Forensics Toxicology Flashcards
What does forensic toxicology deal with?
- postmortem cases = cause and manner of death
- impaired driving and sexual assault
- workplace drug testing
- sports (Olympics for example)
civil issues or cases that could include forensic tox?
non-criminal accidents like falling or drowning
workplace drug testing - usually urine
> condition of employment or site access
T or F. MLTs can testify as a witness in court
T
expert witness in court
must be qualified by the judge to give “opinion” evidence (based on education, training or experience)
doesn’t have to have done any lab work on the case
what do witnesses in court do?
- testifies to facts and observations
- medical techs usually in this category
- what they did or nor mally would have done
during a death investigation which provinces use a medical examiner system?
Alberta
Manitoba
Nova Scotia
Newfoundland
= headed by a forensic pathologist, whereas a coroner system may or may not be headed by a physician
cause of death definition
immediate medical cause of death
NOT circumstances
ex: blunt force trauma rather than motor vehicle accident
manner of death specific categories
homicide
suicide
accident
natural
undetermined
unclassified (MAID deaths)
postmortem BAC
- we dont like to rely on blood alone for alcohol bc of postmortem fermentation (alc formed in blood after death)
- if blood is not accompanied with fluoride = alc formation
- we use vitreous fluid too (eye remains sterile for about 3 days after death; so if alc found here that means person drank before death)
- can get postmortem AC up to legal limit due to fermentation; in rare circumstances >300 mg%
historical belief before postmortem redistribution
drug conctn in blood after somebody died = reflects conctn at time of death
but no found that there can be changed after death
define postmortem redistribution
- time and conctn dependent
- releade and diffusion of drugs from the major organs
- occurs as cells die = pH changes and protein binding weakens
candiddates for postmortem redistribution
- drugs w a high vol of distribution (>5L/kg)
- drugs with basic character like forming HCl salts
impaired metabolism can be due to:
- genetic impairment due to enzyme def (ex: cytochrome P4502D6; 7-10% in Caucasians)
- drug-drug impairment of enzyme system (ex: impairment by SSRIs of CYP4502D6)
- impairment due to high single drug conctn
- impairment due to reduced liver function (age, alc)
difficulties of interpreting postmortem data
- don’t know when drug last taken, rate of metabolism, rate of excretion
- don’t know if postmortem blood level of drug represents blood level at time of death (some conctns increase postmortem, and some decrease)=
cannot reliably calculate dose - don’t know tolerance if person to toxic effects of drug
- must consider autopsy findings, medical history, circumstances of death
how should one interpret tox results in postmortem cases?
interpret with full consideration of:
- circumstances of death
- post-death investigation = medical history, medication history, autopsy findings, toxicology on alternate specimens
if not enough information, don’t offer interpretation or give clear caveats!
describe medication counts
for each important medication determine:
- number prescribed
- date dispensed
- dosage (tablets per day for ex)
- number remaining at death
- calculate meds “unaccounted for”
why? = suicide vs. ‘build-up’
assumptions made in the past about THC
- THC always drops near to zero a few hours after the last smoke
- blood THC >2-3 ng/mL consistent with recent use within 6h = could be used to indicate impairment
- THC:THC-COOH ratio can be used to estimate time of last use – now know it is not reliable
- little postmortem change w THC conctn (but actually can be very significant change)
what we now know about THC
- baseling blood THC several hrs after smoking:
> <2 ng/mL in light smokers (<1 after 24h)
> can be >5 in heavy (could be >10)
> 1.2-5.5 7d after last use
> very high body burden of THC slowly release into blood ( esp. from fatty tissue) - only refers to living ppl
postmortem THC conctn
- undergoes postmortem redistribution (can increase after death)
- PM femoral blood THC = MUCH higher in postmortem blood than pre-mortem clinical blood
- THC concentrates in muscle tissue and may be redistributing postmortem
- much larger effect may be presence of fat in postmortem blood drawn
T or F. THC is very fat soluble
T
how is postmortem blood taken?
external exmaination = no dissectoon, blood taken before dissection => techs take blood do not visualize vein bc can’t see = poking around aggressively to find femoral vein = pulling syringe back = disrupts fatty tissue = therefore blood and fat sucked up
spice and K2
synthetic cannabinoids or cannabimimetics = can mimic effects of cannabis
where is CB1 located?
nervous system
where is CB2 located?
immune system
cannabinoid receptors
CB1 and CB2
T or F. Many cannabimimetics are quite toxic and do not have true THC effects
T
adverse effetcs of synthetitic cannabinoids
- psychiatric: psychosis, agitation, irritability confusion, aggression, etc.
