Elisabeth Leere Øiestad

Prevalence of alcohol and drugs among Norwegian motor vehicle drivers: A roadside survey

The objective of the study was to determine the prevalence of alcohol, psychoactive medicinal drugs and illegal drugs among drivers in Norwegian road traffic. Drivers of motor vehicles were selected from April 2005 to April 2006 in the south-eastern part of Norway, surrounding, but not including the capital, Oslo. A stratified two-stage cluster sampling procedure was used. In the first stage, random road sites and time intervals were selected, and in the second stage, drivers were stopped by random at those sites and time intervals. Altogether about 12,000 drivers were asked to provide a sample of oral fluid (saliva) and answer a few questions. Samples of oral fluid were obtained from 88% of the drivers, of whom 30% were females and 70% males. The prevalence of each drug was estimated by a weighted average using weights adjusted for under- or over-sampling compared to traffic statistics. Alcohol or drugs were found in oral fluid samples of 4.5% of the drivers; alcohol in 0.4%, psychoactive medicinal drugs in 3.4%, and illegal drugs in 1.0%. Illegal drugs were found more frequently in samples from younger drivers, while psychoactive medicinal drugs were more frequently found in samples from older drivers. Psychoactive medicinal drugs were more prevalent among females than males, among drivers stopped on working days rather than weekends, and among those who reported annual driving distances less than 16,000 km. The drugs found most frequently were zopiclone (1.4%), benzodiazepines (1.4%), codeine (0.8%), tetrahydrocannabinol (0.6%) and amphetamines (0.3%). Two or more drugs were found in 0.6% of the samples, corresponding to 15% of the drug-positive drivers.

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.

Electromembrane extraction of stimulating drugs from undiluted whole blood

For the first time, electromembrane extraction (EME) of six basic drugs of abuse from undiluted whole blood and post mortem blood in a totally stagnant system is reported. Cathinone, methamphetamine, 3,4-methylenedioxy-amphetamine (MDA), 3,4-methylenedioxy-methamphet-amine (MDMA), ketamine and 2,5-dimethoxy-4-iodoamphetamine (DOI) were extracted from the whole blood sample, through a supported liquid membrane (SLM) consisting of 1-ethyl-2-nitrobenzene (ENB) immobilized in the pores of a hollow fiber, and into an aqueous acceptor solution inside the lumen of the hollow fiber. The SLM acts as a barrier with efficient exclusion of all macromolecules and acidic substances in the sample. Due to the application of the electrical field, only the cationic compounds of interest are extracted efficiently across the membrane, thus providing extremely clean extracts for analysis with liquid chromatography-mass spectrometry, LC-MS. Recoveries in the range 10-30% were obtained from 80 μl whole blood within 5 min extraction time and an applied voltage of 15V across the SLM. The optimized technique was tested on real forensic whole blood samples taken from three forensic autopsy cases and on five forensic whole blood samples from living persons. The results were in agreement with the analysis using standard sample preparation methods (liquid-liquid extraction) performed on the same samples by Norwegian Institute of Public Health (NIPH), Division of Forensic Toxicology and Drug Abuse Research. Evaluation data were acceptable, with limit of detections (LODs) in the range 40-2610 pg/mL, well below concentrations associated with drug abuse; linearites in the range between 10 and 250 ng/mL with r(2) values above 0.9939, and with repeatability (RSD) of 7-32%.

Comparison of drug concentrations between whole blood and oral fluid

The relationship of drug concentrations between oral fluid and whole blood was evaluated by studying the linear correlation of concentrations and calculating the oral fluid to blood concentration ratios (OF/B) for different substances. Paired oral fluid and whole blood samples were collected from volunteers and persons suspected of drug use in four European countries. Oral fluid samples were collected with the Saliva∙Sampler™ device. All samples were analyzed for drugs of abuse and psychoactive medicines with validated gas and liquid chromatography-mass spectrometric methods. The median OF/B ratios were, for amphetamines 19-22, for opioids 1.8-11, for cocaine and metabolites 1.7-17, for tetrahydrocannabinol (THC) 14, for benzodiazepines 0.035-0.33, and for other psychoactive medicines 0.24-3.7. Most of the these results were close to theoretical values based on the physicochemical properties of the drugs and to values presented earlier, but there was a lot of inter-individual variation in the OF/B ratios. For all substances, except for lorazepam (R(2)  = 0.031) and THC (R(2)  = 0.030), a correlation between the oral fluid and whole blood concentrations was observed. Due to large variation seen here, drug findings in oral fluid should not be used to estimate the corresponding concentrations in whole blood (or vice versa). However, detection of drugs in oral fluid is a sign of recent drug use and oral fluid can be used for qualitative detection of several drugs, e.g. in epidemiological prevalence studies. By optimizing the sampling and the analytical cut-offs, the potential of oral fluid as a confirmation matrix could be enhanced.

