Methamphetamine disposition in oral fluid, plasma, and urine

A phase 3 randomised double-blind placebo-controlled trial of mirtazapine as a pharmacotherapy for methamphetamine use disorder: a study protocol for the Tina Trial

BACKGROUND

There are no approved pharmacotherapies for methamphetamine use disorder. Two preliminary phase 2 randomised controlled trials have found mirtazapine, a tetracyclic antidepressant, to be effective in reducing methamphetamine use. The proposed Tina Trial is the first phase 3 placebo-controlled randomised trial to examine the effectiveness and safety of mirtazapine as an outpatient pharmacotherapy for methamphetamine use disorder.

METHODS

This is a multi-site phase 3 randomised, double-blind, placebo-controlled parallel trial. Participants are randomly allocated (1:1) to receive either mirtazapine (30 mg/day for 12 weeks) or matched placebo, delivered as a take-home medication. The target population is 340 people aged 18-65 years who have moderate to severe methamphetamine use disorder. The trial is being conducted through outpatient alcohol and other drug treatment clinics in Australia. The primary outcome is measured as self-reported days of methamphetamine use in the past 4 weeks at week 12. Secondary outcomes are methamphetamine-negative oral fluid samples, depressive symptoms, sleep quality, HIV risk behaviour and quality of life. Other outcomes include safety (adverse events), tolerability, and health service use. Medication adherence is being monitored using MEMS® Smart Caps fitted to medication bottles.

DISCUSSION

This trial will provide information on the safety and effectiveness of mirtazapine as a pharmacotherapy for methamphetamine use disorder when delivered as an outpatient medication in routine clinical practice. If found to be safe and effective, this trial will support an application for methamphetamine use disorder to be included as a therapeutic indication for the prescription of mirtazapine.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12622000235707. Registered on February 9, 2022.

Methamphetamine detection using portable capillary electrophoresis coupled with a swab-based extraction device

Methamphetamine (MA) is one of the most virulent illicit drugs that can be synthesized from household materials leading to its prevalent trafficking and local manufacturing in clandestine drug laboratories (clan labs). The significant problems of tracing MA in clan labs and monitoring drug abusers lie in the lag time between sample collection and analysis and the number of tests done. Capillary electrophoresis (CE) is a rapid separation technique amenable to miniaturization and field testing. Herein, we developed a simple transient isotachophoretic (tITP)-CE method to detect MA and its precursor pseudoephedrine (PSE) in clan labs and non-invasive biological fluids. The method was implemented on the ETD-100, a commercial fully automated portable CE instrument with an integrated swab-based extraction system. Within 2 min of insertion of the swab, MA and PSE were automatically extracted with a leading electrolyte (LE) and then separated on covalently modified capillaries. The ETD-100 showed a limit of detection (LOD) and quantification (LOQ) of MA 0.02 and 0.05 μg/swab and 0.02 and 0.06 μg/swab of PSE, with an enhancement factor of 118 and 328, respectively, when compared to a normal non-tITP injection. The intra and inter-day relative standard deviation in terms of migration time were in the range of 0.75-1.93 % for both MA and PSE and were 2.0-2.4 % for both MA and PSE peak height. The method was demonstrated with the detection of spiked MA and PSE on different household materials as well as in non-invasive biological fluids with a recovery above 60 %.

Nanostructured Metal Oxide-Based Electrochemical Biosensors in Medical Diagnosis

Nanostructured metal oxides (NMOs) provide electrical properties such as high surface-to-volume ratio, reaction activity, and good adsorption strength. Furthermore, they serve as a conductive substrate for the immobilization of biomolecules, exhibiting notable biological activity. Capitalizing on these characteristics, they find utility in the development of various electrochemical biosensing devices, elevating the sensitivity and selectivity of such diagnostic platforms. In this review, different types of NMOs, including zinc oxide (ZnO), titanium dioxide (TiO2), iron (II, III) oxide (Fe3O4), nickel oxide (NiO), and copper oxide (CuO); their synthesis methods; and how they can be integrated into biosensors used for medical diagnosis are examined. It also includes a detailed table for the last 10 years covering the morphologies, analysis techniques, analytes, and analytical performances of electrochemical biosensors developed for medical diagnosis.

Drugs in dental biofilm and enamel - A pilot study

Objective

Enamel and dental biofilm might serve as alternative matrices for determination of illicit and medical drugs. Thus, this study aims at evaluating possible correlations between detected drug concentrations in the matrices and simulated drug use in situ.

Design

Eleven subjects wore intraoral splints with embedded demineralized bovine enamel samples. Drug use was simulated by mouth rinsing with a 1.0 μg/ml drug solution three times daily for 1 min (study A) or by incubation of the splints in a 10 μg/ml drug solution once a day for 30 min (study B). Amphetamines, opiates, cocaine and benzoylecgonine were used as drugs. After 11 days, biofilm and enamel samples of the intraoral splints were analyzed by liquid chromatography mass spectrometry after drying and extraction via ultrasonication with acetonitrile (biofilm) or methanol (enamel).

Results

In study A, median and mean drug concentration ± standard deviation were 1.3 pg/mg and 6.4 ± 11 pg/mg in biofilm and 0.2 pg/mg and 0.5 ± 0.9 pg/mg in enamel. In study B, median and mean drug concentration ± standard deviation were 350 pg/mg and 1100 ± 1600 pg/mg in biofilm and 5.8 pg/mg and 9.9 ± 10 pg/mg in enamel.

Conclusions

Overall, there were considerable interindividual concentration differences. Correlations between concentrations in the two sample materials were shown. The results of this pilot study revealed a dependence of concentrations on intensity and duration of drug contact. Thus, important information on past drug use might be provided in forensic cases by analysis of dental biofilm and enamel.

[Clinical profile and non-recreational methamphetamine abuse (shabu) among stroke patients in the Philippine population]

INTRODUCTION

Chronic non-recreational use of methamphetamine (shabu) is increasing among the Filipino population in Barcelona. The Asian population presents a different stroke pattern, with a higher incidence of haemorrhage, and different vascular risk factors and health behaviours. The objective of this study is to describe the stroke profile and incidence of methamphetamine use in patients of Filipino origin admitted to our centre.

