Point-of-collection testing for screening of psychoactive substances among drivers of Kerala, India

doi:10.21203/rs.3.rs-1987388/v1

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Point-of-collection testing for screening of psychoactive substances among drivers of Kerala, India

https://doi.org/10.21203/rs.3.rs-1987388/v1

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One of the important risk factors for road traffic crashes is driving under the influence of drugs (DUID). This study aimed to check the prevalence of drugs of abuse (DOA) among the goods carriage drivers associated with the southern state of India, Kerala. Roadside point-of-collection testing (POCT) of oral fluid collected from the participants on the major highways was done using the Evidence MultiSTAT DOA Oral Fluid II Assay kits and the Evidence MultiSTAT analyzer. Out of the total samples (n= 249), 53 (21.29%) were positive for one or more DOA. A high prevalence of tetrahydrocannabinol (THC) (10.04%) and synthetic cannabinoids were detected in the samples. The use of ketamine, alpha-PVP, LSD, methamphetamine, opiate, 6-MAM, benzodiazepines I, methadone, PCP, tramadol, and amphetamine were also detected in oral fluid samples and their frequency of use was ranging between 4.02-0.80%. Confirmatory analysis using ultra-high performance liquid chromatography-tandem mass spectrometry showed excellent agreement with the results of the screening test. This was the first qualitative study conducted among drivers in India for the detection of DOA. Scientific studies are crucial for assessing the effectiveness of strategies for reducing psychoactive substance use by drivers before or while driving.

New psychoactive substances

drivers

point-of-collection testing

bio-chip array technology

Psychoactive substances and drugs are a part of human life and their abuse causes a vulnerable threat to the security and stability of the world. Free markets, free trade, and improved communication have resulted in a considerable increase in the production and consumption of illicit drugs and psychoactive substances worldwide. Regular drug usage causes negative health consequences such as drug use disorders, increased risk of acquiring infectious diseases such as HIV and Hepatitis C, and premature death. According to UNODC (United Nations Office on Drugs and Crime), the estimated number of drug users between 2010 and 2019 was from 226 million to 274 million, and the people aged between 15–64 had a high attraction to drugs (Heikkilä, Maalouf, & Campello, 2021). Between the age group 15–64, the highest level of drug use was found among the people aged 18–25 because adolescence and early adulthood are periods of transition associated with several physical and psychological developments (U. N. O. o. Drugs & Crime, 2018). In India, a substantial number of people in all the population groups use psychoactive substances, but adult men bear the brunt of substance use disorders reported in the national survey report ‘Magnitude of Substance Use in India, 2019’ jointly conducted by the Ministry of Social Justice and Empowerment, National Drug Dependence Treatment Centre (NDDTC) and All India Institute of Medical Sciences (AIIMS) (Ambekar et al., 2019). Over the last decades, the drug market grabs a diversification in available substances. As a result, in addition to plant-based substances, the introduction of synthetic drugs also flourishes in the market (Bewley-Taylor & Nougier, 2018).

Emerging of New Psychoactive Substances (NPS)

As defined by UNODC, New psychoactive substances (NPS) are a group of drugs that are not under international control, but that mimic illicit drugs that are under international control such as Cannabis, Cocaine, MDMA (Ecstasy/Molly, 3,4-Methylenedioxymethamphetamine), and LSD (Lysergic acid diethylamide) (U. UNODC, 2013). NPS has been referred to as designer drugs, legal highs, herbal highs, bath salts, research chemicals, etc., (King & Kicman, 2011). Since the NPS are relatively new, the purity and composition of products containing NPS are often not known, and the unpredictable and poorly understood nature of these drugs continues to be a challenge. NPS are unregulated and untested, hence they do not mark recommended dosage on the label, and more research is needed on their short-term and long-term effects. In January 2020, the emergence of 950 new psychoactive substances has reported by 120 countries and territories to the UNDOC (Heikkilä et al., 2021). Acute and chronic health consequences due to the usage of NPS is depending on the characteristics, level of dosage, the toxicity of the substance, route of administration, and combination with other substances. NPS causes adverse cardiovascular, respiratory, and gastrointestinal consequences, the transmission of blood-borne viruses (HIV and hepatitis C), and neurological and psychiatric harm such as psychosis, suicidal ideation, dependence, and ultimately death. Between January 2019-April 2020, 670 NPS-mediated toxicology cases were reported to UNODC (Blanco & Stokes, 2021).

