Roadside detection of impairment under the influence of ketamine--evaluation of ketamine impairment symptoms with reference to its concentration in oral fluid and urine

Although there are many roadside testing devices available for the screening of abused drugs, none of them can be used for the detection of ketamine, a popular abused drug in Hong Kong. In connection to local drug driving legislation, effective roadside detection of ketamine in suspected drug-impaired drivers has to be established. According to the drug evaluation and classification program (DEC), ketamine is classified in the phencyclidine (PCP) category. However, no study has been performed regarding the signs and symptoms exhibited by users under the influence of ketamine. In a study to develop a protocol for effective roadside detection of drug-impaired drivers, 62 volunteers exiting from discos were assessed using field impairment tests (FIT) that included measurements of three vital signs (i.e. body temperature, pulse rate and blood pressure), three eye examinations [pupil size, lack of convergence (LOC) and horizontal gaze nystagmus (HGN)] and four divided attention tests (Romberg, one-leg stand, finger-to-nose and walk-and-turn tests). Subsequent laboratory analysis of oral fluid and urine samples from the participants revealed the presence of common abused drugs in both the urine and oral fluid samples of 55 subjects. The remaining 7 subjects with no drug in their oral fluid samples were used as drug-free subjects. In addition, 10 volunteers from the laboratory who were regarded as drug-free subjects were also assessed using the same FIT. Among the 62 volunteers, 39 of them were detected with ketamine in their oral fluid. Of these ketamine users, 21 of them (54%) with only ketamine found in their oral fluid samples while the rest (18 subjects) of them had other drugs (i.e. MA, MDMA, benzodiazepines and/or THC) in addition to ketamine. Of the 21 ketamine-only users, 15 of them (71%) were successfully identified by FIT. It was found that when salivary ketamine concentrations were greater than 300 ng/mL, signs of impairment became evident, with over 90% detection rate using the FIT. By comparing the FIT observations on the 21 ketamine-only users with the drug-free subjects, the typical signs and symptoms observable for subjects under the influence of ketamine included LOC, HGN, elevated pulse rate and in general, failing the divided attention tests, especially the walk-and-turn and one-leg stand.     

Driving under the influence of amphetamine-like drugs

Scientific opinions differ whether the use of stimulants causes deterioration in driving skills. In 1857 of 8709 cases of driving under the influence of drugs, amphetamine-like drugs (amphetamine, methamphetamine, and methylendioxyamphetamine) were present either alone or together with other licit or illicit drugs. In 338 cases, amphetamines were the only psychoactive substance group in plasma at mean, median, and highest concentrations of 0.18, 0.12, and 1.05 mg/L, respectively. A widespread opinion is that after the consumption of amphetamines, centrally stimulating effects with corresponding consequences on safe driving are expected. In contrast, many cases were observed that rather suggested an influence of centrally sedating substances when considering the psycho-physical conditions. Relations between concentration and effect could not be established. The apparent sedation is probably the consequence of sleep deprivation during an amphetamine binge and the after-effects of the drug.     

The incidence of drugs of impairment in oral fluid from random roadside testing

Oral fluid (OF) has become a popular specimen to test for presence of drugs, particularly in regards to road safety. In Victoria, OF specimens from drivers have been used to test for the presence of methylamphetamine (MA) and Δ(9)-tetrahydrocannabinol (THC) since 2003 and 3,4-methylenedioxy-N-methylamphetamine (MDMA) since 2006. LC-MS/MS has been used to test the most recent 853 submitted OF specimens from Victoria Police for 31 drugs of abuse including those listed in the Australian Standard AS4760-2006. At least one proscribed drug was detected in 96% of drivers, of which MA was the most common (77%), followed by THC (42%), MDMA (17%) and the combination of all three (3.9%). Opioids were detected in 14% of drivers of which 4.8% were positive for 6-acetylmorphine and 3.3% for methadone. The incidence of the opioids tramadol (1.2%) and oxycodone (1.1%) were relatively low. Cocaine (8.0%) was as commonly detected as benzodiazepines (8.0%), and was almost always found in combination with MA (7.9%). Samples positive to benzodiazepines were largely due to diazepam (3.5%) and alprazolam (3.4%), with only 0.2% of drivers combining the two. Ketamine was also detected in 1.5% of cases. While the incidences of the proscribed drugs itself are concerning, it is clear that many drivers are also using other drugs capable of causing impairment.     