PATIENTS AND METHODS

Demographic data, vascular risk factors, clinical data and prognosis were recorded. Methamphetamine exposure was analysed in plasma samples collected on admission, which were then analysed by liquid chromatography-mass spectrometry.

RESULTS

Of a total of 6,418 stroke patients, 73 (1.1%) were identified as being of Filipino origin. The mean age was 54.4 ± 12.1 years, 54% were male and the stroke was ischaemic in 64.4% of cases. Arterial hypertension was the main risk factor. Ten (13.7%) patients tested positive for methamphetamine and amphetamine. These results confirm recent substance use prior to the stroke, mostly in men (80%). In patients who were consumers, 60% had a haemorrhagic stroke, with a poor functional prognosis at three months in 55.6% of patients.

CONCLUSIONS

In our setting, patients of Filipino ethnicity admitted for stroke related to the consumption of shabu belonged a younger age bracket, with a lower prevalence of vascular risk factors and a predominance of the haemorrhagic subtype. Methamphetamine testing in Filipino stroke patients is recommended due to the high prevalence of methamphetamine use in our country.

Practice Considerations for the Methamphetamine Use Disorder Patient

Methamphetamine substance use disorders (SUD) are a topic of increasing concern in the United States or America and continue to impact families and communities throughout the United States. Methamphetamine users account for approximately 1.6 million individuals. It is important for health care providers to be aware of the potential lethal impacts of restraining aggressive individuals. It is equally important to understand the impacts of increased circulating catecholamines or subsequent dearth after methamphetamine use and how medications may impact either state. Methamphetamine SUD patients can pose challenges to health care workers, however, safe and effective care is obtainable.

Diagnostic accuracy for self-reported methamphetamine use versus oral fluid test as the reference standard in a methamphetamine-dependent intervention trial population

AIMS

Treatment of methamphetamine dependence requires monitoring of recent use or abstinence. Self-report is commonly used for routine monitoring, but the accuracy of self-report is not established. For the treating clinician, the key accuracy statistic is the negative predictive value (NPV). The study aim was to estimate the NPV of self-reported non-use of methamphetamine compared with an oral fluid reference standard.

DESIGN, SETTING AND PARTICIPANTS

This study was a secondary (subgroup) analysis from a randomized controlled pharmacotherapy trial. Three Australian outpatient addiction services took part. Particpants were 139 people dependent on methamphetamine.

MEASUREMENTS

Weekly oral fluid samples over 12 weeks to determine methamphetamine (and amphetamine) concentrations were used as the reference standard. Self-report of any methamphetamine use in the previous 7 days by the time-line follow-back method was the index test. Standard diagnostic accuracy statistics were calculated for all available paired episodes (n = 1134). Three NPV values were calculated: unadjusted NPV and NPV adjusted for clustering of observations through logistic regression and generalized estimating equation (GEE). We also calculated the NPVs for a range of prevalence rates of methamphetamine use, for the calculated levels of sensitivity and specificity.

FINDINGS

Sensitivity was 96.4% [95% confidence interval (CI) = 95-97.5], specificity was 63.7% (95% CI = 57.3-69.8) and positive predictive value (PPV) was 90.8% (95% CI = 88.8-92.6). The unadjusted NPV was 82.7% (95% CI = 76.5-87.9), adjusted NPV by logistic regression 82.7% (95% CI = 73.9-91.5) and GEE 76.8% (95% CI = 66.8-86.8). At a methamphetamine use prevalence of 5%, the estimated NPV would be 99.7% (95% CI = 99.6-99.9) and at 95% prevalence, 48.2% (95% CI = 39.6-57.0).

CONCLUSIONS

Self-report of no recent methamphetamine use appears to be sufficiently accurate to be clinically useful at the expected prevalence rates of methamphetamine use in clinical treatment settings. If generalizable to clinical settings, where these tests are routinely conducted, this may permit a reduction in the frequency and cost of oral fluid assays.

Risk factors for relapse among methamphetamine users receiving a joint legal-medical treatment program as a diversion intervention: A one-year follow-up study

BACKGROUND

Methamphetamine (METH) is a Schedule II illicit drug in Taiwan. A 12-month legal-medical joint intervention program has been developed for first-time METH offenders during deferred prosecution. Risk factors associated with METH relapse use among these individuals were unknown.

METHODS

We enrolled a total of 449 METH offenders referred by the Taipei District Prosecutor's Office to Taipei City Psychiatric Center. The study defines relapse as having any positive urine toxicology result or self-report of METH use during 12-month treatment. We compared demographic and clinical variables between a relapse group and nonrelapse group and used a Cox proportional hazards model to determine variables associated with time to relapse.

RESULTS

Of all participants, 37.8 % relapsed to use METH and 23.2 % were noncompleters in the one-year follow-up. Compared to the nonrelapse group, the relapse group had lower educational attainment, more severe psychological symptoms, longer duration of METH use, higher odds of polysubstance use, higher craving severity, and higher odds of positive baseline urine. The Cox analysis revealed individuals with positive urine results and higher craving severity at baseline were at higher risks of METH relapse (hazard ratio [95 % CI]: 3.85 [2.61-5.68] and 1.71 [1.19-2.46], respectively, p < 0.001). Baseline positive urine results and high craving could also predict a shorter length of time to relapse than their respective counterparts.

CONCLUSIONS

Positive urine screening for METH at baseline and high craving severity are two indicators of an increased risk of drug relapse. Tailored treatment plans incorporating these findings to prevent relapse are warranted in our joint intervention program.

