A Novel Oral Fluid Assay (LC-QTOF-MS) for the Detection of Fentanyl and Clandestine Opioids in Oral Fluid After Reported Heroin Overdose.

INTRODUCTION: The adulteration of heroin with non-pharmaceutical fentanyl and other high-potency opioids is one of the factors contributing to striking increases in overdose deaths. To fully understand the magnitude of this problem, accurate detection methods for fentanyl and other novel opioid adulterant exposures are urgently required. The objective of this work was to compare the detection of fentanyl in oral fluid and urine specimens using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) in a population of heroin users presenting to the Emergency Department after overdose. METHODS: This was a prospective observational study of adult Emergency Department patients who presented after a reported heroin overdose requiring naloxone administration. Participants provided paired oral fluid and urine specimens, which were prepared, extracted, and analyzed using a dual LC-QTOF-MS workflow for the identification of traditional and emerging drugs of abuse. Analytical instrumentation included SCIEX TripleTOF® 5600+ and Waters Xevo® G2-S QTOF systems. RESULTS: Thirty participants (N = 30) were enrolled during the study period. Twenty-nine participants had fentanyl detected in their urine, while 27 had fentanyl identified in their oral fluid (overall agreement 93.3%, positive percent agreement 93.1%). Cohen's Kappa (k) was calculated and demonstrated moderately, significant agreement (k = 0.47; p value 0.002) in fentanyl detection between oral fluid and urine using this LC-QTOF-MS methodology. Additional novel opioids and metabolites, including norfentanyl, acetylfentanyl, and U-47700, were detected during this study. CONCLUSION: In this study of individuals presenting to the ED after reported heroin overdose, a strikingly high proportion had a detectable fentanyl exposure. Using LC-QTOF-MS, the agreement between paired oral fluid and urine testing for fentanyl detection indicates a role for oral fluid testing in surveillance for nonpharmaceutical fentanyl. Additionally, the use of LC-QTOF-MS allowed for the detection of other clandestine opioids (acetylfentanyl and U-47700) in oral fluid.

Energy drink and other substance use among adolescent and young adult emergency department patients.

OBJECTIVE: This study aimed to understand current patterns of energy drink use and compare the extent of usage of energy drinks and other commonly used and misused substances between adolescent (13-17-years-old) and young adult (18-25-years-old) emergency department (ED) patients. METHODS: During a 6-week period between June and August 2010, all patients presenting to an adult or pediatric ED were asked to complete a computer-based, anonymous questionnaire regarding use of energy drinks and other substances. Wilcoxon rank-sum, 2-sample tests of binomial proportions, Pearson χ(2) testing, and regression models were used to compare energy drink and substance use by age groups. RESULTS: Past 30-day energy drink use was greater for young adults (57.9%) than adolescents (34.9%) (P < 0.03). Adolescents typically consumed a mean of 1.5 and young adults a mean of 2.6 energy drinks per day when using energy drinks and drank at most a mean of 2.4 and 2.6 drinks per day, respectively. Among adolescents, energy drink usage was more common than alcohol, "street" or illicit drugs, and tobacco usage, but less common than caffeine product usage. For young adults, energy drink usage was more common than "street" or illicit drugs, but less common than caffeine use, and similar to tobacco and alcohol usage. Young adult energy drink users were more likely than young adult non-energy drink users also to use tobacco and caffeine. CONCLUSIONS: Energy drink use is common among ED patients. Given the high prevalence of energy drink use observed, emergency physicians should consider the involvement of energy drinks in the presentations of young people.

Behavioral and physiologic adverse effects in adolescent and young adult emergency department patients reporting use of energy drinks and caffeine.

INTRODUCTION: This pilot study assessed the prevalence of physiologic and behavioral adverse effects among adolescent (13-17 years) and adult (18-25 years) emergency department patients who reported energy drink and/or caffeinated-only beverage use within the 30 days prior to emergency department presentation. It was hypothesized that energy drink users would report more adverse effects than those who used only traditional caffeinated beverages such as coffee, tea, or soft drinks. METHODS: This cross-sectional pilot study was conducted in two urban emergency departments, one adult and one pediatric. Eligible patients were enrolled during a 6-week period between June and August 2010. Participants completed a tablet computer-based, self-administered, anonymous questionnaire about their past 30-day energy drink and/or caffeinated-only beverage use, substance use, and experience of 10 physiologic and 10 behavioral symptoms. Multivariable logistic regression and negative binomial regression models, adjusted for age, gender, and substance use, were created to compare the occurrence of each adverse effect between energy drink and caffeinated-only beverage users. Odds ratios (ORs) and incidence rate ratios (IRRs) were estimated. RESULTS: Of those enrolled, 53.3% reported consuming energy drinks, 39.1% caffeinated-only beverages, and 7.6% no energy drinks or caffeinated-only beverages within the past 30 days. In multivariable logistic regression models, energy drink users were more likely than caffeinated-only beverage users to report having "gotten into trouble at home, school, or work" in the past 30 days (OR: 3.12 [1.24-7.88]). In the negative binomial regression multivariable models, more behavioral effects were reported among drug users (IRR: 1.50 [1.18-1.93]), and more physiologic effects were reported among tobacco users (IRR: 1.42 [1.13-1.80]) and females (IRR: 1.48 [1.21-1.80]), but not among energy drink users. CONCLUSIONS: Energy drink users and substance users are more likely to report specific physiologic and behavioral adverse effects. Emergency department clinicians should consider asking patients about energy drink and traditional caffeine usage and substance use when assessing patient symptoms.

Caffeine reduces myocardial blood flow during exercise.

Caffeine consumption has been receiving increased interest from both the medical and lay press, especially given the increased amounts now available in energy products. Acute ingestion of caffeine usually increases cardiac work; however, caffeine impairs the expected proportional increase in myocardial blood flow to match this increased work of the heart, most notably during exercise. This appears to be mainly due to caffeine's effect on blocking adenosine-induced vasodilatation in the coronary arteries in normal healthy subjects. This review summarizes the available medical literature specifically relating to pure caffeine tablet ingestion and reduced exercise coronary blood flow, and suggests possible mechanisms. Further studies are needed to evaluate this effect for other common caffeine-delivery systems, including coffee, energy beverages, and energy gels, which are often used for exercise performance enhancement, especially in teenagers and young athletes.