An analysis of cocaine powder in the Netherlands: content and health hazards due to adulterants

Drug checking services for people who use drugs: a systematic review

BACKGROUND AND AIMS

Drug checking services provide people who use drugs with chemical analysis results of their drug samples while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) the influence of drug checking services on the behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services.

METHODS

Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science and Dissertations and Theses Global. Eligible studies were peer-reviewed articles and conference abstracts or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools.

RESULTS

We screened 2463 titles and abstracts and 156 full texts, with 90 studies meeting inclusion criteria. Most (n = 65, 72.2%) were from Europe and used cross-sectional designs (n = 79, 87.7%). Monitoring of drug markets by drug checking services (n = 63, 70%) was the most reported domain, followed by the influence of drug checking services on behaviour (n = 31, 34.4%), including intent to use, actual use and disposal of the drug, and outcomes related to models of drug checking services (n = 17, 18.9%). The most common outcome measures were detection of unexpected substances (n = 50, 55.6%), expected substances (n = 44, 48.9%), new psychoactive substances (n = 40, 44.4%) and drugs of concern (n = 32, 36.5%) by drug checking services.

CONCLUSIONS

Drug checking services appear to influence behavioural intentions and the behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe, and increasingly in North America. Concerns about drug contents and negative health consequences facilitate the use of drug checking services; lack of concern; trust in drug sellers; lack of accessibility of drug checking services; and legal and privacy concerns are barriers to use.

Impurities, adulterants and cutting agents in cocaine as potential candidates for retrospective mining of GC-MS data

Cocaine is one of the most widely used illicit drugs worldwide. Cocaine powders seized by the Police may contain numerous other substances besides the drug itself. These can be impurities originating from the coca plant or the production process, or be purposely added to the drug formulation as adulterants and cutting agents. In forensic laboratories, identification of cocaine is routinely done through GC-MS analysis, but other components are often ignored even if the method allows for their detection. Yet, they can provide valuable insight into the history of a seizure and its potential connection to other samples. To explore this idea, an extensive review of common impurities and adulterants encountered in cocaine is presented. Based on their incidence, concentration in the end product and compatibility with GC-MS methods, their overall usefulness as candidates for the statistical investigation of existing forensic data is evaluated. The impurities cis- and trans-cinnamoylcocaine, tropacocaine, norcocaine and N-benzoylnormethylecgonine as well as the adulterants lidocaine, procaine, tetracaine, benzocaine, caffeine, acetylsalicylic acid, phenacetin, ibuprofen, levamisole, hydroxyzine and diltiazem are promising candidates to provide additional forensic intelligence. Future research on optimized routine GC-MS methods, signal reproducibility, comparison, statistics and databases is suggested to facilitate this concept. Ultimately, such an approach may significantly advance the amount of information that is extracted from routine casework data, elucidate developments in the cocaine markets in the past and facilitate Police work in the future. Preliminary assessment of existing data from the forensic laboratory of the Amsterdam Police has been included to show that the detection of the identified target impurities is feasible, and that small adjustments to the analysis method could significantly increase the detectability of these analytes in prospective drug screenings. Forensic intelligence based on retrospective data mining of cocaine containing casework samples may thus be realized with minimal additional laboratory efforts by using already available instrumentation, samples and data.

Purity of street-level cocaine across Denmark from 2006 to 2019: Analysis of seized cocaine

Cocaine-related emergency department admissions are increasing, and cocaine seizures are at an all-time high in Europe. Our aim was to investigate the trends in purity and adulterants over time in cocaine available to cocaine users at street level in Denmark. We used a representative sample of cocaine seized at street level and analyzed by the national departments of forensic medicine between 2006 and 2019 (n = 1460). Latent profile analysis was used to classify the samples based on cocaine, levamisole, and phenacetin content. Low purity cocaine comprised most of the cocaine seizures in early years, but its share began to decline in 2013, and from 2016 to 2019, the high purity profile was dominant. While the total number of samples containing adulterants decreased, levamisole remained a common and dangerous adulterant. The findings underline the need to inform the public, medical doctors, and service providers for people with drug use disorders about the higher potency of street cocaine.

