone- and buprenorphine-treated patients who relapsed into heroin use, or in patients on hydromorphone therapy. Codeine was detected in 29% of the samples. These concentrations were lower than those in patients who had relapsed to heroin use. Clinical administration of morphine can lead to detectable concentrations of both hydromorphone and codeine in oral fluids. This should be taken into consideration when using drug testing in oral fluid samples for compliance assessment in this patient group.

Dextromethorphan Abuse Among Opioid-Dependent Patients

BACKGROUND

Among opioid-dependent patients on maintenance therapy, concomitant drug abuse is a serious problem. Dextromethorphan, an over-the-counter antitussive agent that can be purchased without prescription, is a drug with a high potential for misuse, especially when consumed in high doses.The objective of this study was to investigate possible abuse of dextromethorphan among substituted opioid-dependent patients and comparison of subjective and objective findings.Due to its ability to increase serotonin levels, opioid-dependent patients may be particularly susceptible to dextromethorphan misuse. Dextromethorphan misuse may have side effects, including psychiatric symptoms and serotonin syndrome, and may induce assault, suicide, or homicide.

METHODS

A total of 104 opioid-dependent patients in maintenance treatment were included in this cross-sectional study conducted in the outpatient department of the Psychiatric Hospital, University of Zurich. Study participants were divided into 2 groups based on laboratory results: dextromethorphan abusers (n = 12) and nonabusers (n = 92). The objective use and concentrations of dextromethorphan was detected using 3-month hair toxicology analysis.Statistical analysis was performed by using χ test, Student t test, Mann-Whitney U test, and Barnard exact test.

RESULTS

Dextromethorphan was abused by 12 (11.5%) patients, 11 (91.7%) of whom did not report concomitant abuse of dextromethorphan but were identified through hair analysis. In general, there were significant differences among patients abusing dextromethorphan compared with nondextromethorphan consumers in terms of trauma due to sexual maltreatment/violence, multiple traumas, or harmful use of hallucinogenic drugs.

CONCLUSIONS

Further studies are necessary to examine dextromethorphan and its impact on patients with psychiatric comorbidities and psychiatric medication. According to literature, there is a significant drug interaction risk due to the impact of dextromethorphan misuse on serotonin syndrome and psychiatric symptoms.1-3 We recommend active inquiry into and testing for concomitant drug abuse among substituted opioid-dependent patients to reduce the risk of drug interactions and side effects in this especially vulnerable group of patients.

Gabapentinoid Abuse in France: Evidence on Health Consequences and New Points of Vigilance

Introduction: Gabapentinoid drugs (gabapentin and pregabalin) are widely used worldwide for epileptic and pain disorders. First signals of gabapentinoid abuse occurred in the last decade. This study aims to describe clinical characteristics of gabapentinoid use related disorders and health consequences in France. Materials and Methods: We designed a multisource investigation reviewing data reported to the French Addictovigilance Network (FAN) with pregabalin and gabapentin from 2010 to 2019. Information was obtained through the analysis of Spontaneous Reports (SRs) notified by health professionals and the pharmacoepidemiological surveys OSIAP (suspicious prescriptions forms indicators of potential abuse), OPPIDUM (observation of illicit drugs and misuse of psychotropic medications), DRAMES (death related to prescription drugs and other substances), and DTA (toxic deaths due to analgesics). Results: Over 2010-2019 period, were collected: (i) 265 SRs (258 pregabalin; 7 gabapentin); (ii) 816 forged prescription forms (805 pregabalin, 10 gabapentin, 1 involving both drugs); (iii) 145 cases of gabapentinoid use in people who use drugs (121 pregabalin; 24 gabapentin) and (iv) 31 cases of gabapentinoid-related deaths (25 pregabalin; 6 gabapentin). Risk factors of gabapentinoid abuse were opioid use disorders or psychiatric history, but cases of primary abuse in subjects without any substance abuse history were observed. Adverse outcomes concern almost exclusively pregabalin, with coma, dyspnea, convulsion, and conduction disorders. Treatment demands increased from 10.6% in 2018 to 23.1% in 2019, with pregabalin cited as the first substance leading to addictological care in the 2019 OPPIDUM survey. Gabapentinoid-related deaths increased over time. Pregabalin has become the first drug mentioned in forged prescriptions in 2019 (23.8% of OSIAP), while it ranked at the 15th position in 2017 (2.6%). Discussion: This study shows the importance of addictovigilance monitoring for gabapentinoids. Addictovigilance data helped to make visible the gabapentinoid-abuse related health harms (hospitalization for serious neurologic, psychiatric or cardiac effects, requests for addictological support and deaths) and to confirm the intrinsic abuse potential of pregabalin. These data highlight new points of vigilance considering observed primary abuse. At this point in France, the risk of abuse and related complications is very apparent with pregabalin. Still, it is identical to that observed elsewhere with gabapentin.

Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update

BACKGROUND

A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially.

OBJECTIVE

Update previous SR and describe new insights regarding gabapentinoid abuse.

METHODS

A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded.

RESULTS

Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk.

CONCLUSION

Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.

