On the Spot at FACTA2019

Peter gets up close and personal with some delegates at the FACTA conference in Adelaide.

Find out more about FACTA at www.facta.org.au


Contact us at toxpod@tiaft.org

Find out more about TIAFT at www.tiaft.org

The Toxpod is a production of The International Association of Forensic Toxicologists. The opinions expressed by the hosts are their own and do not necessarily reflect the views of TIAFT.

Transcript

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Tim 0:01

Hello and welcome to The Toxpod. I'm Tim Scott, and following on from the last episode, which was recorded live during the FACTA conference, today we're going to bring you some short interviews we recorded during the conference with some of the people who were there. You'll hear some noise in the background. These were recorded during breaks in the program, so people are having their lunch or a cup of coffee. Hope you enjoy the interviews.

Jinni Yan

Peter 0:35

So here we are at the 2019 FACTA meeting in Adelaide and I'm speaking with Jinni Yan. She's the recipient of the inaugural Olaf Drummer education scholarship, which is awarded by FACTA. How are you Jinni?

Jinni 0:47

I'm good, thank you. It's been a really good conference for the past few days.

Peter 0:52

There's been a lot of different stuff happening here. We're learning a lot. Yours and a couple of other papers are a little bit different where you're talking about metabolomics and I thought it'd be good for you to sort of explain to us what metabolomics is all about.

Jinni 1:04

So metabolomics is one of the newly emerging types of techniques. So it mainly in basic, what it wants to do is you have three different groups. So you have a control group and then also two groups that have totally different diseases. So it relies heavily on statistical analysis, like chemometrics or principal component analysis. So what we try to do is we have a control group. Um, in this case a control group needs to be quite carefully chosen as well. But I'm really lucky that the children's hospital at Westmead is actually doing this for me and we are collaborating with them as well. And the other two groups, they need to be quite different as well. So sometimes we can say one group can be a treated group and the other group is an untreated group or we just have two totally different conditions. So for example , um , a group that is high in neuro inflammation or a low neuro inflammation and the statistical analysis will tell us if there are any unique metabolites that maybe change in one group from another.

Peter 2:02

So, in this case, we're talking about not drug metabolites, but actually , um , endogenous metabolites of Serotonin and other , uh , neurochemicals.

Jinni 2:11

Yes. So we are more interested in neurotransmitters and their metabolites. So in recent years they have become a more significant clinical tool. They are quite also involved in the toxicology field. So in my presentation I did mention that some of the ones like Tryptophan and Serotonin and also , um, GABA and glutamate is also more commonly involved in the field now. So they're more established in terms of central nervous disorders.

Peter 2:38

So , um , from the presentations I saw you end up with , uh , samples from different groups and you have , uh , you don't necessarily need to know the actual metabolites that you're looking for. Is that the case?

Jinni 2:49

Yeah . So right now what we're doing is some of the untargeted metabolomics work, which, so I'm using pooled cerebrospinal fluids. So another uniqueness of this method is using this matrix. So this matrix is one of the really invasive ones and also challenging to obtain samples from, which is why we're not actually working with a real clinical trial yet. Just because of the method development stages, we want to fill in that gap in literature.

Peter 3:12

So this is cerebospinal fluid, correct?

Jinni 3:14

Yes. Cerebrospinal fluids. Yeah.

Peter 3:16

How do you get hold of that sort of material?

Jinni 3:18

Um , so we're really lucky that our collaborator, the Children's Hospital at Westmead have a cerebrospinal fluid bank and this is something that's not really commonly seen across hospitals. So I'm really lucky to be working with them.

Peter 3:31

Sounds great. Now how are you gonna use your travel scholarship or education award?

Jinni 3:36

Um, so I'll be using this to attend TIAFT in 2019 in Birmingham and also the travel scholarship also includes a tour to another lab in the European. So that is yet to be decided.

Peter 3:48

That's very exciting. Well good luck with your trip and I'm all the best. Thanks very much for joining us, Jinni.

Jinni 3:52

Thank you.

Olaf Drummer

Peter 3:57

Olaf Drummer, Thank you very much for joining us on the Toxpod.

Olaf 4:00

My pleasure.

Peter 4:01

It was very interesting to see your talk the other day about revisiting how toxic cannabis may be. How did this come about?