Over the past few decades, NPS emerged in the drug market which is composed of a diverse group of chemical substances either synthetic or plant-based, which may cause public health consequences similar to substances that are under international control. Synthetic NPS includes synthetic cannabinoid receptor agonists, which have a similar effect to Cannabis. JWH-018 was the first synthetic cannabinoid receptor agonist under NPS which entered the drug market (E. M. C. f. Drugs & Addiction, 2020). Globally reported most common NPS are synthetic cannabinoids receptor agonists, which have several toxic effects including seizures, loss of consciousness, psychosis, vomiting, drowsiness, chest pain, agitation, hot flashes, dilation of pupils, and dry mouth (Sezer, Jannuzzi, Huestis, & Alpertunga, 2020). Synthetic Cathinones, which are stimulants, can speed up the messages between the brain and the body. It first appeared on the drug market in the mid-2000 and mimics illicit drugs such as Cannabis, Cocaine, Ecstasy, and LSD. Phenethylamines are stimulant psychoactive drugs that include amphetamine, MDMA, NBOMes, PMMA, and benzodifurans. Piperazines, which are also stimulants commonly available as pills, capsules, or powder includes, 1-benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP). Tryptamines, which are hallucinogens found in plants, fungi, and animals, produce changes in perception, mood, and cognitive processes. Naturally occurring neurotransmitters such as serotonin and melatonin are included in tryptamines (Shafi, Berry, Sumnall, Wood, & Tracy, 2020). Novel Benzodiazepines, which are not approved as medicine and include diclazepam, flubromazepam, and pyrazolam. According to UNODC, among the toxicology cases involving NPS, 83% of cases are due to the influence of Benzodiazepines (Garneau et al., 2021). Aminoindanes, which are potentially vasoactive and bronchodilatory and the chemical structure is similar to that of AMPHs, are now widely substituted for ecstasy. MDAI, 5,6-methylenedioxy-N-methyl2-aminoindane (MDMAI), 5-iodo-2-aminoindane (5-IAI), 2-aminoindane (2-AI), 5-methoxy-6-methyl-2-aminoindane (MMAI), and 5-methoxy-2-aminoindane (MEAI) are newly emerged aminoindane NPS (Pinterova, Horsley, & Palenicek, 2017). NPS opioids are a category of fast-growing NPS reported over the past five years include a range of fentanyl analogues. Brorphine is a non-fentanyl NPS opioid found on the market since 2019 (UNODC, 2020).

Challenges in detecting NPS in the workplace

Due to the large range of NPS chemical structures, improving determinations in the detection and identification of NPSs have emerged as a global analytical challenge. The range of conventional and non-conventional biological matrices from which the NPS has to be detected also varies. Rapid detection capabilities and screening tools impact many fields and settings, including seized products analysis, emergency rooms, workplace, and roadside drug controls, drug addiction treatment clinics, law enforcement and health interventions, and post-mortem and criminal casework. Several techniques such as colorimetric, immunochemical, and chromatographic-mass spectrometry have been developed for the rapid identification of NPSs (Graziano, Anzillotti, Mannocchi, Pichini, & Busardò, 2019). Advances in immunoassay screening technologies have resulted in the development of test platforms that are simple to use in a non-laboratory environment and do not require specialist laboratory personnel for their operation. Near-subject immunoassay screening for drugs of abuse is now routine in many hospital emergency departments, drug treatment clinics, and workplace drug testing situations because it offers a rapid means of indicating a donor’s recent drug use (McLaughlin, Maskell, Pounder, & Osselton, 2019; McLaughlin, Pounder, Maskell, & Osselton, 2013).

