Prevalence and associated birth outcomes of co-use of Cannabis and tobacco cigarettes during pregnancy

Use of Cannabis and use of tobacco overlap, and co-use of Cannabis and tobacco has increased over the past decade among adults. The current study aims to document the prevalence and correlates of co-use of Cannabis and tobacco cigarettes among adult pregnant women utilizing secondary data from a larger study that compared and validated screeners for illicit and prescription drug use during pregnancy. Pregnant women (N = 500; 71% African American; 65% never married, average age of 28 years) were recruited from two urban University obstetric clinics between January and December 2017. Participants self-reported demographic, Cannabis, and tobacco cigarette use characteristics, and provided urine and hair samples for drug testing. Within two weeks after due date, research staff reviewed participants' electronic medical records to collect birth outcome data. Results showed that 9.0% reported co-use of Cannabis and tobacco, 12.1% reported Cannabis only use, 7.8% reported tobacco cigarette only use, and 71.1% reported no Cannabis or tobacco cigarette use in the past month. The birth outcomes to emerge as significant correlates of co-use of Cannabis and tobacco cigarettes were small head circumference, and the occurrence of birth defects, with the co-use group having the highest odds of a small head circumference [aOR: 5.7 (1.1-28.9)] and birth defects [aOR: 3.1 (1.2-8.3)] compared with other use groups. The Cannabis only group had 12 times higher odds of a stillbirth or miscarriage (aOR = 12.1). Screening and interventions to address concurrent Cannabis and tobacco use during pregnancy are needed, particularly among subpopulations with higher co-use rates. It is imperative to further explore and highlight the possible health implications of maternal co-use given the high prevalence rates found in this study sample.

Detecting biomarkers of secondhand marijuana smoke in young children

BACKGROUND

The impact of secondhand marijuana smoke exposure on children is unknown. New methods allow detection of secondhand marijuana smoke in children.

METHODS

We studied children ages 1 mo to 2 y hospitalized with bronchiolitis in Colorado from 2013 to 2015. Parents completed a survey, and urine samples were analyzed for cotinine using LC/MS/MS (limits of detection 0.03 ng/ml) and marijuana metabolites including COOH-THC (limits of detection 0.015 ng/ml).

RESULTS

A total of 43 subjects had urine samples available for analysis. Most (77%) of the subjects were male, and 52% were less than 1 y of age. COOH-THC was detectable in 16% of the samples analyzed (THC+); the range in COOH-THC concentration was 0.03-1.5 ng/ml. Two subjects had levels >1 ng/ml. Exposure did not differ by gender or age. Non-white children had more exposure than white children (44 vs. 9%; P < 0.05). 56% of children with cotinine >2.0 ng/ml were THC+, compared with 7% of those with lower cotinine (P < 0.01).

CONCLUSION

Metabolites of marijuana smoke can be detected in children; in this cohort, 16% were exposed. Detectable COOH-THC is more common in children with tobacco smoke exposure. More research is needed to assess the health impacts of marijuana smoke exposure on children and inform public health policy.

The impact of non-concordant self-report of substance use in clinical trials research

BACKGROUND

Studies comparing self-report substance use data to biochemical verification generally demonstrate high rates of concordance. We argue that these rates are due to the relatively high true negative rate in the general population, and high degree of honestly in treatment seeking individuals. We hypothesized that high risk individuals not seeking treatment would demonstrate low concordance and a high false negative rate of self-reported substance use.

METHODS

A sample of 500 individuals from a smoking cessation clinical trial was assessed over 1 year. Assessments included semi-structured interviews, questionnaires (e.g. Addiction Severity Index, etc.), and urine drug screen assays (UDS). Generalized estimating equations (GEEs) were used to predict false negative reports for various substances across the study and determine the influence of substance use on the primary study outcome of smoking cessation.

RESULTS

Participants demonstrated high false negative rates in reporting substances use, and the false negative rates increased as the study progressed. Established predictors of false negatives generalized to the current sample. High concordance and low false negative rates were found in self-report of nicotine use. A small but significant relationship was found in for effect of biochemically verified substance use on smoking cessation.

CONCLUSIONS

Biochemical verification of substance use is needed in high risk populations involved in studies not directly related to the treatment of substance use, especially in populations with high threat of stigmatization. Testing should continue through the time period of the study for maximal identification of substance use.

Urinary concentrations of PAH and VOC metabolites in marijuana users

BACKGROUND

Marijuana is seeing increased therapeutic use, and is the world's third most-popular recreational drug following alcohol and tobacco. This widening use poses increased exposure to potentially toxic combustion by-products from marijuana smoke and the potential for public health concerns.

OBJECTIVES

To compare urinary metabolites of polycyclic aromatic hydrocarbons (PAHs) and volatile organic compounds (VOCs) among self-reported recent marijuana users and nonusers, while accounting for tobacco smoke exposure.

METHODS

Measurements of PAH and VOC metabolites in urine samples were combined with questionnaire data collected from participants in the National Health and Nutrition Examination Surveys (NHANES) from 2005 to 2012 in order to categorize participants (≥18years) into exclusive recent marijuana users and nonusers. Adjusted geometric means (GMs) of urinary concentrations were computed for these groups using multiple regression analyses to adjust for potential confounders.

RESULTS

Adjusted GMs of many individual monohydroxy PAHs (OH-PAHs) were significantly higher in recent marijuana users than in nonusers (p<0.05). Urinary thiocyanate (p<0.001) and urinary concentrations of many VOC metabolites, including metabolites of acrylonitrile (p<0.001) and acrylamide (p<0.001), were significantly higher in recent marijuana users than in nonusers.

CONCLUSIONS

We found elevated levels of biomarkers for potentially harmful chemicals among self-identified, recent marijuana users compared with nonusers. These findings suggest that further studies are needed to evaluate the potential health risks to humans from the exposure to these agents when smoking marijuana.