Detection of drugs of abuse in simultaneously collected oral fluid, urine and blood from Norwegian drug drivers

Blood and urine samples are collected when the Norwegian police apprehend a person suspected of driving under the influence of drugs other than alcohol. Impairment is judged from the findings in blood. In our routine samples, urine is analysed if morphine is detected in blood to differentiate between ingestion of heroin, morphine or codeine and also in cases where the amount of blood is too low to perform both screening and quantification analysis. In several cases, the collection of urine might be time consuming and challenging. The aim of this study was to investigate if drugs detected in blood were found in oral fluid and if interpretation of opiate findings in oral fluid is as conclusive as in urine. Blood, urine and oral fluid samples were collected from 100 drivers suspected of drugged driving. Oral fluid and blood were screened using LC-MS/MS methods and urine by immunological methods. Positive findings in blood and urine were confirmed with chromatographic methods. The analytical method for oral fluid included 25 of the most commonly abused drugs in Norway and some metabolites. The analysis showed a good correlation between the findings in urine and oral fluid for amphetamines, cocaine/benzoylecgonine, methadone, opiates, zopiclone and benzodiazepines including the 7-amino-benzodiazepines. Cocaine and the heroin marker 6-monoacetylmorphine (6-MAM) were more frequently detected in oral fluid than in urine. Drug concentrations above the cut-off values were found in both samples of oral fluid and urine in 15 of 22 cases positive for morphine, in 18 of 20 cases positive for codeine and in 19 of 26 cases positive for 6-MAM. The use of cannabis was confirmed by detecting THC in oral fluid and THC-COOH in urine. In 34 of 46 cases the use of cannabis was confirmed both in oral fluid and urine. The use of cannabis was confirmed by a positive finding in only urine in 11 cases and in only oral fluid in one case. All the drug groups detected in blood were also found in oral fluid. Since all relevant drugs detected in blood were possible to find in oral fluid and the interpretation of the opiate findings in oral fluid was more conclusive than in urine, oral fluid might replace urine in driving under the influence cases. The fast and easy sampling is time saving and less intrusive for the drivers.     

Comparison of point-of-collection screening of drugs of abuse in oral fluid with a laboratory-based urine screen.

Oral fluid is becoming increasingly useful for the detection of drugs, since it is a non-invasive specimen to collect and, because collection is directly observed, it is difficult to adulterate. A point-of-collection (POCT) oral fluid drug analysis kit has been developed for use in many drug testing situations. This paper summarizes the results of field evaluations of the ORALscreen System for screening of drugs in oral fluid. The ORALscreen System consists of an oral fluid collection device and a test device containing a lateral flow membrane immunoassay system. Paired samples (oral fluid and urine) were collected from drug users and the results from the ORALscreen POCT system were compared to urine screening results conducted in a licensed laboratory. The results demonstrate that the ORALscreen System has excellent percent agreement with the laboratory-based urine screening test results for the detection of cocaine and opiates through 2.5-3 days following drug use, respectively. Tetrahydrocannabinol (THC) was detected by ORALscreen on the day of use and 1 day after use. Good correlation between urine and oral fluid screening results was observed for the methamphetamine positive samples; however, the number of days following drug use was not determined.     

