TAC topical anesthesia produces positive urine tests for cocaine

The combination of tetracaine, adrenalin, and cocaine (TAC) has become increasingly popular as a topical anesthetic for the suturing of simple skin lacerations. The purpose of this study was to determine the effects of TAC on a urine drug test for cocaine. On the morning after the use of TAC, 14 of 18 patients (78%) studied had positive screening tests for benzoylecgonine (cocaine metabolite) by the enzyme multiplied immunoassay test (EMIT) method. All specimens also were analyzed by gas chromatography and mass spectrometry, the reference standard for analysis of drugs of abuse in urine, and 15 of the specimens (83%) were positive. Four of 18 positive specimens (22%) still had positive EMIT drug screens on the morning of the next day, an average of 36 hours after use of TAC. We recommend that physicians who use TAC solution as a local anesthetic caution their patients that they may fail a urine drug screen for cocaine if they are tested within 36 to 48 hours of the administration of the use of TAC.     

Simplified quantitation of urinary benzoylecgonine in cocaine addiction research and for related pharmacotherapeutic trials

In clinical trials of potential pharmacotherapies for cocaine addiction, objective determination of subject relapse relies on qualitative urine analysis for benzoylecgonine, the major metabolite of cocaine. Unlike qualitative analysis, quantitative measurement allows differentiation between continued cocaine use and a single use, as well as identification of changes in the quantity of cocaine used at different times. The only quantitative technique that has been used is expensive and not generally feasible. This study was performed to modify an existing qualitative technique for use as a new simple and readily available quantitative method for identifying cocaine use among research subjects. Benzoylecgonine levels in 24–hour urine specimens collected from 11 cocaine-addicted subjects hospitalized in a research setting were measured semi-quantitatively by fluorescence polarization immunoassay. Accurate results required thorough mixing of urine specimens prior to analysis. At admission, eight subjects had urinary benzoylecgonine levels 9 0.30 fig/ml, the standard positive/negative cut-off used in qualitative analysis. The mean half-life of benzoylecgonine during initial elimination was 0.46 ± 0.08 (SEM, n = 8) days. Benzoylecgonine (BE)/creatinine (C) levels remained ≥0.30 μgBE/mgC for 4. S ± 0.5 (n = 8) days and ≥ 0.03 μgBE/mgC for 10.5 ± 1.5 (n = 8) days. Relapses in three subjects could be identified by quantitative analysis. This study indicates that quantitation of benzoylecgonine in daily urine specimens provides a sensitive, objective index to cocaine use.     

Persistent Urinary Benzoylecgonine Following Cocaine Use

The authors examine the utility of a fluorescence polarization immunoassay (the ADx Cocaine Metabolite Assay) for the determination of benzoylecgonine in 41 patients (28 women and 13 men) admitted to an inpatient substance abuse treatment unit following recent cocaine use. The assay remained positive (i.e., exceeded 300 ng/ml) in urine for a mean of 84.4 hours from the last reported use. There was no difference by gender or route of administration either for grams used or hours of positivity. Cocaine use in the week prior to admission was the only significant predictor of hours of positivity; age, gender, and weight did not contribute significantly to the variance. The implications of these findings for both cocaine pharmacokinetics and for treatment of cocaine abuse are discussed.     

Detection of drug use in a methadone maintenance clinic: sweat patches versus urine testing

Aims. To evaluate the novel use of sweat patches in outpatients attending a methadone maintenance clinic. Design. Assessment of inter-patch reliability and validity of patch results compared to urine tests at the start and end of the patch period. Semi-structured questionnaire on patients' opinion of the patches. Randomized cross-over trial comparing illicit drug use during the week that the patch was worn with a control period. Setting. Methadone maintenance outpatient clinic in a deprived urban area. Participants. Forty-eight patients with a diagnosis of opiate addiction prescribed methadone for a median of 5 years. Measurements. Analysis of urine and patch tests by standard methods for methadone, opiates, morphine (heroin metabolite) and benzoylecgonine (cocaine metabolite). Findings. There was good inter-patch reliability between arm and side patches for methadone (all positive), opiates ( k = 0.8) and morphine ( k = 1.0) but only moderate agreement for benzoylecgonine ( k = 0.49). There was good agreement between the sweat patches and urine tests for methadone (all positive), opiates ( k = 1.00) and morphine ( k = 0.8), but again only moderate agreement for benzoylecgonine ( k = 0.50). The patches were well tolerated and the main side effect was minor irritation. The majority of men preferred a urine test while more women preferred a sweat patch. There was no evidence of reduced use of illicit drugs during the period that the patch was worn . Conclusion. Sweat patches are reliable and give valid results for patients on maintenance methadone. There are few side effects and it is practical to use them in busy outpatient clinics. They are preferred by some patients but there was no evidence that they altered behaviour.     