- CV: hypertension, tachycardia, MI, etc.
- neurologic: generalized seizures, somnolence, brisk reflexes
- GI: nausea, vomiting, anorexia, increased appetite
- other: hypokalemia, blood shot eyes, hyperglycemia, AKI, xerostomia, diaphoresis
analysis of synthetic cannabinoids
difficult!!
- low blood conctns; lower than THC bc much more potent
- extensively and rapidly metabolized
- over 200 known structures
- keep changing as regulations change
- screening methods do not detect all
- need high-end methods for confirmation such as LC/MS/MS = difficult and time-consuming to develop
bath salts
cathinone
- found in Khat
- used by some African cultures
- some South Americans chew coca leafe
- Europeans use this as caffeine
earliest substances used for doping
cocaine, strychnine, caffeine
initial dope testing mainly focused on this..
stimulants
TUE
Therapeutic use exemption
- certain drugs allowed for athletes if recommended by physician AND approved by WADA
- must be approved before use (duyring or out-of-event)
- athlete’s physician must apply to WADA medical team ahead of tine
monitoring program for sports competititons
to monitor incidence and conctns of drugs not banned but subject to abuse
- stimulants
- narcotics
- glucocorticoids
- B-2-agonists
stimulants effect
sympathomimetic
- raised BP
- increased HR
- greater endurance
- combats fatigue
- improve endurance
T or F. Caffeine is a mild stimulant
T
- used to not be allowed; can be abused by non-coffee drinkers and abstinece followed by use
- main desired stimulant effect is increased aggression
what do masking agents do?
masks presence of banned substances
diiuretics
MASKING AGENT
CAUSE DILUTE URINE
indrirectly masks presence of varous drugs including anabolic steroid metabolites
plasma expanders
masking agent
impairs detection of EPO
- albumin
- Dextran infusion
- gelatin succinylaated
- hydroxylethyl strach
forensic analytical toxicology testing
- not usually “limited”
> drugs can be prescription, non-prescription, and illicit + other poisons such as pesticides and chemicals
> high contcns; overdoses
> low conctns; sexual assault
> may use many methods for single “screen” - most testing on urine or whole blood (clinical lab = serum, plasma or urine)
T or F. Whole blood specimens are more difficult and give more interference than fresh serum or plasma
T
define specimen matrix
the fluid or tissue in which the analyte is contained, such as proteins (blood or solid tissue), lipids/phospholipids, electrolytes, water
when is specimen processing or extraction necessary?
most samples have to be processed/extracted prior to analysis
two main purposes of specimen processing/extraction
minimize or eliminate matrix interference (involves extracting out the analyte)
concentrate the analyte to improve sensitivity of assay
sample extraction for immunoassays
degree of sample extraction depends on assay design
- homogenous enzyme immunoassay vs ELISA
> most clinical immunoassays are designed for urine or serum/plasma
these immunoassays are best suted for forensic work as they are optimised to work with diluted whole blood
ELISA (96-well) plates
tissues must be homogenized and diluted
define tissue homogenization
tissues can rarely be analyzed directly; so need to make fluid sample
- use homogenizer
- eg: Polytron homogenizer
- 1+3 tissue:water
what is critical when differentiating between GC/MS vs. LC/MS/MS
column inlet
GC inlet
heated to vaporize the solvent and the analyte; many drugs will not “chromatograph”
will cause pyrolysis of some analytes, and the matrix = interference
more sample prep needed than for LC-based methods
T or F. GC requires more sample prep than LC-based methods
T
LC inlet
cool (on-column) = little or no destruction of analyte or matrix
sample introduced to MS spray chamber as liquid = then vaporized and ionized
less sample prep required
two basic approaches to sample preparation
- extract the analyte from the sample and leave matrix behind
> liquid-liquid or SPE extractions
> most common for GC-based assays - remove interferences from sample and leave analytes behind
> ex: protein “crash” extracts
> increasingly common approach for LC-MS and LC-TOF
important consideration for sample preparation
considering the analytical instrumentation
simplest sample prep
dilution
- dilute out proteins in plasma or blood sample to allow direct analysis
- ex: Immunoassay
headspace analysis
- ex: alcohols by GC
protein “crash”
