How measurements of illegal drugs, alcohol and

nicotine in wastewater can improve and supplement

substance use epidemiology

NADRA Stockholm 27-29 August 2014

Ellen J. Amundsen, Norwegian Institute for Alcohol and Drug Research

Kevin Thomas, Norwegian Institute for Water Research

Malcolm Reid, Norwegian Institute for Water Research

www.sirus.no

COST is

supported by the

EU Framework

Programme

Horizon 2020

ESF provides

the COST

Office through

an EC contract

Content

• Measurements in substance use epidemiology, brief overview

• Wastewater measurements

1. Examples

2. Measurement procedure

3. Strengths and weaknesses

4. Derived epidemiological measures

5. Researchers in the Nordic countries involved in wastewater

measurements

6. Activities/ networks/ research

7. References

Traditional sources and measurements

• Individual measurements

– Population surveys

– Surveys in user groups (persons in treatment, in relief

measures, among users)

– Biologic materials: Measurements in hair/ saliva/ blood/

urine

– Register data

• Aggregated measurements

– Customs and police seizures

– Sales figures for alcohol and tobacco

– Surveys or registered information reported by personnel in

the municipalities

• Statistical techniques

– Assemble/combine several data sources

– Statistical modelling

Measurements in wastewater

• What is consumed is excreted – some of it in the

toilet

• Substances that can be measured:

– Cocaine

– Amphetamine

– Methamphetamine

– Cannabis

– Ecstasy

– Opioids: Heroin/6MAM, Morphine, Codeine,

Methadone/EDDP

– Synthetic cannabinoids (In progress)

– Alcohol

– Nicotine

– Other pharmaceutical drugs that are misused

Daily measurements of methamphetamine and

cocaine in Oslo from 4-30. September 2009. Milligram per hour

Source: Figure 2 in Malcolm Reid et al.: Quantitative assessment of time dependent drug-

use trends by the analysis of drugs and related metabolites in raw sewage. Drug and

Alcohol Dependence 119 (2011)

Amphetamine consumption in 19 cities in Europe.

2011

Thomas, K. et al. Comparing illicit drug use in 19 European cities through sewage

analysis. Science of The Total Environment 2012

Consumption loads of cocaine, heroin, cannabis (THC)

and methamphetamine in Milan 2005-2009

Source: Zuccato et al. Changes in illicit drug consumption patterns in 2009 detected by

wastewater analysis. DAD 118 (2011)

Source: NIVA

Source: NIVA

From application by NIVA to NRC

Source. Malcolm Read, NIVA

Sources of bias and uncertainty

• What proportion of consumption is excreted from the

body to the toilet?

• Any leaks in the sewer pipes? Overflow during heavy

rain?

• Any influential chemical processes in the sewer?

• Proper wastewater plant description?

• Proper measurement place?

• Proper sampling plan?

• Proper measurement instrument and analysis?

• Proper back calculation estimation procedure?

Requirements for quality measurements

• (Get access to wastewater plant)

• Establish knowledge about wastewater plants

• Standardize procedures for sampling wastewater

• Standardize procedures for chemical analyses

• Measure water flow in wastewater plants

• Estimate population associated with wastewater

plants

Strengths and weaknesses

Strengths

1. Measure consumption in cities with low costs

2. Realistic estimates of uncertainty (with good sampling and

back-calculation procedures)

3. Results on a daily/weekly/monthly/yearly basis

4. Effective to find presence of new drugs (with known

‘chemistry’)

Weaknesses

1. Difficult and costly to measure in areas with many small

wastewater plants and thus for a whole country

2. Aggregated measure, no personal information

3. Variation in measurements vs. variation in consumption to

be explored further

4. No good way of measuring heroin so far

5. Identify the population associated with the plant.

Commuters?

Possible estimates derived from back-calculated

wastewater measurements

1. Grams of pure substance consumed per day (or other period)

2. With knowledge of purity: market size in grams

3. With knowledge of the number of persons associated with the

wastewater plant: grams per 1000 persons per day

4. With knowledge of the average dose consumed of the

substance: the number of doses consumed per day (per 1000

associated person)

5. With knowledge of average consumption per person per day

(24 hour): the number of persons consuming per day (per 1000

associated person)

Methodology: Can use surveys to calculate quantity/frequency

measures of consumption and compare with wastewater results REID, M., LANGFORD, K. H., GRUNG, M. et al. (2012) Estimation of cocaine consumption in the

community: a critical comparison of the results from three complimentary techniques. British

Medical Journal Open, 2:e001637.