Effect of marijuana use on outcomes in traumatic brain injury

Traumatic brain injury (TBI) is associated with significant morbidity and mortality. Several studies have demonstrated neuroprotective effects of cannabinoids. The objective of this study was to establish a relationship between the presence of a positive toxicology screen for tetrahydrocannabinol (THC) and mortality after TBI. A 3-year retrospective review of registry data at a Level I center of patients sustaining TBI having a toxicology screen was performed. Pediatric patients (younger than 15 years) and patients with a suspected nonsurvivable injury were excluded. The THC(+) group was compared with the THC(-) group with respect to injury mechanism, severity, disposition, and mortality. Logistic regression was used to determine independent associations with mortality. There were 446 cases meeting all inclusion criteria. The incidence of a positive THC screen was 18.4 per cent (82). Overall mortality was 9.9 per cent (44); however, mortality in the THC(+) group (2.4% [two]) was significantly decreased compared with the THC(-) group (11.5% [42]; P = 0.012). After adjusting for differences between the study cohorts on logistic regression, a THC(+) screen was independently associated with survival after TBI (odds ratio, 0.224; 95% confidence interval, 0.051 to 0.991; P = 0.049). A positive THC screen is associated with decreased mortality in adult patients sustaining TBI.

Reference ranges for urinary levels of testosterone and epitestosterone, which may reveal gonadal function, in a Korean male population

Cannabis, or marijuana, the most commonly used illicit drug in the world, has been shown to be responsible for suppressing the production and secretion of androgens, particularly testosterone. However, despite such findings in animals, the chronic effects of marijuana use on human endocrine systems have proved to be inconsistent. Here, we investigated the reference ranges of urinary levels of testosterone (T) and epitestosterone (E) as well as their metabolic ratio of T/E in a Korean male population (n=337), which would enable an evaluation of abnormal changes in steroid metabolism induced by habitually administered cannabis. The T/E ratio was significantly decreased in the marijuana group (n=18), while the urinary testosterone concentrations were also tended to decrease. This study is the first to provide data for the reference values of two urinary androgens and T/E values among control Korean males, and, furthermore, suggests that the T/E ratio, though not testosterone levels, might be used to understand the suppression of human male gonadal function affected by smoking marijuana.

Marijuana's dose-dependent effects in daily marijuana smokers

Active marijuana produces significant subjective, psychomotor, and physiological effects relative to inactive marijuana, yet demonstrating that these effects are dose-dependent has proven difficult. This within-subject, double-blind study was designed to develop a smoking procedure to obtain a marijuana dose-response function. In four outpatient laboratory sessions, daily marijuana smokers (N = 17 males, 1 female) smoked six 5-s puffs from 3 marijuana cigarettes (2 puffs/cigarette). The number of puffs from active (≥5.5% Δ⁹-tetrahydrocannabinol/THC) and inactive (0.0% THC) marijuana varied according to condition (0, 2, 4, or 6 active puffs); active puffs were always smoked before inactive puffs. Subjective, physiological, and performance effects were assessed prior to and at set time points after marijuana administration. Active marijuana dose-dependently increased heart rate and decreased marijuana craving, despite evidence (carbon monoxide expiration, weight of marijuana cigarettes post-smoking) that participants inhaled less of each active marijuana cigarette than inactive cigarettes. Subjective ratings of marijuana "strength," "high," "liking," "good effect," and "take again" were increased by active marijuana compared with inactive marijuana, but these effects were not dose-dependent. Active marijuana also produced modest, non-dose-dependent deficits in attention, psychomotor function, and recall relative to the inactive condition. In summary, although changes in inhalation patterns as a function of marijuana strength likely minimized the difference between dose conditions, dose-dependent differences in marijuana's cardiovascular effects and ratings of craving were observed, whereas subjective ratings of marijuana effects did not significantly vary as a function of dose.

Cannabis misinterpretation and misadventure in a coroner's court

A 37-year-old, one-pack-per-day tobacco smoker collapsed and died at home. At autopsy, he had an occluded left anterior descending coronary artery. Δ(9)-Tetrahydrocannabinol-carboxylic acid was found in his urine but no cannabinoids were detected in his blood. Misadventure was the inquest verdict on the basis of the urinary cannabis, with acute myocardial infarction as the primary cause and cannabis as the secondary cause of death. Such a conclusion is a misinterpretation of the evidence when the time duration for cannabis as a trigger for myocardial infarction is at most two hours. The absence of cannabis in the blood likely places the time since inhalation at more than two hours. The role of tobacco smoking as a trigger was ignored. Cotinine, the biochemical marker of tobacco smoke, should be added to the standard toxicological screen in the guidelines on autopsy practice of the Royal College of Pathologists.

Contingency management is efficacious and improves outcomes in cocaine patients with pretreatment marijuana use

BACKGROUND

Marijuana use is common in patients seeking treatment for cocaine use. Nevertheless, few studies have examined effects of marijuana use on treatment outcomes in general, and even fewer with respect to contingency management (CM) treatment, which has been criticized for potentially increasing non-reinforced drug use.

METHODS

Data from three randomized clinical trials of CM versus standard treatment (ST) in cocaine-abusing patients were examined (Petry et al., 2004, 2005a, 2006a; N=393) to assess effects of pretreatment marijuana use on outcomes. Patients were divided into two groups: (1) no self-reported marijuana use (No Pre-M; n=315) and (2) any self-reported marijuana use (Pre-M; n=78) in the 30 days pretreatment.

RESULTS

CM was especially efficacious in enhancing retention in Pre-M patients such that retention nearly doubled among Pre-M patients assigned to CM versus those assigned to ST. In contrast, CM exerted only modest benefits on retention in No Pre-M patients. Pretreatment marijuana use was not related to during-treatment abstinence from cocaine, opioids, and alcohol, or abstinence at a Month 9 follow-up. However, CM treatment and longest duration of abstinence achieved during treatment were significant predictors of Month 9 abstinence. Pre-M patients also evidenced more improvements in drug problems over time when randomized to CM.

CONCLUSIONS

CM was especially efficacious in facilitating retention and improving severity of drug-related problems in those who used marijuana in the month before initiating treatment.

