A placebo-controlled study to assess Standardized Field Sobriety Tests performance during alcohol and cannabis intoxication in heavy cannabis users and accuracy of point of collection testing devices for detecting THC in oral fluid.

RATIONALE: Standardized Field Sobriety Tests (SFST) and oral fluid devices are used to screen for driving impairment and roadside drug detection, respectively. SFST have been validated for alcohol, but their sensitivity to impairment induced by other drugs is relatively unknown. The sensitivity and specificity for Δ(9)-tetrahydrocannabinol (THC) of most oral fluid devices have been low. OBJECTIVE: This study assessed the effects of smoking cannabis with and without alcohol on SFST performance. Presence of THC in oral fluid was examined with two devices (Dräger Drug Test® 5000 and Securetec Drugwipe® 5). METHODS: Twenty heavy cannabis users (15 males and 5 females; mean age, 24.3 years) participated in a double-blind, placebo-controlled study assessing percentage of impaired individuals on the SFST and the sensitivity of two oral fluid devices. Participants received alcohol doses or alcohol placebo in combination with 400 µg/kg body weight THC. We aimed to reach peak blood alcohol concentration values of 0.5 and 0.7 mg/mL. RESULTS: Cannabis was significantly related to performance on the one-leg stand (p = 0.037). Alcohol in combination with cannabis was significantly related to impairment on horizontal gaze nystagmus (p = 0.029). The Dräger Drug Test® 5000 demonstrated a high sensitivity for THC, whereas the sensitivity of the Securetec Drugwipe® 5 was low. CONCLUSIONS: SFST were mildly sensitive to impairment from cannabis in heavy users. Lack of sensitivity might be attributed to tolerance and time of testing. SFST were sensitive to both doses of alcohol. The Dräger Drug Test® 5000 appears to be a promising tool for detecting THC in oral fluid as far as correct THC detection is concerned.

New conopeptides of the D-superfamily selectively inhibiting neuronal nicotinic acetylcholine receptors.

The venom of cone snails (Conus spp.) is a rich source of peptides exhibiting a wide variety of biological activities. Several of these conopeptides are neuronal nicotinic acetylcholine receptor (nAChR) antagonists and belong to the A-, M-, S-, C and the recently described D-superfamily (alphaD-conopeptides). Here we describe the discovery and characterization of two alphaD-conopeptides isolated from the venom of Conus mustelinus and Conus capitaneus. Their primary structure was determined by Edman degradation, MS/MS analysis and by a PCR based approach. These peptides show close structural homology to the alphaD-VxXIIA, -B and -C conopeptides from the venom of Conus vexillum and are dimers (about 11kDa) of similar or identical peptides with 49 amino acid residues and a characteristic arrangement of ten conserved cysteine residues. These novel types of conopeptides specifically block neuronal nAChRs of the alpha7, alpha3beta2 and alpha4beta2 subtypes in nanomolar concentrations. Due to their high affinity, these new ligands may provide a tool to decipher the localisation and function of the various neuronal nAChRs.

Neurocognitive performance during acute THC intoxication in heavy and occasional cannabis users.

Performance impairment during Delta(9)-tetrahydrocannabinol (THC) intoxication has been well described in occasional cannabis users. It is less clear whether tolerance develops to the impairing effects of THC in heavy users of cannabis. The aim of the present study was to assess neurocognitive performance during acute THC intoxication in occasional and heavy users. Twenty-four subjects (12 occasional cannabis users and 12 heavy cannabis users) participated in a double-blind, placebo-controlled, two-way mixed model design. Both groups received single doses of THC placebo and 500 microg/kg THC by smoking. Performance tests were conducted at regular intervals between 0 and 8 h after smoking, and included measures of perceptual motor control (critical tracking task), dual task processing (divided attention task), motor inhibition (stop signal task) and cognition (Tower of London). THC significantly impaired performance of occasional cannabis users on critical tracking, divided attention and the stop signal task. THC did not affect the performance of heavy cannabis users except in the stop signal task, i.e. stop reaction time increased, particularly at high THC concentrations. Group comparisons of overall performance in occasional and heavy users did not reveal any persistent performance differences due to residual THC in heavy users. These data indicate that cannabis use history strongly determines the behavioural response to single doses of THC.

