by: Kelly Hack

Another potent synthetic opioid has recently been identified­ and is creating significant concern among those in the forensic toxicology and law enforcement realm. According to The Center for Forensic Science Research & Education (CFSRE), Isotonitazene (iso) is a synthetic opioid derived from etonitazene, which is a national and international controlled substance that was first synthesized in the 1950s but denied approval for medical use due to the extreme potency of the substance. Iso shares a similar chemical structural resemblance to etonitazene and has been claimed to be more potent than fentanyl and 100 times more powerful than morphine. The emergence of this drug has public health and safety, law enforcement, laboratory personnel, and medical examiners on high alert. In August 2019, eight blood specimens associated with postmortem death investigations identified iso in their toxicology reports.

According to an article by USA Today, alarming data regarding this novel opioid has been documented with recent overdose deaths in Indiana and Illinois. Blood samples taken from these overdose death victims identified the presence of iso leading to conclusions that iso is unknowingly being cut into substances such as cocaine. In 2018, 713 overdose deaths in Indiana involved synthetic opioids like iso, generating a death rate of 11.5 deaths per 100,000 persons compared with the national rate of 9.9.

Medical Express, recently wrote an article explaining that similar to fentanyl, iso is quite lethal, as a minute amount can trigger a near-instant overdose. Iso, due to its slight chemical structural difference remains legal at the national level. Despite the United States’ efforts on prohibiting any distribution of fentanyl from China, chemists are eagerly replacing their demand by utilizing similar derivatives. Iso can be identified as a yellow or off-white powder and is cut into other substances and pressed into counterfeit pills without the user’s awareness.

An article written by Bridges of Hope Rehab Treatment Center, it notes that similar to fentanyl, many people who are overdosing from iso are not aware their substances are tainted with this fatal additive. It also discusses adding iso to drug supplies, amplifies substance use disorder (SUD) by increasing one’s tolerance and dependence.

by: Kelly Hack

Gabapentin prescribing increased 64 percent from 39 million prescriptions in 2012 to 64 million by 2016, becoming the 10th most commonly prescribed medication in the United States.¹

A recent study from the American Journal of Psychiatry disclosed that the number of Appalachian drug users who reported using gabapentin to get “high” has increased nearly 30-fold from 2008-2014.² These alarming statistics among other supporting data significantly contributes to the reality that gabapentin is now considered an emerging threat in today’s opioid epidemic.⁴

What is Gabapentin?

Gabapentin, a gamma-aminobutyric acid (GABA) analog was originally developed as an anticonvulsant and prescribed as an analgesic for neuropathic pain. It is currently sold under the brand names: Neurontin®, Gralise®, Horizant®. The medication is also prescribed as an off-label medication for the treatment of migraines, mental illness, and fibromyalgia. Gabapentin first approved in the United States in 1993 with minimal potential for misuse is now classified as a controlled substance and a current drug of abuse.² Gabapentin’s effects on the central nervous system including drowsiness and low-level euphoria have been recognized within the addiction community to enhance the euphoric effects of heroin and when consumed exclusively in high doses, produces a marijuana-like high.² A study from 2016 found that gabapentin misuse was only 1 percent among the general population, however for those that misuse opioids, gabapentin misuse significantly increased to 15-22 percent.³

Side Effects

• Viral infection
• Fever
• Nausea and vomiting
• Trouble speaking
• Hostility
• Jerky Movements⁴

Gabapentin Overdoses

In 2017, 70,237 drug overdose deaths occurred in the United States, and a vast majority of those fatalities were directly related to opioids.¹ In efforts to significantly reduce opioid abuse, providers began to increase their prescribing of gabapentin, with the understanding that the medication was a safer alternative to opioids for the management of acute pain. However, during 2013-2017, 74,175 gabapentin exposures were reported to poison control centers (PCCs) and a clear correlation was documented that the increase of accessibility to gabapentin directly increased toxic exposures.

According to data from the Louisville coroner’s office in Kentucky, gabapentin was found in nearly one-fourth of all overdoses. Throughout the state, the drug is now showing up in about 1 in every 3 overdose deaths.³ Due to the alarming rates of reported overdoses associated with gabapentin, states including Tennessee and Michigan have reclassified the drug as a Schedule V Controlled Substance. Massachusetts, Minnesota, Nebraska, North Dakota, Ohio, Virginia, West Virginia, and Wyoming also require reporting of gabapentin prescriptions through the Prescription Drug Monitoring Program (PDMP) database.

