Detection of Cutting Agents in Drug‐Positive Seized Exhibits within the United States

The Cytotoxic Effects of Nyaope, a Heroin-based Street Drug, in SH-SY5Y Neuroblastoma Cells

Nyaope is a local adulterated drug that contributes significantly to the psychosocial challenge of substance use in South Africa. Despite being a huge burden on society and the health care system, research into the deleterious effects of nyaope is limited. The aim of the present study was therefore to perform a chemical analysis of the drug and to assess its toxic effects on neuroblastoma cells. Gas chromatography-mass spectrometry (GC/MS) analysis showed that nyaope mainly consists of heroin and heroin-related products. SH-SY5Y cells were subsequently exposed to increasing concentrations of nyaope (0.625, 1.25, 2.5, 5 and 10 µg/µL) for 1, 6 or 24 h. The toxic effects of nyaope were determined by measuring lactate dehydrogenase (LDH) released into the cell culture medium as an indicator of necrosis, the mRNA expression levels of Bax and Bcl-2 as markers of apoptosis, and the mRNA expression levels of p62 and microtubule-associated protein 1 A/1B light-chain 3 (LC3) as indicators of autophagy. Exposing SH-SY5Y cells to concentrations of nyaope 5 µg/µL and greater for 24 h, resulted in a significant increase in LDH levels in the cell culture medium, unchanged mRNA expression of Bax and Bcl-2 mRNA, and significantly reduced p62 and elevated LC3 mRNA expression levels. The chemical analysis suggests that nyaope should be considered synonymous with heroin and the toxic effects of the drug may recruit pathways involved in necrosis and autophagy.

Xylazine: A Drug Adulterant of Clinical Concern

PURPOSE OF REVIEW

The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.

RECENT FINDINGS

Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.

Volatile drug use and overdose during the first year of the COVID-19 pandemic in the United States

BACKGROUND

Overdose deaths in the United States rose substantially during the COVID-19 pandemic. Disruptions to the drug supply and service provision introduced significant instability into the lives of people who use drugs (PWUD), including volatility in their drug use behaviors.

METHODS

Using data from a multistate survey of PWUD, we examined sociodemographic and drug use correlates of volatile drug use during COVID-19 using multivariable linear regression. In a multivariable logistic regression model, we assessed the association between volatile drug use and past month overdose adjusting for sociodemographic and other drug use characteristics.

RESULTS

Among participants, 52% were male, 50% were white, 29% had less than a high school education, and 25% were experiencing homelessness. Indicators of volatile drug use were prevalent: 53% wanted to use more drugs; 45% used more drugs; 43% reported different triggers for drug use, and 23% used drugs that they did not typically use. 14% experienced a past-month overdose. In adjusted models, hunger (β=0.47, 95% CI: 0.21-0.72), transactional sex (β=0.50, 95% CI: 0.06-0.94), and the number of drugs used (β=0.16, 95% CI: 0.07-0.26) were associated with increased volatile drug use. Volatile drug use was associated with increased overdose risk (aOR=1.42, 95% CI: 1.17-1.71) in the adjusted model.

CONCLUSIONS

Volatile drug use during the COVID-19 pandemic was common, appeared to be driven by structural vulnerability, and was associated with increased overdose risk. Addressing volatile drug use through interventions that ensure structural stability for PWUD and a safer drug supply is essential for mitigating the ongoing overdose crisis.

Effects of fentanyl and the adulterant levamisole on the rewarding and locomotor effects of methamphetamine in rats

BACKGROUND

People who use psychostimulant substances can be exposed to unknown adulterants, such as the synthetic opioid fentanyl (FEN) and the anthelmintic cholinergic agent levamisole (LEV). This work explores the rewarding and locomotor effects of methamphetamine (METH) in combination with FEN or LEV.

METHODS

We used adult male Wistar rats in the conditioned-place preference (CPP) paradigm (conditioning, extinction, and reinstatement phases) and in the open field test to study effective doses of METH, FEN, or LEV, or ineffective doses of METH+FEN or METH+LEV in combination.

RESULTS

METH and LEV, at 1mg/kg METH each, and 30µg/kg FEN produced CPP. Extinction to METH- or LEV-induced CPP occurred after eight saline injections, but it took 8-26 sessions to extinguish FEN-induced CPP. A challenge dose of 0.5mg/kg METH reinstated CPP. The same occurred with 15µg/kg FEN but not with 0.5 or 1mg/kg LEV. Training animals with ineffective doses of METH (0.01mg/kg) combined with either FEN (0.3µg/kg) or LEV (0.01mg/kg) produced CPP. Sub-effective doses of METH or FEN alone did not induce reinstatement after extinction. However, animals challenged with LEV, METH+FEN, or METH+LEV mixtures did it. Combining FEN (3µg/kg) with 0.1mg/kg METH increased locomotor activity.

CONCLUSION

Ineffective FEN and LEV doses mixed with METH produce effects larger than would be expected based on the effects of either drug alone. This outcome suggests a supra-additive interaction, which could increase the risk of developing a METH use disorder.

Cd-MOF and Its Ln3+-Post Modification Products: Regulation of Luminescence Properties and Improved Detection of Uric Acid, Quinine, and Quinidine

One 3D Cd-MOF, namely, {[(HDMA)2][Cd3(L)2]·5H2O·2DMF}n (LCU-124, LCU indicates Liaocheng University), was synthesized from an ether-containing ligand 1,3-bis(3,5-dicarboxylphenoxy)benzene (H4L). Its Ln3+-postmodified samples, Eu3+@LCU-124 and Tb3+@LCU-124, were obtained through cation exchange of dimethylamine cation (HDMA) with Eu3+ and Tb3+. The successful entry of rare earth into LCU-124 by cation exchange modification was verified by IR, XRD, XPS, EDS mapping, and luminescence spectra. The proportion of Eu3+/Tb3+ was adjusted during the modification process, leading to fluorescent materials with different emissions. Luminescence measurements indicated that these complexes exhibited interesting multiresponsive sensing activities toward biomarkers urine acid (UA), quinine (QN), and quinidine (QND). First, LCU-124 has a pronounced quenching effect toward UA with the detection limit of 31.01 μM. After modification, the visualization of the detection was improved significantly and the detection limit of Eu3+@LCU-124 was reduced to 0.868 μM. Second, when QN and QND were present in the suspensions of Eu3+@LCU-124 and Tb3+@LCU-124, strong blue light emission peaks occurred, while the characteristic emission of Eu3+/Tb3+ decreased, forming ratiometric fluorescent sensors with the detection limit in the range of 0.199-9.49 μM. The fluorescent probes have high selectivity, excellent sensitivity recycling, and fast response time (less than 1 min). Besides, a simple logic gate circuit and a range of luminescent mixed matrix membranes were designed to provide simple and fast detection of above biomarkers. Our work indicated that modification of Eu3+/Tb3+ could improve the detection ability significantly.