- ex: acetonitrile, methanol
> smoe highly selective LC-MS/MS and LC-QTOF assays
headspace GC analysis
used for volatile liquids such as alcohols and solvents
only volatiles from air above the sample get injected on to the GC
very clean with little interference
how to prepare non-volatile substances such as drugs for chromatography
simpler methods such as protein crash if analytical methods are specific enough
describe acetonitrile/methanol “crash”
- add cold acetonitrile/methanol to blood (or serum/plasma)
- proteins and peptides in whole blood denatured => centrifuge to form pellet
- clear supernatant injected (sometimes after concentration like dilute and shoot)
- increasingly used for LC/MSMS or LC-QCTOF
- this does not remove salts, lipids of phospholipids
caution when using acetonitrile/methanol “crash”
analytes can be trapped in precipitation matrix
need good, validated methods with deuterated internal standards
why are traditional protein precipitation methods (“crash” not good for GC
it does not remove lipids
liquid-liquid extractions with solvents
- simple
- analyte more soluble in solvent than aq specimen
- add solvent to liquid specimen
- mix to temporarily blend phases
- centrifuge to separate
principle of solvent-based extraction
- un-ionized analyte more lipid-soluble
- ionized analyte (like salt form such as HCl or sulfate) is more water soluble
- need to get analyte to un-ionized form in order to extract into organic solvent
- use buffers (adjust pH)
how to simple extract basic drugs
add pH12 buffer to specimen with the solvent
mix & centrifuge
will separate into organic (GC/LC) and aqueous (WASTE) substances
extract acid drugs by adding an acidic buffer
how to back-extract basic drugs
add pH 12 to solvent and specimen
mix & centrifuge = aqueous waste and organic substances
add pH2 to organic
mix & centrifuge = organic waste and aqueous
add pH 12 to aqueous and solvent
mix & centrifuge = ORGANIC to GC/LC and aqueous WASTE
what is back-extraction
extraction of basic drugs that leaves behind neutrals (like fats) and acidic drugs
these are considered problematic drugs for extraction
amphoteric drugs and zwitterions
examples of amphoteric functions
phenolics
amino (morphine)
examples of zwitterion functions
carboxylic
amino (ex: GABA)
extraction method considerations
- specimen type
- instrumentation used/available
- robustness and precision of assay
- purpose of test (quick screen vs quantitative)
- processing time (urgency and speed of test)
- type of analyte/drug being tested
- cost of reagents (solid phase extraction uses less solvent than liquid/liquid, but solid phase extraction columns can be expensive)
pHs to ionize amphoteric drugs
pH 2 = initially + charge
then pH 8 = neutral
then pH 12 = - charge
another method to extract amphoteric and zwitterion analytes
SPE
solid phase extraction
which type of death investigation does Alberta particpate in?
Medical Examiner system
- along with NFL, Manitoba and Nova Scotia
- headed by a forensic pathologist
Coroner system
may or may not be headed by a physician
is time of death reliable in post mortem investigations?
no, not accurate
In Alberta, how many deaths does the OCME investigate annually? and what is the manner of death usually?
~6500 (cases have increased substantially over the past 6-10 yrs)
natural (34%) and accidental (49%)
undetermined and homicidal (both ~2%)
Where are RCMP labs located?
Vancouver, Edmonton, Ottawa
- only handle criminal cases
T or F. Most fatalities due to drugs or poisons will not show specific signs at autopsy
T!
- an autopsy can rule out natural disease or trauma as the cause of death
T or F. We can use serum or plasma for postmortem investigations
F!
Use: whole blood, vitreous, urine, liver, stomach contents, other tissues, hair, other exhibits like syringes and drinking glass
most consistently available abundant fluid
blood
T or F. Postmortem blood is usually partially to fully hemolyzed
T
T or F. Postmortem blood is usually homogenous throughout the body
F!
Why is blood not usually useful for biochemical tests?
drug concentrations can go up or down after death (dependent on drug)
drug concentrations should not be interpreted in isolation
vitreous humour
- clear fluid inside eye
- limited vol (~3mL per eye)
- very useful for alcohol
- can be useful for some drugs like cocaine, heroin, digoxin
- cannot interpret as you would blood
T or F. Vitreous humour fluid concentrations often higher than in blood
F!
