Drug checking services as a surveillance tool for clinical laboratories: Examining trends in the unregulated fentanyl supply.

OBJECTIVES: Timely assessment and understanding of drug trends is essential for clinical laboratories to effectively respond to the overdose epidemic. In this proof-of-concept study, we sought to determine whether information obtained through Toronto's Drug Checking Services (DCS) and cross-provincial urine drug testing (UDT) data can be used as a surveillance tool for clinical laboratories and discuss the value of collaboration between the clinical laboratory, clinicians, and community partners to optimize patient care. DESIGN & METHODS: Mass spectrometry-based UDT data from LifeLabs Ontario (n = 127,529) and British Columbia (n = 14,848), and drug checking data from Toronto DCS (n = 3,308 drugs or used paraphernalia) was collected between August 2020 and October 2021. Fentanyl co-positivity with toxic adulterants such as benzodiazepine-related drugs and fentanyl analogues were examined. RESULTS: The percent co-positivity of fentanyl with etizolam, flualprazolam, flubromazolam, carfentanil, and acetylfentanyl in both Ontario UDT and DCS drugs/used paraphernalia showed similar trends. Regional differences in co-positivity with etizolam and fentanyl analogues were noted between Ontario and British Columbia UDT with patterns consistent over the entire 15-month collection period. CONCLUSIONS: Clinical laboratories should connect with their local DCS, if available, to understand and monitor unregulated drug trends. These data can be used as an important tool to help clinical laboratories tailor their UDT menus and thereby provide a community-focused service to improve patient care.

A direct mass spectrometry method for cannabinoid quantitation in urine and oral fluid utilizing reactive paper spray ionization.

A direct mass spectrometry method utilizing reactive paper spray ionization was developed for sensitive cannabinoid quantitation in biofluid matrices. The ca. 2-minute sample measurements used on-paper derivatization to significantly increase paper spray mass spectrometry (PS-MS) positive ion mode sensitivity while minimizing sample preparation steps. Calibrations demonstrate high linearity, with R2 > 0.99 for (-)-trans-Δ9-tetrahydrocannabinol (THC) in oral fluid and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH) in urine. The limit of detection and lower limit of quantitation were 0.78 and 10 ng mL-1 for THC in oral fluid and 1.3 and 10 ng mL-1 for THC-COOH in urine, respectively. THC-COOH levels measured by reactive PS-MS in seven spiked human urine samples showed bias of -9.4 to 5.9%, and percent difference values of -16.8 to 9.8% in comparison with a reference LC-MS method. Based upon the method simplicity, validation experiments, sensitivity, and rapidity, we conclude that reactive PS-MS has potential applications for rapid cannabinoid drug testing in urine and oral fluid.

A new quantitative drug checking technology for harm reduction: Pilot study in Vancouver, Canada using paper spray mass spectrometry.

INTRODUCTION: Drug checking services for harm reduction and overdose prevention have been implemented in many jurisdictions as a public health intervention in response to the opioid overdose crisis. This study demonstrates the first on-site use of paper spray mass spectrometry for quantitative drug checking to address the limitations of current on-site drug testing technologies. METHODS: Paper spray mass spectrometry was used to provide on-site drug checking services at a supervised consumption site in the Downtown Eastside of Vancouver, British Columbia, Canada during a 2-day pilot test in August 2019. The method included the targeted quantitative measurement of 49 drugs and an untargeted full scan to assist in identifying unknown/unexpected components. RESULTS: During the pilot, 113 samples were submitted for analysis, with 88 (78%) containing the client expected substance. Fentanyl was detected in 45 of 59 expected fentanyl samples, and in 50 (44%) samples overall at a median concentration of 3.6% (w/w%). The synthetic precursor of fentanyl, 4-anilino-N-phenethyl-piperidine (4-ANPP), was found in 74.0% of all fentanyl samples at a median concentration of 2.2%, suggesting widespread poor manufacturing practices. Etizolam was detected in 10 submitted samples anticipated to be fentanyl at a median concentration of 2.5%. No clients submitting these samples expected etizolam or a benzodiazepine in their sample. In three instances, it was co-measured with fentanyl, and in seven cases it was detected alone. DISCUSSION AND CONCLUSIONS: The quantitative capabilities and low detection limits demonstrated by paper spray mass spectrometry offer distinct benefits over existing on-site drug checking methods and harm reduction services.

MASS SPECTROMETRY ANALYSIS OF DRUGS OF ABUSE: CHALLENGES AND EMERGING STRATEGIES.

Mass spectrometry has been the "gold standard" for drugs of abuse (DoA) analysis for many decades because of the selectivity and sensitivity it affords. Recent progress in all aspects of mass spectrometry has seen significant developments in the field of DoA analysis. Mass spectrometry is particularly well suited to address the rapidly proliferating number of very high potency, novel psychoactive substances that are causing an alarming number of fatalities worldwide. This review surveys advancements in the areas of sample preparation, gas and liquid chromatography-mass spectrometry, as well as the rapidly emerging field of ambient ionization mass spectrometry. We have predominantly targeted literature progress over the past ten years and present our outlook for the future. © 2020 Periodicals, Inc. Mass Spec Rev.