Respiratory Depression and Withdrawal

Drug-induced respiratory depression has been well documented with gabapentin use. The Federal Drug Administration (FDA) now requires new warning labels on all gabapentinoids regarding potential respiratory depressant effects. There is an increased risk for serious breathing difficulties among patients who use gabapentanoids alone or with other drugs that depress the central nervous system (CNS). Patients with a preexisting respiratory impairment such as chronic obstructive pulmonary disease (COPD) also have an augmented risk for experiencing respiratory distress with gabapentanoid usage.⁶ Additional health complications affiliated with continued gabapentin use occur with abrupt discontinuation of the medication, which has been documented to often mirror symptoms of those withdrawing from alcohol and benzodiazepines.⁷

Withdrawal Symptoms

• Anxiety
• Irritability
• Agitation
• Confusion
• Tachycardia
• Catatonia⁷

Co-Prescribing

Since gabapentin and opioids have historically been prescribed for pain, co-prescription of these two medications is quite prevalent. In a population-based nest case-control study among opioid users who were residents of Ontario, Canada between August 1, 1997, and December 31, 2013, it was found that among patients receiving prescription opioids, gabapentin was concomitant with a substantial increase to opioid-related deaths.⁵ The primary analysis of the study conveyed that the likelihood of opioid-related death was 49 percent higher among individuals exposed to gabapentin and opioids in comparison to those exposed to opioids solely.⁵ Approximately 8 percent of patients from the study receiving opioids were co-prescribed gabapentin and that co-prescription was directly linked to a 50 percent increase in death probability. Overall, similar studies conducted within the United States and the United Kingdom have drawn parallel conclusions that between 15 and 22 percent of people with opioid use disorder (OUD) are also misusing gabapentin.⁵

“Misuse of gabapentin is just one more collateral effect of the opioid epidemic. When one drug becomes less available, drug users historically seek out alternatives,” said Caleb Alexander, an epidemiologist at Johns Hopkins University.

In Utero Exposure

Studies are finding a definitive correlation to gabapentin and opioid use among pregnant mothers, as increases in co-exposure, are documented. In a study of 19 infants born to mothers who used opioids and gabapentin during pregnancy, 10 percent of those babies developed Neonatal Abstinence Syndrome (NAS). The failure to control gabapentin withdrawal symptoms with methadone exclusively, lead to gabapentin and methadone being administered congruently. The response from this combined medication-assisted treatment (MAT) showed rapid improvement with newborn withdrawal, indicating that the combined usage of opioid and gabapentin during pregnancy is evident.⁸

It is imperative that testing for licit drugs such as gabapentin becomes part of a healthcare system’s newborn toxicology testing protocol. It is our goal to continually adapt our offerings to support the systems that are addressing these issues for their population health.

We offer gabapentin in umbilical cord tissue as part of our 17-Panel test. This specimen type captures substances in the newborn’s system up to approximately 20-weeks prior to birth. As a leader in newborn forensic toxicology, it is our mission to provide the most comprehensive testing panels to meet the needs of our clients and to proactively address the current trends in today’s substance abuse landscape.

References

1. Reynolds, K., Kaufman, R., Korenoski, A., Fennimore, L., Shulman, J. and Lynch, M. (2019). Trends in gabapentin and baclofen exposures reported to U.S. poison centers. [online] Taylor & Francis. Available at: https://www.tandfonline.com/doi/full/10.1080/15563650.2019.1687902 [Accessed 14 Feb. 2020].
2. Vestal, C. (2018). Abuse of Opioid Alternative Gabapentin Is on the Rise. [online] Pewtrusts.org. Available at: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/05/10/abuse-of-opioid-alternative-gabapentin-is-on-the-rise [Accessed 14 Feb. 2020].
3. Mammoser, G. (2019). Opioid Overdoses and Gabapentin. [online] Healthline. Available at: https://www.healthline.com/health-news/gabapentin-latest-pain-medication-in-opioid-overdoses [Accessed 14 Feb. 2020].
4. Healthline. (n.d.). Gabapentin: Side Effects, Dosage, Uses, and More. [online] Available at: https://www.healthline.com/health/gabapentin-oral-capsule [Accessed 14 Feb. 2020].
5. Gomes, T., Juurlink, D., Antoniou, T., Mamdani, M., Paterson, M. and Brink, W. (2017). Gabapentin, opioids, and the risk if opioid-related death: A population-based nested case-control study. [online] Public Library of Science. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626029/ [Accessed 14 Feb. 2020].
6. U.S. Food and Drug Administration. (2019). FDA requires new respiratory depression risk gabapentinoids warnings. [online] Available at: https://www.fda.gov/news-events/fda-brief/fda-brief-fda-requires-new-warnings-gabapentinoids-about-risk-respiratory-depression [Accessed 15 Feb. 2020].
7. Medscape. (2010). Withdrawal Symptoms After Gabapentin Discontinuation. [online] Available at: https://www.medscape.com/viewarticle/722526 [Accessed 15 Feb. 2020].
8. Loudin, S., Murray, S., Prunty, L., Davies, T., Evans, J. and Werthammer, J. (2017). An Atypical Withdrawal Syndrome in Neonates Prenatally Exposed to Gabapentin and Opioids. [online] jpeds.com. Available at: https://www.jpeds.com/article/S0022-3476(16)31232-X/fulltext [Accessed 17 Feb. 2020].

