Attitudes and experiences with fentanyl contamination of methamphetamine: exploring self-reports and urine toxicology among persons who use methamphetamine and other drugs.

BACKGROUND: There are growing concerns about illicitly manufactured fentanyl (IMF) contamination of methamphetamine. This study aims to characterize the lay views and experiences with IMF-contaminated methamphetamine (IMF/meth) and identify participants with unknown IMF exposures through urine toxicology analysis. METHODS: Between December-2019 and November-2021, structured interviews were conducted with 91 individuals who reported past 30-day use of methamphetamine and resided in Dayton, Ohio, USA. Lab-based urine toxicology analyses were conducted to identify fentanyl/analogs, methamphetamine, and other drugs. Bivariate analyses were conducted to identify characteristics associated with attitudes and experiences with IMF/meth, and unknown IMF exposures. RESULTS: The majority (95.6%) of the study participants were non-Hispanic white, and 52.7% were female. Past 30-day use of methamphetamine was reported on a mean of 18.7 (SD 9.1) days, and 62.6% also reported past 30-day use of heroin/IMF. Most (76.9%) had a history of an unintentional drug-related overdose, but 38.5% rated their current risk for an opioid overdose as none. Besides fentanyl (71.9%), toxicology analysis identified nine fentanyl analogs/metabolites (e.g., 42.7% acetyl fentanyl, 19.0% fluorofentanyl, 5.6% carfentanil), and 12.4% tested positive for Xylazine. The majority (71.4%) believed that IMF/meth was common, and 59.3% reported prior exposures to IMF/meth. 11.2% tested positive for IMF but reported no past 30-day heroin/IMF use (unknown exposure to IMF). Views that IMF/meth was common showed association with homelessness (p = 0.04), prior overdose (p = 0.028), and greater perceived risk of opioid overdose (p = 0.019). Self-reported exposure to IMF/meth was associated with homelessness (p = 0.007) and obtaining take-home naloxone (p = 0.025). Individuals with unknown IMF exposure (test positive for IMF, no reported past 30-day heroin/IMF use) were older (49.9 vs. 41.1 years, p < 0.01), and reported more frequent past 30-day use of methamphetamine (24.4 vs. 18.0 days, p < 0.05). They indicated lower perceived risk of opioid overdose (0.1 vs. 1.9, scale from 0 = "none" to 4 = "high," p < 0.001). DISCUSSION: This study suggests a need for targeted interventions for people who use methamphetamine and expansion of drug checking and other harm reduction services.

Lay knowledge and practices of methamphetamine use to manage opioid-related overdose risks.

AIM: Methamphetamine use has increased among individuals with opioid use disorder. The key aims of this study are to detail and contextualise lay knowledge, attitudes, and behaviours related to methamphetamine use in relation to opioid overdose risks in an area dominated by non-pharmaceutical fentanyl-type drugs (NPF). METHODS: The study recruited 41 individuals in Dayton, Ohio, who reported past 30-day use of methamphetamine and heroin/fentanyl. Interviews included structured and qualitative questions. Urine toxicology analysis was conducted to identify NPFs and other drugs. Open-ended interview sections were audio-recorded, transcribed, and analysed qualitatively using NVivo. RESULTS: The mean age was 38.3 years, 51% were female, and 100% non-Hispanic white. Participants described an exceedingly unpredictable local opioid market that became saturated with NPFs. The sample tested positive for 10 NPFs, including fentanyl (100%), acetyl fentanyl (61%), tetrahydrofuran fentanyl (29%), and carfentanil (12%). Most participants believed that methamphetamine could help prevent and/or reverse an opioid-related overdose. Nearly half had personally used it to help manage overdose risks related to NPF. These beliefs were embedded in a lay understanding of how methamphetamine works to stimulate the cardiovascular system. They were acted upon in the context of last resort situations that were determined by a lack of immediate access to naloxone, ambiguities surrounding overdose symptomatology, and easy access to plentiful and inexpensive methamphetamine. CONCLUSION: Lay efforts to rely on methamphetamine to manage NPF-related overdose risks highlight the need for a continuing expansion of take-home-naloxone programs and implementation of other novel harm reduction approaches in communities affected by NPFs.

Tramadol in seized drugs containing non-pharmaceutical fentanyl: Crime lab data from Ohio, USA.