Cutting agents in cocaine: A temporal study of the period 2015-2017 in the Northern Region of Colombia

Cocaine is a naturally occurring psychostimulant drug available worldwide. Drug trafficking networks adulterate pure cocaine with cutting agents to increase their earnings. This study presents a descriptive statistical analysis of the cutting agents found in 2118 cocaine samples that were seized in the Northern Region of Colombia (in the period 2015-2017). The data used in this study was drawn from the GC-MS analytical reports of the National Institute of Legal Medicine and Forensic Sciences -Colombia, Northern Region. Results showed diverse cutting agents in seized cocaine samples, from which the most commonly used are caffeine, phenacetin, lidocaine, imidazole and levamisole. In addition, cocaine samples showed different mixtures of the above cutting agents, predominantly caffeine/phenacetin and caffeine/lidocaine/phenacetin mixtures.

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.

Personal Doses of Cocaine and Coca Paste are Adulterated in Cartagena de Indias (Colombia)

Knowledge of drug composition consumed on the streets and the identification and quantification of their adulterants is essential for understanding unexpected side effects, tracking routes, and drug profiling. Therefore, this work aimed to determine the purity and to identify and quantify the main adulterants found in personal doses of cocaine (perico) and coca paste (bazuco) in Cartagena de Indias (Colombia). The data collected in this study describe a first attempt to introduce the qualitative and quantitative analyses of adulterants present in street drugs in Cartagena de Indias to improve surveillance. Through gas chromatography coupled to mass spectrometry (GC-MS), the purity and adulterants were quantified in 45 personal doses of cocaine powder and coca paste. 100% of the personal doses in the city were adulterated; caffeine, phenacetin, and levamisole were the main adulterants identified in cocaine. Besides the above, lidocaine was also found in coca paste. The purity of cocaine varied from 8% to almost 70%, with caffeine ranging from 6% to 42%. In the case of coca paste, the maximum content of cocaine found was 60%, while some samples contained as little as 14%. The results are consistent with other research in terms of the widespread use of caffeine as an adulterant, but they also follow the growing trend of the use of levamisole and phenacetin. The wide range of cocaine content in samples sold in the illicit market could cause undesirable effects on cocaine users who do not know the exact intended dose for consumption; so, this study intends to make these results available not only to academic, public health, and national security agencies but also to tourists entering Cartagena de Indias, so that they are aware of what they are consuming and the risks to which they are exposed.

An optical sensor for the detection and quantification of lidocaine in cocaine samples

An optical sensor (OS) was synthesized by mixing 10,12-pentacosadiinoic acid (PDA) with a triblock copolymer for use in the detection/quantification of lidocaine (LD) in seized cocaine hydrochloride (seized CH) samples. In the presence of LD, the OS presented a chromatic transition from blue to red, while no chromatic transition was observed for other typical cocaine adulterants or cocaine hydrochloride. Isothermal titration calorimetry analysis revealed specific interactions between the PDA molecules of the OS and the LD molecules, with these interactions being enthalpically favorable (-1.20 to -36.7 kJ mol^-1). Therefore, the OS color change only occurred when LD was present in the sample, making the OS selective for LD. Consequently, LD was successfully detected in seized CH samples, irrespective of the type of adulteration. The OS was used for the quantification of LD in seized CH samples containing different adulterants, providing a linear range of 0.0959 to 0.225% (w/w), a precision of 7.2%, an accuracy ranging from -10 to 10%, and limits of detection and quantification of 0.0110% (w/w) and 0.0334% (w/w), respectively.

The Anesthesiologist's Armamentarium: From Recreation to Medication and Back

For millennia, mankind has sought a means of altering consciousness, often aided by naturally occurring elements. Psychotropic substances have been an integral part of spiritual, medicinal, and recreational aspects of life. The origin of anesthesiology stems directly from the use of recreational drugs; early inhaled anesthetics were first used as a means of entertainment. Hence, it is no surprise that many medications in the anesthesiologist's armamentarium are diverted for recreational use. In the 172 years following the first successful public demonstration of ether anesthesia, many drugs with abuse potential have been introduced to the practice of anesthesia. Although anesthesiologists are aware of the abuse potential of these drugs, how these drugs are obtained and used for recreational purposes is worthy of discussion. There are articles describing the historical and recreational use of specific drug classes. However, to the best of our knowledge, this is the first comprehensive review focusing on the breadth of drugs used by anesthesiologists.

Multi-drug cocktails: Impurities in commonly used illicit drugs seized by police in Queensland, Australia

BACKGROUND

Impurities in commonly used illicit drugs raise concerns for unwitting consumers when pharmacologically active adulterants, especially new psychoactive substances (NPS), are used. This study examines impurities detected in illicit drugs seized in one Australian jurisdiction.