Cocaine liberation from body packets in an in vitro model.

STUDY OBJECTIVE: To quantitatively assess cocaine liberation from various body packet materials. DESIGN: 100-milligram cocaine packets (plastic bags with various wrapping techniques, paper, and condoms) were placed in a simulated gastric medium. Samples were also tested in an alkalinized gastric medium, with determination of both cocaine and benzoylecogonine concentrations using high-performance liquid chromatography with ultraviolet detection. RESULTS: Cocaine liberation was greatest in acid medium, with increasing liberation from condom packets to cellophane bags (three wrapping techniques used) to paper packets. The same trend was noted in alkaline medium but with a far lower maximum cocaine concentration accompanied by rapid hydrolysis to its inactive metabolite, benzoylecgonine. CONCLUSION: Cocaine liberation of a known quantity of drug is dependent on the wrapping method and material used; thus, a good history from the "body-stuffer" is essential to predict potential cocaine liberation and toxicity. Rapid hydrolysis of cocaine to its inactive metabolite in an alkaline medium implies a role for gastric alkalinization in the acute management of these patients.     

Can cocaine use be evaluated through analysis of wastewater? A nation‐wide approach conducted in Belgium

Aims Cocaine is the second most‐used illicit drug world‐wide and its consumption is increasing significantly, especially in western Europe. Until now, the annual prevalence has been estimated indirectly by means of interviews. A recently introduced and direct nation‐wide approach based on measurements of the major urinary excreted metabolite of cocaine, benzoylecgonine, in wastewater is proposed. Design Wastewater samples from 41 wastewater treatment plants (WWTPs) in Belgium, covering approximately 3 700 000 residents, were collected. Each WWTP was sampled on Wednesdays and Sundays during two sampling campaigns in 2007–08. Samples were analysed for cocaine (COC) and its metabolites, benzoylecgonine (BE) and ecgonine methylester (EME) by a validated procedure based on liquid chromatography coupled with tandem mass spectrometry. Concentrations of BE were used to calculate cocaine consumption (g/day per 1000 inhabitants) for each WWTP region and for both sampling campaigns (g/year per 1000 inhabitants). Findings Weekend days showed significantly higher cocaine consumption compared with weekdays. The highest cocaine consumption was observed for WWTPs receiving wastewater from large cities, such as Antwerp, Brussels and Charleroi. Results were extrapolated for the total Belgian population and an estimation of a yearly prevalence of cocaine use was made based on various assumptions. An amount of 1.88 tonnes (t) per year [standard error (SE) 0.05 t] cocaine is consumed in Belgium, corresponding to a yearly prevalence of 0.80% (SE 0.02%) for the Belgian population aged 15–64 years. This result is in agreement with an earlier reported estimate of the Belgian prevalence of cocaine use conducted through socio‐epidemiological studies (0.9% for people aged 15–64 years). Conclusions Wastewater analysis is a promising tool to evaluate cocaine consumption at both local and national scale. This rapid and direct estimation of the prevalence of cocaine use in Belgium corresponds with socio‐epidemiological data. However, the strategy needs to be refined further to allow a more exact calculation of cocaine consumption from concentrations of BE in wastewater.     