by: Kelly Hack

It is undeniable that the market for Cannabidiol (CBD) is booming, profits are generating at $2 billion in sales and projected to reach $16 billion by 2025.¹

Seven percent of Americans are using CBD. That percentage is estimated to increase 10% by 2025, according to investment research firm Cowen & Co.¹ Additional research published in the JAMA Network Open also documented that in April 2019, 6.4 million CBD Google searches were conducted.¹

The ABCs of CBD

CBD and tetrahydrocannabinol (THC) are the primary natural compounds found within the cannabis plant, also known as phytocannabinoids.² CBD is one of more than 80 active phytocannabinoids identified in marijuana and hemp.³

CBD’s chemical structure is very similar to THC (21 carbon atoms, 30 hydrogen atoms, and two oxygen atoms). However, the slight yet significant difference in the atom arrangement between these two compounds produce differing physiological effects.⁴

Both CBD and THC work with receptors that release neurotransmitters in the brain. These compounds interact with CB1 and CB2 receptors, which are located within the endocannabinoid system –an essential component to the human nervous system. CB1 receptors are located in the cerebellum of the brain that influences functions including memory processing, pain regulation, and motor control.⁵ The CB1 receptors are what also activate the euphoric effects from THC, whereas CBD has a very low effectiveness when it binds to CB1 receptors, producing insignificant to non-existent euphoric effects.⁶ CB2 receptors found on white blood cells, in the tonsils, and in the spleen also produce no euphoric effects. However, CB2 receptors have become increasingly popular due to their potential anti-inflammatory properties.⁵

Fact from Fiction

Both THC and CBD derive from the cannabis plant. Marijuana is defined as any cannabis sativa plant that has greater than 0.3 percent THC, which classifies the substance as a federally illegal, Schedule 1 drug by the Drug Enforcement Administration (DEA).⁷ Hemp plants are defined as any cannabis plant that has 0.3 percent or less THC and legal CBD originates from the hemp plant.⁷ The 2014 Farm Bill, national legislation permitting hemp research, began the process of hemp legalization. Within four years, the 2018 Farm Bill was enacted, fully legalizing the production and sale of hemp and its extracts.⁸ Agriculture of the hemp plant is primarily utilized for its CBD content, seeds, and fibers. Whereas, marijuana is usually grown for its psychoactive THC content.² A single hemp plant can produce an estimated half kilogram of plant material for CBD extraction and farmers can legally grow up to 4,000 hemp plants in an acre. A single acre of hemp can generate about 1.4 million bottles of CBD lotion.⁸

Medicinal Benefits and Side Effects

According to the National Institute on Drug Abuse (NIDA), preclinical and clinical studies in animal models have shown potential therapeutic properties in CBD for the following: anti-seizure, antioxidant, neuroprotective, anti-inflammatory, analgesic, anti-tumor, anti–psychotic, anti-anxiety, and substance use disorders.³ Despite several studies eluding to CBD health benefits, currently, the only Food and Drug Administration (FDA) approved medicine containing CBD is Epidiolex. Within a series of scientific studies, CBD intake among those affected by childhood epilepsy syndromes, such as Dravet syndrome and Lennox-Gastaut syndrome (LGS) resulted in significant effectiveness compared to other unresponsive anti-seizure medication.⁹ Although CBD has revealed medical benefits, research has also documented possible side effects of CBD including nausea, diarrhea, upset stomach, tiredness, lightheadedness, crankiness, low blood pressure, and drowsiness.⁵