Dual Microfluidic Sensor System for Enriched Electrochemical Profiling and Identification of Illicit Drugs On-Site

Electrochemical sensors have emerged as a new analytical tool for illicit drug detection to facilitate ultrafast and accurate identification of suspicious compounds on-site. Drugs of abuse can be identified using their unique voltammetric fingerprint at a given pH. Today, the right buffer solution is manually selected based on drug appearance, and in some cases, a consecutive analysis in two different pH solutions is required. In this work, we present a disposable microfluidic multichannel sensor system that automatically records fingerprints in two pH solutions (e.g., pH 5 and pH 12). This system has two advantages. It will overcome the manual selection of a buffer solution at the right pH, decrease analysis time, and minimize the risk of human errors. Second, the combination of two fingerprints, the superfingerprint, contains more detailed information about the samples, which enhances the selectivity of the analytical technique. First, real-time pH measurements proved that the sample can be brought to the desired pH within a minute. Subsequently, an electrochemical study on the microfluidic platform with 1 mM illicit drug standards of MDMA, cocaine, heroin, and methamphetamine showed that the characteristic voltammetric fingerprints and peak potentials are reproducible, also in the presence of common cutting agents. Finally, the microfluidic concept was validated with real confiscated samples, showing promising results for the user-friendly identification of drugs of abuse. In short, this paper presents a successful proof-of-concept study of a multichannel microfluidic sensor system to enrich the fingerprints of illicit drugs at pH 5 and pH 12, thus providing a low-cost, portable, and rapid identification system of illicit drugs with minimal user intervention.

In Support of Community Drug Checking Programs: Position Statement of AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction)

BACKGROUND

Position statements clarify key issues that are in alignment with the vision, mission, and values of the AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). This Position Statement, endorsed by the AMERSA Board of Directors on October 3, 2023, amplifies the position of the organization, guides their activities, and informs the public and policymakers on the organization's stance on this issue.

ISSUE

The unregulated drug supply in the United States evolves constantly, leaving those who use drugs potentially unaware of new adulterants in their drugs. Not knowing that information can leave people vulnerable to serious adverse events such as fatal overdoses, wounds, and other health consequences. Without real-time data on the composition of drugs available in a community, healthcare providers and public health practitioners are left with insufficient data, making it increasingly difficult to know how to best serve people who use drugs. In this context, community-based drug checking has become recognized as an important harm reduction strategy with the potential to provide those who use drugs with more information about their supply.

RECOMMENDATIONS

It is imperative to expand funding and increase access to drug checking programs in communities across the United States. Key policy changes, such as those related to decriminalizing drug and drug paraphernalia possession, are needed to increase the utilization of drug checking programs. Protection of persons who use drugs through harm reduction strategies, including drug checking programs needs to be widely available and accessible.

Forensic Analysis of Synthetic Cathinones on Nanomaterials-Based Platforms: Chemometric-Assisted Voltametric and UPLC-MS/MS Investigation

Synthetic cathinones (SCs) are a group of new psychoactive substances often referred to as "legal highs" or "bath salts", being characterized by a dynamic change, new compounds continuously emerging on the market. This creates a lack of fast screening tests, making SCs a constant concern for law enforcement agencies. Herein, we present a fast and simple method for the detection of four SCs (alpha-pyrrolidinovalerophenone, N-ethylhexedrone, 4-chloroethcathinone, and 3-chloromethcathinone) based on their electrochemical profiles in a decentralized manner. In this regard, the voltametric characterization of the SCs was performed by cyclic and square wave voltammetry. The elucidation of the SCs redox pathways was successfully achieved using liquid chromatography coupled to (tandem) mass spectrometry. For the rational identification of the ideal experimental conditions, chemometric data processing was employed, considering two critical qualitative and quantitative variables: the type of the electrochemical platform and the pH of the electrolyte. The analytical figures of merit were determined on standard working solutions using the optimized method, which exhibited wide linear ranges and LODs suitable for confiscated sample screening. Finally, the performance of the method was evaluated on real confiscated samples, the resulting validation parameters being similar to those obtained with another portable device (i.e., Raman spectrometer).

Isolation and Characterization of the Wastewater Micropollutant Phenacetin-Degrading Bacterium Rhodococcus sp. Strain PNT-23

Phenacetin, an antipyretic and analgesic drug, poses a serious health risk to both humans and aquatic organisms, which is of concern since this micropollutant is frequently detected in various aquatic environments. However, rare pure bacterial cultures have been reported to degrade phenacetin. Therefore, in this study, the novel phenacetin-degrading strain PNT-23 was isolated from municipal wastewater and identified as a Rhodococcus sp. based on its morphology and 16S rRNA gene sequencing. The isolated strain could completely degrade 100 mg/L phenacetin at an inoculum concentration of OD600 1.5 within 80 h, utilizing the micropollutant as its sole carbon source for growth. Strain PNT-23 exhibited optimal growth in LB medium at 37 °C and a pH of 7.0 with 1% NaCl, while the optimal degradation conditions in minimal medium were 30 °C and a pH of 7.0 with 1% NaCl. Two key intermediates were identified during phenacetin biodegradation by the strain PNT-23: N-acetyl-4-aminophenol and 4-aminophenol. This study provides novel insights into the biodegradation of phenacetin using a pure bacterium culture, expands the known substrate spectra of Rhodococcus strains and presents a potential new candidate for the microbial removal of phenacetin in a diverse range of environments.

Detection & identification of hazardous narcotics and new psychoactive substances using Fourier transform infrared spectroscopy (FTIR)

According to the latest World Drug Report, released by the United Nations Office on Drugs and Crime (UNODC), drug use is up 30% over the past decade and there are more drugs, and more types of drugs, than ever. Herein we use Fourier Transform Infrared Spectroscopy (FTIR) for the rapid ID of narcotics in a range of concentrations - from pure forms (as it is likely to be smuggled & transported) to street forms, often mixed with conventional cutting agents. Using FTIR, 75% of "street sample" narcotics were rapidly identified, and the effects of cutting agents on identification (ID) were also investigated. The limit of detection of MDMA was assessed, with a correct ID shown from 25% w/v. Concentration was correlated with Hit Quality Index, showing the capability of FTIR use in concentration estimation.

