Why is exposure to pharmaceuticals and drugs of abuse relevant to health?
The use of drugs, whether illicit, common over-the-counter (OTC), or prescription, are associated with a number of health outcomes. While the use of many of these drugs can be fatal through overdose, non-lethal long term use can lead to abuse or other health effects, some of which are unknown.
While many drugs hold the potential to be abused, it is more common if they possess psychoactive (e.g., depressant, stimulant, psychedelic) properties that can lead to dependence and tolerance. This can leave an individual more vulnerable to serious health outcomes and/or overdose. While there are many different drugs that have psychoactive affects, some do not or it is unknown due to lack of research. It is relevant to monitor and gain an understanding of a diverse range of drugs that may be associated with potential abuse, polysubstance use, or unintentional exposure (e.g., neonatal) that can lead to unknowingly negative health outcomes.
There are three general categories included in HHEAR that cover a variety of drugs. These categories include: opioids, cannabinoids, and other multi-drugs.
Opioids have historically been used for pain relief and are often abused non-medically due to euphoric effects. Opioids can be synthetic (e.g., fentanyl) or semi-synthetic (prescription pain relievers). Semi-synthetic opioids also include opiates, which are the natural compounds derived from opium (e.g., heroin). In 2018, 128 opioid overdose deaths were reported in the U.S. every day (NIDA, 2020; CDC/NCHS, 2018). The ongoing national opioid epidemic stems from past misinformation from pharmaceutical companies to the medical community where a surge in prescription opioids first started. As addiction became apparent over time, opioid use disorder and overdose rates began to increase. A significant surge in synthetic opioids such as fentanyl and fentanyl analogs has been widely responsible for many overdoses and, in many instances, can be an unknown contaminant in other illicit drugs (Tupper et al., 2018). Fentanyl is 50-100 times more potent than morphine and many fentanyl analogs can be just as potent, more potent, or even worse, unknown (NIDA, 2016). The current public health crisis is apparent on many different platforms, including but not limited to the following: an increase in infectious diseases spreading via drug injection (Serota et al., 2019), a rise in misuse and overdoses contributed to unmonitored polysubstance use alongside opioid use (NIDA, 2018a; Schepis et al., 2020; Meacham et al., 2020), and an increase in neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NAS/NOWS) due to opioid misuse during pregnancy (NIDA, 2019; Winkelman et al., 2018).
Cannabinoids are a group of compounds found in cannabis (marijuana), such as tetrahydrocannabinol (THC) (CDC, 2018; NAS, 2017). Cannabinoids are of special health concern recently as both medical and recreational use and production of marijuana is increasing with state legalization. Cannabinoids use has been reported to have a wide range of health effects on the body and brain; however, solid evidence regarding the short- and long-term health effects of cannabis use remains elusive.
Other multi-drugs consists of a compilation of additional compounds that are not categorized in opioids or cannabinoid drugs. Analytes listed within these latter categories can be tested in HHEAR upon request only.
- Designer drugs include synthetic cannabinoids and synthetic cathinones. Synthetic cannabinoids are related to the active ingredients in marijuana, and synthetic cathinones (e.g., bath salts) are related to the active stimulant ingredients found in the khat plant native to east Africa and southern Arabia. Both types of substances can also vary wildly in potency due to non-existent regulation resulting in unknown, unpredictable, and possibly very dangerous health effects (NIDA, 2018b).
- Commonly abused drugs include central nervous system (CNS) stimulants, including cocaine and amphetamines, or CNS depressants which include benzodiazepines, barbiturates, and hallucinogens.
- Other prescription drugs include sedatives, muscle relaxers, antipsychotics, and antidepressants.
- OTC medications, which can be measured, include some compounds that can be abused (e.g., opioids in cough syrup and anti-diarrheal medicines) as well mixed with other drugs that are abused (e.g., acetaminophen with an opioid).
To gauge the full impact of drug dependence, misuse, or exposure it is critical to monitor a wide range of drugs. Monitoring polysubstance use among individuals is important to fully understand, treat, and prevent undesirable health outcomes.
What types of questions can be answered?
The detection of various drugs can be estimated by measuring the compounds (or their metabolites) in urine or blood at a given point in time. Many types of questions can be answered based on the desired study of interest, including concerns of drug contamination in people who use drugs, biosurveillance of drug overdoses, monitoring drug use over an extended period of time for epidemiological studies, etc.
How can exposure to drugs be measured?
- Analytes: Exposure to drugs can be measured by quantifying the parent chemicals or their metabolites in whole blood or urine.
- Methods: Analysis methods for pharmaceuticals and drugs of abuse use liquid chromatography coupled with mass spectrometry.
- Types of biospecimens: Urine and whole blood are the most commonly used biological matrices for the analysis of drugs. Depending on the analytes of interest, there are different advantages associated with the different matrices.
- Types of environmental samples: HHEAR does not provide analysis of drugs in environmental samples.
How does HHEAR ensure the quality of its analyses?
If possible, the inclusion of field “blanks” in a study can help identify any contamination from collection, storage, and processing sources. All assays are well validated with respect to accuracy and precision. All assays have embedded positive and negative controls. The positive controls are used to check assay accuracy within each set of samples. The negative controls are generally blanks that are included to assess the possibility of any cross contamination in the assay procedure. Laboratories participate in rigorous proficiency testing programs to validate assays.
What sample quality and quantity are necessary?
This is highly dependent on the assay to be run and the sample type, but, in general, a few milliliters of whole blood or urine. Less volume/mass usually translates to lower frequency of detection. Multiple freeze-thaw cycles may be a problem for the analysis of these substances in whole blood; the Lab Hubs are prepared to consult with investigators to determine the suitability of samples for analysis.
Centers for Disease Control and Prevention (CDC). Marijuana and Public Health. 20218 Accessed June 2, 2020.
CDC/National Center for Health Statistics (NCHS). National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services. 2018. .
Meacham MC, et al. Addressing overdose risk among unstably housed women in San Francisco, California: an examination of potential fentanyl contamination of multiple substances. Harm Reduction Journal. 2020;17.
National Academies of Science (NAS). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press. 2017.
National Institute of Drug Abuse (NIDA). Fentanyl. National Institute on Drug Abuse. 2016. Accessed June 2, 2020.
NIDA. Benzodiazepines and Opioids. National Institute on Drug Abuse. 2018a. Accessed June 2, 2020.
NIDA. Synthetic Cannabinoids (K2/Spice). National Institute on Drug Abuse. 2018b. Accessed June 1, 2020.
NIDA. Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. National Institute on Drug Abuse. 2019. Accessed June 6, 2020.
NIDA. Opioid Overdose Crisis. National Institute on Drug Abuse. 2020. Accessed June 2, 2020.
Serota DP, Vettese T. New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use. Journal of Hospital Medicine. 2019.
Schepis TS, et al. Prescription Drug Misuse: Taking a Lifespan Perspective. Substance abuse: Research and Treatment. 2020;14.
Tupper KW, et al. Initial results of a drug checking pilot program to detect fentanyl adulteration in a Canadian setting. Drug and Alcohol Dependence. 2018:190:242–245.
Winkelman T, et al. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014. Pediatrics. 2018;141(4):1–10.