Measuring outcome in cocaine clinical trials: a comparison of sweat patches with urine toxicology and participant self-report

Aims To evaluate the advantages of using a sweat patch (PharmCheck?) for detecting cocaine abuse in cocaine‐dependent patients participating in a clinical trial. The utility of the sweat patch was assessed from the following perspectives: the reliability and validity of quantitative sweat patch results, the possible degradation of cocaine to benzoylecgonine (BE) as a function of the length of time that a patch is worn, the completeness of the dataset yielded by thrice‐weekly urine toxicology compared with thrice‐weekly and weekly sweat patches, and the relative costs associated with sweat patch versus urine measures. Design Data were collected during a 10‐week out‐patient clinical trial in which participants wore two sweat patches, one applied every visit and one applied weekly. Urine samples were collected thrice weekly, as were self‐reports of substance use. Setting A multi‐site clinical trial conducted in Boston, Cincinnati and New York, USA. Participants Twenty‐seven participants with comorbid diagnoses of cocaine dependence and adult attention deficit disorder completed the study. Measurements Sweat patch and urine samples were analyzed by standard methods for cocaine and cocaine metabolites. Findings Quantitative sweat patch measures had good reliability in that the correlation between the weekly and per‐visit patches was 0.96 (P < 0.0001). The concurrent validity, as judged by the correlation between quantitative urine BE levels and either weekly (0.76, P < 0.0001) or per‐visit (0.73, P < 0.0001) cocaine sweat patch levels was reasonable. The correlation between the self‐report of cocaine use and these same two patches, however, was lower (0.40, P < 0.05 and 0.30, P < 0.05, respectively). The results revealed no significant degradation of cocaine to BE associated with wearing the patch for a longer time. Finally, the per‐visit patch provided cocaine use data on 80.5% of all study days (a total of 70), while urine toxicology and the weekly patch provided 77.4% and 76.1%, respectively. Conclusions The present findings suggest that the PharmCheck? patch might be an attractive alternative to urine toxicology for use as an outcome measure in cocaine clinical trials.     

Assessment of cocaine use with quantitative urinalysis and estimation of new uses

Abstract Qualitative urinalysis methods of monitoring cocaine use may over-detect frequency of use, possibly decreasing the ability of clinical trials to detect effective treatments. Quantitative urinalysis and newly developed criteria for identifying new cocaine use were evaluated as alternative measures of cocaine use. Urine specimens collected in a cocaine dosing study in non-treatment-seeking subjects (n=5) and a cocaine treatment trial (n=37) were analyzed for the cocaine metabolite, benzoylecgonine, with qualitative and quantitative methods. Pharmacokinetic criteria ('New Use' rules) were applied to quantitative data to identify occasions of new cocaine use. Results were compared to known cocaine administrations in the laboratory study and to self-reported drug use and qualitative urinalysis for subjects in the clinical trial. New Use criteria correctly identified cocaine administrations in the cocaine dosing study in all but a small number of specimens. In the clinical trial, quantitative urinalysis and estimated New Uses provided more information about patterns and frequency of use than qualitative urinalysis in the different treatment conditions in the clinical trial. Interpretation of quantitative urinalysis with New Use rules appears to be a useful method for monitoring treatment outcome and may be more accurate than traditional qualitative urinalysis in estimating frequency of cocaine use.     

Treatment of Polydrug Users in San Francisco

A sample of mothers who had used crack cocaine while pregnant was evaluated during the postpartum period before random assignment to drug treatment. Mean infant age was 74 days. Paired hair samples were acquired from 63 mothers and 63 infants. Maternal urine was screened for cocaine and benzoylecgonine; three different drug use self-report measures were also collected. Normalizing transformations of all hair and urine data preceded analyses. The initial correlation of mother and infant hair (r =. 41, N = 62, P =. 001) was strengthened (r =. 62, N = 30, P <. 0005) by removing from the dataset maternal hair independently judged to be damaged. Damage to hair is associated with certain types of “hair care” products. The damaged maternal hair bore no quantitative relationship to infant hair (r = -.04, N = 30, P =. 41). Poor quality hair samples could have been partly anticipated because self-reported use of hair products had a significant contingent relationship to laboratory-judged damage to hair (Z_kappa = 2.28, P =. 01). Maternal urine benzoylecgonine correlated with maternal hair (r =. 41, N = 60, P =. 001) and, of course, with maternal urine cocaine (r =. 63, N = 60, P <. 0005). None of the three self-report measures (use in past 30 days, duration since first use, average regular use) significantly correlated with any of the hair or urine measures. Factor analysis of drug use variables identified three factors possibly representing long-term use, recent use, and some artifact of self-report. In summary, hair analysis may provide a quantitative index of exposure when the hair is not damaged. The amount of self-reported drug use could not be corroborated with analytic measures of hair or urine. Studies in which self-reported cocaine use is a scalar variable should be interpreted cautiously.     

