Does the preparation for intravenous administration affect the composition of heroin injections? A controlled laboratory study

AIMS

To study whether the preparation procedure, and its acidic and heating conditions, used by heroin users to prepare heroin for intravenous administration affects the final composition of the fluid to be injected.

METHODS

Samples from different seizures of illegal heroin provided by the Norwegian police were prepared by adding water and ascorbic acid before heating under controlled conditions in the laboratory. Further, three seizures were prepared with different amounts of ascorbic or citric acid relative to their diacetylmorphine content. Pure diacetylmorphine base or salt was also submitted to the procedure applying two different heating intensities. The seizures and the final product after preparation were analysed for diacetylmorphine, 6-acetylmorphine and morphine using liquid chromatography with tandem mass spectrometry (LC-MS-MS).

RESULTS

After preparation, a decrease of 19.8% (25th and 75th percentiles = -29.2 and -15.3) in the initial diacetylmorphine content was observed. Both the 6-acetylmorphine and morphine content increased but, due to their low content in the initial product, diacetylmorphine still represented 83.9% (25th and 75th percentiles = 77.3 and 88.0) of the sum of these three opioids in the final solution. The loss of water during preparation caused an increase in the concentration of diacetylmorphine, 6-acetylmorphine and morphine, depending on the heating intensity applied. The content of these opioids was affected by the quantity and type of acid added in relation to the heroin purity and the level of diacetylmorphine dissolved being proportional to the amount of ascorbic acid, but not citric acid, in the sample with high heroin purity.

CONCLUSIONS

Preparation of heroin for intravenous injection appears to change the amount or concentration of diacetylmorphine and its active metabolites, 6-acetylmorphine and morphine in the final product, depending on heroin purity, amount and type of acid used or heating conditions. These circumstances can contribute to unintentional variations in the potency of the final injected solution, and therefore affect the outcome after injection.

The implementation of per-se limits for driving under the influence of benzodiazepines and related drugs: No increased risk for arrest during therapeutic use in Norway

Objective: To investigate whether the use of recommended therapeutic doses of medicinal drugs has led to suspicion of driving under the influence of drugs (DUID) after implementation of legislative limits for illicit and medicinal drugs in 2012.Methods: Data from suspected drug-impaired drivers apprehended by the police from 2013 to 2015 were selected from the Norwegian Forensic Toxicology Database. The blood samples had been analyzed for benzodiazepines (BZDs), z-hypnotics, opioids, stimulants, certain hallucinogens, and alcohol. Drivers who tested positive for one BZD or a z-hypnotic only, were included in the study. Drug concentrations measured in their blood samples were compared to the maximal obtainable steady state concentrations if the drug had been used in accordance with the recommendations set by the Norwegian Directorate of Health.Results: BZDs or z-hypnotics were found in 10 248 samples, representing 59.6% of the total number of drivers arrested for suspected DUID (n = 17 201). Only one BZD or z-hypnotic with a blood drug concentration above the legislative limit was detected in 390 (2.3%) of the total number of samples. Clonazepam was the most frequently detected BZD (n = 4656), while as a single drug above the legislative limit, it was detected in only 3.6% (n = 168) of the clonazepam-positive blood samples. For drivers testing positive for only one z-hypnotic, drug concentrations above the legislative limit were found in 27% (n = 55) of the blood samples that tested positive for zolpidem and 12.4% (n = 53) of the samples that tested positive for zopiclone. In total, 155 subjects out of 10 248 testing positive for BZDs or z-hypnotics displayed concentrations above the legislative limit but within the concentration ranges that are expected when taking recommended therapeutic drug doses, and 77 below the legislativel limit.Conclusions: The results show that the implementation of legislative limits for BZDs and z-hypnotics may have contributed to DUID suspicion for a small group of patients using therapeutic drug doses; only 1.3% of the suspected DUID offenders had concentrations of only one of those drugs in-line with recommended therapeutic dosing.

