A sensitive and specific high-performance liquid chromatography method with ultraviolet detection (HPLC-UV) has been developed for the quantification of morphine sulfate [(5alpha,6alpha)-7,8-didehydro-4,5-epoxy-17-methylmorphinan-3,6-diol],(CAS: 52-26-6) in human plasma. The analyte was extracted from plasma samples with chloroform - isopropyl alcohol (90:10, v/v) and analyzed on a Bondapak C18 column. The calibration curves were linear within the range of 10-150 ng/mL. The lower limit of quantitation was 10 ng/mL with 0.5 mL plasma sample. The mean recovery of the drug from plasma samples was 83.39%. The results from analysis of quality-control samples at concentrations of 30, 75, and 150 ng/mL were indicative of good accuracy and precision. This method was successfully used to analyze morphine in plasma samples of patients after abdominal hysterectomy.

Eradicating or appreciably limiting controlled prescription drug abuse, such as opioids and benzodiazepines, continues to be a challenge for clinicians, while providing needed, proper treatment. Detection of misuse and abuse is facilitated with urine drug testing (UDT). However, there are those who dispute UDT's diagnostic accuracy when done in the office (immunoassay) and claim that laboratory confirmation using liquid chromatography tandem mass spectrometry (LC/MS/MS) is required in each and every examination. A diagnostic accuracy study of UDT. The study was conducted in a tertiary referral center and interventional pain management practice in the United States. Comparing UDT results of in-office immunoassay testing (the index test) with LC/MS/MS (the reference test). A total of 1,000 consecutive patients were recruited to be participants. Along with demographic information, a urine sample was obtained from them. A nurse conducted the immunoassay testing at the interventional pain management practice location; a laboratory conducted the LC/MS/MS. All index test results were compared with the reference test results. The index test's efficiency (agreement) was calculated as were calculations for sensitivity, specificity, false-positive, and false-negative rates. Approximately 36% of the specimens required confirmation. The index test's efficiency for prescribed benzodiazepines was 78.4%. Reference testing improved accuracy to 83.2%, a 19.6% increase, and 8.9% of participants were found to be taking non-prescribed benzodiazepines. The index test's false-positive rate for benzodiazepines use was 10.5% in patients receiving benzodiazepines. This study was limited by its single-site location, its use of a single type of point of care (POC) kit, and reference testing being conducted by a single laboratory, as well as technical sponsorship. Clinicians should feel comfortable conducting in-office UDT immunoassay testing. The present study shows that it is reliable, expedient, and fiscally sound for all involved. In-office immunoassay testing compares favorably with laboratory testing for benzodiazepines, offering both high specificity and agreement. However, clinicians should be vigilant and wary when interpreting results, weighing all factors involved in their decision.

The use and abuse of illegal drugs affects all modern societies, and therefore the assessment of drug exposure is an important task that needs to be accomplished. For this reason, the reliable determination of these drugs and their metabolites in biological specimens is an issue of utmost relevance for both clinical and forensic toxicology laboratories in their fields of expertise, including in utero drug exposure, driving under the influence of drugs and drug use in workplace scenarios. Most of the confirmatory analyses for abused drugs in biological samples are performed by gas chromatographic-mass spectrometric methods, but use of the more recent and sensitive liquid chromatography-(tandem) mass spectrometry technology is increasing dramatically. This article reviews recently published articles that describe procedures for the detection of opiates in the most commonly used human biological matrices, blood and urine, and also in unconventional ones, e.g. oral fluid, hair, and meconium. Special attention will be paid to sample preparation and chromatographic analysis.