Olaf 4:09

Well look as we've seen the last five to 10 years in Australia and around the world, there's been quite a few deaths reported from Synthetic cannabinoids. And while some are perhaps more potent than THC on the cannabinoid receptor, nevertheless pathologists are very happy to, to ascribe them to a cause of death , providing there's no other competing factors. And so my thought was, well over the years we've ignored THC present in cases where , uh , there are no other obvious anatomical cause of death. So my first port of call was to review the literature , see what had been published, and I was aware of at least one publication of deaths from a Norwegian article back in 2001. Uh , and I found there were quite a number of , uh, fatalities reported from pathologists who were , uh, seeing cases and as far as they were concerned, they thought cannabis, or the THC present in cannabis and recent use of cannabis was at least a part cause of their death.

Peter 5:09

Right.

Olaf 5:10

And , um , at the same time, over the last several years there've been , uh, well over 30 publications of case reports and series of case reports of admissions to hospitals of survivors, all of whom were regarded by the emergency physicians as having some circumstantial recent use of THC, quite often, quite high use of THC , and a cardiac event so chest pain , uh, they diagnosed some form of arrhythmias, some had an infarction. So they had raised enzyme levels so there actually was damage to muscle tissue in the heart proving it was a heart attack. But no prior history of heart disease. Some had um , a blood clot, thrombus, causing a minor stroke. And so they reported it, they all survived, but clinically they were regarded as , as being there because of their cannabis intoxication.

Peter 6:05

So they were basically all sort of cardiovascular issues they were experiencing?

Olaf 6:08

Yeah they were all cardiovascular issues. And it was well known, we've known for many years that cannabis causes increases in heart rate , uh , cardiac output and has a blood pressure effects too from time to time. So it wasn't that it was an unusual observation, unusual in the sense that they actually had symptoms of a heart attack. Some had heart attacks. Some had an arrhythmia that subsided once the drug cleared their system. Uh, and there are also some epidemiological studies looking at the association of cardiovascular disease and sudden ischemic deaths from cannabis use. And, and they were variable in terms of their outcomes. But , uh , I think it's pretty clear that given the use of cannabis around Australia, around the world, it's not a big risk factor that, you know 10% of people who smoke cannabis collapse and die, or go to hospital .

Peter 7:00

It's a little bit different to the synthetic cannabinoids, I guess, where they still have the cardiovascular issues, but...

Olaf 7:06

So symptomology is similar except probably they're using higher doses because their powders , not a bit of THC a nd cannabis material, leaf material. So they're probably using higher doses. Some w ere more potent on the CB1 receptor. U h, but nevertheless they were having similar effects on the body, u h, to cannabis.

Peter 7:27

And the CB1 receptors, are they mainly located...

Olaf 7:28

They're mainly located in the brain. And so in , obviously, you know , there's response to a heart rate and on the heart itself as well as on the brain to the cognition and behavioral changes, but predominantly they're affecting the heart and the nerves, control of the heart rate and arrhythmias , uh , that was causing these, these problems. And as I said, there were quite a number of publications they were linking to and so , I was postulating that if , um, a pathologist has a case where there's no obvious anatomical cause of death, like there's injuries or significant natural disease of some type and there's evidence of recent use of cannabis and proven by the lab doing THC levels and then it's there showing at least relatively recent use. So there's some temporal relationship between usage and the collapse and in this case a sudden death, then it would not be inappropriate to actually include THC at least as a part cause of death, so it might well be minor heart disease plus THC. There was some minor heart disease but not of itself sufficient to normally be a cause of death.

Peter 8:37

Yeah to draw the link.

Olaf 8:37

Yeah. So that was really the basis of my paper.

Peter 8:42

So that was a review of many documents. Do you think that will change people's focus when they see THC in cases now?