Introduction: Non-pharmaceutical fentanyl and related drugs (NPF) have contributed to increases in drug-related overdose mortality in the U.S. More data are needed to track the shifting composition of fentanyl-containing drug mixtures. The key aims of the study are to characterize the crime lab data from Montgomery County, Ohio on the increased cases of seized drugs containing mixtures of NPF and tramadol. Methods: Crime lab data on seized drugs in Montgomery County, Ohio (2015 - 2020) were analyzed to extract information on cases that tested positive for NPF and tramadol. Descriptive statistics are provided to characterize NPF/tramadol mixtures in terms of the quantity, weight, form of the drug seized (powder, tablet, capsule, residue), and the types of fentanyl analogs and other drugs identified. Results: In December 2017, the first case of NPF/tramadol mixture was identified in the amount of 0.2 g. Sub-sequently, cases containing NPF/tramadol increased significantly to 149 cases in 2018, 102 in 2019, and 134 in 2020. The total yearly amounts of seized NPF/tramadol mixtures increased to 373.27 g in 2018, 2,601.82 g in 2019, and 13,487.62 g in 2020. The majority (72.6%) of the cases were in powder form. There were 15 other drugs identified along with fentanyl with tramadol mixtures, including heroin (38.8%), 5.7% cocaine (5.7%), and methamphetamine (4.9%). Conclusions: The addition of tramadol to NPF may be viewed as a harm mitigation strategy but contributes to the overall unpredictability of the illicit drug supply. According to Ohio legal statutes, identification of schedule IV drugs such as tramadol with fentanyl (schedule II) may provide a reduction in drug-related charges from a felony to a misdemeanor. More research is needed to characterize potential sources of tramadol in NPF-containing drugs.

Fentanyl, Acetylfentanyl and Carfentanil in Impaired Driving Cases: A Review of 270 Cases.

The detection of fentanyl (FEN) and FEN analogs has been widely communicated throughout the scientific community. While most of the reporting has been in relation to overdose deaths, these drugs are commonly detected in impaired driving cases. A retrospective study of impaired driving cases analyzed between 2017 and 2019 produced 270 cases positive for FEN, carfentanil (CFEN) and/or acetylfentanyl (AFEN). FEN was the predominant drug found in these 270 cases (65.5%) with concentrations ranging from less than 1.0 to 64 ng/mL. CFEN was found alone in 6.6% cases with three concentrations above 1.0 ng/mL. AFEN was always found when FEN was positive with concentrations ranging from <1.0 to 9.2 ng/mL. Detailed case histories are provided with corresponding toxicology results. Toxicology results show impaired drivers using multiple drugs with a wide range of observed behaviors. The inclusion of these drugs in routine impaired driver toxicology testing is extremely important when attempting to determine their overall prevalence.

Street fentanyl use: Experiences, preferences, and concordance between self-reports and urine toxicology.

BACKGROUND: Conducted in Dayton, Ohio, the study aims to characterize user knowledge and experiences with non-pharmaceutical fentanyl-type drugs (NPFs) and compare self-reports with urine toxicology for NPFs and heroin. METHODS: Between May 2017-January 2018, 60 individuals who self-reported heroin/NPF use were interviewed using structured questionnaire on socio-demographics, NPF and other drug use practices. Unobserved urine samples were collected and analyzed using: 1) liquid-chromatography-tandem mass spectrometry (LC-MS/MS)-based method (Toxicology lab) to identify 34 fentanyl analogues, metabolites, and other synthetic opioids; 2) immunoassay-based method to screen for opiates (heroin). Sensitivity, specificity and Cohen's kappa were calculated to assess agreement between self-reports and urine toxicology. RESULTS: The sample was 52% female, and over 90% white. Almost 60% reported preference for heroin, and 40% for NPF. Participants endorsed a number of ways of distinguishing heroin from NPF, including appearance (88.3%), effects (76.7%), taste (55%), and information provided by dealers (53.3%). Almost 80% felt confident they could distinguish heroin from NPF, but knowledge about fentanyl analogues was limited. LC-MS/MS testing identified 8 types of NPFs. Over 88% tested positive for NPFs, including 86% fentanyl, 48% carfentanil, 42% acetyl fentanyl. About 47% screened positive for opiates/heroin, and all of them were also positive for NPFs. When comparing self-reported use of NPF to urine toxicology, sensitivity and specificity were relatively high (84% and 83.3%, accordingly), while Cohen's Kappa was 0.445, indicating fair agreement. Sensitivity and specificity were lower for heroin (77.8% and 50.0%, accordingly), and Cohen's Kappa was 0.296, indicating low agreement between self-reports of heroin use and urine toxicology. DISCUSSION: Nearly 90% of the study participants tested positive for NPF-type drugs. Participants were more likely to over-report heroin use and underreport NPF use. The majority had little knowledge about fentanyl analogues. Study findings will inform development of novel harm reduction approaches to reduce overdose mortality.

