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García Piqueras P, Vírseda González D, Soledad Encalada Luna K, Rodríguez Lomba E. Transdermal Fentanyl in Acute Skin Failure: Risks That Should be Closely Monitored at the Dermatology Emergency Room. ACTAS DERMO-SIFILIOGRAFICAS 2024:S0001-7310(24)00137-6. [PMID: 38373605 DOI: 10.1016/j.ad.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/22/2023] [Accepted: 04/02/2023] [Indexed: 02/21/2024] Open
Affiliation(s)
- P García Piqueras
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, España.
| | - D Vírseda González
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - K Soledad Encalada Luna
- Servicio de Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - E Rodríguez Lomba
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, España
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Sommerfeld-Klatta K, Jiers W, Łukasik-Głębocka M, Tezyk A, Dolińska-Kaczmarek K, Walter K, Świderski P, Rzepczyk S, Zielińska-Psuja B, Żaba C. Severe and Fatal Fentanyl Poisonings from Transdermal Systems after On-Skin and Ingestion Application. TOXICS 2023; 11:872. [PMID: 37888722 PMCID: PMC10610823 DOI: 10.3390/toxics11100872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023]
Abstract
In recent years, the administration of fentanyl (FNTL) implicitly in transdermal drug delivery systems (TDDS) has vastly increased in chronic pain treatment. Non-medical and uncontrolled use of FNTL in TFDS (transdermal fentanyl delivery systems) may reveal toxic effects by the route of exposure, dermal or alternative, by ingestion of patches, and drug release in the stomach. The purpose of this study was to present three different cases of FNTL poisonings, two of which resulted in death due to TFDS abuse. The first case is a 66-year-old woman treated for accidental FTNL poisoning resulting in acute respiratory distress syndrome. Two remaining cases are a 31-year-old woman and a 25-year-old man who died as a result of FNTL overdose after on-skin and ingestion application of the drug patches. During the hospitalization of the 66-year-old patient, in blood samples, FNTL was confirmed at a concentration of 10.0 ng/mL. Tests run on blood taken from the corpses of 25- and 31-year-old patients exhibited FNTL presence in concentrations of 29.1 ng/mL and 38.7 ng/mL, respectively. The various routes of administration and ultimately toxic effects are important to present because, in TDDS, fentanyl can be a reason for severe to fatal poisoning, as shown by the three cases above.
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Affiliation(s)
- Karina Sommerfeld-Klatta
- Department of Toxicology, Poznań University of Medical Sciences, 30 Dojazd Street, 60-631 Poznan, Poland
| | - Wiktoria Jiers
- Department of Toxicology, Poznań University of Medical Sciences, 30 Dojazd Street, 60-631 Poznan, Poland
| | - Magdalena Łukasik-Głębocka
- Department of Emergency Medicine, Poznań University of Medical Sciences, 7 Rokietnicka Street, 60-806 Poznan, Poland
| | - Artur Tezyk
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Klaudia Dolińska-Kaczmarek
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Kamil Walter
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Paweł Świderski
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Szymon Rzepczyk
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Barbara Zielińska-Psuja
- Department of Toxicology, Poznań University of Medical Sciences, 30 Dojazd Street, 60-631 Poznan, Poland
| | - Czesław Żaba
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
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O'Reilly D, McCartan F, Rizvi S. An unusual case of buprenorphine overdose secondary to sibling play: Examining how medication delivery devices appear to children. Br J Clin Pharmacol 2022; 88:2996-2997. [PMID: 34989014 DOI: 10.1111/bcp.15196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/03/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Daniel O'Reilly
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Ireland
| | - Frances McCartan
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Ireland
| | - Syed Rizvi
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Ireland
