Gamma-hydroxybutyrate in urine and serum: additional data supporting current cut-off recommendations.

Besides the use of Gamma-Hydroxybutyrate (GHB) as a recreational drug, use of GHB as an agent in drug-facilitated crime should also be considered. In these cases, there is often a delay of several hours from the incident to collection of the samples. As GHB has a very short plasma half-life, the window of detection is small and in the majority of these specimens, levels of GHB are low. Because GHB is naturally occurring in humans, discrimination between endogenous and exogenous GHB is complicated, particularly in those samples with low concentrations. In this study, endogenous GHB levels of 50 serum and 50 urine samples were determined by GC-MS after conversion to trimethyl-silyl-derivatives. Concentrations in serum ranged from 0.62 to 3.24 mg/L (mean=1.14 mg/L; median=0.97 mg/L) and from 0.64 to 4.20mg/L (mean=1.21 mg/L; median=0.96 mg/L) in urine. Based on this substantial data, the current suggested lower cut-off of 4 mg/L in ante mortem serum samples could be confirmed. For urine, we propose the lower cut-off of 6 mg/L instead of 10mg/L to avoid false negative interpretation.

Mood, cognition and serotonin transporter availability in current and former ecstasy (MDMA) users: the longitudinal perspective.

Although 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) is a known serotonergic neurotoxin in different animal species, there is to date no conclusive evidence of its neurotoxicity in humans. MDMA use was associated with impairments of psychological well-being, verbal memory and altered serotonergic functioning in a number of cross-sectional studies. Due to inherent methodological limitations, such as the notorious polydrug use of ecstasy users and lack of control of possible pre-existing differences between ecstasy users and control participants, researchers have called for well-controlled, prospective longitudinal studies to shed more light on the issue of MDMA neurotoxicity to the human brain. This longitudinal study investigated whether mood, cognition and central serotonin transporters (SERT) would deteriorate with continued MDMA use and whether or not they would recover over increasing periods of MDMA abstinence. In a repeated-measures design, 11 current and ten ex-ecstasy users, and 11 polydrug (but not MDMA) and 15 drug-naive controls participated three times within approximately two years. Both ecstasy user groups reported a polydrug use pattern besides heavy ecstasy use. Subjective reports of ecstasy use or abstinence were verified by toxicological analyses. On each trial, the participants underwent a cognitive test battery and filled in the Symptom Check List. The availability of central SERT was assessed with positron emission tomography using the McN5652 ligand for all groups at t1, and only for the ecstasy user groups on follow-ups. The factor Group yielded significant results in the SCL-90 scales Global Severity Index, Anxiety, Obsessive/compulsive and Interpersonal sensitivity, with the ex-ecstasy users reporting the highest symptom scores. There were significant Group effects in all measures of verbal memory, with the lowest performance in the group of ex-ecstasy users. The repeated-measures analyses yielded no significant Group x Time interactions in any SCL-90 scales or measures of memory performance, with the exception of AVLT 1 immediate recall. Thus the ex-ecstasy users' psychopathological symptoms and memory performance failed to improve, and the current ecstasy users' failed to deteriorate, over time relative to the other groups. While there was a significant effect of Group in all brain regions examined (except the control region white matter), the current users' SERT availability seems to have recovered in the mesencephalon, as indicated by a significant Group x Time interaction. Reduced SERT availability might be a transient effect of heavy ecstasy use, since it partially recovered as the current users reduced their MDMA use. However, this measure may not necessarily be a valid indicator of the number or integrity of serotonergic neurons. Ex-ecstasy users' verbal memory showed no sign of improvement even after over 2.5 years of abstinence and thus may represent persistent functional consequences of MDMA neurotoxicity. However, alternative causes such as pre-existing group differences cannot be completely ruled out in spite of the longitudinal design.

Mental disorders in current and former heavy ecstasy (MDMA) users.

