Analysis of MDMA and its metabolites in urine and plasma following a neurotoxic dose of MDMA.

3,4-Methylenedioxymethamphetamine (MDMA), a commonly encountered drug of abuse, has been shown in a variety of studies to cause neurotoxic effects. Because MDMA itself is not neurotoxic, identifying the potential neurotoxic metabolite(s) was of significant importance. Evaluation of urine and plasma concentrations of MDMA and three of its main metabolites, 3,4-methylenedioxyamphetamine (MDA), 4-hydroxy-3-methoxyamphetamine (HMA), and 4-hydroxy-3-methoxymethamphetamine (HMMA), following administration of a neurotoxic dose (20 mg/kg) to male Dark Agouti rats was accomplished. Currently there are no data available describing urine and plasma concentrations of MDMA and these metabolites over a period of 7 days. The rats received a single 20 mg/kg i.p. dose of MDMA. Blood and urine samples were collected prior to administration and at 2, 4, 8, 12, 16, 20, 24, 48, 96, and 168 h following drug administration. Plasma and urine samples were extracted using solid-phase extraction, derivatized with N-methyl-bis(trifluoroacetamide), then analyzed using gas chromatography-mass spectrometry. Urine samples showed peak concentrations of MDMA at 4 h, MDA at 8 h, HMMA at 12 h, and HMA at 16 h post dose. MDMA and its metabolites were detectable (limit of detection 25 ng/mL) in the urine for up to 168 h post dose. Plasma samples showed mean peak concentrations of MDMA and MDA at 2 h post dose and HMMA at 4 h. Although the highest mean concentration of HMA was seen at 24 h post dose, variability between sample results for this time point was significant. No detectable levels of MDMA, MDA, HMA, and HMMA (LOD 10 ng/mL) were found in plasma at 96 and 168 h post dose.

Determination of l-methamphetamine: a case history.

Methamphetamine was detected in a 77-year-old male who had a history of congestive heart failure. Using a modification of a previously reported method, trifluoroacetyl-l-prolyl chloride was used to derivatize sympathomimetic amines to allow separation and identification of individual enantiomers. The l-enantiomer of methamphetamine and a trace amount of l-amphetamine were found in blood and urine specimens from this case. Further investigation revealed the decedent had bronchial asthma and regularly used a Vicks Inhaler, which contains l-methamphetamine as the active ingredient.

Metabolic profile of famprofazone following multidose administration.

One of the 14 different drugs known to be metabolized to methamphetamine and/or amphetamine is famprofazone, a component in the multi-ingredient formulation Gewodin. Because of its conversion to methamphetamine and amphetamine, which can result in positive drug-testing results, the excretion pattern of these metabolites is critical for proper interpretation of drug-testing results. Multiple doses of famprofazone were administered to healthy volunteers with no previous history of methamphetamine, amphetamine, or famprofazone use. Following administration, urine samples were collected ad lib for nine days, and pH, specific gravity, and creatinine values were determined. To determine the methamphetamine and amphetamine excretion profile, samples were extracted, derivatized, and analyzed by gas chromatography-mass spectrometry (GC-MS). Peak concentrations of methamphetamine ranged from 5327 to 14,155 ng/mL and from 833 to 3555 ng/mL for amphetamine and were reached between 12:22 and 48:45 h post initial dose. There were 15-19 samples per subject that were positive under HHS testing guidelines, with the earliest at 03:37 h post initial dose and as late as 70:30 h post last dose. Methamphetamine and amphetamine were last detected (LOD > or = 5 ng/mL) up to 159 h and 153 h post last dose for methamphetamine and amphetamine, respectively. GC-MS was also used to determine the enantiomeric composition of methamphetamine and amphetamine. This analysis revealed both enantiomers were present in a predictable pattern.

Amphetamine excretion profile following multidose administration of mixed salt amphetamine preparation.