Quantitative method for analysis of six anticoagulant rodenticides in faeces, applied in a case with repeated samples from a dog

Background

Accidental poisoning with anticoagulant rodenticides is not uncommon in dogs, but few reports of the elimination kinetics and half-lives in this species have been published. Our objectives were to develop and validate a new method for the quantification of anticoagulant rodenticides in canine blood and faeces using reversed phase ultra-high performance liquid chromatography–tandem mass spectrometry (UHPLC–MS/MS) and apply the method on a case of anticoagulant rodenticide intoxication.

Results

Sample preparation was liquid–liquid extraction. Six anticoagulant rodenticides were separated using a UPLC^® BEH C₁₈-column with a mobile phase consisting of 5 mM ammonium formate buffer pH 10.2 and methanol. MS/MS detection was performed with positive electrospray ionization and two multiple reaction monitoring transitions. The limits of quantification were set at the levels of the lowest calibrator (1.5–2.7 ng/mL or ng/g). The method was successfully applied to a case from a dog accidentally poisoned with anticoagulant rodenticide. Coumatetralyl and brodifacoum concentrations were determined from serial blood and faecal samples. A terminal half-life of at least 81 days for coumatetralyl in blood was estimated, which is longer than previous reported in other species. A slow elimination of brodifacoum from the faeces was found, with traces still detectable in the faeces at day 513.

Conclusions

This study offers a new method of detection and quantification of six frequently used anticoagulant rodenticides in canine faeces. Such drugs might cause serious health effects and it is important to be able to detect these drugs, to initiate proper treatment. The very long elimination half-lives detected in our study is important to be aware of in assessment of anticoagulant rodenticide burden to the environment.

The Appearance, Taste, and Concentrations of Zolpidem Dissolved in Still Water and Carbonated Beverages

Zolpidem is a sedative that could be used to drug victims, but its suitability to dissolve in drinks is unknown. In this small study, we added either crushed or whole tablets of zolpidem hemitartrate to carbonated beverages or still water to observe how this affected the taste and appearance. Also, concentrations were measured by ultra-high performance liquid chromatography tandem mass spectrometry at different time intervals. Two crushed tablets (20 mg) in cider (250 mL) lead to a maximum concentration of 84 mg/L zolpidem base after 30 min, while the corresponding concentration after adding fifteen tablets (150 mg) was 467 mg/L. There was little change in taste, but froth and turbidity were observed when adding high doses to carbonated beverages. Carbonated beverages spiked with 20 mg of crushed zolpidem hemitartrate tablets reached concentrations that could cause impairment. Spiking with 150 mg could possibly be lethal if several mouthfuls were ingested.

Blood concentrations of new designer benzodiazepines in forensic cases

INTRODUCTION

A number of new designer benzodiazepines have reached the illegal drug market over the past years. Toxicological interpretation of concentrations of these drugs in blood is quite challenging as very limited human data have previously been published. The aim of this study was to report blood concentrations of new designer benzodiazepines in a population of drugged drivers as well as some other criminal offenders, and to relate this to clinical impairment.

METHODS

The present material represents cases involving new designer benzodiazepines (clonazolam, diclazepam, flubromazepam, flubromazolam and pyrazolam) and etizolam, submitted for analyses during the period July 1, 2013-May 31, 2016. Analyses were performed using an ultra-performance liquid chromatography-tandem mass spectrometry method. Blood concentrations and results from the clinical test of impairment are reported.

RESULTS

New designer benzodiazepines were detected in 77 cases during the study period. The median (range) concentrations were 0.012mg/L (0.00048-0.10) for flubromazolam (n=25), 0.055mg/L (0.0047-1.2) for flubromazepam (n=24), 0.013mg/L (0.0021-0.057) for diclazepam (n=15), 0.050mg/L (0.019-0.17) for etizolam (n=14), 0.0053mg/L (0.0019-0.011) for clonazolam (n=7) and 0.074mg/L for pyrazolam (n=1). In six cases, designer benzodiazepines were the only drugs detected in blood, and in two of those cases, the physician had given the conclusion of "considerably impaired" upon performing the clinical test for impairment.

