High prevalence of 6-acetylmorphine in morphine-positive oral fluid specimens

doi:10.1016/S0379-0738(03)00045-8

Forensic Science International

Volume 133, Issues 1–2, 23 April 2003, Pages 22-25

https://doi.org/10.1016/S0379-0738(03)00045-8 Get rights and content

Abstract

Identification of 6-acetylmorphine, a specific metabolite of heroin, is considered to be definitive evidence of heroin use. Although 6-acetylmorphine has been identified in oral fluid following controlled heroin administration, no prevalence data is available for oral fluid specimens collected in the workplace. We evaluated the prevalence of positive test results for 6-acetylmorphine in 77,218 oral fluid specimens collected over a 10-month period (January–October 2001) from private workplace testing programs. Specimens were analyzed by Intercept™ immunoassay (cutoff concentration=30 ng/ml) and confirmed by GC–MS–MS (cutoff concentrations=30 ng/ml for morphine and codeine, and 3 ng/ml for 6-acetylmorphine). Only morphine-positive oral fluid specimens were tested by GC–MS–MS for 6-acetylmorphine. A total of 48 confirmed positive morphine results were identified. An additional 107 specimens were confirmed for codeine only. Of the 48 morphine-positive specimens, 32 (66.7%) specimens were positive for 6-acetylmorphine. Mean concentrations (±S.E.M.) of morphine, 6-acetylmorphine and codeine in the 32 specimens were 755±201, 416±168 and 196±36 ng/ml, respectively. Concentrations of 6-acetylmorphine in oral fluid ranged from 3 to 4095 ng/ml. The mean ratio (±S.E.M.) of 6-acetylmorphine/morphine was 0.33±0.06. It is suggested that, based on controlled dose studies of heroin administration, ratios >1 of 6-acetlymorphine/morphine in oral fluid are consistent with heroin use within the last hour before specimen collection. The confirmation of 6-acetylmorphine in 66.7% of morphine-positive oral fluid specimens indicates that oral fluid testing for opioids may offer advantages over urine in workplace drug testing programs and in testing drugged drivers for recent heroin use.

Introduction

Testing of oral fluid for 6-acetylmorphine offers some appealing advantages over urine testing. Collection procedures for oral fluid specimens are less invasive, and detection of 6-acetylmorphine could be considered as evidence of recent heroin use and possible drug impairment. Detection of 6-acetylmorphine also serves to differentiate heroin use from poppy seed ingestion. Guidelines for interpretation of urine results have been proposed based on measurement of 6-acetylmorphine, morphine and codeine, that provide help in source differentiation of opioids [1]. However, 6-acetylmorphine is difficult to detect in urine because of its short detection window [2]. In the federal workplace drug testing program in the USA, differentiation between heroin use and poppy seed ingestion is based on use of higher cutoff concentration levels for morphine and by testing for 6-acetylmorphine in urine [3]. Recent draft guidelines by the Substance Abuse and Mental Health Services Administration (SAMHSA) include the requirement for testing of 6-acetylmorphine in alternative biological matrices, i.e. oral fluid, hair and sweat [4].

Pharmacokinetic studies of heroin in humans have demonstrated that both heroin and 6-acetylmorphine are cleared rapidly from blood following heroin administration by the intravenous [5], [6], [7], intramuscular [8], smoked [7] and intranasal [8] routes. 6-Acetylmorphine appears in oral fluid (saliva) within minutes after intravenous heroin administration and is generally found in higher concentration than in plasma [9]. Estimates of the elimination half-life for 6-acetylmorphine in blood have ranged from 5 to 52 min [6], [7]. In this report, we presents the results of a study of prevalence rates of 6-acetylmorphine in oral fluid specimens collected in private workplace drug testing programs in the USA.

Section snippets

Oral fluid collection

A total of 77,218 oral fluid specimens (non-regulated) were collected primarily in workplace drug testing programs from across the USA over a 10-month period (January–October 2001) and shipped to LabOne Inc. (Lenexa, KS) for screening and confirmation testing. Specimens were collected with the Intercept™ DOA oral specimen collection device (OraSure Technologies, Bethlehem, PA) according to manufacturer’s instruction. With this device, an average of 0.4 ml of oral fluid is collected. The

Results and discussion

Oral fluid specimens (N=77,218) were collected primarily in workplace settings during the period January–October 2001. A total of 155 (0.20%) oral fluid specimens were confirmed positive for morphine and/or codeine. Of these, 48 (0.06%) specimens tested positive for morphine. Of the 48 morphine-positive specimens, 32 (66.7%) were confirmed positive for 6-acetylmorphine (Table 1). The mean concentration±S.E.M. of 6-acetylmorphine was 416±168 ng/ml and the range was 3–4095 ng/ml. The concentrations

