[Testing for cannabis and synthetic cannabinoids in human specimens]. / Cannabis et cannabinoïdes de synthèse. À propos de leur détection biologique.

Among the 60 or so various cannabinoids which are present in cannabis sativa indica, terpenophenols are mainly found, including delta-9-trans tetrahydrocannabinol (Δ9-THC) which is the major psychoactive ingredient. Over the last decade, due to the emergence of e-commerce and the continuous investigations by pharmaceutical groups to identify new active molecules, synthetic cannabinoids have been proposed. These compounds, under the generic name "spices" have chemical structures very different from that of Δ9-THC, but share the same CB1 and CB2 receptors. They are mimics of Δ9-THC with much powerful pharmacological effects, including thus more deterrent side-effects, and enhanced windows of detection. All these drugs are controlled. This means that they have to be tested in human biological specimens to document abuse. The aim of this mini-review is to present what has been described in the scientific literature according to the available specimens (blood, urine, saliva, sweat, hair and exhaled breath), focussing on the current advantages and limitations of each test.

Semaglutide and health risk: Development and validation of a LC-HRMS method for testing semaglutide in whole blood and application to real cases.

The use of semaglutide, also known by its trade name Ozempic®, has been increasing worldwide in recent years due to its benefits in treating type II diabetes. Thanks to its effects on appetite regulation, in many countries it is also used to treat obesity. However, due to its promotion by social media and celebrities as a weight-loss treatment, semaglutide is misused by a non-diabetic and non-obese population and by a young public, which is the main target of these media. Following the alert by the ANSM (Agence nationale de sécurité du médicament) in France and the FDA (Food and Drug Administration) in the United States, which imposed the addition of fatal effects to the list of side effects, the misuse of semaglutide seems to be becoming a public health problem. For this reason, it seems important that a toxicology laboratory has the capacity to test for semaglutide in blood. In this study, the authors have developed and validated a method for the identification and quantification of semaglutide in whole blood using a LC-HRMS. After the addition of the internal standard (bovine insulin), the blood was subjected to protein precipitation using a mix of acetonitrile/methanol (70:30,v:v). The validation procedure demonstrated an acceptable linearity between 2 and 500 ng/mL. LOD and LOQ were 1 and 2 ng/mL, respectively. Intra and inter-day precision were below 20 % at three concentrations. The method was successfully applied to the blood samples of 3 diabetic patients under treatment of semaglutide. The samples tested positive with concentrations ranging from 31 to 70 ng/mL which fall within the limits of therapeutic blood concentrations described in the literature.

Bariatric surgery and changes in metformin distribution: About a fatal case.

A 65 year-old woman, suffering from mellitus type 2 diabetes and obesity, died at home, three days after bariatric surgery (Roux-en-Y gastric by-pass: RYGB). Her treatment, including metformin and dapagliflozin, was stopped before surgery and not postoperatively reinstalled. A forensic autopsy, toxicological and histological analyses were performed. No macroscopic or microscopic evidence of digestive perforation or peritonitis was identified, excluding an early surgery complication as the cause of death. Toxicological analysis revealed the presence of Metformin in all matrices tested, with a potentially fatal blood concentration. Death was attributed to lactic acidosis caused by a metformin overdose. With no evidence for suicide by ingestion of metformin, the authors supposed that the bariatric surgery might have caused changes in the absorption of metformin, leading to a rapid overdose and death. The only study in the literature on this subject, demonstrated a significant increase in the bioavailability of metformin following oral administration in gastric bypass patients. Thus, it can be anticipated that a therapeutic dose can become toxic when administrated to a subject who recently modified her digestive equipment. As this represents the first case of metformin overdose following bariatric surgery, further cases will be needed to confirm our initial observations.

First identification of a diuretic, hydrochlorothiazide, in hair: Application to a doping case and interpretation of the results.