Trends in fentanyl and fentanyl analogue-related overdose deaths - Montgomery County, Ohio, 2015-2017.

INTRODUCTION: There is a lack of information on illicitly manufactured fentanyl and fentanyl analogue-related (IMF) unintentional overdose death trends over time. The study analyzes IMF-related unintentional overdose fatalities that occurred between July 2015 and June 2017 in Montgomery County, Ohio, an area with the highest rates of unintentional overdose mortality in Ohio. METHODS: LC-MS/MS-based method was used to identify fentanyl analogs and metabolites in 724 unintentional overdose death cases. The Chi-square statistic was used to assess differences over time in demographic and drug-related characteristics. RESULTS: The number of unintentional overdose death cases testing positive for IMFs increased by 377% between second half of 2015 and first half of 2017. The majority of decedents were white (82.5%) and male (67.8%). The proportion of fentanyl-only (no other analogs) cases declined from 89.2%-24.6% (p < 0.001), while proportion of fentanyl analogue-containing cases increased from 9.8%-70.3% (p < 0.001) between the second half of 2015 and first half of 2017. The most commonly identified fentanyl analogs were carfentanil (29.7%), furanyl fentanyl (14.1%) and acryl fentanyl (10.2%). Proportion of IMF cases also testing positive for heroin declined from 21.6% to 5.4% (p < 0.001), while methamphetamine positive cases increased from 1.4%-17.8% (p < 0.001) over the same time period. DISCUSSION: Emergence of fentanyl analogs contributed to substantial increases in unintentional overdose deaths. The data indicate a growing overlap between the IMF and methamphetamine outbreaks. Continuous monitoring of local IMF trends and rapid information dissemination to active users are needed to reduce the risks associated with IMF use.

LC-MS/MS-Based Method for the Multiplex Detection of 24 Fentanyl Analogues and Metabolites in Whole Blood at Sub ng mL-1 Concentrations.

The United States and numerous other countries worldwide are currently experiencing a public health crisis due to the abuse of illicitly manufactured fentanyl (IMF) and its analogues. This manuscript describes the development of a liquid chromatography-tandem mass spectrometry-based method for the multiplex detection of N = 24 IMF analogues and metabolites in whole blood at concentrations as low as 0.1-0.5 ng mL-1. These available IMFs were fentanyl, norfentanyl, furanyl norfentanyl, remifentanil acid, butyryl norfentanyl, remifentanil, acetyl fentanyl, alfentanil, AH-7921, U-47700, acetyl fentanyl 4-methylphenethyl, acrylfentanyl, para-methoxyfentanyl, despropionyl fentanyl (4-ANPP), furanyl fentanyl, despropionyl para-fluorofentanyl, carfentanil, (±)-cis-3-methyl fentanyl, butyryl fentanyl, isobutyryl fentanyl, sufentanil, valeryl fentanyl, para-fluorobutyryl fentanyl, and para-fluoroisobutyryl fentanyl. Most IMF analogues (N = 22) could be easily distinguished from one another; the isomeric forms butyryl/isobutyryl fentanyl and para-fluorobutyryl/para-fluoroisobutyryl fentanyl could not be differentiated. N = 13 of these IMF analogues were quantified for illustrative purposes, and their forensic quality control standards were also validated for limit of detection (0.017-0.056 ng mL-1), limit of quantitation (0.100-0.500 ng mL-1), selectivity/sensitivity, ionization suppression/enhancement (87-118%), process efficiency (60-95%), recovery (64-97%), bias (<20%), and precision (>80%). This flexible, time- and cost-efficient method was successfully implemented at the Montgomery County Coroner's Office/Miami Valley Regional Crime Laboratory in Dayton, Ohio, where it aided in the analysis of N = 725 postmortem blood samples collected from February 2015 to November 2016.