CONCLUSION

Given the lack of previously published data on human concentrations, results presented in this study could be helpful in interpretation of blood concentrations of new designer benzodiazepines. This is crucial for the assessment of the importance of toxicological results in suspected drugged drivers, rape victims, etc.

Characteristics of methadone-related fatalities in Norway

There are currently over 7000 patients enrolled in opioid maintenance treatment (OMT) programs in Norway. A rise in methadone-related deaths proportional to increasing methadone sales over the period 2000-2006 has been observed, but the causative factors for these fatalities have been elusive. In the present study, individual characteristics, methadone concentrations and additional toxicological findings were analyzed. Methadone intoxication deaths (n = 264) were divided into 3 groups according to toxicological findings in whole blood: group 1 - methadone detected alone, or together with one additional drug at low or therapeutic levels, or a low concentration of ethanol (<1 g/L) (n = 21); group 2 - multiple additional drugs/substances detected below lethal levels (n = 175); group 3 - one or more additional drugs/substances detected at lethal levels, or ethanol >3 g/L (n = 55). Methadone blood concentrations in decedents who had been enrolled in OMT were higher than for decedents not in treatment, in all groups. Blood methadone concentrations around 1 mg/L were present in fatal multi-drug intoxications in OMT patients. Results suggest that some patients may be at risk of dying when combining therapeutic concentrations of methadone with other psychoactive substances. Somatic disease was a common finding among deceased OMT patients. Concentrations in methadone users not enrolled in OMT were predominantly between 0.3 and 0.4 mg/L and were not related to the presence of other drugs. However, methadone concentrations below 0.1 mg/L may be associated with intoxication following methadone use, both alone and in combination with other drugs. Younger male users (mean age 34 years) seemed to have a higher susceptibility to methadone intoxication.

Determination of a selection of synthetic cannabinoids and metabolites in urine by UHPSFC-MS/MS and by UHPLC-MS/MS

Two different analytical techniques, ultra-high performance supercritical fluid chromatography-tandem mass spectrometry (UHPSFC-MS/MS) and reversed phase ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS), were used for the determination of two synthetic cannabinoids and eleven metabolites in urine; AM-2201 N-4-OH-pentyl, AM-2233, JWH-018 N-5-OH-pentyl, JWH-018 N-pentanoic acid, JWH-073 N-4-OH-butyl, JWH-073 N-butanoic acid, JWH-122 N-5-OH-pentyl, MAM-2201, MAM-2201 N-4-OH-pentyl, RCS-4 N-5-OH-pentyl, UR-144 degradant N-pentanoic acid, UR-144 N-4-OH-pentyl, and UR-144 N-pentanoic acid. Sample preparation included a liquid-liquid extraction after deconjugation with ß-glucuronidase. The UHPSFC-MS/MS method used an Acquity UPC(2 TM) BEH column with a mobile phase consisting of CO2 and 0.3% ammonia in methanol, while the UHPLC-MS/MS method used an Acquity UPLC® BEH C18 column with a mobile phase consisting of 5 mM ammonium formate (pH 10.2) and methanol. MS/MS detection was performed with positive electrospray ionization and two multiple reaction monitoring transitions. Deuterated internal standards were used for six of the compounds. Limits of quantification (LOQs) were between 0.04 and 0.4 µg/L. Between-day relative standard deviations at concentrations ≥ LOQ were ≤20%, with biases within ±19%. Recoveries ranged from 40 to 90%. Corrected matrix effects were within 100 ± 10%, except for MAM-2201 with UHPSFC-MS/MS, and for UR-144 N-pentanoic acid and MAM-2201 N-4-OH-pentyl with UHPLC-MS/MS. Elution order obtained by UHPSFC-MS/MS was almost opposite to that obtained by UHPLC-MS/MS, making this instrument setup an interesting combination for screening and confirmation analyses in forensic cases. The UHPLC-MS/MS method has, since August 2014, been successfully used for confirmation of synthetic cannabinoids in urine samples revealing a positive immunoassay screening result. Copyright © 2015 John Wiley & Sons, Ltd.

