Long-term wastewater-based surveillance and impacts of the COVID-19 pandemic on drug use trends in a U.S. Northeast rural town.

Herein we discuss the findings of a two-year wastewater-based drug use surveillance from September 2018 to August 2020 and present objective evidence on the impacts of the COVID-19 pandemic on drug use in a rural community. 24-h composite wastewater samples were collected twice each month from a university town in Northeastern United States and were analyzed for ten priority opioids and stimulants: morphine, codeine, hydrocodone, methadone, fentanyl cocaine, methamphetamine, amphetamine, 3,4-methylenedioxymethamphetamine (MDMA), and 3,4-methylenedioxy-N-ethylamphetamine (MDEA). All target drugs were detected at 100 % frequency in wastewater samples. On a mass basis, the average estimated per capita drug consumption were highest for cocaine, morphine, and amphetamine, and lowest for MDMA, MDEA, and hydrocodone. Furthermore, the estimated per capita consumption of fentanyl was higher than previous reports from rural and university settings in the U.S. Generally, drug consumption was higher during the spring semesters, with year-on-year semester increases also noted over the 2-y study period. Except for methadone and cocaine, the estimated average per capita consumption of drugs increased over the pandemic period, with the highest increase noted for MDMA (286 % increase compared to baseline, p = 0.016). Estimated average consumption of methadone and cocaine decreased slightly by 6 % and 7 %, respectively. These results demonstrate the utility and strength of wastewater-based approaches in capturing long-term and evolving trends in drug use within communities. Our study findings reflect the regionwide problem with opioid-related overdoses and increasing stimulant prescription rates. Our findings also provide objective data and insights for health policymakers on the effects of the pandemic period on community drug use in a rural U.S. town.

Follow-Up: Effects of a Pandemic and Isolation on Alcohol and Psychoactive Medication Use in a Population of Rehabilitation and Pain Patients.

OBJECTIVE: The conjunction of the coronavirus disease lockdown and the use of illicit drugs suggests the potential increase in drug usage and opioid deaths. Because of other studies, we felt the need to examine if the lockdown has caused a change in the drug intake of our population of substance abuse and pain management patients. Our initial study indicated no increase in the use of illicit and antianxiety drugs. This study is a continuation of that work. MATERIALS: Urine drug testing is a strategy to reduce harm to patients in pain management and substance abuse treatment programs. We analyzed trends in the clinical drug testing patterns of urine specimens sent by substance abuse and pain clinics to monitor their patients. These specimens were tested by a national clinical laboratory using LC-MS/MS definitive methods. The time frame of these comparative observations was the past six years, including the two years of the pandemic. RESULTS: We observed a 30% reduction in test requests during the second quarter of 2020, the number of test requests and specimens submitted was similar during other times of the six-year period. The observed drug use pattern was similar to the earlier study. Among the patients tested, positivity decreased greatly for the illicit drugs heroin and cocaine but increased for methamphetamine and fentanyl. Use of the antidepressant and anxiolytic drugs remained consistent or declined for some drugs, relative to pre-pandemic patterns. The percent of patients prescribed the opiates morphine and oxycodone decreased, while the use of hydrocodone increased. Positivity for the drug gabapentin increased greatly. The use of alcohol did not increase significantly during the lockdown period. CONCLUSION: In summary, these findings demonstrate relatively consistent drug use, with decreased positivity for high-risk drugs and dangerous drug combinations. We speculate that monitoring of these patients mitigates the possibility of drug misuse and potential overdose and is in concordance with the goals of these monitoring programs.

Driving Impairment Cases Involving Flualprazolam.

Flualprazolam is a novel psychoactive substance in the benzodiazepine class that is increasing in prevalence in the USA. This study describes 19 cases of drivers stopped for impaired driving where flualprazolam was detected. This represents ∼9% of the total cases submitted to the Sedgwick County Regional Forensic Science Center toxicology laboratory between July 2019 and May 2020. Blood concentrations of flualprazolam ranged from 4 to 69 ng/mL, with mean and median concentrations of 20.9 ng/mL and 15 ng/mL, respectively. The increased prevalence in which laboratories are detecting flualprazolam along with the low concentrations necessary for pharmacological effects illustrates the importance of laboratories to remain vigilant in testing for novel psychoactive substances.

Long-term monitoring of drug consumption patterns during the COVID-19 pandemic in a small-sized community in Brazil through wastewater-based epidemiology.