Often lower than in blood = especially highly lipid soluble and protein-bound drugs like benzos, tricyclic antidepressants
clear fluid, no protein, and very little lipid
urine
- exception = decomposed bodies
T or F. Urine is always available in postmortem cases
F! not always
- but if it is = some drug concentrations very high
- some drugs not excreted due to extensive metabolism, but metabolites can be detected
Urine has little to no relationship between _______ _______ ________ and pharmacological effect with some exceptions
urine drug concentration
exceptions = alcohol and some metals
T or F. We can relate urine drug concentration and degree of impairment
F!
liver as postmortem specimen
- always present
- large amount
- need to make liquid prep (homogenize)
- high protein and lipid content can interfere
- drug conctns don’t change much after death
> exceptions:drugs may diffuse from stomach into liver if concentration is high; some drugs are unstable - liver drugs concentrations are often much higher than in blood
- often useful to have BOTH liver and blood conctns
- widely used in past but less now
stomach contents for postmortem
- variable from clear fluid to a “meal”
- drug concentrations can be very high
- need to relate drug concentration to total volume
- total AMOUNT, not concentration
- drug/metabolite can be in stomach after parenteral use due to secretion in gastric juice
- presence in stomach does not prove oral use
is a phenytoin gastric concentration of 150 mg/L toxic? (therapeutic range is 10-20 mg/L in blood)
NO! 150 mg/L may be 15 mg/100mL if volume of gastric contents is 100 mL
- could man partially absorbed 100 mg dose
other specimens used for postmortem investigations
bile, CSF, virtually any fluid
lungs, kidney, muscle, or any solid tissue
bone, nails, hair
injection sites
- need “control” site away from suspected injection site
- can be difficult to prove injection sit if elapsed time, esp. if i/v injection
T or F. Most drugs are distributed to virtually all fluids and tissue in the body
T
when are syringes helpful in a postmortem investigation
heroin
drinking glasses as exhibits
can be useful in drug-facilitated sexual assault cases
can indicate manner of death in suicide
bottles as postmortem exhibits
can indicate source of poison
defin chain of custody
a means of tracking exhibits o specimens from the pt and time of collection to analysis and ultimately disposal
what does a chain of custody entail?
place, date, time and persons (analysts)
purpose is to demonstrate that analysis and reporting was performed on the stated exhibit/specimen
usually involves a reasonable degree of physical security (locked storage), secured facility, and restricted access
physical or electronic log of those entering and leaving the facility
authorized staff may have electronic key card
carbon monoxide binds to Hb ____x stronger than oxygen
200x more
order of increasing magnitude of postmortem redistribution
cardiac > subclavian > femoral > antemortem
increases 2-10 fold or greater
these can cause hypoxic brain damage
depressants such as narcotics and sedatives (with or without alcohol)
near-fatal ethanol can clear in ..
<24 hrs
why are antemortem specimens important
so forensic toxicology can better assess postmortem cases (have something to compare to)
hospitals are encouraged to hold on to antemortem specimens at least until after it seems that pts will recover
besides depressants and ethanol, delayed deaths are also a factor with these…
methanol
ethylene glycol
acetaminophen
case study of young boy who died from his ADHD medication
he had no prior history of side effects
autopsy negative; toxicology = imipramine poisoning (ADHD med)
specimens showed that desipramine (metabolite of imipramine) was high
boy was deficient in CYP2D6 (hydroxylates and glucuronidates imipramine for rapid excretion) so CYP3A4 was breaking own drug to desipramine = accumulation = death
interpretations of postmortem _______ blood levels are very tricky
narcotics
- if naive user = easier
- prescribed = acquire records
- need to know dos and duration as well as a medication count
medical tolerance of fentanyl
starting dose = 25 ug/hr for chronic pain
potentially fatal for non-tolerant pts = 100 ug/hr
what cannabis products do most forensic labs measure?