Methiopropamine in blood samples from drivers suspected of being under the influence of drugs

OBJECTIVES

Methiopropamine (MPA; 1-(thiophen-2-yl)-2-methylaminopropane) belongs to the new psychoactive substances (NPS) that have emerged on the drug market in recent years. MPA appeared in 2011 and is an analogue of methamphetamine, sold as, for example, "Slush Eric" and "Blow." It is reported to have effects similar to those of methamphetamine, but the toxicity in humans is not known. Three fatal cases involving MPA have been reported. One analytical confirmed intoxication case has been published, and this supports the symptoms described by the users. The prevalence of recreational use of MPA is unknown, and no studies have reported the prevalence in driving under the influence of drug (DUID) cases.

METHODS

We investigated the frequency of MPA in DUID cases received at our institute during a 12-week period and report the analytical method using an ultraperformance liquid chromatography.tandem mass spectrometry for quantification of MPA in whole blood. The analytical findings were compared to the results from a clinical test of impairment performed by a physician shortly after the driving episode. The samples were analyzed for 42 different psychoactive substances.

RESULTS

MPA was detected in 10 DUID cases (0.8% of the cases), only from male drivers. Other drugs were detected concomitantly in all the cases. Two of the cases were traffic accidents.

CONCLUSIONS

Our study shows that MPA is found in DUID cases and reveals that NPS are used among drivers and also proven in blood from drivers involved in traffic accidents. More studies are requested regarding the pharmacological and toxicological effects of MPA and other NPS. This is the first article that describes a method for analyzing and quantifying MPA in whole blood samples.

A fatal intoxication with phenazone (antipyrine)

Phenazone is a non-opioid analgesic used to treat acute mild to moderate pain, and is considered to be a safe drug. It is most often sold as a nonprescription/over-the-counter drug. Very few fatalities due to phenazone overdoses are reported in the literature. We present a case where a man in his early sixties was found dead in his home in the bottom of a staircase, the scene suggesting that death might have been caused by blunt force injury. However, in spite of the apparently dramatic scene, the gross findings at autopsy did not reveal lethal injuries. Whole blood from the femoral vein was collected during autopsy and screened for drugs of abuse and medicinal drugs. The only toxicological findings were a very high concentration of phenazone (280mg/L) and a high therapeutic concentration of caffeine (34mg/L). An UPLC-MS/MS method was used for quantification of the drugs.

Use of alcohol and drugs among health professionals in Norway: a study using data from questionnaires and samples of oral fluid

Working under the influence of drugs and/or alcohol may affect safety and job performance. However, the size of this possible problem among health professionals (HPs) is unknown. The aim of this study was threefold: (i) to analyze samples of oral fluid and self-reported data from questionnaires to investigate the prevalence of alcohol and drugs among a sample of HPs in Norway, (ii) to study self-reported absence from or impairment at work due to alcohol and/or drug use, and (iii) to examine whether such use and absence/impairment due to such use depend on socio-demographic variables.

A total of 916 of the 933 invited HPs from hospitals and pharmacies participated in the study (participation rate = 98.2%), and 81.1% were women. Associations were analyzed in bi-variate cross tables with Chi-square statistics to assess statistical significance.

Alcohol was not detected in any of the samples. Ethyl glucuronide, a specific alcohol metabolite, was found in 0.3% of the collected samples. Illicit drugs and medicinal drugs were identified in 0.6% and 7.3% of the samples, respectively. Both analytical results and self-reported use of alcohol and drugs during the past 12 months indicate that recent and past year alcohol and drug use was lower among HPs than among workers in other business areas in Norway, Europe and US. Nevertheless, several HPs reported absence from work due to alcohol (0.9%) and medicinal drug use (0.8%) during the past 12 months. A substantial part (16.7%) of the self-reported medicinal drug users reported absence from work because of use of medicinal drugs during the past 12 months, and more than 1/4 of those reported in-efficiency at work because of the use of medicinal drugs during the past 12 months. Reduced efficiency at work due to alcohol use during the past 12 months was reported by 12.2%.