Opioid cutting agents for use as internal standards in ion mobility spectrometry (IMS)

Opioids have become a serious public health concern over the last decade. These compounds are commonly found mixed, or cut, with safer compounds to make the opioids appear unadulterated while also enhancing the psychoactive effect on the user. Commercial benchtop and handheld IMS devices are capable of detection but published reduced ion mobility (K₀) values, used to identify the target analytes with IMS instrumentation, have shown variability. This lack of agreement, even for compounds used for calibration, is often due to the effects of drift tube temperature, drift gas water vapor levels and the use in-house built instrumentation rather than commercial equipment. Multiple reports exist on assessment of IMS reference standards but a single, consensus universal standard does not exist. Assessment of opioid cutting agents as internal standards is a worthwhile pursuit if precise and accurate K₀ values are obtained. The effects of drift gas water vapor content and drift tube temperature were used to evaluate the cutting agents. The K₀ values of papaverine, a representative opioid with a similar K₀ value to heroin and fentanyl, were calculated with respect to quinine and were in agreement with literature data. The use of quinine as an internal standard also improved precision relative to the instrument standard and shows promise in the application presented here.

Luminescence-based detection and identification of illicit drugs

Luminescence-based sensing is capable of being used for the sensitive, rapid, and in some cases selective detection of chemicals. Furthermore, the method is amenable to incorporation into handheld low-power portable detectors that can be used in the field. Luminescence-based detectors are now commercially available for explosive detection with the technology built on a strong foundation of science. In contrast, there are fewer examples of luminescence-based detection of illicit drugs, despite the pervasive and global challenge of combating their manufacture, distribution and consumption and the need for handheld detection systems. This perspective describes the relatively nascent steps that have been reported in the use of luminescent materials for the detection of illicit drugs. Much of the published work has focused on detection of illicit drugs in solution with less work on vapour detection using thin luminescent sensing films. The latter are better suited for handheld sensing devices and detection in the field. Illicit drug detection has been achieved via different mechanisms, all of which change the luminescence of the sensing material. These include photoinduced hole transfer (PHT) leading to quenching of the luminescence, disruption of Förster energy transfer between different chromophores by a drug, and chemical reaction between the sensing material and a drug. The most promising of these is PHT, which can be used for rapid and reversible detection of illicit drugs in solution and film-based sensing of drugs in the vapour phase. However, there are still significant knowledge gaps, for example, how vapours of illicit drugs interact with the sensing films, and how to achieve selectivity for specific drugs.

Suite of Aptamer-Based Sensors for the Detection of Fentanyl and Its Analogues

Fentanyl and its analogues are potent synthetic opioids that are commonly abused and are currently the number one cause of drug overdose death in the United States. The ability to detect fentanyl with simple, rapid, and low-cost tools is crucial for forensics, medical care, and public safety. Conventional on-site testing options for fentanyl detection─including chemical spot tests, lateral-flow immunoassays, and portable Raman spectrometers─each have their own unique flaws that limit their analytical utility. Here, we have developed a series of new aptamer-based assays and sensors that can detect fentanyl as well as several of its analogues in a reliable, accurate, rapid, and economic manner. These include colorimetric, fluorescent, and electrochemical sensors, which can detect and quantify minute quantities of fentanyl and many of its analogues with no response to other illicit drugs, cutting agents, or adulterants─even in interferent-ridden binary mixtures containing as little as 1% fentanyl. Given the high performance of these novel analytical tools, we foresee the potential for routine use by medical and law enforcement personnel as well as the general public to aid in rapid and accurate fentanyl identification.

Investigating the electrochemical profile of methamphetamine to enable fast on-site detection in forensic analysis

Methamphetamine (MA) is a synthetic psychoactive drug which is consumed both licitly and illicitly. In some countries it is prescribed for attention-deficit and hyperactivity disorder, and short-term treatment of obesity. More often though, it is abused for its psychostimulant properties. Unfortunately, the spread and abuse of this synthetic drug have increased globally, being reported as the most widely consumed synthetic psychoactive drug in the world in 2019. Attempting to overcome the shortcomings of the currently used on-site methods for MA detection in suspected cargos, the present study explores the potential of electrochemical identification of MA by means of square wave voltammetry on disposable graphite screen-printed electrodes. Hence, the analytical characterization of the method was evaluated under optimal conditions exhibiting a linear range between 50 μM and 2.5 mM MA, a LOD of 16.7 μM, a LOQ of 50.0 μM and a sensitivity of 5.3 μA mM^-1. Interestingly, two zones in the potential window were identified for the detection of MA, depending on its concentration in solution. Furthermore, the oxidative pathway of MA was elucidated employing liquid chromatography - mass spectrometry to understand the change in the electrochemical profile. Thereafter, the selectivity of the method towards MA in mixtures with other drugs of abuse as well as common adulterants/cutting agents was evaluated. Finally, the described method was employed for the analysis of MA in confiscated samples and compared with forensic methods, displaying its potential as a fast and easy-to-use method for on-site analysis.

Opioid overdoses involving xylazine in emergency department patients: a multicenter study

INTRODUCTION

Illicit opioids, consisting largely of fentanyl, novel synthetic opioids, and adulterants, are the primary cause of drug overdose fatality in the United States. Xylazine, an alpha-2 adrenergic agonist and veterinary tranquilizer, is being increasingly detected among decedents following illicit opioid overdose. Clinical outcomes in non-fatal overdose involving xylazine are unexplored. Therefore, among emergency department patients with illicit opioid overdose, we evaluated clinical outcome differences for patients with and without xylazine exposures.

METHODS

This multicenter, prospective cohort study enrolled adult patients with opioid overdose who presented to one of nine United States emergency departments between 21 September 2020, and 17 August 2021. Patients with opioid overdose were screened and included if they tested positive for an illicit opioid (heroin, fentanyl, fentanyl analog, or novel synthetic opioid) or xylazine. Patient serum was analyzed via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect current illicit opioids, novel synthetic opioids, xylazine and adulterants. Overdose severity surrogate outcomes were: (a) cardiac arrest requiring cardiopulmonary resuscitation (primary); and (b) coma within 4 h of arrival (secondary).

