Vigdis Vindenes

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

AIMS When non-alcohol drugs are detected in blood samples from apprehended drivers in Norway, individualised expert opinions are required to evaluate degree of impairment. For alcohol, legislative limits have been in use since 1936. To harmonize the current practice for driving under the influence of alcohol and non-alcohol drugs, a judicial reform with legislative limits for non-alcohol drugs has been suggested. METHODS Impairment limits, representing drug concentrations in blood likely to be accompanied by a degree of impairment comparable to a blood alcohol concentration (BAC) of 0.02%, were proposed for 20 psychotropic drugs, including the most prevalent benzodiazepines, cannabis, GHB, hallucinogens and opioids. Limits for graded sanctions, representing drug concentrations in blood likely to induce impairment comparable to BACs of 0.05% and 0.12%, were defined for 13 of the 20 substances. The suggested limits were based on assessments of impairment after single doses of the drugs in naïve individuals. The proposed limits will not apply to individuals with valid prescriptions for medicinal drugs, where the present system with individualised expert evaluations will be maintained. CONCLUSION Norway is the first country planning to implement legislative limits for non-alcohol drugs corresponding to impairment seen at increasing BACs. The background and justification for the suggested limits are presented herein.

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.

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.

Lethal poisonings with AH-7921 in combination with other substances

AH-7921 is a synthetic μ-opioid agonist, approximately equipotent with morphine. We report the death of two young individuals after ingestion of AH-7921 in combination with other psychoactive drugs. In the first case a young man died shortly after ingesting Internet drugs. Toxicological analysis of post mortem peripheral blood revealed AH-7921 (0.43 mg/L), 2-FMA (0.0069 mg/L) and 3-MMC (0.0021 mg/L) as well as codeine (0.42 mg/L), codeine-6-glucuronide (0.77 mg/L) and acetaminophen (18.7 mg/L). The second case involved a young female found dead at home. The only positive finding at medicolegal autopsy was needle marks. Toxicological analysis revealed AH-7921 (0.33 mg/L), methoxetamine (MXE) (0.064 mg/L), etizolam (0.27 mg/L), phenazepam (1.33 mg/L), 7-aminonitrazepam (0.043 mg/L), diazepam (0.046 mg/L), nordiazepam (0.073 mg/L), and oxazepam (0.018 mg/L) in blood. In both cases intoxication with AH-7921 in combination with other psychoactive drugs was considered to be the cause of death.

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).

Recent trends in the availability and use of amphetamine and methamphetamine in Norway

BACKGROUND There is a concern about methamphetamine use in Europe. Methamphetamine fatalities have recently occurred in Southern European countries. The aim of this study is to examine Norwegian methamphetamine trends in recent years, comparing different data sources. MATERIAL AND METHODS Data about amphetamines were collected from five different sources; blood samples from drivers suspected of driving under the influence of drugs and apprehended by the police (during the years 2000-2012), urine samples from inmates in Norwegian prisons (during 2000-2012), post-mortem blood samples from medico-legal autopsies (2000-2012), drug seizures (1994-2012) and wastewater samples from a metropolitan/suburban population (2010-2012). RESULTS The number of cases where methamphetamine was detected has increased during the period studied for the driving under the influence cases, the samples from inmates and from forensic autopsies. The increase seems to be linear up to 2009-2010, with a subsequent stabilisation or even a decline in the market share of methamphetamine for the next few years. The number of methamphetamine seizures has risen from less than 1% in 2000 to approximately 66% in 2009, and a steady share around 60% have been seen between 2010 and 2012. Wastewater samples showed that the share of methamphetamine peaked in 2010-11, before falling. INTERPRETATION It is difficult to obtain reliable data on illicit drugs. Data from different populations might give indications of changes and trends, but are always prone to different biases. By comparing results from different data sources, a better knowledge of the illicit drug market might be obtained. All our data sources confirmed that methamphetamine became a more prevalent drug during the first decade of the new millennium in Norway, but since approximately 2009 the share of methamphetamine stabilised.