Prevalence of synthetic cannabinoids in blood samples from Norwegian drivers suspected of impaired driving during a seven weeks period

From early year 2000 different herbal products containing synthetic cannabinoids (SC) have appeared on the drug market all over the world, and new substances are frequently introduced. The prevalence of SC use in different populations is however still mainly unknown, also in Norway. This information is difficult to obtain, but studies of drivers suspected of driving under the influence of drugs (DUID), might provide important information. The aim of this study was to assess the prevalence of SC in drivers suspected of being under the influence of drugs in Norway, and investigate if SCs impair driving performance. For two periods of three and four weeks all blood samples from drivers suspected of DUID in Norway were analyzed for the presence of 12 and 18 different SCs, respectively. A new ultra performance liquid chromatography tandem mass spectrometry method was developed. A total of 726 cases were analyzed during our study period, and SCs were detected in 16 cases (2.2%) in total. The mean age of these drivers was 29.6 years. High concentrations of other psychoactive drugs were detected in all the blood samples where a SC was found. AM-2201 and JWH-018 were the most frequently detected SCs, each found in five cases. In addition RSC-4, JWH-122, JWH-081 and JWH-250 were detected. None of the drivers had reported using SCs prior to driving. Despite the limited number of SCs investigated in this 7 week study period, a considerable percent of the cases were positive. Other psychoactive drugs of abuse were always found concomitant with the SCs, and the age of these drivers indicates that experienced drug users also ingest SCs. Since other drugs were found in all the samples, the psychomotor impairment caused by the SCs is difficult to estimate. Our study shows the importance of screening analyses of biological samples from different populations to assess the prevalence of drug use, since self-reporting might be encumbered with significant under-reporting.

Drugs of abuse in oral fluid collected by two different sample kits – Stability testing and validation using ultra performance tandem mass spectrometry analysis

Oral fluid (OF) is an alternative matrix for monitoring drugs of abuse in workplace, clinical toxicology, criminal justice, and driving under the influence of drugs (DUID). OF is suitable for detection of drugs that have been taken recently. It is unproblematic to observe the collection and hence avoid the possibility of the samples being tampered. OF often contains compounds in low concentrations, and small volumes are often collected. It is therefore necessary to have a sensitive, multi component method for drug detection. In this study an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS-MS) method has been developed. The samples were prepared by liquid-liquid extraction (LLE) with ethyl acetate/heptane (4:1) and the separation was achieved by an Acquity HSS T3-column (2.1 mm × 100 mm, 1.8 μm particles). Mass detection was performed by positive ion mode electrospray MS-MS. 32 drugs of abuse were determined with a cycle time of 9 min. Stability of drugs in oral fluid before analysis is an important factor that must be evaluated for each sampling device. The collection devices Intercept(®) and StatSure Saliva Sampler™ were tested using pools of real samples containing various drugs. The testing showed that 6-MAM (6-acetylmorphine), cocaine and zopiclone were the least stable compounds. In the testing for short term stability, StatSure Saliva Sampler™ showed better results. The testing of 1 year of storage at -20°C showed that most of the compounds were stable for both sampling devices, except for 6-MAM, cocaine and zopiclone. Samples of OF should be analysed as soon as possible after collection, and they should be kept frozen if immediate analysis is not possible.

Norwegian Roadside Survey of Alcohol and Drug Use by Drivers (2008–2009)