Overdose Deaths Related to Fentanyl and Its Analogs - Ohio, January-February 2017.

Ohio is experiencing unprecedented loss of life caused by unintentional drug overdoses (1), with illicitly manufactured fentanyl (IMF) emerging as a significant threat to public health (2,3). IMF is structurally similar to pharmaceutical fentanyl, but is produced in clandestine laboratories and includes fentanyl analogs that display wide variability in potency (2); variations in chemical composition of these drugs make detection more difficult. During 2010-2015, unintentional drug overdose deaths in Ohio increased 98%, from 1,544 to 3,050.* In Montgomery County (county seat: Dayton), one of the epicenters of the opioid epidemic in the state, unintentional drug overdose deaths increased 40% in 1 year, from 249 in 2015 to 349 in 2016 (estimated unadjusted mortality rate = 57.7 per 100,000) (4). IMFs have not been part of routine toxicology testing at the coroner's offices and other types of medical and criminal justice settings across the country (2,3). Thus, data on IMF test results in the current outbreak have been limited. The Wright State University and the Montgomery County Coroner's Office/Miami Valley Regional Crime Laboratory (MCCO/MVRCL) collaborated on a National Institutes of Health study of fentanyl analogs and metabolites and other drugs identified in 281 unintentional overdose fatalities in 24 Ohio counties during January-February 2017. Approximately 90% of all decedents tested positive for fentanyl, 48% for acryl fentanyl, 31% for furanyl fentanyl, and 8% for carfentanil. Pharmaceutical opioids were identified in 23% of cases, and heroin in 6%, with higher proportions of heroin-related deaths in Appalachian counties. The majority of decedents tested positive for more than one type of fentanyl. Evidence suggests the growing role of IMFs, and the declining presence of heroin and pharmaceutical opioids in unintentional overdose fatalities, compared with 2014-2016 data from Ohio and other states (3-5). There is a need to include testing for IMFs as part of standard toxicology panels for biological specimens used in the medical, substance abuse treatment, and criminal justice settings.

Formation of benzoylecgonine isopropyl ester following solid-phase extraction.

In forensic toxicology general alkaline drug screens typically utilize liquid liquid [LLE] or solid phase extraction [SPE] sample preparation techniques. It is expected that different drugs will be detected when a laboratory changes techniques. In this study, when the authors switched from LLE to SPE they were able to detect benzoylecgonine [BE]. Benzoylecgonine isopropyl ester [BEIE] was also detected. Further investigation demonstrated that the BEIE was formed during sample elution with methylene chloride/isopropanol/ammonium hydroxide. BEIE was not detected if methanol/ammonium hydroxide was used as the elution solvent. Analysts should be aware that BEIE is formed in the presence of BE if elution solvents comprise isopropanol and a strong base. Therefore, use of BEIE as an internal standard in such assays will result in inaccurate quantitation of BE.

Comparison of tissue homogenate analytical results with and without standard addition.

Standard addition (SA) has occasionally been utilized as an analytical tool in forensic toxicology. It is recommended for difficult matrices such as tissue or decomposed specimens in which the accurate quantitation of drug may be problematic. However, the additional preparation time and increased use of specimen may limit its general applicability. In this study, the authors compared SA with direct extraction (DE) and quantitation against a blood calibration curve to assess whether the quantitative results were significantly different. Twenty-two postmortem cases were assayed for drugs such as cocaine and metabolites, opioids, and antidepressants by solid-phase extraction followed by gas chromatography-mass spectrometry operated in the selected ion monitoring mode. A two-tailed, homoscedastic Student's t-test demonstrated that the two sets of data were not statistically different (p = 0.81). In addition, SAs were more likely to demonstrate nonlinearity (r(2) < 0.98).

Concentrations of opiates and psychotropic agents in polydrug overdoses: a surprising correlation between morphine and antidepressants.

The relationship between postmortem concentrations of morphine and co-detected psychoactive drugs in fatal overdoses is examined. Morphine and other drugs were detected in 161 medicolegal autopsy cases. Subsets of these morphine-positive cases based on drug class were established, including opioids, antidepressants, ethanol, benzodiazepines, and "other." Each subset was split into high or low concentration groups based on median drug concentrations. Morphine concentrations of the [high] and [low] groups were compared, with no significant difference in morphine concentration identified in the opioid, ethanol, or benzodiazepine subsets. The "other" drug class was too heterogeneous for statistical assessment. Morphine concentrations did show a significant direct relationship (p = 0.01) with antidepressants, namely increased concentrations of antidepressant drugs are associated with an increased concentration of morphine. This trend probably remains even after excluding cocaine-positive cases. The unsuspected finding that postmortem concentrations of antidepressants positively correlate with morphine levels may be important in the treatment of depression in drug addicts.

