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You have full access to this open access article. Analysis of illicit drugs, medicines, and pathogens in wastewater is a powerful tool for epidemiological studies to monitor public health trends. The aims of this study were to i assess spatial and temporal trends of population-normalized mass loads of illicit drugs and nicotine in raw wastewater in the time of regulations against SARS-CoV-2 infections —21 and ii find substances that are feasible markers for characterizing the occurrence of selected drugs in wastewater. Raw sewage h composite samples were collected in catchment areas of 15 wastewater treatment plants WWTPs in urban, small-town, and rural areas in Germany during different lockdown phases from April to December Parent substances amphetamine, methamphetamine, MDMA, carbamazepine, gabapentin, and metoprolol and the metabolites of cocaine benzoylecgonine and nicotine cotinine were measured. An influence of the regulations to reduce SARS-CoV-2 infections such as contact bans and border closures on drug consumption has been proven in some cases and refuted in several. In addition, metoprolol and cotinine were found to be suitable as marker substances for the characterization of wastewater. Thereafter from mid, no obvious effect was detected with regard to the regulations against SARS-CoV-2 infections on concentration of drugs in wastewater. Wastewater-based epidemiology is suitable for showing changes in drug consumption during the COVID lockdown. Investigations of water are carried out primarily for toxicological reasons, especially in the case of drinking water and surface water. In the case of wastewater, different studies performed eco- toxicological investigations in the inflow and outflow of wastewater treatment plants WWTPs , for example, on hormones estrogenic activity and occurrence of drug-resistant bacteria Rossmann et al. There are already numerous approaches using wastewater for epidemiological studies indicating that wastewater-based epidemiology WBE could become a powerful tool for monitoring public health trends through the analysis of biomarkers such as drugs, chemicals, and pathogens Castiglioni et al. Over the last decade, the application of WBE to monitor illicit drug loads increased. As there is a limited number of high-quality studies, further standardization of the WBE approach for illicit drugs is needed especially with regard to the sampling methodology Huizer et al. The study presented here deals with characterization of changes in the consumption patterns of illicit drugs and nicotine in a project for SARS-CoVtracking in Germany Helm et al. It has been hypothesized that physical distancing and social limitations disproportionately affect people who regularly use illegal drugs and could lead to shifts in the illegal drug markets Dietze and Peacock ; Bade et al. In the Global Financial Crisis , compound specific changes of illicit drug consumption were observed. The use of expensive drugs, such as cocaine, decreased, and the use of cheaper synthetic drugs, such as amphetamine, increased Dom et al. Recently, several studies from Innsbruck, Austria Reinstadler et al. So far, there have only been some studies in Germany that have surveyed consumers about the effects of the lockdown on drug use. The impact was relatively small Scherbaum et al. A second aspect of these investigations are methodological improvements of the WBE. In previous studies, it could be shown that there is a correlation between the amount of prescription drugs and their recovery in wastewater Cisneros and Cunningham However, the significance of this correlation is depending on various prerequisites, mainly regarding the wastewater sampled and the drug investigated. First of all, the wastewater samples should be representative for sewage flow of the population considered. Therefore, h composite samples with information about the flow rate are standard procedures. In practice, the technical requirements for this sampling are not always given, for example, in the case of random samples from the sewer network or during heavy rain events Castiglioni et al. If only the concentrations are known in these cases, but not the flow rates, the amounts might be estimated using suitable and validated target substances. Our study is aimed at determining the influence of COVID and the related restrictions on drug consumption in Germany with wastewater-based epidemiology. The study included about h composite wastewater samples collected at the influents of 15 German WWTPs differing in size-classes in population equivalent PE; Table 1. Brebach, Saarbr. Typically, all h composite samples were collected at the WWTP influent from 8 a. Spatial distribution of sampling sites in Germany and number of inhabitants connected to the wastewater treatment plants; site MLHC is not shown due to anonymity requirements. The study included analysis of markers for tobacco and illicit drug use as well as determination of frequently prescribed drugs. The selected prescription medicaments are not expected to be affected by the SARS-CoV-2 restrictions or other seasonal fluctuations Ludwig et al. Maywald, Saxony, Germany. The drugs include