This sample of HPs seldom used illicit drugs, few had a high level of alcohol consumption, and few tested positive for medicinal drugs. Absence or hangover related to the use of medicinal drugs or alcohol appeared to be a bigger issue than the acute intoxication or the use of illicit drugs.

Prevalence of synthetic cannabinoids in blood samples from Norwegian drivers suspected of impaired driving during a seven weeks period

From early year 2000 different herbal products containing synthetic cannabinoids (SC) have appeared on the drug market all over the world, and new substances are frequently introduced. The prevalence of SC use in different populations is however still mainly unknown, also in Norway. This information is difficult to obtain, but studies of drivers suspected of driving under the influence of drugs (DUID), might provide important information. The aim of this study was to assess the prevalence of SC in drivers suspected of being under the influence of drugs in Norway, and investigate if SCs impair driving performance. For two periods of three and four weeks all blood samples from drivers suspected of DUID in Norway were analyzed for the presence of 12 and 18 different SCs, respectively. A new ultra performance liquid chromatography tandem mass spectrometry method was developed. A total of 726 cases were analyzed during our study period, and SCs were detected in 16 cases (2.2%) in total. The mean age of these drivers was 29.6 years. High concentrations of other psychoactive drugs were detected in all the blood samples where a SC was found. AM-2201 and JWH-018 were the most frequently detected SCs, each found in five cases. In addition RSC-4, JWH-122, JWH-081 and JWH-250 were detected. None of the drivers had reported using SCs prior to driving. Despite the limited number of SCs investigated in this 7 week study period, a considerable percent of the cases were positive. Other psychoactive drugs of abuse were always found concomitant with the SCs, and the age of these drivers indicates that experienced drug users also ingest SCs. Since other drugs were found in all the samples, the psychomotor impairment caused by the SCs is difficult to estimate. Our study shows the importance of screening analyses of biological samples from different populations to assess the prevalence of drug use, since self-reporting might be encumbered with significant under-reporting.

Methyl tert-butyl ether (MTBE) detected in abnormally high concentrations in postmortem blood and urine from two persons found dead inside a car containing a gasoline spill

Two deep frozen persons, a female and a male, were found dead in a car. There had been an explosive fire inside the car which had extinguished itself. On the floor inside the car were large pools of liquid which smelled of gasoline. The autopsy findings and routine toxicological analyses could not explain the cause of death. Carboxyhemoglobin levels in the blood samples were <10%. Analysis with a headspace gas chromatography revealed methyl tert-butyl ether (MTBE) concentrations of 185 mg/L (female victim) and 115 mg/L (male victim) in peripheral blood. The urine MTBE concentrations were 150 mg/L and 256 mg/L, respectively. MTBE is a synthetic chemical which is added to gasoline as a fuel oxygenate. Gasoline poisoning is likely to be the cause of the death in these two cases, and MTBE can be a suitable marker of gasoline exposure, when other volatile components have vaporized.

Long-term stability of GHB in post-mortem samples and samples from living persons, stored at -20°C, using fluoride preservatives

PURPOSE

Reanalyses are frequently requested in forensic toxicology, and knowledge of the stability of drugs in biological samples is of major importance for the interpretation of the toxicological findings. Currently, the literature on stability of gammahydroxybutyrate (GHB) in blood samples from living subjects and in post-mortem blood is limited. The purpose of this study was to evaluate the long-term stability of GHB in both blood samples from persons suspected of drug use and post-mortem blood samples.