Safety

Aside from side effects, a significant concern regarding CBD is it’s primarily marketed and sold as a supplement, not a medication. The FDA does not regulate the safety or purity of dietary supplements; therefore unidentified elements may be found in products labeled as “pure” CBD.⁸ The FDA strictly prohibits the sale of CBD in any unapproved health products, dietary supplements or food.⁸ The FDA has issued warning letters to companies marketing products containing cannabis and cannabis-derived compounds as a treatment of any disease or condition. Firms making unsubstantiated claims regarding CBD are breaking the law. It is a direct violation to the Federal Food, Drug and Cosmetic Act (FD&C Act) and may put the health and safety of consumers at risk.¹⁰ 

Cultivation

Hemp, which is the only current legal plant for extracting CBD can accidentally cause breeding of marijuana by pollination of female and male plants. Due to this biological process, the University of Connecticut is adamant in maintaining all-female greenhouses.⁸ However, hemp grown outside of a controlled environment is much more susceptible to marijuana conversion. Pharmaceutical-grade extraction is imperative. The method for extracting CBD or THC is very similar, therefore if a supplier incorrectly extracts from the hemp plant, a CBD product may contain an illegal dose of THC.⁸ In efforts to prevent CBD products from being unknowingly contaminated with higher levels of THC, a process known as fractional distillation can be implemented, which isolates cannabinoids through temperature variation. With added heat, the evaporation of carbon dioxide and ethanol occurs, resulting in either pure CBD or THC.⁸

“What many consumers don’t realize is that the FDA, who’s charged with protecting our safety with respect to food and medicine in the U.S., is not on top of policing those CBD products that you see in the gas station or at the grocery store,” says Rino Ferrarese, COO of the medical marijuana extractor CT pharma.⁸

Pregnancy & Breastfeeding

According to a recent warning issued by the FDA, using products with CBD or THC is prohibited by women who are breastfeeding or pregnant. There is no comprehensive research studying the effects of CBD on the developing fetus, expectant mother, or breastfed baby.¹¹ Studies have been conducted on pregnant animals and have shown complications with the reproductive system of developing male fetuses.¹² Despite warnings, researchers who surveyed anesthesiologists, certified nurse-midwives, and doulas found the following:

• 7% of physician anesthesiologists would consider using CBD to reduce anxiety in women during pregnancy and labor.
• 12% would consider it to reduce nausea during pregnancy and 8% during labor.
• 13% would consider it to reduce pain during pregnancy and 12% during labor.
• 42% of certified nurse-midwives would consider using CBD to reduce anxiety in women during pregnancy, and 33% would consider it during labor.
• 54% of doulas would consider using CBD to reduce anxiety in women during pregnancy, and 44% would consider it during labor.¹³

Mark Zakowski M.D., FASA, senior author of the study and chief obstetrical anesthesiologist at Cedars-Sinai Medical Center, Los Angeles says, “That’s concerning because CBD may interact with commonly used anesthetics that might be needed during labor and delivery. And ongoing CBD use has shown the potential to act like a common class of antidepressants, SSRI inhibitors, which can adversely interact with other drugs.”¹³

Buyer Beware

Due to the abundance of unsubstantiated claims regarding CBD and the inconclusive research pertaining to the safety of its use, health experts and federal authorities are urging consumers to approach their use with extreme caution. Much of the CBD studies that have been conducted are preliminary research. Therefore, until further concrete evidence regarding the safety and complexity of CBD is concluded, it’s highly advised that all CBD or cannabis products be examined by an FDA review process.¹⁴  

References:

1. Usatoday.com. (2019). [online] Available at: https://www.usatoday.com/story/news/health/2019/10/23/cbd-google-searches-cannabidiol-skyrocket-do-products-works/4062879002/ [Accessed 14 Nov. 2019].
2. Usatoday.com. (2019). [online] Available at: https://www.usatoday.com/story/sponsor-story/medterra/2019/10/01/what-cbd-oil-separate-facts-fiction-learn-truth-cbd/3786588002/ [Accessed 14 Nov. 2019].
3. Drugabuse.gov. (2019). The Biology and Potential Therapeutic Effects of Cannabidiol. [online] Available at: https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/biology-potential-therapeutic-effects-cannabidiol [Accessed 14 Nov. 2019].
4. WebMD. (2019). CBD vs. THC: What’s the Difference?. [online] Available at: https://www.webmd.com/pain-management/cbd-thc-difference#1 [Accessed 14 Nov. 2019].
5. Dr. Ananya Mandal, M. (2019). Cannabinoid Receptors. [online] News-Medical.net. Available at: https://www.news-medical.net/health/Cannabinoid-Receptors.aspx [Accessed 22 Nov. 2019].
6. Analytical Cannabis. (2019). CBD vs THC – What are the Main Differences?. [online] Available at: https://www.analyticalcannabis.com/articles/cbd-vs-thc-what-are-the-main-differences-297486 [Accessed 14 Nov. 2019].
7. Analytical Cannabis. (2019). Hemp vs Marijuana: Is There a Difference?. [online] Available at: https://www.analyticalcannabis.com/articles/hemp-vs-marijuana-is-there-a-difference-311880 [Accessed 22 Nov. 2019].
8. PBS NewsHour. (2019). Is CBD legal? Here’s what you need to know, according to science. [online] Available at: https://www.pbs.org/newshour/science/is-cbd-legal-heres-what-you-need-to-know-according-to-science [Accessed 14 Nov. 2019].
9. Peter Grinspoon, M. (2019). Cannabidiol (CBD) — what we know and what we don’t – Harvard Health Blog. [online] Harvard Health Blog. Available at: https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476 [Accessed 15 Nov. 2019].
10. U.S. Food and Drug Administration. (2019). FDA Regulation of Cannabis and Cannabis-Derived Products: Q&A. [online] Available at: https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd#statesallowing [Accessed 22 Nov. 2019].
11. U.S. Food and Drug Administration. (2019). What You Should Know About Using CBD When Pregnant or Breastfeeding. [online] Available at: https://www.fda.gov/consumers/consumer-updates/what-you-should-know-about-using-cannabis-including-cbd-when-pregnant-or-breastfeeding [Accessed 16 Nov. 2019].
12. DG, D. (2019). Maternal cannabinoid exposure. Effects on spermatogenesis in male offspring. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/3026968 [Accessed 16 Nov. 2019].
13. Medicalxpress.com. (2019). Many women and health care providers assume CBD safe during pregnancy despite lack of research. [online] Available at: https://medicalxpress.com/news/2019-10-women-health-assume-cbd-safe.html [Accessed 16 Nov. 2019].
14. NIH MedlinePlus Magazine. (2019). The ABCs of CBD: Separating fact from fiction | NIH MedlinePlus Magazine. [online] Available at: https://magazine.medlineplus.gov/article/the-abcs-of-cbd-separating-fact-from-fiction [Accessed 16 Nov. 2019].

by: Kelly Hack

As a country, we have found ourselves in the abyss of an addiction epidemic. Policymakers, law enforcement, and public health officials analyzing the true magnitude of this American crisis are faced with yet another public health concern—drug “alternatives”.

Kratom, native to the tropical tree Mitragyna speciose, is quickly gaining popularity among those seeking alternative solutions to treating opioid dependency. The plant’s leaves are known to contain compounds that produce psychotropic effects. It is currently listed as a “drug of concern” by The Drug Enforcement Administration (DEA) due to the substance’s similar addictive traits to opioids including risks of abuse, overdose, and fatality.¹

In understanding the heightened concern regarding Kratom, a study published in the Journal of Clinical Toxicology found that calls to U.S. poison control centers increased more than 50-fold from 13 calls in 2011 to 682 calls in 2017 (equivalent from about one call a month to two calls a day).² Of those calls, serious medical outcomes ranged from rapid heartbeat, agitation, irritability, and hypertension to seizures, coma, kidney failure, and death.

The added risk of Kratom in comparison to other substances of abuse is that it’s currently classified as an herbal supplement and not an illicit substance. According to the National Institute on Drug Abuse (NIDA), kratom is sometimes sold as a green powder in packets labeled “not for human consumption”,³ although kratom consumers report that the botanical supplement can be used for many things including minor pain as well as promoting a sense of health and well-being.

