Oral fluid drug analysis in the age of new psychoactive substances

Comparing presumptive with direct-to-definitive drug testing in oral fluid vs. urine for a U.S. national sample of individuals misusing drugs

BACKGROUND

The aims are to compare the results of presumptive drug testing with confirmation of positives vs. direct-to-definitive drug testing, combined with investigation of urine vs. oral fluid as test matrices.

METHODS

Paired oral fluid and urine specimens were collected voluntarily and anonymously from 1098 individuals applying for methadone treatment in 11 clinics across 7 U.S. states. All specimens were analyzed by immunoassay (IA) and liquid chromatography-tandem mass spectrometry (LC-MS-MS).

RESULTS

Confirmed IA prevalences for urine were significantly higher than for oral fluid for 7 out of 10 drug classes - benzodiazepines, cannabis, cocaine, methadone, opiates, oxycodone and tramadol. Drug prevalences by direct-to-definitive LC-MS-MS were either the same or higher than prevalences by confirmed IA. Drug prevalences by LC-MS-MS were higher in urine for two drug classes (cocaine, methadone) and higher in oral fluid for two drug classes (buprenorphine, tramadol), but were equivalent in urine and oral fluid when averaged over all 10 drug classes. Certain drugs of special concern such as heroin and buprenorphine were more frequently detected in oral fluid than urine.

CONCLUSIONS

Urine analysis showed some technical advantage over oral fluid in sensitivity to several drug classes within a confirmed IA testing protocol, but this may be outweighed if there is reason to believe that tampering with urine specimens is a significant problem. Overall drug detection by direct-to-definitive testing was similar for oral fluid and urine, but one matrix may be preferable if there is a particular drug of clinical or epidemiological interest.

New trends of new psychoactive substances (NPS)-infused chocolate: Identification and quantification of trace level of NPS in complex matrix by GC-MS and NMR

For the first time, the identification and quantification of trace level of new psychoactive substances (NPS) in a complex chocolate matrix have been reported. Since the beginning of 2022, suspected NPS-infused chocolate samples confiscated in inbound packages have been continuously sent to our laboratory for analysis. The qualitative gas chromatography-mass spectrometry (GC-MS) results were verified by ¹H nuclear magnetic resonance (¹H NMR) and ¹⁹F NMR to distinguish between potential aromatic isomers. A total of 11 NPS including deoxymethoxetamine, 3-OH-PCP, 6-APB, 4-APB, 4-OH-MiPT, 3-FEA, 2-FEA, 3-MMC, bromazolam, 2-FDCK, and ADB-BUTINACA were detected in 65 seized chocolate samples. A general ¹H quantitative NMR (¹H qNMR) method for quantification of 297 types of NPS in complex chocolate matrixes was devised for the first time after rigorous analysis of various critical features of merit, including suitable deuterated solvent, internal standard, quantitative peaks, and instrument acquisition parameters. Validation of the method using six different types of NPS afforded limits of detection of 0.05-0.1 mg/mL, limits of quantification of 0.01-0.03 mg/mL, repeatability and reproducibility lower than 0.5% and 3.6%, recoveries of 91.7%∼104.4%, and absence of matrix effect. The quantitative analysis of 65 seized chocolate samples by ¹H qNMR and ¹⁹F qNMR showed that the content of NPS was in the range of 0.5 mg/g∼44.1 mg/g. Generally, the developed qNMR method was simple, fast, precise, and can be performed without reference materials of NPS. Since the type and content of NPS are relatively random, chocolate consumers will face huge health risks. Therefore, this new trend of NPS-infused chocolate deserves and requires more attention from national NPS monitoring departments as well as forensic laboratories.

