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Asphyxia due to Metabolic Poisons
Published in Burkhard Madea, Asphyxiation, Suffocation,and Neck Pressure Deaths, 2020
In recent years, new psychoactive substances have been introduced via internet sites. Whereas most of these are psychostimulants or hallucinogenic, a few may be opioid agonists. One of these, MT-45, was apparently not recognized as an opioid by all users, resulting in many deaths until it was classified and disappeared from the market [21]. In recent years, fentanyl analogues have been produced on a large scale and many of these can be purchased as nasal sprays from internet sites. Acetylfentanyl was among the first to appear on the market and caused a large number of deaths [25,30]. Furanylfentanyl appeared on the market for a short period, and when found in postmortem cases, it was almost always in the context of an opioid overdose [12]. Hence, the mere detection of a fentanyl analogue should raise the suspicion of an opioid toxicity death. The increase in the fentanyl deaths, and in deaths from other opioids has been so great that US President Donald Trump declared the opioid crisis a public health emergency in October 2017.
Licit and illicit drugs
Published in Jason Payne-James, Richard Jones, Simpson's Forensic Medicine, 2019
Jason Payne-James, Richard Jones
Some opioids are much more potent than others. Novel synthetic opioids have recently emerged on the recreational drug market. They include fentanyl (a potent narcotic analgesic) and its analogues (e.g., acetylfentanyl, acryloylfentanyl, carfentanil, α-methylfentanyl, 3-methylfentanyl, furanylfentanyl, 4-fluorobutyrylfentanyl, 4-methoxybutyrylfentanyl, 4-chloroisobutyrylfentanyl, 4-fluoroisobutyrylfentanyl, tetrahydrofuranylfentanyl, cyclopentylfentanyl and ocfentanil) and compounds with different chemical structures, such as AH-7921, MT-45 and U-47700. Fentanyl, for example, is more than 100 times more powerful than morphine, because it is a better fit for the μ1 receptor than morphine. The molecular structure of the opiate can also have an effect on routine drug screening tests. Routine drug screening tests (including the various test kits used in most casualty wards) are antibody based. The antibodies used have usually been designed to attach to morphine and will not react at all in the presence of synthetic opioids such as fentanyl. More worryingly, carfentanil – a synthetic fentanyl analogue approved for veterinary use, with an estimated analgesic potency approximately 10,000 times that of morphine and 20–30 times that of fentanyl, based on animal studies – has become available. Since 2016, an increasing number of reports describe detection of carfentanil in the illicit drug supply. Little is known about the pharmacology of carfentanil in humans. Its high potency and presumed high lipophilicity, large volume of distribution, and potential active metabolites have raised concerns about the management of people exposed to carfentanil as well as the safety of first responders. It has been associated with a number of deaths in association with other illicitly used drugs.
Opioid overdoses involving xylazine in emergency department patients: a multicenter study
Published in Clinical Toxicology, 2023
Jennifer S. Love, Michael Levine, Kim Aldy, Jeffrey Brent, Alex J. Krotulski, Barry K. Logan, Carmen Vargas-Torres, Sara E. Walton, Alexandra Amaducci, Diane Calello, Robert Hendrickson, Adrienne Hughes, Anita Kurt, Bryan Judge, Anthony Pizon, Evan Schwarz, Joshua Shulman, Timothy Wiegand, Paul Wax, Alex F. Manini
Waste clinical specimens were collected as directed by site investigators and ToxIC staff. Serum and/or blood samples drawn in heparinized tubes obtained as part of routine clinical care were collected, de-identified, and stored at −80 °C until sent to the Center for Forensic Science Research and Education (CFSRE) for analysis. Qualitative molecular identification consisted of liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) analysis with secondary analysis by liquid chromatography tandem quadrupole mass spectrometry (LC-QqQ-MS), when necessary. Current CFSRE toxicology testing contains over 900 drugs, including therapeutics, traditional illicit drugs, novel psychoactive substances, adulterants, and other compounds. This methodology has been previously validated [24] and the molecular battery is frequently updated, as drugs in this dynamic market change frequently. Illicit opioids of interest were fentanyl, fentanyl analogs (e.g., acetylfentanyl, furanylfentanyl, carfentanil, para-fluorofentanyl), nitazene analogs (e.g., isotonitazene, metonitazene), and other new synthetic opioids (e.g., brorphine, 2-methyl AP-237), as well as previously prevalent synthetic opioids (e.g., AH-7921, MT-45, U-47700) [5]. The limit of detection for both xylazine and fentanyl was 0.1 µg/L.