METHODS

Queensland Health Forensic and Scientific Services provided analytical data. Data described the chemical composition of 9346 samples of 11 illicit drugs seized by police during 2015-2016. Impurities present in primary drugs were summarized and tabulated. A systematic search for published evidence reporting similar analyses was conducted.

RESULTS

Methamphetamine was the primary drug in 6608 samples, followed by MDMA (1232 samples) and cocaine (516 samples). Purity of primary drugs ranged from ∼30% for cocaine, 2-CB and GHB to >90% for THC, methamphetamine, heroin and MDMA. Methamphetamine and MDMA contained the largest variety of impurities: 22 and 18 variants, respectively. Drug adulteration patterns were broadly similar to those found elsewhere, including NPS, but in some primary drugs impurities were found which had not been reported elsewhere. Psychostimulants were adulterated with each other. Levamisole was a common impurity in cocaine. Psychedelics were adulterated with methamphetamine and NPS. Opioids were quite pure, but some samples contained methamphetamine and synthetic opioids.

CONCLUSIONS

Impurities detected were mostly pharmacologically active adulterants probably added to enhance desired effects or for active bulking. Given the designer nature of these drug cocktails, the effects of the adulterated drugs on users from possible complex multi-drug interactions is unpredictable. Awareness-raising among users, research into complex multi-drug effects and ongoing monitoring is required.

When does the cutting of cocaine and heroin occur? The first large-scale study based on the chemical analysis of cocaine and heroin seizures in Switzerland

BACKGROUND

Illicit drug profiling can provide knowledge about illicit drug markets, informing on the level of distribution and its evolution in space and time. Illicit drug profiling is usually limited to impurities originally present in the illicit drug (e.g. alkaloids, co-extracted compounds or by-products). However, the benefit of a comprehensive analysis of cutting agents in drug seizures for law enforcement agencies, intelligence and health policy has not been thoroughly investigated in the literature and is the focus of this research.

AIM

This research aims at assessing when and how cutting (i.e. adulteration and dilution) occurs in the supply chain by analysing cocaine and heroin seizures made between 2006 and 2015 in Switzerland.

METHODS

Cocaine and heroin seizures made along the supply chain by law enforcement agencies in the Western region of Switzerland were investigated for adulteration and dilution. A total number of 7841 cocaine and 3476 heroin specimens coming from 1341 and 721 seizures, respectively, were analysed.

RESULTS

The results show that, for both illicit drugs, adulteration and/or dilution occur before arrival into Switzerland as well as in Switzerland. While cocaine is adulterated and diluted, heroin is only adulterated. Interestingly, the same mixture of adulterants (i.e. caffeine-paracetamol) is used to cut heroin at each step in the supply chain.

CONCLUSION

Gaining knowledge about adulteration and dilution at different stages in the supply chain enhances our understanding of drug markets. It also highlights differences along the supply chain and in the distribution of both drugs in Switzerland.

Adulterants in crack cocaine in Brazil

Abstract Introduction Brazil is the world’s biggest consumer of crack cocaine, and dependence is a major public health issue. This is the first study to investigate the prevalence of potentially harmful adulterants present in hair samples from Brazilian patients with crack cocaine dependence. Method We evaluated adulterants in hair samples extracted by convenience from 100 patients admitted at the 48 hour-observation unit of Centro de Referência de Álcool, Tabaco e Outras Drogas (CRATOD), Brazil’s largest center for addiction treatment. A cross-sectional analysis was performed with the data obtained. Results Adulterants were found in 97% of the analyzed hair samples. The most prevalent adulterant was lidocaine (92%), followed by phenacetin (69%) and levamisole (31%). Conclusion Adulterants were widely prevalent in hair samples from crack users treated at CRATOD: at least one adulterant was present in virtually all the hair samples collected. This points to a need to monitor adverse effects in the clinical setting in order to provide this high-risk group of patients with prompt and effective care related to the acute and chronic complications associated with these adulterants.