The abuse of legal and illegal drugs is a global public health problem, also affecting the social and economic well-being of the population. Thus, there is a significant interest in monitoring drug consumption. Relevant epidemiological information on lifestyle habits can be obtained from the chemical analysis of urban wastewater. In this work, passive sampling using polar organic chemical integrative samplers (POCIS) was used to quantify licit and illicit drugs biomarkers in wastewater for the application of wastewater-based epidemiology (WBE). In this WBE study, a small urban community of approximately 1179 inhabitants was monitored from 18 March 2020 to 3 March 2021, covering the mobility restriction and flexibilization periods of the COVID-19 pandemic in Brazil. Consumption was estimated for amphetamine, caffeine, cocaine, MDMA, methamphetamine, nicotine, and THC. The highest estimated consumption among illicit drugs was for THC (2369 ± 1037 mg day-1 1000 inh-1) followed by cocaine (353 ± 192 mg day-1 1000 inh-1). There was a negative correlation between consumption of caffeine, cocaine, MDMA, nicotine, and THC with human mobility, expressed by cellular phone mobility reports (P-value = 0.0094, 0.0019, 0.0080, 0.0009, and 0.0133, respectively). Our study is the first long-term drug consumption evaluation during the COVID-19 pandemic, with continuous sampling for almost a whole year. The observed reduction in consumption of both licit and illicit drugs is probably associated with stay-at-home orders and reduced access, which can be due to the closure of commercial facilities during some time of the evaluated period, smaller drug supply, and reduced income of the population due to the shutdown of companies and unemployment. The assay described in this study can be used as a complementary and cost-effective tool to the long-term monitoring of drug use biomarkers in wastewater, a relevant epidemiological strategy currently limited to short collection times.

Retrospective analysis of laboratory data from 19,275 hair samples submitted for drug abuse/misuse analysis from February 2019 to June 2021.

Drug abuse/misuse is now a major global problem affecting public health as well as economic and social stability. This study presents a retrospective view of the prevalence of drugs in hair. Reasons for hair testing include the need for law enforcement to test suspicious individuals and the need for employers in specific industries to test their employees. Toxicology analysis results were reviewed for a total of 19,275 hair samples requested for drug abuse/misuse analysis at the Academy of Forensic Science over 29 months from February 2019 to June 2021. Drugs and their metabolites in hair samples were analyzed by liquid chromatography - tandem mass spectrometry. In the study, the 19,275 hair samples were screened for a total of 62 illegal drugs, which were divided into three categories: illegal-drugs (I), medication (II), and new psychoactive substances (III). These three categories contain 11, 29 and 22 drugs respectively. In these hair samples, 4852 (25.2 %) tested positive for one or more drugs. Among them, the positive rate of category I was the highest (48.7 %), followed by category II (28.5 %), and category III (22.7 %). Over all, the positive rate of male users (26.2 %) was higher than that of female users (23.7 %), and most of them were young people (25-44 years old). Illegal-drugs (morphine, etc.) had the highest positive rate. Under the influence of some certain factors, the drug abuse situation will also undergo corresponding changes. The results can provide a scientific knowledge database which can help in the prevention of drug abuse.

Use of illicit drugs, alcohol and tobacco in Spain and Portugal during the COVID-19 crisis in 2020 as measured by wastewater-based epidemiology.

The COVID-19 pandemic spread rapidly worldwide in the year 2020, which was initially restrained by drastic mobility restrictions. In this work, we investigated the use of illicit drugs (amphetamine, methamphetamine, ecstasy, cocaine and cannabis), and licit substances of abuse (alcohol and tobacco) during the earlier months (March-July 2020) of the pandemic restrictions in four Spanish (Bilbao and its metropolitan area, Vitoria-Gasteiz, Castellón and Santiago de Compostela) and two Portuguese (Porto and Vila do Conde) locations by wastewater-based epidemiology (WBE). The results show that no methamphetamine was detected in any of the locations monitored, while amphetamine use was only detectable in the two locations from the Basque Country (Bilbao and its metropolitan area and Vitoria-Gasteiz), with high estimated average usage rates (700-930 mg day-1 1000 inhabitant-1). The remaining substances were detected in all the investigated catchment areas. In general, no remarkable changes were found in population normalized loads compared to former years, except for cocaine (i.e. its main metabolite, benzoylecgonine). For this drug, a notable decrease in use was discernible in Castellón, while its usage in Porto and Santiago de Compostela seemed to continue in a rising trend, already initiated in former years. Furthermore, two events of ecstasy (3,4-methylenedioxymethamphetamine, MDMA) dumping in the sewage network were confirmed by enantiomeric analysis, one in Santiago de Compostela just prior the lockdown and the second one in the Bilbao and its metropolitan area in July after relieving the more stringent measures. The latter could also be associated with a police intervention. The comparison of WBE with (web) survey data, which do not provide information at a local level, points towards contradictory conclusions for some of the substances, thereby highlighting the need for stable WBE networks capable of near real-time monitoring drug use.

