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Rudy L, Lacroix E. Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention. Palliat Support Care 2024:1-9. [PMID: 38420710 DOI: 10.1017/s1478951523001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges. METHODS A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon. RESULTS Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions. SIGNIFICANCE OF RESULTS By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.
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Affiliation(s)
- Lauren Rudy
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
| | - Emilie Lacroix
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
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2
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Hsu WL, Chen CW, Liang HH, Chiang TL, Lin HW, Lin YH. Innovative analysis of diazepam, zolpidem and their main metabolites in human urine by micelle-to-solvent stacking in capillary electrophoresis. J Pharm Biomed Anal 2024; 239:115898. [PMID: 38064769 DOI: 10.1016/j.jpba.2023.115898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
Diazepam and zolpidem are the most widely used medications for managing insomnia. However, significant concerns regarding the potential risks of misuse and abuse problems arose in many literatures. While urine analysis is a valuable diagnostic tool, a challenge arises from the fact that some parent drugs may remain undetectable in urine. This necessitates concurrent monitoring of their metabolites. Here, we described an innovative on-line sample preconcentration technique known as micelle to solvent stacking (MSS) for the analysis of diazepam, zolpidem, and their main metabolites in urine. Several key parameters warrant further discussion to optimize the MSS model, enhancing its performance in terms of sensitivity and resolution. After optimizing the conditions, we conducted a validation test, achieving high correlation coefficients (greater than 0.9977) for intra-day and inter-day regression lines. Additionally, both the relative standard deviation (RSD) and relative error (RE) remained below 6.10% and 12.55%, respectively. The limits of detection (LODs, S/N = 3) for all five analytes ranged from 2.0 to 56 ng/mL. Compared to the conventional capillary zone electrophoresis method, this new approach exhibited remarkable sensitivity enhancements, ranging from 123 to 235-fold. Upon applying this method to actual urine samples from patients, we successfully detected nordiazepam, zolpidem, and its metabolites. This simple and sensitive approach has promising applications in supporting patient medication safety and bolstering forensic investigations.
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Affiliation(s)
- Wan-Ling Hsu
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan, ROC
| | - Chia-Wen Chen
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan, ROC
| | - Hsin-Hua Liang
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan, ROC
| | - Tia-Ling Chiang
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan, ROC
| | - Hsiang-Wen Lin
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan, ROC; Department of Pharmacy, China Medical University Hospital, Taichung 404332, Taiwan, ROC
| | - Yi-Hui Lin
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan, ROC.
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Coulter C, Garnier M, Moore C. Rapid Extraction and Qualitative Screening of 30 Drugs in Oral Fluid at Concentrations Recommended for the Investigation of DUID Cases. J Anal Toxicol 2022; 46:899-904. [PMID: 35640884 DOI: 10.1093/jat/bkac031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/04/2022] [Accepted: 05/30/2022] [Indexed: 11/12/2022] Open
Abstract
A rapid, simple extraction method followed by qualitative screening using liquid chromatography-tandem mass spectrometry (LC-MS-MS) for drugs in oral fluid is presented. The decision points were selected to be at, or lower, than those recommended as Tier I compounds by the National Safety Council's Alcohol, Drugs, and Impairment Division for toxicological investigation of driving under the influence of drugs cases (DUID) and were also at, or lower, than those recommended by Substance Abuse and Mental Health Service Administration (SAMHSA) and the Department of Transportation (DOT) for Federal workplace drug testing programs. The method included 30 drugs: delta-9-tetrahydrocannabinol (THC), amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxyamphetamine (MDA), cocaine, benzoylecgonine, carisoprodol, meprobamate, zolpidem, alprazolam, clonazepam, 7-aminoclonazepam, diazepam, nordiazepam, lorazepam, oxazepam, temazepam, codeine, morphine, 6-acetylmorphine, buprenorphine, fentanyl, hydrocodone, hydromorphone, oxycodone, oxymorphone, methadone, tramadol, and phencyclidine. Phencyclidine was included because it is in the Federal workplace program even though it is considered a Tier II drug for DUID cases. A liquid-liquid extraction method using isopropanol, hexane, and ethyl acetate to extract drugs from the oral fluid-buffer mix collected in a Quantisal™ device, followed by LC-MS-MS screening was developed and validated according to ANSI/ASB 2019 Standard Practices for Method Validation in Forensic Toxicology. Interference studies, limit of detection, precision at the decision point, ionization suppression/enhancement and processed sample stability were determined for each drug. The method was successfully applied to proficiency specimens and routine samples received into the laboratory.
