Observational Study on the Incorporation of Opioids and Their Metabolites Into Hair of Pediatric Patients

Evaluation of Opioids and Metabolites in Hair and Sweat of Pediatric Patients in a Monitored Clinical Context, by Means of Targeted Liquid Chromatography-tandem Mass Spectrometry

Hair analysis is a well-established and important tool in both forensic and clinical context. When it comes to the interpretation of positive hair analysis results, reliable and comprehensive reference data is essential. Such data on opioids, especially novel synthetic ones (such as fentanyl and its analogues (fentalogs)) is currently highly limited. This applies especially to hair with pediatric origin, due to differences in the metabolism and hair anatomy in children compared to adults.

Investigators hypothesize that opioids, both traditional and novel synthetic ones exhibit detectable concentrations and distinct metabolite ratios within the hair matrices of pediatric patients. Thus, this observational, prospective research study provides 150 hair and sweat samples from children who received opioids as part of surgery or pain management. The samples will be consecutively extracted and analyzed using a sensitive targeted liquid chromatography-tandem mass spectrometry (LC-MS/MS) method, enabling the quantitative determination of the opioid and metabolite concentrations. The study thereby contributes valuable reference data for both forensic and clinical applications, addressing challenges in interpreting hair analysis results in especially pediatric populations. Further, a deeper understanding of the mechanisms (e.g. via sweat) and pharmacokinetic processes involved in the opioid incorporation to hair will be achieved. The study has received ethical approval from the Swiss Ethics Board (approval number: 2022-01693 / amendment approval date: 09.01.2024).

Study Overview

• Status: Completed
• Conditions: Opioid Use, Unspecified
• Intervention / Treatment: Drug: Fentanyl

Detailed Description

In recent years, new synthetic opioids (NSOs) have emerged in the illicit drug supply in an increasing rate. Many of these new registered opioids can structurally be assigned to the so called fentalogs, which are pharmacologically active derivatives of the approved pain management drug fentanyl. Many of these compounds are highly potent, relatively cheap and thereby especially fueling the current opioid crisis in the USA and posing a significant challenge for authorities, the healthcare system and forensic toxicology globally. Most of the time opioids are consumed without the user's knowledge as they are sold as heroin or counterfeit prescription pills like oxycodone or Xanax® which further increases the dangers posed by this problematic substance class. Recent cases of designer fentanyl intoxication show that this problem is also encountering Switzerland. Due to their potency, overdoses of the above-mentioned substances quickly occur, which in absence of intensive medical support can be fatal even when the antagonist naloxone is used. In order to better address the NSOs related socio-economic and health care problems, a fundamental understanding of these substance classes is essential.

As a consequence of the increasing prevalence of designer opioids, forensic and clinical laboratories worldwide are continuously challenged with updating their analytical methods for the identification and quantification of these new drugs in various biological matrices. The classical matrices used in forensic toxicology are blood and urine which represent time windows of hours to days. Keratinized matrices like hair and nail are considered complementary matrices as they provide additional information to the more traditional matrices covering time windows up to several months. The analysis of hair (a keratinized matrix) can provide significant information about the intake of opioids over extended time periods and therefore can provide access to a much wider diagnostic window than blood or urine. It allows getting information about a past exposure to the substance, repeated intake or even a single intake.

According to the Swiss Society of Legal Medicine, Swiss laboratories that offer forensic hair analysis must be able to quantify opioids in hair. The analysis of classical opioids like morphine and respective metabolites is well established in hair. However, knowledge about the incorporation of medically used fentalogs (e.g. fentanyl, remifentanil and sufentanil) and illegal designer fentalogs in hair is still limited.

The goal of this study is to gain knowledge about the incorporation and concentration of fentalogs in hair to help establish a high forensic standard for the detection these new substances. The specific aim of this study is to analyze hair samples from patients (children) of a study cohort described below which received medically approved fentalogs (either fentanyl, remifentanil or sufentanil) and to gain insights into the deposition of these substances into hair. The investigators will focus on a study cohort (150 patients) that has received medical fentanyl for pain management therapy in a clinical and therefore controlled setting. Furthermore, the study cohort consists of children which have some benefits to address the above raised research question. The hair of children is thinner and more porous than adult's hair, so that substances can incorporate into hair more easily. This makes children's hair an ideal target for our research study to see if fentalogs will be incorporated into hair. Furthermore, it is known that cosmetic treatment like e.g. bleaching etc. destroys substance that are incorporated in hair, therefore cosmetically treated hair is not suitable for the study. The probability that young children have cosmetically treated hair is considered very low.

As substances are incorporated into hair via sweat and blood, the analysis of these matrices can help to understand the general incorporation mechanisms of substances into hair. Therefore, the investigators intend to additionally analyze sweat samples from children to gain knowledge about fentalog concentrations and metabolites in sweat which can be helpful to understand their incorporation into hair.

The knowledge of this study can be used in forensic toxicology to distinguish between the intake of medically prescribed opioids and illegal new synthetic opioids.

• Study Type: Observational
• Enrollment (Actual): 150

Contacts and Locations

Study Locations

• Switzerland
  • Zurich, Switzerland, 8032
    • University's Children Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 day to 13 years (Child)
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

The study population consists of patients (newborns, infants, children and adolescents up to 13 years of age) from the pediatric intensive care unit from the Children's Hospital Zurich. Patients in focus are exposed to fentanyl and fentalogs (remifentanil, sufentanil and alfentanil) or other more traditional opioids (such as morphine, oxycodone and methadone) either during surgery or as part of post-operative pain management for up to three months prior to study inclusion.