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Murray H, Gregoriou AN, Lepore A, Booth GJ, Goldman AH, Allen ML, Balazs GC. Why are US military personnel prescribed transdermal fentanyl patches? BMJ Mil Health 2021:bmjmilitary-2021-001894. [PMID: 34625516 DOI: 10.1136/bmjmilitary-2021-001894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Transdermal fentanyl is a continuous release opioid delivery system intended for use in opioid-tolerant patients requiring around-the-clock opioid therapy. The purpose of this study is to identify the most common indications for transdermal fentanyl prescriptions in active duty US military personnel, and determine whether these prescriptions meet US Food and Drug Administration (FDA) labelling. METHODS Active duty US military personnel initiating transdermal fentanyl therapy with prescriptions filled at Military Health System pharmacies between 2015 and 2019 were identified in the Military Data Repository. Electronic health records were searched for patient demographic information, clinical information and prescription data. A total of 225 patients with complete data were identified. RESULTS The most common reason for transdermal fentanyl initiation was chronic non-cancer musculoskeletal pain. Among patients with non-cancer pain, 36% received their initial prescription from an internal medicine/primary care provider, and 35% did not meet published US FDA criteria for opioid tolerance prior to treatment initiation. There was an 81% decrease in patients initiating therapy between 2015 and 2019. CONCLUSIONS While a substantial minority of transdermal fentanyl prescriptions to US military personnel did not meet FDA guidelines on appropriate use, the overall number of prescriptions fell dramatically over the study period. This suggests that automated profile review or additional targeted policies to limit transdermal fentanyl prescribing are unnecessary at this time.
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Affiliation(s)
- Hailey Murray
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - A N Gregoriou
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - A Lepore
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - G J Booth
- Department of Anesthesiology & Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.,Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - A H Goldman
- Bone & Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - M L Allen
- Pharmacy Department, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - G C Balazs
- Bone & Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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Cheema E, McGuinness K, Hadi MA, Paudyal V, Elnaem MH, Alhifany AA, Elrggal ME, Al Hamid A. Causes, Nature and Toxicology of Fentanyl-Associated Deaths: A Systematic Review of Deaths Reported in Peer-Reviewed Literature. J Pain Res 2020; 13:3281-3294. [PMID: 33324089 PMCID: PMC7732170 DOI: 10.2147/jpr.s280462] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/12/2020] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Fentanyl poisoning has been widely reported, yet there is a lack of systematic evaluation of the nature and toxicology of associated deaths in the published literature. This article aims to systematically review the nature, causes, routes of administration and toxicology of fentanyl-associated deaths using case studies and case series in peer-reviewed published literature. METHODS Four electronic databases including Embase, Medline (via Ovid), Scopus and Google Scholar were searched from inception until October 2019 to identify the studies reporting fentanyl related deaths. Two independent reviewers screened and selected the titles and then evaluated the full texts. Only case studies and case series were included. A structured data extraction tool was used to extract data on the number of deaths, routes of administration, concomitant drug use and toxicological data. The Joanna Briggs Institute quality assessment tool was used to evaluate the quality of included studies. Data were synthesized narratively. RESULTS Of 1251 articles identified during initial search, 8 case reports and 9 case series met the inclusion criteria. A total of 1969 deaths were reported in the included studies. Deaths were concentrated in the north American region (n = 1946) and the Nordic region (n = 22). Reported causes of death included fentanyl overdose (n = 321, 56.4%), mixed drug toxicity (n = 196, 34.5%), natural (n = 28, 4.9%), other drug toxicity (n = 10, 1.8%), fentanyl and ethanol intoxication (n = 8, 1.4%), incidental (n = 5, <1%) and aspiration (n = 1). Most common routes of use were intravenous (70.5%) and transdermal routes (23.0%). Deaths came swiftly via the intravenous route. Mean level of blood fentanyl amongst all reported deaths was 0.024 µg/mL. CONCLUSION Literature related to fentanyl-associated deaths predominantly come from North America. Deaths are comparatively lower or not reported in peer-reviewed publications from the rest of the world. Abuse through intravenous administration, mixed drug toxicities and self-treatment of breakthrough pain are mainly responsible for majority of the reported deaths.