Kratom, available as a pill, capsule, or extract can work like an opioid or a stimulant. The two present compounds in its leaves-mitragynine and 7-a-hydroxymitragynine, interact with opioid receptors in the brain, producing sedation and pleasure while also minimizing pain.³ The chemical structure of kratom compounds binds strongly to opioid receptors similar to scheduled opioid drugs.⁴ Through scientific analyzation, kratom compounds are predicted to affect the body just like opioids, producing adverse side effects including seizures and respiratory depression.⁴

Regardless of these findings, kratom in recent years has been used as an herbal alternative for medical treatment in attempts to manage opioid withdrawal symptoms/cravings. In response, the Food and Drug Administration (FDA) in 2017 began issuing a series of warnings about kratom, along with identifying 44 deaths associated with its use.⁴ Supporting studies have found that similar to other drugs that emit opioid-like effects, kratom is subject to dependence and withdrawal symptoms including:

• Muscle aches
• Insomnia
• Irritability
• Hostility
• Aggression
• Emotional changes
• Runny nose
• Jerky movements³

In efforts to prevent new epidemics of abuse, the FDA is working diligently to educate, warn, and fight against how kratom is being misrepresented to the public. According to the FDA, there have been no adequate and well-controlled scientific studies involving the use of kratom as a treatment for opioid withdrawal or other diseases in humans. The substance is currently illegal in Australia, Denmark, Germany, Malaysia, and Thailand and banned in a number of states and municipalities in the U.S.⁵

To combat the use of kratom for treating serious diseases like opioid use disorder (OUD), the FDA has issued additional warning letters to unscrupulous vendors for marketing kratom products with scientifically unsubstantiated claims, which they find a clear violation of federal law. The American Kratom Association claims the contrary, in fact they have stated that kratom is regulated by the FDA as a dietary ingredient/supplement and nearly 5 million Americans safely use the substance.⁶

Understanding the true depth of the opioid epidemic requires a wealth of information regarding the various drugs that are involved and their risk factors. If a drug of concern or an alternative form of the drug is posing a potential health risk to your community, incorporating that drug into your substances of abuse testing efforts can provide a proactive, comprehensive, and advanced approach in addressing the prevalence of opioid use disorder within today’s substance abuse landscape. Kratom detection is available as an add-on to any urine panel and as part of the 18-panel test in hair or fingernail through USDTL.

References:

1. “Poison control calls for kratom have soared in recent years.” (n.d.). Retrieved from https://www.cbsnews.com/news/kratom-poison-control-calls-soared-in-recent-years/
2. “Kratom exposures reported to United States poison control centers”: 2011–2017. (n.d.). Retrieved from https://www.tandfonline.com/doi/full/10.1080/15563650.2019.1569236?scroll=top&needAccess=true
3. National Institute on Drug Abuse. (n.d.). “Kratom.” Retrieved from https://www.drugabuse.gov/publications/drugfacts/kratom
4. Office of the Commissioner. (n.d.). Press Announcements – “Statement from FDA Commissioner Scott Gottlieb, M.D., on the agency’s scientific evidence on the presence of opioid compounds in kratom, underscoring its potential for abuse.” Retrieved from https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm595622.htm
5. Office of the Commissioner. (n.d.). Press Announcements – “Statement from FDA Commissioner Scott Gottlieb, M.D., on new warning letters FDA is issuing to companies marketing kratom with unproven medical claims; and the agency’s ongoing concerns about kratom.” Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm620106.htm
6. “American Kratom Association.” (n.d.). Retrieved from https://www.americankratom.org/

USDTL is honored to announce that our Assistant Laboratory Director of Research, Aileen Baldwin, Ph.D., MPH is a recent coauthor of two published peer-reviewed articles focused on the increased prevalence of prenatal alcohol exposure (PAE).

“Limitations of Nail and Hair Ethyl Glucuronide (EtG) Levels to Assess Maternal Alcohol Use,” was published in the Journal of Drug Dependence and Addiction in July 2019. The study was conducted at a maternity hospital in Montevideo, Uruguay between 2016-2017 in efforts to determine Ethyl Glucuronide (EtG) levels in nail and hair samples collected at the time of delivery in comparison to Phosphatidylethanol (PEth) levels. The research obtained from this analysis finds that EtG levels are of limited value for the assessment of maternal alcohol use during the third trimester of pregnancy or in determining a newborn’s risk for Fetal Alcohol Syndrome Disorder (FASD). This report also suggests PEth is the preferred method to detect alcohol use during the later stages of pregnancy.

