Use of synthetic stimulants and hallucinogens in a cohort of electronic dance music festival attendees.

Novel psychoactive substances (NPS), often characterized as unregulated psychoactive compounds designed to circumvent existing legislation, have become mainstream on the illicit drug market. Because of their physical and mind-altering properties, NPS may be deliberately or inadvertently ingested at electronic dance music (EDM) festivals to enhance the attendees' appreciation of the music and overall experience. Their widespread use at EDM festivals have been well documented and several adverse events and fatalities associated with NPS ingestion have been reported in the United States. The diversity and rapid turnover in the prevalence of any particular NPS at any given point of time has created several challenges for public health officials, law enforcement, and forensic science communities. Epidemiological studies are often published long after drugs have cycled through the peak of their popularity with users and the scope of testing frequently failing to detect, identify or report the most recently available drugs. The aims of the study included discovering emerging NPS, ascertaining their overall prevalence and determining patterns of use and trends within this targeted population. Over the course of two years, biological samples were collected from 396 (126 blood samples; 227 urine samples; and 384 oral fluid samples) EDM festival attendees. Additionally, survey data regarding prescription and recreational drug use within the last week were collected with follow-up questions related to what substance(s) the person had ingested, amount taken, when the substance was last taken and perceived effects. All biological samples were screened and subsequently confirmed and/or quantified, when appropriate. In response to survey questions, 72% of the participants reported using a recreational drug or medicinal substance within the last week. Users most commonly reported using marijuana and alcohol, followed by "Molly" and cocaine. Of the 396 individuals tested, approximately 75% of the population was positive in at least one biological specimen for drugs and/or alcohol. Of those positive samples, 36% were confirmed to contain one or more NPS and/or 3,4-methylenedioxy-methamphetamine (MDMA). High rates of turnover and spikes in popularity related to NPS are supported by samples confirming positive for alpha-PVP in 2014, however, one year later not a single case was positive for alpha-PVP, and instead increasing numbers of subjects were positive for ethylone.

Blood synthetic cannabinoid concentrations in cases of suspected impaired driving.

Twelve cases of suspected impaired driving are discussed in which the drivers who subsequently tested positive for synthetic cannabinoid drugs underwent a psychophysical assessment. The attitude of the drivers was described as cooperative and relaxed, speech was slow and slurred and coordination was poor. Pulse and blood pressure were generally elevated. Horizontal gaze nystagmus was assessed in nine of the subjects, but was present in only two. The most consistent indicator was a marked lack of convergence. In all cases where a Drug Recognition Expert (DRE) officer evaluated and documented impairment (10 cases), it was attributed to the DRE cannabis category. Performance in field sobriety tests was variable, ranging from poor to minimal observable effect. Synthetic cannabinoid testing was performed by LC-MS-MS. Positive results included: JWH-018 (n = 4), 0.1-1.1 ng/mL; JWH-081 (n = 2) qualitative only; JWH-122 (n = 3), 2.5 ng/mL; JWH-210 (n = 4), 0.1 ng/mL; JWH-250 (n = 1), 0.38 ng/mL and AM-2201 (n = 6), 0.43-4.0 ng/mL. While there is good evidence of psychophysical impairment in these subjects, further structured data collection is needed to fully assess the relationship between synthetic cannabinoid use and psychomotor and cognitive impairment.

Recommendations for toxicological investigation of drug-impaired driving and motor vehicle fatalities.

This report describes the review and update of a set of minimum recommendations for the toxicological investigation of suspected alcohol and drug-impaired driving cases and motor vehicle fatalities involving drugs or alcohol. The recommendations have the goal of ensuring that a consistent set of data regarding the most frequently encountered drugs linked to driving impairment is collected for practical application in the investigation of these cases and to allow epidemiological monitoring and the development of evidence-based public policy on this important public safety issue. The recommendations are based on a survey of practices in US laboratories performing this kind of analysis, consideration of existing epidemiological crash and arrest data and practical considerations of widely available technology platforms in laboratories performing this work. The final recommendations were derived from a consensus meeting of experts recruited from survey respondents and the membership of the National Safety Council's Alcohol, Drug and Impairment Division (formerly known as the Committee on Alcohol and Other Drugs, CAOD).

Butalbital and driving impairment.

Butalbital (Fiorinal(®)), used in the treatment of migraines and muscle pain, is the most commonly encountered barbiturate in impaired driving cases. It has central nervous system (CNS) depressant properties, including sedation, drowsiness, and feelings of intoxication, which can contribute to driving impairment. Twenty-six driving under the influence cases are reviewed including results from field sobriety tests and toxicology testing. Blood samples were screened using enzyme multiplied immunoassay technique immunoassay, and the presence of butalbital was confirmed and quantified using gas chromatography/mass spectrometry, gas chromatography with flame ionization detection, or gas chromatography nitrogen/phosphorus detection. Butalbital concentrations ranged from 1.0 to 30.2 mg/L, with a mean and median of 16.0 mg/L. General impairment indicators in these cases included horizontal and vertical nystagmus, lack of convergence, poor motor coordination, and balance and speech problems, which are common to CNS depressant intoxication, similar to that associated with alcohol. These findings indicate the importance of toxicological testing for butalbital in cases where CNS depressants are indicated.

Dextromethorphan abuse leading to assault, suicide, or homicide.

Dextromethorphan is a commonly encountered antitussive medication which has found additional therapeutic use in the treatment of pseudobulbar disorder and as an adjunct to opiate use in pain management. Dextromethorphan at high doses has phencyclidine-like effects on the NMDA receptor system; recreational use of high doses has been found to cause mania and hallucinations. The toxicology and pharmacology of the drug in abuse are reviewed, and the historical literature of adverse psychiatric outcomes is assessed. Five new cases of dextromethorphan intoxication that resulted in assault, suicide, and homicide are reported, together with the corresponding toxicology results. Blood concentrations ranged from 300 to 19,000 µg/L. These results are compared with typical concentrations reported in therapeutic use and impaired driving cases. Based on these findings, dextromethorphan should be considered as a potential causative agent in subjects presenting with mania, psychosis, or hallucinations, and abusers are at risk for violent and self-destructive acts.