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Affiliation(s)
- Ejaz Cheema
- School of Pharmacy, University of Birmingham, Birmingham, UK
| | | | | | - Vibhu Paudyal
- School of Pharmacy, University of Birmingham, Birmingham, UK
| | - Mohammed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University, Kuantan, Malaysia
| | - Abdullah A Alhifany
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Mahmoud E Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
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Pain Management in Childhood Leukemia: Diagnosis and Available Analgesic Treatments. Cancers (Basel) 2020; 12:cancers12123671. [PMID: 33297484 PMCID: PMC7762342 DOI: 10.3390/cancers12123671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
Pain is one of the most common symptoms in children suffering from leukemia, who are often misdiagnosed with other childhood painful diseases such as juvenile idiopathic arthritis. Corticosteroid-induced osteonecrosis (ON) and vincristine-induced peripheral neuropathy (VIPN) are the most common painful manifestations. Additionally, ongoing pain may continue to impact quality of life in survivorship. This narrative review focuses on the pathophysiological mechanisms of pain in childhood leukemia and current available indications for analgesic treatments. Pain management in children is often inadequate because of difficulties in pain assessment, different indications across countries, and the lack of specific pediatric trials. Analgesic drugs are often prescribed off-label to children by extrapolating information from adult guidelines, with possible increased risk of adverse events. Optimal pain management should involve a multidisciplinary team to ensure assessment and interventions tailored to the individual patient.
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Zanon M, Valentinuz E, Montanaro M, Radaelli D, Consoloni L, D’Errico S. Fentanyl transdermal patch: The silent new killer? FORENSIC SCIENCE INTERNATIONAL: REPORTS 2020. [DOI: 10.1016/j.fsir.2020.100104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Chesser R, Pardi J, Concheiro M, Cooper G. Distribution of synthetic opioids in postmortem blood, vitreous humor and brain. Forensic Sci Int 2019; 305:109999. [PMID: 31671355 DOI: 10.1016/j.forsciint.2019.109999] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/30/2019] [Accepted: 10/06/2019] [Indexed: 12/22/2022]
Abstract
In the US, the use of synthetic opioids (e.g. fentanyl and derivatives) has become an increasing health issue with thousands of overdose deaths being observed since 2013. With the high mortality rate associated with these substances, postmortem analyses and interpretation of synthetic opioids has become extremely important. However, due to the novelty of these compounds, the available data are limited and provides challenges to toxicologists. The objectives of this study were (1) to develop and validate analytical methods for the determination of synthetic opioids in vitreous humor and brain, and (2) to investigate the postmortem distribution of new synthetic opioids in blood, vitreous humor, and brain tissue. Vitreous humor (0.5mL) and brain tissue (5g) homogenized in water (diluted 1:3, w/w) were extracted by mixed mode cation exchange-reversed phase solid phase extraction. Extracts were analyzed by liquid chromatography tandem mass spectrometry (LC-MSMS). The chromatographic separation was performed by reversed-phase with 0.1% formic acid in water and in acetonitrile as mobile phases in gradient mode, with a total run time of 21min. Data were acquired with ESI+ in dynamic multiple reaction mode (dMRM), monitoring 2 transitions per compound. The methods were succesfully validated following SWGTOX guidelines, with limits of quantification of 0.1ng/mL in vitreous humor and 0.1ng/g in brain. Fifty-eight authentic case samples from the New York City Office of the Chief Medical Examiner (NYC-OCME) were analyzed to assess the distribution and detectability of synthetic opioids in these postmortem samples. Of the fifteen synthetic opioids included in the method, six synthetic opioids and metabolites (4-ANPP, acetylfentanyl, fentanyl, furanylfentanyl, norfentanyl, U-47700) were detected in the authentic cases. Concentrations for most analytes were within the 0.1 to 100ng/mL or ng/g calibration range across all three matrices, with only concentrations from acetylfentanyl and U-47700 exceeding 100ng/mL or ng/g. The highest concentrations were observed in brain (except norfentanyl), followed by blood and vitreous humor. Most analytes were detected in all three matrices in a given case. This was followed by detection of an analyte in combinations of brain and another matrix or brain only. Through the case analyses, vitreous humor and brain demonstrated to be viable alternatives to blood when performing postmortem analyses of synthetic opioids. Brain exhibited a higher detectability for most analytes when compared to blood and vitreous humor.