RESULTS

Three hundred and twenty-one patients met inclusion criteria: 90 tested positive for xylazine and 231 were negative. The primary outcome occurred in 37 patients, and the secondary outcome occurred in 111 patients. Using multivariable regression analysis, patients positive for xylazine had significantly lower adjusted odds of cardiac arrest (adjusted OR 0.30, 95% CI 0.10-0.92) and coma (adjusted OR 0.52, 95% CI 0.29-0.94).

CONCLUSIONS

In this large multicenter cohort, cardiac arrest and coma in emergency department patients with illicit opioid overdose were significantly less severe in those testing positive for xylazine.

Environmental Uncertainty and Substance Use Disorders: A Behavior Analytic Perspective

Substance use disorder (SUD) and drug overdose deaths represent major economic, health, and safety issues in the United States. The psychology of uncertainty provides a mechanism for understanding, reducing, and controlling the damage from substance misuse. Illicit drugs (such as heroin or cocaine) are uncertain in their availability, quality, and acquisition (the time and effort required to obtain them) compared with nondrug-related alternatives (such as consumable goods, hobbies, or paychecks). Furthermore, the severity and likelihood of negative outcomes associated with drug use likewise are uncertain. Such uncertainties worsen substance use outcomes. The current review conveys what is known about the impact of uncertainty on substance use: laboratory investigations of uncertain time and effort required to obtain a substance and uncertain drug quality show uncertainty exacerbates harm. Furthermore, uncertain negative outcomes are not likely to deter substance use in individuals with a SUD. Finally, several policy implications include access to agonist medications; creating a safer drug supply; access to clean syringes/needles, naloxone, and safe-injection sites; and ending incarceration for substance use.

Evaluation of "Real-Time" Fatal Drug Overdose Surveillance by King County Medical Examiner's Office, Seattle, Washington

ABSTRACT

To address the challenges in monitoring the continuously accelerating drug overdose epidemic, the King County Medical Examiner's Office in Seattle, Washington, instituted a "real-time" fatal drug overdose surveillance project, depending on scene investigations, autopsy findings, and in-house testing of blood, urine, and drug evidence collected from death scenes. Validation of the project's rapid death certification methodology from 2019 through 2021 was performed at the following 3 levels: blood testing, urine testing, and death certification, and for the following 4 drugs: fentanyl, opiate, methamphetamine, and cocaine. For blood testing, sensitivity ranged from 90% to 99%, and specificity ranged from 86% to 97%. For urine testing, sensitivity ranged from 91% to 92%, and specificity ranged from 87% to 97%. The positive predictive value for cocaine was poor for both blood testing (57%) and urine testing (72%). Of 1034 deaths, 807 were certified as overdose by rapid methodology, and 803 (99.5%) were confirmed by formal toxicology results. Manners of death were changed from accident to natural in 3 of 1034 cases (0.29%). Results of this study indicate that the rapid overdose surveillance methodology described in this study offers benefits to families and provides useful, timely information for responding law enforcement and public health agencies.

Isotonitazene, a novel psychoactive substance opioid, detected in two cases following a local surge in opioid overdoses

BACKGROUND

Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity.

AIM

There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples.

METHODS

Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database.

RESULTS

There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml).

CONCLUSION

We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations.

Preliminary investigation into isolation and extraction of DNA recovered from drug residues

It is a commonly held belief that drug residues may affect the integrity of DNA and/or interfere with DNA analysis, and therefore DNA on drug paraphernalia and the associated drugs may be overlooked as a source of evidence. This study investigated whether DNA could be isolated from a drug residue-bearing surface to ascertain whether a forensically useful DNA profile could be obtained. Human blood and pre-extracted "naked" DNA were deposited on samples of acetaminophen, codeine, morphine, oxycodone, ketamine, and synthetic cannabinoids and left for an hour before DNA extraction using DNA-IQ™. To investigate DNA integrity, the absolute amount of DNA recovered, degradation index, and number of PCR cycles required for the IPC to reach threshold (Ct), number of reportable alleles and average peak height (APH) in the DNA profile, were examined. The samples were also qualitatively analysed using LC:MS to determine if any residual drugs were present in the samples post-DNA extraction. Overall, the drugs had no to minimal degradation or inhibitory effects on the DNA with sufficient DNA recovered to generate a partial or full DNA profile in 80% of naked DNA samples and 100 % of blood samples. The amount of DNA collected was sufficient for further analysis in 86% of naked DNA samples, and 100% of blood samples, with all median APH values being over the 175 RFU standard. Chemical analysis showed that traces of the drug were still present in the samples after DNA extraction was performed. Therefore, this study demonstrates forensically useful DNA can be recovered from surfaces bearing drug residues, even when sampling directly from the samples of drugs.

Clustering patterns in polysubstance mortality in the United States in 2017: a multiple correspondence analysis of death certificate data

PURPOSE

The main goal of this analysis was to identify mortality patterns apparent when many drug classes are analyzed together.

METHODS

The Drug Involved Mortality database is a registry of drug terms mentioned on death certificates of all drug-related deaths in the United States. Means of total number of drugs involved and percentages of specific drug combinations were calculated. Dimensionality reduction using multiple correspondence analysis and hierarchical clustering identified clusters of drugs listed on death certificates.

RESULTS

An average of 2.4 specific drugs were listed on death certificates in 2017. For 9 of the top 10 drugs involved, over 80% of deaths involved at least one other drug. As expected, opioid drugs and psychostimulants clustered together, but other psychoactive substances (non-opioid analgesics, sedatives, antidepressants, antipsychotics) clustered together into multi-class groups. Other drugs (e.g., acetaminophen, oxymorphone) were frequently involved in polysubstance death, but did not cluster with any other specific drug. Deaths involving illicit drugs listed fewer drugs than deaths involving prescription drugs.

CONCLUSIONS

While individual drug substances might contribute to many deaths (e.g., fentanyl), polysubstance mortality is more common than single substance mortality. Multidimensional analyses integrating all drugs involved are useful to identify uncommon patterns of overdose and changing trends.