Psychoactive drug usage in the workplace leads to severe occupational health problems. Vehicle drivers are important contributors to the economy of every country and also, they are a more stressed working population due to irregular working schedules, night shifts, being distant from families for long periods, short deadlines, etc. The stressful conditions forced them to use psychoactive substances for reducing sleepiness during the trips and increasing their willingness to work and socialize (McLaughlin et al., 2019). The use of such harmful substances affects the functionality of the brain, which may cause threats to the individual and society. The use of psychoactive substances during driving is a major public health concern, which may impact drivers’ health and safety, also increasing the risk of injuries and traffic accidents. The most commonly used substances among drivers are cannabis, alcohol, amphetamines, cocaine, benzodiazepines, opioids, etc. (Girotto, Mesas, de Andrade, & Birolim, 2014). A comprehensive analysis of this issue can adequately inform policy-makers and law-enforcement officers to address legislative shortcomings and implement preventive measures in the workplace.

In the context of the law’s application, blood is the matrix that must be collected to determine if a driver is under the influence of any drug. However, the collection of blood is very invasive, and the refusal rates are high in studies where participation is voluntary (Gjerde, Øiestad, & Christophersen, 2011). Urine can also be used to verify drug intake; however, a drug can be detected several days or weeks after drug consumption. Therefore, a positive drug finding does not indicate that driver was under the influence while driving (Kelley-Baker, Moore, Lacey, & Yao, 2014). Instead of using samples of blood or urine, oral fluid may be collected, because a positive drug finding in oral fluid indicates in most cases that the drugs are also present in the blood (Kelley-Baker et al., 2014; Moore, Kelley-Baker, & Lacey, 2013). The salivary glands are highly perfused, which guarantees a rapid transfer of a substance from blood to oral fluid. Besides, the collection of oral fluid is a fast, easy, and non-invasive method, and it is difficult to adulterate because the collection occurs in the presence of the researcher (Vindenes et al., 2012).

Since drugs are the important risk factors for traffic accidents, there is growing interest in the development of non-invasive, and rapid procedures for detecting the drug use associated with persons driving motor vehicles. The Randox biochip array technology can provide the facility of testing the oral fluid to detect the presence of drugs of abuse in point-of-collection testing (POCT), which would enable authorities for evidence-based interventions and to propose drug testing policies for occupational driving regulation (Dasgupta, 2019). The Randox immunoassay screening system relies on biochip technology; each biochip is 9 x 9 mm and has drug-specific antibodies immobilized in predefined regions on the biochip. Nine biochips are mounted within individual wells on a single cassette, and six cassettes can be run alongside one another. To obtain semi-quantitative concentrations, chemiluminescent technology is employed for the drugs-of-abuse (DOA) arrays. Light signals generated from each antibody site on the biochip are simultaneously detected using digital imaging technology and compared to that from a calibration curve (Ellefsen et al., 2014). The present study aims to generate scientific data regarding the consumption and prevalence of usage of new drugs of abuse (DOA) among the drivers of goods carriages associated with Kerala State, India using the DOA Oral Fluid II Array panels to screen oral fluid samples collected on-site using ‘Neosal Oral Fluid Collection Device’ and to reduce the knowledge gap, which in turn to allow the implementation of effective countermeasures.

Sample collection

The study protocol was approved by the Institutional ethics committee, Calicut University Human Ethical Committee, Malappuram, Kerala, India (Ref. No.: 001/CUHEC/2020-21 dated 20.01.2021). Informed consent was obtained from all individual participants included in the study. ‘National ethical guidelines for biomedical and health research involving human participants’ formulated by the Indian Council of Medical Research, New Delhi, India was followed throughout this work. of The collection of oral fluid samples were performed at the check posts of the Kerala State Excise department located on the national highways passing through Walayar, Palakkad district; Tholpetty, Wayanad district; Manjeshwar, Kasaragod district in the state of Kerala, between 7 p.m. and 12 a.m. during July to September 2021. The location and date of sample collection were previously chosen after discussion with the officials of the Kerala State Excise department. Excise officers randomly stopped goods carriages and invited them to participate in the study. The participants were informed about the study and those who agreed to participate signed an informed consent form. All drivers who agreed to participate were included in the study. Age, type of goods carriage, place of departure, destination, and travel length were recorded.

