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Giorgetti A, Große Perdekamp M, Franchetti G, Pircher R, Pollak S, Pelotti S, Auwärter V. Intoxications involving methoxyacetylfentanyl and U-47700: a study of 3 polydrug fatalities. Int J Legal Med 2024:10.1007/s00414-024-03263-7. [PMID: 38831139 DOI: 10.1007/s00414-024-03263-7] [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: 01/18/2024] [Accepted: 05/28/2024] [Indexed: 06/05/2024]
Abstract
Novel synthetic opioids (NSOs) represent an emerging group of novel psychoactive substances, acting as agonists at the opioid receptors. NSOs include fentanyl-related compounds, e.g. methoxyacetylfentanyl (MeACF), and non-fentanyl analogs, e.g. "U compounds" including U-47700. Here we present three cases of death involving MeACF and U-47700, with particular reference to preliminary data on pharmacokinetics and tissue distribution.After a complete post-mortem examination, general unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassays, gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry. To quantify the analytes of interest in post-mortem blood and tissues, the standard addition method was used. A toxicological significance score (TSS), weighing the role of the NSO in each death case, was assigned.Case 1 died at the hospital after consumption of U-47700, methadone (serum levels: 2,600 ng/ml and 37 ng/ml), tilidine and benzodiazepines. In case 2, U-47700 (204 ng/ml) together with methadone (290 ng/ml), flubromazepam (480 ng/ml) and diazepam (300 ng/ml) were detected in peripheral blood. In case 3, methoxyacetylfentanyl (266 ng/ml), furanylfentanyl (4.3 ng/ml) 4-ANPP (15 ng/ml) and alprazolam (69 ng/ml) were quantified in femoral blood. In all cases, the NSO likely contributed to the death (TSS = 3).NSOs appear to be often consumed in the setting of polydrug intoxications, especially in combination with other opioids and benzodiazepines, which often exert synergistic effects. The standard addition method remains the most reliable in post-mortem analysis and toxicological results should always be evaluated together with circumstantial and autopsy data.
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Affiliation(s)
- Arianna Giorgetti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy.
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Marcus Große Perdekamp
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Giorgia Franchetti
- Legal Medicine, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35121, Padua, Italy
| | - Rebecca Pircher
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Pollak
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susi Pelotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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2
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Esdar N, Pawlik E, Eickhoff SB, Raupach A, Ritz-Timme S, Mayer F. Cardiac effects of 5F-Cumyl-PEGACLONE. Int J Legal Med 2024; 138:823-831. [PMID: 38214738 PMCID: PMC11003885 DOI: 10.1007/s00414-023-03146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/06/2023] [Indexed: 01/13/2024]
Abstract
Synthetic cannabinoids become increasingly popular as a supposedly safe and legal alternative to cannabis. In order to circumvent the German New Psychoactive Substances Law, producers of so-called herbal mixtures rapidly design new substances with structural alterations that are not covered by the law. Acting as full agonists not only at the cannabinoid receptors 1 and 2, synthetic cannabinoids might have not only desired mental but also serious physical adverse effects. However, knowledge of adverse effects of specific substances is sparse and incomplete. This also accounts for 5F-Cumyl-PEGACLONE, a synthetic cannabinoid, which has been detected regularly in Germany in recent years. By using an animal model, the isolated perfused Langendorff heart, the study at hand aimed on finding out more about possible cardiovascular adverse effects of 5F-Cumyl-PEGACLONE. Hearts of male Wistar rats, which were excised postmortem, were exposed to two different concentrations of 5F-Cumyl-PEGACLONE: 13 hearts were exposed to 50 ng/ml and 12 hearts were exposed to 100 ng/ml. Thirteen control hearts were merely exposed to an additional amount of buffer solution. Functional parameters heart rate, minimal and maximum left ventricular pressure and coronary flow were documented at pre-defined time points during and after the administration of 5F-Cumyl-PEGACLONE/additional buffer solution. Electrocardiograms (ECGs) were documented throughout the experiments and evaluated afterwards. Kruskal-Wallis analysis was performed for each functional parameter as well as for the duration of the QRS complexes and the duration of RR intervals as derived from the ECGs. Furthermore, a multivariate analysis, comprising all functional and ECG parameters, was performed. Kruskal-Wallis analysis revealed only single significant p-values for QRS duration and minimum left ventricular pressure that did not pass a Bonferroni test. The results of the multivariate approach were also comparably homogeneous, but still the model correctly recognized hearts exposed to 100 ng/ml of 5F-Cumyl-PEGACLONE more often than hearts exposed to the low concentration of 5F-Cumyl-PEGACLONE or additional buffer solution. Evaluation of the ECGs presented single cases of ST depression and QT prolongation. Though certainly not unambiguous, these findings support the assumption that 5F-Cumyl-PEGACLONE can cause severe, if not lethal, cardiac adverse effects like arrhythmias or myocardial infarctions especially if it is consumed in combination with other drugs like alcohol or if the consumer suffers from pre-existing heart diseases.