Elimination of 11-nor-9-carboxy-delta-9-tetrahydrocannabinol when normalized to urinary creatinine

Gas chromatography mass/spectrometry quantitative analysis of 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THCCOOH), the major metabolite of delta-9-tetrahydrocannabinol (THC) found in urine following marijuana use, was performed on serial urine specimens collected from an inpatient adolescent population of marijuana users. Creatinine normalization of THCCOOH was used to compensate for dilute or concentrated urine specimens. The urinary terminal elimination rate constant and terminal half-life was calculated for each subject. The mean urinary elimination rate constant for THCCOOH normalized to creatinine was 0.08433 days(-1) (range 0.05408-0.16544) reflecting a 8.22 day terminal half-life. A half-life of 1.15 days was observed for the initial decline phase of THCCOOH corrected by creatinine suggesting that reuse of marijuana can be detected after this phase ends. The creatinine normalized THCCOOH level was a better indicator for predicting reuse of marijuana than urinary concentrations of THCCOOH. The Mean Residence Time (MRT) of THCCOOH/Cr (5.7 days) correlated well with the length of time a subject will have detectable urinary THCCOOH concentrations (20.8 days).

Qualitative high performance thin layer chromatography (HPTLC) analysis of cannabinoids in urine samples of Cannabis abusers

BACKGROUND & OBJECTIVES

Cannabis is one of the most commonly abused drugs worldwide. There is a distinct clinical correlation between cannabis abuse and mental disorders. However, it is essential to establish cannabis intake in the abusers in order to establish causality between cannabis and psychiatric illness. The limitations of current detection methods using commercial cassettes prompted us to standardize the method of extraction and detection of cannabinoids in the urine samples of cannabis abusers attending a de-addiction centre in south India.

METHODS

In this study, diagnostic tests on 102 male patients suspected with cannabis abuse were done. Liquid-liquid extraction of cannabinoids from urine was done and screened by Duquenois-Levine, fast blue B salt and p-dimethylaminobenzaldehyde (p-DMAB) tests. All the results were confirmed by high performance thin layer chromatography (HPTLC). Samples were considered positive for cannabis based on the positive indication in colour test and by detection of 11-nor-delta(9) tetrahydrocannabinol-9-carboxylic acid (THC-COOH) on HPTLC.

RESULTS

Based on the colour tests and HPTLC, cannabis abuse was detected in 64 of 102 patients tested. HPTLC method was found to be sensitive for detection and possible quantitation of THC-COOH.

INTERPRETATION & CONCLUSION

We report the standardization and utility of cannabinoid extraction, screening and detection by HPTLC in the urine samples of cannabis abusers. The HPTLC method was found to be high throughput, sensitive, reproducible and cost-effective compared to commercial kits.

Detection of cannabigerol and its presumptive metabolite in human urine after Cannabis consumption

Kemp et al. (1995) could detect delta9-tetrahydrocannabinol (delta9-THC), cannabinol and cannabidiol, three neutral cannabinoids, and the metabolites of delta9-THC in urine samples of Cannabis consumers. In this study we aimed to identify cannabigerol (CBG), which in its acid form is one of the main intermediate compounds of the biosynthesis of cannabinoids in hemp, in authority urine samples of proved Cannabis consumers. For this reason we applied the modified method of Kemp et al. to test for CBG, since enzymatic hydrolysis seems to be necessary for the formation of free neutral cannabinoids from conjugates. After extraction, derivatisation with N-Methyl-N-(trimethylsilyl)trifluoroacetamide (MSTFA) and GC/MS analysis, peaks of characteristic fragment ions (m/z 337, 391, 377 and 460) of bis-trimethylsilyl derivative of CBG appeared at 12.48 minutes in both real sample and the urine spiked with CBG. It shows that CBG enters the body during Cannabis smoking and is excreted with urine in a conjugated form, like other neutral cannabinoids. Analysing the chromatograms of hydrolysed and trimethylsilylated extracts we checked for the presence of CBG-metabolites based on the study of Harvey and Brown (1990). We detected a compound in the Cannabis consumers' urine extracts, having fragment ions at m/z 425, 465 and 479 at the retention time of 14.19 min which is presumed to be the 4"-hydroxy-CBG or 5"-hydroxy-CBG. However, it could not be identified completely by GC/MS. This peak was absent in non-hydrolysed urine samples, indicating that it is also excreted in glucuronated form.

Urine drug test interpretation: what do physicians know?

OBJECTIVE

To determine the level of urine drug test (UDT) interpretive knowledge of physicians who use these instruments to monitor adherence in their patients on chronic opioid therapy.

METHODS

A seven-question instrument consisting of six five-option, single-best-answer multiple choice questions and one yes/no question was completed by 114 physicians (77 who employ UDT and 37 who do not) attending one of three regional opioid education conferences. We calculated frequencies and performed chi2 analyses to examine bivariate associations between UDT utilization and interpretive knowledge.

RESULTS

The instrument was completed by 80 percent of eligible respondents. None of the physicians who employ UDT answered all seven questions correctly, and only 30 percent answered more than half correctly. Physicians who employ UDT performed no better on any of the questions than physicians who do not employ UDT.

CONCLUSIONS

Physicians who employ UDT to monitor patients receiving chronic opioid therapy are not proficient in test interpretation. This study highlights the need for improved physician education; it is imperative for physicians to work closely with certified laboratory professionals when ordering and interpreting these tests.

Cannabis use and misuse prevalence among people with psychosis

BACKGROUND

Increasing attention has been given by researchers to cannabis use in individuals with psychosis. As psychoses are relatively low-prevalence disorders, research has been mostly been restricted to small-scale studies of treatment samples. The reported prevalence estimates obtained from these studies vary widely.

AIMS

To provide prevalence estimates based on larger samples and to examine sources of variability in prevalence estimates across studies.

METHOD

Data from 53 studies of treatment samples and 5 epidemiological studies were analysed.

RESULTS

Based on treatment sample data, prevalence estimates were calculated for current use (23.0%), current misuse (11.3%), 12-month use (29.2%), 12-month misuse (18.8%), lifetime use (42.1%) and lifetime misuse (22.5%). Epidemiological studies consistently reported higher cannabis use and misuse prevalence in people with psychosis.

CONCLUSIONS

The factor most consistently associated with increased odds of cannabis prevalence was specificity of diagnosis. Factors such as consumption patterns and study design merit further consideration.

Estimating the prevalence of cannabinoid use urine testing: a preliminary study in Kerman, Iran

AIMS

This primary study was performed to determine the prevalence rate of cannabinoid consumed in Kerman (Iran).