Conclusion

Oral fluid testing of specimens collected primarily in workplace setting revealed that 6-acetylmorphine was present in 66.7% of morphine-positive specimens. Further, the mean concentration of 6-acetylmorphine was approximately one-half that of morphine, but exceeded morphine concentrations in two instances. Based on controlled dose studies of heroin administration, it is suggested that ratios >1 for 6-acetylmorphine/morphine in oral fluid are consistent with heroin use within the last hour

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Guidelines for interpretation of salivary drug of abuse concentrations, proposed by the SFTA
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Poppy Seed Defense and Workplace Drug Testing: Does It Work in the Court?
2020, Fighting the Opioid Epidemic: The Role of Providers and the Clinical Laboratory in Understanding Who is Vulnerable
In general, morphine is the most abundant alkaloid found in raw opium, followed by noscapine, codeine, papaverine, and thebaine. Morphine, codeine, and thebaine are also found in the opium poppy latex. Opium alkaloids are not found in poppy seeds but are transferred onto the seed coats during harvesting process. As a result, alkaloid content of poppy seeds varies widely with morphine content ranging from 0.1 to 620 mg/kg of seeds and codeine content varying from 0.08 to 57.1 mg/kg of seeds. In general morphine content is significantly higher than codeine. As a result both morphine and codeine are found in urine of subjects eating poppy seed–containing foods. However, both morphine and codeine levels are relatively low in urine after eating poppy seed–containing food because more than 90% morphine present in raw poppy seeds are destroyed during food processing especially baking. Therefore, it is unlikely that after eating poppy seed–containing food, a person will test positive for opiates during immunoassay screening where cutoff concentration for opiate is 2000 ng/mL. Moreover, the presence of 6-monoacetylmorphine, a marker of heroin abuse, is not consistent with eating poppy seed–containing food.
Detection of heroin intake in patients in substitution treatment using oral fluid as specimen for drug testing
2019, Drug and Alcohol Dependence
Citation Excerpt :
A similar detection rate of 6-AM has been seen in another investigation (Di Rago et al., 2016; Wagner et al., 2018), and even a higher detection rate than for morphine in patients in opiate substitution treatment has been reported in OF (Kunkel et al., 2015; Vindenes et al., 2011). A similar observation was also made in a study using OF samples collected from a more general drug addiction population (Flood et al., 2016), and in samples from workplace testing (Presley et al., 2003). The classification of the other cases than 6-AM positives as probable heroin intake was based on the morphine/codeine ratio being ≥1.
Detection of heroin use is among the major tasks for drug testing and can be best performed by using 6-acetylmorphine as the target analyte. This study was performed to document analytical findings in oral fluid after OF heroin intake.
The samples were from routine drug testing of patients in substitution treatment. The analytical investigation was made with a forensic accredited liquid chromatography-tandem mass spectrometry method.
Out of 2814 samples, from 1875 patients, sent for routine drug testing, 406 contained one or more opiate in the drug screening when applying a cutoff limit of 1 ng/mL neat OF. Out of these 406, 314 had a measured 6-AM concentration in neat OF ≥ 1 ng/mL. The study demonstrated that 6-AM is a viable parameter in oral fluid drug testing with an about 80% sensitivity compared to using morphine and codeine as biomarkers. An additional value of using 6-AM is the confidence in concluding a heroin intake. The 6-AM concentrations varied between 1 and >1000 ng/mL, with a median value of 18.6 ng/mL. Heroin was measured in 35 samples with a median value of 0.72 ng/mL. The positive rate for opiates in urine and OF drug testing was the same, 13.5%, in similar populations of patients.
6-AM is a preferred parameter in OF drug testing for monitoring heroin use and makes OF drug testing for detecting heroin use more effective than urine drug testing when using highly sensitive mass spectrometry methods.
Positivity rates of drugs in patients treated for opioid dependence with buprenorphine: A comparison of oral fluid and urine using paired collections and LC-MS/MS
2018, Drug and Alcohol Dependence
Citation Excerpt :
Oral fluid collections may also have greater patient acceptance (MacCall et al., 2013). In addition, a significant body of research has shown that OF is suitable for the detection of many medications and drugs of abuse, and may offer advantages for certain analytes (Presley et al., 2003; Choo and Huestis, 2004; Cone and Huestis, 2007; Allen, 2011; Quest Diagnostics, 2011; Vindenes et al., 2011; Conermann et al., 2014; Moore, 2015). However, OF collection may not be suitable for all patients, including those prescribed tricyclic antidepressants or other anticholinergic agents that inhibit saliva production.