BACKGROUND: Ecstasy use has often been found to be associated with psychopathology, yet this research has so far been based largely on subjective symptom ratings. AIMS: To investigate whether ecstasy users suffered from long-term psychopathological consequences. MEASUREMENTS: We compared the prevalence of Diagnostic and Statistical Manual version IV (DSM-IV) mental disorders in 30 current and 29 former ecstasy users, 29 polydrug and 30 drug-naive controls. Groups were approximately matched by age, gender and level of education. The current ecstasy users reported a life-time dose of an average of 821 and the former ecstasy users of 768 ecstasy tablets. FINDINGS: Ecstasy users did not significantly differ from controls in the prevalence of mental disorders, except those related to substance use. Substance-induced affective, anxiety and cognitive disorders occurred more frequently among ecstasy users than polydrug controls. The life-time prevalence of ecstasy dependence amounted to 73% in the ecstasy user groups. More than half of the former ecstasy users and nearly half of the current ecstasy users met the criteria of substance-induced cognitive disorders at the time of testing. Logistic regression analyses showed the estimated life-time doses of ecstasy to be predictive of cognitive disorders, both current and life-time. CONCLUSIONS: The motivation for ecstasy use is not likely to be self-medication of pre-existing depressive or anxiety disorders as these did not occur more frequently in the ecstasy users than in control groups or in the general population. Cognitive disorders still present after over 5 months of ecstasy abstinence may well be functional consequences of serotonergic neurotoxicity of 3,4-methylenedioxymethamphetamine (MDMA).

[AWMF-guideline: cocaine-, amphetamine-, ecstasy- and hallucinogen-related disorders]. / AWMF-Behandlungsleitlinie: Psychische und Verhaltensstörungen durch Kokain, Amphetamine, Ecstasy und Halluzinogene.

Actually, guidelines for treatment of substance-related disorders were written under the overall control of the DG-Sucht e. V. and the DGPPN e. V. This appears within the framework of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaft (AWMF). The leading objective of these guidelines is the description of the current scientifically proven and evidence-based medicine in addiction to derive recommendations to therapy. In this context, the guideline for treatment of cocaine-, amphetamine-, ecstasy-, and halluzinogen-related disorders is introduced.

Rapid and sensitive quantitative analysis of alkyl phosphates in urine after organophosphate poisoning.

Organophosphate compounds are widely used as pesticides. After ingestion by humans, organophosphates decompose into alkyl phosphates. Decomposition continues postmortem. We developed a rapid (< 3 h), quantitative, and sensitive analysis of the human organosphosphate metabolites O,O-dimethylphosphate (DMP), O,O-diethylphosphate (DEP), O,O-dimethylthiophosphate (DMTP), O,O-diethylthiophosphate (DETP), O,O-dimethyldithiophosphate (DMDTP), and O,O-diethyldithiophosphate (DEDTP). Urine is dried under azeotropic conditions with isopropanol and nitrogen. All metabolites are converted into their corresponding benzyl esters reacting with benzyl bromide and diazotoluene. The protocol prevents the isomerization of DMTP and DETP occurring when diazo compounds are used exclusively. The benzyl ester derivatives are purified on solid-phase extraction silica columns. The quantitative analysis is performed by gas chromatography-mass spectrometry. All metabolites can be identified by the parent molecular ions. Urine samples from eight cases of fatal suicidal poisoning dialkyl phosphates were quantitated. The limits of detection ranged from 3 to 6 ng/mL. Hence, this protocol is sufficiently sensitive to detect and quantitate organophosphate metabolites beyond cases of fatal poisoning, in the clinical setting, and even following average environmental exposure.

Therapeutic and toxic blood concentrations of more than 800 drugs and other xenobiotics.

In order to assess the significance of drug levels measured in clinical and forensic toxicology as well as for Therapeutic Drug Monitoring (TDM) it is essential that good collections of data are readily available. For more than 800 substances, therapeutic ('normal') and, if data was available, toxic, and fatal plasma concentrations as well as elimination half-lives were compiled in a table. The compilation includes data for hypnotics, benzodiazepines, neuroleptics, antidepressants, sedatives, analgesics, anti-inflammatory agents (e.g., NSAIDs), antihistamines, antiepileptics, betaadrenergic antagonists, antibiotics (penicillins, cephalosporins, aminoglycosides, gyrase inhibitors), diuretics, calcium-channel blockers, cardiac glycosides, antiarrhythmics, antiasthmatics, ACE-inhibitors, opiate agonists, and local anesthetics, among others. In addition, toxicologically relevant xenobiotics were listed. Data have been abstracted from published information, both compilations and primary sources and have been completed with data collected in our own forensic and clinical toxicology laboratories. Wherever possible, ranges for therapeutic plasma concentrations are expressed as trough concentration at steady state. The half-life values given for each drug are chosen to represent the terminal log-linear phase at most. It is the purpose to rapidly assess the significance of drug levels for the therapeutic monitoring of patients, and to facilitate the diagnostic and clinical assessment in case of intoxications.