Refining the estimation of amphetamine consumption by wastewater-based epidemiology

Consumption of amphetamine and methamphetamine, two common illicit drugs, has been monitored by wastewater-based epidemiology (WBE) in many countries over the past decade. There is potential for the estimated amount of amphetamine used to be skewed at locations where methamphetamine is also consumed, because amphetamine is also excreted to wastewater following methamphetamine consumption. The present study aims to review the available data in the literature to identify an average ratio of amphetamine/methamphetamine (AMP/METH) that is excreted to wastewater after methamphetamine consumption. This ratio could then be used to refine the estimation of amphetamine consumption in catchments where there is both amphetamine and methamphetamine use. Using data from more than 6000 wastewater samples from Australia where methamphetamine is the dominant illicit amphetamine-type substance on the market, we were able to subtract the contribution of legal sources of amphetamine contribution and obtain the median AMP/METH ratio in wastewater of 0.09. Using this value, the amphetamine derived from methamphetamine consumption can be calculated and subtracted from the total amphetamine mass loads in wastewater samples. Without considering the contribution of amphetamine from methamphetamine use, selected European catchments with comparable consumption of amphetamine and methamphetamine showed up to 83% overestimation of amphetamine use. For catchments with AMP/METH ratio greater than 1.00, the impact of amphetamine from methamphetamine would be negligible; for catchments with AMP/METH ratio in the range of 0.04-0.19, it will be difficult to accurately estimate amphetamine consumption.

Methamphetamine-Induced Bowel Ischemia in a 50-Year-Old Male

Methamphetamine intoxication is a known risk factor for nonocclusive mesenteric ischemia (NOMI). We describe a case of a 50-year-old male with a history of polysubstance abuse who presented to the Emergency Department with severe abdominal pain and coffee-ground emesis. Computed tomographic (CT) imaging demonstrated portal venous gas and diffuse colonic wall thickening concerning for ischemic colitis. The patient underwent exploratory laparotomy with resection of the ascending colon as well as a necrotic section of the jejunum. Further embolic workup was negative with a subjective history of amphetamine use prior to presentation. NOMI has a high fatality rate, and we recommend providers include drug-induced bowel infarction on their differential when presented with findings of ischemic bowel of unclear etiology.

Methamphetamine use and technology-mediated psychosocial interventions: A mini-review

Engagement with face-to-face psychosocial interventions is often compromised in people using methamphetamine (MA), in the context of high rates of polysubstance use, mental health disorders, cognitive impairment and geographic isolation. Technology-mediated interventions offer flexible ways of engaging with treatment and are readily accessible. This mini-review evaluates evidence from eight studies for the effectiveness of telephone, mHealth (text-messaging and apps) and computer-based interventions for MA use. Two papers from one telephone counselling study showed a small improvement in MA-related outcomes, particularly for individuals in active use. However, a directive counselling style was associated with a higher likelihood of MA use during recovery for those higher in resistance to authority. Text-messaging interventions generally showed small but significant reductions in MA use in non-treatment seekers. When compared, there was no significant difference in level of MA use reduction between interactive, automated and self-monitoring text messages. Studies in other modalities (smartphone app, one trial; computer-based interventions, two trials) did not confer statistically significant reductions in MA use, though were likely impacted by app design and participant characteristics. Preliminary findings hint at the potential effectiveness of telephone counselling in aftercare and the capacity for text-messaging to reach those who are not in treatment. Given the small amount of existing literature, this review discusses the potential value of emerging interventions, the importance of adapting interventions to the characteristics of people who use MA and suggests specific directions for research in each technology modality.

Electrochemiluminescent screening for methamphetamine metabolites

The abuse of methamphetamine (MA) is to date detected and subsequently verified through the monitoring of MA and its metabolites within biological specimens. Current approaches require complex sample purification strategies alongside significant analysis time. Given the high prevalence of MA within the global drug market, there remains a need for rapid, portable and alternative screening approaches appropriate for direct detection within biological matrices for employment across the forensic and clinical environments. This contribution illustrates the use of an electrochemiluminescence (ECL) strategy for the screening of MA, amphetamine (AMP) and para hydroxy-methamphetamine (pOH-MA) for such applications. The sensing system showed ideal analytical performance with linear ranges at forensically relevant concentrations of 0.1 μM to 0.5 mM for MA, 10 μM to 1 mM AMP and 10 μM to 5 mM for pOH-MA, and superb detection limits of 74.6 nM, 6 μM and 82. μM for MA, AMP and pOH-MA respectively. Furthermore, the sensor was successful in the detection of MA, AMP and pOH-AMP within human pooled serum, artificial urine and saliva, without any prior purification strategies. Here a portable ECL sensor is detailed for the successful employment of the direct screening of these amphetamine type substances and their corresponding metabolites at clinically and forensically relevant concentrations within a range of biological matrices. This approach successfully represents a strong proof-of-concept, for a novel, simple and rapid screening method with significant potential for high-throughput screening of biological samples for drug metabolites, widening the avenues where ECL sensors could be employed.

Toward Addiction Prediction: An Overview of Cross-Validated Predictive Modeling Findings and Considerations for Future Neuroimaging Research

Substance use is a leading cause of disability and death worldwide. Despite the existence of evidence-based treatments, clinical outcomes are highly variable across individuals, and relapse rates following treatment remain high. Within this context, methods to identify individuals at particular risk for unsuccessful treatment (i.e., limited within-treatment abstinence), or for relapse following treatment, are needed to improve outcomes. Cumulatively, the literature generally supports the hypothesis that individual differences in brain function and structure are linked to differences in treatment outcomes, although anatomical loci and directions of associations have differed across studies. However, this work has almost entirely used methods that may overfit the data, leading to inflated effect size estimates and reduced likelihood of reproducibility in novel clinical samples. In contrast, cross-validated predictive modeling (i.e., machine learning) approaches are designed to overcome limitations of traditional approaches by focusing on individual differences and generalization to novel subjects (i.e., cross-validation), thereby increasing the likelihood of replication and potential translation to novel clinical settings. Here, we review recent studies using these approaches to generate brain-behavior models of treatment outcomes in addictions and provide recommendations for further work using these methods.