Underreporting of drug use among electronic dance music party attendees
Published in Clinical Toxicology, 2021
Joseph J. Palamar, Alberto Salomone, Katherine M. Keyes
Specimens were tested via published methods using ultra-high performance liquid chromatography–tandem mass spectrometry [41–43]. We tested for common drugs including cannabis (THC), amphetamine, methamphetamine, cocaine, MDMA, ketamine, PCP, heroin (6-MAM), and prescription opioids including morphine, codeine, oxycodone, hydrocodone, hydromorphine, and oxymorphone. We also tested for a variety of uncommon drugs and NPS including 19 synthetic cathinones (i.e. mephedrone, 4-MEC, methylone, 3,4-MDPV, pentedrone, 3-MMC, ethylcathinone, alpha-PVP, butylone, buphedrone, mexedrone, amfepramone, pentylone, methedrone, ethylone, naphyrone, 4-F-methylcathinone, 3,4-DMMC, alpha-PHiP) and 7 psychedelic phenethylamines (i.e. 2 C-B, 2 C-P, 25B-NBOMe, 25 C-NBOMe, 25H-NBOMe, 25I-NBOMe, 4-EA-NBOMe). We also tested for 5 other euphoric stimulants (i.e. 4-FA, 5/6-APB, 5-MAPB, PMA, PMMA) and 3 dissociative NPS (i.e. MXE, 4-MeO-PCP, diphenidine). In addition, we tested for fentanyl, 8 fentanyl analogs (i.e. carfentanyl, acetylfentanyl, furanylfentanyl, butyrfentanyl, acryloylfentanil, 4-fluorofentanyl, 3-methylfentanyl, ocfentanyl), and for 5 other opioid NPS (i.e. U-47,700, U-49900, AH-7921, MT-45, U-51,754).
Poison control center experience with tianeptine: an unregulated pharmaceutical product with potential for abuse
Published in Clinical Toxicology, 2018
Jeanna M. Marraffa, Christine M. Stork, Robert S. Hoffman, Mark K. Su
The United States is experiencing an epidemic of opioid addiction and overdose that has been steadily increasing over the past 15 years [1]. Initially precipitated by increased prescribing of opioid analgesics, the public health crisis of opioid addiction expanded to include heroin, fentanyl, and other novel opioid agonists [1,2]. Creative and often desperate Americans suffering from an Opioid Use Disorder are increasingly turning to “legal highs” such as over-the-counter (OTC) medications, plants and research chemicals to “get high,” or to mitigate the symptoms of opioid withdrawal. Examples of substances exploited for their opioid agonism include the OTC anti-diarrheal loperamide [3,4], the traditional medicinal plant kratom [5], and an ever-expanding list of “research chemicals” such as acetylfentanyl, acryloylfentanyl, carfentanil, ocfentanil, AH-7921, MT-45, and U-47700 [6,7]. The opioid epidemic has brought drug-related deaths across the United States to unprecedented highs in recent years, in part due to increases in illicit fentanyl and fentanyl analogs in the drug supply [6–11]. In New York City, the prevalence of novel psychoactive substance (NPS) exposures reported to poison control centers (PCCs) increased from 7.1% in 2011 to 12.6% in 2014 [12]. Between 2010 and 2016, New York City experienced a 143% increase in the rate of death due to unintentional overdose, and medical examiner data have determined that illicit fentanyl and fentanyl analogs contributed to the increase in deaths [9]. Although unpublished, these trends are consistent in all parts of New York State.