delta 9 THC
11-OH-THC
THC-COOH
most forensic labs do not measure CBD
delta 9 tetrahydrocannabinol (delta9THC)
highly lipid soluble
usually measured in whole blood
majority of research was conducted in serum or plasma
THC blood:plasma ratio is 0.5 - 0.6
11-hydroxytetrahydrocannabinol (11-OH-THC)
pharmacologically “active”
concentrations higher after oral ingestion (first pass effect)
11-caboxytetrahydocannabinol (THC-COOH)
inactive metabolite
forms waer soluble glucuronide metabolite
majority present as glucuronide
most labs measure the UNconjugated THC-COOH in blood
most urine testing labs for workplace measure TOTAL THC-COOH
Cannabidiol (CBD)
can be up to 40% of cannabis plant extract
has been studied to treat anxiety, cognition, movement disorders, pain and epilepsy
little (if any) psychoactivity
may modify the effect of THC if both are present
legal in USA (cannabis extracts are NOT)
Cannabinol (CBN)
mildly psychoactive, but present in only small amounts in cannabis
delta-9-THC metabolite
psychoactive effects of delta-9-THC
- relaxation, euphoria
- philosophical thinking, introspection
- anxiety, paranoia
- increased heart rate, hunger, reddening of eyes
- reduces nausea and vomiting
- impaired motor skills
- impaired judgment of tie and distance
T or F. THC interpretation is much easier than alcohol
F! for alcohol, there is a generally direct correlation between blood concentration and effect/impairment
ethanol: can estimate “dose” from a blood level and can estimate a blood level from a dose
THC: the correlation between blood level and “effect” is very poor except in very early stages of smoking
T or F. In most people, duration of ‘high’ lasts 2-6 hours which is much longer than the blood THC concentration is elevated
T
pharmacokinetics of delta-9-THC
short distribution half-life
long elimination of half-life resulting in baseline blood THC concentrations up to 7 ng/mL after heavy chronic use
Bill in Canadian criminal code regarding cannabis
Bill C-46
- June 21, 2018
low-level THC concentrations of __ ng/mL to <__ng/mL within 2 hours of driving is an offense
2 - <5 ng/mL
higher-level THC concentrations of __ng/mL or more within __ hours of driving
> =5ng/mL
2 hrs
this offence recognizes the effects of combined marijuana and alcohol consumption
50 mg of alcohol per 100 mL blood plus >/=2.5 ng/mL THC within 2 hours of driving
THC has relatively short half-life here
in blood
THC longer half-life here
BRAIN - where it has its main effect related to impairment
and much longer half-life in body
T or F. THC concentration decreases after death due to postmortem redistribution
F, it increases
baseline blood THC several hours after smoking:
typically <2 ng/mL in light smothers (<1 after 24 hr)
can be > 5ng/mL in heavy smokers (may be >10)
in one study - 1.2-5.5 ng/mL seven days after last use
very high body burden of THC slowly released into blood
- living ppl
THC concentrates in ____________ tissue and may be redistributing postmortem but a much larger effect may be the presence of ____ in the postmortem blood drawn
muscle; fat
T or F. THC is very fat soluble
T
spice and K2
synthetic cannabinoids
aka cannabimimetics
synthetic cannabinoids
- chemicals impregnated into various dried plant materials
- synthetic chemicals that may or may not be closely related to the structure of delta-9-THC
> interacts with cannabinoid receptors
> partial agonist activity at the cannabinoid receptor CB1 located mainly in the CNS
> and the CB2 receptor, mainly in cells of the immune system - many do not have true THC effects
cannabimimetic properties
- similar to cannabis
- some may have more intense effect in ability to produce psychosis
- psychoactive effects include:
> relaxation, perhaps euphoria
> philosophical thinking, introspection
> anxiety and paranoia, also increase in HR and hunger, reddening of eyes
> reduces nausea and vomiting
> impaired motor skills; judging time and distance
psychiatric adverse effects of synthetic cannabinoids
psychiatric
- psychosis (new-onset, or exacerbation of pre-existing disease)
- agitation
- anxiety,
- irritability
- confusion
- suicidality
- memory changes
- aggression
- tolerance
- withdrawal
- dependence
CV adverse effects of synthetic cannabinoids
- hypertension
- tachycardia
- ST- segment changes
- chest pain
- myocardial infarction
- tachyarrhythmia
neurologic adverse effects of synthetic cannabinoids
generalized seizures, somnolence, brisk reflexes
gastrointestinal adverse effects of synthetic cannabinoids
nausea, vomiting, anorexia, increased appetite
other symptoms or side effects of synthetic cannabinoids
hypokalemia
conjunctival injection (bloodshot eyes)
hyperglycemia
acute kidney injury
xerostomia (dry mouth)
diaphoresis
refers to any chemical that activates mu receptors mainly in spinal cord and brain
opioid
- endogenous neuropeptides (ex: endorphins/ endogenous morphine)
- opiates (opium-derived, found naturally in opium poppy)
- semi-synthetic opioids (derived thebaine/opium poppy); NOT naturally occurring
- synthetic opioids: not usually structurally related to morphine; fentanyl, methadone, tramadol, meperidine
opioid tolerance
the ability to withstand increasing dosages with static or decreasing side effects
this can enable a person to take doses doses of an opioid that would kill most non-tolerant persons
tolerance
- tolerance is relative
(dose-related; not absolute)
T or F. Cross-tolerance from one opioid to another occurs
T!