Whether drug detection in urine and oral fluid is similar? A systematic review

Urine has been a biological matrix of choice for drug screening, but recent advances in technology and the introduction of commercial oral fluid assays have effectively established oral fluid as a viable alternative matrix. This systematic review aimed to evaluate the sensitivity of oral fluid in detecting some illicit drugs compared to urine, and to compare the initial and final detection times of these drugs in both fluids. The electronic search in MEDLINE, Cochrane Library, Scopus, and Web of Science was carried out covering studies published from January 2003 and June 2019, in order to find all valid studies that detected drugs in oral fluid and urine in the same patient. Studies about illicit drugs, such as tetrahydrocannabinol, cocaine, amphetamines and illicit opioids, with fluids collection at the same day, controlled drug administration during the study, reported administration interval and time of collection were favored. Out of 2598 studies identified by electronic search, 7 studies were selected for qualitative analysis. Five were clinical trials and 2 were crossover trials. In total, 74 patients aged 20-52 years underwent a diagnostic examination (4 studies with tetrahydrocannabinol, 1 with methamphetamine, and 2 with cocaine) after drug administration. Illicit drug detection in oral fluid is similar to urine but oral fluid has a strong potential for the immediate detection of recent marijuana use compared to urine. In relation to cocaine and methamphetamine, the largest drugs detection window is obtained through urine analysis. Oral fluids cannot replace urine for most of the purposes of drug testing.

A surface plasmon resonance immunoassay for the rapid analysis of methamphetamine in forensic oral fluid

Background

Current chromatographic methods applied for the forensic analysis of methamphetamine are costly, time‐consuming, and require complicated pretreatment procedures. Thus, the rapid detection of methamphetamine is a critical and unmet need. In this study, a surface plasmon resonance (SPR) system based on indirect inhibitive immunoassay was designed for the analysis of methamphetamine in forensic oral fluid samples.

Methods

For the inhibition immunoassay, the diluted oral fluid was mixed with methamphetamine antibody and then injected into the SPR sensor chip. The biosensor chip was constructed by covalently immobilizing of methamphetamine‐bovine serum albumin conjugate onto a carboxymethyl dextran surface at an optimized pH. The concentration of antibody was also optimized.

Results

The SPR biosensor showed good sensitivity with a limit of detection of 0.44 ng/mL and was comparable or lower than the pre‐existing methods. The method was finally tested using oral fluid samples from 20 suspected drug abusers in forensic cases, and it provided an acceptable recovery of 113.2%, indicating good anti‐interference capability of the SPR sensor.

Conclusion

The SPR biosensor was rapid, reproducible, and had a great potential approach for the forensic detection of methamphetamine.

Fluorescence Excitation-Emission Spectroscopy: An Analytical Technique to Monitor Drugs of Addiction in Wastewater

Emerging contaminants of concern have become a serious issue for the scientific community and society more broadly in recent years due to their increasingly widespread environmental distribution and largely unknown environmental and human health impacts. This study aimed to explore the use of fluorescence excitation-emission (F-EEM) spectroscopy as an alternative analytical method to evaluate the presence of key drugs of addiction (benzoylecgonine, methamphetamine, MDMA, codeine and morphine) in wastewater treatment plants. The chemicals of interest from wastewater were extracted by mixed-mode solid phase extraction and quantified using liquid chromatography tandem mass spectrometry. The same wastewater samples were also analysed by a fluorescence spectrophotometer for fluorescence spectra at wavelengths 280–600 nm (emission) and 200–600 nm (excitation). The study also investigated the relevance of different methods for interpreting F-EEM matrices data including parallel factor analysis (PARAFAC) modelling and fluorescence regional integration technique. PARAFAC identified four components, and among them, component C2, identified at the λex/λem = 275/340 nm wavelength associated with proteinaceous compounds most likely related to tryptophan amino acid, showed significant correlation with codeine removal. MDMA and morphine were not correlated to any of the fluorescence regions. The fluorescence regions related to aromatic protein-like fluorescence were correlated significantly with drug concentration and so may offer a suitable alternative approach for monitoring drugs including benzoylecgonine, methamphetamine and codeine.

Dielectrophoretic Nanoparticle Aggregation for On-Demand Surface Enhanced Raman Spectroscopy Analysis

Rapid chemical identification of drugs of abuse in biological fluids such as saliva is of growing interest in healthcare and law enforcement. Accordingly, a label-free detection platform that accepts biological fluid samples is of great practical value. We report a microfluidics-based dielectrophoresis-induced surface enhanced Raman spectroscopy (SERS) device, which is capable of detecting physiologically relevant concentrations of methamphetamine in saliva in under 2 min. In this device, iodide-modified silver nanoparticles are trapped and released on-demand using electrodes integrated in a microfluidic channel. Principal component analysis (PCA) is used to reliably distinguish methamphetamine-positive samples from the negative control samples. Passivation of the electrodes and flow channels minimizes microchannel fouling by nanoparticles, which allows the device to be cleared and reused multiple times.

Dynamic surface-enhanced Raman spectroscopy and Chemometric methods for fast detection and intelligent identification of methamphetamine and 3, 4-Methylenedioxy methamphetamine in human urine

Conventional Surface-Enhanced Raman Spectroscopy (SERS) for fast detection of drugs in urine on the portable Raman spectrometer remains challenges because of low sensitivity and unreliable Raman signal, and spectra process with manual intervention. Here, we develop a novel detection method of drugs in urine using chemometric methods and dynamic SERS (D-SERS) with mPEG-SH coated gold nanorods (GNRs). D-SERS combined with the uniform GNRs can obtain giant enhancement, and the signal is also of high reproducibility. On the basis of the above advantages, we obtained the spectra of urine, urine with methamphetamine (MAMP), urine with 3, 4-Methylenedioxy Methamphetamine (MDMA) using D-SERS. Simultaneously, some chemometric methods were introduced for the intelligent and automatic analysis of spectra. Firstly, the spectra at the critical state were selected through using K-means. Then, the spectra were proposed by random forest (RF) with feature selection and principal component analysis (PCA) to develop the recognition model. And the identification accuracy of model were 100%, 98.7% and 96.7%, respectively. To validate the effect in practical issue further, the drug abusers'urine samples with 0.4, 3, 30ppm MAMP were detected using D-SERS and identified by the classification model. The high recognition accuracy of >92.0% can meet the demand of practical application. Additionally, the parameter optimization of RF classification model was simple. Compared with the general laboratory method, the detection process of urine's spectra using D-SERS only need 2 mins and 2μL samples volume, and the identification of spectra based on chemometric methods can be finish in seconds. It is verified that the proposed approach can provide the accurate, convenient and rapid detection of drugs in urine.