METHODS

A total of 59 reanalyses were performed in whole blood samples, 27 samples from living subjects and 32 samples taken at autopsies. The samples were stored in the freezer between 0.4 and 7.2 years at -20°C in vials containing preservatives. Analyses were performed by GC-FID, and cut-off level was 10.3 mg/L. The concentrations in 22 of the samples were below cut-off.

RESULTS

The mean change in concentration between initial analysis and reanalysis was -0.8% for the positive samples from living persons and -7.1% for the positive post-mortem samples. Changes ranged from -32.4% to 21.0% for samples from living and from -30.4% to 34.4% for post-mortem samples. All negative samples were still negative at the time of reanalysis.

CONCLUSION

Reanalysis of these forensic whole blood samples stored several years at -20°C with fluoride preservation did not exhibit changes in GHB concentrations of practical significance for the interpretation of toxicological findings.

Surveillance of abused drugs in forensic autopsy cases in Norway

High drug related mortality has been registered in Norway. Although comparison between countries relies on a standard international coding system of diseases, different practices in verifying cause of death and applying codes could lead to variation. The comparison gives no information on drug findings or drug patterns underlying the cause of deaths. To evaluate deaths involving illicit drugs in Norway, we examined drug patterns in 2735 forensically examined post-mortem samples collected from 15-64 year-old individuals from 2000 to 2009. There were four times as many men as women among the deceased illicit drug users, and the majority were in the age group 25-44 years. The number of deceased showing signs of illicit drug use has gradually declined during the study period. The decline was found among younger individuals, while a larger proportion of the deceased were above 45 years of age in 2009, compared to 2000. Cases positive for heroin, ethanol, ecstasy and flunitrazepam were fewer in 2009, while the prevalence of amphetamine, cannabis, methadone and other opioids has increased. The prevalence of methamphetamine has increased ten fold, and the prevalence of benzodiazepines doubled. Thus, the drug pattern and age of the deceased has changed markedly during the last 10 years. Heroin and ethanol use has partly been substituted by use of amphetamines, cannabis, benzodiazepines and other opioids. This change could possibly be explained by the prolonged survival of drug users on substitution treatment and by the reduced toxicity of consumed drugs.

Ethyl glucuronide concentrations in oral fluid, blood, and urine after volunteers drank 0.5 and 1.0 g/kg doses of ethanol

The aim of this study was to investigate the concentrations of ethyl glucuronide (EtG) in oral fluid, blood, and urine after healthy volunteers drank two doses of ethanol, 0.5 (n = 11) and 1.0 g/kg (n = 10), after an overnight fast. Samples of oral fluid, blood, and urine were collected before drinking started and at 1.5, 3.5, 5.5, 8.5, 11.5, and 24 h post-dosing. Following ingestion of low dose of ethanol, the Cmax for EtG was 0.36 mg/L (range 0.28-0.41 mg/L) in blood and 69.8 mg/L (range 47.1-96.5 mg/L) in urine. In oral fluid, the concentrations were < 1% of those in blood, and only three subjects exceeded the limit of quantification for EtG in oral fluid. After ingestion of the high dose of ethanol, the Cmax for EtG was 1.06 mg/L (range 0.8-1.22 mg/L) in blood, 159.9 mg/L (range 97.2-225.5 mg/L) in urine, and 0.032 mg/L (range 0.013-0.059 mg/L) in oral fluid. The median oral fluid/blood ratio was 0.029 (range 0.012-0.054) for EtG. The detection time for EtG was median 11.5 h (range 3.5-11.5 h) in oral fluid. According to this, the detection time for EtG in oral fluid is therefore only a few hours longer than for ethanol itself and represents limited additional value.

Disappearance of ethyl glucuronide during heavy putrefaction

INTRODUCTION

There are previous publications showing the use of ethyl glucuronide (EtG), a non-oxidative metabolite of ethanol, as a marker of ante-mortem ingestion of alcohol in forensic autopsy cases. The problem of possible degradation or formation of EtG during putrefaction is however not well studied and the aim of this study was to investigate the possibility of false negative and false positive EtG results by an in vitro study. Further, we used the information from the in vitro study on real cases, to get an impression of the practical problem of degradation or formation of EtG.