MEASUREMENTS

Urine samples of 700 males, referred to a clinical lab in Kerman city were collected for detection of cannabinoid metabolites. Assessment analysis was a monophasic immunoassay rapid technique. The study was completely blind and only age and residence of samples were revealed. All stages were confirmed and supervised by the ethics committee.

RESULTS

The prevalence of cannabinoid use was 0.6%. All four positive cases were urban, with ages 31, 36, 40 and 67. More than 90% of referred cases were urban with mean age of 46.8+/-16 while the mean age of rural cases was 54.3+/-17 years.

CONCLUSIONS

Considering the age range and possibility of the underlying disease in the study population, the prevalence of cannabinoid use was more than what was expected. Urine analysis as a method for assessing the prevalence rate requires a wide sample size and age distribution matching the age distribution of the study population. In addition, the entrance criteria should not include sick cases.

Passive cannabis smoke exposure and oral fluid testing

Oral fluid testing for Delta(9)-tetrahydrocannabinol (THC) provides a convenient means of detection of recent cannabis usage. In this study, the risk of positive oral fluid tests from passive cannabis smoke exposure was investigated by housing four cannabis-free volunteers in a small, unventilated, and sealed room with an approximate volume of 36 m(3). Five active cannabis smokers were also present in the room, and each smoked a single cannabis cigarette (1.75% THC). Cannabis smoking occurred over the first 20 min of the study session. All subjects remained in the room for approximately 4 h. Oral fluid specimens were collected with the Intercept DOA Oral Specimen Collection Device. Three urine specimens were collected (0, 20, and 245 min). In addition, three air samples were collected for measurement of THC content. All oral fluid specimens were screened by enzyme immunoassay (EIA) for cannabinoids (cutoff concentration = 3 ng/mL) and tested by gas chromatography-tandem mass spectrometry (GC-MS-MS) for THC (LOQ/LOD = 0.75 ng/mL). All urine specimens were screened by EIA for cannabinoids (cutoff concentration = 50 ng/mL) and tested by GC-MS-MS for THCCOOH (LOQ/LOD = 1 ng/mL). Air samples were measured for THC by GC-MS (LOD = 1 ng/L). A total of eight oral fluid specimens (collected 20 to 50 min following initiation of smoking) from the four passive subjects screened and confirmed positive for THC at concentrations ranging from 3.6 to 26.4 ng/mL. Two additional specimens from one passive subject, collected at 50 and 65 min, screened negative but contained THC in concentrations of 4.2 and 1.1 ng/mL, respectively. All subsequent specimens for passive participants tested negative by EIA and GC-MS-MS for the remainder of the 4-h session. In contrast, oral fluid specimens collected from the five cannabis smokers generally screened and confirmed positive for THC throughout the session at concentrations substantially higher than observed for passive subjects. Urine specimens from active cannabis smokers also screened and confirmed positive at conventional cutoff concentrations. A biphasic pattern of decline for THC was observed in oral fluid specimens collected from cannabis smokers, whereas a linear decline was seen for passive subjects suggesting that initial oral fluid contamination is cleared rapidly and is followed by THC sequestration in the oral mucosa. It is concluded that the risk of positive oral fluid tests from passive cannabis smoke inhalation is limited to a period of approximately 30 min following exposure.

Neurocognitive consequences of marihuana--a comparison with pre-drug performance

In determining the effects of regular marihuana use on neurocognition, abilities within specific relevant cognitive domains prior to regular drug use have not been available. The present study examined effects of current and past regular use of marihuana in subjects for whom pre-drug performance had been ascertained in a prospective, longitudinal fashion. A total of 113 young adults, assessed since infancy, were evaluated using neurocognitive tests for which commensurate measures were obtained prior to the initiation of marihuana smoking. Marihuana users, determined by urinalysis and self-report, were categorized as light (< 5 joints per week) and heavy (> or = 5 joints per week) current users and former users, the latter having used the drug regularly in the past (> or = 1 joint per week) but not for at least 3 months. A third of the subjects were using marihuana on a regular basis at the time of assessment with half being heavy users. Among former, regular users, approximately half had been smoking 5 or more joints per week. Overall IQ, memory, processing speed, vocabulary, attention, and abstract reasoning were assessed. After accounting for potentially confounding factors and pre-drug performance in the appropriate cognitive domain, current regular heavy users did significantly worse than non-users in overall IQ, processing speed, immediate, and delayed memory. In contrast, the former marihuana smokers did not show any cognitive impairments. It was concluded that residual marihuana effects are evident beyond the acute intoxication period in current heavy users after taking into account pre-drug performance but similar deficits are no longer apparent 3 months after cessation of regular use, even among former heavy using young adults.

Marijuana impairs growth in mid-gestation fetuses

Marijuana (Cannabis sativa) is the most commonly used illicit drug by pregnant women, but information is limited about the effects of prenatal cannabis exposure on fetal development. The present study evaluated the influence of early maternal marijuana use on fetal growth. Women electing voluntary saline-induced abortions were recruited at a mid-gestational stage of pregnancy (weeks 17-22), and detailed drug use and medical histories were obtained. Toxicological assays (maternal urine and fetal meconium) were used in conjunction with the maternal report to assign groups. Subjects with documented cocaine and opiate use were excluded. Main developmental outcome variables were fetal weight, foot length, body length, and head circumference; ponderal index was also examined. Analyses were adjusted for maternal alcohol and cigarette use. Marijuana (n=44)- and nonmarijuana (n=95)-exposed fetuses had similar rates of growth with increased age. However, there was a 0.08-cm (95% CI -0.15 to -0.01) and 14.53-g (95% CI -28.21 to 0.86) significant reduction of foot length and body weight, respectively, for marijuana-exposed fetuses. Moreover, fetal foot length development was negatively correlated with the amount and frequency of marijuana use reported by the mothers. These findings provide evidence of a negative impact of prenatal marijuana exposure on the mid-gestational fetal growth even when adjusting for maternal use of other substances well known to impair fetal development.