Oral fluid samples were collected using the Neosal Oral Fluid Collection Device (Neogen, MI, USA). The NeoSal Oral Fluid Collection System consists of an absorbent pad (Collection Pad) affixed to a plastic handle and a proprietary buffer solution in a plastic tube (Buffer Tube). The NeoSal Collection Pad was placed between the cheek and gum of the participants which enhanced the flow of oral fluid onto the absorbent Collection Pad. The Sample Volume Adequacy Indicator (SVAI) was built into the device to ensure a suitable volume of oral fluid was collected and had a visible line in the clear plastic window before the collection of the sample. This line turned distinctly blue when a sufficient sample was collected. After collecting the sample, the saturated Collection Pad was inserted into the Buffer Tube and the handle was tightly screwed into the Buffer Tube. After the Collection Pad had been secured in the Buffer Tube, the tube was gently inverted 4 or 5 times thoroughly to distribute the buffer solution into the collection pad. The samples were labeled with a number linking the sample to the information collected. The collected samples were kept inside the icebox and transported to the testing facility nearby.

Screening Test

The samples were tested for the presence of drugs using Evidence MultiSTAT analyzer, a fully automated Biochip Array System which performed simultaneous detection of multiple analytes from a single sample. The Evidence MultiSTAT DOA Oral Fluid II Assay kits were used for testing the qualitative determination of the parent molecule and metabolites of drugs in the oral fluid collected. They are competitive enzyme immunoassays run on the automated biochip array analyzer, Evidence MultiSTAT. The core technology is the Randox Biochip, a solid-state device containing an array of discrete test regions containing immobilized antibodies specific to the different drug of abuse (DOA) compound classes. A competitive chemiluminescent immunoassay was employed for the DOA assays with the drug in the specimen and the drug labeled with horseradish peroxidase (HRP) was in direct competition for the antibody binding sites. Increased levels of a drug in a specimen lead to reduced binding of the drug labeled with HRP and thus a reduction in chemiluminescence being emitted. The light signal generated from each of the test regions on the biochip was detected using digital imaging technology and compared to that from the cut-off material. The classification of test analyte present in the sample was determined from the cut-off material.

Assay protocol

Ready-to-use reconstitution buffer of 1 ml each was added to the lyophilized cut-off and control powders and kept for 30 minutes out of bright light before use. USB provided along with the assay kit was inserted into the USB port of the analyzer. Then the cartridge barcode was scanned to import the batch details from the provided USB. The batch update was selected on the screen of the Evidence MultiSTAT analyzer. Then, 220 microliters of oral fluid cut-off and 220 microliters of the sample (buffer mixed with oral fluid) were pipetted out to the respective well of the cartridge. Along with this, positive control was also run as indicated in the assay protocol. It took 20 min to get the result on the display of the analyzer. The Evidence MultiSTAT DOA Oral Fluid II array Technology facilitates simultaneous screening of NPSs and/or their metabolites such as Fentanyl, Ketamine, LSD, Methamphetamine, Barbiturates, Benzodiazepines I, Benzodiazepines II, Methadone, Opiate, PCP, BZG/Cocaine, Oxycodone, Tramadol, Cannabinoids (THC), Amphetamine, Buprenorphine, 6-MAM, Synthetic Cannabinoids (JWH-018), alpha-PVP, and Synthetic Cannabinoids (UR-144).

