This study investigated the presence of designer benzodiazepines in 35 urine specimens obtained from emergency department patients undergoing urine drug screening. All specimens showed apparent false-positive benzodiazepine screening results (i.e., confirmatory testing using a 19-component liquid chromatography–tandem mass spectrometry (LC–MS/MS) panel showed no prescribed benzodiazepines at detectable levels). The primary aims were to identify the possible presence of designer benzodiazepines, characterize the reactivity of commercially available screening immunoassays with designer benzodiazepines and evaluate the risk of inappropriately ruling out designer benzodiazepine use when utilizing common urine drug screening and confirmatory tests. Specimens were obtained from emergency departments of a single US Health system. Following clinically ordered drug screening using Abbott ARCHITECT c assays and laboratory-developed LC–MS/MS confirmatory testing, additional characterization was performed for investigative purposes. Specifically, urine specimens were screened using two additional assays (Roche cobas c502 and Siemens Dimension Vista) and LC–quadrupole time-of-flight mass spectrometry (LC–QTOF–MS) to identify presumptively positive species, including benzodiazepines and non-benzodiazepines. Finally, targeted, qualitative LC–MS/MS was performed to confirm the presence of 12 designer benzodiazepines. Following benzodiazepine detection using the Abbott ARCHITECT, benzodiazepines were subsequently detected in 28/35 and 35/35 urine specimens using Siemens and Roche assays, respectively. LC–QTOF–MS showed the presumptive presence of at least one non-Food and Drug Administration (FDA)-approved benzodiazepine in 30/35 specimens: flubromazolam (12/35), flualprazolam (11/35), flubromazepam (2/35), clonazolam (4/35), etizolam (9/35), metizolam (5/35), nitrazepam (1/35) and pyrazolam (1/35). Two or three designer benzodiazepines were detected concurrently in 13/35 specimens. Qualitative LC–MS/MS confirmed the presence of at least one designer benzodiazepine or metabolite in 23/35 specimens, with three specimens unavailable for confirmatory testing. Urine benzodiazepine screening assays from three manufacturers were cross-reactive with multiple non-US FDA-approved benzodiazepines. Clinical and forensic toxicology laboratories using traditionally designed LC–MS/MS panels may fail to confirm the presence of non-US FDA-approved benzodiazepines detected by screening assays, risking inappropriate interpretation of screening results as false positives.

中文翻译：

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苯二氮卓类药物时代的尿液药物筛选：LC-QTOF-MS 和 LC-MS/MS 三种免疫分析平台的比较

本研究调查了从接受尿液药物筛查的急诊科患者获得的 35 份尿液样本中设计的苯二氮卓类药物的存在。所有样本均显示出明显的假阳性苯二氮卓筛查结果（即，使用 19 组分液相色谱-串联质谱 (LC-MS/MS) 面板进行的验证性测试显示没有可检测水平的规定苯二氮卓类药物）。主要目的是确定设计苯二氮卓类药物的可能存在，表征市售筛查免疫测定与设计苯二氮卓类药物的反应性，并评估在使用普通尿液药物筛查和确认测试时不恰当地排除使用设计苯二氮卓类药物的风险。标本来自单一美国卫生系统的急诊科。在使用 Abbott ARCHITECT c 分析和实验室开发的 LC-MS/MS 确认测试进行临床订购药物筛选后，出于调查目的进行了额外的表征。具体来说，使用另外两种检测方法（Roche cobas c502 和 Siemens Dimension Vista）和 LC-四极杆飞行时间质谱法 (LC-QTOF-MS) 对尿液样本进行筛查，以鉴定推测为阳性的物种，包括苯二氮卓类药物和非苯二氮卓类药物。最后，进行有针对性的定性 LC-MS/MS 以确认 12 种设计苯二氮卓类药物的存在。在使用 Abbott ARCHITECT 检测苯二氮卓后，随后分别使用 Siemens 和 Roche 测定法在 28/35 和 35/35 尿液样本中检测到苯二氮卓。LC-QTOF-MS 显示在 30/35 样本中推定存在至少一种非食品和药物管理局 (FDA) 批准的苯二氮卓类药物：氟溴唑仑 (12/35)、氟阿普唑仑 (11/35)、氟溴西泮 (2/35) )、氯硝唑仑 (4/35)、依替唑仑 (9/35)、甲替唑仑 (5/35)、硝西泮 (1/35) 和吡唑仑 (1/35)。在 13/35 的样本中同时检测到两种或三种设计的苯二氮卓类药物。定性 LC-MS/MS 证实了 23/35 样本中至少存在一种设计苯二氮卓类药物或代谢物，其中三个样本无法进行确认测试。来自三个制造商的尿液苯二氮卓筛查检测与多种非美国 FDA 批准的苯二氮卓类药物发生交叉反应。