An epidemic of fatal 3-methylfentanyl poisoning in Estonia

Drug Use during Incarceration: A Comprehensive Quality and Prevalence Study in Three Danish Prisons

BACKGROUND

Drug use in Danish prisons has previously not been investigated in detail using confirmatory, laboratory analysis. The objective of the present quality study, initiated by the Danish Prison and Probation Service, was to i) evaluate the performance of an initial, on-site drug screening strategy; ii) gain insights into emerging drug trends; and iii) suggest evidence-based strategies for future drug testing.

METHODS

Over a two-year period, routine urine samples (n = 1952 from 710 inmates) from three Danish prisons were subjected to comprehensive drug testing. Immunoassay screening was conducted on-site. A parallel sample aliquot was forwarded to laboratory analysis by confirmatory methods: High-performance liquid chromatography and tandem mass spectrometry (LC-MS/MS) and gas chromatography and mass spectrometry (GC-MS) targeting 56 drugs-of-abuse/medical drugs, 26 key metabolites, 41 new psychoactive substances (NPS), including specific biomarkers for heroin, crack cocaine, or ethanol (a total of 123 target analytes/sample).

RESULTS

The on-site immunoassay method showed a sensitivity from 66 to 100%; specificity was above 98%; accuracy was above 95%. Laboratory analysis detected compounds not screened for including tramadol, oxycodone, buprenorphine, ketamine, MDMA, 4-fluoroamphetamine, and GHB. The prevalence of drug use was in the order: cannabis > ethanol > cocaine > benzodiazepines > amphetamine.

CONCLUSION

The performance of the immunoassay was found acceptable; however, the screening program was inadequate for detecting other significant substances. Based on these findings, a broader screening method will be implemented in future at Danish Prisons to minimize false negative results. The data did not indicate a trend of using NPS in Danish prisons.

Abuse potential of fentanyl and fentanyl analogues

Introduction

In this perspective review, we evaluated the clinical management of fatal fentanyl overdose in several routes of administration, concentrating on both legally prescribed and illegally produced formulations.

Methods

A literature search was conducted on Web of Science, PubMed, and Google Scholar databases, using the following keywords: fentanyl, illicit fentanyl, deaths, misuse, abuse, and naloxone. We included only articles whose abstracts were available in English. All articles were screened using their abstracts to determine their relevance to the current review.

Results

The gold standard for treating both acute and chronic pain is fentanyl, but abuse of the drug has exploded globally since the late 2000s. Fentanyl abuse has been shown to frequently result in serious harm and even death.

Conclusion

By educating patients and physicians, making rescue kits easily accessible, developing vaccines to prevent opioid addiction, and perhaps even creating new tamper-resistant fentanyl formulations, it may be possible to prevent fentanyl misuse, therapeutic errors, and the repercussions that follow.

The Baltic and Nordic responses to the first Taliban poppy ban: Implications for Europe & synthetic opioids today

The 2000-2001 and the 2022-2023 Taliban opium bans were and could be two of the largest ever disruptions to a major illegal drug market. To help understand potential implications of the current ban for Europe, this paper analyzes how opioid markets in seven Baltic and Nordic countries responded to the earlier ban, using literature review, key informant interviews, and secondary data analysis. The seven nations' markets responded in diverse ways, including rebounding with the same drug (heroin in Norway), substitution to a more potent opioid (fentanyl replacing heroin in Estonia), and substitution to one with lower risk of overdose (buprenorphine replacing heroin in Finland). The responses were not instantaneous, but rather evolved, sometimes over several years. This variety suggests that it can be hard to predict how drug markets will respond to disruptions, but two extreme views can be challenged. It would be naive to imagine that drug markets will not adapt to shocks, but also unduly nihilistic to presume that they will always just bounce back with no lasting effects. Substitution to another way of meeting demand is possible, but that does not always negate fully the benefits of disrupting the original market. Nonetheless, there is historical precedent for a European country's opioid market switching to synthetic opioids when heroin supplies were disrupted. Given how much that switch has increased overdose rates in Canada and the United States, that is a serious concern for Europe at present. A period of reduced opioid supply may be a particularly propitious time to expand treatment services (as Norway did in the early 2000s).

Blood concentrations of new synthetic opioids

PURPOSE

Over the last decade, there has been a significant growth in the market and number of new psychoactive substances (NPS). One of the NPS groups that has grown rapidly in recent years, bringing a new set of problems, consists of new synthetic opioids. The extreme potency of these compounds poses a high risk of acute poisoning, as an overdose can cause respiratory depression. Most of the information regarding human pharmacokinetics of new opioids is based on toxicological case reports and the data on concentrations of new opioids in human blood are scarce. The interpretation of results usually requires a comparison to previously published cases; therefore, a referenced compilation of previously published concentration data would be useful.