Rapid analysis of fentanyls and other novel psychoactive substances in substance use disorder patient urine using paper spray mass spectrometry.

RATIONALE: Drug overdose deaths due to fentanyls and other novel psychoactive substances (NPS) are on the rise. The higher potencies of fentanyl analogs compared with morphine require new technologies to identify and quantitate NPS. METHODS: Paper spray tandem mass spectrometry (MS/MS) and high-resolution mass spectrometry were used to identify and measure fentanyl analogs as well as common drugs of abuse in urine samples from substance use disorder clinics. Ten-microliter urine samples were deposited directly on paper spray cartridges previously loaded with internal standards, dried, and analyzed with no other sample treatment. Quantitative results were obtained using MS/MS. Individual drugs were identified using high-resolution accurate mass spectrometry, and confirmed by data-dependent MS/MS. RESULTS: Calibration curves in urine were linear over a range of 0.5-50 ng/mL with R2 of 0.99 or better for eight representative fentanyl analogs. Cartridges preloaded with internal standards demonstrated satisfactory quantitative results compared with LC/MS. Direct identification and confirmation of fentanyl analogs and other common drugs of abuse in urine using high-resolution accurate mass and MS/MS fragmentation were demonstrated at low picogram levels. CONCLUSIONS: Paper spray mass spectrometry can reliably identify and quantitate fentanyl analogs and other drugs of abuse in urine. Using paper spray cartridges as collection devices reduces exposure and transportation risks associated with biological fluids. Cartridges preloaded with labeled internal standards can be effective for targeted screening of fentanyl analogs and other drugs of abuse.

Paper spray mass spectrometry for the direct, semi-quantitative measurement of fentanyl and norfentanyl in complex matrices.

BACKGROUND: Fentanyl is a potent, synthetic opioid at the centre of an international health crisis that has seen thousands of fatal overdoses. Most analytical methods focus on the detection of fentanyl in blood and/or urine (i.e., post-drug use). Harm reduction (including pre-screening before drug use) may be an effective strategy against fentanyl overdoses. METHOD: Paper spray-mass spectrometry (PS-MS) is an inexpensive, direct sampling strategy where a small volume of sample (<10 µL) is spotted onto a piece of paper that is then wetted and connected to high voltage. Ions are emitted from the paper and enter a mass spectrometer for sensitive and selective semi-quantitation using labeled internal standards. RESULTS: We present the use of PS-MS for the direct measurement of fentanyl and norfentanyl using a custom PS interface, demonstrating that paper tip position and quality can significantly affect quantitative results. Furthermore, we observe comparable calibrations for fentanyl and norfentanyl (0.5 to 600 ng/mL) across a variety of complex matrices (methanol, diluted urine, analgesic slurry). Detection limits for fentanyl are as low as 0.049 ng/mL (0.4 pg total material) in methanol, and 0.66 ng/mL (5.3 pg total material) spiked in an analgesic slurry (illicit substance simulation). PS-MS was compared with liquid chromatography-MS for the analyses of real urine samples, with satisfactory results. CONCLUSION: PS-MS shows potential as a sensitive and selective direct measurement strategy for use in fentanyl harm reduction strategies, and may also be used for pre-screening in advance of or in combination with more conventional (i.e., chromatographic) analyses.

Newborn screening for MCAD deficiency: experience of the first three years in British Columbia, Canada.

BACKGROUND: Medium Chain Acyl-CoA Dehydrogenase (MCAD) Deficiency is an autosomal recessive disorder of fatty acid oxidation, with potential fatal outcome. MCAD deficiency is diagnosed by acylcarnitine analysis on newborn screening blood spot cards by tandem mass spectrometry. Early diagnosis of MCAD and presymptomatic treatment can potentially reduce morbidity and mortality. OBJECTIVES: To evaluate incidence, clinical outcome, biochemical and molecular phenotype of MCAD cases detected in the first three years of newborn screening in British Columbia (BC). METHODS AND RESULTS: Medium chain length acylcarnitines, octanoylcarnitine (C8) and decanoylcarnitine (C10), were measured on newborn screening blood spot cards. Out of 121,000 live births, 17 newborns had C8 values above the screening cut-off of 0.38 umol/L. Ten newborns had elevated C8 on repeat cards and were investigated further. Both C8 and C8/C10 ratios remained abnormal in all confirmed MCAD cases. Positive predictive value of screening was 58% with no false negative results. Seven patients were homozygous for the common c.985A > G MCAD mutation and three others were compound heterozygous for the c.985A > G and a second mutation. Two novel mutations were identified (c.260T > C and c.382T > A). The estimated incidence of MCAD was approximately 1:12,000 live births. Upon frequent feeding and carnitine supplementation, none of the patients had metabolic crises or adverse outcomes. CONCLUSION: Frequency of MCAD in BC is comparable to reports from other newborn screening programs. Persistence of elevated C8 levels and C8/C10 ratios in confirmed MCAD cases suggest that these are sensitive markers for newborn screening. Early detection and treatment have successfully prevented adverse health outcomes in patients with MCAD.