The National Laboratory Certification Program undertook an evaluation of the dynamics of external contamination of hair with cocaine (COC) while developing performance testing materials for Federal Drug-Free Workplace Programs. This characterization was necessary to develop performance materials that could evaluate the efficacy of hair testing industry's decontamination procedures. Hair locks (blonde to dark brown/black) from five different individuals were contaminated with cocaine HCl. Hair locks were then treated with a synthetic sweat solution and hygienic treatments to model real-life conditions. Hair locks were shampooed daily (Monday through Friday) for 10 weeks, and samples of the hair locks were analyzed for COC, benzoylecgonine (BE), cocaethylene (CE), and norcocaine (NCOC). Three commercial analytical laboratories analyzed samples under three protocols: no decontamination procedure, individual laboratory decontamination, or decontamination by an extended buffer procedure at RTI International. Results indicated substantial and persistent association of all four compounds with all hair types. Hair that was not decontaminated had significantly greater quantities of COC and BE than did hair that was decontaminated. The only hair samples below detection limits for all four compounds were those decontaminated 1 h after contamination. Additionally, BE/COC ratios increased significantly over the 10-week study (regardless of decontamination treatment). From 21 days postcontamination until the end of the study, the mean BE/COC ratio for all hair types exceeded 0.05, the proposed Federal Mandatory Guidelines requirement. The largest variability in results was observed for samples decontaminated by participant laboratories. This suggests that current laboratory decontamination strategies will increase variability of performance testing sample results. None of the decontamination strategies used in the study were effective at removing all contamination, and some of the contaminated hair in this study would have been reported as positive for cocaine use based on the proposed Federal Mandatory Guidelines.

Hair specimens were analyzed for cocaine (COC), benzoylecgonine (BE), cocaethylene (CE) and norcocaine (NCOC) by liquid chromatography-tandem mass spectrometry. Drug-free hair was contaminated in vitro with COC from different sources with varied COC analyte concentrations. Results were compared to COC analyte concentrations in drug users' hair following self-reported COC use (Street) and in hair from participants in controlled COC administration studies (Clinical) on a closed clinical research unit. Mean ± standard error analyte concentrations in Street drug users' hair were COC 27,889 ± 7,846 (n = 38); BE 8,132 ± 2,523 (n = 38); CE 901 ± 320 (n = 20); NCOC 345 ± 72 pg/mg (n = 32). Mean percentages to COC concentration were BE 29%, CE 3% and NCOC 1%. Concentrations in hair were lower for Clinical participants. COC contamination with higher CE, BE or NCOC content produced significantly higher concentrations (p = 0.0001) of all analytes. CE/COC and NCOC/COC ratios did not improve differentiation of COC use from COC contamination. COC concentrations in illicit and pharmaceutical COC affect concentrations in contaminated hair. Criteria for distinguishing COC use from contamination under realistic concentrations were not significantly improved by adding CE and NCOC criteria to COC cutoff concentration and BE/COC ratio criteria. Current criteria for COC hair testing in many forensic drug-testing laboratories may not effectively discriminate between COC use and environmental COC exposure.

A case report involving a 34-year-old white male who was found dead at home by his roommate is presented. At the time of his death, he was being treated with tramadol/acetaminophen, metaxalone, oxycodone, and amitriptyline. The decedent's mother stated that he had been taking increasing amounts of pain medication in order to sleep at night. There were no significant findings at autopsy; however, toxicology results supported a cause and manner of death resulting from suicidal mixed tramadol and amitriptyline toxicity. This case reports the tissue and fluid distribution of tramadol, amitriptyline, and their metabolites in an acutely fatal ingestion in an effort to document concentrations of these analytes in 12 matrices with respect to one another to assist toxicologists in difficult interpretations.

The increasing prevalence and use of herbal mixtures containing synthetic cannabinoids presents a growing public health concern and legal challenge for society. In contrast to the plant-derived cannabinoids in medical marijuana and other cannabinoid-based therapeutics, the commonly encountered synthetic cannabinoids in these mendaciously labeled products constitute a structurally diverse set of compounds of relatively unknown pharmacology and toxicology. Indeed, the use of these substances has been associated with an alarming number of hospitalizations and emergency room visits. Moreover, there are already several hundred known cannabinoid agonist compounds that could potentially be used for illicit purposes, posing an additional challenge for public health professionals and law enforcement efforts, which often require the detection and identification of the active ingredients for effective treatment or prosecution. A solid-phase microextraction headspace gas chromatography-mass spectrometry method is shown here to allow for rapid and reliable detection and structural identification of many of the synthetic cannabinoid compounds that are currently or could potentially be used in herbal smoking mixtures. This approach provides accelerated analysis and results that distinguish between structural analogs within several classes of cannabinoid compounds, including positional isomers. The analytical results confirm the continued manufacture and distribution of herbal materials with synthetic cannabinoids and provide insight into the manipulation of these products to avoid legal constraints and prosecution.

