Application of drug testing using exhaled breath for compliance monitoring of drug addicts in treatment

Sample Matrices for Mass Spectrometry-Based Adherence Monitoring: A Systematic Critical Review

BACKGROUND

Analytical monitoring of adherence using mass spectrometry (MS) plays an important role in clinical toxicology. Unambiguous detection of drugs (of abuse) and/or their metabolites in body fluids is needed to monitor intake of medication as prescribed or to monitor abstinence as a follow-up to detoxification procedures. This study focused on the advantages and disadvantages of different sample matrices used for MS-based adherence monitoring.

METHODS

Relevant articles were identified through a literature search in the PubMed database. English articles published between January 01, 2017, and December 31, 2022, were selected using the keywords "adherence assess*" or "adherence monit*" or "compliance assess*" or "compliance monit*" in combination with "mass spectrom*" in the title or abstract.

RESULTS

A total of 51 articles were identified, 37 of which were within the scope of this study. MS-based monitoring was shown to improve patient adherence to prescribed drugs. However, MS analysis may not be able to assess whether treatment was rigorously followed beyond the last few days before the sampling event, except when hair is the sample matrix. For medication adherence monitoring, blood-based analyses may be preferred because reference plasma concentrations are usually available, whereas for abstinence control, urine and hair samples have the advantage of extended detection windows compared with blood. Alternative sample matrices, such as dried blood samples, oral fluid, and exhaled breath, are suitable for at-home sampling; however, little information is available regarding the pharmacokinetics and reference ranges of drug (of abuse) concentrations.

CONCLUSIONS

Each sample matrix has strengths and weaknesses, and no single sample matrix can be considered the gold standard for monitoring adherence. It is important to have sufficient information regarding the pharmacokinetics of target substances to select a sample matrix in accordance with the desired purpose.

Detection of abused drugs in human exhaled breath using mass spectrometry: A review

RATIONALE

Human breath analysis has been attracting increasing interest in the detection of abused drugs in forensic and clinical applications because of its noninvasive sampling and distinctive molecular information. Mass spectrometry (MS)-based approaches have been proven to be powerful tools for accurately analyzing exhaled abused drugs. The major advantages of MS-based approaches include high sensitivity, high specificity, and versatile couplings with various breath sampling methods.

METHODS

Recent advances in the methodological development of MS analysis of exhaled abused drugs are discussed. Breath collection and sample pretreatment methods for MS analysis are also introduced.

RESULTS

Recent advances in technical aspects of breath sampling methods are summarized, highlighting active and passive sampling. MS methods for detecting different exhaled abused drugs are reviewed, emphasizing their features, advantages, and limitations. The future trends and challenges in MS-based breath analysis of exhaled abused drugs are also discussed.

CONCLUSIONS

The coupling of breath sampling methods with MS approaches has been proven to be a powerful tool for the detection of exhaled abused drugs, offering highly attractive results in forensic investigations. MS-based detection of exhaled abused drugs in exhaled breath is a relatively new field and is still in the early stages of methodological development. New MS technologies promise a substantial benefit for future forensic analysis.

Probing for the presence of doping agents in exhaled breath using chromatographic/mass spectrometric approaches

RATIONALE

Exhaled breath (EB) has been demonstrated to be a promising alternative matrix in sports drug testing due to its non-invasive and non-intrusive nature compared with urine and blood collection protocols. In this study, a pilot-test system was employed to create drug-containing aerosols simulating EB in support of the analytical characterization of EB sampling procedures, and the used analytical method was extended to include a broad spectrum of prohibited substances.

METHODS

Artificial and authentic EB samples were collected using sampling devices containing an electret filter, and doping agents were detected by means of liquid chromatography and tandem mass spectrometry with unispray ionization. The analytical approach was characterized with regard to specificity, limits of detection, carry-over, recovery and matrix effects, and the potential applicability to routine doping controls was shown using authentic EB samples collected after single oral dose applications of glucocorticoids and stimulants.

RESULTS

The analytical method was found to be specific for a total of 49 model substances relevant in sports drug testing, with detection limits ranging from 1 to 500 pg per cartridge. Both ion suppression (-62%) and ion enhancement (+301%) effects were observed, and all model compounds applied to EB sampling devices were still detected after 28 days of storage at room temperature. Authentic EB samples collected after the oral administration of 10 mg of prednisolone resulted in prednisolone findings in specimens obtained from 3 out of 6 participants up to 2 h. In octodrine, dimethylamylamine (DMAA) and isopropylnorsynephrine post-administration EB samples, the drugs were detected over a period of 50, 48, and 8 h, respectively.

CONCLUSIONS

With the analytical approach developed within this study, the identification of a broad spectrum of prohibited doping agents in EB samples was accomplished. Application studies and stability tests provided information to characterize EB as a potential matrix in sports drug testing.