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Affiliation(s)
- Nicole Esdar
- Institute of Legal Medicine, University Hospital Düsseldorf, 40225, Düsseldorf, Germany
- Departement of Trauma Surgery, Hand Surgery and Orthopedics, Petrus Hospital Wuppertal, 42283, Wuppertal, Germany
| | - Evelyn Pawlik
- Institute of Legal Medicine, University Hospital Düsseldorf, 40225, Düsseldorf, Germany
| | - Simon B Eickhoff
- Institute for Systems Neuroscience, University Hospital Düsseldorf, 40225, Düsseldorf, Germany
| | - Annika Raupach
- Departement of Anaesthesiology, University Hospital Düsseldorf, 40225, Düsseldorf, Germany
| | - Stefanie Ritz-Timme
- Institute of Legal Medicine, University Hospital Düsseldorf, 40225, Düsseldorf, Germany
| | - Felix Mayer
- Institute of Legal Medicine, University Hospital Düsseldorf, 40225, Düsseldorf, Germany.
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3
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Groth O, Roider G, Angerer V, Schäper J, Graw M, Musshoff F, Auwärter V. "Spice"-related deaths in and around Munich, Germany: A retrospective look at the role of synthetic cannabinoid receptor agonists in our post-mortem cases over a seven-year period (2014-2020). Int J Legal Med 2023:10.1007/s00414-023-02995-2. [PMID: 37072496 PMCID: PMC10247575 DOI: 10.1007/s00414-023-02995-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/03/2023] [Indexed: 04/20/2023]
Abstract
Synthetic cannabinoid receptor agonists (SCRAs, "Spice") are a diverse group of recreational drugs, with their structural and pharmacological variability still evolving. Forensic toxicologists often rely on previous reports to assess their role in intoxication cases. This work provides detailed information on the "Spice"-related fatalities around Munich, Germany, from 2014 to 2020. All cases underwent an autopsy. Pharmaceutical and illicit drugs were detected and quantified in post-mortem peripheral blood or liver by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Based on circumstantial evidence, only those cases for which a prior consumption was suspected underwent additional analyses for SCRAs and other new psychoactive substances in post-mortem blood, liver or antemortem specimens. Drug concentrations, pathological findings at autopsy and case histories were considered to assess and rank the SCRAs' involvement in each death. Concentration ranges for the individual substances in blood were defined and their distribution patterns over the investigated period were determined and correlated with their legal status and local police seizures. We identified 41 different SCRAs among 98 fatalities. 91.8% were male, at a median age of 36 years. SCRAs played a causative role in 51%, contributory role in 26%, and an insignificant role in 23% of cases. In correlation with local police seizures and legal status, 5F-ADB was the most prevalent in our cases, followed by 5F-MDMB-PICA and AB-CHMINACA. Cumyl-CBMICA and 5F-MDMB-P7AICA were among the least frequently detected SCRAs. "Spice"-related fatalities and SCRAs' causative role have significantly decreased among our cases since the German New Psychoactive Substances Act.