Oral fluid analysis to monitor recent exposure to synthetic cannabinoids in a high-risk subpopulation

Among novel psychoactive substances, synthetic cannabinoid receptor agonists (SCRA) seem to have the widest diffusion in the population with no limitation to any particular demographic group. Information on drug consumption relies mostly on anonymized surveys and less on clinical or analytical data; notwithstanding, the huge efforts constantly made to enroll subjects to gather epidemiological data. In the present study, we collected 66 oral fluid samples from volunteers in a drug rehabilitation center in 2019 and early 2020. A liquid chromatography-mass spectrometry method previously developed and validated by our Unit was applied to detect SCRA (n = 10) in oral fluid. Results proved the presence of synthetic cannabinoids at a positivity rate of almost 20%, with detection frequency HU211(5/13) > UR144/JWH122 (3/13) > JWH019/JWH081/AM2201 (1/13). Concentrations were in the range < LOQ -0.36 ng/ml. Synthetic cannabinoids consumption had not been declared by any volunteer. This study enabled for the unprecedent detection of synthetic cannabinoids use in the territory of Parma (Italy) in a high-risk subpopulation. The identified SCRA proved the persistence into the market of the "first-generation" JWH family into the Italian territory and the marketing of relatively new ones (AM-2201). Public health consequences represented by NPS consumption are still scarce; therefore, further studies are needed to understand the real diffusion in the population.

Gender Differences in Drug Use among Individuals Under Arrest

Background

Drug monitoring by drug testing of individuals under arrest provides an opportunity to detect drug use patterns within geographic areas. However, women have been omitted from large-scale monitoring efforts in criminal justice populations. The purpose of this study was to examine whether gender differences exist in drug use indicated by oral fluid collected in one U.S. jail.

Methods

The study analyzed data collected in 2019-2020 from individuals under arrest (N = 191). Twenty-four percent of the sample identified as female. Oral fluid specimens were collected and then analyzed with enzyme-linked immunosorbent assay and liquid chromatography/tandem mass spectrometry. Logit regression models examined gender differences.

Results

Women were more likely to test positive for methamphetamines than men (41% versus 22%, OR = 0.42, 95% CI 0.21-0.84). Significant gender differences were not found for other substances (marijuana, cocaine, and opioids), legality of drugs, or overall drug use.

Conclusions

Because the National Institute on Drug Abuse aims to promote health equity, future drug monitoring in criminal justice populations should employ sampling approaches representing both women and men. This research would identify possible gender-based patterns of drug use and inform gender-based policies and clinical practices to prevent and treat drug misuse.

Rethinking Drug Analysis in Healthcare: High-Throughput Analysis of 71 Drugs of Abuse in Oral Fluid using Ion Mobility - High Resolution Mass Spectrometry

We have identified a clinical need for a sensitive, specific, flexible, comprehensive, and affordable analytical technology to efficiently detect polydrug use. In addition, the current standard practise of surveilled urine sampling is uncomfortable for the patient, hence more patient-friendly sample collection methods are requested. To fill these needs, we have developed and validated a high-throughput liquid chromatography - high resolution mass spectrometry (LC-HRMS) method for analysis of DoA in oral fluid (OF). The method covers a panel of 71 substances including traditional drugs of abuse (DoA), prescription narcotics and new psychoactive substances (NPS), with a guaranteed limit of identification of <3 µg/L for 87% of the analytes. Method validation showed high accuracy (>99.7%), sensitivity (>99.7%) and specificity (100%). Most analytes had a high process efficiency during the salting out liquid-liquid extraction (SALLE) workup and no or only a minor matrix effect during the analysis. We have implemented this method in clinical routine, and present data from 18,579 OF samples collected during routine patient treatment in mainly psychiatric and addiction clinics in West Sweden between September 2020 and June 2021. 71% of the samples were positive and a total of 41,472 DoA findings were detected. Amphetamine (27%), buprenorphine (25%), nordiazepam (18%) and alprazolam (16%) were most prevalent. NPS were detected in 189 samples (1.0%). Occurrence of polydrug use was common, 34% of the positive samples contained three analytes or more and 12% six or more. To the best of our knowledge, this is the first method for comprehensive analysis of DoA in OF using HRMS and the largest dataset published on detection of DoA in OF. With the current complex and variable drug use pattern, this broad, cost-effective and reliable method has largely replaced immunoassay screening in urine in our laboratory.