Objective: To examine alcohol and drug use among random drivers in different regions of Norway by analyzing oral fluid, compare drivers in urban and rural areas, compare with results from the roadside survey in southeastern Norway in 2005–2006, and roughly estimate the prevalence of driving with blood drug concentrations above the new Norwegian legislative limits among random drivers. This roadside survey was part of the European DRUID (Driving Under the Influence of Drugs, Alcohol and Medicines) Project. Methods: Drivers were selected for a voluntary and anonymous study using a stratified multistage cluster sampling procedure in collaboration with the Mobile Police Service. Samples of oral fluid were taken using the Statsure Saliva Sample (Statsure Diagnostic Systems, Framingham, MA), and the drivers’ gender, age, and nationality were recorded. Samples of oral fluid were analyzed for alcohol or drugs, for a total 28 psychoactive substances. Results: One hundred eighty-four roadside survey sessions were conducted and 10,004 drivers were asked to participate. The refusal rate was 5.8 percent. Psychoactive substances were found in 4.8 percent of the 9410 oral fluid samples analyzed. Alcohol was detected in 0.3 percent, medicinal drugs in 3.2 percent, and illegal drugs in 1.5 percent of the samples. Illegal drugs were significantly more frequently detected in samples from southeastern Norway including the capital Oslo, whereas medicinal drugs were more frequently detected in samples from southeastern Norway excluding Oslo. Illegal drugs were significantly more frequently detected in samples from drivers in urban areas than in rural areas, though there were no significant differences for alcohol and medicinal drugs. Medicinal drugs were most commonly found in samples collected during the daytime on weekdays (3.8%), and illegal drugs were most commonly found in samples collected during late night on weekdays or weekends (2.8%–3.2%). The most commonly found substances were the sleeping agent zopiclone (1.4%), the main active substance in cannabis tetrahydrocannabinol (1.1%), and the sedative drug diazepam (0.7%). The prevalence of driving with drug concentrations above the Norwegian legislative limits for blood was estimated to be about 0.2 percent for alcohol, 0.6 percent for illegal drugs, and about 1.3 percent for medicinal drugs. Conclusions: The incidence of drink driving was very low, though driving after using psychoactive illegal or medicinal drugs was more frequent. Supplemental materials are available for this article. Go to the publishers online edition of Traffic Injury Prevention to view the supplemental file.

Concentrations of APINACA, 5F-APINACA, UR-144 and its degradant product in blood samples from six impaired drivers compared to previous reported concentrations of other synthetic cannabinoids

A large number of new psychoactive substances are available at the illicit drug market and the synthetic cannabinoids (SCs) are among the substances that have led to serious side effects and death. Knowledge about common concentrations of these drugs are however sparse. Concentrations of APINACA and 5F-APINACA in biological matrixes have previously not been reported, and concentrations of UR-144 and its degradant product in blood samples from driving under the influence of drug (DUID) cases have not been published. The aims of this study were to report concentrations of APINACA, 5F-APINACA, UR-144 and UR-144 degradant from DUID cases analyzed at the Norwegian Institute of Public Health (NIPH), and also previously unpublished concentrations of AM-2201 in cases from our Institute. We have further summarized all the former published studies where concentrations of SCs have been reported, to compare with the results from these newer SCs. In whole blood from one driver we have found 5F-APINACA and from three drivers both APINACA and 5F-APINACA in concentrations from 0.24 to 24.5 and 0.9 to 6.5 μg/L, respectively, and UR-144 in two cases in concentrations of 0.22 and 0.47 μg/L. UR-144 degradant in a concentration of 0.15 μg/L was found in one of the cases. A summary of the literature reveals major deficiencies regarding concentrations of most of the SCs. The SCs most frequently detected in DUID cases were (n≥8) AM-2201, JWH-122, JWH-018 and JWH-210. In intoxication cases AM-2201 (n=517) was the most often detected SC, followed by JWH-122, JWH-210, UR-144, JWH-018, and MAM-2201 (n>100). Four studies regarding concentrations in autopsy cases have been published, and concentrations of four different SCs have been reported (JWH-018, JWH-073, JWH-210, AM-2201 and the metabolites of AM-2201; 4-OH-pentyl, JWH-018 5-OH-pentyl and JWH-018 pentanoic acid). Pharmacokinetic data are only available for JWH-018 (n=3), JWH-073 (n=1) and the metabolites of AM-2201; 4-OH-pentyl, 6-OH-indole, JWH-018 5-OH-pentyl and JWH-018 pentanoic acid (n=1).

Levels of heroin and its metabolites in blood and brain extracellular fluid after i.v. heroin administration to freely moving rats.

Heroin, with low affinity for μ‐opioid receptors, has been considered to act as a prodrug. In order to study the pharmacokinetics of heroin and its active metabolites after i.v. administration, we gave a bolus injection of heroin to rats and measured the concentration of heroin and its metabolites in blood and brain extracellular fluid (ECF).

Screening of synthetic cannabinoids in preserved oral fluid by UPLC–MS/MS

BACKGROUND The abuse of a rapidly changing range of synthetic cannabinoids is increasing worldwide. Oral fluid, which contains the parent compounds and is easily collected, could be a good alternative medium for drug screening for synthetic cannabinoids. RESULTS A method for screening of 18 synthetic cannabinoids in preserved oral fluid collected with the Intercept® collection device, using UPLC-MS/MS, was validated. Limits of quantification ranged from 0.2 to 2 ng/ml in oral fluid. In several real cases, AM-2201 and/or JWH-018 were found. CONCLUSION The presented method allowed rapid and sensitive screening of synthetic cannabinoids in preserved oral fluid collected with the Intercept collection device.