Prevalence of Five Commonly Analyzed Cannabinoids in Forensic Toxicology Casework from Orange County CA, USA, from 2016 to 2019.

Over the last 25 years, marijuana laws have been changing throughout the USA. California started legalizing medicinal marijuana in 1996 and has since continued to relax laws. Compared to Washington and Colorado, there are little data on how the changing laws have affected the cannabinoid detection rate in California. This paper looks at the prevalence of five cannabinoids (Δ9-tetrahydrocannabinol (THC), 11-hydroxy-tetrahydrocannabinol (hydroxy-THC), 11-nor-9-carboxy-tetrahydrocannabinol (carboxy-THC), cannabinol and cannabidiol) in Orange County, CA, from 2016 to 2019. From 2016 to 2017, after legalizing recreational marijuana, there was an increase in the presence of THC, carboxy-THC and hydroxy-THC in postmortem and major crime cases, consisting mostly of sexual assaults. However, driving under the influence of drugs (DUID) saw a slight decrease. In 2018, when shops could be licensed to sell marijuana to anyone over 21 years old, there was an increase seen in all five cannabinoids for DUID and postmortem cases. The age group from 21 to 30 years showed the most prevalent cannabinoid use in all case types for all years except in major crime cases in 2019, where <21 year-old age group was the most prevalent. Surprisingly, the >50-year-old group in death investigation cases was a close second in prevalence in all years, which differs from DUID and major crime cases.

Temporal monitoring of stimulants during the COVID-19 pandemic in Belgium through the analysis of influent wastewater.

BACKGROUND AND AIMS: Wastewater-based epidemiology (WBE) is a complementary epidemiological data source to monitor stimulant consumption. The aims were to: (i) study intra- and inter-year temporal changes in stimulant use in Belgium during the first wave of the COVID-19 pandemic; and (ii) evaluate the effect of COVID-19 restrictive measures on stimulant consumption. METHODS: The study population corresponded to the catchments of four wastewater treatment plants corresponding with four Belgian cities (i.e., Antwerp-Zuid, Boom, Brussels, Leuven). Daily 24-h composite influent wastewater samples collected over one week in September 2019 and March through June 2020 during the first wave of the COVID-19 pandemic were analyzed for biomarkers of amphetamine, cocaine, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA). Measured concentrations were converted to population-normalized mass loads by considering the daily flow rate and the catchment population size. Mobile network data was used to accurately capture population movements in the different catchment areas. Temporal changes were assessed with multiple linear regression models, and the effect of the COVID-19 interventions on stimulant consumption were investigated. RESULTS: An increase in amphetamine use was observed in three cities during governmental restrictions, with highest consumption predominantly during lockdown. Similarly, cocaine consumption was higher after the pandemic started, with highest consumption noted during the lockdown period in Boom and Leuven. Consumption of MDMA was similar in Antwerp-Zuid, Brussels and Leuven throughout the entire sampled period. In Boom, the highest consumption was observed during the full lockdown period. CONCLUSIONS: The present study shows the potential of WBE to assess the impact of stringent lockdown measures on stimulant use in Belgium. This paper shows that strong restrictive measures did not have a profound effect on stimulant consumption.

Changes in the frequency and pattern of drugs detected among suspected drug users during the COVID-19 pandemic in Turkey.