Uptake of cadmium from Pacific oysters (Crassostrea gigas) in British Columbia oyster growers.

BACKGROUND: Pacific oysters along the North American coast from Washington to Alaska contain concentrations of cadmium (Cd) that are high by comparison with Atlantic oysters, frequently exceeding 2mug/g wet weight, but it is unclear whether this Cd is absorbed by consumers. OBJECTIVES: To determine the effect of oyster consumption on Cd in blood and urine among a group with high oyster consumption. METHODS: Sixty-one non-smoking oyster growers and family members with a mean age of 47.3+/-7.6 years (range 33-64) were interviewed by telephone to assess their oyster consumption and other sources of Cd exposure at present and 5 years prior to the start of oyster farming. Their blood and urine Cd concentrations were measured. RESULTS: The geometric mean Cd concentration in blood was 0.83mug/L and in urine was 0.76mug/g creatinine. Thirty-six percent of participants had urinary Cd levels above 1mug/g creatinine and 5% were above 2mug/g creatinine. Recent (last 12 months) and long-term oyster consumptions were positive predictors of blood Cd but did not directly predict urinary Cd. The optimal model for predicting the variance in blood Cd included recent intake of oyster-derived Cd, serum iron concentration and recent ketchup consumption (R(2)=0.34, p=0.00004), with the latter two variables showing a protective effect. The factors found to predict urinary Cd were blood Cd concentration and duration of oyster farming. A rise in blood Cd was observed after 12 years of farming oysters, likely caused by higher consumption of oysters during this period. CONCLUSIONS: Oyster-derived Cd is bioavailable and affects body stores of the metal.

The human cytochrome c oxidase assembly factors SCO1 and SCO2 have regulatory roles in the maintenance of cellular copper homeostasis.

Human SCO1 and SCO2 are metallochaperones that are essential for the assembly of the catalytic core of cytochrome c oxidase (COX). Here we show that they have additional, unexpected roles in cellular copper homeostasis. Mutations in either SCO result in a cellular copper deficiency that is both tissue and allele specific. This phenotype can be dissociated from the defects in COX assembly and is suppressed by overexpression of SCO2, but not SCO1. Overexpression of a SCO1 mutant in control cells in which wild-type SCO1 levels were reduced by shRNA recapitulates the copper-deficiency phenotype in SCO1 patient cells. The copper-deficiency phenotype reflects not a change in high-affinity copper uptake but rather a proportional increase in copper efflux. These results suggest a mitochondrial pathway for the regulation of cellular copper content that involves signaling through SCO1 and SCO2, perhaps by their thiol redox or metal-binding state.

Increased levels of mercury associated with high fish intakes among children from Vancouver, Canada.

OBJECTIVE: To assess exposure to mercury (Hg) among children in population subgroups whose traditional dietary practices include fish. STUDY DESIGN: We determined blood Hg, red blood cell phosphatidylethanolamine omega-3 eicosapentaenoic acid as a marker of fish intake, and assessed indexes of childhood behavior in preschool children 1.5 to 5 years of age (n = 228) living in an ethnically diverse neighborhood in Vancouver, British Columbia, Canada. RESULTS: The median blood Hg was 4.6 nmol/L, range 0-67.9 nmol/L. Twelve (6%) children, all of whom were Chinese, had a blood Hg > 28.9 nmol/L. Blood Hg, total fish intake, and eicosapentaenoic acid were higher among Chinese than Caucasian children; however, higher fish intake did not predict blood Hg. Blood Hg was inversely associated with attentional focusing in children over 3 years of age after adjusting for confounding family variables, iron deficiency anemia, and zinc deficiency. Major sources of fish among Chinese children were imported fish rather than local fish. CONCLUSION: Children from population subgroups within populations not considered at risk may be at increased risk of neurotoxicity caused by Hg exposure from fish.

Reference limits for copper and iron in liver biopsies.

Using 141 liver biopsy results (103 adults, 38 children) and a rank-order approach, the following reference limits were found: copper 55 microg/g dry weight, iron 1800 microg/g dry weight (adults only), and iron index 1.0. The study was made feasible by the fact that both copper and iron were measured as standard practice in every liver biopsy received for either test. The added analyte tended to contribute more to normal results. Specimens with elevations of both were infrequent (7 of 141) and significant elevations of both (copper >200 microg/g, iron index >2.0) were suggestive of contamination. Advantages of using patient data included studying specimens of limited availability and acquiring information on the distribution of elevated results seen in clinical practice. Disadvantages included increased uncertainty in the reference limits relative to a normal population. Although most of the study population consisted of patients referred for diagnosis of Wilson's disease or hemochromatosis, the reference intervals were similar to those reported from autopsy studies.