Determination of drug exposure using hair: application to child protective cases

Specific laboratory investigations for assessments and management of drug problems

Much of the drug testing available today is able to determine the presence or absence of a variety of psychoactive substances in a range of body fluids and tissues. For the results of such tests to be confidently interpreted, additional information is required, including general assessment and history-taking. In a wide range of large psychiatric surveys, substance dependence emerges as one of the most common mental health-related disorders, and it is also the one that is least likely to be treated. The range of available tests can be best considered as acting to support and complement a broader assessment and diagnostic procedure.

Exposures associated with clandestine methamphetamine drug laboratories in Australia

The clandestine manufacture of methamphetamine in residential homes may represent significant hazards and exposures not only to those involved in the manufacture of the drugs but also to others living in the home (including children), neighbours and first responders to the premises. These hazards are associated with the nature and improper storage and use of precursor chemicals, intermediate chemicals and wastes, gases and methamphetamine residues generated during manufacture and the drugs themselves. Many of these compounds are persistent and result in exposures inside a home not only during manufacture but after the laboratory has been seized or removed. Hence new occupants of buildings formerly used to manufacture methamphetamine may be unknowingly exposed to these hazards. Children are most susceptible to these hazards and evidence is available in the literature to indicate that these exposures may result in immediate and long-term adverse health effects. The assessment of exposure within the home can be undertaken by measuring contaminant levels or collecting appropriate biological data from individuals exposed. To gain a better understanding of the available data and key issues associated with these approaches to the characterisation of exposure, a review of the published literature has been undertaken.

Risk of neurobehavioral disinhibition in prenatal methamphetamine-exposed young children with positive hair toxicology results

BACKGROUND

The objective was to evaluate the effects of prenatal methamphetamine exposure (PME) and postnatal drug exposures identified by child hair analysis on neurobehavioral disinhibition at 6.5 years of age.

METHODS

Mother-infant pairs were enrolled in the Infant Development, Environment, and Lifestyle (IDEAL) Study in Los Angeles, Honolulu, Tulsa, and Des Moines. PME was determined by maternal self-report and/or positive meconium results. At the 6.5-year follow-up visit, hair was collected and analyzed for methamphetamine, tobacco, cocaine, and cannabinoid markers. Child behavioral and executive function test scores were aggregated to evaluate child neurobehavioral disinhibition. Hierarchical linear regression models assessed the impact of PME, postnatal substances, and combined PME with postnatal drug exposures on the child's neurobehavioral disinhibition aggregate score. Past year caregiver substance use was compared with child hair results.

RESULTS

A total of 264 children were evaluated. Significantly more PME children (n = 133) had hair positive for methamphetamine/amphetamine (27.1% versus 8.4%) and nicotine/cotinine (38.3% versus 25.2%) than children without PME (n = 131). Overall, no significant differences in analyte hair concentrations were noted between groups. Significant differences in behavioral and executive function were observed between children with and without PME. No independent effects of postnatal methamphetamine or tobacco exposure, identified by positive hair test, were noted and no additional neurobehavioral disinhibition was observed in PME children with postnatal drug exposures, as compared with PME children without postnatal exposure.

CONCLUSIONS

Child hair testing offered a noninvasive means to evaluate postnatal environmental drug exposure, although no effects from postnatal drug exposure alone were seen. PME, alone and in combination with postnatal drug exposures, was associated with behavioral and executive function deficits at 6.5 years.

Children intoxications: what is abuse and what is not abuse

The curiosity and the natural tendency to explore the environment put young children at an increased risk of poisoning over older children and adults. Poisonings are a significant area of concern from 1 year of age and progressively contribute more to overall rates of morbidity and mortality until children reach adulthood. Particularly, the abuse of children by poisoning is also highly common with thousands of fatalities. A practical strategy is presented that aims to alert health, forensic, and law enforcement professionals to this problem and to demystify the preconception that it is a rare form of abuse or neglect. Compounds that are foreign to a living organism (xenobiotics) and those present within body (endobiotics), mainly involved in children intoxications and contextual examples related to exposure are also reviewed. Particular concern is given to concepts in the field of children poisoning. The described history and the clinical and toxicological evaluation are discussed, and harmonized protocols regarding correct procedures for sample collection to forensic toxicological analysis are proposed. Since children are particularly vulnerable to the toxic effects of high doses of xenobiotics and endobiotics, special consideration on the preparation of the environment that surrounds children in order minimize all possible risks will be also considered.