Confirmation

Confirmatory analyses of the saliva were performed at Forensic Fluids Laboratories, Michigan, United States, using ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Chromatographic separation was performed on an Acquity UPLC system (Waters) equipped with an Acquity BEH (C-18, 100 x 2.1 mm, 1.7 µm) analytical column (Waters). Mobile Phase A was 0.1% formic acid in water: acetonitrile (95: 5, v/v), and mobile Phase B was 0.1% formic acid in acetonitrile. The column and autosampler were kept at 50 and 15°C, respectively. The flow rate was kept at 0.7 mL/min, and the total run time was 4.5 min. The gradient conditions were as follows: from time 0 to 0.5 min 60% A; from time 0.5 to 4.0 min, mobile phase A was decreased to 10%; from time 4.01 to 4.4 min, mobile phase A was further decreased to 0%. At 4.41 min, mobile phase A was returned to 60% and the column was equilibrated at the mobile phase ratio until 4.5 min. The injection volume was 5.0 µL. The needle was washed with 600 µL of DI water: acetonitrile (90: 10, v/v) and 200 µL of methanol: isopropanol: acetonitrile solution (25:25:50, v/v) in between injections.

Electrospray ionization (ESI) mass spectrometry was performed on a TQD instrument (Waters). Analysis was performed in positive ionization (ESI+) and multiple reaction monitoring (MRM) mode. The source temperature was 150°C, and the desolvation gas temperature was 450°C. The flow rates of the desolvation gas (nitrogen) and the cone gas (nitrogen) were set at 850 and 50 mL/min, respectively. Collision gas (argon) flow was set at 0.18 mL/min. Collision cell pressure was 3.59E^− 3 mbar of argon. The MRM conditions were developed and optimized using the IntelliStart software (Waters).

Statistical Analyses

All the statistical tests were performed using SPSS v. 21.

A total of 290 drivers were invited to participate, and of those, only 255 drivers participated in this study and all were men with an average age of 36.53 years. Since no oral fluids were obtained from 6 drivers, the total sample size was reduced to 249. Out of the 249 samples, 53 tested positive (21.29%), and 196 samples (78.71%) were negative for any of the considered DOA. Majority of the participants belongs to the age group of 36–46 (n = 90; 36.1%), followed by 26–35 (n = 83; 33.3%), 18–25 (n = 43; 17.3%), and 47–57 (n = 31; 12.4%). Only 0.8% (n = 2) of the samples were representing the age group of 58 years and above (Fig. 1).

Of the total samples, 53 (21.29%) were positive for one or more substances (Table 1). Among the positive samples, the multiple uses of THC + UR144 drugs were more prominent and this combination was found positive in 11 cases (4.42%). Four samples were positive for the multiple uses of THC + JWH-018 (1.61%), and two samples (0.80%) were positive for the multiple uses of THC + Methamphetamine and THC + Alpha-PVP. However, one sample each were found positive for the combination uses of THC + 6-MAM + JWH-018 + UR144; Ketamine + Methadone + Opiate; Ketamine + LSD; LSD + Opiate + Alpha-PVP; Ketamine + Tramadol; and Ketamine + PCP (Table 1). In samples identified with a single use of substances, THC, ketamine, and JWH-018 were prominent and found in 6 samples (2.41%), followed by UR-144 in 4 samples (1.61%), and Alpha-PVP in 2 samples (0.80%) (Table 1).

Table 1

Number of positive oral fluids (n = 53) collected from drivers in the state of Kerala, India during 2021.
DOA	Number of positive samples	Percentage (%)
THC + UR-144	11	4.42
THC + JWH-018	4	1.61
THC + Methamphetamine	2	0.80
THC + Alpha- PVP	2	0.80
THC + 6-MAM + JWH-018 + UR-144	1	0.40
Ketamine + Methadone + Opiate	1	0.40
Ketamine + LSD	1	0.40
Ketamine + Tramadol	1	0.40
Ketamine + PCP	1	0.40
LSD + Opiate + Alpha-PVP	1	0.40
THC	6	2.41
Ketamine	6	2.41
JWH-018	6	2.41
UR-144	4	1.61
Alpha- PVP	2	0.80
6-MAM	1	0.40
Amphetamine	1	0.40
Benzodiazepines1	1	0.40
LSD	1	0.40