Comparison of desipramine or carbamazepine to placebo for crack cocaine-dependent patients

The authors compared the effects of desipramine or carbamazepine to placebo in an intensive outpatient program for cocaine abuse. Subjects recruited from an urban drug treatment program were randomly assigned to a double-blind, placebo-controlled, eight-week trial of desipramine, carbamazepine, or placebo. Patient ratings, urine drug screens, and blood samples were obtained weekly. Using survival analysis, the three groups did not differ in time to drop out of treatment. While subjects improved over time on all self-ratings related to cocaine use, mood, and craving, only two items related to mood were significantly different over time as a function of treatment group. Subjects in the two treated groups reported significantly more improvement on self-ratings of depression and irritability. No treatment differences were noted for sustained abstinence or for proportion of positive urine drug screens. Desipramine subjects who attained a minimum blood level were retained in treatment significantly longer than placebo or other non-compliant treatment groups. This finding supports previous reports of a possible role for desipramine in cocaine abuse treatment.     

Cocaine use and its rheumatic manifestations: a case report and discussion

Cocaine use can be associated with a wide spectrum of rheumatic manifestations. It poses a diagnostic challenge as the patients usually withhold the information of cocaine use, and no serological tests are available to establish this diagnosis. We report a patient with vasculopathic syndrome secondary to cocaine use. Despite initial denial of drug abuse, skin biopsy suggested the diagnosis, which was subsequently confirmed by urine drug testing. Differentiating cocaine-associated pseudovasculitis from true vasculitis is necessary, as conventional treatment is usually ineffective without complete abstinence from cocaine use and may be associated with significant morbidity as well as mortality.     

The effect of stimulant and sedative use on treatment outcome of patients admitted to methadone maintenance treatment

While methadone maintenance treatment (MMT) has been demonstrated to be an effective treatment for opiate dependence, its impact on the treatment outcome of other illicit drug abuse is not as clear. Using the initial urine drug screen (UDS) and follow-up UDS at 1, 6, 12, and 24 months, 167 patients consecutively admitted to MMT were evaluated for opiate, sedative (predominantly benzodiazepine), and stimulant (predominantly cocaine) use. Retention for the opiate only group was 97.32 days longer on average than for patients using opiates along with stimulants, sedatives, or both stimulants and sedatives. Patients abusing opiates only had the greatest decrease in drug use; however, MMT was also associated with decreases in cocaine and sedative use over the 24 month follow-up period. There was no evidence that patients "switched" their drugs of abuse with time in treatment. The negative impact of non-opiate drug use on outcome in MMT and its implications for treatment planning are discussed.     

Disulfiram treatment for cocaine dependence in methadone-maintained opioid addicts

Aims: Cocaine use by patients on methadone maintenance treatment is a widespread problem and is associated with a poorer prognosis. Recent studies have evaluated disulfiram as a treatment for individuals with comorbid alcohol and cocaine abuse. We evaluated the efficacy of disulfiram for cocaine dependence, both with and without co-morbid alcohol abuse, in a group of methadone-maintained opioid addicts. Design: Randomized double-blind, placebo-controlled trial. Setting: Urban methadone maintenance clinic. Participants: Sixty-seven cocaine-dependent, methadone-maintained, opioid-dependent subjects (52% female; 51% Caucasian). Intervention: Study medication, either disulfiram or placebo, was placed directly in the methadone to ensure compliance for 12 weeks. Measurements: Primary outcome measures included weekly assessments of the frequency and quantity of drug and alcohol use, weekly urine toxicology screens and breathalyzer readings. Findings: Disulfiram treated subjects decreased the quantity and frequency of cocaine use significantly more than those treated with placebo. Alcohol use was minimal for all subjects regardless of the medication. Conclusions: Disulfiram may be an effective pharmacotherapy for cocaine abuse among methadone-maintained opioid addicts, even in those individuals without co-morbid alcohol abuse. Disulfiram inhibits dopamine beta-hydroxylase resulting in an excess of dopamine and decreased synthesis of norepinephrine. Since cocaine is a potent catecholamine re-uptake inhibitor, disulfiram may blunt cocaine craving or alter the "high", resulting in a decreased desire to use cocaine.     