eg. if a person develops tolerance to heroin, they will also have a degree of tolerance to fentanyl
- the degree of cross-tolerance can be difficult to predict
naloxone
reversing agent of opioids
- competitive antagonist that binds mu receptor
- displaces opioids that are already bound there, without activating the receptors (no analgesia)
naloxone half-life
30 to 80 minutes
fentanyl half life
3-12 hours
why is repeat naloxone injection often required?
naloxone half life 30-80 mins
and fentanyl half life is 3-12 hrs
- if minimal or no response within two to three minutes, dosing may be repeated every 2 mins to a max of 10 mg
(ex: 0.4 mg per injection -> 25 injections for 10 mg)
what happens if no opioids and you give someone naloxone
minimal toxicity if opioids not present; very low risk for repeat administration!
how to administer naloxone
medical administration intravenous or intramuscular
- intra-nasal formulation available for public
- orally = poor oral bioavailability, takes too long to act
are some opioids tolerant to naloxone?
- effectiveness depends on dose of naloxone administered vs potency and dose of opioid
- highly tolerant abusers using high doses will require higher doses of nalocone to reverse a coma
- some newer opioids may be more dangerous bc users not familiar to right dose/potency of specific batch being sold
these will increase CNS depression caused by opioids
benzos (etizolam)
NOTE: benzos are not reverse by naloxone
medical use for fentanyl
- short-term anesthesia
- induction of anesthesia
- adjunct to anesthesia in more prolonged surgical procedures
- transdermal patches for long-term chronic pain
- sublingual lozenge for breakthrough pain (0.1 to 1.6 mg)
fentanyl for shortterm anesthesia
acute surgial procedures such as intubation
50 -200 ug intravenous
fentanyl for induction of anesthesia
often with midazolam
fentanyl as adjunct to anesthesia in longer procedures
dose dependent on surgery type
airway must be supported for higher doses and longer surgeries
fentanyl as transdermal patches for long-term chronic pain
12.5, 25, 50, 100 ug/hr
NOT for acute or post-surgery pain
fentanyl analogues studied with animal testing
carfentanil and 3-methylfentanyl
fentanyl abuse
highly addictive narcotic
- injectable fentanyl - abused by medical personnel with easy access
- 50 to 100x more potent than morphine and 25x> heroin
abuse also as ilicit tablets and powder
Duragesic
transdermal patch (fentanyl) for chronic pain
how is fentanyl abused?
snorting
smoking
injecting
TD patch: inject, chew
less convention modes of abuse of fentanyl
nasal spray
e-cig
T or F. Most fentanyl fatalities include a stimulant
T!
fentanyl rarely acts alone, usually methamphetamine or cocaine; some have both
- many fentanyl-related deaths include ethanol and/or prescription or illicit benzos and/or prescription drugs
xylazine
vet sedative
stimulant used with fentanyl
unintentional fentanyl poisoning deaths in Alberta - most common additional substances
methamphetamine
carfentanil
cocaine
estimated fatal dose of fentanyl (non-medical)
0.5 to 1.0 mg
presuming low tolerance and IV administration
- lower with alcohol or depressant drugs
- higher with tolerance, >2-3 mg
fake Oxys: amount of fentanyl
1-4 mg
but not always fentanyl; may be carfentanil or another drug
this is estimated to be 100x more potent than fentanyl (based on animal studies)
carfentanil
- restrivted for vet use for large animals
- fatal doses could be as low as 10-20 ug!!!
nitazenes
isotonitazene
- same potency as fentanyl
- some estimated to be 20x more potent than fentanyl
- classed as benzimidazol opioid analgesics
pharmaceutical benzos as fentanyl adulterants
alprazolam
bromazepam
clonazepam
diazepam
nitrazepam
illicit benzos
adinazolam
bromazolam
clonazolam
etizolam, etc.
how to increase the success of finding the more potent fentanyl and other opioid analogues
- seizing and analyzing drug paraphernalia
- optimizing and/or developing new analytical methods (screening urine samples bc likely more concentrated!)
- information gathering
drugs: stimulants, psychedelics and hallucinogens
cocaine
amphetamines
phenethylamines
> 2C-X series and N-BOMe drugs
cathinones (aka bath salts)
tryptamines
others = LSD, PCP, mescaline, psilocin
powerful stimulant, local anesthetic, highly addictive and routinely used in lower doses (South America)
cocainm
cocaine adulteration: cardiac drug
Diltiazem
cocaine adulteration: antihistamine/sedative
hydroxyzine
cocaine adulteration: anticancer/vet de-worming agent
Levamisole
- life-threatening blood dyscrasias = agranulocytosis/neutropenia
phenacetin
obsolete OTC analgesic (“Superbuff”)
- causes kidney damage and potentially carcinogenic?