METHODS

An in vitro study was carried out to study the concentrations of EtG in blood samples under controlled conditions during putrefaction. In addition, to illustrate the practical problem of degradation or formation of EtG, we used routine samples analysed for EtG in blood. Blood samples from forensic autopsies with ethanol detected but EtG not detected in blood, and therefore suspected post-mortem ethanol formation, were identified. Fifteen such cases had urine samples available, and these were analysed for EtG. We hypothesised that since concentrations are often higher in urine, there would still be traces of EtG left in this medium if post-mortem degradation was the reason for the negative result in blood.

RESULTS

In this in vitro experiment, EtG was very unstable in blood samples at 30/40 degrees C without preservatives. On the other hand, EtG was stable with potassium fluoride at room temperature, and there was no formation of EtG either at 30 degrees C without preservatives, or at room temperature with potassium fluoride. Of the 15 routine cases where EtG in blood was negative, and the ethanol detected was assumed endogenous, six were positive for EtG in urine. In these cases, ethanol was probably ingested, and the negative EtG in blood may be a false negative result due to degradation during putrefaction.

CONCLUSION

Analysis of EtG in blood is a helpful tool to determine in vivo ingestion of ethanol in post-mortem cases. A negative result, however, especially in heavily putrefied cases, must be interpreted with caution. Analysis of an additional medium would be valuable in these cases.

A pharmacokinetic study of ethyl glucuronide in blood and urine: Applications to forensic toxicology

This pharmacokinetic study investigated the kinetics of ethanol and its metabolite ethyl glucuronide (EtG) in blood and urine during the whole time course of absorption and elimination. There are few previous studies on the kinetics of EtG in blood, and we wanted to evaluate whether such knowledge could yield valuable information regarding the time of ethanol ingestion in forensic cases, such as, for instance, drunk driving. Ten male volunteers consumed ethanol at a fixed dose of 0.5 g/kg body weight in a fasted state. Blood samples were collected for 14 h and urine samples were collected for 45-50 h after the start of drinking. EtG reached its maximum concentration (C(max)) in blood after a median of 4 h (range 3.5-5), a median of 3 h (range 2-4.5) after C(max) for ethanol. The ethanol-to-EtG ratios in blood (ethanol in g/L, EtG in mg/L) were >1 only for the first median 3.5 h (range 2.5-3.5) after drinking. EtG elimination occurred with a median half-life of 2.2 h (range 1.7-3.1 h), and the renal clearance was 8.32 L/h (median, range 5.25-20.86). The concentrations of EtG were always much higher in urine than in blood. The total amount of EtG excreted in the urine was median 30 mg (range 21.5-39.7), representing 0.017% (median, range 0.013-0.022) of the ethanol given, on a molar basis. The information from the present study may be a valuable supplement to determine the time of ethanol ingestion. For this purpose, two subsequent increasing EtG values and a high ethanol-to-EtG ratio in blood would support information of recent drinking.

Relationship between methadone and EDDP (2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine) in urine samples from Norwegian prisons

BACKGROUND

Methadone maintenance treatment is a widely used therapy in the rehabilitation of opioid addiction the world over. Methadone is metabolised in the body to a number of inactive metabolites, but primarily to 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). The Division of Forensic Toxicology and Drug Abuse (DFTDA) of the Norwegian Institute of Public Health carries out drug analysis of urine samples from inmates of prisons throughout Norway. Methadone and EDDP in the urine are also tested for upon request. The results are stored in a secure database at the DFTDA.

OBJECTIVES

The aims of the present study were (1) to observe variations in methadone and EDDP concentrations in urine in relation to urine pH in a large set of urine samples obtained from prison inmates and (2) to analyse samples testing methadone-positive/EDDP-negative and investigate whether such results could occur naturally, without sample tampering.