Description

Inclusion Criteria:

• Obtained written informed-consent from legal representatives (and oral consent from the patient).
• Patient's age must be within date of birth irrespective of gestational age to completed 13th year of life
• Patients that received single or multiple treatment (either with single doses or continuous infusion) of fentanyl, remifentanil or sufentanil either during surgery or during stay in the pediatric intensive care unit

Exclusion Criteria:

• Patient's age of 14 or older
• Inability to understand the study procedure due to language or cognitive reasons (applies to legal representatives and elder children)
• Denied or missing informed consent
• Insufficient amount of head hair to obtain hair sample
• Cosmetic hair treatment, like coloring, bleaching and dying

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
KISPI 000; Patients of the group received one or multiple clinically approved opioids, namely; Fentanyl, Remifentanil, Sufentanil, Alfentanil, Oxycodone, Morphine, Nalbuphine, Hydromorphone and Methadon. The drugs were administered in the course of a surgery or for pain management.	Drug: Fentanyl; The drugs were administered in the course of a surgery or for pain management.; Other Names: Sufentanil; Morphine; Nalbuphine; Oxycodone; Hydromorphone; Remifentanil; Alfentanil; Methadon

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Evaluation of the opioid and metabolite concentrations (pg/mg: units of picograms of opioid per milligram hair) in the hair samples of the study population.	For the collected hair samples, a two-stage extraction is performed, using methanol and a buffered methanol-water mixture for 90 minutes each. The extracts are then evaporated, resuspended in a 3:7 mixture of methanol and eluent A (20 mM ammonium formate with 0.1% (v/v) formic acid in water). The hair sample extracts will then be measured on an the LC-MS/MS system (SCIEX Triple Quad™ 7500 LC-MS/MS (QTRAP) System). A validated analysis method will be used for the analysis of the following opiates, opioids or their metabolites: hydromorphone, 4-ANPP, acetylcodeine, acetylmorphine, alfenanil, betahydroxyfentanyl, codeine, dihydrocodeine, fentanyl, hydrocodone, methadone, morphine, naloxone, norfentanyl, norsufentanil, omegahydroxyfentanyl, oxycodone, oxymorphone, pethidine, remifentanil, remifentanil-acid, sufentanil and tramadol. The data is processed with the software SciexOS version 1.6.7.	Through study completion, an average of two years
Evaluation of the opioid and metabolite concentrations (ng/mL: units of nanograms of opioid per milliliter) in the sweat extracts of the study population.	The extraction procedure of the sweat swabs looks as follows: the cotton ends of the forensic swabs will be cut and extracted with methanol. The methanol extracts will then be diluted to avoid detector saturation and mixed in a 3:7 ratio with eluent A. The sweat sample extracts will then be measured on an the LC-MS/MS system (SCIEX Triple Quad™ 7500 LC-MS/MS (QTRAP) System). A validated analysis method will be used for the analysis of the following opiates, opioids or their metabolites: hydromorphone, 4-ANPP, acetylcodeine, acetylmorphine, alfenanil, betahydroxyfentanyl, codeine, dihydrocodeine, fentanyl, hydrocodone, methadone, morphine, naloxone, norfentanyl, norsufentanil, omegahydroxyfentanyl, oxycodone, oxymorphone, pethidine, remifentanil, remifentanil-acid, sufentanil and tramadol. The data is processed with the software SciexOS version 1.6.7.	Through study completion, an average of two years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Normative opioid concetration values and metabolite reatios in pediatric hair.	This data will be analyzed by using descriptive statistics (box plots) including the median, mean, 10th percentile, and 90th percentile values and for their distribution (normal or non-normal) by Shapiro-Wilks Test. Thus, opioid specific concentration values and metabolite ratios in hair of children will be established.	after data evaluation, 3 months after end of study

Collaborators and Investigators

• Sponsor: University of Zurich
• Collaborators: University Children's Hospital, Zurich
• Investigators: Principal Investigator: Tina Binz, University Zurich; Principal Investigator: Florian Zapf, Dr., University's Children Hospital

Study record dates

Study Major Dates

• Study Start (Actual): December 6, 2022
• Primary Completion (Actual): February 28, 2025
• Study Completion (Actual): February 28, 2025

Study Registration Dates

• First Submitted: January 31, 2023
• First Submitted That Met QC Criteria: February 13, 2023
• First Posted (Actual): February 23, 2023

Study Record Updates

• Last Update Posted (Actual): March 30, 2025
• Last Update Submitted That Met QC Criteria: March 25, 2025
• Last Verified: March 1, 2025

More Information

Terms related to this study

• Keywords: fentanyl; opioids; hair analysis; fentalogs; new synthetic opioids
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Peripheral Nervous System Agents; Anesthetics; Central Nervous System Depressants; Sensory System Agents; Analgesics; Analgesics, Opioid; Narcotics; Adjuvants, Anesthesia; Anesthetics, Intravenous; Anesthetics, General; Respiratory System Agents; Antitussive Agents; Remifentanil; Morphine; Fentanyl; Nalbuphine; Hydromorphone; Methadone; Oxycodone; Sufentanil; Alfentanil
• Other Study ID Numbers: 2022-01693

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The outcomes of the research will be published in peer-reviewed journals. Data will be strictly anonymized.
• IPD Sharing Time Frame: starting after publication
• IPD Sharing Access Criteria: upon request via e-mail
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No