An athlete contested an adverse analytical finding involving hydrochlorothiazide, and requested our laboratory for testing his hair. As there is no reference in the literature about identification of hydrochlorothiazide in hair, several volunteers were first enrolled (4 after a single 25 mg administration and 10 with daily therapeutic treatment). A specific method was developed by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS. Hair samples were decontaminated with dichloromethane and 30 mg were incubated in buffer at pH 7.0 for 15 hours at 50°C. Then, 5 mL ethyl acetate was added for extraction. Linearity was observed for hydrochlorothiazide concentrations ranging from 5 to 2000 pg/mg. The limit of quantification was 5 pg/mg. The coefficients of variation (CVs) of repeatability and matrix effect were lower than 20%. Analysis of the 0-2-cm segment of the 4 volunteers having received a single dose, collected 1 month after administration, was negative at the limit of quantification. The hair of the 10 patients (proximal 2 cm) on daily treatment was positive with concentrations ranging from 12 to 1845 pg/mg, with no correlation between daily dose and concentration. The athlete's hair tested positive for hydrochlorothiazide at 36 pg/mg in the segment corresponding to the period of the urinary control. Since a single exposure to hydrochlorothiazide is not detectable in hair and based on the results of the patients on daily treatment, the concentration found in the athlete has been interpreted as corresponding to repeated exposures, where it was not possible to establish the dosage and the frequency.

Retrospective diagnosis of an adverse drug reaction in a breastfed neonate: liquid chromatography-tandem mass spectrometry quantification of dextropropoxyphene and norpropoxyphene in newborn and maternal hair.

Dextropropoxyphene (DP) and norpropoxyphene (NP) are commonly used in the treatment of postpartum pain. The drug is widely prescribed in Europe and Canada and has been recently approved for use in the U.S. Its safety during breastfeeding, however, has not been fully established. Very few reports on its effects on neonates have been published. We report here the case of a mother treated with DP (6 capsules a day for 10 days) while she was breastfeeding. On day 7, her baby was lethargic and had difficulties with breastfeeding, which led to early weaning. The correlation between side effects observed in the infant and DP was made retrospectively by measuring DP and NP hair concentrations in the mother-infant pair with liquid chromatography-tandem mass spectrometry. Breastfeeding mothers taking DP expose their infants to high doses of DP and NP. In agreement with previously published reports, these data indicate that acetaminophen and nonsteroidal antiinflammatories are preferable for analgesia during breastfeeding. Breastfeeding should be encouraged under most circumstances, and if the mother takes any treatment for pain, a commonly prescribed drug with pharmacologic data available must be used.

Use of drugs of abuse in less than 30-year-old drivers killed in a road crash in France: a spectacular increase for cannabis, cocaine and amphetamines.

A collaborative study was conducted in France in order to determine the prevalence of cannabinoids, opiates, cocaine metabolites and amphetamines in blood samples from drivers killed in road accidents in 2003 and 2004 and to compare these values with those of a previous study performed during the period 2000-2001 involving 900 drivers. Blood samples were provided from 2003 under 30-year-old drivers, killed in a traffic accident. Drugs of abuse were determined by gas chromatography-mass spectrometry using the same analytical procedures in all the 12 laboratories. The most frequently observed compounds were by far cannabinoids, that tested positive in 39.6% of the total number of samples. Delta9 tetrahydrocannabinol (THC), the most active of the principle constituents in marijuana (cannabis sativa), was detected in the blood of 28.9% drivers and was the single drug of abuse in 80.2% of the positive cases. It was associated with amphetamines in 7.4% and with opiates and cocaine in 1.9 and 4.8%, respectively. Amphetamines were present in 3.1% of the total number of samples, cocaine metabolites in 3.0% and opiates in 3.5%. When comparing these results with those of a previous study performed 3 years before, a significant increase is observed for THC (28.9% versus 16.9%), cocaine metabolites (3.0% versus 0.2%) and amphetamines (3.1% versus 1.4%). This study demonstrates the critical necessity of implementing in France as soon as possible systematical roadside testing for drugs of abuse.

European guidelines for workplace drug and alcohol testing in hair.

Guidelines for Legally Defensible Workplace Drug Testing have been prepared and updated by the European Workplace Drug Testing Society (EWDTS). They are based on the 2010 version published by Pascal Kintz and Ronald Agius (Guidelines for European workplace drug and alcohol testing in hair. Drug Test. Anal. 2010, 2, 367) and in concordance with the Society of Hair Testing guidelines (Society of Hair Testing guidelines for drug testing in hair. Forensic Sci. Int. 2012, 218, 20-24). The European Guidelines are designed to establish best practice procedures whilst allowing individual countries to operate within the requirements of national customs and legislation. The EWDTS recommends that all European laboratories that undertake legally defensible workplace drug testing use these guidelines as a template for accreditation. Copyright © 2016 John Wiley & Sons, Ltd.