Comparison of liquid/liquid and solid-phase extraction for alkaline drugs.

The extraction of drugs from biological matrices is an essential specimen preparation step in current forensic postmortem laboratories. Traditionally, liquid/liquid extractions (LLE) were developed and employed to screen for the general unknown. However, solid-phase extractions (SPE) are becoming more popular as the availability of columns with suitable stationary phases increased. The purpose of this work was to determine if switching from an existing LLE to SPE was feasible. The limits of detection (LOD) for 122 drugs and metabolites were determined in blood following SPE and compared to previously determined LOD's by LLE, if available. There were 41 drugs that had LOD's in blood established by both methods; LLE had a lower LOD for 8 drugs (19.5%), SPE had a lower LOD for 16 (39%), and the LOD's were comparable in the remaining drugs. Although SPE cartridges were more expensive than LLE, SPE was determined to be a faster technique and doubled the number of specimens that could be extracted by one analyst within a specific timeframe. The SPE method utilized enabled the detection of several drugs not detectable after LLE (most notably, morphine and benzoylecgonine) and allowed the extraction of weakly acidic and neutral drugs with only one extra step.

An estimate of the proportion of drug-facilitation of sexual assault in four U.S. localities.

In recent years, drugs including flunitrazepam, gamma-hydroxybutyrate, ketamine, and ethanol, have become popularly associated with drug-facilitated sexual assault. Other drugs are also candidates as factors in "drug facilitated sexual assault" (DFSA). The true extent of DFSA is not known, and is difficult to estimate. We recruited sexual assault complainants at four clinics in different parts of the U.S. to anonymously provide urine and hair specimens, and to answer questions about suspected drugging, drug use, and the sexual assault incident. Urine and hair specimens were tested for 45 drugs, including ethanol, and those pharmacologically capable of inducing sedation, amnesia, or impairment of judgment. Analytical test results were used to estimate the proportion of subjects, and the proportion of all complainants to the clinic in the same time period, who were victims of DFSA. Overall, cases of 43% of 144 subjects, and 7% of 859 complainants, were characterized as DFSA. Subjects underreported their use of drugs. The role of toxicological results and history in characterizing DFSA cases is discussed.

Fatalities associated with fentanyl and co-administered cocaine or opiates.

Fatalities associated with fentanyl hydrochloride are increasingly seen in Massachusetts. Between September 2005 and November 2006, 5009 medicolegal investigations associated 107 deaths with licit or illicit fentanyl use, along with a co-detection of an opiate/opioid or cocaine/benzoylecognine, or both. Deaths associated with illicit fentanyl use occur in younger people (39.4 vs. 61.5 years) with higher fentanyl (17.1 ng/mL vs. 4.4 ng/mL) and lower morphine (76.9 ng/mL vs. 284.2 ng/mL) postmortem blood concentrations, and more frequent cocaine co-intoxication (65% vs. 3%), than deaths associated with illicit fentanyl use. A wide range of postmortem blood concentrations of fentanyl was detected (trace-280 ng/mL), with a minimum concentration of 7 ng/mL of fentanyl strongly associated with illicit use of fentanyl in poly-drug cases. The most commonly detected opiates/opioids in illicit fentanyl users were: morphine (29%), oxycodone (14.5%), and methadone (14.5%). Ethanol, cannabinoids, diazepam, citalopram, and diphenhydramine were each detected in greater than 10% of the licit fentanyl cases. Most fentanyl abusers died at their own home and their deaths were most often classified as accidental. Mapping of primary residences of decedents revealed conspicuous clustering of the illicit fentanyl use cases, as opposed to the random pattern in licit use cases. Fentanyl misuse is a public health problem in Massachusetts.

Validation of an ELISA method for screening methadone in postmortem blood.