In the ‘Evidence MultiSTAT DOA Oral Fluid II Assay’ there were twenty DOA that could be readily identified from the oral fluid sample. THC and ketamine were prominent in use among the participants either alone or as multiple drugs use. Considering the frequency of the substance use, THC was the most preferred DOA, which was found in a total of 25 samples (10.04%). It was followed by UR-144 in 16 samples (6.43%), JWH-018 in 12 samples (4.82%), Ketamine in 10 samples (4.02%), and Alpha-PVP in 6 samples (2.41%) (Table 2). The use of other drugs such as LSD, methamphetamine, opiate, 6-MAM, benzodiazepines1, methadone, PCP, tramadol, and amphetamine was also detected in oral fluid samples and their frequency of use was ranging between 3.77–5.66%. However, fentanyl, barbiturate, benzodiazepines2, benzoylecgonine, oxycodone, buprenorphine was not detected in any oral samples collected for the present study.

Table 2

Frequency of use of DOA detected in the oral fluid samples (n = 54) collected from drivers in the state of Kerala, India in 2021.
Sl. No.	DOA in the assay	Frequency of DOA use in drivers	Percentage use in positive samples (%) (n = 53)	Percentage use in total samples (%) (n = 249)
1	THC	25	47.17	10.04
2	UR-144	16	30.19	6.43
3	JWH-018	12	22.64	4.82
4	Ketamine	10	18.87	4.02
5	Alpha-PVP	6	11.32	2.41
6	LSD	3	5.66	1.20
7	Methamphetamine	2	3.77	0.80
8	Opiate	3	5.66	1.20
9	6-MAM	3	5.66	1.20
10	Benzodiazepines1	2	3.77	0.80
11	Methadone	2	3.77	0.80
12	PCP	2	3.77	0.80
13	Tramadol	2	3.77	0.80
14	Amphetamine	2	3.77	0.80
15	Fentanyl	0	0	0
16	Barbiturate	0	0	0
17	Benzodiazepines 2	0	0	0
18	Benzoylecgonine	0	0	0
19	Oxycodone	0	0	0
20	Buprenorphine	0	0	0

Of the 53 tested positive samples in the screening test, a representative sample from single DOA and also DOA combinations underwent confirmatory analysis. Positive samples in which a combination of natural and synthetic cannabinoids was detected as THC only in the three corresponding samples in the confirmatory analysis. Rest all samples showed 100% agreement of the screening results to the confirmatory analysis.

The prevalence of drug use was higher among the drivers of the age group between 47–57 years (45.2%) than in the age groups of 36–46 years (34.4%), 26–35 years (30.1%), and 18–25 years (23.3%) (Table 3). On the other hand, the consumption of different drugs was more prominent among drivers of 36–46 years than in the other age groups. No substance use was found in samples from drivers of age 58 years and above (Table 3).

Table 3

Percentage of drug use in the different age categories of drivers (n = 249) who participated in the present the study from the state of Kerala, India in 2021.
	Number of positive samples in each age category
DOA	Between 18–25 years (n = 43)	Between 26–35 years (n = 83)	Between 36–46 years (n = 90)	Between 47 − 57 years (n = 31)	58 years and above (n = 2)
Ketamine	1 (2.3%)	4 (4.8%)	4 (4.4%)	1 (3.2%)	0
LSD	0	1 (1.2%)	0	2 (6.5%)	0
Methamphetamine	1 (2.3%)	1 (1.2%)	0	0	0
Benzodiazepines1	0	0	1 (1.1%)	0	0
Methadone	0	0	1 (1.1%)	0	0
Opiate	0	0	1 (1.1%)	1 (3.2%)	0
PCP	1 (2.3%)	0	0	0	0
Tramadol	0	0	1 (1.1%)	0	0
THC	4 (9.3%)	7 (8.4%)	10 (11.1%)	4 (12.9%)	0
Amphetamine	0	1 (1.2%)	0	0	0
6-MAM	0	1 (1.2%)	1 (1.1%)	0	0
JWH-018	2 (4.7%)	4 (4.8%)	4 (4.4%)	1 (3.2%)	0
Alpha-PVP	0	1 (1.2%)	1 (1.1%)	2 (6.5%)	0
UR-144	1 (2.3%)	5 (6.0%)	7 (7.8%)	4 (12.9%)	0
Total	10 (23.3%)	25 (30.1%)	31 (34.4%)	14 (45.2%)	0