A vulnerability assessment for the HCV infections associated with injection drug use

After the 2014-2015 HIV outbreak in Scott County, Indiana, United States Centers for Disease Control and Prevention (CDC) conducted a nationwide analysis to identify vulnerable counties to an outbreak of Hepatitis C Virus (HCV)/Human Immunodeficiency Virus (HIV) and prevent such an outbreak in the future. We developed a jurisdiction-level vulnerability assessment for HCV infections associated with injection drug use (IDU) in Utah. We used three years of data (2015-2017) from 15 data sources to construct a regression model to identify significant indicators of IDU. A ZIP Code, county, or individual-level measure of IDU does not exist, therefore, CDC has suggested using HCV cases as a proxy for IDU. We used the Social Vulnerability Index to highlight vulnerable areas to HCV outbreaks and applied Geographical Information System (GIS) to identify hot spots of HCV infections (i.e. current/ongoing HCV transmissions). Rates of skin infection, buprenorphine prescription, administered naloxone, teen birth, and per capita income were associated with HCV infections. The opioid epidemic is dynamic and over time, it impacts different communities through its sequelae such as HCV outbreaks. We need to conduct this vulnerability assessment frequently, using updated data, to better target our resources. Moreover, we should consider evaluating whether the improvement of HCV screening has an impact on controlling HCV outbreaks. The analysis informs Utah's agencies and healthcare officials to target resources and interventions to prevent IDU-related HCV outbreaks. Our results inform policymakers at the national level on possible indicators of HCV outbreaks as well.

Opioid and Polydrug Use Among Patients in Opioid Maintenance Treatment

Purpose

Opioid maintenance treatment reduces a person’s use of heroin. However, frequent substance use in treatment is a problem.

Aim

To examine the association between opioid maintenance treatment and opioid/polydrug use, and whether social factors, adverse experiences, social resources, and quality of life are associated with opioid/polydrug use during the first 12 months in treatment.

Patients and Methods

Forty-seven participants from treatment units in Bergen, Norway participated in five waves of data collection. Every third month, a structured face-to-face interview collected self-reported data on sociodemographic characteristics, opioid/polydrug use, participants’ social resources or adverse experiences, and quality of life. Data were collected as part of KVARUS, the National Quality Register for Substance Abuse Treatment. A multilevel binary logistic regression analysis was conducted to examine the association of opioid/polydrug use and time in current treatment. The analysis included regressions of opioid/polydrug use on time-invariant baseline adverse experiences and social resources, and time-varying reports of quality of life.

Results

There was a significant negative association between time in treatment and use of opioids, b =−0.89, SE = 0.19, p = <0.01. Furthermore, a negative association of age at substance use on polydrug use was found, b =−0.40, SE =0.19, p = 0.03. A higher overall quality of life was significantly associated with lower odds of opioid use during opioid maintenance treatment, b = −0.62, SE = 0.23, p = < 0.01. Social dimensions, participants’ adverse experiences, and social resources were not associated with polydrug or opioid use.

Conclusion

Opioid maintenance treatment is associated with lowered opioid use, but to a lesser degree with polydrug use. Our findings add quality of life as an important factor that should be given particular attention because it can offer insight to aspects that can affect the patients’ opioid use.

Detection of heroin intake in patients in substitution treatment using oral fluid as specimen for drug testing

BACKGROUND

Detection of heroin use is among the major tasks for drug testing and can be best performed by using 6-acetylmorphine as the target analyte. This study was performed to document analytical findings in oral fluid after OF heroin intake.

METHODS

The samples were from routine drug testing of patients in substitution treatment. The analytical investigation was made with a forensic accredited liquid chromatography-tandem mass spectrometry method.

RESULTS

Out of 2814 samples, from 1875 patients, sent for routine drug testing, 406 contained one or more opiate in the drug screening when applying a cutoff limit of 1 ng/mL neat OF. Out of these 406, 314 had a measured 6-AM concentration in neat OF ≥ 1 ng/mL. The study demonstrated that 6-AM is a viable parameter in oral fluid drug testing with an about 80% sensitivity compared to using morphine and codeine as biomarkers. An additional value of using 6-AM is the confidence in concluding a heroin intake. The 6-AM concentrations varied between 1 and >1000 ng/mL, with a median value of 18.6 ng/mL. Heroin was measured in 35 samples with a median value of 0.72 ng/mL. The positive rate for opiates in urine and OF drug testing was the same, 13.5%, in similar populations of patients.

CONCLUSIONS

6-AM is a preferred parameter in OF drug testing for monitoring heroin use and makes OF drug testing for detecting heroin use more effective than urine drug testing when using highly sensitive mass spectrometry methods.

A validated workflow for drug detection in oral fluid by non-targeted liquid chromatography-tandem mass spectrometry

Oral fluid is recognized as an important specimen for drug testing. Common applications are monitoring in substance abuse treatment programs, therapeutic drug monitoring, pain management, workplace drug testing, clinical toxicology, and driving under the influence of drugs (DRUID). In this study, we demonstrate that non-targeted LC-MS/MS with subsequent compound identification by tandem mass spectral library search is a valuable tool for comprehensive detection and confirmation of drugs in oral fluid samples. The workflow developed involves solid-phase extraction and chromatographic separation on reversed phase materials. Mass spectrometric detection is accomplished on a quadrupole-quadrupole-time-of-flight instrument operated with data-dependent acquisition control. The workflow was optimized for 500 μl of neat oral fluid collected with the Greiner Bio-One saliva collection system. The fitness of the developed method was tested and proven by analyzing blank and spiked samples as well as 59 authentic patient samples. We could demonstrate that compounds with logP values in the range 0.5-5.5 are efficiently detected at low nanograms per milliliter concentrations. The true positive and true negative rates of automated library search were equal or close to 100%. The beauty of the non-targeted LC-MS/MS approach is the ability to detect compounds hardly included in routinely applied targeted assays, and this was demonstrated by detecting the synthetic opioid U-47700 in two patient samples. Graphical abstract ᅟ.