Atomoxetine (Strattera, Lilly) is a selective norepinephrine reuptake inhibitor (SNRI) prescribed for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, adolescents, and adults. It is the first nonstimulant drug-therapy option for ADHD. Three case reports are presented in which atomoxetine was detected in two individuals who died from causes unrelated to the drug and a third from the intentional ingestion of atomoxetine and other drugs. In addition, a brief description of the pharmacokinetics and side effects of atomoxetine are given. Postmortem fluid and tissue concentrations of atomoxetine were as follows: aortic blood,<0.1-8.3 mg/L; femoral blood, 0.33-5.4 mg/L; vitreous humor, 0.1-0.96 mg/L; bile, 1.0-33 g/L; urine,<0.1 mg/L; liver,<0.44-29 mg/kg; and gastric contents, 0.0097-16.8 mg total. Autopsy findings in the two cases in which death was not attributed to drug toxicity included arrhythmogenic right ventricular dysplasia and hypertrophic cardiomyopathy. The analytical method utilized was a modified basic drug, liquid-liquid procedure followed by gas chromatography/mass spectrometry and nitrogen phosphorous detection. Atomoxetine can be considered nontoxic at whole blood and liver concentrations below 1.3 mg/L and 5 mg/kg, respectively.

Performance of the Roche Online KIMS (kinetic interaction of microparticles in solution) benzodiazepine (BZD) immunoassay (IA) with and without beta-glucuronidase treatment was evaluated on a Hitachi Modular automated IA analyzer calibrated using nordiazepam at 100 ng/mL. Reproducibility, linearity, accuracy, sensitivity, and interferences were evaluated. Precision of the assay (percent coefficient of variation (%CV)) with and without addition of the enzyme was less than 6% and 9%, respectively, with linearity (r(2) value of 0.9578 and 0.9746), respectively. Between-run precision of a 125 ng/mL nordiazepam control (n = 287) over 67 days, produced a %CV of 13.6% for the hydrolytic assay. Modification of the BZD assay to include automated hydrolysis of urinary BZD glucuronide conjugates was evaluated using three glucuronidated BZD standards prepared at concentrations ranging from 250 to 10,000 ng/mL. With hydrolysis, temazepam, oxazepam, and lorazepam glucuronides, produced cross-reactivities of 25%, 15%, and 20%, respectively. Without hydrolysis, the glucuronidated BZD standards produced less than 1% cross-reactivity in the assay. The ability of the assay to differentiate between positive and negative samples was evaluated by assaying 20 negative urine samples and serial dilutions of certified drug-free urine fortified with 28 different BZDs. All of the negative and positive urine samples produced the appropriate screening result. Cross-reactivities of 27 different BZDs, calculated as the normalized IA response divided by the BZD concentration that produced a response approximately equivalent to the response of a 100 ng/mL nordiazepam standard and multiplied by 100, ranged from 15% to 149%. Human urine samples (n = 28) that were previously found to contain BZDs by gas chromatography-mass spectrometry (GC-MS) also produced a positive BZD IA result. The IA was challenged with 78 potentially interfering compounds, and none produced a positive BZD response. As a part of the validation, a large number of human urine samples (29,500) were assayed using the modified Online BZD IA method to evaluate the performance of the method in production. Of the 29,500 samples tested, 80 produced a positive IA result. Analysis by GC-MS confirmed the presence of at least 1 BZD compound in 61 of the samples corresponding to a confirmation rate of 76%. The Online BZD IA modified by the automatic addition of beta-glucuronidase appears well adapted for the rapid detection of BZDs and their metabolites in human urine.