Interpretation of drug testing results requires detailed scientific information, particularly in those cases where the question of legitimate use versus illicit use arises. Amphetamine remains a widely abused drug throughout the world, although it is also used therapeutically for weight loss, narcolepsy, and attention-deficit disorder with hyperactivity (ADHD). Treatment of ADHD using stimulant drugs is much more common now than it was in even the recent past. Increasingly, older individuals are diagnosed and treated for ADHD, and treatment often continues into adulthood. Amphetamine is commonly used for the treatment of ADHD and is available by prescription as either the d-enantiomer or a mixture of enantiomers. Although used for many years, there are no data available to describe the excretion profile of amphetamine and its enantiomers following repeated use of the drug. As a result, medical review officers (MROs) and forensic toxicologists have no direct evidence to base their decisions on when it comes to evaluation of use of these drugs. The current study was designed to determine the concentration and enantiomer excretion profile following repeated daily administration of mixed enantiomers of amphetamine. Twenty milligrams of Adderall was administered daily to five healthy subjects with all subsequent ad lib urine samples collected for at least five days following administration of the five-dose regimen. Adderall is a 3:1 mixture of d- and l-enantiomers of amphetamine salts and represents the mixed enantiomer proportion of amphetamine available in the United States through pharmaceutical channels. Peak amphetamine concentrations ranged from 5739 to 19,172 ng/mL. Samples containing > or = 500 ng/mL amphetamine (the administrative cutoff for a positive result by gas chromatography-mass spectrometry) were seen up to 60:15 (h:min) following administration of the last dose. Enantiomer analysis showed the d-enantiomer to be in excess of the l-enantiomer for as long as the drug was administered. After administration of the last dose of drug, the proportion of l-enantiomer increased over time. Not all samples that contained > or = 500 ng/mL total amphetamine were positive when tested by immunoassay because of the differing cross-reactivity of the enantiomers. This study provides the first description of the excretion of amphetamine following repeated administration of Adderall. The presence of the l-enantiomer separates this drug from other formulations composed of only the d-enantiomer (i.e., Dexedrine and much illicit amphetamine), thus readily differentiating them from Adderall use. Some illicit and medicinal amphetamine is, however, a mixture of amphetamine enantiomers. Because the enantiomers are metabolized at different rates, their proportion offers the opportunity to describe excretion versus time. Coupling this data with drug concentration makes it possible for forensic toxicologists and MROs to come to an informed decision regarding the involvement of this drug in a positive drug test result.

Performance of military-trained physician assistants on the physician assistant national certification examination.

Although the first physician assistant (PA) program was born at a civilian academic institution, the impact of the military was immediately obvious as evidenced by the entire first class of PA students being Vietnam veteran Navy Corpsmen. Following initiation of the PA profession, the armed services established their own PA training programs that were eventually consolidated into a single interservice program in 1996. The mission of the Interservice PA Program is to produce high-quality PAs prepared to provide medical care in not only the traditional clinical arena but in the more unique situations seen in both peacetime and wartime military settings. PAs must complete an approved formal training program encompassing didactic and clinical training and pass a national certification examination to be licensed to practice. Pass rates are a key measure of the quality of a training program. We compared the national certification examination pass rates for our program with those of accredited civilian programs. Graduates of our program had a significantly higher pass rate and higher average scores than their civilian counterparts. These results are due to the strength of the program and faculty as well as the considerable hard work and dedication of the students who are drawn from a community that is, in many ways, non-traditional compared with other PA programs. These results demonstrate that the military training of PAs continues to provide high-quality health care providers who perform above their civilian-trained counterparts.

Metabolic profile of amphetamine and methamphetamine following administration of the drug famprofazone.

There are a several drugs that lead to the production of methamphetamine and/or amphetamine in the body which are subsequently excreted in the urine. These drugs raise obvious concerns when interpreting positive amphetamine drug testing results. Famprofazone is an analgesic found in a multi-ingredient medication (Gewodin) used for pain relief. Two Gewodin tablets (50 mg of famprofazone) were administered orally to healthy volunteers with no history of amphetamine, methamphetamine, or famprofazone use. Following administration, urine samples were collected ad lib for up to six days, and pH, specific gravity, and creatinine values were determined. In order to determine the quantitative excretion profile of amphetamine and methamphetamine, samples were extracted using liquid-liquid extraction, derivatized with heptafluorobutyric anhydride, and analyzed by gas chromatography-mass spectrometry (GC-MS). The ions monitored were 91, 118, 240 for amphetamine and 254, 210, 118 for methamphetamine. Amphetamine-d(6) and methamphetamine-d(11) were used as internal standards. Peak concentrations for amphetamine ranged from 148 to 2271 ng/mL and for methamphetamine 615 to 7361 ng/mL. Concentrations of both compounds peaked between 3 and 7 h post-dose. Amphetamine and methamphetamine could be detected (limit of detection = 5 ng/mL) at 121 and 143 h post-dose, respectively. Using a cutoff of 500 ng/mL, all subjects had individual urine samples that tested positive. One subject had 14 samples above the cutoff with the last positive being detected over 48 h post-dose. The profile of methamphetamine and amphetamine enantiomers was also determined using liquid-liquid extraction, derivatization with N-trifluoroacetyl-l-prolyl chloride and analysis by GC-MS. Data showed the famprofazone metabolites amphetamine and methamphetamine to be both d- and l-enantiomers. The proportion of l-methamphetamine exceeded that of its d-enantiomer from the first sample collected. Initially, the proportion was approximately 70% l-methamphetamine and this proportion increased over time. Amphetamine results showed l- and d-amphetamine were virtually the same in the early samples with the proportion of l-amphetamine increasing as time progressed. Forensic interpretation of drug testing results is a challenging critical part of forensic drug testing area because of the potential repercussions the results found may have on an individual's life. The finding of each enantiomers by itself differentiates famprofazone use from the most commonly abused form of methamphetamine and all medicinal methamphetamine available in the U.S., which is either d-methamphetamine (prescription medication) or l-methamphetamine (Vicks inhaler). Coupling this information with the concentrations of amphetamine and methamphetamine helps to determine the potential for use of this drug.