Identification of alprazolam in hair in two cases of drug-facilitated incidents.

The use of a drug to modify a person's behaviour for criminal gain is not a recent phenomenon. However, the recent increase in reports of drug-facilitated crimes (sexual assault, robbery) has caused alarm by the general public. Among the drugs that can be used, alprazolam (Xanax), an anxiolytic benzodiazepine, has been seldom observed. To document two cases involving this drug, we have developed an approach based on hair testing by LC-MS/MS. After pH 8.4 buffer incubation and extraction with methylene chloride/diethyl ether (80/20, v/v), hair extracts were separated on a XTerra MS C18 column using a gradient of acetonitrile and formate buffer. Alprazolam and diazepam-d5, used as internal standard, were detected by electrospray tandem mass spectrometry. In the first criminal case, alprazolam tested positive in two consecutive 2 cm hair segments at 4.9 and 2.4 pg/mg, from a 12-year-old girl, assaulted by her father who had sedated her three or four times. In the other case, alprazolam was detected in four consecutive 1cm hair segments at 3.1-0.4 pg/mg, obtained from an adolescent who had been forced to prostitute herself.

Evidence of addiction by anesthesiologists as documented by hair analysis.

Chemical dependency is a disease that can affect all professions. Among the health care professionals, anesthesiologists represent a specific group. Numerous factors have been proposed to explain the high incidence of drug abuse among anesthesiologists. These include: easy access to potent drugs, particularly narcotics, highly addictive potential of agents with which they are in contact, and easy diversion of these agents since only small doses will initially provide an effect desired by the abuser. Opioids are the drugs of choice for anesthesiologists, and among them fentanyl and sufentanil are the most commonly used. Alcohol is mostly abused by older anesthesiologists. Propofol, ketamine, thiopental and midazolam are also abused. In fact, all but quaternary ammonium drugs can be observed. Signs and symptoms of addiction in the hospital workplace include: unusual changes in behavior, desire to work alone, refusal of lunch relief or breaks, volunteer for extra cases, call, come in early and leave late, frequent restroom breaks, weight loss and pale skin, malpractice, behind on charts .... Toxicological investigations are difficult, as the drugs of interest are difficult to test for. In most cases, half-lives of the compounds are short, and the circulating concentrations weak. It is, therefore, necessary to develop tandem mass spectrometry procedures to satisfy the criteria of identification and quantitation. In most cases, blood and/or urine analyses are not useful to document impairment, as these specimens are collected at inadequate moments. Hair analysis appears, therefore, as the unique choice to evidence chronic exposure. Depending the length of the hair shaft, it is possible to establish an historical record, associated to the pattern of drug use, considering a growth rate of about 1cm/month. An original procedure was developed to test for fentanyl derivatives. After decontamination with methylene chloride, drugs are extracted from the hair by liquid/liquid extraction after incubation in pH 8.4 phosphate buffer. Fentanyl derivatives are analyzed by GC-MS/MS. The following cases are included in this paper: Case 1: 50-year-old anesthetist, positive for fentanyl (644 pg/mg); Case 2: 42-year-old anesthetist, positive for fentanyl (101 pg/mg) and sufentanil (2 pg/mg); Case 3: 40-year-old anesthetist, positive for codeine (210 pg/mg), alfentanil (30 pg/mg) and midazolam (160 pg/mg); Case 4: 46-year-old nurse, found dead, positive for alfentanil (2 pg/mg) and fentanyl (8 pg/mg). In these cases, the combination of an alternative specimen (hair) and hyphenated analytical techniques (tandem mass spectrometry) appears to be a pre-requisite.

Dioxins and furans determination in postmortem blood by gas chromatography--high-resolution mass spectrometry.