In this study, we evaluate Venture Labs' enzyme-linked immunosorbent assay (ELISA) for the detection of methadone in postmortem specimens. Sixty-one postmortem specimens that previously screened positive for methadone along with 59 specimens which screened negative for methadone were included. All specimens were screened using the Venture Labs methadone assay in conjunction with a liquid-liquid basic extraction and gas chromatographic-mass spectrometric (GC-MS) analysis. All cases screening positive by either method were confirmed for methadone and its metabolite 2-ethylidene-1,5-dimethyl- 3,3-diphenylpyrrolidine by a solid-phase extraction utilizing deuterated internal standards and GC-MS-SIM. Twenty-four postmortem samples that screened negative by both methods were also extracted and analyzed using the confirmation method to demonstrate the validity of both screening methods. The intra- and interassay precision for the ELISA method was evaluated at the cut-off concentration used for the analysis (50 ng/mL). True positives, true negatives, false positives, and false negatives were calculated for the ELISA results as compared to the GC-MS screening data. The Venture Labs methadone assay demonstrated a sensitivity of 96.7%+/-2.3% and a specificity of 98.3%+/-1.7% relative to the GC-MS method.

Detection of ketamine and norketamine in urine of nonhuman primates after a single dose of ketamine using microplate enzyme-linked immunosorbent assay (ELISA) and NCI-GC-MS.

The general anesthetic ketamine (Ketalar, Ketaject, Vetalar) (KET) is used in human and veterinary medicine for induction of anesthesia for short surgical procedures and routine veterinary examination. Its illicit use by teenagers in rave parties has been reported, and it has recently been identified as a substance associated with sexual assault. One aim of this paper was to study the elimination of KET and its major metabolite norketamine (NKET) in urine collected from five nonhuman primates that received a single dose (5 mg/kg, I.M.) of KET and to study elimination patterns to determine how long after drug administration KET and NKET can be detected. Another aim of this study was to develop and validate a highly sensitive negative ion chemical ionization-gas chromatography-mass spectrometry (NCI-GC-MS) method for the simultaneous quantitation of KET and its major metabolite NKET in urine and to analyze urine samples collected from the animals. The last aim of this study was to apply and evaluate a newly developed ELISA screening methodology for detection of KET and its metabolites in the same urine samples collected from primates which received a single dose of KET. In two monkeys, KET was detected in urine up to 3 days after drug administration (32-7070 ng/mL); in one monkey, it was detected up to 4 days (65-13,500 ng/mL); in one monkey, it was detected only on days 1 and 2 (4000 and 70 ng/mL, respectively); and in one monkey, it was detected 10 days after KET injection (22-35,000 ng/mL). NKET concentrations ranged from 63 pg/mL to 1.75 microg/mL, and it remained in the urine throughout the entire 35-day study period in 4 out of 5 animals. In one monkey, NKET was detected up to 31 days after KET administration. Urine analysis using ELISA revealed that KET and NKET can be easily detectable at 25 ng/mL. In one monkey, KET and its metabolites were detected in urine up to 4 days after drug administration, up to 7 days in two monkeys, up to 11 days in one monkey, and 16 days after KET injection in one monkey. Urine extraction followed by screening using ELISA methodology allowed for significant extension of the detection period in all animals from the study. It is believed that the KET elimination in urine of nonhuman primates is slightly faster than in humans. We propose that NCI-GC-MS be employed to detect NKET as a target compound in urine in toxicological investigations of drug-facilitated sexual assault when KET use by the perpetrator is suspected.

Development of an analytical approach to the specimens collected from victims of sexual assault.

The objective of this study was to develop a screening process for the analysis of sexual assault samples. Recently, the Society of Forensic Toxicologists created a committee to address the issue of drug-facilitated sexual assault (DFSA) in the toxicology field. This committee prepared a list of drugs that could be, or have been, used in DFSAs. The list comprises about 50 compounds, including illicit, prescription, and over-the-counter drugs. Using this list, our laboratory wanted an easy, fast, and sensitive method to analyze a urine sample for all 50 of these drugs. We screened and confirmed for 20 compounds, including cocaine, amphetamines, benzodiazepines, barbiturates, opiates, methadone, alcohol, and PCP. A gas chromatographic-mass spectrometric screening method that was able to detect the remaining 30 compounds following 1 extraction and using only 2 mL of urine was developed. The process is inexpensive and uses equipment available in most forensic toxicology laboratories. This method is recommended for any laboratory that commonly receives specimens collected from sexual assault victims and is interested in a more thorough analysis.