Cognition and motor control as a function of Delta9-THC concentration in serum and oral fluid: limits of impairment.

Cannabis use has been associated with increased risk of becoming involved in traffic accidents; however, the relation between THC concentration and driver impairment is relatively obscure. The present study was designed to define performance impairment as a function of THC in serum and oral fluid in order to provide a scientific framework to the development of per se limits for driving under the influence of cannabis. Twenty recreational users of cannabis participated in a double-blind, placebo-controlled, three-way cross-over study. Subjects were administered single doses of 0, 250 and 500 microg/kg THC by smoking. Performance tests measuring skills related to driving were conducted at regular intervals between 15 min and 6h post smoking and included measures of perceptual-motor control (Critical tracking task), motor impulsivity (Stop signal task) and cognitive function (Tower of London). Blood and oral fluid were collected throughout testing. Results showed a strong and linear relation between THC in serum and oral fluid. Linear relations between magnitude of performance impairment and THC in oral fluid and serum, however, were low. A more promising way to define threshold levels of impairment was found by comparing the proportion of observations showing impairment or no impairment as a function of THC concentration. The proportion of observations showing impairment progressively increased as a function of serum THC in every task. Binomial tests showed an initial and significant shift toward impairment in the Critical tracking task for serum THC concentrations between 2 and 5 ng/ml. At concentrations between 5 and 10 ng/ml approximately 75-90% of the observations were indicative of significant impairment in every performance test. At THC concentrations >30 ng/ml the proportion of observations indicative of significant impairment increased to a full 100% in every performance tests. It is concluded that serum THC concentrations between 2 and 5 ng/ml establish the lower and upper range of a THC limit for impairment.

[Death in homes for the aged/nursing homes from the legal medicine viewpoint]. / Zum Tod im Senioren-/Pflegeheim aus rechtsmedizinischer Sicht.

Following the death of 16 inhabitants of a nursing home within a period of 2 weeks, the prosecution ordered legal autopsies in all of the cases, which had not yet been buried or cremated, suspecting a neglect of nursing or active euthanasia respectively. Two out of a total of ten cases revealed drug overdoses which could have explained death. However, due to concurring causes of death, the evidence could not be furnished with adequate security. In the present case, the examinations helped--already in a preliminary stage of the investigations--to prevent the authorities from more expensive proceedings as well as the respective nursing home from being unjustly suspected of having committed a criminal offense.

Importance of vacutainer selection in forensic toxicological analysis of drugs of abuse.

The enzymatic degradation of cocaine in blood samples, even during transport to a forensic laboratory, is a common problem in toxicological analysis. This can be avoided by the use of blood-sampling devices such as gray-top Vacutainers containing the cholinesterase inhibitor sodium fluoride. In the present study, which included 147 authentic cases, blood samples were collected into two different tubes, one containing fluoride/oxalate and one without stabilizing agents. In all cases, both samples were analyzed for drugs of abuse using Abbott FPIA immunoassays after precipitation and gas chromatography-mass spectrometry (GC-MS) for quantitative analysis. The cannabinoid immunoassay showed markedly lower values in the fluoride-containing samples; this was investigated further and could be explained by hemolysis of these samples. In addition, the concentrations of 11-nor-delta9-tetrahydrocannabinol-9-carboxylic acid (THCCOOH) were lower in these samples. A stability study with the THCCOOH acyl glucuronide showed that it is unstable in unpreserved serum, which could explain our observation. GC-MS quantitative data for amphetamine and derivatives, opiates, delta9-tetrahydrocannabinol, and 11-hydroxy-delta9-tetrahydrocannabinol were essentially identical; however, they also differed substantially for cocaine, cocaethylene, ecgonine methylester, and benzoylecgonine. Unexpectedly, the concentrations of benzoylecgonine in unpreserved serum were almost half as high as in the fluoride-containing samples.