Mood, cognition and serotonin transporter availability in current and former ecstasy (MDMA) users.

RATIONALE: Chronic recreational ecstasy (MDMA) use has often been reported to be associated with psychopathology, memory impairments and serotonergic alterations. However, the findings have not been consistent. OBJECTIVES: To attempt to replicate these findings, to investigate whether such alterations would be reversible and whether they could be predicted by parameters of previous drug use. METHODS: In a cross-sectional design, 30 current and 31 ex-ecstasy users with ecstasy abstinence of at least 5 months, and 29 polydrug and 30 drug-naive controls were compared on measures of psychopathology, cognitive performance and serotonin transporter availability. RESULTS: The groups did not differ significantly in age, gender distribution, education level and premorbid intelligence. The ecstasy groups did not differ significantly from polydrug controls on most of the relevant parameters of concomitant illegal drug use. Reported drug use was confirmed by hair and urine analyses. All three groups of drug users exhibited significantly elevated psychopathology compared with drug-naive controls. Only ex-ecstasy users were significantly impaired on verbal recall. Current ecstasy users showed significantly reduced distribution volume ratios of serotonin transporter availability in the mesencephalon and caudate nucleus. Regression analyses indicated that psychopathology and serotonergic alterations were best predicted by the number of ecstasy tablets taken on a typical event. CONCLUSION: The results indicate that verbal memory impairments were possibly aggravated after prolonged ecstasy abstinence while there was tentative evidence of serotonergic recovery. On the other hand, self-reported elevated psychopathology appeared to be associated with polydrug use in general and not specifically with ecstasy use.

Specific neurotoxicity of chronic use of ecstasy.

The use of the illicit drug ecstasy (mainly containing methylenedioxymethamphetamine, MDMA) is widespread among young people in western Nations. Animal experiments indicate that MDMA is a potent neurotoxin specifically affecting the serotonergic system. A few functional neuroimaging studies revealed central nervous alterations after the repeated use of ecstasy. We examined 94 ecstasy users in comparison to 27 control subjects by means of positron emission tomography (PET) with 2-[18F]-fluoro-2-deoxy-D-glucose (FDG). The FDG uptake rates were globally reduced in ecstasy users, most pronounced in the striatum. The uptake rates tended to be negatively correlated with the cumulative ecstasy doses. The results indicate that younger ecstasy users may be more vulnerable with regard to neurotoxicity.

Contribution of nonsteroidal anti-inflammatory drugs to deaths associated with peptic ulcer disease: a prospective toxicological analysis of autopsy blood samples.