METHODS

All urine samples that tested positive for methadone over the period 2004-2005 were collected from the DFTDA database, and the relation between methadone and EDDP excretion in urine, and urinary pH was determined. Samples that tested positive for methadone but negative for EDDP were picked out and studied individually.

RESULTS

A total of 1539 urine samples (cases) had tested positive for methadone in our database for the period 2004-2005. There was a strong correlation between the concentration of methadone in urine and urine pH in these samples, with higher concentrations of methadone present at lower pH levels. Cases that tested positive for methadone but negative for EDDP were rare - a total of five (0.3% of all cases tested). These cases were studied in more detail.

CONCLUSION

Methadone excretion in urine is dependent on urinary pH. Methadone-positive/EDDP-negative results may suggest sample tampering in some, but not all, cases.

A study of ethyl glucuronide in post-mortem blood as a marker of ante-mortem ingestion of alcohol

The possibility of post-mortem production of ethanol makes correct interpretation of ethanol detection in forensic autopsy samples difficult. Even though the levels of ethanol formed post-mortem are generally low, this may be highly relevant in cases where intake of alcohol was forbidden, for instance for pilots, professional drivers and countries with low legal alcohol limits for driving. Different criteria are used to determine whether a finding of ethanol is of exogenous origin, but there is no marker for alcohol ingestion that has been studied in detail. In this study, we wanted to evaluate the sensitivity and specificity of ethyl glucuronide (EtG), a direct minor metabolite of ethanol, measured in blood, as a marker of ante-mortem alcohol ingestion. Forensic autopsy cases were divided into groups with and without ante-mortem alcohol ingestion, according to strict inclusion criteria. In 93 cases with information on ante-mortem alcohol ingestion, EtG was detected in blood in all cases, even when levels of ethanol were low. In another 53 cases where there were no indications of ante-mortem alcohol intake, EtG could not be detected in blood in a single case, also in 11 cases in which ethanol was detected and considered to be most probably formed post-mortem. In conclusion, blood EtG determination seems to be a reliable marker of ante-mortem ingestion of alcohol, and it could be considered in forensic autopsy cases when post-mortem formation of ethanol is questioned.

The concentrations, appearance and taste of nine sedating drugs dissolved in four different beverages

Sedating drugs are reported to be used in cases where people have been drugged unwittingly. In the present experiments we studied whether nine sedating medicinal drugs would dissolve in four different beverages to reach concentrations which could possibly cause impairment and whether the drugs altered the appearance and taste of the beverages. Nine sedating medicinal drugs were added separately to water, beer, Coca-Cola and ethanol. Drug concentrations were measured 5, 10, 20 and 40 min after spiking. The amount of drug in one swallow (50 mL) was calculated. Appearance and taste were recorded after 10 min. Flunipam, Sobril, Valium and Xanor dissolved faster than Rohypnol, Imovane, Somadril, Rivotril and Dolcontin. Ten minutes after adding Flunipam, Sobril, Imovane (in beer and Coca-Cola), Valium and Xanor, the concentrations had reached more than 50% of maximum theoretical concentration. Most of the drugs caused sediment, pieces and/or turbidity in one or more of the beverages. Some of the solutions were dyed from added Rohypnol (turquoise or green), Dolcontin (red) and Valium (yellow). Flunipam and Valium caused extensive frothing in beer. The tastes of Imovane and Somadril were distinct in all the beverages, while the taste of other drug solutions was less distinct. The ingestion of all solutions could probably have caused impairment. All the nine drugs were, however, apparent to the consumer from the altered appearance and/or taste of the beverages.

Fatal overdose of zopiclone in an elderly woman with bronchogenic carcinoma

The death of a 72-year-old woman with respiratory debilitation due to bronchogenic carcinoma is described. She overdosed herself with probably 200 to 350 mg of zopiclone. Zopiclone, quantitated by HPLC in femoral postmortem blood, was found to be 1.9 mg/L (4.8 micromol/L). This level is higher than many other zopiclone fatalities reported. We report a case where only zopiclone was detected.