METHODS

The data were collected by searching the PubMed and Scopus databases and by using the Google search engine. All the available data from articles and reports that measured new opioid concentrations in plasma, serum, or whole blood were included in the data analysis.

RESULTS

The presented tables list the observed concentrations in fatal and nonfatal cases involving 37 novel synthetic opioids.

CONCLUSIONS

Blood levels of new opioids are extremely difficult to interpret. Low blood concentrations of these substances do not rule out acute poisoning as their high potency creates a risk of respiratory depression even at low doses. Opioid tolerance, frequent presence of other drugs, and additional diseases make it impossible to define concentration ranges, especially the minimum fatal concentrations. This report provides quick access to the source articles quantifying novel synthetic opioids.

The dawn of a new synthetic opioid era: the need for innovative interventions

BACKGROUND

Overdose deaths related to illegal drugs in North American markets are now dominated by potent synthetic opioids such as fentanyl, a circumstance foreshadowed by often-overlooked events in Estonia since the turn of the century. Market transitions generate important and far-reaching implications for drug policy.

ARGUMENT AND ANALYSIS

The supplier-driven introduction of illegally manufactured synthetic opioids into street opioids is elevating the risk of fatal overdose. Using the most recent overdose mortality and drug seizure data in North America, we find that overdose deaths and seizures involving synthetic opioids are geographically concentrated, but this might be changing. Examination here suggests that in some places fentanyl and its analogues have virtually displaced traditional opioids, such as heroin. The concealing of synthetic opioids in powders sold as heroin or pressed into counterfeit medications substantially increases harms. The nature and scale of the challenge posed by synthetic opioids is unprecedented in recent drug policy history.

CONCLUSIONS

There is urgent need for policy and technological innovation to meet the challenges posed by illegally produced synthetic opioids. Novel interventions worth examining include supervising drug use, proactively deterring on-line distribution and new technologies aimed at improving transparency, such as point-of-use drug content testing. Continuing to approach this problem only with existing policies and available methods, such as naloxone, is unlikely to be enough and will result in many premature deaths.

Gas Chromatography-Mass Spectrometry Analysis of Synthetic Opioids Belonging to the Fentanyl Class: A Review

The rising number of deaths caused by fentanyl overdosing in the US due to the overwhelming illicit use of this synthetic opioid has started a global campaign to develop efficient ways to control its production and distribution as well as discovering efficient antidotes to mitigate its lethal effects. Another important vein of focused research established by various agencies lies in the development of efficient and practical protocols for the detection of this opioid and analogs thereof in various matrices, whether environmental or biological in nature, particularly in the field of gas chromatography-mass spectrometry (GC-MS). The following review will cover the literature dealing with the detection and identification of synthetic opioids belonging to the fentanyl class by GC-MS means and hyphenated versions of the technique. Detailed descriptions will be given for the GC-MS methods employed for the analysis of the opioid, starting with the nature of the extraction protocol employed prior to analysis to the actual findings presented by the cited reports. Great effort has gone into describing the methods involved in each paper in a detailed manner and these have been compiled by year in tables at the end of each section for the reader's convenience. Lastly, the review will end with concluding remarks about the state of GC-MS analysis with regards to these powerful opioids and what lies ahead for this analytical field.

Zebrafish early life stages as alternative model to study 'designer drugs': Concordance with mammals in response to opioids

The number of new psychoactive substances (NPS) on the illicit drug market increases fast, posing a need to urgently understand their toxicity and behavioural effects. However, with currently available rodent models, NPS assessment is limited to a few substances per year. Therefore, zebrafish (Danio rerio) embryos and larvae have been suggested as an alternative model that would require less time and resources to perform an initial assessment and could help to prioritize substances for subsequent evaluation in rodents. To validate this model, more information on the concordance of zebrafish larvae and mammalian responses to specific classes of NPS is needed. Here, we studied toxicity and behavioural effects of opioids in zebrafish early life stages. Synthetic opioids are a class of NPS that are often used in pain medication but also frequently abused, having caused multiple intoxications and fatalities recently. Our data shows that fentanyl derivatives were the most toxic among the tested opioids, with toxicity in the zebrafish embryo toxicity test decreasing in the following order: butyrfentanyl>3-methylfentanyl>fentanyl>tramadol> O-desmethyltramadol>morphine. Similar to rodents, tramadol as well as fentanyl and its derivatives led to hypoactive behaviour in zebrafish larvae, with 3-methylfentanyl being the most potent. Physico-chemical properties-based predictions of chemicals' uptake into zebrafish embryos and larvae correlated well with the effects observed. Further, the biotransformation pattern of butyrfentanyl in zebrafish larvae was reminiscent of that in humans. Comparison of toxicity and behavioural responses to opioids in zebrafish and rodents supports zebrafish as a suitable alternative model for rapidly testing synthetic opioids.