Drugged Driving in Wisconsin: Oral Fluid Versus Blood

A pilot project was conducted in Dane County, Wisconsin, to evaluate the frequency of individuals driving under the influence of drugs (DUID). Evidentiary blood specimens, collected from subjects arrested for Operating While Intoxicated (OWI), were compared to oral fluid (OF) results obtained with the Alere DDS2®, a handheld screening device. The project objectives were to evaluate (i) the Alere DDS2® for use by police officers in the field, (ii) the frequency of individuals DUID and drugs combined with alcohol among OWI cases, (iii) the differences between detecting drugs in OF and in blood, and (iv) the effect of the laboratory drug testing cancellation policy (LCP) when the blood alcohol concentration (BAC) exceeds 0.100 g/100 mL. Following the arrest and collection of blood, subjects were asked to voluntarily participate in the project and provide an OF specimen. The OF was presumptively screened with the Alere DDS2® for six drug categories including (ng/mL) amphetamine (50), benzodiazepines (temazepam, 20), cocaine (benzoylecgonine, 30), methamphetamine (50), opioids (morphine, 40) and THC (delta-9-THC, 25). Results obtained with the OF screening instrument were not confirmed. A total of 104 subjects (22 female, 82 male), ages 18-72, were included in the project. Blood specimens were tested by gas chromatography-headspace (GCHS-FID) for volatiles, enzyme immunoassay (Siemens Viva-E Drug Testing System), and an alkaline basic drug screen with gas chromatography-mass spectrometry (GCMS) analysis. To compensate for differences between the EIA and the Alere DDS2® drug categories, results from the enzyme immunoassay and the alkaline basic drug screen were combined for purposes of comparing OF to blood. Seventy-six of 104 (73%) subjects arrested for OWI were driving under the influence of alcohol; 71 of the 76 had a BAC exceeding 0.10 g/100 mL. Subjects with a BAC exceeding the LCP, screened positive for drugs in both OF (n = 29) and blood (n = 28). Overall, one or more positive drug screening result was observed in 57 (55%) and 50 (48%) subjects for OF and blood specimens, respectively. THC was the most frequently detected drug category in both OF (n = 46) and whole blood (n = 44). Drug Recognition Expert (DRE) evaluations were performed on 18 subjects. In general, the Alere DDS2® results were consistent with the combined screening results observed in evidentiary blood specimens. This project was limited in scope as a second OF specimen was not collected for confirmation of drugs, however it did demonstrate that nearly 40% of the subjects with concentrations of alcohol exceeding 0.10 g/100 mL, screened positive for one or more drug categories in both OF and blood. The Alere DDS2® portable OF screening instrument may be useful in assisting law enforcement with identifying individuals driving under the influence of drugs and establishing probable cause at roadside for making DUID arrests.

The Clinical Pharmacokinetics of Amphetamines Utilized in the Treatment of Attention-Deficit/Hyperactivity Disorder

Amphetamine (AMP), an indirectly acting psychostimulant approved for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, adolescents, and adults, is among the most long-standing therapeutic agents in all of clinical psychopharmacology. This review focuses on AMP absorption, metabolism, and elimination brought to bear on comparative pharmacokinetics in its various formulations. A comprehensive search of the published literature was conducted using MEDLINE (PubMed) and Google Scholar databases through April 2017 to retrieve all pertinent in vitro and human studies for review and synthesis. Additionally, Food and Drug Administration (FDA) databases were accessed for otherwise unavailable data when possible. Initially available as racemic (dl)-AMP, this drug was later supplanted by enantiopure (d)-AMPH or enantioenriched (75:25 dl)-AMP formulations; although racemic AMP returned as an approved drug to treat ADHD in 2014. Presently, there are several immediate-release (IR) formulations available, including d-AMP, dl-AMP, and mixed amphetamine salts, which are neither racemic nor the pure d-enantiomer (i.e., a 3:1 mixture of d-AMP and l-AMP). Furthermore, new modified-release AMP formulations, including an oral suspension and an orally disintegrating tablet, are now available. A lysine-bonded prodrug form of d-AMP also serves as a treatment option. Oral AMP is rapidly absorbed, with high absolute bioavailability, followed by extensive metabolism involving multiple enzymes. Some metabolic pathways exhibit stereoselective biotransformations favoring the l-isomer substrate. Drug exposure exhibits dose-proportional pharmacokinetics. Body weight is a fundamental determinant of differences in observed AMP plasma concentrations. IR formulations typically provide a T_max from 2 to 3 hours. In replicated studies, children exhibit a shorter plasma T_1/2 (∼7 hours) relative to adults (∼10 to 12 hours). There are few documented pharmacokinetic drug interactions of clinical significance beyond influences of drug-induced alteration of urinary pH. The array of AMP formulations addressed in this review offer flexibility in dosing, drug onset, and offset to assist in individualized pharmacotherapy of ADHD.

Refining correction factors for back-calculation of illicit drug use

The estimation of illicit drugs use through wastewater analysis has become an important issue in the last few years due to their large worldwide consumption, which results in economic, social and health costs. The amounts of urinary biomarkers of illicit drugs (selected drugs or their metabolites) measured in wastewater are used to back-calculate the consumption of a particular drug by the population and to monitor temporal and spatial trends of illicit drug use in a community. The reliability of back-calculation depends on different factors, one being the accuracy of correction factors. A wide range of correction factors have been used in different studies and some biases must be expected when comparing results. Most of the correction factors were developed several years ago, so they need to be updated to include the latest information on pharmacokinetics. Moreover, new comprehensive methods to treat data should be adopted. The goal of this study is to refine current correction factors for back-calculation of the most widely used illicit drugs: amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA) and tetrahydrocannabinol (THC). The mean percentages of excretion of the parent drugs and their metabolites were calculated for each route of administration, utilizing all accessible pharmacokinetic studies in the literature. This allowed to select the most suitable drug target residue and a refined correction factor was obtained for each substance considering the most frequent route of administration. The refined correction factors we propose can be used in wastewater based epidemiology to standardize the back-calculation of these drugs. These results can be included in the best practice protocol currently adopted in EU studies in order to reduce uncertainty and improve the comparability of results.