CONTEXT: Of the side effects occurring in temporal association with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), peptic ulcer disease is reported most often. OBJECTIVES: To (1) provide information on the temporal association between fatal peptic ulcer presenting as sudden death and NSAID use prior to death, and (2) to examine the diagnostic efficiency of postmortem determination of NSAID levels using high-pressure liquid chromatography. DESIGN: Prospective autopsy study of all cases of sudden death associated with peptic ulcer disease from a total of 1139 medicolegal autopsies performed during a 12-month period. METHODS: Postmortem femoral blood samples were analyzed for NSAIDs using high-pressure liquid chromatography, and specimens of gastric and duodenal mucosa were examined for coexisting pathologic conditions. RESULTS: Twelve fatalities that occurred out of hospital as a result of peptic ulcer disease and presented as sudden death were identified. Autopsy blood samples were positive for NSAIDs in 7 cases (ibuprofen in 4 cases, levels 0.8 to 1.4 microg/mL; diclofenac in 2 cases, levels 0.6 and 1.6 microg/mL; and ketoprofen in 1 case, level 0.3 microg/mL). The ages of the affected individuals (3 men, 4 women) ranged from 43 to 60 years. No other drugs, including corticosteroids, anticoagulants, salicylic acid, and salicylates, were present. Microscopic examination revealed no pathologic antemortem mucosal conditions in any of the cases. CONCLUSIONS: For the postmortem elucidation of etiopathogenetic factors contributing to fatal peptic ulcer disease, high-pressure liquid chromatography to determine NSAID levels in autopsy blood samples is of considerable diagnostic benefit, especially when combined with histology. The number of cases of sudden death involving younger individuals dying as a result of peptic ulcer disease in temporal association with preceding use of NSAIDs seems to be underestimated from the clinical viewpoint due to the underrepresentation of out-of-hospital fatalities in the field of clinical pathology.

Death after excessive propofol abuse.

Abuse of the anaesthetic agent propofol (2,6-diisopropylphenol) is rare, but we report a case of a 26-year-old male nurse in which the autopsy showed unspecific signs of intoxication and criminological evidence pointed towards propofol abuse and/or overdose. Intravenously administered propofol is a fast and short-acting narcotic agent, therefore it seemed questionable whether the deceased would have been able to self-administer a lethal overdose before losing consciousness. The blood and brain concentrations corresponded to those found 1-2 min after bolus administration of a narcotic standard dose of 2.5 mg propofol/kg body weight. Extremely high propofol concentrations were found in the urine indicating excessive abuse before death. However, due to the short half-life of propofol, the cumulative effects of repeated injections should not be relevant for toxicity, since this would result in a blood level increase of only 1-2 micrograms/ml. Furthermore, the detection and quantitation of propofol in three different hair segments indicated chronic propofol abuse by the deceased. The results of the investigation suggest that death was not caused by a propofol overdose but by respiratory depression resulting from overly rapid injection.

Lack of methemoglobinemia with flutamide.

OBJECTIVE: To determine whether the nonsteroidal antiandrogenic drug flutamide is a clinically relevant inducer of methemoglobinemia in patients with prostatic cancer. METHODS: Fifty consecutive outpatients with prostatic cancer stage D2 entered the study (age 71.1 +/- 7.3 y). Five patients were lost to follow-up; the remaining 45 patients received the recommended oral dose of flutamide 250 mg three times daily. Total hemoglobin (Hb) and methemoglobin (Met-Hb) concentrations were measured on varying days using an ultraviolet/visible-spectrophotometric method with an intra- and interday variability < 8%. In 12 patients, Met-Hb was analyzed before initiating flutamide therapy and after therapy was begun. RESULTS: On average, 2.6 venous blood samples per patient were analyzed with a mean Met-Hb concentration of 1.9% of total Hb. Mean concentrations of > or = 3% were detected in only six patients (13%). The data from 12 patients evaluated before and after initiating flutamide therapy were without significantly different changes. During the study period, no clinical signs of methemoglobinemia were reported or observed. CONCLUSIONS: This study found no clinically relevant increase of Met-Hb concentrations in elderly patients with prostatic cancer during chronic treatment with flutamide. However, clinicians should be aware of the very rare possibility of flutamide-induced methemoglobinemia.

Fatal intoxication with melperone.

Melperone is judged to be a safe neuroleptic drug. Until now there has been no report of a melperone fatality, though it has been used in suicide attempts. We report on a case of a 36-year-old woman where no cause of death could be established at autopsy. Criminological investigation pointed to a homicide by poisoning but also the possibility of a suicide had to be taken in account. The toxicological analysis of blood, cerebral spinal fluid and urine revealed extremely high concentrations of melperone which had never been reported before. Furthermore, diazepam, nordazepam and carbamazepine were detected. To our knowledge, this case is the first melperone fatality. Possible interactions with diazepam and carbamazepine are discussed.

Methadone-related fatalities in Hamburg 1990-1999: implications for quality standards in maintenance treatment?