Illicit synthetic opioid consumption in Asia and the Pacific: Assessing the risks of a potential outbreak

BACKGROUND

Illegally manufactured potent synthetic opioids (IMPSO) like fentanyl have contributed to rises in overdose deaths in parts of North America and Europe. While many of these substances are produced in Asia, there is little evidence they have entered markets there. We consider the susceptibility to IMPSO's encroachment in markets in the Asia-Pacific region.

METHODS

Our analysis focuses on Australia, China, India, and Myanmar. Using a mixed-methods approach comprising interviews, literature review, and secondary data analyses, we examine factors facilitating or impeding incursion of IMPSO. Finally, we illustrate the potential for IMPSO fatalities in Australia.

RESULTS

Australia reports some signs of three facilitating factors to IMPSO's emergence: 1) existing illicit opioid markets, 2) disruption of opioid supply, and 3) user preferences. The other three countries report only existing illicit opioid markets. While diverted pharmaceutical opioids are a noted problem in Australia and India, heroin is the dominant opioid in all four countries. There are divergent trends in heroin use, with use declining in China, increasing in India, and stable in Australia and Myanmar. If IMPSO diffused in Australia as in North America from 2014 to 2018, and our assumptions generally hold, deaths from IMPSO could range from 1500-5700 over a five-year period.

CONCLUSIONS

This analysis and illustrative calculations serve as an early indication for policymakers. With the exception of Australia, many countries in the region fail to properly record overdose deaths or monitor changes in local drug markets. Early assessment and monitoring can give officials a better understanding of these changing threats.

The fentanyl epidemic in Estonia: factors in its evolution and opportunities for a comprehensive public health response, a scoping review

BACKGROUND

The spread of illicitly manufactured fentanyl has the potential to greatly increase the fatal overdoses in many places in the world. The purpose of this paper is to analyse the evolution of fentanyl use epidemic in Estonia.

METHODS

this scoping review is based on extensive review and synthesis of broad range of literature: research reports, newspaper, magazine, coverage of illicit fentanyl use; policy documents, position papers, reports released by government agencies, and surveillance data.

RESULTS

For an over a decade up to 2017, Estonia has had the highest overdose death mortality in Europe. The use of (injected) fentanyl is a major contributor to the Estonian overdose death epidemic. Shutting down a major producer and distributor of illicit fentanyl has been extremely effective in curbing the number of overdose deaths. Unfortunately, this supply-side intervention came ten years into the epidemic, and might be difficult to replicate in settings with decentralized production. In areas faced by fentanyl we would recommend large-scale implementation of opiate substitution treatment and naloxone distribution, syringe service programs to provide for safer injecting and link to other services (high frequencies of fentanyl injection create high risk for HIV and HCV transmission), and programs, such as "Break the Cycle," to reduce initiation into injecting drug use. Further, the means of responding to emerging substances should match the world in which different substances can be rapidly introduced, and where people who use drugs can change preferences based on market availability.

CONCLUSION

Addressing illicitly manufactured fentanyl may serve as a public health learning experience for developing early detection and rapid response programs in rapidly changing drug use environments.

Distinguishing Between Cyclopropylfentanyl and Crotonylfentanyl by Methods Commonly Available in the Forensic Laboratory

BACKGROUND

The opioid analgesic fentanyl and its analogues pose a major health concern due to its high potency and the increasing number of overdose deaths worldwide. The analogues of fentanyl may differ in potency, toxicity, and legal status, and it is therefore important to develop analytical methods for their correct identification. This can be challenging since many fentanyl analogues are structural isomers. Two fentanyl isomers that have been in the spotlight lately due to difficulties regarding separation and identification are cyclopropylfentanyl and crotonylfentanyl, which have been reported to display nearly identical fragmentation patterns and chromatographic behavior.

METHODS

Chromatographic separation of cyclopropylfentanyl and crotonylfentanyl by ultra-high-performance liquid chromatography was investigated using 3 different stationary phases (high strength silica T3, ethylsiloxane/silica hybrid C18, and Kinetex biphenyl) using gradient elution with a mobile phase consisting of 10 mM ammonium formate pH 3.1 and MeOH. Detection was performed by tandem mass spectrometry. In addition, the major metabolites of the 2 compounds formed on incubation with human liver microsomes were identified by ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry analysis.

RESULTS

Baseline separation of cyclopropylfentanyl and crotonylfentanyl was achieved on the ethylsiloxane/silica hybrid C18 column with retention times of 6.79 and 7.35 minutes, respectively. The major metabolites of the 2 analogues formed by human liver microsomes differed, with the main biotransformation being N-dealkylation and carboxylation for cyclopropylfentanyl and crotonylfentanyl, respectively. We demonstrated the usefulness of the 2 approaches by unambiguously identifying cyclopropylfentanyl, as well as its metabolites, in 2 authentic postmortem blood samples.