Amphetamine enantiomer excretion profile following administration of Adderall.

Amphetamine remains a widely abused drug throughout the world. It is also used therapeutically for weight loss, narcolepsy, and attention deficit disorder with hyperactivity (ADHD). ADHD has grown dramatically recently both in terms of diagnosis and treatment. Increasingly, older individuals are diagnosed and treated for ADHD, and treatment often continues into adulthood. Of the available treatments for ADHD, Adderall is widely prescribed. Despite its widespread use, there are no published data regarding the expected amphetamine excretion profile following its use. This is problematic because, in this case, medical review officers (MRO) and forensic toxicologists are asked to assess results in terms of use pursuant to valid medical prescription without specific data on which to base a sound decision. To address this situation, a study to determine the concentration and enantiomer composition of amphetamine excretion following administration of Adderall was undertaken. Adderall (20 mg) was administered to five healthy subjects with all subsequent ad lib urine samples (total urine void) collected for seven days. Adderall is a 3:1 mixture of d- and l-enantiomers of amphetamine salts. Peak amphetamine concentrations ranged from 2645 to 5948 ng/mL. Samples containing > or = 500 ng/mL of amphetamine (the administrative cutoff for a positive result by gas chromatography-mass spectrometry) were seen up to 47:30 h post dose. The number of samples that contained amphetamine concentrations of > or = 500 ng/mL ranged among individuals from 7 to 13. As anticipated, analysis showed the d-enantiomer to be in excess of the l-enantiomer, with the proportion of l-enantiomer increasing over time. Because of the mixture of enantiomers, not all samples that contained > or = 500 ng/mL of amphetamine were positive when tested by immunoassay. The drug concentration profiles were quite variable within and between subjects because of dilution and fluctuations in pH of the samples. These results are the first to describe the excretion of amphetamine following administration of Adderall. The presence of the l-enantiomer separates this drug from other preparations of the drug that are composed of only the d-enantiomer (i.e., dexedrine and much illicit amphetamine), thus readily differentiating them from Adderall use. Some illicit and medicinal amphetamine is, however, a mixture of amphetamine enantiomers. Because the enantiomers are metabolized at different rates, their proportion offers the opportunity to describe excretion versus time. Coupling this data with drug concentration makes it possible for forensic toxicologists and MROs to come to an informed decision about the involvement of this drug in a positive drug test result. Using the combination of enantiomer composition and quantitative data will allow MROs and forensic toxicologists to better assess the use of this drug from abuse of amphetamine.

Precursor medications as a source of methamphetamine and/or amphetamine positive drug testing results.

Medical Review Officer interpretation of laboratory results is an important component of drug testing programs. The clinical evaluation of laboratory results to assess the possibility of appropriate medical use of a drug is a task with many different facets, depending on the drug class considered. This intercession prevents the reporting of positive results unless it is apparent that drugs were used illicitly. In addition to the commonly encountered prescribed drugs that yield positive drug testing results, other sources of positive results must be considered. This review describes a series of compounds referred to as "precursor" drugs that are metabolized by the body to amphetamine and/or methamphetamine. These compounds lead to positive results for amphetamines even though neither amphetamine nor methamphetamine were used, a possibility that must be considered in the review of laboratory results. Description of the drugs, their clinical indications, and results seen following administration are provided. This information allows for the informed evaluation of results with regard to the potential involvement of these drugs.

A procedure for the detection of Stealth adulterant in urine samples.

Stealth is an adulterant that is advertised as not only preventing a positive drug test in urine, but also to be undetectable by currently available adulteration testing. It has previously been described as a peroxidase and peroxide that is added to urine for the sole purpose of preventing a positive drug test. The product was found to have a significant impact on the ability to detect several drugs of abuse, however, detecting the presence of the adulterant in urine had not yet been reported. A simple procedure to detect the presence of this adulterant in urine was developed. This simple color test procedure using commercially available reagents commonly used in clinical laboratories is based on the use of a chromogen to detect the peroxidase reaction in urine samples. If Stealth is present in the urine, the test sample will show an immediate color change from clear to dark brown. This qualitative test can also be adapted for use with a spectrophotometer or autoanalyzer.