- cocaine cutting agent
amphetamine vs methamphetamine
methamph = crystal meth
amph = metabolite used for ADHD, narcolepsy, weight loss
ecstasy group
MDMA
MDA
MDEA
PMMA
PMA
etc.
this has become a MAJOR contributing factor in the opioid crisis
methamphetamines
psychopharmacology of cocaine and methamphetamine
- both stimulate release and block reuptake to varying degrees of dopamine, serotonin, norepi = increased CNS stimulation, CV, and other systems
- abuse = tolerance, sleep disturbances, psychosis, violent/aggressive behaviour (esp. meth)
meth vs cocaine halflife
meth = 10-15h
cocaine = 0.5-1.5h
meth binge can last…
2-3 days
- involves doses of up to 1000 mg or more a day
- may be in 100-250 mg doses
- “therapeutic” = 5-20 mg
- neurotransmitter levels in brain may be depleted and sensitivity of neurons to meth decreased
psychosis
a severe mental disorder
- thought and emotions so impaired that contact is lost with external reality
- can be a form of medical illness unrelated to drugs or can be caused by alc or drug use
> delusional behaviour
> hallucinations
> delirium
these can cause psychosis
stimulants like cocaine and meth
where a person has strong beliefs that are not shard by others
delusional behaviour
- common = someone believing there is conspiracy to harm them (paranoia)
when a person hears, sees, and, in some cases, feels, smells, or tastes things that do not exist outside their mind but can feel very real to the person affected by them
hallucination
- common = hearing voices
temporary mental state characterized by confusion, anxiety, incoherent speech, hallucinations
delirium
excited delirium
potentially fatal state
- extreme agitation and delirium
- potentially violent behaviour
= agitated delirium
- often bc of acute abuse of cocaine, meth or other powerful stimulants but not always
these death causes frequently involve heavy police restraint
excited delirium deaths
- could be the cause of death and not drugs themselves
initial effects of meth, MDMA, and PMMA
stimulant
wakefulness
hyperactivity
risk-taking
mydriasis
toxic effects of meth, MDMA, PMMA
jerky movements, muscle rigidity, hyperthermia, reduced consciousness, rhabdomyolysis, coma, death
love drug
MDMA due to serotonin effects
PMMA effects
similar to MDMA but slower to act, less potent initially, users may take additional doses, increased lethality compared to MDMA
phenethylamine
structurally related to amphetamine
has been used as a “weight loss” ingredient
putrefactive amine seen in decomposing samples
T or F. substituted phenethylamines have stimulant and psychedelic properties
T! - most common are 2C-X series = 2C-B, 2C-C, 2C-I, etc.
what distinguishes toxic phenethylamines?
degree of psychedelic properties and overt toxicity
- detection not as easy as meth but good lab should be able to detect
N-Bombs
- very potent derivatives of 2C-X family of phenethylamines with effects similar to LSD
- strongly hallucinogenic, toxic, low-dose drugs
= sub mg doses = 0.05 to 0.8 mg) - difficult for labs to detect in bodily fluids
most common N-Bomb
25I-NBOMe
- also 25B-NBOMe, 25C-NBMe, 25H-NBOMe, 25N-NBOMe
bath salt designer drugs
substituted and modified cathinone
- stimulants with some psychedelic activity
- MDPVm, mephedrone pyrovalerone, etc.
monitoring program: to monitor incidence and concentrations of drugs not banned outright, but subject to abuse -
- stimulants: in-comp only = Bupropion, caffeine, nicotine, phenylephrine, etc.
- narcotics: in-comp only = hydrocodone, mitragynine, morphine/codeine ratio, tapentadol, tramadol
- glucocorticoids: in-competition only = by routes of administration other than oral, IV, IM, or rectal; out of competition too (all routes of admin)
- beta-2-agonists/bronchodilators: any combination of two
stimulants allowed in sports
now ephedrine and pseudoephedrine and other mild stimulants allowed
- in monitoring program
- ephedrine allowed if <10 mg/L in urine
- pseudoephedrine allowed if <150 mg/L in urine
main desired stimulant effect of caffeine
increased aggression
how can caffeine be abused?
by non-coffee drinkers
abstinence followed
B2 agonists
bronchodilators
- most banned, except salbutamol, salmeterol, terbutaline, and formoterol allowed in inhaled form if athlete is granted TUE for asthma or similar condition
asthma, similar conditions allowed drug
B2 agonists/bronchodilators
- must be <1000 ng/mL in urine unless athlete can above abnormal metabolism
main reason for narcotic ban
protects the athlete
= prevents aggravation of an injury through competition
- morphine and most other narcotics
like buprenorphine, dextromoramide, heroin, etc.