Oral fluid testing for driving under the influence of drugs: history, recent progress and remaining challenges

In recent years the demand for drug testing in oral fluid in cases of driving under the influence has been increasing. The main advantages of saliva/oral fluid are the possibility for non-medical personnel to collect it without embarrassment and a better correlation between presence of drugs in oral fluid and impairment. Several surveys have been performed since the 1980s using saliva, and researchers encountered problems related to insufficient sample volume and insufficient sensitivity of the analytical methods. Steady progress has been shown in sample collection, knowledge of toxicokinetics in oral fluid, reliability of on-site and laboratory-based immunoassays and confirmation methods. In a few countries, legislation was passed that allows the use of saliva as a matrix for screening or confirmation.Despite this progress, some more work needs to be done, principally in the areas of the sensitivity and reliability of on-site screening devices, particularly for cannabis and benzodiazepines, knowledge about passive contamination and more generalised proficiency testing before oral fluid testing for DUID will have the reliability needed to be used forensically.     

Stability study of the designer drugs "MDA, MDMA and MDEA" in water, serum, whole blood, and urine under various storage temperatures.

A controlled study was undertaken to determine the stability of the designer drugs MDA, MDMA and MDEA in pooled serum, whole blood, water and urine samples over a period of 21 weeks. The concentrations of the individual designer drugs in the various matrices were monitored over time, in the dark at various temperatures (-20, 4 or 20 degrees C), for a low (+/- 6 ng/ml for water, serum and whole blood and +/- 150 ng/ml for urine) and a high concentration level (+/- 550 ng/ml for water, serum and whole blood and +/- 2500 ng/ml for urine). Compound concentrations were measured using a validated HPLC assay with fluorescence detection. Our study demonstrated no significant loss of the designer drugs in water and urine at any of the investigated temperatures for 21 weeks. The same results were observed in serum for up to 17 weeks, and up to 5 weeks in whole blood. After that time, the compounds could no longer be analyzed due to matrix degradation, especially in the low concentration samples that were stored at room temperature. This study demonstrates that the designer drugs, MDA, MDMA and MDEA are stable when stored at -20 degrees C for 21 weeks, even in haemolysed whole blood.     

Driving under the influence of alcohol and/or drugs in the Netherlands 1995-1998 in view of the German and Belgian legislation

This study presents the test results of blood and urine samples of impaired drivers in the Netherlands between January 1995 and December 1998. In this period, the blood alcohol concentrations of 11,458 samples have been determined and 1665 blood or urine samples have been analysed for drugs. The median alcohol concentration was between 1.7 and 1.8 mg/ml blood. In 80% of the 1665 analysed samples drugs were detected. At least 42% (702/1665) of the impaired drivers were poly-drug users, with cocaine present in the most frequent combinations. In the Netherlands, the procedure to prove driving under the influence is complex. This procedure can be made more efficient and more effective by embedding the analytical test results, needed to prosecute an impaired driver, in the law. In Belgium and Germany, such laws already are in force. If we would apply the qualifications of the new Belgian law on our analytical data, 67% of the impaired drivers included in this comparison could have been prosecuted without discussion in court.     

Driving under the influence of khat--alkaloid concentrations and observations in forensic cases

The use of the herbal stimulant khat (Catha edulis FORSK) is maintained by immigrants from countries where it is part of their cultural life (Arabian Peninsula and eastern Africa). In western countries the drug and its effects are largely unknown and no experience in evaluating impairment symptoms due to the khat-alkaloids, e.g. cathinone, cathine and norephedrine exists. Blood and urine samples from khat users involved in 19 cases of suspected driving under the influence of drugs were analysed and correlated with the results of medical examination and police officer reports. In 3 cases impaired driving and in 10 cases marked impairment of psychophysical functions was observed such as effects on the nervous system (slow pupil reaction to light, dry mouth, increased heart-rate), trembling, restlessness/nervousness, daze/apathy/dullness, impairment of attention, walking and standing on one leg. However, the alkaloid concentrations assayed in blood did not correlate with the impairment symptoms. Apart from an acute phase of indirect sympathomimetic action the development of habituation and withdrawal symptoms must also be considered in explaining the diversity of effects observed. From these results it can be concluded that chewing khat may severely impair driving ability, but may also be without noticeable effects.     