In January 2020, “Prevalence of alcohol use in late pregnancy,” was published in Pediatric Research. The study highlights the increased prevalence of prenatal alcohol exposure (PAE) specifically in the state of West Virginia (WV) and identifies risk factors associated with PAE including smoking, preterm birth, lower gestational birth weight, and a reduction in breastfeeding. The findings from this study demonstrate that the detection of PEth in residual dried blood spots is an effective surveillance screening tool to improve methods for detection of prevalence estimate of PAE.  The use of PEth screening can provide accurate and timely estimates of PAE, which is vital to inform public health workers, policymakers, researchers, and clinicians to develop and promote effective prevention strategies to lower PAE prevalence and provide targeted interventions and treatment services for infants affected by PAE.

This study was picked up by several news outlets, see them all on our In The News page.

Congratulations to Aileen and all of our research collaborators on your continued success in research development!

To read more, click on the publication links below:

• Limitations of Nail and Hair Ethyl Glucuronide (Etg) Levels to Assess Maternal Alcohol Use
• Prevalence of alcohol use in late pregnancy

Alcohol abuse, a historical public health concern, is gaining increased interest among medical professionals and analysts. Developing assessments are unveiling the significance of our country’s alcohol crisis despite overshadowing drug epidemics.

An estimated 88,000 people die from alcohol-related causes annually, which makes alcohol the third leading preventable cause of death in the United States.¹ The prevalence of alcohol in our society is generating alarming statistics of abuse and death that can’t be ignored. According to the 2015 National Survey on Drug Abuse and Health, 15 million adults over the age of 18 and 600,000 of 12-17-year-olds have an alcohol use disorder.¹

Alcohol Use Disorder (AUD) is a chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using.² AUD diagnosis is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its severity is categorized from mild to moderate, or severe. In efforts to identify an individual suffering from AUD the following symptoms may be present:

• Inability to limit the amount of alcohol consumed
• An increased time limit for drinking, getting alcohol, or recovering from alcohol use.
• Feeling a strong craving or urge to drink alcohol.
• Failing to fulfill major obligations at work, school, or home due to repeated alcohol use.
• Eliminating or reducing social and work activities, or hobbies
• Developing a tolerance to alcohol, causing an increased need for more to feel its effect or experiencing a reduced effect from the same amount.
• Subjected to withdrawal symptoms—such as nausea, sweating, and shaking when not drinking and often drinking to avoid these symptoms.³

AUD is more prone to develop during an individual’s early to mid-adult life, although the onset of the disorder can begin at any age. Certain risk factors can generate hazardous drinking behaviors including:

• Steady Drinking-drinking too much on a regular basis
• A Premature Introduction to Alcohol-putting individuals at a higher risk for AUD
• Family History-influenced genetic variables
• Mental Health-disorders including anxiety, depression, schizophrenia, or biopolar³

The identification process of AUD is an initial step in addressing a multi-faceted disorder—untreated AUD can lead to long-term health complications ranging from:

• liver disease, digestive, and heart problems
• diabetes complications
• sexual function and menstruation issues
• eye problems
• birth defects
• bone damage
• neurological complications
• weakened immune system
• increased risk of cancer
• medical and alcohol interactions³

Alcohol is currently a regulated and licit substance in the United States; therefore, it is imperative to adhere to the safe drinking recommendations put forth by health organizations monitoring its usage. According to the Center for Disease Control (CDC), the recommended consumption of alcohol for women is up to 1 drink a day and for men, up to 2 drinks a day.⁴ If you are under the age of 21, may be pregnant, or have other health problems —abstaining from drinking is strongly advised. In efforts to elaborate on moderating your drinking, understanding what constitutes a “drink” is crucial.

