Fatal methadone intoxication in an infant.

Presented are the case history and toxicological findings of an infant fatality involving methadone. A mother found her 10-month-old infant unresponsive in a crib. The infant was taken to a hospital; however, she was cold and stiff on arrival and was pronounced dead. Few details regarding the case history were known at the time, and the autopsy findings were unremarkable. Specimens were submitted for a full toxicological analysis, including an alcohol analysis by headspace gas chromatography with flame ionization detection; a screen for drugs of abuse and several prescription drug classes using an enzyme-linked immunosorbent assay technique (ELISA); and a screen for basic compounds using gas chromatography-mass spectrometry (GC-MS). Positive findings were confirmed and quantitated using GC-MS. Methadone was detected in subclavian blood at a concentration of 0.67 mg/L. The cause of death was determined to be "methadone intoxication", and the manner of death was "homicide". A discussion of the case circumstances, the toxicology findings and methadone pharmacokinetics are presented.

Concentrations of AB-CHMINACA and AB-PINACA and Driving Behavior in Suspected Impaired Driving Cases.

This article reviews case reports for 58 suspected impaired driving cases that were positive for the synthetic cannabinoids AB-CHMINACA or AB-PINACA. All cases were submitted to the Washington State Patrol Toxicology Laboratory in 2014 from either Washington State or State of Alaska law enforcement agencies. The population of drivers was predominantly male (95%), with a mean age of 28 years (range, 18-61 years). The range of blood concentrations was 0.6->10 ng/mL for AB-CHMINACA (N = 33) and 0.6-41.3 ng/mL for AB-PINACA (N = 25). Drug Recognition Expert exams were performed in 10 cases for each AB-CHMINACA and AB-PINACA. Horizontal gaze nystagmus was observed in 50 and 60% of the cases, respectively. Overall, several physiological indicators varied from those typically observed with marijuana use. The majority of these cases had very poor driving; subjects were involved in an accident, found passed out in a vehicle or were called in as a suspected impaired driver. Slurred speech, confusion, lack of coordination/dexterity and lethargy were commonly observed.

A Case Review of the First Analytically Confirmed 25I-NBOMe-Related Death in Washington State.

This case was submitted to the Washington State Patrol Toxicology Laboratory in September 2014. A 15-year-old male went to a party where he ingested 25I-NBOMe and mushrooms. A short time later, he started to vomit and began seizing until he eventually passed out. Resuscitation efforts were made, but were unsuccessful. He was transported to a local hospital, where he died three days later of multi-system organ failure following cardiopulmonary arrest. The hospital admission samples were negative for ethanol and basic drugs and their metabolites. The hospital serum confirmed positive for delta-9-tetrahydrocannabinol (THC) and carboxy-THC at 4.1 and 83 ng/mL, respectively. On the basis of the case history, the hospital blood and urine were sent to NMS Labs for NBOMe and psilocin confirmation. The blood was positive for 25I-NBOMe, and the urine was positive for 25C-, 25H- and 25I-NBOMe, as well as, psilocin. Antemortem and postmortem blood were also sent to AIT Laboratories for NBOMe confirmation. The antemortem blood confirmed positive for 25I-NBOMe with a concentration of 0.76 ng/mL. The manner of death was ruled an accident as a result of combined 25I-NBOMe and psilocin intoxication.

Addicted to driving under the influence--a GHB/GBL case report.

A 38-year-old male was arrested 7 times over an 8-month period for driving under the influence (DUI) of drugs. In each incident, gamma-hydroxybutyrate (GHB) was determined to be the causative agent. A blood specimen was drawn between 1.5 and 2.5 h after first police contact in each arrest. GHB was analyzed by gas chromatography-mass spectrometry, following extraction from blood using ethyl acetate and subsequent derivatization using BSTFA/TMCS. Blood GHB concentrations ranged from 44 to 184 mg/L (N = 7, mean 100 mg/L, median 73 mg/L). Overall signs of impairment included erratic driving (severe lane travel, collisions, and near-collisions), slurred speech, disorientation, slow to react, shaking, agitation, unable to focus, poor coordination and balance, poor performance in field sobriety tests, somnolence, and unconsciousness. On only one occasion were other drugs present in the subject's blood (thiopental and diazepam), which may have contributed to the observed driving impairment. During several police interviews, the subject stated he was addicted to GHB and gamma-butyrolactone (GBL), and admitted to previously taking "RenewTrient", "Dream On", "V35", "fitness supplements", and/or "GBL". During the same period as his DUI arrests, the subject had been admitted at least six times to different hospitals for GHB/GBL intoxications.