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Affiliation(s)
- Rachel Chesser
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York City, NY, United States
| | - Justine Pardi
- Department of Forensic Toxicology, Office of Chief Medical Examiner, New York City, NY, United States
| | - Marta Concheiro
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York City, NY, United States.
| | - Gail Cooper
- Department of Forensic Toxicology, Office of Chief Medical Examiner, New York City, NY, United States
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Thornton SL, Darracq MA. Patch Problems? Characteristics of Transdermal Drug Delivery System Exposures Reported to the National Poison Data System. J Med Toxicol 2019; 16:33-40. [PMID: 31410729 DOI: 10.1007/s13181-019-00723-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/10/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Transdermal drug delivery systems (TDDS) pose special risks considering a large amount of drug they contain and their modified release properties. We sought to characterize TDDS exposures reported to the National Poison Data System (NPDS). METHODS NPDS was searched for all human exposures to a TDDS from 1/1/2006 to 12/31/2015. Only single-substance TDDS exposures followed to a known medical outcome were included for final analysis. Specific data analyzed was date, sex, age, TDDS product, exposure reason, route of exposure, medical outcome, management site, level of health care facility care, clinical effects, and interventions. RESULTS Over that 10-year period, 6746 adults and 1917 pediatric exposures were identified. Exposures declined over the study period. The most common exposure reason in adults was intentional abuse (n = 1622) compared to unintentional-general (n =1 070) in pediatric cases. TDDS ingestion was reported in 4519 adults and 2825 pediatric cases. Fentanyl was the most common substance encountered in adult (n = 4656) and pediatric cases (n = 474). No or minor effect were the most common medical outcomes in both groups. In fentanyl cases, moderate or major outcomes were seen in 54 % (n = 1062) of adult and 26 % (n = 54) of pediatric cases. Naloxone was given in 1080 cases. Ninety-seven deaths (91 adults, 6 pediatrics) were reported, all involving ingestion of the TDDS. Fentanyl was associated with 80 adult and 5 pediatric deaths. CONCLUSION Overall, single-substance TDDS exposures decreased over the duration of this study and typically resulted in no or mild effects. However, exposures involving fentanyl resulted in higher rates of major or moderate medical outcomes and were associated with multiple deaths.
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Affiliation(s)
- Stephen L Thornton
- University of Kansas Health System Poison Control Center, University of Kansas Hospital, 4000 Cambridge St, Delp 4045B, Kansas City, KS, 66103, USA.
