Newly Emerging Drugs of Abuse and Their Detection Methods

An ACLPS Critical Review

Li Liu, MD, PhD; Sarah E. Wheeler, PhD; Raman Venkataramanan, PhD; Jacqueline A. Rymer, MT(ASCP); Anthony F. Pizon, MD; Michael J. Lynch, MD; Kenichi Tamama, MD, PhD


Am J Clin Pathol. 2018;149(2):105-116. 

In This Article

Overview of Drug Abuse Epidemic in the Us

The abuse of illicit drugs, including newly emerging drugs of abuse, poses a serious threat to public health, not to mention a great challenge to the health care system. In the past several years, the incidence of drug abuse and drug overdose death has rapidly increased, reaching epidemic levels. The number of deaths caused by drug overdose has surpassed that caused by motor vehicles accidents and firearms since 2008, becoming the leading cause of injury death. In 2015, the Centers for Disease Control and Prevention (CDC) reported 52,404 deaths, an 11.4% increase from 2014, as a result of unintentional overdose, with more than 60% (33,091) attributed to opioids. For the first time, deaths from heroin and nonmethadone synthetic opioids including illicitly obtained fentanyl and its analogues, surpassed deaths related to prescription opioids.[1]

Heroin abuse has surged since 2007, with the number of users almost tripled from 161,000 in 2007 to 435,000 in 2014.[2,3] The number of deaths involving heroin overdose increased 248% between 2007 and 2014. This is partly driven by the increasing availability of heroin in the US, and consequently some prescription drug abusers convert to heroin as a cheaper alternative.[2,3]

Abuse of controlled prescription drugs (CPDs) poses another major threat. This is mainly due to the diversion of prescription opioid analgesics, most commonly those containing oxycodone and hydrocodone. The number of deaths attributable to CPDs has outpaced that of cocaine and heroin combined since 2002; and in 2014 alone, the number of drug overdose deaths involving CPD reached 25,760, compared to that of heroin (10,574) and cocaine (5,415).[2,3]

As a strategy to reduce the abuse of CPDs and protect the health and safety of our community, state-run programs called prescription drug monitoring programs have been launched in every US state. Prescription drug monitoring programs collect and maintain information on all filled prescriptions for controlled substances in a searchable database for use by prescribers and providers. This statewide electronic database has been shown to decrease drug diversion and to improve patient safety.[4] Periodic urine drug testing for prescribed pain medications is another way to monitor patient compliance.[4] Currently, many reference toxicology laboratories offer quantitative drug screening results with interpretation (eg, medMATCH at Quest Diagnostics, Secaucus, NJ) to detect consistency or inconsistency of the drug screening results with the patient's prescribed medications, allowing clinicians to easily detect the abuse of CPDs. The combination of these strategies may effectively curtail prescription drug diversion and CPD abuses in the future.

While the above-mentioned "old drugs" still play major roles in the abuse drug market, novel substances such as synthetic designer drugs continue to emerge and attract many recreational users. The most common designer drugs include synthetic cathinones, commonly known as "bath salts," and synthetic cannabinoids, also known as "Spice" and "K2." These newly emerging drugs are easily accessible, causing harmful health consequences and presenting an ongoing challenge for clinical toxicology and forensic laboratories.

According to the 2016 Drug Enforcement Agency (DEA) Emerging Threat Report, 2,679 identifications of psychoactive compounds were made among seized and analyzed drugs by the DEA's laboratory system. Among them, 1,299 identifications (48.4%) fall in opioids, 984 identifications (36.7%) fall in synthetic cannabinoids, and 347 identifications (13.0%) fall in synthetic cathinones. Among the 1,299 opioid identifications, fentanyl is comprised of 877 identifications (67.5% of opioid identifications).[5] These statistics underline the significance of the threat by emerging drugs of abuse.