Suspected GHB overdoses in the emergency department.

Blood specimens from 146 suspected gamma-hydroxybutyrate (GHB) overdose cases, presenting to an emergency department in Washington State over a 12-month period, were analyzed for GHB and other drugs. Of these 146 patients, GHB was confirmed in approximately one-third of the patients (N = 54), sometimes in potentially toxic concentrations. These patients were aged between 17 and 59 years (median 28 years), and 83% were male. Blood GHB concentrations ranged from 29 to 490 mg/L (mean 137 mg/L; median 103 mg/L). In 36 (67%) of the 54 patients, other drugs were additionally detected. Ethanol was measured in 22 (41%) patients, with concentrations ranging from 0.01 to 0.26 g/100 mL (median 0.04 g/100 mL). Other commonly co-administered drugs included 3,4-methylenedioxymethamphetamine, marijuana, methamphetamine, cocaine, and citalopram. Frequently observed clinical symptoms on admission for the GHB overdose group included copious vomiting, ataxia, lack of gag reflex, respiratory depression, mild acute respiratory acidosis, unconsciousness, and sudden altered states of consciousness. Many patients required intubation, and several became combative and required restraints. The majority of patients were discharged within 6 h of hospital admission. However, despite presenting with similar clinical symptoms on admission, GHB was not confirmed in 92 of the 146 overdose patients, suggesting that GHB overdose cases may frequently be indistinguishable from other drug overdoses or medical conditions.

Prevalence of drug use in commercial tractor-trailer drivers.

An enforcement emphasis project, "Operation Trucker Check," was established in order to determine the extent to which commercial tractor-trailer drivers were operating their vehicles while impaired by drugs. A total of 1079 drivers and their vehicles were assessed for driver and equipment violations, and drivers additionally underwent preliminary field sobriety tests conducted by drug recognition expert (DRE) officers. Anonymous urine specimens for drug analysis were requested, and 822 urine specimens were obtained in total. Compliance with the drug-testing portion was voluntary, and there was a 19% refusal rate. Overall, 21% of the urine specimens tested positive for either illicit, prescription, and/or over-the-counter drugs, and 7% tested positive for more than one drug. Excluding caffeine and nicotine, the largest number of positive findings (9.5%) were for CNS stimulants, such as methamphetamine, amphetamine, phentermine, ephedrine/pseudoephedrine, and cocaine. The second most frequently encountered drug class were the cannabinoids, with 4.3% of drivers testing positive for marijuana metabolites. Only 11 drivers (1.3%) were positive for alcohol. Sixteen truck drivers (1.6%) were charged with driving under the influence of drugs after a full DRE evaluation was conducted. The results indicate that in spite of comprehensive drug testing in the trucking industry, some tractor-trailer drivers are continuing to take illicit and other drugs with the potential of having a negative effect on their driving ability. On the other hand, only a few drivers were, in fact, deemed to be under the influence of drugs at the time of driving when evaluated by DRE officers.

The prevalence of marijuana in suspected impaired driving cases in Washington state.