Olaf 8:48

Well I think we'll see how time develops, certainly at the Institute, um , it's been discussed and the head of the Institute has been involved in, in writing up the paper . So he will, he obviously will look out for these cases with his own pathologists and look, around the world the paper's now been published in Forensic Science International and so will have a much more wider focus than simply just a local focus. So time will tell whether the pathologists actually take on that and because it's been excluded as being just a nuisance factor in non driver sort of cases, a bit like small amounts of caffeine and nicotine, um , it doesn't appear in any statistics. So when you know, we're talking about medicinal cannabis and prescribing cannabis to people with certain diseases, or even decriminalizing cannabis because it's not so dangerous then because it's not in statistics because people are ignoring its effects . Therefore, it's seen by people outside the system as being a benign, relatively safe drug. And so I'm just trying to paint a picture that it's probably not as benign as some people think. And also as part of the review, what also came out while I was focused on cardiovascular issues, it's been well known to cause arteritis, so inflammation of the arteries, inflammation leading to amputation of limbs . So quite serious , uh , hyper emesis syndrome where they just completely, they're vomiting all the time and they can't stop vomiting. So that's a pretty serious outcome, but they're all heavy users.

Peter 10:14

Are they going to be likely due to cannabinoid effects or more the smoke inhalation?

Olaf 10:18

It's regarded as being an effect on stomach, receptors in the stomach rather than, normally it's used as an antiemetic or can be, but high dose use seems to effect the stomach, causes hyperemesis. So you know, uncontrolled vomiting, which is obviously pretty serious. As well as you know , longterm use leads to cancers. We've known that for some years now . Throat cancers, lung cancers, psychoses. If people are heavy, high dose users. That often resolves if they stop using the stuff so it certainly has effects, not just on perhaps affecting driving skills.

Peter 10:51

Yes and also bearing in mind there's such a large user group of THC. There's still only a small proportion of people who are getting these effects.

Olaf 10:59

Yes. Well we don't know exactly, there's no statistics there, but we do know that , uh , with a drug and alcohol rehab centers around the country over the last 10 and 20 years, that the strength of cannabis has increased. There's more and more presentations to those centers for psychoses that wasn't really seen much for low dose, low strength THC. So now they usually resolve, some are associated with schizophrenia as well with longterm use. That's not quite well established. Given they may have mental illness or be in a position of mental illness who happened to be using, wanting to use cannabis rather than not. But nevertheless, it's , um , is a public health issue. So this is just another dimension to that issue that relates more to pathologists and the determination of cause of death. But nevertheless, we'll see how that changes in time to come.

Peter 11:48

Thank you very much. Now moving on to a different topic . So you are past president of TIAFT. You're , um , influenced people all over the world with Australian toxicology, you've got the TIAFT lifetime achievement award and now you're on the Toxpod as well, so that's got to count up there too. But, you're the founder of FACTA. That was about 10 years ago. And how do you , how have you seen the organization evolve over that time?

Olaf 12:11

Yeah, look, I'm really, I'm impressed by the way our association has grown in those 10 years.Ten years ago we had a meeting in Melbourne and everyone who , until over a hundred people thought it was good idea, which, you know, people didn't have another forum for both clinical and forensic toxicologists in this country and New Zealand. So we started off that association and this year is the 10th year.

Peter 12:32

Yeah, it's amazing.

Olaf 12:33

And we have what, 140, 150 people here. The papers have been incredibly good quality papers and also importantly, a lot of young people there . So traditionally, and even in TIAFT, the early days in TIAFT it was mainly older practitioners, very few younger practitioners. And maybe they didn't get the opportunity to travel to those meetings. But now with both TIAFT and also now FACTA, we see a lot of younger people there, and they're great presentations, from all around the country. So that's impressive to see them and they'll be people from which will run labs in the future.

Peter 13:05

And they will hopefully provide younger people as they get older, provide younger people that come into the organization, the same sort of hospitality that , that you have and the older members of these groups have.

Olaf 13:14

Yeah, absolutely, yeah.

Peter 13:16

So thank you very much Olaf.

Olaf 13:17

No, my pleasure.

Michael Robertson

Peter 13:22

Okay, here I am with Michael Robertson. Today Michael, you gave a talk about the new oral fluid standard revision. Can you tell us a little bit about it?

Michael 13:29

Yeah, I gave a fairly lengthy discussion to the group about the , uh, the, the recent updated oral fluid standard that's just been published by Standards Australia, which incorporates both , uh, Australian interests and New Zealand interests.

Peter 13:44

What precipitated this revision?

Michael 13:46

Well, the first, the first standard was published in 2006, which really assisted in , um, bringing together a wide group of people that were doing oral fluid testing at the time and giving them some guidance on how to do it if they wanted to do it. Obviously a number of years have passed since the 2006 standard was prepared. Uh, devices have changed a lot. There's been a lot of new requirements, new drugs, so on and so forth. And uh, our accrediting body basically identified some deficiencies in that the update, or the requirement for an update, and so , uh, the updates taken in the order of about sort of three to four years to, to get to this point.