Drug testing is recommended as part of comprehensive monitoring for medication-assisted treatment. Alternative matrices including oral fluid offer a number of advantages when compared with conventional urine testing but are not as well characterized. This study aims to compare positivity rates of drugs and drug classes in oral fluid and urine as a measure of the clinical utility of oral fluid in the evaluation and treatment of patients with opioid use disorders.
A retrospective review of paired oral fluid and urine test results from Millennium Health’s laboratory database was performed for 2746 patients with reported prescriptions for buprenorphine products used in the treatment of opioid dependence. Specimens were tested using quantitative LC–MS/MS for 34 medications, metabolites and illicit drugs.
A number of medications and illicit drugs were detected at comparable or higher rates in oral fluid vs. urine such as cocaine (15.7% vs. 7.9%), opiates (13.4% vs. 10.0%), oxycodone (8.6% vs. 3.7%), hydrocodone (3.0% vs. 1.2%) and others. Lower detection rates were observed in oral fluid vs. urine for benzodiazepines (6.6% vs. 8.7%), cannabinoids (15.5% vs. 19.5%), oxymorphone (1.8% vs. 3.1%) and hydromorphone (0.8% vs. 4.5%).
Clinicians may find oral fluid advantageous for detection of specific drugs and medications in certain clinical situations. Understanding the relative differences between urine and oral fluid can help clinicians carefully select tests best suited for detection in their respective matrix. To our knowledge, this is the largest inter-matrix patient comparison study using paired collections and direct to definitive testing.
Pain Management Testing by Liquid Chromatography Tandem Mass Spectrometry
2018, Clinics in Laboratory Medicine
Detection of drugs of abuse in simultaneously collected oral fluid, urine and blood from Norwegian drug drivers
2012, Forensic Science International
Citation Excerpt :
In a previous study we compared drug findings in oral fluid and urine in samples collected from patients admitted to a drug treatment program and we found good correspondence in the majority of the cases [16]. As seen in previous studies [17–19], detection of 6-monoacetylmorphine (6-MAM) as a marker of heroin intake was found in more oral fluid samples compared to urine. In our previous study [16] Intercept Oral Specimen Collection Device®, a device that stimulates oral fluid production, was used for collection of the samples, and drug screening was performed by a liquid chromatography–tandem mass spectrometry (LC–MS/MS) method [2].
Blood and urine samples are collected when the Norwegian police apprehend a person suspected of driving under the influence of drugs other than alcohol. Impairment is judged from the findings in blood. In our routine samples, urine is analysed if morphine is detected in blood to differentiate between ingestion of heroin, morphine or codeine and also in cases where the amount of blood is too low to perform both screening and quantification analysis. In several cases, the collection of urine might be time consuming and challenging. The aim of this study was to investigate if drugs detected in blood were found in oral fluid and if interpretation of opiate findings in oral fluid is as conclusive as in urine.
Blood, urine and oral fluid samples were collected from 100 drivers suspected of drugged driving. Oral fluid and blood were screened using LC–MS/MS methods and urine by immunological methods. Positive findings in blood and urine were confirmed with chromatographic methods. The analytical method for oral fluid included 25 of the most commonly abused drugs in Norway and some metabolites.
The analysis showed a good correlation between the findings in urine and oral fluid for amphetamines, cocaine/benzoylecgonine, methadone, opiates, zopiclone and benzodiazepines including the 7-amino-benzodiazepines. Cocaine and the heroin marker 6-monoacetylmorphine (6-MAM) were more frequently detected in oral fluid than in urine. Drug concentrations above the cut-off values were found in both samples of oral fluid and urine in 15 of 22 cases positive for morphine, in 18 of 20 cases positive for codeine and in 19 of 26 cases positive for 6-MAM. The use of cannabis was confirmed by detecting THC in oral fluid and THC-COOH in urine. In 34 of 46 cases the use of cannabis was confirmed both in oral fluid and urine. The use of cannabis was confirmed by a positive finding in only urine in 11 cases and in only oral fluid in one case. All the drug groups detected in blood were also found in oral fluid.
Since all relevant drugs detected in blood were possible to find in oral fluid and the interpretation of the opiate findings in oral fluid was more conclusive than in urine, oral fluid might replace urine in driving under the influence cases. The fast and easy sampling is time saving and less intrusive for the drivers.

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High prevalence of 6-acetylmorphine in morphine-positive oral fluid specimens

Abstract

Introduction

Section snippets

Oral fluid collection

Results and discussion

Conclusion

J. Chromatogr.

Morphine and codeine in biological fluids: approaches to source differentiation

Forensic Sci. Rev.

Forensic drug testing for opiates. I. Detection of 6-acetylmorphine in urine as an indicator of recent heroin exposure: drug and assay considerations and detection times

J. Anal. Toxicol.

The pharmacokinetics of heroin in patients with chronic pain

NEJM