In December 2012, the possession and private use of limited quantities of marijuana and marijuana products became legal in the state of Washington. At the same time, the state's driving under the influence statutes were amended to include a per se level of 5 ng/mL delta(9)-tetrahydrocannabinol (THC) in whole blood for drivers aged 21 years and older. The aim of this study was to assess the effect of marijuana legalization on the prevalence of marijuana in suspected impaired driving cases. The prevalence of both active THC and its metabolite carboxy-THC detected in such cases pre-legalization was compared with the prevalence post-legalization. In 2009-2012, the average yearly percentage of cases positive for THC and carboxy-THC was 19.1% (range: 18.2-20.2%) and 27.9% (range: 26.3-28.6%), respectively. In 2013, the percentages had significantly increased to 24.9 and 40.0%, respectively (P < 0.05). The median THC concentration over the 5-year period ranged from 5.2 to 6.3 ng/mL, with individual concentrations ranging up to 90 ng/mL. An average of 56% of cases were at or >5 ng/mL over the 5-year period. The prevalence of alcohol and the majority of other drugs in this same population of suspected impaired drivers submitted for testing did not change during this same 5-year period-marijuana was the only drug to show such an increase in frequency. Further, this observed increase remained after the data had been normalized to account for changes in laboratory testing procedures that occurred during this time period. Future studies need be conducted to ascertain whether the observed increase has had any effect on the incidence of crashes, serious injuries and/or traffic fatalities.

XLR-11 and UR-144 in Washington state and state of Alaska driving cases.

The case reports for 18 driving cases positive for the synthetic cannabinoid substances XLR-11 and/or UR-144 are discussed. Eleven of these cases had drug recognition expert evaluations performed. Slurred speech, lack of convergence and body and eyelid tremors were the most consistently noted interview characteristic. Pulse and blood pressure of the subjects were within the expected range. Most of the drivers contacted demonstrated poor driving; however, their performance on the standardized field sobriety tests yielded inconsistent diagnostic information. All cases were negative for other commonly detected drugs that affect the central nervous system, although one case was additionally positive for other synthetic cannabinoids. Of the studied cases, six were positive for only UR-144, whereas eight contained only XLR-11. Four cases were found to have both.

Suspected impaired driving case involving α-pyrrolidinovalerophenone, methylone and ethylone.

This is the first reported case of α-pyrrolidinovalerophenone (α-PVP), methylone and ethylone in a suspected impaired driving case in the state of Washington. An initial traffic stop by law enforcement was made of a driver due to poor navigation of the roadway. The drug recognition expert (DRE) officer observed slurred speech, bloodshot watery eyes, dilated pupils, involuntary muscle movements and an elevated pulse and blood pressure. The DRE deduced that the driver was likely under the influence of central nervous system (CNS) stimulants, specifically 'bath salts'. Routine testing of the blood did not reveal the presence of alcohol or common drugs of abuse. Upon further review of the officer's report and the unconfirmed identification of α-PVP, blood was sent to NMS Labs in Willow Grove, PA, USA for bath salts and stimulant designer drugs testing. Analysis was conducted by liquid chromatography-time-of-flight mass spectrometry with the following results: 63 ng/mL α-PVP, 6.1 ng/mL methylone and positive for ethylone. These results are consistent with the DRE opinion of driving performance being impaired by a CNS stimulant.

Calculation and verification of blood ethanol measurement uncertainty for headspace gas chromatography.

An estimate was made of the measurement uncertainty for blood ethanol testing by headspace gas chromatography. While uncertainty often focuses on compliance to a single threshold level (0.08 g/100 mL), the existence of multiple thresholds, related to enhanced sentencing, subject age, or commercial vehicle licensure, necessitate the use of an estimate with validity across multiple specification levels. The uncertainty sources, in order of decreasing magnitude, were method reproducibility, linear calibration, recovery, calibrator preparation, reference material, and sample preparation. A large set of reproducibility data was evaluated (n = 15,433) in order to encompass measurement variability across multiple conditions, operators, instruments, concentrations and timeframes. The relative, combined standard uncertainty was calculated as ±2.7%, with an expanded uncertainty of ±8.2% (99.7% level of confidence, k = 3). Bias was separately evaluated through a recovery study using standard reference material from a national metrology institute. The uncertainty estimate was verified through the use of proficiency test (PT) results. Assigned values for PT results and their associated uncertainties were calculated as robust means (x*) and standard deviations (s*) of participant values. Performance scores demonstrated that the uncertainty estimate was appropriate across the full range of PT concentrations (0.010-0.370 g/100 mL). The use of PT data as an empirical estimate of uncertainty was not examined. Until providers of blood ethanol PT samples include details on how an assigned value is obtained along with its uncertainty and traceability, the use of PT data should be restricted to the role of verification of uncertainty estimates.