the beta adrenoceptor antagonist metoprolol, the anticonvulsants carbamazepine and gabapentin, and the antifungal fluconazole. The nicotine metabolite cotinine and the illegal drugs methamphetamine, amphetamine, MDMA, cocaine, and its metabolite benzoylecgonine as well as the heroin metabolite 6-acetylmorphine were determined as in the SCORE drug screening Gonzalez-Marino et al. The separation was carried out using reversed phase chromatography and tandem mass spectrometry based on Rossmann et al. The evaluation in part 1 was carried out in accordance with the international standard Castiglioni et al. Measured substance concentrations in the wastewater had to be normalized. The daily wastewater flow was known for most of the h composite samples examined. In these cases, the flow rate was used to calculate the load, i. Additionally mass loads were normalized to the number of people served by the WWTP. The result represents the amount of drug excreted daily per inhabitants. This value is valid for the comparison between different locations and between different time periods. In part 2 of the study, an alternative normalization with marker substances was tested in order to validate this procedure of a drug related normalization. For the investigations regarding the influence of the SARS-CoV-2 measures, the available flow rates were used for normalization, and the marker substances were only used for scaling in a few cases. When looking at drug consumption behavior depending on the SARS-CoV-2 measurements, different time periods were set characterizing the extent of restrictions. The investigated samples were assigned to these periods Table 2. The number of samples per sewage treatment plant and period was different and is given in the Appendix Table 7. For example, there is only one sample for Dresden in the first hard lockdown in April In other cities, the periods April and May up to the opening of the border in June can be evaluated and compared separately. Regional differences in drug use were confirmed for the other illegal drugs. This has not been established for methamphetamine. Regarding the investigation of an influence of the measurements for SARS-CoV-2 management contact restriction, border closure on the change of leisure behavior and of party scene as well on the absolute consumption volumes of drugs, the number of available positive data is a critical point. Therefore, evaluation was limited to the larger towns. Results from large cities like Hamburg Fig. Samples from Nuremberg and Magdeburg were available for a longer period in spring In mid-April and from the beginning of June , no samples from the weekend were available, and therefore, no weekend trend was detectable. Thus, the first lockdown had obviously a strong impact on cocaine consumption Fig. The methamphetamine levels found in Nuremberg were constant over the entire period and independent of the day of the week. Unfortunately, the samples from the weekends in June and July were not available due to technical reasons. Five to ten samples are included in the presented mean values. Horizontal boxlines are showing 25, 50, and 75 percentiles; whiskers represent Min and Max values. Results from the pre-lockdown period were available for two of the WWTPs in These results can be found in Table 7 in the Appendix. In this area, there is the already known local peculiarity that amphetamine is the drug most consumed in the catchment area and that methamphetamine plays no role up to now. Amphetamine consumption decreased during the lockdown phase and increases again from June Appendix Table 8. Consumption did not depend on the day of the week. No clear changes could be identified for cocaine as a result of the regulations according to the SARS-CoV-2 epidemiology. As at the other locations examined, MDMA and cocaine are consumed somewhat more on the weekends than during the week. The measured values scattered very widely and, moreover, mostly low concentrations or no drugs of interest were found Table 3. With regard to the capacity of the monitored WWTPs, there was a clear positive correlation between population equivalents and the amount of drugs found in wastewater indicating a higher consumption in larger cities. In Dresden, Chemnitz, Plauen, and Annaberg-Buchholz, as in the locations already described, relatively constant amounts of methamphetamine, amphetamine, and cotinine were found throughout the week. Figure 4 shows changes in drug consumption: in the first lockdown phase LD1 and pLD1 , methamphetamine and to a lesser extend its metabolic product amphetamine were detected in higher concentrations in comparison with those in the rest of the study period and before restrictions against SARS-CoV-2 Gonzalez-Marino et al. MDMA was found in a lesser extent in the first lockdown phase. On the weekends in the first lockdown period, the measured MDMA amounts were slightly lower than at later periods. Little higher concentrations of cotinine were determined in the first lockdown phase. Values represent amounts calculated from flow rates abbreviations of the restriction periods are explained in Table 2. Figure 5 shows that the amount of methamphetamine excreted in the wastewater of Dresden decreased