Quantitative analysis of methamphetamine in hair of children removed from clandestine laboratories--evidence of passive exposure?

In New Zealand many children have been removed from clandestine laboratories following Police intervention. In the last few years it has become standard procedure that these children have hair samples taken and these samples are submitted to the laboratory for analysis. There are various mechanisms for the incorporation of drugs into hair. The hair follicle has a rich blood supply, so any drug that may be circulating in the blood can be incorporated into the growing hair. Another mechanism is via external contamination, such as spilling a drug on the hair or through exposure to fumes or vapours. Hair samples were analysed for methamphetamine and amphetamine. From the 52 cases analysed 38 (73%) were positive for methamphetamine (>0.1 ng/mg) and amphetamine was detected in 34 of these cases. In no case was amphetamine detected without methamphetamine. The hair washes (prior to extraction) were also analysed (quantified in 30 of the positive cases) and only 3 had a wash to hair ratio of >0.1 (all were <0.5), which may be indicative of a low level of external contamination. This low level of evidence of external contamination suggests that the children are exposed to methamphetamine and are incorporating it into the hair through the blood stream.

Illicit drug exposure in patients evaluated for alleged child abuse and neglect

BACKGROUND

Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs.

OBJECTIVE

The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect.

DESIGN AND METHODS

The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study.

RESULTS

Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034).

CONCLUSIONS

The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.

[Drugs of abuse acute intoxication in paediatric emergencies]

Documented cases show that acute drugs of abuse intoxication in children usually is the Fritz clinical evidence of a chronic exposure. Published clinical reports of drugs of abuse acute poisonings in children are reviewed, above all those with an underlying chronic exposure to the same or another substance. Biological matrices and exposure biomarkers useful in toxicology analysis in Paediatrics are reviewed. In toxicology, biomarkers refer to original parental substances and its metabolites and matrices refer to body substances where biomarkers are detected. In these matrices acute and chronic (previous days, weeks or months) exposures can be detected. Hair analysis has become the gold standard of drugs of abuse chronic exposure. Recommendation includes to confirm previous chronic exposure to drugs of abuse by hair analysis of children and their parents. This protocol must be applied in all cases with suspicion of acute drugs of abuse intoxication, parental consumption and/or children living in a risk environment.

Hair drug testing of children suspected of exposure to the manufacture of methamphetamine

INTRODUCTION

This study compares hair color and age in children tested for methamphetamine by hair analysis due to suspicion of exposure to the manufacture of methamphetamine by their caregivers.

METHODS

A retrospective analysis evaluated differences in hair drug testing results of 107 children less than 12 years of age tested due to clinical suspicion of having been exposed to the manufacture of methamphetamine. Results (confirmed by gas chromatography-mass spectroscopy) were compared for differences in likelihood of testing positive in relation to the subject's age and having light or dark colored hair and reported with crude and adjusted odds ratios with 95% confidence intervals.

RESULTS

Of 107 children, 103 had a sufficient hair specimen for analysis. A third (36%) of the study population was less than 3 years of age. Almost half (45%) of the children tested positive for methamphetamine. 15% of the total study population tested positive for methamphetamine in combination with amphetamine indicating some degree of systemic exposure. No children were positive for amphetamine without also being positive for methamphetamine. Children less than 3 years of age were more likely to test positive. Positive hair drug tests for the combination of methamphetamine and amphetamine occurred in children with both light and dark colored hair.

DISCUSSION AND CONCLUSION

Children living in homes where methamphetamine is being manufactured can have drug identified in their hair regardless of hair color. This testing can aid in illuminating the child's presence in an at-risk environment and a family in need of services.