Associations between biologically confirmed marijuana use and laboratory-confirmed sexually transmitted diseases among African American adolescent females

BACKGROUND

Numerous studies have examined the association between adolescents' marijuana use and their high-risk sexual behaviors and sexually transmitted diseases (STDs). However, the validity of the findings is questionable because most of the studies relied on self-reporting for measurement of marijuana use and key outcome (i.e., STDs).

GOAL

The goal was to investigate associations between biologically confirmed marijuana use and laboratory-confirmed STDs and condom use.

STUDY DESIGN

African American females adolescents (n = 522) completed a self-administered survey and face-to-face interview. The adolescents provided urine and vaginal swab specimens that were analyzed for marijuana metabolites and STDs, respectively.

RESULTS

Among the study subjects, 5.4% tested positive for marijuana. These adolescents were more likely to test positive for Neisseria gonorrhoeae (adjusted odds ratio [AOR] = 3.4) and Chlamydia trachomatis (AOR = 3.9). They were more likely to have never used condoms in the previous 30 days (AOR = 2.9) and to have not used condoms consistently in the previous 6 months (AOR = 3.6).

CONCLUSION

The findings represent unique biologic evidence that STDs and sexual risk behavior may co-occur with marijuana use. Interventions designed to reduce adolescents' risk of STDs and HIV infection should address marijuana use.

Marijuana use and HIV risk among adolescent offenders: the moderating effect of age

PURPOSE

This study examined gender and age as potential moderators of the association between marijuana use and human immunodeficiency virus (HIV) risk among 272 adolescent offenders.

METHODS

Analyses were based on biological and self-report measures of both marijuana use and HIV risk.

RESULTS

Results revealed that the association between marijuana use and HIV risk was moderated by age but not gender across both biological and self-report measures. Specifically, marijuana use was associated with a higher occurrence of HIV risk among younger but not older adolescent offenders.

IMPLICATIONS

These findings provide meaningful information that can be used to guide future research as well as interventions with adolescent offenders.

Concurrent substance use and outcome in combined behavioral and naltrexone therapy for opiate dependence

The effect of concurrent nonopiate drug use on outcome of treatment for opiate dependence.

METHOD

Forty-seven opiate-dependent patients received a 6-month course of outpatient treatment with naltrexone and cognitive-behavioral therapy (behavioral naltrexone therapy, BNT) at a university-based research clinic. Opiate-negative urines and naltrexone ingestion were rewarded with monetary vouchers. Abstinence from other drugs was encouraged verbally, but no contingencies were placed on nonopiate drug use. The proportions of all urines (collected twice weekly) positive for cocaine, cannabis, and benzodiazepines over the course of treatment were evaluated as predictors of outcome of opiate dependence treatment, as measured by proportion of opiate-positive urines, days retained in treatment, and proportion of naltrexone doses taken, using Pearson product moment correlations and one-way analysis of variance (ANOVA).

RESULTS

The majority of patients (78%) used a nonopiate drug at least once during the trial. There were no significant correlations between concurrent drug use measures and opiate dependence treatment outcomes, indicating no simple linear relationship between these measures. However, when concurrent drug use was trichotomized into abstinent, intermittent, and heavy use groups, groups with intermittent use had superior outcome compared to both abstinent and heavy use groups in several contrasts.

CONCLUSIONS

Intermittent use of nonopiate drugs is common during outpatient treatment for opiate dependence and may be a favorable prognostic indicator. This may support a "harm reduction" approach as opposed to a strict abstinence-oriented approach. Further research is needed to identify the optimal therapeutic stance toward other drug use during treatment for opiate dependence.

Detection of marijuana use by oral fluid and urine analysis following single-dose administration of smoked and oral marijuana

We compared oral fluid testing to urine testing in subjects who were administered single doses of marijuana by smoked and oral routes. Oral fluid specimens were collected with the Intercept DOA Oral Specimen Collection Device, screened for THC with the Cannabinoids Intercept MICRO-PLATE Enzyme Immunoassay (EIA) utilizing a 1.0-ng/mL cutoff concentration, and confirmed for THC by gas chromatography-tandem mass spectrometry (GC-MS-MS) with a 0.5-ng/mL cutoff concentration. Urine specimens were screened for 11-nor-carboxy-delta9-tetrahydrocannabinol (THCCOOH) by immunoassay utilizing a 50-ng/mL cutoff concentration and confirmed for THCCOOH by GC-MS with a 15-ng/mL cutoff concentration. Oral fluid specimens tested positive following smoked marijuana (N = 10) consecutively for average periods (+/-SEM; range) of 15 (+/-2; 1-24) and 13 h (+/-3; 1-24) by EIA and GC-MS-MS, respectively. The average THC detection times of the last oral fluid positive specimen following smoked marijuana by EIA and GC-MS-MS were 31 (+/-9; 1-72) and 34 h (+/-11; 1-72), respectively. In comparison to oral fluid, urine specimens generally tested negative for THCCOOH immediately after marijuana use. The average times to detection of the first urine specimen positive for THCCOOH by EIA and GC-MS were 6 (+/-2; 1-16) and 4 h (+/-1; 2-8), respectively. Urine specimens tested positive consecutively for average periods of 26 (+/-9; 2-72) and 33 h (+/-10; 4-72) for EIA and GC-MS, respectively. The average THCCOOH detection times of the last specimen by EIA and GC-MS were 42 (+/-10; 2-72) and 58 h (+/-6; 16-72), respectively. Considering the noninvasive nature of oral fluid collection and improved detection of recent marijuana use compared to urine testing, it was concluded that oral fluid testing for THC offers specific advantages over other means of marijuana testing when used in safety-sensitive testing programs.

Concordance between verbal report and urine screen of recent marijuana use in adolescents

This study compared the concordance of self-report for recent marijuana use with results obtained from urine drug screen. The sample consisted of adolescent sons of fathers with DSM-III-R lifetime substance use disorder (SUD) [high average risk (HAR); N= 75] and sons of fathers with no Axis 1 psychiatric or SUD [low average risk (LAR); N= 125]. To avoid recall bias, and to ensure that the timeframe for accurate detection was restricted to promote accuracy, urine drug screen results were compared to self-reported marijuana use during the prior 48 h using an interview format. The HAR group of adolescents reported a higher rate of recent cannabis use and also had a higher rate of cannabis detection as measured in urine. The two groups did not differ with respect to either over or under-reporting marijuana use. Overall, of 19 participants who obtained positive urine cannabis results, six (31.5%) verbally denied that they used marijuana within the previous 2 days. Among the 181 participants who obtained a negative urine drug screen, 20 subjects (11.5%) inaccurately asserted that they had used marijuana within the prior 2 days. In total, 13% of the participants (26/200) inaccurately reported recent cannabis use. These results underscore the need for caution in interpreting the results of self-report methods documenting the prevalence of drug use among youth.