Cocaine adulteration with the anthelminthic tetramisole (levamisole/dexamisole): Long-term monitoring of its intake by chiral LC-MS/MS analysis of cocaine-positive hair samples

Recent studies indicate that not only the anthelminthic levamisole but also the racemate tetramisole (R-/S-phenyltetraimidazothiazole, PTHIT) was found as an adulterant for cocaine. We herein report on the investigation of the prevalence of PTHIT among cocaine-positive hair samples and the discrimination of the presence of its stereoisomers levamisole and dexamisole. Cocaine-positive hair samples were collected in a forensic context in 2015 and mainly 2017 (n = 724). Cocaine and PTHIT concentrations have been determined by achiral liquid chromatography-tandem mass spectrometry (LC-MS/MS). For distinction of levamisole/dexamisole chiral LC-MS/MS was performed. Cocaine hair concentrations ranged from 500 (cut-off) to approximately 800 000 pg/mg. The study demonstrates a strong prevalence of PTHIT in cocaine users' hair (87%, n = 627). PTHIT hair concentrations ranged from below LLOQ 3.5 to approximately 61 000 pg/mg (median: 260 pg/mg). Surprisingly, enantiomeric ratios of levamisole/dexamisole ranged from 0.17 to 1.34 (median: 0.63). Therefore, PTHIT-adulterated street cocaine samples (n = 24) seized between 2013 and 2016 were tested. Samples mainly contained racemic tetramisole (87.5%), only one sample contained levamisole only and two samples contained non-racemic PTHIT. Our experiments suggest that the presence of tetramisole in biological samples may have hitherto been underestimated. Most probably higher dexamisole than levamisole concentrations in hair specimens arise from stereoselective metabolism and/or elimination. This is particularly important in light of the different pharmacological activities of the two enantiomers and potentially different adverse effects. Toxicological interpretations in intoxication cases with adulterated cocaine should not only consider levamisole but also tetramisole and terminology in scientific contributions should be used accordingly.

Analysis of cocaine adulterants in human brain in cases of drug-related death

For different reasons, street cocaine is often diluted with pharmacologically active substances, the so-called adulterants such as levamisole or hydroxyzine. A controversial debate exists currently on the uptake of adulterants from cocaine preparations and drug-related death. Previous research convincingly argues that serious adverse side effects that affect the central nervous and cardiovascular systems can be a consequence of adulterated cocaine.

AIMS

Having identified the presence of adulterants in lung tissue and blood, the concentrations of these substances in brain, an important target location, was of interest. This provides an opportunity to assess their role in cases of drug-related deaths.

MATERIALS AND METHODS

We developed and validated a method for the analysis of cocaine, two cocaine metabolites and six adulterants, which can typically be found in cocaine preparations, and one adulterant metabolite in brain tissue by gas chromatography-mass spectrometry (GC-MS)¹. Ten brain samples which were tested positive for cocaine were analyzed. The homogenized brain tissue was embedded into drying paper for protein precipitation. During a subsequent solid-phase extraction (SPE), the eluate and one of the wash fractions were collected. After derivatization with N-Methyl-N-(trimethylsilyl)trifluoroacetamide (MSTFA) in pyridine and isooctane, the extracts were analyzed by GC-MS.

RESULTS AND DISCUSSION

The method was fully validated for cocaine (COC), benzoylecgonine (BZE), ecgonine methyl ester (EME), diltiazem (DIL), hydroxyzine (HYD), and levamisole (LEV) and partly validated for cetirizine (CET), lidocaine (LID), phenacetin (PHE), and procaine (PRO) in brain material. By analyzing post-mortem brain tissue of ten cocaine users, LEV, LID, and HYD as well as PHE were identified in contrast to DIL, PRO, and the HYD metabolite CET. HYD and LEV were found in moderate to high concentrations in some cases. Therefore, it cannot be excluded that they have caused adverse side effects.

CONCLUSION

Because adulterants can potentially affect the central nervous and cardiac systems, it is likely that they enhance COC toxicity.

Surgical Management of Levamisole-Adulterated Cocaine Induced Soft Tissue Necrosis: Case Study and Treatment Algorithm