Analysis of umbilical cord tissue as an indicator of in utero exposure to toxic adulterating substances

In utero drug exposure is a significant public health threat to the well-being and normal development of the neonate. Recently, testing of umbilical cord tissue (UCT) has been employed to measure illicit drug exposure, as drugs used by the mother during the third trimester may be retained in the UCT. Focus has also been given to potential adverse health effects among drug users, resulting from exposure to pharmacologically active adulterants and cutting agents in the street drug supply. The in utero effects of these substances have not been well studied in humans, nor has their presence been demonstrated as a means for assessing adverse health effects in the neonate. Here, we describe the application of a novel test method to analyze UCT for the presence of more than 20 common adulterating/cutting substances via LC/Q-TOF. In total, 300 de-identified UCT samples were analyzed-all had previously tested positive for cocaine or opiates. Generally, the positivity rates of individual compounds were similar between the Cocaine and Opiates Subgroups, apart from levamisole, xylazine, dipyrone (metabolites), and promethazine. Many of the adulterants used in the street drug supply do have legitimate medicinal/therapeutic uses, including several of the compounds most frequently detected in this study. Caffeine and lidocaine were the most frequently identified compounds both individually (>70% each) and in combination with each other. Alternatively, levamisole, an adulterant with no legitimate therapeutic use, was present in 12% of cases. Importantly, this data demonstrates that the detection of traditional drugs of abuse may serve as indicators of potential in utero exposure to toxic adulterating substances during gestation. While there is cause for concern with respect to any unintentional drug exposure, illicit drug use during pregnancy, including uncontrolled dosing, poly-adulterant consumption, and the interactions of these drug mixtures, produces a significant public health threat to the neonate which warrants further study.

Molecular Insights and Clinical Outcomes of Drugs of Abuse Adulteration: New Trends and New Psychoactive Substances

Adulteration is a well-known practice of drug manufacturers at different stages of drug production. The intentional addition of active ingredients to adulterate the primary drug may enhance or mask pharmacological effects or may produce more potent drugs to increase the number of available doses and the dealer's profit. Adulterants found in different drugs change over time in response to different factors. A systematic literature search in PubMed and Scopus databases and official international organizations' websites according to PRISMA guidelines was performed. A total of 724 studies were initially screened, with 145 articles from PubMed and 462 from Scopus excluded according to the criteria described in the Method Section. The remaining 117 records were further assessed for eligibility to exclude articles without sufficient data. Finally, 79 studies were classified as "non-biological" (n = 35) or "biological" (n = 35 case reports; n = 9 case series) according to the samples investigated. Although the seized samples analyses revealed the presence of well-established adulterants such as levamisole for cocaine or paracetamol/acetaminophen for heroin, the reported data disclosed new adulteration practices, such as the use of NPS as cutting agents for classic drugs of abuse and other NPS. For example, heroin adulterated with synthetic cannabinoids or cocaine adulterated with fentanyl/fentalogues raised particular concern. Notably, adulterants play a role in some adverse effects commonly associated with the primary drug, such as levamisole-adulterated cocaine that may induce vasculitis via an autoimmune process. It is essential to constantly monitor adulterants due to their changing availability that may threaten drug consumers' health.

Xylazine: Pharmacology Review and Prevalence and Drug Combinations in Forensic Toxicology Casework

Xylazine, an alpha-2 receptor agonist used in veterinary medicine for its sedative and muscle relaxant effects, has been reported in forensic toxicology casework since the 1980s. It is not approved for human use, but it is used as an adulterant in heroin and illicit fentanyl. The prevalence and concentrations of xylazine in 2.5 years (January 2019-June 2021) of driving-under-the-influence-of-drugs (DUID) and medical-death-investigation (MDI) cases was investigated, including other drugs detected in combination with xylazine. Of over 170,000 cases screened for xylazine, 97% were classified as MDI. Over the course of the study period the prevalence and geographical spread of xylazine increased. Overall, 2.8% of DUID and 2.1% of MDI cases screened positive for xylazine with concentrations of 5.1-450 ng/mL (mean = 36 ng/mL) and 5.0-11,000 ng/mL (mean = 41 ng/mL), respectively. Two MDI cases which had xylazine concentrations of 9,100 and 11,000 ng/mL were drug overdose suicides that did not involve any opioids. Opioids, primarily fentanyl and/or a fentanyl byproduct/metabolite were detected in 100% of DUID and all but two MDI cases. After opioids, stimulants, phyto-cannabinoids and benzodiazepines were the most common drug classes detected in conjunction with xylazine in both DUID and MDI casework. In summary, xylazine exposure continues to increase, mostthrough the adulteration of illicit opioids. There is extensive overlap in the concentrations between living and deceased individuals making it difficult to interpret the role of the drug in MDI or DUID cases without other case information.

Severe bacterial infections in people who inject drugs: the role of injection-related tissue damage

Background

In the context of the current U.S. injection drug use epidemic, targeted public health harm reduction strategies have traditionally focused on overdose prevention and reducing transmission of blood-borne viral infections. Severe bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This qualitative study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.

Methods

Qualitative analysis (n = 15) was performed using an in-depth, semi-structured interview of participants admitted to Bellevue Hospital, NYC, with SBI and recent history of injection drug use. Participants were identified through a referral from either the Infectious Diseases or Addition Medicine consultative services. Interviews were transcribed, descriptively coded, and analyzed for key themes.

Results

Participants reported a basic understanding of prevention of blood-borne viral transmission but limited understanding of SBI risk. Participants described engagement in high risk injection behaviors prior to hospitalization with SBI. These practices included polysubstance use, repetitive tissue damage, nonsterile drug diluting water and multipurpose use of water container, lack of hand and skin hygiene, re-use of injection equipment, network sharing, and structural factors leading to an unstable drug injection environment. Qualitative analysis led to the proposal of an Ecosocial understanding of SBI risk, detailing the multi-level interplay between individuals and their social and physical environments in producing risk for negative health outcomes.

Conclusions

Structural factors and injection drug use networks directly impact drug use, injection drug use practices, and harm reduction knowledge, ultimately resulting in tissue damage and inoculation of bacteria into the host and subsequent development of SBI. Effective healthcare and community prevention efforts targeted toward reducing risk of bacterial infections could prevent long-term hospitalizations, decrease health care expenditures, and reduce morbidity and mortality.

Using death scene and toxicology evidence to define involvement of heroin, pharmaceutical morphine, illicitly manufactured fentanyl and pharmaceutical fentanyl in opioid overdose deaths, 38 states and the District of Columbia, January 2018-December 2019

BACKGROUND AND AIMS

Tracking specific drugs contributing to drug overdose deaths is limited when relying on death certificate (DC) data alone. This study aimed to determine whether integrating DC data with medical examiner/coroner reports, including postmortem toxicology and death investigation findings, would enhance identification of (1) heroin and pharmaceutical morphine involvement in overdose deaths and (2) fentanyl source (illicitly manufactured versus pharmaceutical).