Detecting opioid metabolites in exhaled breath condensate (EBC)

Exhaled breath condensate (EBC) collection provides a promising matrix for bioanalysis of endogenous biomarkers of health and also for exogenous compounds like drugs. There is little information regarding drugs and their metabolites contained in breath, as well as their pharmacokinetics. In this present work, we use a simple and non-invasive technique to collect EBC from chronic pain patients using different analgesic opioid drugs to manage pain. Six patients received continuous infusion of morphine and hydromorphone intravenously (IV), together with other analgesic drugs (IV and orally). Repeated sampling of serum and EBC was done at two time points separated by 90 min. The EBC was collected using a glass tube surrounded by dry ice, and an ethanol solvent wash of the glass was performed after EBC extraction to retrieve the apolar compounds stuck to the glass surface. All samples were analyzed with liquid chromatography coupled to mass spectrometry (LC-MS/MS) to identify possible metabolites present in the sample, and to quantify the drugs being used. Several metabolites, such as normorphine (norM), norhydromorphone (norHM) and dihydromorphone (diHM) were detected in both fractions, while hydromorphone 3-glucuronide (HM 3G) was only detected in the solvent rinse fraction. Results were correlated to explain the pharmacokinetics of the main drugs administered. This pilot study presented promising correlations between drug concentrations in blood and breath at different time points for norM, norHM and HM 3G.

Technological Interventions for Medication Adherence in Adult Mental Health and Substance Use Disorders: A Systematic Review

BACKGROUND

Medication adherence is critical to the effectiveness of psychopharmacologic therapy. Psychiatric disorders present special adherence considerations, notably an altered capacity for decision making and the increased street value of controlled substances. A wide range of interventions designed to improve adherence in mental health and substance use disorders have been studied; recently, many have incorporated information technology (eg, mobile phone apps, electronic pill dispensers, and telehealth). Many intervention components have been studied across different disorders. Furthermore, many interventions incorporate multiple components, making it difficult to evaluate the effect of individual components in isolation.

OBJECTIVE

The aim of this study was to conduct a systematic scoping review to develop a literature-driven, transdiagnostic taxonomic framework of technology-based medication adherence intervention and measurement components used in mental health and substance use disorders.

METHODS

This review was conducted based on a published protocol (PROSPERO: CRD42018067902) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines. We searched 7 electronic databases: MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, Web of Science, Engineering Village, and ClinicalTrials.gov from January 2000 to September 2018. Overall, 2 reviewers independently conducted title and abstract screens, full-text screens, and data extraction. We included all studies that evaluate populations or individuals with a mental health or substance use disorder and contain at least 1 technology-delivered component (eg, website, mobile phone app, biosensor, or algorithm) designed to improve medication adherence or the measurement thereof. Given the wide variety of studied interventions, populations, and outcomes, we did not conduct a risk of bias assessment or quantitative meta-analysis. We developed a taxonomic framework for intervention classification and applied it to multicomponent interventions across mental health disorders.

RESULTS

The initial search identified 21,749 results; after screening, 127 included studies remained (Cohen kappa: 0.8, 95% CI 0.72-0.87). Major intervention component categories include reminders, support messages, social support engagement, care team contact capabilities, data feedback, psychoeducation, adherence-based psychotherapy, remote care delivery, secure medication storage, and contingency management. Adherence measurement components include self-reports, remote direct visualization, fully automated computer vision algorithms, biosensors, smart pill bottles, ingestible sensors, pill counts, and utilization measures. Intervention modalities include short messaging service, mobile phone apps, websites, and interactive voice response. We provide graphical representations of intervention component categories and an element-wise breakdown of multicomponent interventions.

CONCLUSIONS

Many technology-based medication adherence and monitoring interventions have been studied across psychiatric disease contexts. Interventions that are useful in one psychiatric disorder may be useful in other disorders, and further research is necessary to elucidate the specific effects of individual intervention components. Our framework is directly developed from the substance use disorder and mental health treatment literature and allows for transdiagnostic comparisons and an organized conceptual mapping of interventions.

Determining the Method Threshold of Identification via Gas Chromatography-Mass Spectrometry of Weathered Gasoline Extracted from Burnt Nylon Carpet

The Organization of Scientific Area Committees defines threshold of identification as the minimum concentration of ignitable liquid identifiable from gas chromatographic-mass spectrometry data using accepted pattern identification criteria. We propose a method for determining this threshold for gasoline based on base peak to qualifier ratios of six compounds. The ion ratios were established for each compound in the neat gasoline. These ratios were then compared to those obtained for gasoline and 98% weathered gasoline both spiked onto burnt nylon carpet at 20 ppt down 0.50 ppt, and recovered from the carpet using headspace extraction (ASTM 1412). Identification was confirmed if the compounds' ion ratios fell within ±25% of that in the neat sample. We found that ion ratios for all samples were acceptable for six compounds at 1.60 and 0.80 ppt for extracted neat and extracted 98% weathered gasoline, respectively, illustrating potential for incorporating into Quality Assurance Programs.