Has the intake of THC by cannabis users changed over the last decade? Evidence of increased exposure by analysis of blood THC concentrations in impaired drivers

The main psychoactive substance, Δ9-tetrahydrocannabinol (THC) can be present in highly variable amounts in different cannabis preparations. An increase in THC content in cannabis products has been suggested, and reported from several countries. However, it has not yet been investigated if products with high potency lead to increased human exposure, and thus to higher risk of adverse effects. In this study, we examined the mean concentrations of THC in whole blood samples from drivers apprehended in Norway in the period between 2000 and 2010 suspected of driving under the influence of drugs. Cases with only THC (n=1747) have been compared to cases with only ethanol (n=38796) or amphetamines (n=2493). The increase in mean THC concentration measured from 2000 to 2010 was from 4.0 ± 0.3 to 6.6 ± 0.4 ng/ml (58%), compared to 3% for ethanol and 16% for the amphetamines. This increase in THC concentrations was to some extent paralleled by an increase in the percentage of drivers which were judged as lightly impaired by a physician. Monitoring concentrations of drugs of abuse in blood from apprehended drivers indicated an increasing exposure to THC in Norway. If similar trends are observed globally, it should be further explored if this type of information could be used to elucidate the drug consumption patterns in a population and accordingly the consequences with regard to adverse effects of cannabis from a public health perspective.

Long-term stability of morphine, codeine, and 6-acetylmorphine in real-life whole blood samples, stored at −20 °C

PURPOSE Stability of drugs during storage is important in forensic toxicology. For the analytes detected after intake of heroin (6-acetylmorphine (6-AM), morphine and codeine), long-time stability in real life whole blood samples are studied in only a small number of cases. METHODS Whole blood post mortem (n=37) and whole blood samples from living persons (n=22) containing morphine and codeine as well as 6-AM in blood or urine were selected. All cases represented intake of heroin. All samples contained fluoride and were initially analysed and stored in normal conditions (-20°C) for 4-9 years. All samples were then reanalysed using the same analytical methods and the results were compared. RESULTS For samples from living persons, the median change in concentration was -3.7% for morphine and -5.3% for codeine. For post mortem samples, the median change in concentration was -12% for morphine and -11% for codeine. Both for samples from living persons and post mortem samples, the decrease in the concentrations from the original analysis to reanalysis were statistically significant for morphine and codeine. Regarding 6-AM, all living samples were negative at reanalysis. For post mortem samples, four cases still tested positive for 6-AM at reanalysis with a median change in the concentrations of -81%. There was no significant change in the morphine to codeine concentration ratios neither for living nor post mortem samples. CONCLUSION This study showed that in real life whole blood samples, the concentrations of morphine and codeine are relatively stable during long-term storage at -20°C. 6-AM on the other hand, shows a considerable decrease in concentrations that is important to consider when interpreting results from reanalyses of forensic cases.

Simultaneous measurement of heroin and its metabolites in brain extracellular fluid by microdialysis and ultra performance liquid chromatography tandem mass spectrometry.

INTRODUCTION The pharmacokinetic profile and systemic bioavailability of a substance is often described by blood or total tissue concentrations. For centrally acting drugs, like opioids, the free fraction of active compound in brain extracellular fluid (ECF) is more likely to be correlated to the pharmacodynamic effects than the blood concentrations. Drugs of abuse, like heroin, are often administered intravenously as bolus injections, and the blood concentrations might change rapidly due to metabolism and distribution. The aim of our study was to establish a method to measure the free fraction of heroin and its metabolites in brain ECF, and follow their fast changes in concentration. METHODS Sprague-Dawley rats were injected intravenously with a bolus of heroin. Heroin and its main metabolites 6-monoacetylmorphine, morphine and morphine-3-glucuronide were measured simultaneously. Brain microdialysis was used for sampling and a method for quantification using ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) was developed. Deuterated analogues for each analyte were included in the microdialysis perfusion solution as calibrators for recovery estimation. RESULTS A highly sensitive UPLC-MS/MS method allowed short sampling intervals, down to one minute, and the simultaneous detection of each analyte and its specific deuterated analogues, making possible the individual recovery calculation for each compound of interest. This method allowed us to determine the pharmacokinetic profiles of heroin and its metabolites in brain-ECF in the same animal after an intravenous injection of heroin. DISCUSSION Our method makes detecting concurrently the rapid changes in concentrations of heroin and its metabolites in brain ECF possible, despite the rapid metabolism of heroin. Recovery was measured specifically for each analyte in the same sample by carefully combining different deuterated analogues. This technique can be applied to pharmacokinetic studies where more than one compound of interest has to be monitored, and to study distribution of prodrugs or drugs with active metabolites.