The case history and toxicological findings of a fatal multi-drug overdose involving metaxalone (Skelaxin) are presented. Gas-liquid chromatography with flame-ionization detection and gas chromatography-mass spectrometry were used to determine the following drug concentrations (mg/L) in aortic blood: 19 mg/L metaxalone; 190 mg/L acetaminophen; 0.28 mg/L hydrocodone; and < 0.1 mg/L diazepam, nordiazepam, amitriptyline, and nortriptyline. The following concentrations of metaxalone were reported in alternate specimens: 17 mg/L in femoral blood; 44 mg/L in bile; 70 mg/kg in liver; 7 mg/L in urine; 202 mg/kg in gastric contents; and 14 mg/L in vitreous humor. These concentrations were determined using both direct extraction and the method of standard addition. The quantitative results obtained by both procedures were in good agreement. Because of the limited information published on metaxalone toxicity, the pathologist assigned the manner and cause of death as accidental acute hydrocodone intoxication. Four additional cases in which metaxalone was present were analyzed for comparison. Two cases were probable drug-related deaths and had metaxalone aorta blood concentrations of 18 and 11 mg/L. The other two cases had therapeutic metaxalone concentrations in the aortic blood of < 0.75 and 2.1 mg/L.

A simple method for analyzing nitrite in urine has been developed to confirm and quantify the amount of nitrite in potentially adulterated urine samples. The method involved separation of nitrite by capillary electrophoresis and direct UV detection at 214 nm. Separation was performed using a bare fused silica capillary and a 25 mM phosphate run buffer at a pH of 7.5. Sample preparation consisted of diluting the urine samples 1:20 with run buffer and internal standard, and centrifuging for 5 min at 2500 rpm. The sample was hydrodynamically injected, then separated using -25 kV with the column maintained at 35 degrees C. The method had upper and lower limits of linearity of 1500 and 80 microg/mL nitrite, respectively, and a limit of detection of 20 microg/mL. The method was evaluated using the National Committee for Clinical Laboratory Standards (NCCLS) protocol (Document EP10-A2), and validated using controls, standards, and authentic urine samples. Ten anions, ClO-, CrO4(-2), NO3-, HCO3-, I-, CH3COO-, F-, SO4-, S2O8(-2), and Cl-, were tested for potential interference with the assay. Interferences with quantitation were noted for only CrO4(-2) and S2O8(-2). High concentrations of Cl- interfered with the chromatography. The method had acceptable accuracy, precision, and specificity.

Understanding the pharmacokinetics of orally administered cannabinoids is vitally important for optimizing therapeutic usage and to determine the impact of positive tests on drug detection programs. In this study, gas chromatography-mass spectrometry (limit of quantitation = 2.5 ng/mL) was used to monitor the excretion of total 11-nor-9-carboxy-Delta(9)-tetrahydrocannabinol (THCCOOH) in 4381 urine voids collected from seven participants throughout a controlled clinical study of multiple oral doses of THC. The National Institute on Drug Abuse Institutional Review Board approved the study and each participant provided informed consent. Seven participants received 0, 0.39, 0.47, 7.5, and 14.8 mg THC/day for five days in this double blind, placebo-controlled, randomized protocol conducted on a closed research ward. No significant differences (P </= 0.05) were observed in mean time of maximum excretion rate, mean maximum excretion rate, and mean terminal elimination half-life (t(1/2)) between the four THC doses, with ranges of 67.4 to 94.9 h, 0.9 to 16.3 micro g/h, and 44.2 to 64.0 h, respectively. Mean apparent elimination t(1/2) of 24.1 +/- 7.8 and 21.1 +/- 4.3 h for the 7.5 and 14.8 mg/day doses, respectively, were calculated from the excretion rate curve prior to the last urine sample with a THCCOOH concentration >/= 15 ng/mL. An average of only 2.9 +/- 1.6%, 2.5 +/- 2.7%, 1.5 +/- 1.4%, and 0.6 +/- 0.5% of the THC in the 0.39, 0.47, 7.5, and 14.8 mg/day doses, respectively, was excreted as THCCOOH in the urine over each 14-day dosing session. This study demonstrated that the terminal urinary elimination t(1/2) of THCCOOH following oral administration was approximately two to three days for doses ranging from 0.39 to 14.8 mg/d. These data also demonstrate that the apparent urinary elimination t(1/2) of THCCOOH prior to reaching a 15 ng/mL concentration is significantly shorter than the terminal urinary elimination t(1/2). These controlled drug administration data should assist in the interpretation of urine cannabinoid results and provide clinicians with valuable information for future pharmacological studies.