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Affiliation(s)
- Cynthia Coulter
- 9-Delta Analytical LLC, 4365 E. Lowell Street, Suite E, Ontario, CA 91761, USA
| | - Margaux Garnier
- 9-Delta Analytical LLC, 4365 E. Lowell Street, Suite E, Ontario, CA 91761, USA
| | - Christine Moore
- 9-Delta Analytical LLC, 4365 E. Lowell Street, Suite E, Ontario, CA 91761, USA
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Wang LL, Ren XX, He Y, Cui GF, Liu JJ, Jia J, Cao J, Liu Y, Cong B, Wei ZW, Yun KM. Pharmacokinetics of Diazepam and Its Metabolites in Urine of Chinese Participants. Drugs R D 2022; 22:43-50. [PMID: 35099786 PMCID: PMC8885946 DOI: 10.1007/s40268-021-00375-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Urine is conventionally used as a specimen to document diazepam-related crimes; however, few reports have described the pharmacokinetics of diazepam and its metabolites in urine. OBJECTIVE This study aimed to investigate the pharmacokinetics of diazepam and its metabolites, including glucuronide compounds, in the urine of Chinese participants. METHODS A total of 28 volunteers were recruited and each participant ingested 5 mg of diazepam orally. Ten milliliters of urine were collected from each participant at post-consumption timepoints of prior (zero), 1, 2, 4, 8, 12, and 24 h and 2, 3, 6, 12, and 15 days. All samples were extracted by solid-phase extraction and analyzed using high-performance liquid chromatography-tandem mass spectrometry. Diazepam and its main metabolites, except for temazepam, were detected in the urine of volunteers. Pharmacokinetic parameters were analyzed using the pharmacokinetic software DAS according to the non-compartment model. RESULTS Urinary diazepam peaked at 2.38 ng/mL (Cmax) and 1.93 h (Tmax). The urinary metabolite nordiazepam peaked at 1.17 ng/mL and 100.21 h; temazepam glucuronide (TG) peaked at 145.61 ng/mL and 41.14 h; and oxazepam glucuronide (OG) peaked at 101.57 ng/mL and 165.86 h. The elimination half-life (t½z) and clearance (CLz/F) for diazepam were 119.58 h and 65.77 L/h, respectively. The t½z of the metabolites nordiazepam, TG, and OG was 310.58 h, 200.17 h, and 536.44 h, respectively. Finally, this study found that both diazepam and its main metabolites in urine were detectable for at least 15 days, although there were individual differences. CONCLUSION The results regarding diazepam pharmacokinetics in urine would be of great help in forensic science and drug screening.
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Affiliation(s)
- Le-le Wang
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China
- Key Laboratory of Forensic Toxicology of Ministry of Public Security, Jinzhong, 030600, Shanxi, China
| | - Xin-Xin Ren
- Institute of Forensic Science, Ministry of Public Security, Beijing, 100038, China
| | - Yi He
- Institute of Forensic Science, Ministry of Public Security, Beijing, 100038, China
| | - Guan-Feng Cui
- Institute of Forensic Science, Ministry of Public Security, Beijing, 100038, China
| | - Jia-Jia Liu
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China
- Key Laboratory of Forensic Toxicology of Ministry of Public Security, Jinzhong, 030600, Shanxi, China
| | - Juan Jia
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China
- Key Laboratory of Forensic Toxicology of Ministry of Public Security, Jinzhong, 030600, Shanxi, China
| | - Jie Cao
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China
- Key Laboratory of Forensic Toxicology of Ministry of Public Security, Jinzhong, 030600, Shanxi, China
| | - Yao Liu
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China
- Institute of Forensic Science, Ministry of Public Security, Beijing, 100038, China
| | - Bin Cong
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China
- Department of Forensic Medicine, Hebei Medical University, Shijiazhuang, 050017, China
| | - Zhi-Wen Wei
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China.
- Key Laboratory of Forensic Toxicology of Ministry of Public Security, Jinzhong, 030600, Shanxi, China.
| | - Ke-Ming Yun
- School of Forensic Medicine, Shanxi Medical University, Jinzhong, 030600, Shanxi, China.
- Key Laboratory of Forensic Toxicology of Ministry of Public Security, Jinzhong, 030600, Shanxi, China.