Peter 14:27

So what were the key areas that were updated? Well, obviously having to deal with some of the deficiencies that were identified, which was really around device capability and demonstrating that devices could do what people thought they could do. So these are the onsite testing devices that people go out to work sites with, for example.

Michael 14:43

Correct. That's right and that really, it was really this, this standard is really the only standard in the world that assists in giving organizations that want to do on site testing as opposed to just on site collection, but actually onsite testing for drugs, really giving them some guidance in , in how to do that testing. And a part of that was things like , uh , required quality control testing, device capability, these sorts of things for that onsite testing.

Peter 15:12

So the original standard, did that include any cutoffs?

Michael 15:17

No. So the original standard, as I said, was really just a guidance document. So it gave people some recommended target concentrations. So if you were testing for drugs such as the amphetamines, cannabis, cocaine, and the opiates, they were really the only classes included at that point in time. And it was really just if you're looking for them, these are the sorts of levels you should be looking at. Uh, and these are the sorts of levels your devices should be capable of detecting. But really they were just recommendations, there was really nothing mandatory about the testing that was being performed.

Peter 15:50

Was there laboratory levels included in the first standard?

Michael 15:54

Yeah, so the laboratory again had, they had levels. Um, again, really just recommended levels that when , uh, when an onsite device presumptively detects something , uh , the sample is then sent to the laboratory and again, it gave the laboratory some guidance in what sort of numbers they should have their methods validated to . Uh , so again, it was very much, a sort of, here's an idea, here's a way forward, here's some recommended approaches without it really being more of a strict, a strict guideline.

Peter 16:26

So oral fluid of course throws up some complications because unlike blood or oral fluid, there's different sort of collection devices and sometimes some of them involve dilution and some of them just involve a wipe. So what do we , what did we end up deciding to do, are we doing a diluted oral fluid or...?

Michael 16:41

Yeah. Well, you , I mean, you identify a , you know, one of the problems with the industry is there's a lot of manufacturers out there and , and some of them are, devices are frankly quite poor. Yet they'll say they're quite good. Um, some devices are quite good but haven't been demonstrated to be good. Some devices are simply collecting neat fluid, other devices used , uh , diluted fluid. So there's a whole range of issues then that we have to deal with when it comes to both the collection, detection , um, we've shied away from using numbers or generating a concentration in the oral fluid and publishing that. We've really focused on is the drug present or is it not present?

Peter 17:21

So you have a cutoff , but you don't, the laboratories don't have to report a concentration, or they shouldn't be reporting a concentration.

Michael 17:27

They shouldn't be. That's right. We've certainly said in the standard and we've made it fairly clear that it's not recommended that laboratory publish a concentration. And that's really around interpretation. I mean, we , we really don't know what numbers necessarily mean. Uh , so it's really around is the drug present and if the drugs present, then the theory is it's been used relatively recently and therefore the possibility of impairment is present. It's certainly not a test for impairment and shouldn't be interpreted that way. But it really tells us that the drug's been used relatively recently and it's, it's a standard that's meant to complement the urine standard, the Australian standard for urine testing, which is really a case of, has drug being used in the previous sort of 24, 48 hours. The two are meant to compliment each other. There's, one's not meant to replace the other.

Peter 18:17

And I should have mentioned earlier, you are the chair of the committee that revised the standard. What sort of different groups were involved? I know there was over 20 groups?

Michael 18:26

Yeah, so one of the challenges we had with this committee was, you know, we had uh, in the order of about 26 people around the table. I was asked to chair , uh , the committee, which, you know, was a great honor given the importance of this standard.

Peter 18:39

As an independent chair, so you weren't...

Speaker 5 19:37

That's right, I wasn't an advocate for anyone or anything, other than to manage the process. My experience really covered all, everything from the laboratory testing right through to onsite testing and training. I've done that for a number of years, so I was in a nice position to be able to offer some suggestions and, and understand what was going on. But we certainly had a number of subject matter experts on the committee, but we also had a number of people, union representatives, uh and some other legal representatives who really weren't subject matter experts, but were able to bring, I guess, a refreshing perspective to the process, and really challenge what to us scientists might have been well understood and well accepted principles, they were able to say, well prove it to us. And so they did stop us in our tracks on occasion and make us have to demonstrate to them that what we've been saying for years is actually supported by the evidence.

