Surveys of current trends indicate
heroin abuse is associated with nonmedical use of
pain relievers. Consequently, there is an interest in evaluating the presence of
heroin-specific markers in
chronic pain patients who are prescribed
controlled substances. A total of 926,084 urine specimens from
chronic pain patients were tested for
heroin/
diacetylmorphine (DAM),
6-acetylmorphine (6AM),
6-acetylcodeine (6AC),
codeine (COD), and
morphine (MOR).
Heroin and markers were analyzed using liquid chromatography tandem mass spectrometry (LC-MS-MS).
Opiates were analyzed following hydrolysis using LC-MS-MS. The prevalence of
heroin use was 0.31%, as 2871 were positive for one or more
heroin-specific markers including DAM, 6AM, or 6AC (a known contaminant of illicit
heroin). Of these, 1884 were additionally tested for the following markers of
illicit drug use: 3,4-methylenedioxymethamphetamine (
MDMA),
3,4-methylenedioxyamphetamine (MDA),
methamphetamine (MAMP), 11-nor-9-carboxy-Δ(9)-tetracannabinol (THCCOOH), and
benzoylecgonine (BZE); 654 (34.7%) had positive findings for one or more of these analytes. The overall prevalence of
heroin markers were as follows: DAM 1203 (41.9%), 6AM 2570 (89.5%), 6AC 1082 (37.7%). MOR was present in 2194 (76.4%) and absent (<LOQ) in 677 (23.6%) of the
heroin-positive specimens. COD was present in 1218 (42.4%) specimens. Prevalence of combinations for specimens containing MOR were as follows: DAM only 13 (0.59%), 6AM only 1140 (52.0%), 6AC only 24 (1.1%), DAM/6AM/6AC 710 (32.4%), 6AM/6AC 188 (8.6%), DAM/6AM 113 (5.2%), DAM/6AC 6 (0.27%). Importantly, the prevalence of combinations for specimens without MOR were as follows: DAM only 161 (23.8%), 6AM only 217 (32.1%), 6AC only 92 (13.6%), DAM/6AM/6AC 50 (7.4%), 6AM/6AC 7 (1.0%), DAM/6AM 145 (21.4%), DAM/6AC 5 (0.74%). Unexpected patterns of excretion were observed, such as the presence of DAM and 6AC in the absence of 6AM and MOR; therefore, multiple
heroin markers may be useful to assess for
heroin use.