Drug-related fatal poisonings were analysed in Hamburg from 1990 to 30th June 1999 with special attention to the role of methadone. The first methadone-related fatalities were observed in Hamburg three years after methadone maintenance treatment (MMT) was introduced in 1990. Meanwhile more than half of all fatal poisonings among drug addicts are monovalent or polydrug intoxications with evidence for methadone. From January 1997 until June 1999 methadone was the predominant cause of death in about 39% of all drug-related fatal poisonings while the proportion of mixed heroin/methadone intoxications was about 10%. The rising problem of methadone-related fatalities goes with a decline of monovalent heroin intoxications which decreased in the last 9 years from 60% to 11%. Sixty-five per cent of those who died of fatal methadone-related poisonings had no history of MMT (60% of those with methadone as predominant cause of death). Since take-home doses for up to 7 days are prescribed to the patient due to a change in the German Narcotics Act in 1998, the diversion of methadone into illegal markets may have been accelerated. This results in rising numbers of non-intentional methadone-related fatalities among addicts who have never been in MMT. The prerequisites for the prescription of take-home doses should be taken more serious. There is no doubt that MMT reduced the mortality rate among the great majority of patients in Hamburg but supreme efforts should be made to prevent or reduce fatal intoxications by methadone in the non-treatment group.

Acute intoxication with aniline: detection of acetaminophen as aniline metabolite.

A 47-year-old woman unwittingly ingested an unknown substance together with her breakfast coffee. She suffered effects such as strong headache, generalized cyanosis, and a burning sensation of the lips and collapsed some minutes later. After admission into hospital a methemoglobin level of 35% was determined in the blood. Treatment by administration of tolonium chloride (toluidine blue) resulted in complete recovery of the patient. The toxic agent was identified as aniline by GC with mass selective detection after organic solvent extraction and 11 h after ingestion the plasma aniline level was 0.13 mg/l. Acetanilide (0.79 mg/ml) and acetaminophen (2.3 mg/ml) were identified in plasma as metabolites of aniline. It was assumed that a high metabolic capacity for acetylation protected the victim from more severe reactions. Her husband confessed later that he had tried to poison her.

Direct semiquantitative screening of drugs of abuse in serum and whole blood by means of CEDIA DAU urine immunoassays.

The purpose of this study was to test the direct applicability of CEDIA DAU urine immunoassays to serum or whole blood. The performance of the urine assays for sensitive screening of amphetamines (AMP), benzoylecgonine (BZE), benzodiazepines (BENZ), methadone (MET), opiates (OPI), and tetrahydrocannabinol carboxylic acid (THCCOOH) was evaluated on the BM/Hitachi 911 analyzer with unpretreated serum and whole blood. The limit of detection was 0 ng/mL for all tests. Cutoff values were set from 10 to 40 ng/mL for the different assays. The assays were found to be linear between the following concentrations: AMP 0-2500 ng/mL, BZE 0-1200 ng/mL, BENZ 0-1600 ng/mL, MET 0-600 ng/mL, OPI 0-720 ng/mL, and THCCOOH 24-60 ng/mL. Precision results (within run) for different concentrations were as follows: AMP 3.1-5.7%, BZE 2.4-6.6%, BENZ 4.3-8.0%, MET 2.0-5.5%, OPI 2.8-7.6%, and THCCOOH 1.4-2.4%. Between-run results were as follows: AMP 8.7-15.5%, BZE 6.4-7.5%, BENZ 8.2-15.8%, MET 2.7-5.1%, OPI 4.3-11.2%, and THCCOOH 2.6-7.4%. Sensitivity, specificity, and comparison of CEDIA semiquantitation with GC-MS quantitative results were performed on 500 original serum and whole blood samples. The data provided sufficient documentation to use the CEDIA urine-screening technique without any adaptation as a sensitive serum/whole blood screening for BZE, BENZ, MET, OPI, and THCCOOH. Serum screening for amphetamines is not sensitive enough in the unchanged urine mode. It will require some adaptation to a serum mode (probably a higher sample volume [BM/Hitachi 911] combined with protein precipitation of the sample).