Dioxins and related compounds (furans) are persistent environmental contaminants that cause adverse biological effects. Their influence on humans is still unclear, except for accidental high-dose exposure. However, chronic exposure to these compounds seems to be involved in cancer, endocrine disruption, and neurobehavioral effects. For several years, a large concern about the potential health risks of dioxins is emerging in Europe and United States. Dioxin levels in biological specimens are extremely low and require very sensitive and specific methods of analysis. In this study, gas chromatography coupled to high-resolution mass spectrometry was used to evaluate dioxin body burden of two women deceased from generalized cancer. Fat fraction of blood specimens was obtained after precipitation with ethanol and extraction of both liquid and solid phases spiked with labeled 13C12-dioxin analogues. Organic phases were grouped, washed, and evaporated to weigh the lipid content. Lipids were dissolved in hexane, hydrolyzed with concentrated sulfuric acid, and discarded during water washes. Dioxins purification was achieved using three successive columns: silica, alumina/sodium sulfate, and carbon/Celite. Finally, the toluene eluent was evaporated and the extract injected in the analytical system. After chromatographic separation, detection was achieved in single ion monitoring mode using a high-resolution mass spectrometer operating in electron impact ionization mode (40 eV, minimal resolution of 10,000). Dioxin levels were expressed in pg TEQ/g of fat as defined by the World Health Organization. Quantification limits for each dioxin congener ranged from 2.5 to 12.0 pg/g fat with a relative extraction recovery always higher than 60%. Dioxin concentrations in the blood of the two deceased women were 35.0 and 42.7 pg TEQ/g fat, respectively. These concentrations are largely lower than those observed after accidental releases, but in the range of those observed in the general European population. Therefore, it was not possible to correlate dioxin body burden of the two women as a potential contributor of their cancer pathology. Nevertheless, knowledge of dioxin body burden in the French population would be of interest for an accurate interpretation of these results.

Contribution of in utero drug exposure when interpreting hair results in young children.

Hair specimen is necessary to complement blood and/or urine analyses as it permits differentiation of a single exposure from chronic use of a drug by segmentation of the hair for a stated growth period. Moreover, due to a frequent long delay between event and police declaration, hair can be the only solution for lack of corroborative evidence of a committed crime. With the exception of lower amount of biological material in children versus adults, there is no specific analytical problem when processing samples from children. The issue is the interpretation of the findings, with respect to the different pharmacological parameters. In some very young children, the interpretation can be complicated by potential in utero exposure. Twenty-four cases from daily practice have been reviewed. Children were less than 1 year old, hair was always longer than 4 cm and the corresponding mothers admitted having used drugs during pregnancy. Drugs involved include methadone, tramadol, diphenhydramine, diazepam, cannabis, heroin, amitriptyline and bromazepam. Analyses were achieved by hyphenated chromatographic validated procedures after hair decontamination and segmentation. The concentrations measured in the hair of children were lower than those observed in subjects using therapeutically (or illegally) these drugs. In that sense, the frequency of exposures appears as un-frequent (low level of exposure), with marked decrease in the more recent period. However, the parents denied any administration in all cases and there was no reason to suspect re-exposure after delivery and no clinical problem during the period between delivery and hair collection during regular visits to the physician was noticed. The pattern of drug distribution was similar in all these cases, low concentrations in the proximal segments and highest concentration in the distal segment (last segment). When considering the concentration in the distal segment as the 100% of the response (highest concentration), after analysis of 4 segments (irrespective of the length of the segment but longer than 1cm), it was observed the following pattern: proximal segment, 5-35% of the response; segment 2, 15-50% of the response; segment 3, 25-60% of the response; and distal segment, 100% of the response. It is proposed to consider 100% in utero contribution to the final interpretation when the ratio concentration of the proximal segment to the concentration of the distal segment is lower than 0.5. This can be applied only when the child is under 1 year old and the hair shaft length is at least 4 cm (to achieve suitable segmentation). It is important, when using this cut-off to have at least 3 or 4 segments to be able to observe the variation in drug concentrations, whatever the length of each segment (>1cm).

Tissue distribution of dextromoramide in the rat.

The tissue distribution of dextromoramide was studied in rats after the intraperitoneal injection of 0.2 mg/kg of the drug. The pattern of distribution was similar at 15, 30, 60 and 90 min, with the highest concentrations being found in the liver and the myocardium, while other organs were not able to concentrate dextromoramide.

Screening procedure for eight quaternary nitrogen muscle relaxants in blood by high-performance liquid chromatography-electrospray ionization mass spectrometry.