T or F. NSAIDs, acetaminophen, salicylate, and recently codeine permitted
T, but codeine:morphine ratio monitored
hydrocodone and tramadol also allowed
beta blockers
beta-adrenergic blockers
- reduce BP and are antiarrhythmic
- by reducing BP and HR, produces a “steadying effect” = archery, shooting, etc.
beta blockers sport
archery
shooting
Darts
examples of beta blockers
Propranolol
metaprolol
oxprenolol
atenolol
timolol
acebutolol
these actively promote excretion of water via the kidneys, including:
diuretics
- furosemide
- hydrochlorothiazide
- chlorothiazide
two main uses for diuretics:
reduce body weight in “weight class” sports (eg. boxing)
produce dilute urine in a bid to avoid detection of banned drugs
These are rarely used medically, mainly in diseases involving severe muscle wasting
anabolic steroids
bolasterone
nandrolone
stanozolol
methandionin
methyltestosterone
anabolic steroids
serious side effects from anabolic steroid use
massive doses
- stunted growth
- defeminizing of females (androgenic effects)
- demasculinizing of men (suppression of testosterone synthesis?)
-impaired liver function
- heart disease
- cancer
primarily an androgenic steroid with minor anabolic effects
testosterone
testosterone tests
- T:epi-T ratio normally 1:1; >4:1 is suspicious
- > 150 ug/L in urine is suspicious
- now labs may look at C12:C13 ratio
aromatase inhibitors
prevents excess testosterone from being converted to estrogen
- aminoglutethimide, anastrozole, etc.
anti-estrogenic substances
clomiphene, cyclofenil, fulvestrant
SERMs
selective estrogen receptor modulators
- inhibits action of estrogen on estrogen receptor
- raloxifene, tamoxifen, toremifene
SARMs
selective androgen receptor modulators (SARMs)
- have anabolic effects with minimal androgenic effects
- some in clinical or -preclinical trial; available illicitly
myostatin
muscle loss
so myostatin inhibitors leads to increased muscle mass
metabolic modulators
- increases exercise endurance
- activators of AMP-activated protein kinase (AMPK); peroxisome proliferator-activated receptor agonists
- insulins, trimetazidine
define SERMs
- class of compounds that act on estrogen receptor
- not a pure agonist/antagonist
- prevents estrogen from binding to receptors by binding itself to the receptor in its place which can be advantageous
effects of SERMs
stimulates release of LH & FSH = produce and release testosterone
- also helps block paradoxical feminizing effects of testosterone caused by excess estrogen = hypogonadism (lack of testosterone)
a selective androgen receptor
Ligandrol
- VK5211, LGD-4033
- osteoporosis and muscle wasting treatment
this can stimulate muscle growth and has shown superior side effect profiles compared to anabolic steroids
SARM
ostarine
SARM
S-23
SARM
soda loading
consuming large amounts of alkali like sodium bicarb to increase body’s base rserve = delay lactic acid onset /buildup and cramps
blood doping
injecting one with own blood
increases O2 carrying capacity of body
- side effect = erythrocythemia (+ clotting), even if cross-matching not an issue (i.e. athlete’s own packed cells)
how can recombinant EPO be detected?
isoelectric points
ESAs & Mimetics
erythropoeisis stimulating agents
- EPO receptor agonist, non-EPO receptor agonist
ESAs
darbepoetin
EPO
EPO-Fc
EPO-mimetic peptides (EMP)
CNT-530
peginesatide
- methoxy polyethylene glycol-epoetin beta
Non-erythropoitic EPO receptor agonists
ARA-290
asialo EPO
carbamylated EPO
hypoxia-inducible factor stabilizers
HIF stabilizers
cobalt
FG-4592
activators such as argon, xenon, krypton
a protein that in humans is encoded by the HIF1A gene
hypoxia inducible factor 1-alpha
this is used to treat chronic kidney disease
HIF stabilizer
this activates the activity of EPO due to anemia induced hypoxia, metabolic stress, and vasculogenesis = creation of new blood vessels
HIF stabilizer
cyclists use this
HIF stabilizers in combo with cobalt chloride/desferrioxamine
- stimulate and de-regulate natural production of EPO