Cannabinoid mimics in chocolate utilized as an argument in court

A case is presented involving chocolate cannabinoid mimics which have been utilized in court by the defendant's lawyer in order to clear the accused of smoking and dealing in marijuana after he was found positive for cannabis in a routine urine immunoassay screening test. The argumentation in this case was that the accused had supposedly eaten a massive amount of chocolate which contained anandamide-related lipids. These lipids inhibit anandamide hydrolysis in the brain, act as cannabinoid mimics and, according to the lawyer, were the cause of the positive cannabinoid test. To investigate this in detail, we synthesized N-oleoyl- and N-linoleoylethanolamide and spiked these compounds together with N-arachidonoylethanolamide in urine for immunological investigations. None of the samples were found positive, indicating that no cross-reactivity occurs with cannabinoids. As a result, the lawyer's claim could be refuted and the accused was convicted.

In vivo adulteration: excess fluid ingestion causes false-negative marijuana and cocaine urine test results

Drug users can be highly motivated to obtain negative results on urine drug tests and may attempt to subvert the process by in vivo adulteration. The use of herbal products for "flushing" and "detoxification" is frequently advertised as an effective means of passing drug tests. Accordingly, a study was designed to determine the effects of ingestion of two herbal products, Naturally Klean Herbal Tea and Golden Seal root, and a diuretic medication, hydrochlorothiazide. The herbal tea was prepared in 1 gal of water as specified by the manufacturer. All other products were consumed with 1 gal of water. Two control conditions in which the subject consumed only water (1 gal; 12 oz) were included. The 1-gal liquid treatments were divided into 4-qt aliquots, and 1-qt was consumed each hour for 4 h. All treatments were begun approximately 22 h after smoking of a marijuana cigarette (3.58% THC) and 22 h after intranasal administration of cocaine hydrochloride. Following all treatments with excess fluid, creatinine and specific gravity dropped in 1.5-2.0 h to levels indicative of diluted specimens (<20 mg/dL creatinine, <1.003 specific gravity). Marijuana and cocaine metabolite concentrations by immunoassay (EMIT and TDx) also dropped rapidly, and the results frequently switched from positive to negative. By the time subjects had consumed 2 qt of any fluid, they were generally producing false-negative results. For example, ingestion of excess water produced dilute specimens (<20 mg/dL creatinine; <1.003 specific gravity) in an average time plus or minus the standard error of the mean of 1.47 +/- 0.17 h (N = 5) and 1.45 +/- 0.2 h (N = 5) following smoked marijuana and intranasal cocaine, respectively. In comparison, ingestion of Klean Tea produced dilute specimens in 1.36 +/- 0.07 h (N = 4) and 1.39 +/- 0.11 h (N = 4) following marijuana and cocaine administration. Recovery of urine test measures to pre-treatment levels occurred over a period of 8-10 h. Average detection times for marijuana metabolite appeared to be slightly shorter following ingestion of 1 gal of fluids compared with ingestion of 12 oz of water as a result of the time of testing being near the end of the cannabinoid metabolite excretion phase. Consequently, negative cannabinoid results induced by fluid ingestion rarely returned to positive after excess water was eliminated. In contrast, negative cocaine results reverted to positive quickly after the dilution effects disappeared. It was concluded that excess water ingestion can produce false-negative test results, but the claims of herbal products to be an aid in passing a urine test appear to be unfounded.

Differentiating new marijuana use from residual drug excretion in occasional marijuana users

Increases in urine drug concentration that result from changes in urinary output may be mistakenly interpreted as new drug use rather than carryover from previous drug exposure. Normalization of drug excretion to urine creatinine concentration reduces the variability of drug measurement attributable to urine dilution. A specimen ratio of 1.5 or greater between two creatinine normalized positive urine cannabinoid tests was previously proposed as an indicator of new marijuana use. This approach has received wide attention for potential use in treatment and employee assistance programs associated with workplace drug testing. Unfortunately, there has been limited evaluation of the usefulness of this ratio under controlled-dosing conditions with marijuana smokers. A controlled clinical study was conducted to examine the excretion profile of creatinine and marijuana metabolites in a group of six marijuana users who smoked two different doses of marijuana over a 4-week period. A relative operating characteristic curve was constructed from sensitivity and specificity data for 26 different specimen ratios ranging from 0.1 to 2.0. The most accurate specimen ratio (85.4%) for differentiating new use from residual excretion was 0.5. Use of this ratio provided a sensitivity of 80.1%, a specificity of 90.2%, and 5.6% false-positive and 7.4% false-negative predictions. To substantiate the validity of the 0.5 specimen ratio, urine cannabinoid and creatinine data from a controlled clinical trial specifically addressing water dilution as a means of specimen adulteration were evaluated. Sensitivity, specificity, accuracy, and percent false-positive and percent false-negative predictions were 71.9%, 91.6%, 83.9%, 5.4%, and 10.7%, respectively. These data compared favorably with the results from the first clinical study, with the exception of slightly lower sensitivity and higher false-negative percentages in the water dilution study. This would be expected because of the ingestion of large amounts of water and consequent dilution of urine drug concentration. These data indicated that selection of a specimen ratio to evaluate sequential creatinine normalized urine drug concentrations can improve the ability to distinguish residual excretion from new marijuana usage. The selection of an appropriate specimen ratio can be made based on the needs of a specific urine drug-testing program taking into account sensitivity, specificity, and accuracy data.