A screening procedure was developed for the identification and the quantification of eight quaternary nitrogen muscle relaxants, including d-tubocurarine, alcuronium, pancuronium, vecuronium, atracurium, mivacurium, rocuronium and mebezonium, in blood samples. The procedure involves ion-pair extraction with methylene chloride at pH 5.4, reversed-phase HPLC separation and electrospray ionization mass spectrometry detection. The procedure was validated in terms of linearity (0.9295 for all the target compounds at 0.1 mg/l). The screening test was found satisfactory and applied in two fatal deaths. In the first case, toxicological investigations on biological fluids collected during the autopsy revealed the presence of vecuronium (1.2 and 0.6 mg/l in blood and urine, respectively) and its desacetylated metabolite, 3-hydroxy-vecuronium (4.4 and 0.7 mg vecuronium equivalent/l in blood and urine, respectively). In the second forensic case, blood analysis showed high levels of mebezonium (6.5 mg/l). The developed procedure was found suitable for forensic investigations.

Doping control for methenolone using hair analysis by gas chromatography-tandem mass spectrometry.

A sensitive, specific and reproducible method for the quantitative determination of methenolone in human hair has been developed. The sample preparation involved a decontamination step of the hair with methylene chloride. The hair sample (about 100 mg) was solubilized in 1 ml 1 M NaOH, 15 min at 95 degrees C, in presence of 1 ng testosterone-d3 used as internal standard. The homogenate was neutralized and extracted using consecutively a solid-phase (Isolute C18 eluted with methanol) and a liquid-liquid (pentane) extraction. The residue was derivatized by adding 50 microl MSTFA-NH4I-2-mercaptoethanol (1000:2:5, v/v/v), then incubated for 20 ml at 60 degrees C. A 1.5-microl aliquot of the derivatized extract was injected into the column (HP5-MS capillary column, 5% phenyl-95% methylsiloxane, 30 m x 0.25 mm I.D., 0.25 microm film thickness) of a Hewlett-Packard (Palo Alto, CA, USA) gas chromatograph (6890 Series). Methenolone was detected by its parent ion at m/z 446 and daughter ions at m/z 208 and 195 through a Finnigan TSQ 700 MS-MS system. The assay was capable of detecting 1 pg/mg of methenolone when approximately 100 mg hair material was processed. Linearity was observed for methenolone concentrations ranging from 2 to 100 pg/mg with a correlation coefficients of 0.965-0.981. Intra-day and between-day precisions at 2, 10 and 25 pg/mg were 10.9-14.1% and 13.7-16.8%, respectively, with an extraction recovery of 97.6%. The analysis of a strand of hair obtained from two bodybuilders, revealed the presence of methenolone at the concentrations of 7.3 and 8.8 pg/mg.

Testing for kavain in human hair using gas chromatography-tandem mass spectrometry.

A sensitive, specific and reproducible method for the quantitative determination of kavain in human hair has been developed. The sample preparation involved a decontamination step of the hair with methylene chloride. The hair sample (about 50 mg) was incubated in 1 ml of methanol for 1 h, in an ultrasonic bath, in presence of 20 ng of methaqualone-d7 used as internal standard. The methanolic solution was evaporated to dryness, and the residue reconstituted by adding 30 microl of methanol. A 2 microl aliquot of the extract was injected onto the column (Optima5-MS capillary column, 5% phenyl-95% methylsiloxane, 30 m x 0.25 mm i.d. x 0.25 mm film thickness) of a Hewlett-Packard (Palo Alto, CA) gas chromatograph (5890). Kavain was detected by its parent ion at m/z 230 and daughter ions at m/z 111 and 202 through a Finnigan TSQ 700 MS/MS system. The assay was capable of detecting 30 pg/mg of kavain (limit of detection (LOD)). Linearity was observed for kavain concentrations ranging from 100 to 2000 pg/mg with a correlation coefficient of 0.998. Intra-day precision at 400 pg/mg was 13.7%. The analysis of a segment of hair, obtained from an occasional consumer, revealed the presence of kavain at the concentration of 418 pg/mg. A higher concentration (1708 pg/mg) was detected in the corresponding pubic hair.

Hair testing and doping control in sport.