[Explanation of an unclear neurological syndrome by toxicologic investigation]. / Aufklärung eines unklaren neurologischen Syndroms durch toxikologische Untersuchungen.

HISTORY AND CLINICAL FINDINGS: A 51-year-old man without relevant previous illness developed vomiting and diarrhoea, later also tingling and hypaesthesias in the limbs, as well as optical hallucinations that had occurred after a mid-day meal and drinking red wine. Neurological examination revealed variable pupillary reactions with anisocoria that would change from one side to the other. There was no paresis, muscle reflexes were brisk, more so on the right. Babinski reflex was positive on the right, there was an unsustained clonus of the right foot and the coordination tests were normal. Distal symmetrical hypaesthesias and paraesthesias were present in all limbs. An exogenous psychosis with restlessness and optical hallucinations was observed. INVESTIGATIONS: Routine blood count revealed leukocytosis. Serum concentrations of cGt and GPT were raised. Cerebral computed tomography and cerebrospinal fluid as well as microbiological tests of the mid-day meal were normal. DIAGNOSIS, TREATMENT AND COURSE: As the cause of the symptoms was initially unclear the patient was admitted to hospital and monitored without any specific treatment. Within one night all symptoms had disappeared and he was discharged the next morning without any complaints. Later the red wine which he had drunk was examined toxicologically and found to contain the "designer drug" DOB (2,5-dimethoxy-4-bromamphetamine). CONCLUSION: Accidental poisoning with DOB is probably a rare event which can hardly be included in routine differential diagnosis. If an acute cerebral organic syndrome has been excluded, only toxicological investigation can help in establishing the diagnosis in such cases.

[Angel trumpet: a poisonous garden plant as a new addictive drug?]. / Die Engelstrompete: Giftige Gartenpflanze als neues "Suchtmittel"?

BACKGROUND AND OBJECTIVE: Angel's trumpet (Species Brugmansia) is widely used as a garden plant because it is easily kept and the luxuriance of its flowering. Belonging to the Family Solanacea it contains a large amount of alkaloids (parasympatholytics). Because of its hallucinogenic action, its leaves and flowers are increasingly used by young people as a substitute for the hallucinogen LSD (lysergic acid diethylamide). In the summer of 1997, one of a group of youths died after they had ingested its flowers which they had gathered from front gardens. An investigation was undertaken to identify the alkaloids and measure their concentration in the various parts of the plant. METHODS: Four young and one eight-year old plant were kept outdoors from May until October, and its flowers and leaves were removed for analysis weekly. All samples were deep-frozen at -20 degrees C and later, at the same time, thawed out, weighed and extracted in methanol. The alkaloids were identified by high pressure liquid chromatography (HPLC), diode array detector, separated by means of a Hypersil HyPurity cartridge, and measured at a wave-length of 220 nm. RESULTS: All 66 flowers, 32 leaves and 2 speed capsules contained tropane alkaloids, mainly scopolamine. The highest concentrations were found in the seed capsules, lower ones in the flowers, while the leaves contained only small amounts. Total alkaloid content per flower of the younger plants averaged 0.94 mg, of the younger ones 1.81 mg. The flowers of the old plant contained up to 3 mg scopolamine. CONCLUSION: The ingestion of even a few flowers of Angel's trumpet can cause symptoms of poisoning. Easy availability of the plant thus presents a danger. Because of the increasing incidence of deliberate ingestion by young people, poisoning by Angel's trumpet should be included in the differential diagnosis in patients with confusion and hallucinations of uncertain origin, especially during the summer months.

Gas chromatographic-mass spectrometric detection of anhydroecgonine methyl ester (methylecgonidine) in human serum as evidence of recent smoking of crack.