Rapid reversed-phase high-performance liquid chromatographic method for the assay of urinary 11-nor-delta 9-tetrahydrocannabinol-9-carboxylic acid and confirmation of use of cannabis derivatives

The main active cannabis (marijuana and hashish) derivative delta 9-tetrahydrocannabinol is, in vivo, transformed and excreted mainly as 11-nor-delta 9-tetrahydrocannabinol-9-carboxylic acid (THC-COOH) and its glucuronide. The method presented here allows the confirmation of the presence of THC-COOH by means of a basic hydrolysis, solid-phase extraction clean-up on reversed-phase (RP) disposable cartridges followed by analysis on a C8 RP column and UV detection; the mobile phase used was a 55% acetonitrile solution in acid phosphate buffer. Over 600 samples both from drug addicts in therapeutic communities and subjects who were not on any drugs therapy were analysed. This method was precise with a linearity range from 10 to more than 500 ng/ml [the lower limit proposed by the National Institute on Drug Abuse (NIDA) for cannabinoid confirmation method is 15 ng/ml]. The sample preparation is simple and fast, allowing the analysis of large numbers of samples. Perfect correlation was observed between data from the HPLC method and a fluorescence polarization immunoassay screening method. The THC-COOH metabolite was found to constitute 30% of all the cannabinoids excreted in urine of abusers.

Validity testing of the accuPINCH THC test

Self-contained drug-testing kits are currently being marketed for a variety of drugs of abuse. These tests are designed to provide rapid access to test results without the need for laboratory facilities. This report describes a validity study of the accuPINCH THC test, a self-contained test for cannabinoids in urine. Three healthy male volunteers with a history of marijuana use participated in the clinical study. Each subject smoked one, two, or four marijuana cigarettes (2.6% THC) on each test day. Urine samples were collected and incorporated into a specimen set consisting of 178 clinical samples, 72 urine samples containing known amounts of drug, and 50 drug-free urine samples. The specimen set was randomized and analyzed under blind conditions by the accuPINCH test and by gas chromatography-mass spectrometry (GC-MS) for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH). AccuPINCH results were interpreted independently by three readers as positive at either two calibration points (positive A < 100 ng/mL THCCOOH; positive B > or = 100 ng/mL THCCOOH) or negative. Concordance analysis was performed by comparison of the accuPINCH results with GC-MS. In addition, the effects of changes in sample turbidity, temperature, and assay reading time on test outcome were assessed. For the clinical samples, positive B results were associated exclusively with THCCOOH concentrations greater than or equal to 15 ng/mL, whereas positive A and negative results were obtained at all concentrations. All drug-free urine samples were interpreted as either negative or positive A. The test demonstrated relatively low cross-reactivity with THC and other cannabinoids.(ABSTRACT TRUNCATED AT 250 WORDS)

Cigarette, alcohol, and other drug use by school-age pregnant adolescents: prevalence, detection, and associated risk factors

Use of cigarettes, alcohol, and other drugs among pregnant adolescents is just beginning to be documented. This study sought to determine the prevalence and associated risk factors of cigarette, alcohol, and other drug use among school-age adolescents attending a comprehensive teenage pregnancy program. All enrollees completed a self-administered questionnaire and provided a breath sample for carbon monoxide analysis. Urine was obtained for quantitative determination of drug metabolites at the initial and one third-trimester visit. A chart review determined medical provider recognition of cigarette, alcohol, and other drug use. Results were analyzed for 93% of 229 eligible patients. Seventeen percent were positive for alcohol or other drug use by questionnaire self-report, provider report, or initial urine screen. Eleven percent were positive by urine screen alone at either the initial or third-trimester visit. Medical providers were successful in identifying nearly all of the cigarette smokers, but fewer than half of the alcohol drinkers and few of the other drug users. Forward stepwise multiple regression determined the most efficient model for predicting alcohol and other drug use. A report of having been high at school and personal or friends' use of cigarettes were the most significant risk factors. Results indicate a high prevalence of alcohol and other drug use and suggest a need for changes in current practice related to the detection and management of such drug use in pregnant adolescents.

Passive inhalation of marijuana smoke: a critical review

A number of research studies have been published which have attempted to determine the relationship of the passive inhalation of marijuana smoke to the consequent production of urinary cannabinoids. At least superficially, most of these studies appear to support the proposition that passive inhalation should be seriously considered as a possible explanation for a positive urine test for marijuana. Examination of the experimental conditions that are required to produce positive test results indicates that passive inhalation does not have a major effect outside the laboratory and should not affect drug test results in the workplace.

Genital warts do not respond to systemic recombinant interferon alfa-2a treatment during cannabis consumption

The case of a 22-year-old man suffering from genital warts is described. The lesions responded completely to recombinant interferon alfa-2a only after discontinuation of cannabis consumption. Cannabis was detected using the enzyme immunoassay/1-trans-tetrahydrocannabinoid method in urine. Southern blotting of frozen genital wart biopsy material revealed papillomavirus type 11 DNA, the amount of which increased significantly during interferon treatment. The final clearing of lesions after discontinuation of cannabis consumption implicates that the drug-induced impairment of cellular immunity was reversible. It is concluded that drug abuse and especially cannabis consumption may play some role in the world-wide increase in genital papillomavirus disease and in the high number of recalcitrant courses of genital warts.

Prevalence of marijuana use during pregnancy. A pilot study

We examined the prevalence of marijuana use in a group of pregnant women using a qualitative, rapid urine screen to detect marijuana metabolites. Between July 1, 1987, and Aug 15, 1987, 322 consecutive patients underwent an anonymous urine toxicology screen at the time of admission to the labor-and-delivery unit. Patients were identified only by a consecutive number and by their age, race, marital status, gravidity, parity and obstetric service (clinic vs. private). The prevalence of positive urine toxicologic screens for marijuana was 19.9% among the study population (64 positive tests among 322 women screened). The prevalence was greater among the clinic patients than the private patients (52 of 161, or 32.3%, vs. 12 of 161, or 7.5%, respectively). The distribution of race and marital status among the marijuana-positive and -negative groups were also significantly different. Specifically, the proportions of black and single women were higher among the marijuana-positive group. Our findings suggest that marijuana use is common in our obstetric patients. The possible association between marijuana use during pregnancy and perinatal morbidity, as well as the unreliable nature of patient drug histories, may support the use of rapid, inexpensive screening techniques, especially if general screening is considered.