Levamisole is an increasingly common cocaine adulterant that can cause severe and rapid onset cutaneous vasculitis in humans. While most cases may be managed conservatively, we describe a series of patients in whom the extent of skin and soft tissue necrosis mandated surgical intervention. A retrospective review of all patients admitted to one of two regional burn centers between 2006 and 2016 for soft tissue necrosis after exposure to levamisole-adulterated cocaine was included in our study. Ten patients, majority female (9/10) with an average age of 43.4 years (range 31-57), were included. Cocaine usage before presentation averaged 6 days (range 1-14). Presenting complaints consisted of arthralgia (5/10), fever (7/10), and purpuric lesions (10/10). Average TBSA involvement was 23.5% (range 4-70). Immunological testing revealed perinuclear antineutrophil cytoplasmic antibody (pANCA+) in 8 of 10 and cytoplasmic antineutrophil cytoplasmic antibody (cANCA+) in 4 of 8 patients. Operative intervention occurred by postadmission day 11.6 (range 3-30). The mean number of operations required was 3 (range 2-6); length of stay averaged 46.8 days (range 14-120); and survival to discharge was 100% (10/10). To our knowledge, this is the largest case study detailing the surgical management of levamisole-associated skin necrosis. Additionally, we describe the most extensive case of this disease process at 70% TBSA involvement. Based on our experience, we recommend waiting for purpuric rash resolution and soft tissue necrosis to be fully demarcated before fascial debridement and then staged skin grafting with allograft followed by autograft.

Levamisole in Illicit Trafficking Cocaine Seized: A One-Year Study

Cocaine use is increasing around the world and its purity is frequently altered through dilution, substitution, contamination, and adulteration. Sugars, talc, starch, and carbonates represent the principal diluents of cocaine, while phenacetin, levamisole, caffeine, and lidocaine are its major adulterants in Europe. Levamisole is used because it is an odorless powder, with physical properties similar to cocaine, and it has reasonable cost and availability, being widely used in veterinary medicine. For this study, we analyzed 88 cocaine samples. The seized cocaine analyzed showed an average purity of 55% and the most frequent adulterants identified were: levamisole (31.8%), caffeine (6.8%), lidocaine (2.3%), acetaminophen (2.3%), and phenacetin (1.1%). Our aim is the study of the presence of levamisole, over other adulterants in seized cocaine samples, due to its recognized human toxicity. The chronic use of levamisole-adulterated cocaine represents a serious public health issue because it may be responsible for side-effects such as dermal vasculopathy, leukoencephalopathy, leukopenia, agranulocytosis, pulmonary hemorrhage, multiple emboli, and several other effects. Moreover, aminorex can cause idiopathic pulmonary hypertension, presenting another harmful and mostly lethal side-effect from cocaine cut with levamisole. In conclusion, levamisole determination should be performed in routine toxicological analysis in deaths due to cocaine use.

An exploratory study of information sources and key findings on UK cocaine-related deaths

Cocaine-related deaths have increased since the early 1990s in Europe, including the UK. Being multi-factorial, they are difficult to define, detect and record. The European Monitoring Centre for Drugs and Drug Addiction commissioned research to: describe trends reported to Special Mortality Registries and General Mortality Registers; provide demographic and drug-use characteristic information of cases; and establish how deaths are identified and classified. A questionnaire was developed and piloted amongst all European Monitoring Centre for Drugs and Drug Addiction Focal Point experts/Special Mortality Registries: 19 (63%) responded; nine countries provided aggregated data. UK General Mortality Registers use cause of death and toxicology to identify cocaine-related deaths. Categorisation is based on International Classification of Diseases codes. Special Mortality Registries use toxicology, autopsy, evidence and cause of death. The cocaine metabolites commonly screened for are: benzoylecgonine, ecgonine methyl ester, cocaethylene and ecgonine. The 2000s saw a generally accelerating upward trend in cases, followed by a decline in 2009. The UK recorded 2700-2900 deaths during 1998-2012. UK Special Mortality Registry data (2005-2009) indicate: 25-44 year-olds account for 74% of deaths; mean age=34 (range 15-81) years; 84% male. Cocaine overdoses account for two-thirds of cases; cocaine alone being mentioned/implicated in 23% in the UK. Opioids are involved in most (58%) cocaine overdose cases.

Purity, adulteration and price of drugs bought on-line versus off-line in the Netherlands

BACKGROUND AND AIMS

On-line drug markets flourish and consumers have high expectations of on-line quality and drug value. The aim of this study was to (i) describe on-line drug purchases and (ii) compare on-line with off-line purchased drugs regarding purity, adulteration and price.

DESIGN

Comparison of laboratory analyses of 32 663 drug consumer samples (stimulants and hallucinogens) purchased between January 2013 and January 2016, 928 of which were bought on-line.

SETTING

The Netherlands.

MEASUREMENTS

Primary outcome measures were (i) the percentage of samples purchased on-line and (ii) the chemical purity of powders (or dosage per tablet); adulteration; and the price per gram, blotter or tablet of drugs bought on-line compared with drugs bought off-line.