The discrimination between smoking of crack and other routes of cocaine application has forensic implications. The pyrolysis product anhydroecgonine methyl ester (AEME, methylecgonidine) has been found to be a marker for smoked cocaine. An improved method for the determination of AEME in serum was developed, consisting of mixed phase solid-phase extraction and GC-MS. Special care was taken for the volatility of AEME and tert.-butyldimethylsilylation was used for derivatization. Thus AEME could be determined for the first time in 13 serum samples from living subjects. The concentrations found were in a range of 3 to 34 ng/ml, a correlation with the storage time of the samples or with benzoylecgonine concentrations could not be found.

Determination of amphetamine and methylenedioxy-amphetamine-derivatives in hair.

Two GC/MS-procedures for the detection of amphetamine and its methylenedioxy-derivatives (MDA, MDMA and MDE) in hair are presented. In these methods a methanol sonication extraction technique was applied. The extracted drugs were derivatized either with propionic acid anhydride (PSA) or trifluoroacetic acid anhydride (TFA). PSA-derivatives are more stable than TFA-derivatives, but the latter provide more specific mass-spectrometric information, and, therefore, seem to be preferably for amphetamine determination. The detection limit for all compounds was in a range of about 0.01 ng/mg, if at least 50-100 mg of hair were analyzed, independent of the derivatization used.

Nonoxidative ethanol and methanol changes in the heart and brain tissue of alcohol abusers.

Fatty acid ethylesters (FAEE) are synthesized from ethanol and fatty acids in the heart and brain. Similarly fatty acid methylesters (FAME) are synthesized from methanol and fatty acids. Whereas methanol reportedly indicates recent or chronic consumption of alcoholic beverages, an elevated serum methanol concentration (SMC) indicates mainly chronic alcohol intake. We compared levels of FAEE and FAME in cardiac and brain tissues with the blood ethanol concentration(BEC) and SMC in 18 alcohol abusers and 29 control subjects without history of alcohol abuse(control) to clarify the relationships between BEC and FAEE levels and that between SMC and FAME levels. We also assessed the possibilities of discriminating the alcohol abusers from the control group and of detecting FAEE and FAME accumulations in cardiac and brain tissues. Levels of FAEE and FAME were determined by gas chromatography (GC) in autopsied cardiac and brain tissues. Heart FAEE (HFAEE) levels correlated with BEC (r = 0.61) and it was possible to distinguish between alcohol abusers and controls using discriminant analysis. HFAEE levels in the alcohol abusing group were elevated even with low BEC. Therefore, HFAEE levels indicate ethanol accumulation in cardiac tissues of alcohol abusers. Brain FAEE (BFAEE) and heart and brain FAME (HFAME and BFAME) levels did not correlated closely with BEC and SMC, respectively. However, there are some possible means of discriminating between the two groups in terms of BEC and BFAEE, and SMC and FAME respectively, using discriminant analysis. Employing this analysis, the rate of misclassification was 17-25.5%. The mean levels of HFAEE, BFAEE, HFAME and BFAME were higher in the alcohol abusing group than in the control group, even when their BEC and SMC were quite low.

Concentrations of delta 9-tetrahydrocannabinol, cocaine and 6-monoacetylmorphine in hair of drug abusers.

Hair samples taken from 850 individuals with presumed drug abuse were tested simultaneously for delta 9-tetrahydrocannabinol (THC), cocaine, heroin, the primary heroin metabolite 6-monoacetylmorphine (6-MAM) and morphine. The drugs were extracted with methanol under sonication. Compared to other extraction procedures this solvent extraction technique provides high extraction yields and less experimental effort. The analyses were carried out using gas chromatography-mass spectrometry (GCMS) in selected ion monitoring (SIM) mode. This procedure allows the simultaneous detection of amphetamine, methylenedioxyamphetamine (MDA), methylenedioxymethamphetamine (MDMA) and methylenedioxylamphetamine (MDE). THC was found in 104 (12.2%), cocaine in 230 (27%) and 6-MAM in 141 (16.6%) samples. In addition to 6-MAM, morphine was detected in 87 (10.2%) and heroin in 38 samples (4.5%). The concentrations found were in a range 0.009-16.7 ng/mg for THC, 0.037-129.68 ng/mg for cocaine, 0.028-79.82 ng/mg for 6-MAM, 0.045-53.14 ng/mg for heroin and 0.011-7.800 ng/mg for morphine. The statistical distribution of the drug concentrations compared with the self-reported consumption behaviour of the users may possibly lead to a better understanding of the relationship between drug dosage and corresponding concentrations in hair.