significantly by the end of after higher values in the first lockdown phase. The other observed differences in drug use were not significant. The amount of methamphetamine observed in Dresden from the first lockdown phase in April to lockdown light 3 at the end of A significant decrease was observed throughout the sample period linear regression analysis on log transformed y values with GraphPad Prism 9. Sometimes, only the drug concentrations in waste water are known, and the calculation of the amount is not possible, for example, in the case of random samples from the sewer network or in the event of heavy rain events. In these cases, a normalization of the measured concentrations could be desirable. It was tested whether the prescription drugs metoprolol, carbamazepine, gabapentin, and fluconazole are excreted daily in the different locations in the same amounts and whether this amount is comparable per inhabitant of the different catchment areas. For that purpose, all sample results from and from the first half of were evaluated. Data from and were available for three sewage treatment plants Dresden, Chemnitz, and Annaberg-Buchholz. These were first analyzed separately. No obvious difference was observed between the 2 years, so that these values will be summarized for further evaluations. In contrast to previous investigations, fluconazole could not be detected in numerous samples from smaller sewage treatment plants. Therefore, this parameter was excluded from further analysis. Table 5 shows the number of samples, the mean of the elimination amount, and the coefficient of variation for three active substances and one metabolite in the raw water from 13 plants in Germany over the entire specified period. The assessment of the other substances, which were originally intended to be examined to determine whether the lockdown and other restrictions due to the epidemiology of SARS-CoV-2 resulted in a change in consumer behavior, showed that cotinine was always very easily detectable and the amount excreted per inhabitants per day was always relatively constant Table 5 last column. Cotinine is a stable metabolic product of nicotine and thus a marker for tobacco consumption Shahab et al. Therefore, the drug concentrations were scaled with the assumed constant cotinine and metoprolol concentrations. The scaling with cotinine and metoprolol provided very similar, comparable results Fig. For reasons of clarity, only normalization with metoprolol was shown here, and the concentrations of MDMA and methamphetamine were normalized with metoprolol Fig. The hypothesis of this study was that the SARS-CoV-2 regulations, such as contact bans and border closures, would affect illicit drug use. This has been proven in some cases and disproven in several others. Wastewater samples from April were available from Nuremberg and Magdeburg. In the first lockdown in April , an influence of the regulations on drug use was observed in these samples. Typically, methamphetamine loads are evenly distributed throughout the week. Thus, like cotinine, methamphetamine shows no weekend trend and was consumed evenly. Also, the results of the samples from the WWTP in Hamburg from May to July show strong differences depending on the day of the week for appropriate illicit drugs. The maximum and minimum amounts of MDMA and cocaine excreted per inhabitant and day remained relatively constant over the 2 months. An effect of regulations against SARS-CoV-2 infections on the consumption of illegal drugs and parties was not detectable during this period Fig. The results of this study also indicated that the amount of benzoylecgonine in Nuremberg wastewater decreased during the first lockdown. In Innsbruck, an increase in the use of methamphetamine and a decrease in MDMA and cocaine were found in the first lockdown Manchikanti et al. In our data, less benzoylecgonine was also found in wastewater in Germany. The other two trends for methamphetamine and MDMA could not be shown. Amphetamine use decreased regardless of the day of the week during the lockdown phase and increased again from June MDMA was found significantly more in than in MDMA and cocaine were consumed more on the weekends than during the week Table 7. This is observed in the wastewater of different cities. Further studies should investigate whether this change in consumer behavior is reversible. The samples from the Dresden and Chemnitz WWTP offer the opportunity to monitor drug consumption over a longer period from Lockdown 1 to Lockdown light 3. The measured values in the plants treating smaller populations fluctuate strongly, and mostly, no or only low concentrations of drugs were found. The fluctuations could be increased by the time-proportional sampling. Therefore, precise evaluation of drug distribution pattern is more difficult. The results in Table 3 clearly show the different consumer behavior of the urban and rural populations. While the medically prescribed beta adrenoceptor antagonist metoprolol was distributed equally in all wastewaters investigated, we determined strong differences in the concentration of illegal drugs, most notably in cocaine and MDMA, but also significantly in methamphetamine. The differences