In the age group of 47 − 57 years, the rate of usage of both THC and UR144 was the same and higher (12.9%) than the use of other drugs (Table 3). Likewise, the usage of THC was prevalent among the age groups of 36–46 years (11.1%), 18–25 years (9.3%), and 26–35 years (8.4%). UR144 was the second most prominent drug in usage after THC in the age groups of 26–35 years (6.0%) and 36–46 years (7.8%). However, JWH-018 was the second most prominent drug in usage after THC in the 18–25 age group (4.7%) (Table 3).

The use of oral fluid has been found to offer significant promise since it is a non-invasive method and allowed on-site detection of drugs. It is pertinent to mention that in the majority of the participants during oral fluid collection using the NeoSal Oral Fluid Collection System, the Sample Volume Adequacy Indicator (SVAI) formed a distinct blue line in the clear window after 10–15 min. However, in six participants, the line in the clear window of the Sample Volume Adequacy Indicator (SVAI) of the NeoSal Oral Fluid Collection System did not turn blue even after 20–30 minutes since the mouth was dry. The lowered salivary flow rate may be due to the perceived stress as the participants were stopped by the law-enforcement officers or due to xerostomia (Gholami, Sabzvari, Razzaghi, & Salah, 2017). The consumption of smokeless tobacco, such as paan and gutkha was very common among the participants and oral dryness may happen due to these habits also (Niaz et al., 2017; Scully Cbe, 2003).

The main finding in this study was the high prevalence of the psychoactive ingredient of cannabis, the delta-9-tetrahydrocannabinol (THC) in oral fluids of the participants followed by the presence of synthetic cannabinoids (UR-144 & JWH-018). Cannabis is the most frequently used illicit psychoactive substance worldwide (Merz, 2018). The National Survey on Extent, Pattern, and Trends of Drug Use in India also found cannabis is the most common illicit substance of use in the country (Ray, 2004). Several studies reveal that cannabis effect drivers’ psychomotor and cognitive skills which make it difficult in keeping vehicles on track due to impaired brain mechanisms (Ménétrey et al., 2005; Nicholson, Turner, Stone, & Robson, 2004). The usage of methamphetamine, alpha- PVP, and 6- MAM along with cannabis was also identified in this very alarming study.

Ketamine is the second most prevalent DOA among the participants in this study. Ketamine has hallucinogenic effects including analgesia and dissociation/ disconnection from reality and is popular among youngsters as a party drug or as a sexual assault drug (Jansen, 1993). Also, among the participants, the usage of ketamine was seen in combination with other psychoactive substances such as methadone, opiate, LSD, tramadol, and PCP. Ketamine has both physical and mental effects which became a potential source of dangerous driving (Giorgetti, Marcotulli, Tagliabracci, & Schifano, 2015). Similarly, Lysergic Acid Diethylamide (LSD) and α-Pyrrolidinopentiophenone (Alpha- PVP) were also used by the participants along with other DOA. Small doses of LSD can produce changes in perception, sense of time and space, and mood (Schechter, 1998).

We observed an increase of cannabinoid-positive cases with age and a higher number of cannabinoid-positive cases in 26–57 years old, which is similar to a previous study that described the incidence of drugs in the fatally injured driver’s population in France (Labat et al., 2008).