CONCLUSIONS

In this study, we successfully demonstrated that cyclopropylfentanyl and crotonylfentanyl can be distinguished by methods commonly available in forensic laboratories.

Unique Structural/Stereo-Isomer and Isobar Analysis of Novel Fentanyl Analogues in Postmortem and DUID Whole Blood by UHPLC–MS-MS

The presented analytical method enabled the Toxicology Department at the Cuyahoga County Medical Examiner’s Office to identify 26 and quantitatively report 24 compounds in 500 μL of whole blood, including fentanyl analogues (fentalogues) such as methoxyacetyl fentanyl (MeOAF) and cyclopropyl fentanyl (CPF). This second-generation method (FG2) was developed with the objective to improve the existing analysis (FG1) by decreasing sample size, lowering limits of detection (LOD) and lower limit of quantitation, minimizing ion suppression and resolving chromatographic interferences. Interferences may occur in the analysis of fentanyl, MeOAF, CPF, 3-methylfentanyl (3MF), butyryl fentanyl and isobutyryl fentanyl due to isobars and structural or geometric isomerism with another analogue or metabolite. The isomeric and isobaric fentalogues were grouped into three sets. The LOD established for Set 1 [MeOAF, para-methoxyacetyl fentanyl, para-fluoro acryl fentanyl (isobar), fentanyl carbamate], 2-furanyl fentanyl, Set 2 [CPF, (E)-crotonyl fentanyl] and carfentanil was 0.0125 ng/mL. The LOD established for N-methyl norfentanyl, norfentanyl, norcarfentanil, despropionyl fentanyl (4-ANPP), acetyl fentanyl, β-hydroxy fentanyl, benzyl fentanyl, acryl fentanyl, alfentanil, fentanyl, para-fluoro fentanyl, Set 3 [(±)-trans-3MF, (±)-cis-3MF, isobutyryl and butyryl fentanyl], para-fluoroisobutyryl fentanyl, sufentanil, phenyl fentanyl and cyclopentenyl fentanyl was 0.0625 ng/mL. Seven-point linear calibration curves were established between 0.025 and 4.0 ng/mL for the 8 analytes with the lower LOD and 0.125 and 20 ng/mL for the 18 analytes with the higher LOD. 4-ANPP and cyclopentenyl fentanyl met qualitative reporting criteria only. The results for five postmortem and two driving under the influence of drugs authentic case samples are presented. To the authors’ knowledge, FG2 is the first published method that achieved baseline resolution of the nine structural/stereo isomers and one isobar by ultra-high performance liquid chromatography–MS-MS and provided quantitative validation data for nine compounds. FG2 may be used as the new baseline for future isomers that need to be chromatographically separated.

Novel synthetic opioids - toxicological aspects and analysis

Over the past few years, there has been an emerging number of new psychoactive drugs. These drugs are frequently mentioned as "legal highs", "herbal highs", "bath salts" and "research chemicals". They are mostly sold and advertised on online forums and on the dark web. The emerging new psychoactive substances are designed to mimic the effects of psychoactive groups, which are often abused drugs. Novel synthetic opioids are a new trend in this context and represent an alarming threat to public health. Given the wide number of fatalities related to these compounds reported within the last few years, it is an important task to accurately identify these compounds in biologic matrices in order to administer an effective treatment and reverse the respiratory depression caused by opioid related substances. Clinicians dealing with fentanyl intoxication cases should consider that it could, in fact, be a fentanyl analogue. For this reason, it is a helpful recommendation to include synthetic opioids in the routine toxicological screening procedures, including analysis in alternative matrices, if available, to investigate poly-drug use and possible tolerance to opioids. To address this public health problem, better international collaboration, effective legislation, effective investigation, control of suspicious "research chemicals" online forums and continuous community alertness are required. This article aims to review diverse reported fatalities associated with new synthetic opioids describing them in terms of pharmacology, metabolism, posology, available forms, as well as their toxic effects, highlighting the sample procedures and analytical techniques available for their detection and quantification in biological matrices.

Determination of Fentanyl Analog Exposure Using Dried Blood Spots with LC-MS-MS

Fentanyl, and the numerous drugs derived from it, are contributing to the opioid overdose epidemic currently underway in the USA. To identify human exposure to these growing public health threats, an LC-MS-MS method for 5 μL dried blood spots (DBS) was developed. This method was developed to detect exposure to 3-methylfentanyl, alfentanil, α-methylfentanyl, carfentanil, fentanyl, lofentanil, sufentanil, norcarfentanil, norfentanyl, norlofentanil, norsufentanil, and using a separate LC-MS-MS injection, cyclopropylfentanyl, acrylfentanyl, 2-furanylfentanyl, isobutyrylfentanyl, ocfentanil and methoxyacetylfentanyl. Preparation of materials into groups of compounds was used to accommodate an ever increasing need to incorporate newly identified fentanyls. This protocol was validated within a linear range of 1.00-100 ng/mL, with precision ≤12% CV and accuracy ≥93%, as reported for the pooled blood QC samples, and limits of detection as low as 0.10 ng/mL. The use of DBS to assess fentanyl analog exposures can facilitate rapid sample collection, transport, and preparation for analysis that could enhance surveillance and response efforts in the ongoing opioid overdose epidemic.