| | - Micheal A Darracq
- Department of Emergency Medicine, University of California- San Francisco-Fresno, Fresno, CA, 93701, USA
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Nara A, Yamada C, Saka K, Kodama T, Yoshida M, Iwahara K, Takagi T. A Fatal Case of Poisoning with Fentanyl Transdermal Patches in Japan. J Forensic Sci 2019; 64:1936-1942. [DOI: 10.1111/1556-4029.14127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Akina Nara
- Division of Legal Medicine Faculty of Medicine Tohoku Medical and Pharmaceutical University 1‐15‐1 Fukumuro, Miyagino‐ku Sendai‐shi Miyagi983‐8536 Japan
| | - Chiho Yamada
- Division of Legal Medicine Faculty of Medicine Tohoku Medical and Pharmaceutical University 1‐15‐1 Fukumuro, Miyagino‐ku Sendai‐shi Miyagi983‐8536 Japan
| | - Kanju Saka
- Department of Forensic Medicine Graduate School of Medicine The University of Tokyo 7‐3‐1 Hongo Bunkyo‐ku Tokyo113‐0033 Japan
| | - Takanori Kodama
- Division of Legal Medicine Faculty of Medicine Tohoku Medical and Pharmaceutical University 1‐15‐1 Fukumuro, Miyagino‐ku Sendai‐shi Miyagi983‐8536 Japan
| | - Masaki Yoshida
- Division of Legal Medicine Faculty of Medicine Tohoku Medical and Pharmaceutical University 1‐15‐1 Fukumuro, Miyagino‐ku Sendai‐shi Miyagi983‐8536 Japan
- Department of Legal Medicine Kyorin University 6‐20‐2 Shinkawa Mitaka‐shi Tokyo181‐8611 Japan
| | - Kaori Iwahara
- Division of Legal Medicine Faculty of Medicine Tohoku Medical and Pharmaceutical University 1‐15‐1 Fukumuro, Miyagino‐ku Sendai‐shi Miyagi983‐8536 Japan
- Center of Legal Medicine of Dentistry The Nippon Dental University School of Dentistry at Tokyo 1‐9‐20 Fujimi Chiyoda‐ku Tokyo102‐8159 Japan
| | - Tetsuya Takagi
- Division of Legal Medicine Faculty of Medicine Tohoku Medical and Pharmaceutical University 1‐15‐1 Fukumuro, Miyagino‐ku Sendai‐shi Miyagi983‐8536 Japan
- Center of Legal Medicine of Dentistry The Nippon Dental University School of Dentistry at Tokyo 1‐9‐20 Fujimi Chiyoda‐ku Tokyo102‐8159 Japan
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Hoizey G, Rey-Salmon C, Meyer P, Chèze M, Billault F, Medrano É, Deveaux M. Intoxication mortelle d’un nourrisson par un dispositif transdermique de fentanyl. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2018. [DOI: 10.1016/j.toxac.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Concheiro M, Chesser R, Pardi J, Cooper G. Postmortem Toxicology of New Synthetic Opioids. Front Pharmacol 2018; 9:1210. [PMID: 30416445 PMCID: PMC6212520 DOI: 10.3389/fphar.2018.01210] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/04/2018] [Indexed: 01/09/2023] Open
Abstract
One hundred fifteen Americans die every day from opioid overdose. These overdose fatalities have been augmented by the increased availability of potent synthetic opioids, such as fentanyl and its derivatives. The death rate of synthetic opioids, other than methadone, increased by 72.2% from 2014 to 2015, and doubled from 2015 to 2016, situating the USA in the midst of an opioid overdose epidemic. The analytical identification of these opioids in postmortem samples and the correct toxicological data interpretation is critical to identify and implement preventive strategies. This article reviews the current knowledge of postmortem toxicology of synthetic opioids and the chemical and pharmacological factors that may affect drug concentrations in the different postmortem matrices and therefore, their interpretation. These factors include key chemical properties, essential pharmacokinetics parameters (metabolism), postmortem redistribution and stability data in postmortem samples. Range and ratios of concentrations reported in traditional and non-traditional postmortem specimens, blood, urine, vitreous humor, liver and brain, are summarized in tables. The review is focused on fentanyl and derivatives (e.g., acetyl fentanyl, butyryl fentanyl, carfentanil, furanyl fentanyl, 4-methoxybutyrylfentanyl, 4-fluorobutyrylfentanyl, ocfentanil) and non-traditional opioid agonists (e.g., AH-7921, MT-45, U-47700). All of these data are critically compared to postmortem data, and chemical and pharmacological properties of natural opioids (morphine), semi-synthetic (oxycodone, hydrocodone, hydromorphone, and oxymorphone), and synthetic opioids (methadone and buprenorphine). The interpretation of drug intoxication in death investigation is based on the available published literature. This review serves to facilitate the evaluation of cases where synthetic opioids may be implicated in a fatality through the critical review of peer reviewed published case reports and research articles.