In this study, out of twenty DOA, we could detect fourteen different drugs mentioned in the Evidence MultiSTAT DOA Oral Fluid II array, which shows the diversity of DOA among the participants. The use of psychoactive substances by drivers is reported in many countries (66), however, there are no systematic scientific studies conducted in India to understand the prevalence of drugs of abuse (DOA) among drivers (Das, Gjerde, Gopalan, & Normann, 2012). As suggested by the WHO, this knowledge is important to improve public policies on traffic safety so that India could decrease the mortality rate from traffic accidents. Point-of-collection testing (POCT) is the need of the hour as the DOA and the usage of NPS are increasing alarmingly among different populations (Arkell et al., 2019).

This is the first qualitative study on DOA conducted among drivers in India. The Randox DOA Oral Fluid II Array panel offer law enforcement agencies, forensic scientists, and toxicologists, the opportunity to screen oral fluid samples for the presence of common therapeutic, abused drugs, and NPS. Driving under the influence of drugs (DUID) is a topic of concern to both the medical and legal fields and one for which science has not yet provided sufficient guidance to the policy-making community. India is reporting the highest number of road traffic crashes, related injuries, and deaths among all countries in the world. The intake of psychoactive substances by drivers is a relatively frequent occurrence, although the prevalence varies according to the place and methodology employed. Furthermore, intake seems to be higher when working conditions are poor and can have a direct impact on the health of individual drivers and society as a whole due to the increase in traffic accidents.

Although from a scientific standpoint the knowledge on the use of psychoactive substances by these professionals still needs to be broadened, the available evidence is more than enough to justify facing and addressing the problem. Well-planned and well-executed studies are crucial for assessing the effectiveness of strategies for reducing psychoactive substance use by drivers before or while driving, in addition to improving their working conditions. Also, the tendency to use drugs of abuse (DOA) and new psychoactive substances (NPS) among youth is increasing day by day. Hence point-of-collection testing (POCT) at schools/colleges will help to generate scientific data about the prevalence of these substances in society and help the law-enforcement agencies to develop preventive measures.

Acknowledgments

The authors are thankful to Randox Toxicology, UK, and Intra Globus Biosystems Pvt. Ltd (IGB), India for technical assistance. The support from the officers of the Excise Department, Government of Kerala, India, directly and indirectly, supported this study; especially Shri. S. Aananthakrishnan IPS, Excise Commissioner, Shri. R. Jayachandran, Assistant Excise Commissioner, EI & IB, North Zone is gratefully acknowledged. Special thanks to Shri. Sangeeth M.S., and Shri. Binshad M.S., M.Sc. Forensic Science students, Kerala Police for their assistance in sample collection. The cooperation and continuous support in the assay of the samples by the technical team from the CDRL, St. Joseph’s College, Irinjalakuda, Thrissur, Kerala; Department of Zoology, University of Calicut, Kerala; M.Sc. Forensic Science program, Department of Life Sciences, University of Calicut, Kerala Police Academy, Thrissur, Kerala was essential for this study.

Author’s contribution

Concept - S.P.M.S.; Design - S.P.M.S., A.E.M., J.K.J.; Supervision – A.E.M; Data Collection and Processing - S.P.M.S., A.E.M., J.K.J.; Analysis and Interpretation – P.C.V., S.P.M.S., A.E.M.; Literature Search - S.P.M.S..; Writing Manuscript - S.P.M.S., P.C.V., A.E.M.; Critical Review - S.P.M.S., A.E.M.

Data availability

The data generated/analyzed as part of this study are available from the corresponding author upon reasonable request.

Ethical clearance

The methodology for this study was approved by the Calicut University Human Ethical Committee, Malappuram, Kerala, India (Ref. No.: 001/CUHEC/2020-21 dated 20.01.2021).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

No approval is required by the ethics committee.

Conflict of interest

The authors have no conflicts of interest to declare that are relevant to the content of this article.

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No competing interests reported.

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Point-of-collection testing for screening of psychoactive substances among drivers of Kerala, India

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Abstract

Figures

Introduction

Emerging of New Psychoactive Substances (NPS)

Challenges in detecting NPS in the workplace

Materials And Methods

Sample collection

Screening Test

Assay protocol

Confirmation

Statistical Analyses

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

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