Subject-collateral reports of drinking in inpatient alcoholics with comorbid cocaine dependence.

Greater substance abuse severity has been associated with less reliable self-reports of drinking in individuals with only an alcohol use disorder. In addition, individuals with multiple substance use disorders often report greater substance abuse severity. Therefore, it is important to be confident in the self-reports of substance use in individuals with multiple substance use disorders. Although there is considerable confidence in the use of collateral reports as a measure of drinking in individuals with only a diagnosis of alcohol abuse or dependence, information about subject-collateral agreement for individuals who meet the criteria for more than one substance use disorder is lacking. In this study, we examined subject-collateral reports of substance abuse in individuals presenting for alcohol treatment who met DSM-III-R criteria for alcohol and cocaine use disorder (n = 85). We then compared subject-collateral reports of those individuals to subject-collateral reports for individuals with only a diagnosis of alcohol abuse or dependence (n = 99). Overall, the results demonstrate that self-reports of individuals with alcohol and cocaine use disorders are generally valid. The results revealed no significant differences between groups on measures of subject-collateral consistency for several alcohol use variables. However, a significant difference was found for the number of days of drug use, with subject-collateral agreement being greater for individuals with an alcohol and cocaine use disorder. Additional analyses revealed that subject-collateral discrepancy scores were positively related to the participants' severity of alcohol and drug dependence. Recommendations for enhancing the accuracy of self-reports of drinking and drug use in alcoholics with comorbid cocaine use disorders are discussed.     

The spatial epidemiology of cocaine, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA) use: a demonstration using a population measure of community drug load derived from municipal wastewater

Aims   To determine the utility of community-wide drug testing with wastewater samples as a population measure of community drug use and to test the hypothesis that the association with urbanicity would vary for three different stimulant drugs of abuse.
Design and participants   Single-day samples were obtained from a convenience sample of 96 municipalities representing 65% of the population of the State of Oregon.
Measurements   Chemical analysis of 24-hour composite influent samples for benzoylecgonine (BZE, a cocaine metabolite), methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA). The distribution of community index drug loads accounting for total wastewater flow (i.e. dilution) and population are reported.
Findings   The distribution of wastewater-derived drug index loads was found to correspond with expected epidemiological drug patterns. Index loads of BZE were significantly higher in urban areas and below detection in many rural areas. Conversely, methamphetamine was present in all municipalities, with no significant differences in index loads by urbanicity. MDMA was at quantifiable levels in fewer than half the communities, with a significant trend towards higher index loads in more urban areas.
Conclusion   This demonstration provides the first evidence of the utility of wastewater-derived community drug loads for spatial analyses. Such data have the potential to improve dramatically the measurement of the true level and distribution of a range of drugs. Drug index load data provide information for all people in a community and are potentially applicable to a much larger proportion of the total population than existing measures.     

False-positive urine phencyclidine immunoassay screen result caused by interference by tramadol and its metabolites

Phencyclidine is one of the drugs of abuse included in qualitative urine drug screens that are frequently ordered in the emergency department despite concerns about specificity and clinical utility. Many drugs have been described to cause false-positive results for phencyclidine. We present 2 cases of false-positive phencyclidine qualitative urine drug screen results in patients with seizures from tramadol misuse or abuse. The involvement of tramadol and its active metabolite, N-desmethyltramadol, was confirmed by in vitro testing. These cases illustrate that tramadol and its metabolites can trigger a false-positive phencyclidine urine drug screen result in nonfatal cases and highlight the lack of specificity of the phencyclidine qualitative urine drug screen.     