Saliva diagnostics - Current views and directions

In this review, we provide an update on the current and future applications of saliva for diagnostic purposes. There are many advantages of using saliva as a biofluid. Its collection is fast, easy, inexpensive, and non-invasive. In addition, saliva, as a "mirror of the body," can reflect the physiological and pathological state of the body. Therefore, it serves as a diagnostic and monitoring tool in many fields of science such as medicine, dentistry, and pharmacotherapy. Introduced in 2008, the term "Salivaomics" aimed to highlight the rapid development of knowledge about various "omics" constituents of saliva, including: proteome, transcriptome, micro-RNA, metabolome, and microbiome. In the last few years, researchers have developed new technologies and validated a wide range of salivary biomarkers that will soon make the use of saliva a clinical reality. However, a great need still exists for convenient and accurate point-of-care devices that can serve as a non-invasive diagnostic tool. In addition, there is an urgent need to decipher the scientific rationale and mechanisms that convey systemic diseases to saliva. Another promising technology called liquid biopsy enables detection of circulating tumor cells (CTCs) and fragments of tumor DNA in saliva, thus enabling non-invasive early detection of various cancers. The newly developed technology-electric field-induced release and measurement (EFIRM) provides near perfect detection of actionable mutations in lung cancer patients. These recent advances widened the salivary diagnostic approach from the oral cavity to the whole physiological system, and thus point towards a promising future of salivary diagnostics for personalized individual medicine applications including clinical decisions and post-treatment outcome predictions. Impact statement The purpose of this mini-review is to make an update about the present and future applications of saliva as a diagnostic biofluid in many fields of science such as dentistry, medicine and pharmacotherapy. Using saliva as a fluid for diagnostic purposes would be a huge breakthrough for both patients and healthcare providers since saliva collection is easy, non-invasive and inexpensive. We will go through the current main diagnostic applications of saliva, and provide a highlight on the emerging, newly developing technologies and tools for cancer screening, detection and monitoring.

What is the contribution of human FMO3 in the N-oxygenation of selected therapeutic drugs and drugs of abuse?

Little is known about the role of flavin-containing monooxygenases (FMOs) in the metabolism of xenobiotics. FMO3 is the isoform in adult human liver with the highest impact on drug metabolism. The aim of the presented study was to elucidate the contribution of human FMO3 to the N-oxygenation of selected therapeutic drugs and drugs of abuse (DOAs). Its contribution to the in vivo hepatic net clearance of the N-oxygenation products was calculated by application of an extended relative activity factor (RAF) approach to differentiate from contribution of cytochrome P450 (CYP) isoforms. FMO3 and CYP substrates were identified using pooled human liver microsomes after heat inactivation and chemical inhibition, or single enzyme incubations. Kinetic parameters were subsequently determined using recombinant human enzymes and mass spectrometric analysis via authentic reference standards or simple peak areas of the products divided by those of the internal standard. FMO3 was identified as enzyme mainly responsible for the formation of N,N-diallyltryptamine N-oxide and methamphetamine hydroxylamine (>80% contribution for both). A contribution of 50 and 30% was calculated for the formation of N,N-dimethyltryptamine N-oxide and methoxypiperamide N-oxide, respectively. However, FMO3 contributed with less than 5% to the formation of 3-bromomethcathinone hydroxylamine, amitriptyline N-oxide, and clozapine N-oxide. There was no significant difference in the contributions when using calibrations with reference metabolite standards or peak area ratio calculations. The successful application of a modified RAF approach including FMO3 proved the importance of FMO3 in the N-oxygenation of DOAs in human metabolism.

Relationship between discriminative stimulus effects and plasma methamphetamine and amphetamine levels of intramuscular methamphetamine in male rhesus monkeys

Methamphetamine is a globally abused drug that is metabolized to amphetamine, which also produces abuse-related behavioral effects. However, the contributing role of methamphetamine metabolism to amphetamine in methamphetamine's abuse-related subjective effects is unknown. This preclinical study was designed to determine 1) the relationship between plasma methamphetamine levels and methamphetamine discriminative stimulus effects and 2) the contribution of the methamphetamine metabolite amphetamine in the discriminative stimulus effects of methamphetamine in rhesus monkeys. Adult male rhesus monkeys (n=3) were trained to discriminate 0.18mg/kg intramuscular (+)-methamphetamine from saline in a two-key food-reinforced discrimination procedure. Time course of saline, (+)-methamphetamine (0.032-0.32mg/kg), and (+)-amphetamine (0.032-0.32mg/kg) discriminative stimulus effects were determined. Parallel pharmacokinetic studies were conducted in the same monkeys to determine plasma methamphetamine and amphetamine levels after methamphetamine administration and amphetamine levels after amphetamine administration for correlation with behavior in the discrimination procedure. Both methamphetamine and amphetamine produced full, ≥90%, methamphetamine-like discriminative stimulus effects. Amphetamine displayed a slightly, but significantly, longer duration of action than methamphetamine in the discrimination procedure. Both methamphetamine and amphetamine behavioral effects were related to methamphetamine and amphetamine plasma levels by a clockwise hysteresis loop indicating acute tolerance had developed to the discriminative stimulus effects. Furthermore, amphetamine levels after methamphetamine administration were absent when methamphetamine stimulus effects were greatest and peaked when methamphetamine discriminative stimulus effects returned to saline-like levels. Overall, these results demonstrate the methamphetamine metabolite amphetamine does not contribute to methamphetamine's abuse-related subjective effects.

Chiral separation and determination of R/S-methamphetamine and its metabolite R/S-amphetamine in urine using LC-MS/MS

Methamphetamine (MA) and amphetamine (AM) are widely abused drugs. Differentiation of MA and/or AM abuse from therapeutic ingestion of MA and/or AM or one of their precursor drugs is therefore of relevance in clinical and forensic toxicology. The aim of the study was to develop a simple, rapid, and accurate method for the chiral separation and determination of R/S-MA and R/S-AM in urine using liquid chromatography electrospray ionization tandem mass spectrometry operating in the positive ion multiple-reaction monitoring (MRM) mode. 20 μL of urine was diluted 500 times and 20 μL was injected. The chromatographic system consisted of a Chirobiotic™ V2 column (2.1 mm × 250 mm, 5 μm), and the mobile phase was methanol containing 0.1% (v/v) glacial acetic acid and 0.02% (v/v) ammonium hydroxide. The method was fully validated through assessments of its linearity (0.05-50.00 mg/L, r(2)>0.994 for all analytes), and LOQ (0.05 mg/L for all analytes). No matrix effect was observed. The method was successfully applied to 86 urine samples from suspected MA abusers. Only the S-isomers of MA and AM were detected in 72 samples. The concentrations of R-MA ranged from below the LOQ to 13.76 mg/L in 14 urine samples with both enantiomers of MA and/or AM. Pure S-MA is the most common found analyte in urine and principally used by abusers.