Evidence of gestational heroin exposure by comparative analysis of fetal and maternal body fluids, tissues, and hair in a heroin-related death.

In order to determine the fetal-maternal distribution of heroin and its main metabolites (6-monoacetylmorphine and morphine) the drug concentrations were measured in autopsy material. The heroin-related death of a pregnant drug abuser (approximately the 32nd week of gestation) provided the fetal and maternal material. Fetal and maternal hair was analyzed in order to obtain long-term information on the transplacental opiate transfer. Morphine and 6-monoacetylmorphine were detected in toxic concentrations in maternal as well as in fetal tissues and body fluids. The drug concentrations in the fetal blood were significantly lower than in the maternal blood. The ratio of fetal-to-maternal (F/M) blood morphine concentration was found to be 0.39, whereas the F/M ratio of 6-monoacetylmorphine in blood was 0.15. In fetal hair analysis, morphine, heroin, and, for the first time, 6-monoacetylmorphine were measured. The resulting F/M ratios were 0.49, 0.36, and 0.6, respectively.

Body-packing as cause of unexpected sudden death.

Four fatalities related to smuggling of drugs by body-packing were investigated. The victims were examined at the Institute of Forensic Medicine of Hamburg University between 1983 and 1995, two of them due to "sudden" unknown cause of death. All victims were male. Two of them were found already dead in a backyard and in a hotel, two other were emergency cases and died at a hospital. Smuggled substances included cocaine (two cases), heroin and amphetamine/caffeine. In all cases, the cause of death was intoxication caused by torn packages which were detected at autopsy. The maximum weight of the packet's contents was 630 g divided in 90 packages. Only one victim was apparently an intravenous drug-abuser. Hair analysis was performed in three cases and revealed in one case a difference between a concealed and a habitually consumed drug. Toxicological analysis revealed that the substances were quite pure and provided evidence that rather long survival was possible following intoxication in three cases, in two cases supported by hospital treatment in the final stage. The procedural regimen in cases of suspected body-packing is discussed.

A specific hydroxysteroid UGT is responsible for the conjugation of aliphatic alcohols in rats: an estimation of the importance of glucuronidation versus oxidation.

UDP-glucuronosyltransferase (UGT) activity for aliphatic alcohols was determined in microsomal liver fractions of Wistar rats. The rats were pretreated with inducers of cytochrome P450 and UGTs [phenobarbital (PB), beta-naphtoflavone (betaNF), and ethanol (10%)], and inhibition experiments with aliphatic alcohols and specific substrates for UGTs were performed to characterize the UGT form(s) responsible for the glucuronidation of aliphatic alcohols. Several UGT isoforms were purified from liver microsomes of low-androsterone-conjugating activity (LA), controls, and ethanol-pretreated rats by chromatofocusing and affinity chromatography. The results show aliphatic alcohols to be specific substrates for 17beta-hydroxysteroid UGT with considerable glucuronidation rates. This elimination pathway for aliphatic alcohols is not inducible by the tested inducers. Compared with kinetic data of oxidation, glucuronidation is probably the main elimination pathway for alcohols with a longer chain length than C3, especially when oxidation pathways are inhibited by the presence of proportionately high ethanol concentrations.

Massive ingestion of the herbicide 2-methyl-4-chlorophenoxyacetic acid (MCPA).

OBJECTIVE: To report the course of a massive ingestion of the herbicide 2-methyl-4-chlorophenoxyacetic acid or MCPA (4-chloro-2-methyl phenoxy acetic acid) and to correlate plasma 2-methyl-4-chlorophenoxyacetic acid levels with symptoms of intoxication and treatment. CASE REPORT: After intentional ingestion of the herbicide, 2-methyl-4-chlorophenoxyacetic acid, a young man suffered burning in his mouth, spasmodic pain in the extremities and a severe hypotensive crisis. Plasma 2-methyl-4-chlorophenoxyacetic acid concentration was 546 mg/L two hours after ingestion. Therapy by forced diuresis was ineffective until the urine was alkalinized (Day 4). This resulted in a rapid decline of the plasma 2-methyl-4-chlorophenoxyacetic acid level to 6 mg/L and recovery of the patient.