Human urinary excretion profile after smoking and oral administration of [14C]delta 1-tetrahydrocannabinol

The urinary excretion profiles of delta 1-tetrahydrocannabinol (delta 1-THC) metabolites have been evaluated in two chronic and two naive marijuana users after smoking and oral administration of [14C]delta 1-THC. Urine was collected for five days after each administration route and analyzed for total delta 1-THC metabolites by radioactivity determination, for delta 1-THC-7-oic acid by high-performance liquid chromatography, and for cross-reacting cannabinoids by the EMIT d.a.u. cannabinoid assay. The average urinary excretion half-life of 14C-labeled delta 1-THC metabolites was calculated to be 18.2 +/- 4.9 h (+/- SD). The excretion profiles of delta 1-THC-7-oic acid and EMIT readings were similar to the excretion profile of 14C-labeled metabolites in the naive users. However, in the chronic users the excretion profiles of delta 1-THC-7-oic acid and EMIT readings did not resemble the radioactive excretion due to the heavy influence from previous Cannabis use. Between 8-14% of the radioactive dose was recovered in the urine in both user groups after oral administration. Lower urinary recovery was obtained both in the chronic and naive users after smoking--5 and 2%, respectively.

Federal guidelines for marijuana screening should have lower cutoff levels. A comparison of results from immunoassays and gas chromatography-mass spectrometry

Federal guidelines for urine marijuana testing use a screening cutoff of 100 ng/mL and a confirming cutoff of 15 ng/mL. We tested 75 urine samples with two different immunoassays with cutoff points of 100 and 20 ng/mL. The same samples were also analyzed with gas chromatography-mass spectrometry. At the government recommended cutoff levels for screening and confirming, test sensitivity was 47% and specificity was 91%. With a screening cutoff of 20 ng/mL confirmed at 5 ng/mL, test sensitivity was 88% and specificity was 94%. We suggest adoption of these lower cutoff levels.

Urinary excretion half-life of delta 1-tetrahydrocannabinol-7-oic acid in heavy marijuana users after smoking

The urinary excretion of the total amount of delta 1-tetrahydrocannabinol (delta 1-THC) metabolites, with special emphasis on delta 1-tetrahydrocannabinol-7-oic acid (delta 1-THC-7-oic acid), was studied in thirteen heavy Cannabis users after smoking administration of delta 1-THC, followed by a four week discontinuation period. The total amount of delta 1-THC metabolites and the levels of delta 1-THC-7-oic acid could be followed up to 25 days after abstinence using EMIT d.a.u. cannabinoid assay and high-performance liquid chromatography (HPLC). The urinary excretion half-life, calculated from the concentrations of delta 1-THC-7-oic acid versus time, ranged from 0.8-9.8 days with a mean (+/- SD) of 3.0 +/- 2.3 days. Most of the delta 1-THC-7-oic acid was excreted as conjugate and only trace amounts of unconjugated delta 1-THC-7-oic acid were detected. The total concentrations of delta 1-THC-7-oic acid in urine were compared to the concentrations of "cross-reacting cannabinoids", within the linear range of 20-75 ng/mL, obtained in the semiquantitative EMIT d.a.u. cannabinoid assay. The average ratio of "EMIT concentrations"/delta 1-THC-7-oic acid concentrations obtained by HPLC analysis was 1.23 +/- 84% (C.V.) for 78 urine samples. A total of 83% of the samples with positive EMIT levels (cutoff 20 ng/mL) was confirmed by HPLC analysis (cutoff 7 ng/mL).

Comparison of drug abuse in different military populations

Quantitative analytical data, generated at the Navy Drug Screening Laboratory, Great Lakes, Illinois, expressed as percent confirmed positives for four drugs of abuse (marijuana metabolite, cocaine metabolite, amphetamines, and opiates) are summarized and compared according to their population of origin. The four populations of interest included U.S. Navy and Marine Corps recruits and service school members. Conformed positive urines for marijuana showed a small but significant decline (p less than 0.001) from about 1.2% confirmed positive among U.S. Navy recruits entering service school commands in 1984 to 0.9% among Navy service school members in 1988 and from 2.0% among U.S. Marine Corps recruits entering service schools in 1984 to 0.8% among Marine Corps service school members in 1988. Navy and Marine Corps recruits showed a significantly higher (p less than 0.001) confirmed positive use rate (6.1 and 3.3%, respectively) compared to service school members, perhaps reflecting their recent civilian use pattern. The relatively high confirmed positive cocaine rate among all groups may have reflected an increasing trend in all populations, confirming a similar trend in high school and other civilian populations. Generally, the frequency of confirmed positive urines with amphetamines and opiates, based upon the findings at the Navy Drug Screening Laboratory at Great Lakes, has been static except for an apparent recent increase in amphetamine use in 1988. The decline in confirmed positive drug urinalyses among service school members from both the Navy and Marine Corps indicated that perhaps education and maturity had a positive effect upon their behavior.

Drug use among adolescent mothers: profile of risk

Adolescent pregnancy and adolescent drug use are important clinical and public health problems. Yet, few studies have systematically investigated the patterns of substance use among pregnant and parenting adolescents. Because adverse outcomes are not found uniformly for all adolescent mothers, use of illicit drugs may be a key factor in determining which mothers and their infants will have poor outcomes. In this study, the patterns of drug use are described and differences in the demographic and psychosocial profile among 253 pregnant adolescents are investigated. Results obtained from interviews and urine assay for marijuana and cocaine indicate that lifetime use was 84% for alcohol, 62% for marijuana, and 23% for cocaine, whereas use in the past year was 40% for marijuana and 17% for cocaine. Compared with nonusers, pregnant adolescent drug users were more likely to be North American black, have a history of elective abortion and venereal disease, report more negative life events and violence during pregnancy, and receive more support from the father of the baby who was more likely to use marijuana and cocaine (P less than .01). Furthermore, according to logistic regression analysis results after controlling for age and ethnicity, adolescents who used illicit substances in the past year were three times more likely to have a male partner who used marijuana or cocaine and were two times more likely to have a history of venereal disease compared with nonusers. The findings suggest that drug use, whether as a mechanism or a marker, is associated with social and medical characteristics that are likely to contribute to negative outcomes among adolescent mothers and their infants.(ABSTRACT TRUNCATED AT 250 WORDS)