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Andresen Bergström M, Lövgren H, Abrahamsson A, Eriksson EK, Lindbjer Andersson M, Komorowska M, Axelsson MAB. Rethinking Drug Analysis in Healthcare: High-Throughput Analysis of 71 Drugs of Abuse in Oral Fluid using Ion Mobility - High Resolution Mass Spectrometry. J Anal Toxicol 2021; 46:765-775. [PMID: 34746960 DOI: 10.1093/jat/bkab114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/26/2021] [Accepted: 11/04/2021] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Moa Andresen Bergström
- Laboratory of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hanna Lövgren
- Laboratory of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Abrahamsson
- Laboratory of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma K Eriksson
- Laboratory of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Marta Komorowska
- Laboratory of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus A B Axelsson
- Laboratory of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Zheng Y, Sparve E, Sparring S, Bergström M. Detection of Drugs in Oral Fluid Samples Using a Commercially Available Collection Device: Agreement with Urine Testing and Evaluation of A and B Samples Obtained from Employees at Different Workplace Settings with Uncontrolled Sampling Procedures. J Anal Toxicol 2021; 44:1004-1011. [PMID: 32128555 DOI: 10.1093/jat/bkaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The use of oral fluid tests to detect drugs is of growing interest in various areas, including treatment centers, roadside and workplace testing. In this study, we investigated drug detection in oral fluid samples collected using a commercially available device, Oral Eze. Drug detection in oral fluid was compared to paired urine samples, which were simultaneously collected. We also evaluated the collection device by comparing A and B oral fluid samples. Finally, we studied the stability of various drugs in samples stored for at least 1 year. The drug profile was investigated by comparing the drugs detected in oral fluid samples with paired urine samples collected in a treatment center. A total of 113 paired oral fluid and urine samples were investigated for the presence of drugs in the following groups: amphetamines, benzodiazepines, opiates and opioids, cocaine and cannabis. A and B samples were collected from different workplaces through an uncontrolled sampling procedure (n = 76). The stability of drugs in A samples was assessed after storage at -20°C for 1 year. Generally, there was a good correlation between drugs detected in oral fluid samples and urine samples. The heroin metabolite, 6-MAM, was more frequently detected in oral fluid samples than in urine samples, while cannabis was better detected in urine samples. Drugs in oral fluid samples were stable when stored at -20°C for at least 1 year. However, in many positive A and B oral fluid samples, there was significant variation in the concentrations obtained. Hence, the collection device may need to be further standardized and improved.
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Affiliation(s)
- Yufang Zheng
- Clinical Chemistry, Unilabs, Mälarsjukhuset, SE-63188 Eskilstuna, Sweden
| | - Erik Sparve
- Clinical Chemistry, Unilabs, Mälarsjukhuset, SE-63188 Eskilstuna, Sweden
| | - Stefan Sparring
- Psychiatric Clinic, Mälarsjukhuset, SE-63188 Eskilstuna, Sweden
| | - Mats Bergström
- Clinical Chemistry, Unilabs, Mälarsjukhuset, SE-63188 Eskilstuna, Sweden
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Wang LL, Ren XX, He Y, Cui GF, Wei ZW, Yun KM. An Experimental Pharmacokinetics Study of Diazepam and Its Metabolites in Oral Fluid of Chinese Population. J Anal Toxicol 2020; 44:348-353. [PMID: 31965188 DOI: 10.1093/jat/bkz101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 11/13/2022] Open
Abstract
Diazepam abuse is widespread all over the word, leading to an increasing number of forensic cases such as suicide, drug-driving and robbery, but relevant studies are limited regarding the extraction of diazepam and its metabolites in oral fluid. This study aimed to investigate the pharmacokinetics of diazepam and its metabolites in oral fluid after a single oral dose in healthy volunteers. There was a total of 28 volunteers, and each ingested 5 mg diazepam orally, then ~2 mL oral fluid were collected from each participant at post-consumption time-points of prior (zero), 1, 2, 4, 8, 12, 24 h and 2, 3, 6, 12 and 15 days, respectively. All samples were extracted with solid-phase extraction and analyzed with high-performance liquid chromatography-tandem mass spectrometry method, and diazepam and nordazepam were detected in the oral fluid of volunteers. Pharmacokinetics of diazepam in oral fluid conformed to a two-compartment model, and k01_HL, k12_HL, k10_HL were 0.7 ± 1.1, 31.4 ± 68.5, 12.1 ± 11.6 h, respectively, nordazepam conformed to an one-compartment model, and k01_HL, k10_HL were 41.5 ± 44.8, 282.3 ± 365.5 h, respectively. Both diazepam and nordazepam could be detected continuously for 15 days, although there were individual differences, and the results regarding diazepam detecting in oral fluid will be of much help in forensic science and drug screening filed.
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Affiliation(s)
- Le-le Wang
- School of Forensic Medicine, Shanxi Medical University, Taiyuan 030001, China
| | - Xin-Xin Ren
- Institute of Forensic Science, Ministry of Public Security, Beijing 100038, China
| | - Yi He
- Institute of Forensic Science, Ministry of Public Security, Beijing 100038, China
| | - Guan-Feng Cui
- Institute of Forensic Science, Ministry of Public Security, Beijing 100038, China
| | - Zhi-Wen Wei
- School of Forensic Medicine, Shanxi Medical University, Taiyuan 030001, China
| | - Ke-Ming Yun
- School of Forensic Medicine, Shanxi Medical University, Taiyuan 030001, China
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