The Fentanyl Epidemic and Evolution of Fentanyl Analogs in the United States and the European Union

BACKGROUND

Since 2013, an unprecedented surge in fentanyl overdose deaths has been caused by heroin laced with illicitly produced fentanyl and/or fentanyl analogs (FAs) sold as heroin. The US Drug Enforcement Agency's National Forensic Laboratory Information System reported a >300% increase in fentanyl encounters from 4697 in 2014 to 14440 in 2015. In 2015, the CDC reported 9580 deaths caused by synthetic opioids, primarily fentanyl, a 72% increase from 2014. The European Monitoring Centre for Drugs and Drug Addiction has also encountered several new FAs in the heroin supply. Counterfeit pharmaceuticals containing mixtures of fentanyl and FAs continue to be a poorly recognized worldwide problem despite the WHO classifying several FAs as a serious threat to public health.

CONTENT

This review covers the epidemiology of fentanyl abuse and discusses the clinical practice implications of widespread fentanyl abuse. It includes a historical perspective on the illicit FAs that have appeared in the US and European Union and reviews the methods available to identify FAs and emerging technologies useful for identifying previously undescribed analogs. A compilation of structural and mass spectral data on FAs reported thus far is provided.

SUMMARY

Fentanyl and FAs have evolved into a global public health threat. It is important to understand the analytical, clinical, and regulatory efforts underway to assist communities affected by the current fentanyl epidemic.

Novel Synthetic Opioids: The Pathologist's Point of View

Background: New Psychoactive Substances (NPS) constitute a broad range of hundreds of natural and synthetic drugs, including synthetic opioids, synthetic cannabinoids, synthetic cathinones, and other NPS classes, which were not controlled from 1961 to 1971 by the United Nations drug control conventions. Among these, synthetic opioids represent a major threat to public health. Methods: A literature search was carried out using public databases (such as PubMed, Google Scholar, and Scopus) to survey fentanyl-, fentanyl analogs-, and other synthetic opioid-related deaths. Keywords including “fentanyl”, “fentanyl analogs”, “death”, “overdose”, “intoxication”, “synthetic opioids”, “Novel Psychoactive Substances”, “MT-45”, “AH-7921”, and “U-47700” were used for the inquiry. Results: From our literature examination, we inferred the frequent implication of fentanyls and synthetic opioids in side effects, which primarily affected the central nervous system and the cardiovascular and pulmonary systems. The data showed a great variety of substances and lethal concentrations. Multidrug-related deaths appeared very common, in most reported cases. Conclusions: The investigation of the contribution of novel synthetic opioid intoxication to death should be based on a multidisciplinary approach aimed at framing each case and directing the investigation towards targeted toxicological analyses.

Fatalities caused by novel opioids: a review

Drugs related to morphine represent not only large range of important therapeutic applications for the relief of moderate to severe pain but also give rise to a relatively large series of novel opioids that mimic the action of this naturally occurring analgesic. Most of these are based on fentanyl structures that are much more potent, and dangerous, than fentanyl itself. This publication reviews reports of fatalities attributed to 15 novel opioids with the view to assessing mortality associated with their misuse as well as reviewing published analytical procedures that would be able to detect these and other novel opioids. These drugs include reports of deaths to acetylfentanyl, acrylfentanyl, butr(yl)fentanyl, carfentanil, 2- and 4-fluorofentanyls, 4-fluorobutyrfentanyl, 4-fluoroisobutyrfentanyl, furanylfentanyl, α- and 3-methylfentanyls, 4-methoxyfentanyl, ocfentanil, as well as AH-7921, U-47700 and MT-45. Most of these cases reporting a drug-caused death involved other drugs in addition to the opioid. No obvious minimum fatal concentration was discerned for any of the opioids for which details were provided, however, the more potent members required detection limits well under 1 ng/mL and often even well below 0.1 ng/mL requiring use of the most sensitive mass spectral detection procedures, particularly when screening specimens using a non-targeted mode. Four other novel opioids have been reported in admissions to hospitals include 4-chloroisobutryfentanyl, cyclopentylfentanyl and tetrahydrofuranfentanyl, all of which are likely to have the potential to cause death. It is also likely that other analogues will appear with time.

[Bonzai, lead and bath salt-poisoning with new and old drugs : Synthetic amphetamines, cathinones, cannabinoids and opioids-an overview]

BACKGROUND

There has been an increase in the number of serious poisonings and deaths after the use of new psychoactive substances (NPS). These are usually bought online: sometimes legally, often illegally or "in the grey area".