Driving under the influence of alcohol and/or drugs in the Netherlands 1995–1998 in view of the German and Belgian legislation

This study presents the test results of blood and urine samples of impaired drivers in the Netherlands between January 1995 and December 1998. In this period, the blood alcohol concentrations of 11,458 samples have been determined and 1665 blood or urine samples have been analysed for drugs. The median alcohol concentration was between 1.7 and 1.8 mg/ml blood. In 80% of the 1665 analysed samples drugs were detected. At least 42% (702/1665) of the impaired drivers were poly-drug users, with cocaine present in the most frequent combinations. In the Netherlands, the procedure to prove driving under the influence is complex. This procedure can be made more efficient and more effective by embedding the analytical test results, needed to prosecute an impaired driver, in the law. In Belgium and Germany, such laws already are in force. If we would apply the qualifications of the new Belgian law on our analytical data, 67% of the impaired drivers included in this comparison could have been prosecuted without discussion in court.     

Screening for the presence of drugs in serum and urine using different separation modes of capillary electrophoresis

Capillary electrophoresis (CE) is a modern separation technique that has some distinct advantages for toxicological analysis, such as a high efficiency, fast analysis, flexibility, and complementary separation mechanisms to chromatographic methods. CE can be applied in various modes, which each have a different separation mechanism or selectivity. The most common mode is capillary zone electrophoresis (CZE), in which charged analytes migrate in a buffer under the influence of an electric field. In micellar electrokinetic chromatography (MEKC), micelles are added to the buffer which interact with the analytes. MEKC can also be used for the separation of neutral compounds. In non-aqueous CE (NACE), the aqueous buffer is replaced by a background of electrolytes in organic solvents. A sample that needs to be screened can easily be analyzed subsequently by these CE modes using the same instrumentation.The aim of the study was to develop procedures for the analysis of basic and acidic drugs in serum and urine using CZE, MEKC, and NACE. A test mixture that consisted of six basic and six acidic compounds was used to study the separation behavior of five CE methods. The results showed that three methods (based on CZE, MEKC, and NACE) were suitable for the analysis of basic compounds and three methods (based on CZE and MEKC) for the analysis of acidic compounds.For the extraction of analytes from serum and urine, a solid-phase extraction (SPE) and a liquid-liquid extraction (LLE) method were compared. Both SPE and LLE methods provided clean extracts after extraction of the basic compounds from serum and urine. The extracts of acidic compounds contained more matrix interferences, especially for urine. The SPE method had some advantages compared to LLE, as it lead to cleaner extracts and higher peaks, and as it elutes basic and acidic compounds in one fraction.The potentials and pitfalls of the various methods for screening purposes in analytical toxicology are discussed.     

The use of oral fluid and sweat wipes for the detection of drugs of abuse in drivers

Blood, urine, oral fluid (by spitting or with a Salivette), and sweat samples (by wiping the forehead with a fleece moistened with isopropanol) were obtained from 180 drivers who failed the field sobriety tests at police roadblocks. With quantitative GC-MS, the positive predictive value of oral fluid was 98, 92, and 90% for amphetamines, cocaine, and cannabis respectively. The prevalence of opiate positives was low. The proposed SAMHSA cut-off values for oral fluid testing at the workplace, proved their usefulness in this study. The positive predictive value of sweat wipe analysis with GC-MS was over 90% for cocaine and amphetamines and 80% for cannabis. The accuracy of Drugwipe was assessed by comparing the electronic read-out values obtained on-site after wiping the tongue and the forehead, with the corresponding GC-MS results in plasma, oral fluid, and sweat. The accuracy was always less than 90% except for the amphetamine-group in sweat.     