From March 13 until May 31, 2020, a complete lockdown in Turkey was planned and implemented by the government of Turkey. The vulnerable population with substance use disorders was affected more than others due to the social isolation measures meant to control the pandemic. This study presents detailed and broad data on drug abuse in suspected cases during the first wave of the COVID-19 pandemic in Turkey and compares the frequencies and patterns of drug abuse before and during the pandemic. The samples were screened by liquid chromatography-high resolution mass spectrometry and liquid chromatography-tandem mass spectrometry. Blood and urine samples of suspected users (n = 9669) were analyzed for drugs of abuse during the first wave of the COVID-19 pandemic and compared with their results (n = 8727) obtained just before the COVID-19 pandemic. The use of party drugs, such as MDMA and cocaine, and the classic illicit drug cannabis was significantly decreased and followed the same trend after complete lockdown was over. In contrast, methamphetamine use increased significantly during the lockdown period and continued after the lockdown. Interestingly, the number of tests that were positive for pregabalin as a misused licit drug increased, and this increase continued after the lockdown. The results showed a significant increase in drug abuse cases and changes in drug abuse trends, with an alteration toward more easily obtainable and lower-priced drugs. Using more dangerous and easily available licit and illicit drugs may cause serious health problems.

Impact of COVID-19 pandemic on emergency department substance use screens and overdose presentations.

BACKGROUND: The COVID-19 pandemic can exacerbate underlying substance use disorder and has impacted this vulnerable population in a variety of ways. There are limited data regarding how this pandemic has impacted emergency department (ED) patient presentations. METHODS: We extracted data on ED visits from the electronic health record (EHR) of a large healthcare system in the Washington, DC/Baltimore, MD metropolitan area. The dataset includes data from 7 hospitals on ED visits between 11/1/2019-6/30/2020. The health system utilizes a validated screening program for substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT), for ED patients who are clinically stable and willing to complete screening. We evaluated trends in patients with a positive SBIRT screen and those presenting with a clinical diagnosis of acute alcohol or substance intoxication/overdose before (11/1/19-2/29/2020-pre) and during the first wave of the COVID pandemic (3/1/2020-6/30/2020-post). Data were described using descriptive statistics. Bivariate analyses were conducted using chi-square test and two-sample t-tests. Interrupted time series analysis was used to evaluate the changes in the weekly trends with the start of the pandemic. RESULTS: There were 107,930 screens performed in the EDs during the study period (61,961 pre, 45,969 post). The population was primarily African American (64.7%) and female (57.1%). Positive SBIRT screens increased from 12.5% to 15.8% during COVID (p < 0.001). Alcohol intoxication presentations increased as a proportion of positive screens from 12.6% to 14.4% (p = 0.001). A higher percentage of screened patients reported problem drinking (AUDIT score ≥ 7) during the pandemic (2.4% pre vs 3.2% post, p < 0.001). Substance intoxication/overdoses among all screened increased from 2.1% to 3.1% (p < 0.001) and as a percentage of positive screens during the pandemic (16.8% to 20%, p < 0.001). The proportion of opioid vs. non-opioid overdoses remained unchanged before (67%) and during the pandemic (64%, p = 0.33). DISCUSSION: There was an increase in the proportion of positive SBIRT screens and visits for acute overdoses and intoxication during the first wave of the COVID-19 pandemic. Additional research should focus on mitigation strategies to address substance use during this vulnerable time.

Illicit drug use in Reykjavik by wastewater-based epidemiology.

Estimation of illicit drug use on a community level by wastewater-based epidemiology (WBE) is both an objective and reliable way to establish near real-time results. Wastewater samples were collected at eleven timepoints in Reykjavik from 2017 to 2020. The use of commonly abused illicit drugs in Iceland (amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), cocaine, and cannabis) was estimated. Solid phase extraction and ultra-high performance liquid chromatography coupled to tandem mass spectrometry was used for analysis. Estimated amphetamine and methamphetamine use showed signs of an increase from 2017 to 2020 with amphetamine being the dominant stimulant on the market. MDMA use remained stable from 2017 to 2020. Results showed a large increase in cocaine use from 2017 to 2019 but interestingly, a marked decrease in 2020 during the COVID-19 pandemic. Cannabis use was stable from 2017 to 2019 but showed signs of an increase during the pandemic in 2020. Results by WBE corresponded with data based on two other indicators of drug use, seizure data and driving under the influence cases. Both temporal and spatial trends in illicit drug use were successfully estimated by using WBE, complimenting other indicators which provided a comprehensive picture of drug abuse in Reykjavik.

"Waste Not, Want Not" - Leveraging Sewer Systems and Wastewater-Based Epidemiology for Drug Use Trends and Pharmaceutical Monitoring.