OBJECTIVES

Characteristics of different NPS. Legal status concerning the New Psychoactive Substances Act (NpSG). Risk assessment of several substance groups, possible complications of acute poisonings, therapeutic recommendations.

MATERIALS AND METHODS

Literature search and evaluation of own case data. Discussion of official statistics, literature and expert recommendations.

RESULTS

There has been an increase in the number of poisonings with NPS and associated deaths: in Germany in 2016 there were 98 deaths compared to 39 deaths in 2015. Serious acute poisonings require intensive care therapy. Therapy is usually symptomatic. Referring to the drugs discussed in this article an antidote is only available for the synthetic opioid: naloxone.

CONCLUSIONS

With the NpSG being in force since the end of 2016, the number of severe intoxications with NPS will probably (not immediately) decrease. It remains to be seen if the increasing number of fatalities will decrease again. Consultation with a poison centre is recommended in cases of suspected intoxication with NPS. Diagnosis and therapy can then be discussed. Toxicological screening may be false negative because many synthetic drugs are not detected in standard analysis. The NPS often require a special analysis.

Responding to New Psychoactive Substances in the European Union: Early Warning, Risk Assessment, and Control Measures

New psychoactive substances (NPS) are drugs that are not controlled by the United Nations international drug control conventions of 1961 and 1971 but that may pose similar threats to public health. Many of them are traded as "legal" replacements to controlled drugs such as cannabis, heroin, benzodiazepines, cocaine, amphetamines, and 3,4-methylenedioxymethamphetamine (MDMA). Driven by globalization, there has been a large increase in the availability and, subsequently, harms caused by these substances over the last decade in Europe. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is monitoring more than 670 NPS that have appeared on Europe's drug market in the last 20 years, of which almost 90% have appeared in the last decade. While some recent policy responses have been successful in reducing availability and sales of these substances in some settings - such as "legal highs" and "research chemicals" sold openly in the high street and online - and there are signs that growth in the market is slowing, new challenges have emerged. This includes monitoring a growing number of highly potent substances - including 179 synthetic cannabinoid receptor agonists and 28 fentanils - that can pose a high risk of life-threatening poisoning to users and can cause explosive outbreaks. This chapter briefly traces the origins of NPS, provides an overview of the situation in Europe, and discusses the work of the EMCDDA as part of a legal framework of early warning, risk assessment, and control measures that allows the European Union to rapidly detect, assess, and respond to public health and social threats caused by these substances.

An Expanding World of Novel Psychoactive Substances: Opioids

The abuse of novel psychoactive substances (NPS) has been increasing dramatically worldwide since late 2000s. By the end of 2015, more than 560 NPS had been reported to the European Monitoring Centre for Drugs and Drug Addiction. Although the most popular compounds are synthetic cannabinoids and psychostimulatory derivatives of cathinone (so-called β-keto-amphetamines), novel synthetic opioids have recently emerged on the recreational drug market. They include fentanyl (a potent narcotic analgesic) and its analogs (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. This survey provides an overview of the pharmacological properties, pattern of use, and desired and unwanted effects of the above-listed novel opioids. Special emphasis is given to cases of non-fatal and lethal intoxication involving these compounds.

Fentanyl novel derivative-related deaths

OBJECTIVE

Fentanyl (FEN) is a potent, synthetic narcotic used as an anaesthetic and a pain reliever, but also illegally manufactured. For diversion purpose, it is being steadily modified to produce new analogous compounds and derivatives (FENS), categorised as novel psychoactive substances. While potential FEN abuse is already known, even in the absence of a clear lethal dosage, there is still a shortage of data on its derivatives.

METHODS

A literature review of FENS-related deaths was performed, to better understand potential damage and future perspectives of FEN congeners.

RESULTS

Epidemiological data, pathological findings, administration routes, average concentrations and lethal doses, toxicological issues, trends in misuses, comparison among FENS, and possible explanation for FENS abuse are reviewed and discussed in depth.

CONCLUSIONS

This study provides a medical-legal and toxicological assessment of this phenomenon in order to understand the role of illegal fentanyl and its congeners in deaths from FENS overdose.

High Concomitant Misuse of Fentanyl in Subjects on Opioid Maintenance Treatment

BACKGROUND

Concomitant opioid misuse is an increasing problem in opioid maintenance treatment as it interferes with treatment success.

OBJECTIVE

Therefore, the rates of concomitant fentanyl misuse in opioid maintained patients were investigated.

METHODS

We conducted a cross-sectional study which consisted in collecting data via urine samples and questionnaires in Germany. Urine samples of patients on opioid maintenance treatment were gathered and fentanyl concentrations were measured from 2008 to 2012. An anonymous questionnaire provided data on the consumption of fentanyl as concomitant drug. Data were analyzed with descriptive statistics and group differences were calculated using the Chi-Square test.