Peter 19:37

So you mentioned earlier this is the first standard of this kind in the world. Why, why is it that Australia has been the first one, do we have more oral fluid testing companies around the place or, what's going on?

Michael 19:46

Well, I think this standard is really uh for oral fluid testing for drugs. Um, and it's really applicable to anyone that wants to do oral fluid testing, but the majority of users of this standard will be workplace drug testing organizations and uh , and in particular companies that do mining, high risk type activities like, you know, mining, driving, construction, transport. Now there's other guidances out there around the world in the transport industry. But given I think Australia's got a lot of high risk occupations, particularly in the mining sector , uh , this standard gets used widely in that, in that industry and therefore, and they want onsite testing. And that's very different to anywhere else in the world where, as I said earlier, it's really just collection and sending it to the lab and let's see if this person's used the drug. Whereas here in Australia and now in New Zealand, there's very much that interest in, this person's at work, they've got drug in their oral fluid. We want to make a decision about what we do with that person today, not in three days time. And so they often will be stood down if they have something in their oral fluid. It doesn't have to be illegal, it might be a legal drug, but as we all know...

Peter 20:59

Like codeine for example?

Michael 20:59

Codeine's a good example where , uh , if someone's got codeine in their oral fluid , they may be impaired and we may not want to put them behind the wheel of a large train or a dumper or any these sorts of things. And so that's really where the standard gets used. And, and today , nowhere else in the world has really picked up on that, valued that, has chosen to go down that path. Uh , and so here we are with really the first in, first in the world.

Peter 21:23

That's good news. Congratulations on your achievements, you should be really proud you got such a diverse group of people to get them to get a document in place and see how it goes moving forward.

Michael 21:32

Yeah, thanks Peter. And look, it's been a great process and I think everyone enjoyed the process. I mean, it was long and at times frustrating, but it was a, it was a good process. And I think everyone with a whole range of interests in the standard came out of the process, feeling like , uh, the standard satisfies their needs. Um, there was an element of compromise certainly through the process, but I think the documents come out really well. I think everyone can now use it and be confident of the results that they get when they do use it.

Peter 22:02

And it was published earlier this year , so it's now in effect.

Michael 22:04

It is in effect, 2019, earlier in 2019 it's published. It is now the official document. So now there's laboratories scrambling to , uh, to update their methods and procedures and there's onsite testing organizations scrambling to get their devices verified fit for purpose and so on and so forth. So there's certainly a lot of activity happening in the industry at the moment. Um, and it can only , uh , it can only go to improve the overall , uh , science and the overall , uh , reliability of the onsite drug testing in particular.

Peter 22:36

Okay, thank you very much Michael Robertson. Congratulation again and , uh , all the best.

MIchael 22:39

Cheers. Thanks Peter.

The Toxpod goes on the road

Peter 22:45

Thankyou.

Tim 22:45

Thanks for listening, hope you enjoyed these last couple of episodes from the FACTA conference.

Peter 22:45

Yeah, they were good fun, I think we'll do that again. What do you reckon?

Tim 22:45

Yeah, well we liked it so much, The Toxpod is going on the road to TIAFT in Birmingham in a week or two.

Peter 22:45

Very excited. So I'll be just grabbing a couple of people in corridors, hopefully having a quick chat about maybe some of the stuff they've been doing, maybe they had an interesting presentation, and maybe some award winners toward the end of the week.

Tim 22:45

Yeah and unfortunately I'm leaving you to do all the work this time Pete, I'm on home duties, expecting the birth of my fourth child, so, just you.

Peter 22:45

Yeah I suppose that's a good enough excuse, I'll let you off.

Tim 22:45

But you've got a couple of excellent toxicologists doing a live episode on the Friday?

Peter 22:45

Yes, we've got Sarah Wille from Belgium, and Luke Rodda from the United States joining us for a lunchtime session to do a live recording, so that should be interesting.

Tim 22:45

Sounds great. And if you want to contact us, as always you can email us at thetoxpod@sa.gov.au. Thanks for listening and we'll see you next time.

Peter 22:58

Thankyou very much, I've got to catch a plane!