Opioid detection in maternal and neonatal hair and meconium: characterization of an at-risk population and implications to fetal toxicology

Identification of maternal opioid abuse in pregnancy is often difficult to ascertain in the absence of a reliable self-report. We aimed to characterize an at-risk neonatal population for opioid exposures as well as other drugs of abuse and alcohol. From June 2007 to January 2009, 563 neonatal hair and 1318 meconium specimens were assessed for opioids and were positive in 11.4% and 17.0%, respectively. Neonates testing positive for opioids in hair or meconium analysis were also more likely to test positive for other licit and illicit substances (odds ratiohair, 1.75; 95% confidence interval, 1.03-2.97; odds ratiomeconium, 1.61; 95% confidence interval, 1.16-2.22). Specifically, a positive neonatal hair test for opioids also predicted a positive result for oxycodone. In addition, a positive meconium test result for opioids was associated with positive results for cocaine, oxycodone, methadone, benzodiazepines, and fatty acid ethyl esters (alcohol). Finally, there was a significant correlation between maternal and neonatal hair test results for opioids (Spearman rank rho = 0.657, P = 0.03). Understanding the addiction profiles of these women may lead to better clinical and social management and may largely benefit an at-risk population.

The efficacy of hair and urine toxicology screening on the detection of child abuse by burning

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Methamphetamine detection in maternal and neonatal hair: implications for fetal safety

BACKGROUND

Methamphetamine misuse is a serious health problem of epidemic proportions. Use of this drug, particularly during pregnancy, is difficult to ascertain. Sparse information is available on gestational exposure.

OBJECTIVES

To quantify methamphetamine accumulation in hair, identify the use of methamphetamine with other drugs of abuse and characterise correlations between concentrations of methamphetamine in maternal and neonatal hair.

SUBJECTS AND METHODS

Motherisk laboratory at the Hospital for Sick Children routinely carries out analysis of methamphetamine in hair. Mothers and infants with positive results for methamphetamine in hair were identified. Drugs present in hair were analysed by ELISA and positive results were confirmed by gas chromatgraphy/mass spectrometry.

RESULTS

396 people positive for methamphetamine in their hair were identified from our database. Almost 85% of them were positive for at least one other drug of abuse, mostly cocaine. Eleven mother-baby pairs with hair positive for methamphetamine were identified. Methamphetamine levels in hair ranged between 0.13 and 51.97 ng/mg in the mothers and between 0 and 22.73 ng/mg in the neonates. Methamphetamine levels in mothers and neonates correlated significantly. One (9%) neonate was negative for methamphetamine even though the mother was positive.

CONCLUSION

To our knowledge, this is the first report on fetal exposure to methamphetamine during pregnancy, showing transplacental transfer of the drug, with accumulation in fetal hair. Hair measurement for methamphetamine in neonates is a useful screening method to detect intra-uterine exposure to the drug. The data also indicate that positive exposure to methamphetamine strongly suggests that the person is a polydrug user, which may have important implications for fetal safety.

The detection of sedatives in hair and nail samples using tandem LC–MS–MS

Drug screening methods were developed to detect alprazolam, clobazam, clonazepam, diazepam, midazolam, oxazepam, temazepam, triazolam, zopiclone, and selected metabolites in human hair and nail samples employing liquid-liquid extraction and tandem liquid chromatography-mass spectrometry (LC-MS-MS). Hair and nail samples were obtained from patients who had recently discontinued or were currently prescribed one or more of the targeted drugs. Prazepam was used as the internal standard for all compounds. Some components in the hair matrix gave the same transitions as some of the analytes but did not compromise the analyses because their retention times differed from those for the target compounds. The analytical run time was 8-10min. Results of the hair analysis of a DFSA victim are also presented.

Cocaine found in a child’s hair due to environmental exposure?

We report a case of a 6-year-old boy who had been living with his parents, both cocaine smokers, and who was urgently admitted to hospital for general distress. Upon examination, cocaine and cocaine metabolites were detected in hair and urine samples. These toxicological findings most likely indicate that the child had passively consumed the drug when living in a heavily contaminated environment.