A Fast Analytical Method for Determining Synthetic Cathinones in Oral Fluid by Liquid Chromatography-Tandem Mass Spectrometry

In this paper, we present a method for simultaneously determining 11 synthetic cathinones in oral fluid (OF) by liquid chromatography-tandem mass spectrometry. Synthetic cathinones, a wide variety of which are available on the market, are constantly evolving. It is therefore important to provide efficient methods for determining cathinones in different matrices. A common matrix for detecting recent drug intake is OF, which can easily be collected using one of numerous commercial devices. Most methods aimed at determining drugs in biological samples such as OF require labor-intensive and time-consuming sample-preparation steps. However, the pretreatment of complex samples is often a challenge in the development of a method. For this reason, in this paper, we present a simple, easy-to-handle alternative that uses a Salivette® device and pretreats the sample in the same device. Matrix-matched calibration curves were used to cover the concentration range at which these substances are usually present in the OF from drug consumers. The method detection limits ranged from 0.003 to 0.03 ng/g, and the method quantification limits were set at 0.075 ng/g. This is a simple, rapid and sensitive method with good potential for determining recent drug consumption in OF.

Surveillance by oral fluid of drugs subject to misuse among individuals under arrest

Background: Between 1988 and 2013 the U.S. government conducted surveillance of national drug misuse use trends by collecting voluntary urine specimens from individuals under arrest in major counties. It was discontinued for financial reasons. The program was the only national survey that used a bioassay to measure drug use. Other national drug surveys continue to be based entirely on self-reports of drug use.Objective: Given the current opioid and incipient methamphetamine epidemics, this study aimed to demonstrate the feasibility of surveilling drugs subject to misuse among individuals under arrest using oral fluid collected anonymously by jail staff in one U.S. county. This method has never been previously employed with an offender population.Methods: The subjects were adults arrested for any reason and booked in one Midwest county jail in the U.S. between July 2019 - January 2020 (N = 196; 145 males). Oral fluid specimens were provided for research purposes voluntarily and anonymously.Results: 79% of individuals approached consented to participation. The most frequently detected drugs were cannabis (53%), methamphetamine (27%), cocaine (9%) and opioids (11%). Further, 74% tested positive for at least one drug; 36% tested positive for at least one illegal drug, 10% tested positive for at least one possibly illegal drug, and 54% tested positive for at least one legal drug (predominantly cannabis). (Tests for nicotine and ethanol were not included.)Conclusion: The feasibility of collecting oral fluid from individuals under arrest in a jail setting to measure the prevalence of drugs subject to misuse was demonstrated.

Determination of Synthetic Cathinones in Urine and Oral Fluid by Liquid Chromatography High-Resolution Mass Spectrometry and Low-Resolution Mass Spectrometry: A Method Comparison

Synthetic cathinones have become very popular recreational drugs. Therefore, determining them in biological samples is now a matter of concern. In recent years, different methods that have been developed can determine these drugs at low-concentration levels. In general, liquid chromatography mass spectrometry detection plays an important role in these methods and the trend is to use low-resolution and high-resolution mass spectrometry. In this article, for the first time, we compare these two analyzers using an Orbitrap and a triple quadrupole mass spectrometer in order to determine a group of synthetic cathinones in urine and oral fluid samples. For this comparison, we evaluated and compared different parameters: Method detection and quantification limits, linearity, apparent recoveries, matrix effect, repeatability (intra-day), reproducibility (inter-day), and accuracy. Similar results were obtained for the two analyzers for the apparent recoveries and matrix effect. However, triple quadrupole showed higher sensitivity compared to Orbitrap for both urine and oral fluid samples. The quantification limits in urine and the detection limits in saliva were two times lower for triple quadrupole. Finally, when blind samples were analyzed to study the accuracy, similar results were obtained for both analyzers.