During the current global COVID-19 pandemic and opioid epidemic, wastewater-based epidemiology (WBE) has emerged as a powerful tool for monitoring public health trends by analysis of biomarkers including drugs, chemicals, and pathogens. Wastewater surveillance downstream at wastewater treatment plants provides large-scale population and regional-scale aggregation while upstream surveillance monitors locations at the neighborhood level with more precise geographic analysis. WBE can provide insights into dynamic drug consumption trends as well as environmental and toxicological contaminants. Applications of WBE include monitoring policy changes with cannabinoid legalization, tracking emerging illicit drugs, and early warning systems for potent fentanyl analogues along with the resurging wave of stimulants (e.g., methamphetamine, cocaine). Beyond drug consumption, WBE can also be used to monitor pharmaceuticals and their metabolites, including antidepressants and antipsychotics. In this manuscript, we describe the basic tenets and techniques of WBE, review its current application among drugs of abuse, and propose methods to scale and develop both monitoring and early warning systems with respect to measurement of illicit drugs and pharmaceuticals. We propose new frontiers in toxicological research with wastewater surveillance including assessment of medication assisted treatment of opioid use disorder (e.g., buprenorphine, methadone) in the context of other social burdens like COVID-19 disease.

Chemsex/slamsex-related intoxications: A case report involving gamma-hydroxybutyrate (GHB) and 3-methylmethcathinone (3-MMC) and a review of the literature.

Chemsex and slamsex represent a serious public health concern that has to be considered by both clinical and forensic toxicologists. Indeed, such practices appear to carry a significant degree of risk, including acute intoxication. Here we report the case of the intoxication of a 31-year-old male involving 3-methylmethcathinone (3-MMC) and gamma-hydroxybutyrate (GHB) during a slamsex session. In addition, we conducted a review of further cases. The 31-year-old man was admitted to the emergency department for severe impaired consciousness following the administration of psychoactive substances during a chemsex party. The detection and determination of 3-MMC and GHB concentrations were achieved using liquid chromatography-tandem mass spectrometry. 3-MMC and GHB blood concentrations were 177 ng/mL and 131 mg/L, respectively. Further, an English and French exhaustive literature search was performed using several different electronic databases without any limiting period in order to identify all published case reports detailing chemsex/slamsex-related (fatal and nonfatal) intoxications. Nine publications detailing chemsex/slamsex-related intoxication cases have been published (between 2016 and 2020). These articles reported an overall of 13 cases, all involving men with a mean age of 39.1±9.8 years. The outcome was fatal in only 6 cases. 4-MEC and GHB were the two predominant drugs identified. However, given the rapid emergence of novel NPSs in the global market as well as the ease with which they can be accessed through the Internet, toxicological laboratories have to be ready to face new patterns of intoxications resulting from chemsex/slamsex.

Primary care-based screening and management of depression amongst heavy drinking patients: Interim secondary outcomes of a three-country quasi-experimental study in Latin America.

INTRODUCTION: Implementation of evidence-based care for heavy drinking and depression remains low in global health systems. We tested the impact of providing community support, training, and clinical packages of varied intensity on depression screening and management for heavy drinking patients in Latin American primary healthcare. MATERIALS AND METHODS: Quasi-experimental study involving 58 primary healthcare units in Colombia, Mexico and Peru randomized to receive: (1) usual care (control); (2) training using a brief clinical package; (3) community support plus training using a brief clinical package; (4) community support plus training using a standard clinical package. Outcomes were proportion of: (1) heavy drinking patients screened for depression; (2) screen-positive patients receiving appropriate support; (3) all consulting patients screened for depression, irrespective of drinking status. RESULTS: 550/615 identified heavy drinkers were screened for depression (89.4%). 147/230 patients screening positive for depression received appropriate support (64%). Amongst identified heavy drinkers, adjusting for country, sex, age and provider profession, provision of community support and training had no impact on depression activity rates. Intensity of clinical package also did not affect delivery rates, with comparable performance for brief and standard versions. However, amongst all consulting patients, training providers resulted in significantly higher rates of alcohol measurement and in turn higher depression screening rates; 2.7 times higher compared to those not trained. CONCLUSIONS: Training using a brief clinical package increased depression screening rates in Latin American primary healthcare. It is not possible to determine the effectiveness of community support on depression activity rates due to the impact of COVID-19.

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing in 2020.