Post-mortem cases involving amphetamine-based drugs in the Netherlands: Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999–2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death.In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41–84 mg/L with a median concentration of 3.7 mg/L (n = 30). MDMA blood concentrations in the MDMA related deaths (n = 20) and in the DUI cases (n = 360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n = 7). The median concentrations of amphetamine in the amphetamine related deaths (n = 13) and the DUI cases (n = 208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

唾液中滥用药物分析及其与血液中药物浓度的相关性

唾液是一种成分简单、易于采集的体液,某些药物在唾液中的浓度可以反映其血药浓度。本文分析了滥用药物进入唾液的机制和影响因素,综述了唾液中滥用药物分析时样品的采集、前处理和检测方法以及唾液与血液中药物浓度的相关性。认为唾液是临床和法医学方面很有价值的分析样品,用唾液中滥用药物浓度来推测血药浓度具有一定的法医学意义。     

Post-mortem cases involving amphetamine-based drugs in The Netherlands. Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999-2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death. In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41-84 mg/L with a median concentration of 3.7 mg/L (n=30). MDMA blood concentrations in the MDMA related deaths (n=20) and in the DUI cases (n=360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n=7). The median concentrations of amphetamine in the amphetamine related deaths (n=13) and the DUI cases (n=208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

Impairment based legislative limits for driving under the influence of non-alcohol drugs in Norway

Bloodstains at crime scenes are among the most important types of evidence for forensic investigators. They can be used for DNA-profiling for verifying the suspect's identity or for pattern analysis in order to reconstruct the crime. However, until now, using bloodstains to determine the time elapsed since the crime was committed is still not possible. From a criminalistic point of view, an accurate estimation of when the crime was committed enables to verify witnesses' statements, limits the number of suspects and assesses alibis. Despite several attempts and exploration of many technologies during a century, no method has been materialized into forensic practice. This review gives an overview of an extensive search in scientific literature of techniques that address the quest for age determination of bloodstains. We found that most techniques are complementary to each other, in short as well as long term age determination. Techniques are compared concerning their sensitivity for short and long term ageing of bloodstains and concerning their possible applicability to be used on a crime scene. In addition, experimental challenges like substrate variation, interdonor variation and environmental influences are addressed. Comparison of these techniques contributes to our knowledge of the physics and biochemistry in an ageing bloodstain. Further improvement and incorporation of environmental factors are necessary to enable age determination of bloodstains to be acceptable in court.     

Driving and the combined use of drugs and alcohol in The Netherlands

The extent and nature of the use of medicinal drugs by drivers who had undergone a blood test on suspicion of driving under the influence of alcohol was ascertained by analysing some 40,000 case records in which the suspect had been questioned about the use of drugs. No chemical analyses were performed. 9.7% of the road users indicated that they used drugs in combination with alcohol, and more than 50% of the drugs used must be considered to have a negative impact on driving performance. The influence of the combined use of benzodiazepines and alcohol on behaviour was also investigated. The finding here was that drivers using these drugs should be warned against the consumption of alcohol.     

The diagnostic value of determining the level of acetaldehyde in blood,urine, and cerebrospinal fluid

The contents of acetaldehyde (AA) in biological fluids obtained from the dead with the confirmed lethality causes, i.e. ischemic heart disease (IHD), alcoholic cardiomyopathy (ACMP) and mechanical traumas (MT), were examined on an actual forensic-medical material (AFMM). 14 death cases of males, aged 18 to 45, were studied. The method of gas-liquid chromatography (GLC), or rather its variation of vaporphase analysis, was used to state the presence and to assess the concentration of acetaldehyde. The results revealed differences between concentrations of acetaldehyde in the examined groups depending on the presence or absence of alcoholemia. Thus, the AA concentrations were found in trace quantities in the MT group free of alcoholic intoxication; while, when it was present in this group, the concentrations went up several-fold. A higher AA content was typical of the ACMP group in all examined subjects both with and without alcoholic intoxication. The final study results are suggestive of that the AA determination in blood, urine and liquor by GLC could be used, within the forensic medical practice, in assessing a severity degree of alcoholic intoxication while establishing the lethal outcome cause due to chronic pathologies and MT.