FINDINGS

The proportion of drug samples purchased on-line increased from 1.4% in 2013 to 4.1% in 2015. The frequency varied widely, from a maximum of 6% for controlled, traditional substances [ecstasy tablets, 3,4-methylenedioxy-methamphetamine (MDMA) powder, amphetamine powder, cocaine powder, 4-bromo-2,5-dimethoxyphenethylamine (2C-B) and lysergic acid diethylamide (LSD)] to more than a third for new psychoactive substances (NPS) [4-fluoroamphetamine (4-FA), 5/6-(2-aminopropyl)benzofuran (5/6-APB) and methoxetamine (MXE)]. There were no large differences in drug purity, yet small but statistically significant differences were found for 4-FA (on-line 59% versus off-line 52% purity for 4-FA on average, P = 0.001), MDMA powders (45 versus 61% purity for MDMA, P = 0.02), 2C-B tablets (21 versus 10 mg 2C-B/tablet dosage, P = 0.49) and ecstasy tablets (131 versus 121 mg MDMA/tablet dosage, P = 0.05). The proportion of adulterated samples purchased on-line and off-line did not differ, except for 4-FA powder, being less adulterated on-line (χ²  = 8.3; P < 0.02). Drug prices were mainly higher on-line, ranging for various drugs from 10 to 23% higher than that of drugs purchased off-line (six of 10 substances: P < 0.05).

CONCLUSIONS

Dutch drug users increasingly purchase drugs on-line: new psychoactive substances in particular. Purity and adulteration do not vary considerably between drugs purchased on-line and off-line for most substances, while on-line prices are mostly higher than off-line prices.

Medical complications of psychoactive substances with abuse risks: Detection and assessment by the network of French addictovigilance centres

The use of psychoactive substances, whether occasional or regular, can induce a large number of clinical and/or biological complications. These complications may be related to the effects of the active substance itself and/or adulterants, but also to the modalities for use (administrations route, contexts of use). The detection and evaluation of these potentially severe complications are a public health issue. Beyond the assessment of the potential for abuse of and dependence on psychoactive substances, the collection and evaluation of complications related to the use of the substances are one of the roles of addictovigilance centres. In this article, the expertise of the French addictovigilance centres in the detection and assessment of medical complications related to psychoactive substances, adulterants or route of administration of substances is advanced through a few recent examples.

Simple and Sensitive Paper-Based Device Coupling Electrochemical Sample Pretreatment and Colorimetric Detection

We report the development of a simple, portable, low-cost, high-throughput visual colorimetric paper-based analytical device for the detection of procaine in seized cocaine samples. The interference of most common cutting agents found in cocaine samples was verified, and a novel electrochemical approach was used for sample pretreatment in order to increase the selectivity. Under the optimized experimental conditions, a linear analytical curve was obtained for procaine concentrations ranging from 5 to 60 μmol L(-1), with a detection limit of 0.9 μmol L(-1). The accuracy of the proposed method was evaluated using seized cocaine samples and an addition and recovery protocol.

Drug testing in Europe: monitoring results of the Trans European Drug Information (TEDI) project

Drug testing is a harm reduction strategy that has been adopted by certain countries in Europe. Drug users are able to hand in their drugs voluntarily for chemical analysis of composition and dose. Drug users will be alerted about dangerous test results by the drug testing systems directly and through warning campaigns. An international collaborative effort was launched to combine data of drug testing systems, called the Trans European Drug Information (TEDI) project. Drug testing systems of Spain, Switzerland, Belgium, Austria, Portugal, and the Netherlands participated in this project. This study presents results of some of the main illicit drugs encountered: cocaine, ecstasy and amphetamine and also comments on new psychoactive substances (NPS) detected between 2008 and 2013. A total of 45 859 different drug samples were analyzed by TEDI. The drug markets of the distinct European areas showed similarities, but also some interesting differences. For instance, purity of cocaine and amphetamine powders was generally low in Austria, whilst high in Spain and the Netherlands. And the market for ecstasy showed a contrast: whereas in the Netherlands and Switzerland there was predominantly a market for ecstasy tablets, in Portugal and Spain MDMA (3,4-methylenedioxymethamphetamine) crystals were much more prevalent. Also, some NPS appearing in ecstasy seemed more specific for one country than another. In general, prevalence of NPS clearly increased between 2008 and 2013. Drug testing can be used to generate a global picture of drug markets and provides information about the pharmacological contents of drugs for the population at risk. Copyright © 2016 John Wiley & Sons, Ltd.