The standard in drug testing for doping control is gas chromatography/mass spectrometry conducted on a urine sample. For the past 20 years, hair analysis has been proposed for identifying drug abusers in forensic science. Specimens can be collected under close supervision without embarrassment and are not subject to evasive maneuvers. In contrast with urine, hair analysis has a wide window of detection, ranging from weeks to months, depending on the length of the hair shaft, and provides information concerning the pattern of an individual's drug abuse. Hair analysis is not yet recognized by the International Olympic Committee, although this technology is accepted in most courts of Justice. In light of potential applications, hair should be included as a suitable specimen to document positive urine cases in doping control.

Characterization of alpha 2-adrenergic receptors, negatively coupled to adenylate cyclase, in rabbit ciliary processes.

Inhibition of ciliary process adenylate cyclase was studied on rabbit membrane preparations. When considered individually, epinephrine, GTP and NaCl did not inhibit adenylate cyclase activity. On the other hand, when present together, epinephrine, GTP (10(-5) M) and NaCl (200 mM) acted synergistically to cause a 27% inhibition of basal activity. A similar inhibition was observed with 1-norepinephrine. Clonidine and BHT 920, two alpha 2-agents were found to be partial agonists causing 63% and 82% as much inhibition as epinephrine. Phenylephrine, an alpha 1-agonist did not inhibit adenylate cyclase activity at concentrations up to 10(-4) M. Yohimbine and phentolamine prevented the inhibition of adenylate cyclase by epinephrine, while prazosin was ineffective. Alpha 2-receptor selectivity in rabbit ciliary processes and their negative coupling to an adenylate cyclase via a NaCl-dependent GTP binding protein, Ni, is thus well established.

GC-MS procedure for the analysis of zipeprol.

A sensitive and specific quantitative method for the determination of zipeprol, a newly abused antitussive, in human fluids is described. Zipeprol and an internal standard, levallorphan, are isolated by a basic extraction and back-extraction process. The final extract is derivatizated with BSTFA + 1% TMCS and separated on a 12-m HP-1 capillary column. Drugs are detected by selected ion monitoring at m/z 335 and m/z 355 for zipeprol and the internal standard, respectively. The minimum detectable quantities are 0.6 and 0.4 ng ml-1, for zipeprol in plasma and urine, respectively. Relative standard deviations for within-run data are less than 6%.

Doping control for nandrolone using hair analysis.

A sensitive, specific and reproducible method for the quantitative determination of nandrolone in human hair has been developed. The sample preparation involved a decontamination step of the hair with methylene chloride. The hair sample (about 100 mg) was solubilized in 1 ml NaOH IN, 15 min at 95 degrees C, in presence of 10 ng nandrolone-d(3) used as an internal standard. The homogenate was neutralized and extracted using consecutively a solid phase (Isolute C18) and a liquid--liquid (pentane) extraction. The residue was derivatized by adding 50 microl MSTFA/NH4I/2-mercaptoethanol (1000:2:5; v/v/v), then incubated for 20 min at 60 degrees C. A 4-microl aliquot of the derivatized extract was injected into the column (HP5-MS capillary column, 5% phenyl--95% methylsiloxane, 30 m x 0.25 mm i.d. x 0.25 mm film thickness) of a Hewlett Packard (Palo Alto, CA) gas chromatograph (6890 Series) via a Hewlett Packard (7673) autosampler. The assay was capable of detecting 0.5 pg of nandrolone per mg of hair when approximately 100 mg of hair were processed. Linearity was observed for nandrolone concentrations ranging from 1 to 50 pg/mg with a correlation coefficient of 0.997. Intra-day and between-day precisions at 10 pg/mg were 11.2 and 15.1%, respectively, with an extraction recovery of 81.7%. The analysis of three strands of hair, obtained from three bodybuilders, revealed the presence of nandrolone at the concentration of 1, 3.5 and 7.5 pg/mg.

Interlaboratory comparison of quantitative determinations of drug in hair samples.

Testing human hair for drugs of abuse is a relatively new technique which requires control before being fully accepted in Justice applications. A consensus procedure was recently proposed to the four French Laboratories performing hair analysis for opiates and cocaine. Results of two independent controls have shown that the laboratories have performed very well quantitatively, using the recommended method. In order to compare these results with those obtained by other procedures, one sample was sent to 15 laboratories concerned with the analysis of human hair for drugs of abuse in Germany, Italy, Spain, and United States. Results from this study have indicated that the French recommended method is in accordance with the general procedures.