DESIGN

Retrospective analysis of heroin, pharmaceutical morphine, illicitly manufactured fentanyl (IMF) and pharmaceutical fentanyl involvement in fatal overdoses. DC and toxicology data were compared with enhanced definitions integrating overdose scene, witness and toxicology evidence.

SETTING

United States: 38 states and the District of Columbia, participating in Centers for Disease Control and Prevention (CDC)-funded opioid overdose death surveillance.

CASES

Opioid overdose decedents from funded jurisdictions; deaths during 1 January 2018-31 December 2019.

MEASUREMENTS

Using medical examiner/coroner report data, deaths with 6-acetylmorphine and/or morphine detected by postmortem toxicology were defined as confirmed, probable or suspected heroin deaths, or probable pharmaceutical morphine deaths. Fentanyl was defined as probable or suspected IMF or probable pharmaceutical fentanyl.

FINDINGS

The enhanced definition defined 18 393 deaths as confirmed, probable, or suspected heroin deaths (including 2678 with morphine listed as cause of death on the DC) and 404 as probable pharmaceutical morphine deaths. Among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF and 1.0% as probable pharmaceutical fentanyl. Fentanyl source could not be determined for 9.7% of deaths.

CONCLUSIONS

Integrating drug overdose scene, witness and toxicology findings can improve identification of specific drugs contributing to overdose deaths and enhance overdose intervention targeting.

Rapid On-Site Detection of Illicit Drugs in Smuggled Samples with a Portable Electrochemical Device

The smuggling of illicit drugs urges the development of new tools for rapid on-site identification in cargos. Current methods rely on presumptive color tests and portable spectroscopic techniques. However, these methods sometimes exhibit inaccurate results due to commonly used cutting agents, the colorful nature of the sample or because the drugs are smuggled in common goods. Interestingly, electrochemical sensors can deal with these specific problems. Herein, an electrochemical device is presented that uses affordable screen-printed electrodes for the electrochemical profiling of several illicit drugs by square-wave voltammetry (SWV). The identification of the illicit compound is based on the oxidation potential of the analyte. Hence, a library of electrochemical profiles is built upon the analysis of illicit drugs and common cutting agents. This library allows the design of a tailor-made script that enables the identification of each drug through a user-friendly interface (laptop or mobile phone). Importantly, the electrochemical test is compared by analyzing 48 confiscated samples with other portable devices based on Raman and FTIR spectroscopy as well as a laboratory standard method (i.e., gas chromatography–mass spectrometry). Overall, the electrochemical results, obtained through the analysis of different samples from confiscated cargos at an end-user site, present a promising alternative to current methods, offering low-cost and rapid testing in the field.

Application of dose-addition analyses to characterize the abuse-related effects of drug mixtures

Polysubstance use makes up a majority of drug use, yet relatively few studies investigate the abuse-related effects of drug mixtures. Dose-addition analyses provide a rigorous and quantitative method to determine the nature of the interaction (i.e., supraadditive, additive, or subadditive) between two or more drugs. As briefly reviewed here, studies in rhesus monkeys have applied dose-addition analyses to group level data to characterize the nature of the interaction between the reinforcing effects of stimulants and opioids (e.g., mixtures of cocaine + heroin). Building upon these foundational studies, more recent work has applied dose-addition analyses to better understand the nature of the interaction between caffeine and illicit stimulants such as MDPV and methamphetamine in rats. In addition to utilizing a variety of operant procedures, including drug discrimination, drug self-administration, and drug-primed reinstatement, these studies have incorporated potency and effectiveness ratios as a method for both statistical analysis and visualization of departures from additivity at both the group and individual subject level. As such, dose-addition analyses represent a powerful and underutilized approach to quantify the nature of drug-drug interactions that can be applied to a variety of abuse-related endpoints in order to better understand the behavioral pharmacology of polysubstance use.

Quantification of mixtures of analogues of illicit substances by benchtop NMR spectroscopy

This paper investigates the possibility of using benchtop NMR spectroscopy for quantification of illicit drugs (methamphetamine) in binary and ternary mixtures with impurities and cutting agents (N-isopropylbenzylamine, phenethylamine and dimethylsulfone). To avoid handling regulated substances, methamphetamine in our experiments is substituted with amino-2-propanol, which has similar functional groups and chemical structure to methamphetamine and hence a related NMR spectrum. Binary and ternary mixtures at concentrations from 30 mmol/L up to 500 mmol/L for each of these species were measured using a 60 MHz benchtop spectrometer. The spectra were analysed using both integration and a model-based algorithm that relies on a full quantum mechanical description of the studied spin systems. Both techniques were able to quantify the composition of the mixtures. The root mean squared error in the measured concentration using the model-based algorithm was < 10 mmol/L, whereas the error using integration was typically > 20 mmol/L. Thus, we conclude benchtop NMR is viable for quantitative measurements of mixtures of illicit substances, particularly when coupled with a quantum mechanical model for the analysis.

Impurities, adulterants and cutting agents in cocaine as potential candidates for retrospective mining of GC-MS data

Cocaine is one of the most widely used illicit drugs worldwide. Cocaine powders seized by the Police may contain numerous other substances besides the drug itself. These can be impurities originating from the coca plant or the production process, or be purposely added to the drug formulation as adulterants and cutting agents. In forensic laboratories, identification of cocaine is routinely done through GC-MS analysis, but other components are often ignored even if the method allows for their detection. Yet, they can provide valuable insight into the history of a seizure and its potential connection to other samples. To explore this idea, an extensive review of common impurities and adulterants encountered in cocaine is presented. Based on their incidence, concentration in the end product and compatibility with GC-MS methods, their overall usefulness as candidates for the statistical investigation of existing forensic data is evaluated. The impurities cis- and trans-cinnamoylcocaine, tropacocaine, norcocaine and N-benzoylnormethylecgonine as well as the adulterants lidocaine, procaine, tetracaine, benzocaine, caffeine, acetylsalicylic acid, phenacetin, ibuprofen, levamisole, hydroxyzine and diltiazem are promising candidates to provide additional forensic intelligence. Future research on optimized routine GC-MS methods, signal reproducibility, comparison, statistics and databases is suggested to facilitate this concept. Ultimately, such an approach may significantly advance the amount of information that is extracted from routine casework data, elucidate developments in the cocaine markets in the past and facilitate Police work in the future. Preliminary assessment of existing data from the forensic laboratory of the Amsterdam Police has been included to show that the detection of the identified target impurities is feasible, and that small adjustments to the analysis method could significantly increase the detectability of these analytes in prospective drug screenings. Forensic intelligence based on retrospective data mining of cocaine containing casework samples may thus be realized with minimal additional laboratory efforts by using already available instrumentation, samples and data.