Amount of self-reported illicit drug use compared to quantitative hair test results in community-recruited young drug users in Amsterdam

Aims To assess the dose–effect relationship between self‐reported drug intake and the concentration of drugs and/or their metabolites in hair and to examine factors that may mediate this relationship. Design and setting A cohort study among young drug users (YDU) in Amsterdam, the Netherlands, which began in July 2000. At intake, YDU were asked to report their average drug intake over a 2‐month period. A hair sample was taken and then analysed for cocaine, benzoylecgonine (BE), morphine, 6‐monoacetylmorphine and methadone. Weighted least‐squares regression analysis was used to model hair‐test results as a function of reported drug use. Participants Subjects were 95 YDU (using cocaine, heroin, methadone and/or amphetamines at least 3 days/week) aged 18–30 residing in Amsterdam in 2000–2001. Findings Of the 95 YDU, one‐third were women; mean age was almost 26; 30% had black hair, 33% blond hair and 37% brown hair. Cocaine use was reported by 92%, heroin by 75% and methadone by 64% of participants. All hair samples contained one or more drugs. Crude correlation coefficients between reported drug doses and drug concentrations in hair ranged between 0.45 and 0.59. The multivariate regression analysis showed that, for one or more types of drug, black‐haired people, women and non‐western European people had relatively high drug concentrations in hair (significant slope effects). The corresponding multivariate correlation coefficients ranged between 0.63 and 0.87. Conclusions Hair testing can be used to quantify drug use in epidemiological studies, given that factors such as hair colour and sex are taken into account.     

Toxicity from the use of niacin to beat urine drug screening

Niacin (vitamin B3) is promoted for rapidly clearing the body of drugs of abuse, such as cocaine and cannabis, and is alleged to interfere with urine drug screening. We present 4 cases of such novel use associated with significant adverse effects. Two cases had isolated skin manifestations, whereas the other 2 presented with life-threatening manifestations, including nausea, vomiting, dizziness, hepatotoxicity, metabolic acidosis, and hypoglycemia evolving into hyperglycemia. One patient also had profound neutrophilia and QT(C)-interval prolongation. All patients improved after cessation of the drug use and supportive treatment. Health care providers should be aware of these potential adverse effects of niacin and of the misguided use of this vitamin by patients seeking to interfere with urine drug screening.     

Substance abuse in an inpatient psychiatric sample.

The relationship between psychoactive drug abuse and psychopathology is complex. There have been few systematic explorations of substance abuse in psychiatric populations since the recent epidemic of cocaine abuse. To update and further explore the relationship between psychiatric illness and substance abuse, 100 consecutively admitted patients to an inpatient psychiatry unit were administered a drug and alcohol use/abuse questionnaire. Sixty-four percent endorsed current or past problems with substance abuse and 29% met DSM-III-R criteria for substance abuse in the 30 days prior to admission. For the major diagnostic categories, there were no significant differences between groups in percentages of patients with substance abuse disorders. There was a trend (p less than or equal to .2) toward an increased number of lifetime psychiatric hospitalizations in the substance-abusing group. Alcohol was the most common drug of choice followed by stimulants, cannabis, and sedative hypnotics. Differences in drug choices between diagnostic categories are discussed. Forty-three percent of urine drug screens obtained were positive, and of those with positive urine drug screens, 42% denied drug use upon admission. Only 40% of patients with current or past substance abuse problems had received treatment for their chemical dependency. In our sample, while substance abuse was very prevalent, it was underreported and undertreated.     

Changing patterns of illicit substance use among schizophrenic patients: 1984-1996

Over 1,700 psychiatric emergency room visits of schizophrenic and schizoaffective patients between 1984 and 1996 were reviewed, and urine drug screens (UDS) were recorded. Illicit drug use increased significantly over the 12-year period, with a large increase for cocaine (0% to 73% of positive UDS), a decline for amphetamines (60% to 0%), and a small increase for marijuana (0% to 27%). Opiate and sedative use remained unchanged. The results support the impression that cocaine use increased dramatically among urban schizophrenic patients beginning in 1988 and continuing to the present. Furthermore, cocaine seems to have replaced amphetamines as the preferred drug of abuse among schizophrenic persons following the crack epidemic.