Cannabinoid disposition in oral fluid after controlled cannabis smoking in frequent and occasional smokers

Oral fluid (OF) is an increasingly popular alternative matrix for drug testing, with cannabinoids being the most commonly identified illicit drug. Quantification of multiple OF cannabinoids and understanding differences in OF cannabinoid pharmacokinetics between frequent and occasional smokers improve test interpretation. The new Oral-Eze® OF collection device has an elution buffer that stabilizes analytes and improves drug recovery from the collection pad; however, its performance has not been independently evaluated. After controlled smoking of a 6.8% Δ(9) -tetrahydrocannabinol (THC) cannabis cigarette by frequent and occasional smokers, OF was collected with the Oral-Eze device for up to 30 h. Samples were analyzed for multiple cannabinoids by a validated 2D-GC-MS method. Frequent smokers had significantly greater OF THCCOOH concentrations than occasional smokers at all times, and showed positive results for a significantly longer time. We evaluated multiple cannabinoid cut-offs; the shortest last detection times were observed when THC ≥ 1 μg/L was combined with CBD or CBN ≥ 1 μg/L. With these cut-offs, last detection times(1-13.5 h) were not significantly different between groups, demonstrating suitability for short-term cannabinoid detection independent of smoking history. Cut-offs utilizing THC alone or combined with THCCOOH showed significantly different last detection times between groups. The widest detection windows were observed with THC ≥ 1 or 2 μg/L or THCCOOH ≥ 20 ng/L. Our data illustrate the effectiveness of the Oral-Eze® device for OF collection, the impact of self-administered smoked cannabis history on OF cannabinoid results, and the ability to improve interpretation and tailor OF cannabinoid cut-offs to fulfill the detection window needs of a given program.

Comparing drug detection in oral fluid and blood: data from a national sample of nighttime drivers

OBJECTIVE

The National Roadside Survey is a study undertaken in the United States to determine the prevalence of alcohol and drugs in randomly selected drivers. Following the success of a 2006 pilot study, the 2007 survey incorporated, for the first time, the collection of biological specimens for drug analysis. This article compares the results obtained from blinded analyses of pairs of oral fluid and blood samples obtained from the same subject.

METHODS

During the 2007 survey, more than 7000 nighttime drivers were randomly stopped and surveyed for their self-reported drug use and were requested to donate an oral fluid specimen using the Quantisal (Immunalysis Corporation, Pomona, CA) device and a blood sample. Overall, 5869 oral fluid specimens were collected from nighttime drivers with 3236 corresponding blood samples.

RESULTS

Biological specimens were analyzed for a wide range of drugs. At nighttime, 14.4 percent of the drivers were positive for drugs in oral fluid, with just over half of those having marijuana present (7.6%). Of the 3236 pairs of specimens, 2676 were negative for all drugs, and 326 matched pairs of samples were both positive, out of which 247 (75.8%) were an exact match for all drug classes and 70 (21.5%) were positive for at least one common drug class.

CONCLUSIONS

Oral fluid and blood samples provided very similar information regarding recent drug intake by randomly tested drivers and oral fluid yielded a higher detection rate for one drug (cocaine) than blood. Oral fluid can be considered a reliable alternative to blood as a matrix for drug testing.

Identifying methamphetamine exposure in children

OBJECTIVE

Methamphetamine (MAMP) use, distribution, and manufacture remain a serious public health and safety problem in the United States, and children environmentally exposed to MAMP face a myriad of developmental, social, and health risks, including severe abuse and neglect necessitating child protection involvement. It is recommended that drug-endangered children receive medical evaluation and care with documentation of overall physical and mental conditions and have urine drug testing. The primary aim of this study was to determine the best biological matrix to detect MAMP, amphetamine (AMP), methylenedioxymethamphetamine (MDMA), methylenedioxyamphetamine (MDA), and 3,4-methylenedioxyethylamphetamine (MDEA) in environmentally exposed children.

METHODS

Ninety-one children, environmentally exposed to household MAMP intake, were medically evaluated at the Child and Adolescent Abuse Resource and Evaluation Diagnostic and Treatment Center at the University of California, Davis Children's Hospital. MAMP, AMP, MDMA, MDA, and MDEA were quantified in urine and oral fluid (OF) by gas chromatography mass spectrometry and in hair by liquid chromatography tandem mass spectrometry.

RESULTS

Overall drug detection rates in OF, urine, and hair were 6.9%, 22.1%, and 77.8%, respectively. Seventy children (79%) tested positive for 1 or more drugs in 1 or more matrices. MAMP was the primary analyte detected in all 3 biological matrices. All positive OF (n = 5), and 18 of 19 positive urine specimens also had a positive hair test.

CONCLUSIONS

Hair analysis offered a more sensitive tool for identifying MAMP, AMP, and MDMA environmental exposure in children than urine or OF testing. A negative urine or hair test does not exclude the possibility of drug exposure, but hair testing provided the greatest sensitivity for identifying drug-exposed children.