Hair testing for drugs of abuse: evaluation of external cocaine contamination and risk of false positives

In some laboratories hair testing may be the main method for the evaluation of individual's drug history, however, compelling evidence supports the possibility that the presence of a small amount of drug in hair can derive from external contamination. The aim of the present study is to verify if a single external contamination with a small amount of cocaine will last sufficiently long to make a contaminated subject indistinguishable from active users, and if normal washing practices together with the decontamination procedures are sufficient to completely remove the external contamination. The results obtained using the decontamination methods suggested in literature demonstrate that significant concentrations of cocaine (>1 ng/mg) and moderate quantities of benzoylecgonine (generally <0.5 ng/mg) are still detectable up to 10 weeks after contamination. These results question the reliability of hair testing. In fact, even using the most sophisticated decontamination procedures it is not possible to distinguish a drug-contaminated subject from an active user. Thus, while a negative result excludes both chronic use and "contact" with drugs, a positive result cannot and must not be interpreted as a sure sign of drug addiction, but should be further confirmed by urine analysis.

Evidence for bias in hair testing and procedures to correct bias

A number of in vitro experiments show that different hair samples incorporate differing amounts of drugs under identical conditions. Incorporation of cocaine and morphine tends to be correlated with race, in that the hair of African American females incorporates higher concentrations of cocaine than does the hair of Caucasian males or females. Extrapolation of these data into populations has been fraught with difficulties because the dosages of drugs and their use patterns are unknown. Cosmetic treatments and hygiene alter drug binding, which must be considered in comparing populations because cosmetic treatments are often group dependent. Four reasons are proposed that account for the uptake and retention of drugs by hair and that may differ among groups: (1) permeability and other characteristics of the hair due to genetic influences, (2) cosmetic hair treatments and hair care habits (which may be culturally influenced), (3) drug removal during personal hygiene, and (4) manner and route of drug administration which can affect passive exposure to residual drugs in the environment. The data supporting bias in hair testing are reviewed and methods are proposed that use either the uptake of dyes or the incorporation of drug homologs to reduce bias.

Immunological screening of drugs of abuse and gas chromatographic-mass spectrometric confirmation of opiates and cocaine in hair

The work presents an analytical strategy to detect drugs of abuse in hair. It involves two sequential steps: a screening by a simple enzyme-linked immunosorbent assay (ELISA) methodology to detect opiates, cocaine and its metabolites, and benzodiacepines, followed by confirmation of opiates and cocaine metabolites in positive samples by gas chromatography coupled to mass spectrometry (GC-MS). In the same GC-MS run other drugs for substitution therapy (e.g. methadone and its main metabolite) can also be detected. After a double washing of hair samples with dichloromethane, hair specimens were cut into small pieces and 10 mg samples were incubated in 2 ml of methanol-trifluoroacetic acid (9:1) mixture, overnight at 37 degrees C. Aliquots of the extract were then evaporated, reconstituted in buffer and analysed according to the ELISA procedure. Confirmation involved solid-phase extraction of another fraction of the extract kept at -20 degrees C, derivatization with heptafluorobutyric anhydride and hexafluoroisopropanol and detection of cocaine, benzoylecgonine, ecgonine methylester, cocaethylene, morphine, codeine, 6-monoacetylmorphine, methadone and 2-ethylidene-1.5-dimethyl-3,3-diphenylpirrolidine (methadone metabolite) by selective ion monitoring after gas chromatographic separation. During the development of the method it was verified that no more than 10% of cocaine, opiates and benzodiacepines were lost when dichloromethane was used to wash real samples. The results also confirmed the increase of extractability power of TFA when it was added to methanol: the recovery for the analytes (cocaine and its metabolites and opiates) added to methanol-TFA alone was of the order of 90% except for benzoylecgonine (75%), and the recovery for the analytes added to methanol-TFA extract of drug-free hair was about 90% for all analytes except for benzoylecgonine and 6-MAM (around 70%). Regarding the stability of labile compounds, only small amounts of ecgonine methylester (2.3%) and morphine (7.2%) were produced, from cocaine and 6-MAM respectively, after the whole extraction procedure and two weeks of storage of methanol-TFA extracts at -20 degrees C. Satisfactory results were obtained when the procedures were applied to the analysis of external proficiency testing hair samples and actual specimens from drug addicts.