The convergence of the opioid epidemic and the coronavirus disease 2019 (COVID-19) pandemic has created new health care challenges. The authors analyzed changes in clinical drug testing patterns and results at a national clinical laboratory, comparing data obtained before and during the pandemic. Testing for prescription and illicit drugs declined rapidly during the pandemic, with weekly test volumes falling by approximately 70% from the baseline period to the trough (the week beginning March 29) before rising in subsequent weeks. Among individuals tested, positivity increased by 35% for non-prescribed fentanyl and 44% for heroin during the pandemic. Positivity for non-prescribed fentanyl increased significantly among patients positive for other drugs: by 89% for specimens positive for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (P < 0.01 for all comparisons). These findings suggest significant increases in dangerous drug combinations. Positivity for non-prescribed use of many other drugs remained consistent or declined for some drugs, relative to pre-pandemic patterns. Models adjusting for potential confounding variables, including medication-assisted treatment and treatment at a substance use disorder facility indicated that the risk for non-prescribed fentanyl positivity rose by more than 50% during the pandemic. In summary, these findings demonstrate decreased drug testing overall, with increased positivity for high-risk drugs and dangerous drug combinations. The convergence of the drug abuse epidemic and COVID-19 pandemic has led to an increased need for health care and public health resources dedicated to supporting vulnerable patients and addressing the underlying causes of these disturbing trends.

The Role of Alcohol Biomarkers in Detecting a Physician's COVID-19-Related Acute Stress Response: A Case Report.

OBJECTIVES: Alcohol biomarkers are used to detect alcohol exposure in clinical and forensic settings. This includes professional health program (PHP) monitoring of healthcare workers in recovery from substance use disorders. Here we present the case of a physician whose positive alcohol biomarker test result was complicated by a traumatic stress response to frontline work during COVID-19. METHODS: An anesthesiologist under PHP monitoring for substance use disorder and depression was interviewed extensively, urine and blood biomarkers were obtained, and longitudinal structured and semi-structured interviews related to anxiety, depression, posttraumatic stress, and cravings were used to monitor responses to the unanticipated death of a patient who succumbed to COVID-19. RESULTS: After an initial positive ethylglucuronide (EtG) and ethylsulfate (EtS) toxicology test result, all subsequent testing was negative. The physician described compulsive sanitizing hands/arms and mask with highly concentrated ethanol-based products. Standardized assessments and clinical interviews provided documentation of a COVID-19-related post-traumatic stress response. He was connected to additional therapeutic support services and monitoring continued. CONCLUSIONS: Inhalation of ethanol vapors was initially accepted as a possible explanation for the positive EtG/EtS results, though the physician later acknowledged that limited alcohol beverage consumption occurred 6 days prior to the positive test, further complicating its interpretation. Detection of aberrant behavior through ongoing monitoring helps to protect both healthcare workers and the patients they serve.

Changes in drug use in European cities during early COVID-19 lockdowns - A snapshot from wastewater analysis.

The COVID-19 outbreak has forced countries to introduce severe restrictive measures to contain its spread. In particular, physical distancing and restriction of movement have had important consequences on human behaviour and potentially also on illicit drug use and supply. These changes can be associated with additional risks for users, in particular due to reduced access to prevention and harm reduction activities. Furthermore, there have been limitations in the amount of data about drug use which can be collected due to restrictions. To goal of this study was to obtain information about potential changes in illicit drug use impacted by COVID-19 restrictions. Wastewater samples were collected in seven cities in the Netherlands, Belgium, Spain and Italy at the beginning of lockdowns (March-May 2020). Using previously established and validated methods, levels of amphetamine (AMP), methamphetamine (METH), MDMA, benzoylecgonine (BE, the main metabolite of cocaine) and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH, main metabolite of tetrahydrocannabinol (THC)) were measured and compared with findings from previous years. Important differences in levels of consumed drugs were observed across the considered countries. Whilst for some substances and locations, marked decreases in consumption could be observed (e.g., 50% decrease in MDMA levels compared to previous years). In some cases, similar or even higher levels compared to previous years could be found. Changes in weekly patterns were also observed, however these were not clearly defined for all locations and/or substances. Findings confirm that the current situation is highly heterogeneous and that it remains very difficult to explain and/or predict the effect that the present pandemic has on illicit drug use and availability. However, given the current difficulty in obtaining data due to restrictions, wastewater analysis can provide relevant information about the situation at the local level, which would be hard to obtain otherwise.