Comparison of drug concentrations between whole blood and oral fluid

The relationship of drug concentrations between oral fluid and whole blood was evaluated by studying the linear correlation of concentrations and calculating the oral fluid to blood concentration ratios (OF/B) for different substances. Paired oral fluid and whole blood samples were collected from volunteers and persons suspected of drug use in four European countries. Oral fluid samples were collected with the Saliva∙Sampler™ device. All samples were analyzed for drugs of abuse and psychoactive medicines with validated gas and liquid chromatography-mass spectrometric methods. The median OF/B ratios were, for amphetamines 19-22, for opioids 1.8-11, for cocaine and metabolites 1.7-17, for tetrahydrocannabinol (THC) 14, for benzodiazepines 0.035-0.33, and for other psychoactive medicines 0.24-3.7. Most of the these results were close to theoretical values based on the physicochemical properties of the drugs and to values presented earlier, but there was a lot of inter-individual variation in the OF/B ratios. For all substances, except for lorazepam (R(2)  = 0.031) and THC (R(2)  = 0.030), a correlation between the oral fluid and whole blood concentrations was observed. Due to large variation seen here, drug findings in oral fluid should not be used to estimate the corresponding concentrations in whole blood (or vice versa). However, detection of drugs in oral fluid is a sign of recent drug use and oral fluid can be used for qualitative detection of several drugs, e.g. in epidemiological prevalence studies. By optimizing the sampling and the analytical cut-offs, the potential of oral fluid as a confirmation matrix could be enhanced.

Rapid detection of drugs of abuse in saliva using surface enhanced Raman spectroscopy and microfluidics

We present a microfluidic device that detects trace concentrations of drugs of abuse in saliva within minutes using surface-enhanced Raman spectroscopy (SERS). Its operation is demonstrated using methamphetamine. The detection scheme exploits concentration gradients of chemicals, fostered by the laminar flow in the device, to control the interactions between the analyte, silver nanoparticles (Ag-NPs), and a salt. Also, since all species interact while advecting downstream, the relevant reaction coordinates occur with respect to the position in the channel. The system was designed to allow the analyte first to diffuse into the side stream containing the Ag-NPs, on which it is allowed to adsorb, before salt ions are introduced, causing the Ag-NPs to aggregate, and so creating species with strong SERS signal. The device allows partial separation via diffusion of the analyte from the complex mixture. Also, the reproducible salt-induced NP aggregation decouples the aggregation reaction (necessary for strong SERS) from the analyte concentration or charge. This method enables the creation of a region where detection of the analyte of interest via SERS is optimal, and dramatically extends the classes of molecules and quality of signals that can be measured using SERS, compared to bulk solution methods. The spatial distribution of the SERS signals was used to map the degree of nanoparticle aggregation and species diffusion in the channel, which, together with numerical simulations, was used to describe the kinetics of the colloid aggregation reaction, and to determine the optimal location in the channel for SERS interrogation.

Normalized diurnal and between-day trends in illicit and legal drug loads that account for changes in population

Drug concentrations in composite municipal wastewater samples and census-based estimates of population are used to derive daily loads of illicit substances that are indexed to population. However, such estimates do not provide information on the diurnal trends of substance excretion nor can they account for changes in population. To address these limitations, a series of 1 h composites created by sampling wastewater influent at 6 min intervals was collected over four consecutive days at a single wastewater treatment plant. Creatinine (a urinary indicator), caffeine, methamphetamine, benzoylecgonine (BZE), and cocaine were analyzed by liquid chromatography/tandem mass spectrometry (LC-MS/MS). Diurnal trends and between-day trends were substance specific and related to the number of estimated doses and excretory half-life. Normalization to creatinine yielded trends in substances that differed significantly from non-normalized trends by accounting for changes in population within the municipality studied. Increases in normalized substance excretion observed during early morning hours originate from individuals among the resident population of the municipality due to the absence of commuters.

[Workplace testing of drugs of abuse and psychotropic drugs]

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.

Immunoassay cross-reactivity of phenylephrine and methamphetamine

Phenylephrine, an α(1) -adrenergic agonist, and methamphetamine, a prescription drug and substance of abuse, have similar chemical structures and thus have the potential to cross-react in qualitative screening tools such as a urine drug screening (UDS) performed by immunoassay. This cross-reactivity may yield a false-positive result that may affect the provision of care in certain patient populations and clinical situations. We describe a 36-year-old woman with confirmed brain death after a short hospital stay who had an initial UDS that was negative for methamphetamine. The patient was assessed for potential organ donation, which included obtaining a follow-up UDS. A urine sample was obtained after being hospitalized for 36 hours, which tested positive for methamphetamine, with no suspected ingestion of the target substance. Confirmatory laboratory testing indicated that intravenous phenylephrine and its metabolites were the likely cause of the false-positive UDS. However, the patient was not deemed to be a suitable candidate for organ donation, but clear documentation of the reason for denial of organ donation was not available in the patient's medical record. To our knowledge, this is the first case published in the English-language literature that describes the clinical occurrence of apparent immunoassay cross-reactivity of methamphetamine and phenylephrine that resulted in a false-positive UDS for methamphetamine. In addition, this report describes the potential implications of this situation on clinical care, including organ donation acceptance. Toxicology screening in the emergency department and intensive care unit is a tool to assist in the diagnosis of medical conditions, but it may not always be reliable. Therefore, positive immunoassay results that may change the management of a patient's condition should be quickly verified with confirmatory testing to minimize unfavorable consequences.

Primary outcome indices in illicit drug dependence treatment research: systematic approach to selection and measurement of drug use end-points in clinical trials

AIMS

Clinical trials test the safety and efficacy of behavioral and pharmacological interventions in drug-dependent individuals. However, there is no consensus about the most appropriate outcome(s) to consider in determining treatment efficacy or on the most appropriate methods for assessing selected outcome(s). We summarize the discussion and recommendations of treatment and research experts, convened by the US National Institute on Drug Abuse, to select appropriate primary outcomes for drug dependence treatment clinical trials, and in particular the feasibility of selecting a common outcome to be included in all or most trials.

METHODS

A brief history of outcomes employed in prior drug dependence treatment research, incorporating perspectives from tobacco and alcohol research, is included. The relative merits and limitations of focusing on drug-taking behavior, as measured by self-report and qualitative or quantitative biological markers, are evaluated.

RESULTS

Drug-taking behavior, measured ideally by a combination of self-report and biological indicators, is seen as the most appropriate proximal primary outcome in drug dependence treatment clinical trials.

CONCLUSIONS

We conclude that the most appropriate outcome will vary as a function of salient variables inherent in the clinical trial, such as the type of intervention, its target, treatment goals (e.g. abstinence or reduction of use) and the perspective being taken (e.g. researcher, clinical program, patient, society). It is recommended that a decision process, based on such trial variables, be developed to guide the selection of primary and secondary outcomes as well as the methods to assess them.