Defining A “Drink”

• 12-ounces of beer (5% alcohol content)
• 8-ounces of malt liquor (7% alcohol content)
• 5-ounces of wine (12% alcohol content)
• 1.5-ounces of 80 proof (40% alcohol content) distilled spirits or liquor (e.g., gin, rum, vodka, whiskey)⁴

Binge Drinking

Binge drinking is defined as a pattern of drinking that brings a person’s blood alcohol concentration (BAC) to 0.08 grams percent or above. This type of intoxication generally occurs when men consume 5 or more drinks or women consume 4 or more drinks in 2 hrs.⁵

Heavy Drinking

Heavy alcohol use is defined as binge drinking on 5 or more days within a month period.⁵

An Alcohol Epidemic

The depth of AUD in comparison to other national emergency drug epidemics has often gone underestimated, but in 2016, deaths caused by alcohol were more than double those involving opioids.⁶  The American Academy of Pediatrics (AAP), recommends adopting universal substance abuse screening, brief intervention, and referrals to treatment.⁶ Identifying adolescents who are at high risk for developing AUD by utilizing screening tools can help accurately predict problematic drinking behaviors. The National Institute on Alcohol Abuse and Alcoholism (NIAAA), have recently developed a two-question alcohol screening designed for middle school and high school students asking the following:

Middle School

1. Do you have any friends who drank beer, wine, or any alcohol in the past year?
2. How about you? In the past year how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?

High School:

1. In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?
2. If your friends drink, how many drinks do they drink on an occasion?⁷

The Importance of Utilizing Alcohol Assessment Tools

Administering evaluative tools in efforts to properly assess risky drinking behaviors can be a useful tactic. However, self-report reliability can become questionable –utilizing additional evidence-based measurements can assist in depicting the true magnitude of one’s drinking behaviors. Several studies have reported difficulties in measuring alcohol-related dependence using self-reporting tools, due to misinterpretation by respondents, lack of specificity, and misperception of AUD symptoms such as after-effects and acute intoxication.⁸ As a leading forensic toxicology laboratory, we provide alcohol biomarker testing to assist in identifying at-risk drinking behaviors. Our laboratory offers alcohol biomarkers in several specimen types including:

Newborn:

• Meconium-Fatty Acid Ethyl Ester (FAEE)-window of detection up to approximately 20 weeks prior to collection. (i.e., Birth)
• Umbilical Cord-Ethyl Glucuronide (EtG)-window of detection up to approximately 20 weeks prior to collection. (i.e., Birth)
• Blood– Phosphatidylethanol (PEth)-window of detection is up to approximately 2-4 weeks prior to collection.

Adult/Child:

• Fingernail-Ethyl Glucuronide (EtG)-window of detection is up to approximately 3 months prior to collection.
• Hair-Ethyl Glucuronide (EtG)-window of detection is up to approximately 3 months prior to collection.
• Blood-Phosphatidylethanol (PEth)-window of detection is up to approximately 2-4 weeks prior to collection.
• Urine-Ethyl Glucuronide/Ethyl Sulfate (EtG/EtS) and ethanol-window of detection is up to approximately 2-3 days prior to collection.

An estimated 16 million people in the United States have AUD.² Incorporating detection methods to assist in identifying individuals exhibiting indicators of destructive drinking can create an effective awareness about AUD –a crisis that affects so many of us today.  

References:

1. “Alcohol Facts and Statistics.” (n.d.). Retrieved from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics
2. “Alcohol Use Disorder.” (n.d.). Retrieved from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders
3. “Alcohol use disorder.” (2018, July 11). Retrieved from https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/symptoms-causes/syc-20369243
4. CDC – “Fact Sheets-Alcohol Use And Health” – Alcohol. (n.d.). Retrieved from https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
5. CDC – “Fact Sheets-Binge Drinking” – Alcohol. (n.d.). Retrieved from https://www.cdc.gov/alcohol/fact-sheets/binge-drinking.htm
6. Hadland, S. E., Knight, J. R., & Harris, S. K. (2019, March 01). “Alcohol Use Disorder: A Pediatric-Onset Condition Needing Early Detection and Intervention.” Retrieved from https://pediatrics.aappublications.org/content/143/3/e20183654
7. Spirito, A., Bromberg, J. R., Casper, C., Chun, T. H., Mello, M. J., Dean, M., & Linakis, J. G. (2016, September 22). “Reliability and Validity of a Two-Question Alcohol Screen in the Pediatric Emergency Department.” Retrieved April 3, 2019, from https://pediatrics.aappublications.org/content/pediatrics/138/6/e20160691.full.pdf
8. Iglesias, K., Sporkert, F., Daeppen, J., Gmel, G. and Baggio, S. (2018). Comparison of self-reported measures of alcohol-related dependence among young Swiss men: a study protocol for a cross-sectional controlled sample. [online] Available at: https://bmjopen.bmj.com/content/8/7/e023632 [Accessed 3 Feb. 2020].