Norcocaine and cocaethylene distribution patterns in hair samples from light, moderate, and heavy cocaine users

Even though hair analysis often seems to be the best choice for retrospective monitoring of cocaine intake, differentiating between incorporated cocaine and external contamination is widely debated. In this study we report results obtained in 90 hair samples from addicts. All samples were analyzed for cocaine, benzoylecgonine, norcocaine, cocaethylene, and tropococaine by gas chromatography‐mass spectrometry (GC‐MS) techniques coupled with direct immersion solid‐phase micro‐extraction. Cocaine concentrations were stratified into three classes of usage: light (0.5–3 ng/mg), moderate (3.1–10 ng/mg) and heavy (10.1–40 ng/mg). The Substance Abuse and Mental Health Services Administration cut‐off criteria for establishing active cocaine use were applied to the results. For all samples criteria were cocaine levels above 0.5 ng/mg (ranging from 1.63 to 39.29 ng/mg, mean 9.49 ng/mg), benzoylecgonine concentrations ≥ 0.05 ng/mg (ranging from 0.19 to 5.77 ng/mg, mean 1.40), and benzoylecgonine to cocaine % ratio ≥5% (from 6.43 to 26.09%). Norcocaine was present in 58.9% of samples (concentration range: 0.22–3.14 ng/mg) and was strongly predictive only of heavy cocaine use (sensitivity 100% for cocaine concentrations above 9.58 ng/mg). Twenty hair samples from moderate and heavy users tested positive for cocaethylene (concentration range: 0.22–1.98 ng/mg, mean 0.73 ng/mg). This study on hair samples with no chance of false positive cases highlights the very limited applications of testing minor cocaine metabolites for definitive proof of active cocaine consumption. © 2015 The Authors. Drug Testing and Analysis Published by John Wiley & Sons, Ltd.

Qualitative, quantitative and temporal study of cutting agents for cocaine and heroin over 9 years

Forensic laboratories mainly focus on the qualification and the quantitation of the illicit drug under analysis as both aspects are used for judiciary purposes. Therefore, information related to cutting agents (adulterants and diluents) detected in illicit drugs is limited in the forensic literature. This article discusses the type and frequency of adulterants and diluents detected in more than 6000 cocaine specimens and 3000 heroin specimens, confiscated in western Switzerland from 2006 to 2014. The results show a homogeneous and quite unchanging adulteration for heroin, while for cocaine it could be characterised as heterogeneous and relatively dynamic. Furthermore, the results indicate that dilution affects more cocaine than heroin. Therefore, the results provided by this study tend to reveal differences between the respective structures of production or distribution of cocaine and heroin. This research seeks to promote the systematic analysis of cutting agents by forensic laboratories. Collecting and processing data related to the presence of cutting agents in illicit drug specimens produces relevant information to understand and to compare the structure of illicit drug markets.

CHECK!NG: A última fronteira para a Redução de Riscos em contextos festivos

No contexto atual de proliferação de novas substâncias psicoativas (NSP) e de adulteração de substâncias psicoativas que circulam no mercado negro o Drug Checking é aqui encarado como uma estratégia major de redução de riscos e minimização de danos (RRMD). É um serviço que se tem vindo a afirmar como uma necessidade em termos de saúde pública, através da monitorização informal de mercados informais de substâncias psicoativas e emitindo alertas sempre que se identificam substâncias potencialmente tóxicas. É também uma boa prática na mediação da comunicação entre o técnico de RRMD e o utilizador de substâncias psicoativas, fornecendo informação objetiva sobre a substância que o utilizador disponibilizou para análise e produzindo e disseminando informação sobre os padrões de adulteração locais. Através da apresentação de práticas e resultados referentes à intervenção do projeto CHECK!NG, pretende-se neste artigo levantar pistas para uma reflexão sobre a pertinência e as particularidades de um serviço de Drug Checking em contexto festivos.

Potential diversion of local anesthetics from dental offices for use as cocaine adulterants

BACKGROUND

Reports of lidocaine and benzocaine in the bloodstreams of people who abuse cocaine with accompanying reports of seizures and methemoglobinemia indicate that there is a potential that local anesthetics are being diverted from dental offices and being used as cocaine adulterants. These adulterants augment the nasal numbness produced by inhaling cocaine.