Thermal desorption bridged the gap between dielectric barrier discharge ionization and dried plasma spot samples for sensitive and rapid detection of fentanyl analogs in mass spectrometry

Guided by finite element simulations and 3D-printing, we constructed a semi-covered flat-TD surface for sufficient thermal desorption and ionization of fentanyl analogs from dried plasma/blood spot samples.

Qualitative LC/Q-TOF Analysis of Umbilical Cord Tissue via Data-Dependent Acquisition as an Indicator of In Utero Exposure to Toxic Adulterating Substances

Toxic adulterants are drug or chemical agents used to add bulk volume to traditional drugs of abuse such as cocaine, and heroin. These cutting agents include levamisole, metamizole, noxiptillin, phenacetin, and xylazine as well as common legal drugs such as acetaminophen, caffeine, diphenhydramine, lidocaine, quinine, quetiapine, and tramadol. Because they possess pharmacological activity they result in exposure of the user, but also in the case of pregnant women, the developing fetus, to potential drug toxicity. We describe the development, validation, and implementation of a rapid (48 second sample-to-sample) test based on a qualitative data-dependent liquid chromatography-quadrupole time of flight mass spectrometry (LC/Q-TOF) method for the analysis of toxic adulterating substances in umbilical cord tissue (UCT) samples. The method provides a means of studying potential in utero exposure to these agents. Library spectra comparison at 3 different collision energies was used in conjunction with retention time and accurate mass to identify these substances in UCT. Analytically based reporting limits were established to determine positivity rates of adulterants in UCT utilizing a standard addition approach. The method was applied to authentic cocaine and opioid positive UCT's to screen for toxic adulterants. There were a total of 82 potential adulterant positives found in a 30-sample cohort of authentic UCT samples, with an average of 2.7 substances per case. Lidocaine was the predominant finding followed by caffeine, and diphenhydramine all of which could result from non-illicit drug exposure, however, there were positives for levamisole, phenacetin, noxiptillin, and xylazine none of which are approved in the United States for human therapeutic use. This initial set of data established a preliminary positivity rate of potentially toxic adulterants in UCT samples positive for cocaine or opioid use.

Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse

Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.

Cocaine profiling method retrospectively developed with nontargeted discovery of markers using liquid chromatography with time-of-flight mass spectrometry data

Illicit drug profiling performed by forensic laboratories assists law enforcement agencies through providing information about chemical and/or physical characteristics of seized specimens. In this article, a model was developed for the comparison of seized cocaine based on retrospective analysis of data generated from ultrahigh performance liquid chromatography with time‐of‐flight mass spectrometry (UHPLC‐TOF‐MS) comprehensive drug screening. A nontargeted approach to discover target compounds was employed, which generated 53 potential markers using data from cocaine positive samples. Twelve marker compounds were selected for the development of the final profiling model. The selection included a mixture of commonly used cocaine profiling targets and other cocaine‐related compounds. Combinations of pretreatments and comparison metrics were assessed using receiver operating characteristic curves to determine the combination with the best discrimination between linked and unlinked populations. Using data from 382 linked and 34,519 unlinked distances, a classification model was developed using a combination of the standardization and normalization transformations with Canberra distance, resulting in a linked cut‐off with a 0.5% false positive rate. The present study demonstrates the applicability of retrospectively developing a cocaine profiling model using data generated from UHPLC‐TOF‐MS nontargeted drug screening without pre‐existing information about cocaine impurities. The developed workflow was not specific to cocaine and thus could potentially be applied to any seized drug in which there are both sufficient data and impurities present.

Strategic Decision-Making by a Forensic Toxicology Laboratory in Response to an Emerging NPS: Detection, Quantitation and Interpretation of Carfentanil in Death Investigations in Ontario, Canada, July 2017 to June 2018

The proliferation of novel psychoactive substances (NPS) and the current opioid epidemic creates challenges for a toxicology laboratory. Methods capable of detecting and quantitating emerging compounds must be established despite limited information on toxicologically relevant concentrations. This paper will (i) describe how a publicly funded forensic laboratory reacted to the emergence of carfentanil as a public safety concern and (ii) contribute to the existing forensic literature by presenting a series of deaths involving carfentanil between July 2017 and June 2018. The Centre of Forensic Sciences is the primary provider of forensic toxicology testing in medicolegal death investigations in the province of Ontario. When carfentanil was first identified in the illicit drug supply, routine screening methods used by this laboratory were not sufficiently sensitive to detect the drug at concentrations expected in blood samples. Previously validated, multi-target liquid chromatography-tandem mass spectrometry (LC-MS-MS) quantitative methods already in use by the laboratory did show improved detectability for carfentanil. Thus, an existing LC-MS-MS method was adapted to include carfentanil, achieving improved sensitivity while also providing quantitation in suspected drug-related deaths. This approach had the added benefit that the LC-MS-MS method selected for modification was used in all death investigations requiring toxicology analysis in Ontario, thereby providing an opportunity for surveillance. Using this method, 4,953 cases were analyzed with carfentanil detected at a concentration greater than the limit of detection (0.05 ng/mL) in 160 decedents. Postmortem blood carfentanil concentrations ranged from less than 0.1 to 9.2 ng/mL. Of the 160 carfentanil-positive cases, 156 were classified as either mixed drug toxicity or carfentanil overdose. The approach described enabled this laboratory to efficiently implement a quantitative test for carfentanil in all death investigations, providing a useful template for modifying existing methods when a new psychoactive substance becomes available in the population.

Electrochemical Fingerprints of Illicit Drugs on Graphene and Multi-Walled Carbon Nanotubes

Illicit drugs use and abuse remains an increasing challenge for worldwide authorities and, therefore, it is important to have accurate methods to detect them in seized samples, biological fluids and wastewaters. They are recently classified as the latest group of emerging pollutants as their consumption increased tremendously in recent years. Nanomaterials have gained much attention over the last decade in the development of sensors for a myriad of applications. The applicability of these nanomaterials, functionalized or not, significantly increases and it is therefore highly suitable for use in the detection of illicit drugs. We have assessed the suitability of various nanoplatforms, such as graphene (GPH), multi-walled carbon nanotubes (MWCNTs), gold nanoparticles (AuNPs) and platinum nanoparticles (PtNPs) for the electrochemical detection of illicit drugs. GPH and MWCNTs were chosen as the most suitable platforms and cocaine, 3,4-methylendioxymethamfetamine (MDMA), 3-methylmethcathinone (MMC) and α-pyrrolidinovalerophenone (PVP) were tested. Due to the hydrophobicity of the nanomaterials-based platforms which led to low signals, two strategies were followed namely, pretreatment of the electrodes in sulfuric acid by cyclic voltammetry and addition of Tween 20 to the detection buffer. Both strategies led to an increase in the oxidation signal of illicit drugs. Binary mixtures of illicit drugs with common adulterants found in street samples were also investigated. The proposed strategies allowed the sensitive detection of illicit drugs in the presence of most adulterants. The suitability of the proposed sensors for the detection of illicit drugs in spiked wastewaters was finally assessed.