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Affiliation(s)
- Olwen Groth
- Institute of Forensic Medicine, University of Munich, 80336, Munich, Germany.
| | - Gabriele Roider
- Institute of Forensic Medicine, University of Munich, 80336, Munich, Germany
| | - Verena Angerer
- Institute of Forensic Medicine, Medical Center, University of Freiburg, 79104, Freiburg, Germany
- Institute of Forensic Medicine, Forensic Toxicology, St. Gallen Cantonal Hospital, 9010, St. Gallen, Switzerland
| | - Jan Schäper
- Forensic Science Institute, Bavarian State Criminal Police Office (BLKA), 80636, Munich, Germany
| | - Matthias Graw
- Institute of Forensic Medicine, University of Munich, 80336, Munich, Germany
| | - Frank Musshoff
- Forensic Toxicological Center (FTC) Munich, Dessauerstrasse 13-15, 80992, Munich, Germany
| | - Volker Auwärter
- Institute of Forensic Medicine, Medical Center, University of Freiburg, 79104, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79110, Freiburg, Germany
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4
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Balcaen M, Ventura M, Gil C, Luf A, Martins D, Cunha M, Tögel-Lins K, Wolf D, Blanckaert P, Deconinck E. Challenges in Drug Surveillance: Strengthening the Analysis of New Psychoactive Substances by Harmonizing Drug Checking Services in Proficiency Testing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4628. [PMID: 36901637 PMCID: PMC10002093 DOI: 10.3390/ijerph20054628] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Drug checking is a proven harm reduction strategy and provides real-time information on the market of new psychoactive substances (NPS). It combines chemical analysis of samples with direct engagement with people who use drugs (PWUD), giving the ability to increase preparedness and responsiveness towards NPS. Next to that, it supports rapid identification of potential unwitting consumption. However, NPS cause a toxicological battle for the researchers, as factors such as the unpredictability and quick shift of the market complicate the detection. METHODS To evaluate challenges posed towards drug checking services, proficiency testing was set up to evaluate existing analytical techniques and investigate the capability to correctly identify circulating NPS. Twenty blind substances, covering the most common categories of substances, were analyzed according to the existing protocols of the existing drug checking services, including several analytical methods such as gas chromatography-mass spectrometry (GC-MS) and liquid chromatography with diode array detector (LC-DAD). RESULTS The proficiency test scores range from 80 to 97.5% accuracy. The most common issues and errors are mainly unidentified compounds, presumably due to no up-to-date libraries, and/ or confusion between structural isomers, such as 3- and 4-chloroethcathinone, or structural analogs, such as MIPLA (N-methyl-N-isopropyl lysergamide) and LSD (D-lysergic acid diethylamide). CONCLUSIONS The participating drug checking services have access to adequate analytical tools to provide feedback to drug users and provide up-to-date information on NPS.
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Affiliation(s)
- Margot Balcaen
- Unit Illicit Drugs, Lifestyle and Chronic Diseases, Scientific Direction Epidemiology, Sciensano, 1050 Brussels, Belgium
| | - Mireia Ventura
- Energy Control, Associació Benestar i Desenvolupament, 08041 Barcelona, Spain
| | - Cristina Gil
- Energy Control, Associació Benestar i Desenvolupament, 08041 Barcelona, Spain
| | - Anton Luf
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
| | | | - Mar Cunha
- Kosmicare, 1170-283 Lisbon, Portugal
| | | | - Danny Wolf
- Legal-high-Inhaltsstoffe, 60439 Frankfurt, Germany
| | - Peter Blanckaert
- Unit Illicit Drugs, Lifestyle and Chronic Diseases, Scientific Direction Epidemiology, Sciensano, 1050 Brussels, Belgium
| | - Eric Deconinck
- Service Medicines and Health Products, Scientific Direction Physical and Chemical Health Risks, Sciensano, J. Wytsmanstraat 14, 1050 Brussels, Belgium
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5
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Janssens LK, Ametovski A, Sparkes E, Boyd R, Lai F, Maloney CJ, Rhook D, Gerona RR, Connolly M, Liu H, Hibbs DE, Cairns EA, Banister SD, Stove CP. Comprehensive Characterization of a Systematic Library of Alkyl and Alicyclic Synthetic Cannabinoids Related to CUMYL-PICA, CUMYL-BUTICA, CUMYL-CBMICA, and CUMYL-PINACA. ACS Chem Neurosci 2023; 14:35-52. [PMID: 36530139 DOI: 10.1021/acschemneuro.2c00408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Over 200 synthetic cannabinoid receptor agonists (SCRAs) have been identified as new psychoactive substances. Effective monitoring and characterization of SCRAs are hindered by the rapid pace of structural evolution. Ahead of possible appearance on the illicit drug market, new SCRAs were synthesized to complete a systematic library of cumyl-indole- (e.g., CUMYL-CPrMICA, CUMYL-CPMICA) and cumyl-indazole-carboxamides (e.g., CUMYL-CPrMINACA, CUMYL-CPMINACA), encompassing butyl, pentyl, cyclopropylmethyl, cyclobutylmethyl, cyclopentylmethyl, and cyclohexylmethyl tails. Comprehensive pharmacological characterization was performed with three assay formats, monitoring the recruitment of either wild-type or C-terminally truncated (βarr2d366) β-arrestin2 to the activated cannabinoid 1 receptor (CB1) or monitoring Gβγ-mediated membrane hyperpolarization. Altered compound characterization was observed when comparing derived potency (EC50) and efficacy (Emax) values from both assays monitoring the same or a different signaling event, whereas ranges and ranking orders were similar. Structure-activity relationships (SAR) were assessed in threefold, resulting in the identification of the pendant tail as a critical pharmacophore, with the optimal chain length for CB1 activation approximating an n-pentyl (e.g., cyclopentylmethyl or cyclohexylmethyl tail). The activity of the SCRAs encompassing cyclic tails decreased with decreasing number of carbons forming the cyclic moiety, with CUMYL-CPrMICA showing the least CB1 activity in all assay formats. The SARs were rationalized via molecular docking, demonstrating the importance of the optimal steric contribution of the hydrophobic tail. While SAR conclusions remained largely unchanged, the differential compound characterization by both similar and different assay designs emphasizes the importance of detailing specific assay characteristics to allow adequate interpretation of potencies and efficacies.
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Affiliation(s)
- Liesl K Janssens
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Adam Ametovski
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Eric Sparkes
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Rochelle Boyd
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
| | - Felcia Lai
- School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
| | - Callan J Maloney
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Dane Rhook
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Roy R Gerona
- Clinical Toxicology and Environmental Biomonitoring Laboratory, University of California, San Francisco, California 94143, United States
| | | | | | - David E Hibbs
- School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
| | - Elizabeth A Cairns
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
| | - Samuel D Banister
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia.,School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Christophe P Stove
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000 Ghent, Belgium
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6
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Sommer MJ, Halter S, Angerer V, Auwärter V, Eyer F, Liebetrau G, Ebbecke M, Hermanns-Clausen M. Effect of new legislation in Germany on prevalence and harm of synthetic cannabinoids. Clin Toxicol (Phila) 2022; 60:1130-1138. [PMID: 36074033 DOI: 10.1080/15563650.2022.2095282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT New psychoactive substances (NPS) have become an ongoing threat to public health. To prevent the emergence and spread of NPS, a new German law, the 'NpSG' took effect in November 2016. This study presents an overview of analytically confirmed synthetic cannabinoid (SC) intoxications from January 2015 to December 2018. In order to demonstrate effects of the NpSG, the results of 23 month before and 25 month after the introduction of the law were compared. METHODS Within the scope of a prospective observational study blood and urine samples were collected from emergency patients with suspected NPS intoxication. Comprehensive drug analyses were performed by LC-MS/MS analysis. RESULTS In the period considered, 138 patients were included. Within these, SC intake was verified in 65 patients (73%) in the period before the law change, and in 30 patients (61%) after. The median age increased significantly from 19.5 to 26 years. Seizures and admission to the ICU were reported significantly less frequently (seizures 29% versus 6.7%, p = 0.0283; ICU admission 42% versus 13%, p = 0.0089). 34 different SCs were detected, including four SCs (Cumyl-PEGACLONE, 5 F-MDMB-P7AICA, EG-018, 5 F-Cumyl-P7AICA) not covered by the NpSG at the time of detection. In the first period the most prevalent SC was MDMB-CHMICA (n = 24). 5 F-ADB was the most prevalent SC overall, detected in 7 patients (11%) in the first, and in 24 patients (80%) in the second period. CONCLUSION The number of SC intoxications decreased overall after the implementation of the NpSG. The shift in the detected SCs can be considered a direct effect of the NpSG but unfortunately the market supply does not appear to have been reduced. Although changes in the age distribution and in the severity of intoxications may be seen as secondary effects of the law, the main objectives of the new law to prevent the emergence and spread of further chemical variations of known scheduled drugs, have apparently not been achieved from the perspective of this study.