METHODS

The authors conducted a PubMed search by using the following terms: "adulterants," "benzocaine," "cocaine," "lidocaine" and "methemoglobinemia."

RESULTS

The authors identified two case reports as a result of their PubMed search. Each case involved a patient with symptoms of both cocaine overdose and methemoglobinemia who sought treatment at an emergency department. The results of urine samples from each patient, as well as the results from an analysis of a sample of one patient's cocaine, revealed the presence of many adulterants, including lidocaine and benzocaine.

CONCLUSIONS

Injectable lidocaine and topical benzocaine are cheap and readily available substances found in dental offices that may be diverted by anyone-including dentists, office staff members or patients-to adulterate cocaine.

PRACTICAL IMPLICATIONS

Additional research is needed to identify whether dental offices are a common source of cocaine adulterants. The authors recommend that dentists keep track of their local anesthetic supplies.

Monitoring trends in recreational drug use from the analysis of the contents of amnesty bins in gay dance clubs

BACKGROUND

In 2011/12, 8.9% of the UK population reported use of recreational drugs. Problems related to drug use is a major financial burden to society and a common reason for attendance to hospital.

AIM

The aim of this study was to establish current trends in recreational drug use amongst individuals attending gay-friendly nightclubs in South London.

METHOD

Contents of drug amnesty bins located at two night clubs were documented and categorized into powders, herbal products, liquids, tablets and capsules. These were then sent to a Home Office licensed laboratory for identification through a pre-existing database of almost 25 000 substances. If required, further qualitative analysis was performed.

RESULTS

A total of 544 samples were obtained. Of them, 240 (44.1%) were liquids, 220 (40.4%) powders, 42 (7.7%) herbal and 41 (7.5%) tablets or capsules. Gamma-butyrolactone (GBL) was the most common liquid drug (n = 160, 66.7%) followed by poppers (n = 72, 30.0%). Powders provided the widest range of drugs with mephedrone being the most common (n = 105, 47.7%) followed by ketamine (n = 28, 12.7%), 3,4-methylenedioxy-N-methylamphetamine (MDMA) (n = 26, 11.8%), and cocaine (n = 21, 9.5%). Tablets and capsules included medicinal drugs, recreational drugs and plaster of Paris tablets that mimicked the appearance of 'ecstasy' tablets.

CONCLUSION

This study has provided a snapshot of the pattern of drug use in the gay community which compliments findings of the self-reported surveys and other studies from the same population. The information obtained will be helpful in guiding in designing harm reduction interventions in this community and for monitoring the impact of changes in legislation.

Lupus anticoagulant and ANCA associated thrombotic vasculopathy due to cocaine contaminated with levamisole: a case report and review of the literature

A 2010 US report recently detected the presence of levamisole in greater than 77 % of seized cocaine samples. A syndrome of retiform purpura, often involving ears and flanks, with vasculopathy or vasculitis on biopsy, associated with anti-nuclear cytoplasmic antibodies as well as antiphospholipid antibodies, previously associated with therapeutic use of levamisole has now re-emerged, and is associated with cocaine adulterated with levamisole. Patients with this unusual constellation of signs and laboratory findings should be questioned about exposure to cocaine.

Pharmacotherapeutics directed at deficiencies associated with cocaine dependence: focus on dopamine, norepinephrine and glutamate

Much effort has been devoted to research focused on pharmacotherapies for cocaine dependence yet there are no FDA-approved medications for this brain disease. Preclinical models have been essential to defining the central and peripheral effects produced by cocaine. Recent evidence suggests that cocaine exerts its reinforcing effects by acting on multiple neurotransmitter systems within mesocorticolimibic circuitry. Imaging studies in cocaine-dependent individuals have identified deficiencies in dopaminergic signaling primarily localized to corticolimbic areas. In addition to dysregulated striatal dopamine, norepinephrine and glutamate are also altered in cocaine dependence. In this review, we present these brain abnormalities as therapeutic targets for the treatment of cocaine dependence. We then survey promising medications that exert their therapeutic effects by presumably ameliorating these brain deficiencies. Correcting neurochemical deficits in cocaine-dependent individuals improves memory and impulse control, and reduces drug craving that may decrease cocaine use. We hypothesize that using medications aimed at reversing known neurochemical imbalances is likely to be more productive than current approaches. This view is also consistent with treatment paradigms used in neuropsychiatry and general medicine.