were so large that any fluctuations between the different periods can be neglected. The size of the city also played a role here. The reasons for this are related to lifestyle, demographics, and social differences. The amounts of amphetamines occurring in the wastewater in Saxony are very low compared to the amounts of methamphetamine. It can be assumed that most of them were the metabolic product of methamphetamine, and only a small amount was consumed directly. In Dresden, Chemnitz, Plauen, and Annaberg-Buchholz, as in the locations already described, relatively constant amounts of methamphetamine, amphetamine, and cotinine were found during the week. For MDMA and cocaine, the consumption on the weekend was significantly higher than during the week, and this was true for the entire period of the study, i. Looking at the long period from Lockdown 1 to Lockdown light 3, the different changes in consumption can be seen in Dresden. In the first lockdown phase, methamphetamine use was significantly higher than in the rest of the study period and before measurements against SARS-CoV The amount of methamphetamine excreted in Dresden decreased significantly from the first lockdown phase in April to Lockdown Light 3 at the end of Cocaine and its metabolite have been found in larger quantities since the summer of and also before the SARS-CoV-2 pandemics. At this location, higher cocaine consumption has been observed during the second half of , which cannot be explained by SARS-CoV-2 regulations. In two Italy plants using one sample per month, a significant increase in cocaine consumption was observed in Di Marcantonio et al. Obviously, there was a shift from methamphetamine to cocaine, but whether this happened due to the measures against SARS-CoV-2 infections cannot be clarified here Figs. In Reykjavik, h composite wastewater samples of a week were examined, for example, in June The estimated amphetamine and methamphetamine use showed signs of increasing from to , cocaine use increased from to and decreased in during the COVID pandemic Love et al. On the one hand, this has to do with national and local peculiarities and differences. On the other hand, the data situation is different, which limited comparability. MDMA loads were lower during the initial lockdown phase, probably party- and event-related consumption was reduced. In particular, on the weekends of the first lockdown, the measured MDMA quantities were significantly lower than in later periods. In contrast, other drugs did not show this pattern. Despite more severe restriction measures during Lockdown2a than Lockdown 2b, the drug consumption differed only slightly. The reasons for the slight increase in amphetamine and the slight decrease in cocaine can only be speculated here. Little higher loads of cotinine were found in the first phase of lockdown; otherwise, nicotine consumption does not change. The study is limited by the strong fluctuations in the measured values in small systems and the small number of samples at the beginning of the SARS-CoV2 pandemic. In the present study, the beta adrenoceptor antagonist metoprolol and the nicotine metabolite cotinine were found to be suitable marker substances for the characterization of wastewater. The smallest coefficient of variation was found for these substances in the specified period Table 5. The search for suitable marker substances in the wastewater yielded various findings. The largest amount was found from gabapentin. This can be explained by the frequent prescription in Germany Ludwig et al. However, there are relatively large fluctuations in the amounts eliminated, both per site and between sites. Comparable results have been found for carbamazepine, which represented another pharmaceutical substance with frequent prescription in Germany and high daily defined dose of 1. The high proportion of hospital wastewater in this treatment plant might contribute to these variations. The high fluctuations in the values observed in the small WWTP Elsterberg are striking and unfavorable for comparative considerations. In all other WWTPs, the excreted amounts of metoprolol showed the smallest scatter. The cotinine values determined as part of the investigations of nicotine consumption in this study also showed relatively constant values. Tobacco smoking is still common in Germany and the regulations against SARS-CoV-2 infections seemingly had only a negligible impact on consumption. A comparison of the average amounts of cotinine and metoprolol excreted in the wastewater suggests that both substances are suitable as marker substances in Germany. Discharge of hospital sewage played no discernable role in cotinine excretion. The comparatively low values in the small WWTPs, often receiving wastewater from rural catchments, are striking. Demographic factors might contribute to this observation, since a larger proportion of older people live in rural areas. Finally, the proportion of human excretions in the wastewater can therefore be estimated from the concentrations of metoprolol and cotinine. Data in Table 5 part 1 of the study , clearly confirm that the beta adrenoceptor antagonist metoprolol and the nicotine metabolite cotinine were excreted in constant