Levamisole-a Toxic Adulterant in Illicit Drug Preparations: a Review

ABSTRACT

Discovered in the 1960s, the common anthelminthic levamisole has seen widespread use in veterinary applications. Its use rapidly expanded thereafter to include human medical treatments for a variety of acute and chronic disorders. Because of reports of severe adverse effects, the US Food and Drug Administration withdrew levamisole's approval for human use in 2000; however, medical options outside the United States and illicit options worldwide allow continued accessibility to levamisole. The compound is rapidly metabolized in the body, with at least 2 known active metabolites. Levamisole has a broad range of immunomodulatory effects, including both stimulatory and inhibitory effects on immune responses. It is generally well tolerated at therapeutic concentrations, although a variety of autoimmune-related adverse effects have been reported, including agranulocytosis, leukopenia, purpura, and visible necrotized skin tissue. Individuals with levamisole-compromised immune systems are more susceptible to infections, including COVID-19. Since the early 2000's, levamisole has been frequently used as an adulterating agent in illicit street drugs, especially cocaine, fentanyl, and heroin. Although its prevalence has varied over time and geographically, levamisole has been detected in up to 79% of the street supply of cocaine at levels up to 74% by weight. Its presence in illicit drug markets also raises concern over the potential for exposure of children and neonates, although this is supported by only limited anecdotal evidence. Levamisole is not currently included in routine drug testing panels, although a variety of confirmatory testing techniques exist across a range of antemortem and postmortem specimen options. Because of its varying presence in illicit drug markets, both the medical and forensic communities need to be aware of levamisole and its potential impact on toxicological investigations.

A Semi-quantitative method for the detection of fentanyl using surface-enhanced Raman scattering (SERS) with a handheld Raman instrument

A handheld, spatially offset Raman spectroscopy (SORS) system was successfully used to obtain Surface-enhanced Raman Scattering (SERS) spectra of fentanyl under simulated field conditions. A series of aqueous fentanyl solutions were prepared with commercially available gold nanoparticle solution, at concentrations ranging from 0.003 to 1697 μM. These SERS spectra were then used to generate two concentration calibration models (via a plot of peak area (1026 cm^-1 ) versus concentration, and quantitative spectral decomposition using partial least squares (PLS1)). For both models, the relationship followed Langmuir adsorption and became non-linear at concentrations above ~0.2 μM, with a limit of detection (LOD) of approximately 3 nM. The same technique was successfully used to measure fentanyl in the presence of two common "cutting agents," heroin and glucose, at 1% and 2% fentanyl proportions (w/w). Fentanyl detection was successfully achieved, but mixture interference from the cutting agents prevented a calibration model being generated. Four fentanyl analogues were also investigated-butyrylfentanyl, furanylfentanyl, acetylfentanyl, and ocfentanyl. A concentration calibration model for each species was successfully generated, but differentiation from fentanyl proved more challenging, although several potential diagnostic peaks were identified. These results identified a pathway forward in using handheld equipment for the reliable detection of ultra-low concentrations of fentanyl and fentanyl analogues via SERS, even when mixed with diluents. However, quantitative detection is negatively impacted in the presence of heroin and glucose. This also provides a starting point for a SERS-based spectral library of fentanyl analogues, in combination with a range of different diluents.

Wearable Electrochemical Sensors for the Monitoring and Screening of Drugs

Wearable electrochemical sensors capable of noninvasive monitoring of chemical markers represent a rapidly emerging digital-health technology. Recent advances toward wearable continuous glucose monitoring (CGM) systems have ignited tremendous interest in expanding such sensor technology to other important fields. This article reviews for the first time wearable electrochemical sensors for monitoring therapeutic drugs and drugs of abuse. This rapidly emerging class of drug-sensing wearable devices addresses the growing demand for personalized medicine, toward improved therapeutic outcomes while minimizing the side effects of drugs and the related medical expenses. Continuous, noninvasive monitoring of therapeutic drugs within bodily fluids empowers clinicians and patients to correlate the pharmacokinetic properties with optimal outcomes by realizing patient-specific dose regulation and tracking dynamic changes in pharmacokinetics behavior while assuring the medication adherence of patients. Furthermore, wearable electrochemical drug monitoring devices can also serve as powerful screening tools in the hands of law enforcement agents to combat drug trafficking and support on-site forensic investigations. The review covers various wearable form factors developed for noninvasive monitoring of therapeutic drugs in different body fluids and toward on-site screening of drugs of abuse. The future prospects of such wearable drug monitoring devices are presented with the ultimate goals of introducing accurate real-time drug monitoring protocols and autonomous closed-loop platforms toward precise dose regulation and optimal therapeutic outcomes. Finally, current unmet challenges and existing gaps are discussed for motivating future technological innovations regarding personalized therapy. The current pace of developments and the tremendous market opportunities for such wearable drug monitoring platforms are expected to drive intense future research and commercialization efforts.

MASS SPECTROMETRY ANALYSIS OF DRUGS OF ABUSE: CHALLENGES AND EMERGING STRATEGIES

Mass spectrometry has been the "gold standard" for drugs of abuse (DoA) analysis for many decades because of the selectivity and sensitivity it affords. Recent progress in all aspects of mass spectrometry has seen significant developments in the field of DoA analysis. Mass spectrometry is particularly well suited to address the rapidly proliferating number of very high potency, novel psychoactive substances that are causing an alarming number of fatalities worldwide. This review surveys advancements in the areas of sample preparation, gas and liquid chromatography-mass spectrometry, as well as the rapidly emerging field of ambient ionization mass spectrometry. We have predominantly targeted literature progress over the past ten years and present our outlook for the future. © 2020 Periodicals, Inc. Mass Spec Rev.