Nordic monitoring activity

• Norway: Norwegian Institute for Water Research: Kevin Thomas and

Malcolm Reid/ SIRUS Ellen J. Amundsen / SERAF (Sewprof) Jørgen

Bramness

• Finland: Åbo Academic University: Axel Meierjohann/ National Institute

for Health and Welfare (THL): Aino Kankaanpää, Kari Ariniemi, Kimmi

Kuoppasalmi and Teemu Gunnar / Helsinki Regions Environmental

Services HSY: Mari Heinonen

• Sweden: Umeå University: Marcus Østman

• Denmark: Technical University of Denmark: Benedek Plosz

• Iceland: University of Iceland: Kristin Olafsdottir, Arndis Löve

Activities, networks, research

• Conference on Wastewater-based Epidemiology: Testing the

Waters 2015, 11-15 October, Monte Verità, Ascona,

Switzerland. www.testingthewaters2015.ch

• SCORE COST Action ES1307: Sewage biomarker analysis for

community health assessment. http://www.SCORE-cost.eu/ and

http://www.cost.eu/domains_actions/essem/Actions/ES1307

• SEWPROF: SEWPROF aims to develop inter-disciplinary and

cross-sectorial research capability for the next generation of

scientists working in the newly-emerging field of sewage

epidemiology . http://sewprof-itn.eu/

References

1.(2008) Assessing Illicit Drugs in Wastewater: Potential and Limitations of

a New Monitoring Approach (Luxembourg, European Monitoring Centre for

Drugs and Drugs Addiction: Office for Official Publications of the European

Communities).

2. VAN NUIJS, A. L. N., CASTIGLIONI, S., TARCOMNICU, I. et al. (2011) Illicit

drug consumption estimations derived from wastewater analysis: A critical

review, Science of the Total Environment, 409, 3564-3577.

3.REID, M., HARMAN, C., GRUNG, M. & THOMAS, K. V. (2011) The current

status of community drug testing via the analysis of drugs and drug

metabolites in sewage, Norwegian Journal of Epidemiology, 21, 15-24.

4.REID, M. J., LANGFORD, K. H., MORLAND, J. & THOMAS, K. V. (2011)

Quantitative assessment of time dependent drug-use trends by the analysis

of drugs and related metabolites in raw sewage, Drug and Alcohol

Dependence, 119, 179-186.

5.REID, M. J., LANGFORD, K. H., MORLAND, J. & THOMAS, K. V. (2011)

Analysis and Interpretation of Specific Ethanol Metabolites, Ethyl Sulfate,

and Ethyl Glucuronide in Sewage Effluent for the Quantitative Measurement

of Regional Alcohol Consumption, Alcoholism-Clinical and Experimental

Research, 35, 1593-1599.

6.ZUCCATO, E., CASTIGLIONI, S., TETTAMANTI, M. et al. (2011) Changes in illicit drug

consumption patterns in 2009 detected by wastewater analysis, Drug and Alcohol

Dependence, 118, 464-469.

7.REID, M. J., BAZ-LOMBA, J. A., RYU, Y. & THOMAS, K. V. (2014) Using biomarkers

in wastewater to monitor community drug use: A conceptual approach for dealing

with new psychoactive substances, Science of the Total Environment, 487, 651-658.

8.THOMAS, K. V., BIJLSMA, L., CASTIGLIONI, S. et al. (2012) Comparing illicit drug use

in 19 European cities through sewage analysis, Science of the Total Environment,

432, 432-439.

9.ORT, C., VAN NUIJS, A. L. N., BERSET, J.-D. et al. (2014) Spatial differences and

spatial changes in illicit drug use in Europe quantified by wastewater analysis,

Addiction, 109, 1338-1352.

10.REID, M., LANGFORD, K. H., GRUNG, M. et al. (2012) Estimation of cocaine

consumption in the community: a critical comparison of the results from three

complimentary techniques. British Medical Journal Open, 2:e001637.

11.AMUNDSEN, E. J. & REID, M. J. (2014) Self-reports of consumption of

amphetamines, cocaine and heroin in a survey among marginalized drug users,

Science of the Total Environment, 487, 740-745.