amounts and are well suited as marker substances. These two marker substances are useful when the wastewater cannot be characterized in terms of flow rate and inhabitants in the catchment area, for example, when sewer sub-networks were sampled. Other substances can be related to these markers, for example, to assess whether drug or substance abuse changes, i. The amounts of metoprolol and cotinine excreted differ between the sites, so the use of marker substances cannot be transferred from one WWTP to another, which limits the study. In the case of special dischargers such as hospitals or regarding very small catchment areas, the results of wastewater analysis are more difficult to interpret. The main results of the study are summarized in Table 6. Wastewater-based epidemiology is suitable for showing changes in drug use during the COVID lockdown. With regard to consum of illicit drugs, a distinction was made between two aspects: the absolute amount of substance and its distribution over the week. Cocaine and especially MDMA Ecstasy are recreational drugs; they are increasingly consumed at weekends. At all other times and in all WWTPs examined, the typical increase of consumption of party drugs on weekends was found. In Dresden and to a lesser extent in Chemnitz, it was observed that methamphetamine levels increased during the lockdown1, but decreased from summer on. Overall, the results suggest that drug consumption changed in the observed WWTPs at the beginning of the SARS-CoV-2 pandemics but later restrictions had lesser effects on consumption behavior. This study also showed that both the beta adrenoceptor antagonist metoprolol and the nicotine metabolite cotinine are excreted at constant loads throughout the seasons and epidemic phases. Hence, they are suitable as marker substances for the analysis of wastewater from a pharmacological point of view. Inhabitant specific loads of these markers differed among the sites. So, a local adjustment of expected consumption levels seems necessary. Pharmacological markers provide reliable site specific validation, of sample integrity or when the amount of wastewater at the sampling point is unknown. Sci Total Environ Environ Sci Technol Lett — Environ Int Environ Sci Technol — Neuropharmacology Drug Alcohol Rev — J Med Toxicol — Addiction — Article PubMed Google Scholar. Sci Total Environ — Water Res Environ Pollut — Springer Berlin. Pain Ther — Talanta — Water Res — Drug Alcohol Depend J Subst Use — Article Google Scholar. Front Psychiatry Addict Biol — Br J Pharmacol — Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz — Download references. You can also search for this author in PubMed Google Scholar. Oertel and B. Renner wrote the main text of the manuscript and prepared Figs. Schubert prepared Figs. Helm and R. Mayer created Fig. Dumke and B. Renner carried out the statistical evaluation. All authors reviewed the manuscript. Correspondence to Reinhard Oertel. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Reprints and permissions. Oertel, R. Naunyn-Schmiedeberg's Arch Pharmacol , — Download citation. Received : 09 December Accepted : 28 December Published : 12 January Issue Date : May Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Download PDF. Abstract Analysis of illicit drugs, medicines, and pathogens in wastewater is a powerful tool for epidemiological studies to monitor public health trends. Temporal profile of illicit drug consumption in Guangzhou, China monitored by wastewater-based epidemiology Article 15 June Wastewater-based epidemiology in low Human Development Index states: bias in consumption monitoring of illicit drugs Article 14 August Use our pre-submission checklist Avoid common mistakes on your manuscript. Introduction Investigations of water are carried out primarily for toxicological reasons, especially in the case of drinking water and surface water. Method Wastewater samples The study included about h composite wastewater samples collected at the influents of 15 German WWTPs differing in size-classes in population equivalent PE; Table 1. Full size image. Results Study part 1—determination of illicit drugs For the investigations regarding the influence of the SARS-CoV-2 measures, the available flow rates were used for normalization, and the marker substances were only used for scaling in a few cases. Discussion Study part 1—determination of illegal drugs The hypothesis of this study was that the SARS-CoV-2 regulations, such as contact bans and border closures, would affect illicit drug use. Study part 2—establishment of marker substances In the present study, the beta adrenoceptor antagonist metoprolol and the nicotine metabolite cotinine were found to be suitable marker substances for the characterization of wastewater. Table 6 Most important results Full size table. Data availability Not applicable. View author publications. Competing interests The authors declare no competing interests. Additional information Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information. Supplementary file 1 Docx About this article. Cite this article Oertel, R. Copy to clipboard. Search Search by keyword or author Search. Navigation Find a journal Publish with us Track your research.