A liquid chromatography and tandem mass spectrometry method to determine 28 non-volatile drugs of abuse in exhaled breath

Exhaled breath carries aerosol micro-particles containing nonvolatile organic substances. Recently, the analysis of drugs of abuse (DOA) have become of interest in exhaled breath particles (EBP). In this study, a liquid chromatography - tandem mass spectrometry (LC-MS/MS) method was developed and validated to analyze 28 DOA in 30L of EBP collected on a permeable polymer filter. After extraction, the chromatographic separation was achieved on a UPLC BEH phenyl column using a mobile phase consisting of methanol and water both containing 4mmol/L ammonium formate and 0.05% ammonia. The column temperature was set at 50°C and mobile phase flow rate 0.5mL/min in gradient mode with a total run time of 5min. The mass spectrometer was operated in positive electrospray ionization and selected reaction monitoring mode. Acquired limits of quantification were in the range of 1-66pg/filter for all substances except DM-tramadol. Excellent linearity over the concentration range from LLOQs - 15ng/filter with r2 values >0.99 and satisfactory recoveries (70-116% at 100pg/filter) were achieved. During method application a total 26 samples were analyzed of which 24 were found to be positive for 13 analytes. The highest amount was found for methadone (56ng/filter) and the lowest amount was found for the methadone metabolite EDDP (2pg/filter) in two different samples.

Expanding analytical options in sports drug testing: Mass spectrometric detection of prohibited substances in exhaled breath

RATIONALE

Continuously refining and advancing the strategies and methods employed in sports drug testing is critical for efficient doping controls. Besides improving and expanding the spectrum of target analytes, alternative test matrices have warranted in-depth evaluation as they commonly allow for minimal-/non-invasive and non-intrusive sample collection. In this study, the potential of exhaled breath (EB) as doping control specimen was assessed.

METHODS

EB collection devices employing a non-woven electret-based air filter unit were used to generate test specimens, simulating a potential future application in doping controls. A multi-analyte sports drug testing approach configured for a subset of 12 model compounds that represent specific classes of substances prohibited in sports (anabolic agents, hormone and metabolic modulators, stimulants, and beta-blockers) was established using unispray liquid chromatography/tandem mass spectrometry (LC/MS/MS) and applied to spiked and elimination study EB samples. The test method was characterized concerning specificity, assay imprecision, and limits of detection.

RESULTS

The EB collection device allowed for retaining and extracting all selected model compounds from the EB aerosol. Following elution and concentration, LC/MS/MS analysis enabled detection limits between 5 and 100 pg/filter and imprecisions ranging from 3% to 20% for the 12 selected model compounds. By means of EB samples from patients and participants of administration studies, the elimination of relevant compounds and, thus, their traceability in EB for doping control purposes, was investigated. Besides stimulants such as methylhexaneamine and pseudoephedrine, also the anabolic-androgenic steroid dehydrochloromethyltestosterone, the metabolic modulator meldonium, and the beta-blocker bisoprolol was detected in exhaled breath.

CONCLUSIONS

The EB aerosol has provided a promising proof-of-concept suggesting the expansion of this testing strategy as a complement to currently utilized sports drug testing programs.

Guidelines for Collection of Biological Samples for Clinical and Forensic Toxicological Analysis

This article aims to review general procedures for sampling of routinely collected as well as on alternative samples that may provide additional information regarding intoxication. These approaches may be applied whenever sample collection for clinical and forensic toxicology is required and should be considered as general guidelines that must be adapted to each specific case. It is expected that this article will help toxicologists and other forensic experts to accomplish their mission, since the toxicological result is first influenced by the quality and quantity of the sample available for analysis. These guidelines were approved by the European Council of Legal Medicine.

Current advances in biosampling for therapeutic drug monitoring of psychiatric CNS drugs

Many CNS drugs are effective for the treatment of psychiatric disorders. Psychotropic drugs work differently, thus clinical outcomes for many patients may be insufficient. For this reason it could be useful the measurement of drug levels for clinical decision-making. Analytical goals in therapeutic drug monitoring (TDM) should be established by selecting the appropriate biological matrix. The aim of this review is to highlight the usefulness of TDM for antiepileptics, antidepressants and antipsychotics, with a focus on current advances in biosampling. The literature on TDM was reviewed up to March 2015. An overview on the use of alternative biological matrices is provided to address the current issues and advances in the field of biosampling for psychiatric CNS drug TDM.