RESULTS

Among the total sample (urine probes of 960 patients), 6.8% opioid maintained patients had positive urine samples for fentanyl and 37.9% reported concomitant fentanyl misuse (401 of these patients filled out the questionnaire). A significant age-related association of concomitant fentanyl misuse was identified in the urine analyses (χ² = 7.489; p = .024) and also in the questionnaire data (χ² = 11.899, p = .003), indicating that young age increased the probability of fentanyl consumption. Patients receiving methadone had the highest rates of concomitant fentanyl misuse with 18.4% according to urine analysis. In addition, the results show that patients who are on diamorphine are significantly less likely to misuse fentanyl.

CONCLUSIONS

Fentanyl is a frequently used concomitant drug. Especially young patients and patients taking methadone are at high risk. Because of the life-threatening consequences of fentanyl overdose, patients taking fentanyl should be intensively medically surveilled.

Studies on the metabolism of the fentanyl-derived designer drug butyrfentanyl in human in vitro liver preparations and authentic human samples using liquid chromatography-high resolution mass spectrometry (LC-HRMS)

Increasing numbers of new psychoactive substances (NPS) among them fentanyl derivatives has been reported by the European monitoring centre for drugs and drug addiction (EMCDDA). Butyrfentanyl is a new fentanyl derivative whose potency ratio was found to be seven compared to morphine and 0.13 compared to fentanyl. Several case reports on butyrfentanyl intoxications have been described. Little is known about its pharmacokinetic properties including its metabolism. However, knowledge of metabolism is essential for analytical detection in clinical and forensic toxicology. Therefore, in vitro and in vivo phase I and phase II metabolites of butyrfentanyl were elucidated combining liquid chromatography with a qTOF high resolution mass spectrometer. Human liver microsomes and recombinant cytochrome P450 enzymes (CYP) were used for in vitro assays. Authentic blood and urine samples from a fatal intoxication case were available for in vivo comparison. Butyrfentanyl was shown to undergo extensive metabolism. Six pathways could be postulated with hydroxylation and N-dealkylation being the major ones in vitro. In vivo, hydroxylation of the butanamide side chain followed by subsequent oxidation to the carboxylic acid represented the major metabolic step in the authentic case. Initial screening experiments with the most relevant CYPs indicated that mainly CYP2D6 and 3A4 were involved in the primary metabolic steps. Altered CYP2D6 and CYP3A4 status might cause a different metabolite pattern, making the inclusion of metabolites of different pathways recommendable when applying targeted screening procedures in clinical and forensic toxicology. Copyright © 2016 John Wiley & Sons, Ltd.

Non-fatal overdoses and related risk factors among people who inject drugs in St. Petersburg, Russia and Kohtla-Järve, Estonia

Background

This study seeks to identify the prevalence of, and risk factors associated with, non-fatal overdose among people currently injecting drugs (PWID) in St. Petersburg (Russia) and in Kohtla-Järve (Estonia).

Methods

Five hundred eighty-eight study participants in Kohtla-Järve (in 2012) and 811 in St. Petersburg (in 2012–2013) were recruited using respondent driven sampling for interviewing and HIV testing.

Results

Three-quarters (76 %) of the current PWID were male. Participants from St. Petersburg were older (mean age 32.1 vs. 29.6 years, p < 0.0001) and reported a longer average duration of injecting drugs (mean duration: 13.3 vs. 10.9 years, p < 0.0001). Main drugs injected were opioids (fentanyl in Kohtla-Järve, heroin in St Petersburg). HIV prevalence was 63 % (95 % CI 59–67 %) in Kohtla-Järve and 56 % (95 % CI 52–59 %) in St. Petersburg. Two thirds of the PWID in Kohtla-Järve and St. Petersburg reported ever having experienced a drug overdose involving loss of consciousness or stopping breathing. In Kohtla-Järve, 28 % (95 % CI 24–31 %) of participants and, in St Petersburg, 16 % (95 % CI 14–19 %) of participants reported an overdose within the previous 12 months. Characteristics of injection drug use practice (longer duration of injection drug use, main drug injected), correlates of high-risk injection behaviour (higher injecting frequency, sharing), and problem alcohol use were associated with the risk of overdose within the previous 12 months. The significant factors effects did not differ between the sites.

Conclusions

PWID are at high risk for overdose. Effective overdose prevention efforts at the public health scale are therefore warranted.