Drug death autopsies at the Munich Institute of Forensic Medicine (1981-1992).

A total of 638 drug death autopsy cases in southern Bavaria from 1981 to 1992 were analysed, including epidemiological and toxicological investigations. The rate of HIV infections decreased during the last few years. Cocaine does not (yet) play a major role. Suicide rates are high. Heroin intoxications are the most frequent cause of death, mostly in combination with other drugs and alcohol. In 1992 we observed a sharp increase of the number of deaths associated with dihydrocodeine abuse. This seems to be a local phenomenon and has to be explained by uncritical and uncontrolled prescription of large amounts of this opiate by individual physicians.

Quantification of dimethindene in plasma by gas chromatography-mass fragmentography using ammonia chemical ionization.

A gas chromatographic-mass fragmentographic method using ammonia chemical ionization for the determination of dimethindene in human plasma is described. The drug was isolated from plasma by liquid-liquid extraction with hexane-2-methylbutanol. Plasma components were separated on a capillary column coated with chemically bonded methyl silicone. For detection of dimethindene, its quasi-molecular ion (M + H+) was mass fragmentographically monitored after chemical ionization with ammonia as reagent gas. Dimethindene was quantified using methaqualone as the internal standard: the quantification limit in plasma was 0.2 ng/ml, the within-run precision was 8.0% and the inter-run precision 5.6%. The plasma concentration-time profile was established after a single dose of 4 mg of dimethindene with an average maximum concentration of 5.5 ng/ml, detectable up to 48 h post application.

[Legal medicine aspects of current abuse potential]. / Rechtsmedizinische Aspekte des heutigen Missbrauchspotentials.

Abuse is defined as use of a thing, which deviates from the original use and its purpose resp. in qualitative as well as quantitative manner. The task of the forensic medicine is to evidence the abuse and the misused substance resp. in order to find a basis for the judgement of the ability of the offenders guilt. The potential of abuse of several psychotropic drugs and their proof with its possibilities and limitations are described.

Benzodiazepine dependence: detoxification under standardized conditions.

In an analysis of the withdrawal syndrome of 12 patients dependent on benzodiazepines (BZD), important factors such as underlying psychiatric disease, precipitating life events, complaints leading to BZD use, and also positive and negative psychological and social consequences, duration of intake, dose and type of BZD dependence are discussed. Withdrawal was completed under standardized inpatient conditions reducing the BZD dose to 50% of the previous dose once every 5 days and maintaining control through regular measurements of the BZD urine concentrations. The course of the somatic, psychological and perceptual withdrawal phenomena was documented according to Lader's BZD withdrawal symptom checklist (Lader, M. (1983) J. Clin. Psychiatry 44, 121-127). The reduction scheme proved to be safe and efficient; no major withdrawal syndromes developed. Abstinence phenomena largely disappeared within 10 days of discontinuation.

[Plasma and urine catecholamines in a 7-day survival of parathion poisoning]. / Plasma- und Urin-Katecholamine bei einer 7 Tage überlebten Parathion-Intoxikation.

During the intensive medical treatment of a finally fatal parathion poisoning (survival time 7 days) with shock symptoms (lung and kidney) the kinetic profiles of both plasma and urinary catecholamines were taken up. In addition the parathion concentrations of the same plasma samples were measured. There could have been found plasma catecholamine profiles exhibiting peak concentrations in the initial phase, followed by a period of 4 days without any detectable plasma epinephrine and finally an extreme elevation of both catecholamines in the last period before death. The excretion patterns confirmed the plasma results. Imaginable pathophysiological mechanisms in consideration of the shock induced renal insufficiency are discussed. The question is raised whether the kinetics of plasma catecholamines may be a possible marker for the prognosis of organophosphate poisoning.