Combining ecological momentary assessment with objective, ambulatory measures of behavior and physiology in substance-use research

Whereas substance-use researchers have long combined self-report with objective measures of behavior and physiology inside the laboratory, developments in mobile/wearable electronic technology are increasingly allowing for the collection of both subjective and objective information in participants' daily lives. For self-report, ecological momentary assessment (EMA), as implemented on contemporary smartphones or personal digital assistants, can provide researchers with near-real-time information on participants' behavior and mood in their natural environments. Data from portable/wearable electronic sensors measuring participants' internal and external environments can be combined with EMA (e.g., by timestamps recorded on questionnaires) to provide objective information useful in determining the momentary context of behavior and mood and/or validating participants' self-reports. Here, we review three objective ambulatory monitoring techniques that have been combined with EMA, with a focus on detecting drug use and/or measuring the behavioral or physiological correlates of mental events (i.e., emotions, cognitions): (1) collection and processing of biological samples in the field to measure drug use or participants' physiological activity (e.g., hypothalamic-pituitary-adrenal axis activity); (2) global positioning system (GPS) location information to link environmental characteristics (disorder/disadvantage, retail drug outlets) to drug use and affect; (3) ambulatory electronic physiological monitoring (e.g., electrocardiography) to detect drug use and mental events, as advances in machine learning algorithms make it possible to distinguish target changes from confounds (e.g., physical activity). Finally, we consider several other mobile/wearable technologies that hold promise to be combined with EMA, as well as potential challenges faced by researchers working with multiple mobile/wearable technologies simultaneously in the field.

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

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

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

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

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

Oral fluid testing for marijuana intoxication: enhancing objectivity for roadside DUI testing

Reducing marijuana-impaired driving is an important part of any strategy to prevent motor vehicle traffic injuries. In Colorado, the first of eight US states and the District of Columbia to legalise marijuana for recreational use, drivers with positive tests for the presence of marijuana accounted for a larger proportion of fatal MVCs after marijuana commercialisation. The use of blood tests to screen for marijuana intoxication, in Colorado and elsewhere in the USA, poses a number of challenges. Many high-income countries use oral fluid drug testing (OF) to provide roadside evidence of marijuana intoxication. A 2009 Belgium policy implementing OF roadside testing increased true positives and decreased false positives of suspected marijuana-related driving under the influence (DUI) arrests. US policy-makers should consider using roadside OF to increase objectivity and reliability for tests used in marijuana-related DUI arrests.

Parallel artificial liquid membrane extraction of new psychoactive substances in plasma and whole blood

Parallel artificial liquid membrane extraction (PALME) was combined with ultra-high performance liquid chromatography-mass spectrometry (UHPLC-MS) and the potential for screening of new psychoactive substances (NPS) was investigated for the first time. PALME was performed in 96-well format comprising a donor plate, a supported liquid membrane (SLM), and an acceptor plate. Uncharged NPS were extracted from plasma or whole blood, across an organic SLM, and into an aqueous acceptor solution, facilitated by a pH gradient. MDAI (5,6-methylenedioxy-2-aminoindane), methylone, PFA (para-fluoroamphetamine), mCPP (meta-chlorophenylpiperazine), pentedrone, methoxetamine, MDPV (methylenedioxypyrovalerone), ethylphenidate, 2C-E (2,5-dimethoxy-4-ethylphenethylamine), bromo-dragonfly, and AH-7921 (3,4-dichloro-N-{[1-(dimethylamino)cyclohexyl]methyl}benzamide) were selected as representative NPS. Optimization of operational parameters was necessary as the NPS were novel to PALME, and because PALME was performed from whole blood for the very first time. In the PALME method developed for plasma, NPS were extracted from a 250μL alkalized donor solution consisting of 125μL plasma sample, 115μL 40mM NaOH, and 10μL internal standard. In the PALME method from whole blood, the 250μL alkalized donor solution consisted of 100μL whole blood, 50μL deionized water, 75μL 80mM NaOH, and 25μL internal standard. In both methods, extraction was accomplished across an SLM of 5μL dodecyl acetate with 1% trioctylamine (w/w), and further into an acidic acceptor solution of 50μL 20mM formic acid. The extraction was promoted by agitation at 900rpm and was carried out for 120min. Method validation was performed and the following parameters were considered: linearity, limits of quantification (LOQ), intra- and inter-day precision, accuracy, extraction recoveries, carry-over, and matrix effects. The validation results were in accordance with FDA guidelines.