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Affiliation(s)
- Marta Concheiro
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY, United States
| | - Rachel Chesser
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY, United States
| | - Justine Pardi
- Department of Forensic Toxicology, New York Office of the Chief Medical Examiner, New York, NY, United States
| | - Gail Cooper
- Department of Forensic Toxicology, New York Office of the Chief Medical Examiner, New York, NY, United States
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D'Errico S. Commentary. Fentanyl-related death and the underreporting risk. J Forensic Leg Med 2018; 60:35-37. [PMID: 30265903 DOI: 10.1016/j.jflm.2018.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 02/06/2023]
Abstract
Novel synthetic opioid overdose deaths have been rising largely worldwide as a result of fentanyl adulteration in the illegal drug supply. Interpretation of post mortem analytical results concerning fentanyl can be challenging in particular due to redistribution phenomena. Lacking of resources, infrastructures and expertise to perform forensic toxicological investigation when an unknown drug or complex mixture of drugs is suspected can affect failure in exactly reporting cause in drug related death. Public safety and public health entities are called working together to enhance the timeliness and accuracy of the analytical characterization and toxicology testing of novel synthetic opioids.
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Affiliation(s)
- Stefano D'Errico
- Department of Legal Medicine, Azienda USL Toscana Nordovest, Lucca, Italy.
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Novel Synthetic Opioids: The Pathologist's Point of View. Brain Sci 2018; 8:brainsci8090170. [PMID: 30200549 PMCID: PMC6162684 DOI: 10.3390/brainsci8090170] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 02/03/2023] Open
Abstract
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.
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Current State of the Opioid Epidemic as it Pertains to Pediatric Orthopaedics From the Advocacy Committee of the Pediatric Orthopaedic Society of North America. J Pediatr Orthop 2018; 38:e238-e244. [PMID: 29489736 DOI: 10.1097/bpo.0000000000001143] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The opioid epidemic in the United States has reached crisis proportions. Urgent response is needed. Hydrocodone in combination with acetaminophen is the most prescribed drug in the United States. The most common source of opioids available for misuse is the unused portions of postoperative prescriptions. Among high school seniors, 80% of those who reported nonmedical use of prescription opioids previously had legitimate prescriptions but recreationally used leftover doses. Roughly one-quarter of patients do not take any of their postoperatively prescribed opioids and the remainder take one-third to two-thirds of the prescribed doses. METHODS A summary of the literature is presented beginning from historical perspective to current status and pertinent strategies in dealing with this complicated problem. This review includes data from an electronic survey of the members of the Pediatric Orthopaedic Society of North America (POSNA) with regard to the prescriptions they would provide for 7 treatment scenarios. RESULTS Strategies for the preoperative, intraoperative, and postoperative phases of management of pain as well as strategies for education, research, and advocacy are presented. The Pediatric Orthopaedic Society of North America survey yielded 264 respondents. The 3 most commonly used opioid medications were hydrocodone, oxycodone, and acetaminophen with codeine, in that order, for most of the scenarios. The time period covered by postoperative prescriptions varied considerably. CONCLUSIONS The magnitude of this problem is overwhelming. Education of care providers, patients and families, standardization of narcotic prescribing practices which incorporate patient characteristics, and appropriate plans for disposal of unused narcotics are immediate concepts to consider in correcting this problem. Long-term issues to tackle will be changing patient a family expectations, legislation, and obtaining additional resources directed towards this issue.
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Abstract
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.
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Affiliation(s)
- Olaf H Drummer
- Department of Forensic Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Southbank, Victoria, Australia
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18
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Abstract
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.
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Affiliation(s)
- Arianna Giorgetti
- Section of Legal Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Carmela Centola
- Section of Legal Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Raffaele Giorgetti
- Section of Legal Medicine, Università Politecnica delle Marche, Ancona, Italy
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