[The kinetics of plasma catecholamine in alkylphosphate poisoning and their therapy]. / Plasma-Katecholamin-Verlauf bei Alkylphosphat-Intoxikationen und deren Therapie.

In connection with the "endogenous acetylcholine-poisoning" due to organophosphorous compounds beside the clinical important muscarinic and nicotinic symptoms an activation of the sympathetic nervous system (adrenal medulla, sympathetic ganglia) is expected. Therefore a kinetic profile of norepinephrine and epinephrine in the plasma of two patients with severe parathion-poisonings was taken up through the whole period of the intensive-medical treatment. The method used was HPLC with electrochemical detection. The parathion-concentration of the same plasma samples were measured, too. The result were individual different courses with periodically appearing, markedly increased plasma catecholamine values. A direct correlation of catecholamines with the parathion-concentration was not recognizable. A possible influence of the atropine-treatment as well as of stress-factors is discussed but estimated as not responsible for the observed peaks.

Longitudinal study on pharmacodynamics and pharmacokinetics of acute, steady-state and withdrawn quazepam.

To assess pharmacodynamic and pharmacokinetic properties of acute, subchronic and withdrawn quazepam, a single-blind, longitudinal study was run in eight male, healthy young volunteers. The design covered a 1-week placebo run-in period, a period with daily oral night-time administration of 15 mg quazepam until a pharmacokinetic steady-state was reached (3 weeks) and a 2-week placebo withdrawal period. Oculodynamic Test (ODT) (EOG-registration with simultaneous choice reaction task, CRT) and Adaptive Pursuit Tracking Test (APTT) were used for assessment of intradiurnal and long-term profiles of attention, perception, cognition, objective sedation, psychomotor and muscular (force-related) parameters and cardiorespiratory measures under workload. Visual analogue scales (VAS) of sedation, excitation and state anxiety were applied additionally. Plasma levels of quazepam and its metabolites (oxoquazepam and desalkyl-oxoquazepam) were intermittently analyzed by GC, within 24 h after actual blood sampling in the morning of assessment days, to check the attainment of the intended criterion for termination of medication (steady-state, "on-line kinetic procedure"). Adverse effects were recorded by subjects' written free recall and a symptom-checklist. Although a pharmacokinetic steady-state could be reached in sequence for the parent drug quazepam and its metabolites within 3 weeks, there was no pharmacodynamic steady-state at the end of this period, but a continuous impairment in oculomotor variables. Performance in the choice reaction task and the APTT showed a similar tendency, which was masked to a certain extend by learning effects. There were no signs for rebound effects within the 2 weeks after withdrawal. Relevant carry-over phenomena declined after 3 days of withdrawal.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of oxilofrine in plasma and urine by high-performance liquid chromatography with electrochemical detection and comparison with gas chromatography-mass spectrometry.

A high-performance liquid chromatographic (HPLC) method with electrochemical detection for the determination of oxilofrine [1-(4-hydroxyphenyl)-2-methylaminopropanol] in human plasma and urine (before and after cleavage of the metabolic conjugates) is described. Isolation from biological fluids is performed batchwise by weak acid cation exchange. Separation of plasma and urine components is achieved on a reversed-phase C18 column as an ion pair with heptanesulphonic acid. For amperometric detection the potential of the electrode was set at 0.95 V versus an Ag/AgCl reference electrode. The detection limit for oxilofrine in plasma is 1 ng/ml and in urine 12.5 ng/ml at a signal-to-noise ratio of 2.0 using 1.0 ml of plasma and 0.02 ml of urine. The method was compared with a gas chromatographic-mass spectrometric method and showed a good concordance for plasma (r = 0.996) and urine (r = 0.994). With the HPLC method it is also possible to determine related sympathomimetic drugs, e.g., etilefrine, norefenefrine or octopamine, after a slight modification of the mobile phase.