Postmortem Toxicology Findings of Acetyl Fentanyl, Fentanyl, and Morphine in Heroin Fatalities in Tampa, Florida

In the last two years, an epidemic of 40 fatal heroin overdose cases has occurred in the Tampa area of Florida. Of these cases, 14 involved fentanyl and acetyl fentanyl. Victim demographics, case histories, toxicology findings, and causes and manners of death for all 40 deaths are presented. In 26 deaths in which acetyl fentanyl or fentanyl were not involved, free and total peripheral blood morphine concentrations were consistent with fatal heroin intoxications, averaging 0.16 mg/L and 0.35 mg/L, respectively. In the heroin cases with fentanyl present (n=7), the average free morphine concentration was 0.040 mg/L, the average total morphine concentration was 0.080 mg/L, and the average fentanyl concentration was 0.012 mg/L. In the cases with heroin, fentanyl, and acetyl fentanyl (n=3), the average free morphine concentration was 0.010 mg/L, the average total morphine concentration was 0.030 mg/L, the average fentanyl concentration was 0.018 mg/L, and the average acetyl fentanyl concentration was 0.008 mg/L. In the cases involving only acetyl fentanyl (without heroin or fentanyl, n=4), the average acetyl fentanyl concentration was 0.47 mg/L and the average acetyl norfentanyl concentration was 0.053 mg/L. The presented cases, with associated drug concentrations, case histories, demographics, and causes and manners of death may help provide assistance with the interpretation of the postmortem findings. Based on case circumstances, autopsy results, and toxicology results, it is evident that fentanyl and/or acetyl fentanyl, when present, contributed to the cause of death.

[Metabolism of designer drugs. The fentanyl derivatives]

This literature review is focused on the studies of metabolism of designer drugs, with special reference to fentanyl derivatives. Certain physicochemical characteristics of the main metabolites most frequently encountered in the illegal trade of the fentanyl group analgesics have been calculated. The proposed recommendations include the methods for the identification of certain fentanyl derivatives during analysis of biological media.

Fentanyls: Are we missing the signs? Highly potent and on the rise in Europe

Fentanyl is a synthetic opioid analgesic historically used as a pain reliever and an anaesthetic. Recent concerns have arisen around the illicit use of fentanyl and its analogues in a number of European countries, linked to their high potency and associated risk of fatal overdose. Evidence has been emerging from Estonia for over a decade of entrenched patterns of fentanyl use, including injection of the drug and hundreds of overdose deaths. More recently, reports indicate that both fentanyl and 3-methylfentanyl (TMF) have been marketed as a replacement for heroin in European countries (e.g. Bulgaria, Slovakia) affected by heroin shortages. In addition, Germany, Finland and the United Kingdom, reported new outbreaks of fentanyl-related deaths. This combination of increasing mortality data alongside law enforcement intelligence suggesting both diversion and illicit production of fentanyls, prompted wider investigation using a targeted multi-source data collection exercise and analysis. This identified that in the European context, fentanyls are 'low use but high risk/harm' substances. Evidence shows that Estonia stands out as having an endemic problem, while the use of fentanyls in other European countries appears to be geographically localised. Developments in illicit supply of fentanyls reflect the complexity of Europe's contemporary drug market: manifesting illicit production and use, the diversion and misuse of medicines, and the online sale of non-controlled new psychoactive substances. Likewise effective and integrated responses will need to address fentanyl production, diversion as well as ensuring the availability of harm reduction measures to users.

Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world?

AIMS

This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions.

METHODS

Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated.

RESULTS

We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America.

CONCLUSIONS

Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.

Qualitative studies on the metabolism and the toxicological detection of the fentanyl-derived designer drugs 3-methylfentanyl and isofentanyl in rats using liquid chromatography-linear ion trap-mass spectrometry (LC-MS(n))

The opioid 3-methylfentanyl, a designer drug of the fentanyl type, was scheduled by the Controlled Substance Act due to its high potency and abuse potential. To overcome this regulation, isofentanyl, another designer fentanyl, was synthesized in a clandestine laboratory and seized by the German police. The aims of the presented study were to identify the phase I and phase II metabolites of 3-methylfentanyl and isofentanyl in rat urine, to identify the cytochrome P450 (CYP) isoenzymes involved in their initial metabolic steps, and, finally, to test their detectability in urine. Using liquid chromatography (LC)-linear ion trap-mass spectrometry (MS(n)), nine phase I and five phase II metabolites of 3-methylfentanyl and 11 phase I and four phase II metabolites of isofentanyl could be identified. The following metabolic steps could be postulated for both drugs: N-dealkylation followed by hydroxylation of the alkyl and aryl moiety, hydroxylation of the propanamide side chain followed by oxidation to the corresponding carboxylic acid, and, finally, hydroxylation of the benzyl moiety followed by methylation. In addition, N-oxidation of isofentanyl could also be observed. All hydroxy metabolites were partly excreted as glucuronides. Using recombinant human isoenzymes, CYP2C19, CYP2D6, CYP3A4, and CYP3A5 were found to be involved in the initial metabolic steps. Our LC-MS(n) screening approach allowed the detection of 0.01 mg/L of 3-methylfentanyl and isofentanyl in spiked urine. However, in urine of rats after the administration of suspected recreational doses, the parent drugs could not be detected, but their common nor metabolite, which should therefore be the target for urine screening.