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Affiliation(s)
- Michaela J Sommer
- Forensic Toxicology, Institute of Forensic Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Poisons Information Center, Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Mecine, University of Freiburg, Freiburg, Germany.,Hermann Staudinger Graduate School, University of Freiburg, Freiburg, Germany
| | - Sebastian Halter
- Forensic Toxicology, Institute of Forensic Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Mecine, University of Freiburg, Freiburg, Germany
| | - Verena Angerer
- Forensic Toxicology, Institute of Forensic Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Mecine, University of Freiburg, Freiburg, Germany
| | - Volker Auwärter
- Forensic Toxicology, Institute of Forensic Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Mecine, University of Freiburg, Freiburg, Germany
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Martin Ebbecke
- GIZ-Nord Poisons Centre, University Medical Centre Göttingen, Göttingen, Germany
| | - Maren Hermanns-Clausen
- Poisons Information Center, Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Mecine, University of Freiburg, Freiburg, Germany
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7
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Malaca S, Busardò FP, Nittari G, Sirignano A, Ricci G. Fourth Generation of Synthetic Cannabinoid Receptor Agonists: A Review on the Latest Insights. Curr Pharm Des 2022; 28:2603-2617. [PMID: 34781870 DOI: 10.2174/1381612827666211115170521] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/08/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Over the past few years, an emerging number of new psychoactive substances (NPSs) entered the illicit market. NPSs are designed to resemble the effects of classical drugs of abuse, reinforcing their effects and duration. Among the most abused NPS, synthetic cannabinoids are cannabinoid receptor agonists (SCRAs) that mimic the effect of the main psychotropic phytocannabinoid Δ9-tetrahydrocannabinol (THC). METHODS We herein reviewed the international literature to provide available information on the newest SCRAs generation. RESULTS Compared to the previous SCRAs generations, the structures of the last generation result in increased affinity for and efficacy at cannabinoid CB1 receptors, which are thought to be mainly responsible for the psychoactive effects of THC and its analogues. Accordingly, these more potent cannabimimetic effects may increase the number of adverse reactions such as neurological disorders (e.g., psychosis, agitation, irritability, paranoia, confusion, and anxiety), psychiatric episodes (e.g., hallucinations, delusions, self-harm), other physical conditions (e.g., tachycardia, hypertension, arrhythmia, chest pain, nausea, vomiting, and fever) and deaths. In the last decade, more than a hundred SCRAs from different chemical classes emerged on the illicit web market. SCRAs have been thoroughly studied: they were physico-chemically characterized, and pharmaco-toxicological characteristics were investigated. The last SCRAs generations include increasingly potent and toxic compounds, posing a potential health threat to consumers. CONCLUSION From November 2017 to February 2021, at least 20 new "fourth-generation" SCRAs were formally reported to international drug agencies. Our understanding of the neurotoxicity of these compounds is still limited due to the lack of global data, but their potency and their toxicity are likely higher than those of the previous generations.
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Affiliation(s)
- Sara Malaca
- Department of Excellence of Biomedical Sciences and Public Health, University "Politecnica delle Marche" of Ancona, Ancona, Italy
| | - Francesco P Busardò
- Department of Excellence of Biomedical Sciences and Public Health, University "Politecnica delle Marche" of Ancona, Ancona, Italy
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8
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Mohr ALA, Logan BK, Fogarty MF, Krotulski AJ, Papsun DM, Kacinko SL, Huestis MA, Ropero-Miller JD. Reports of Adverse Events Associated with Use of Novel Psychoactive Substances, 2017-2020: A Review. J Anal Toxicol 2022; 46:e116-e185. [PMID: 35445267 PMCID: PMC9282356 DOI: 10.1093/jat/bkac023] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022] Open
Abstract
An important role of modern forensic and clinical toxicologists is to monitor the adverse events of novel psychoactive substances (NPS). Following a prior review from 2013 to 2016, this critical literature review analyzes and evaluates published case reports for NPS from January 2017 through December 2020. The primary objective of this study is to assist in the assessment and interpretation of these cases as well as provide references for confirmation methods. Chemistry, pharmacology, adverse events and user profiles (e.g., polypharmacy) for NPS are provided including case history, clinical symptoms, autopsy findings and analytical results. Literature reviews were performed in PubMed and Google Scholar for publications using search terms such as NPS specific names, general terms (e.g., ‘designer drugs’ and ‘novel psychoactive substances’), drug classes (e.g., ‘designer stimulants’) and outcome-based terms (e.g., ‘overdose’ and ‘death’). Government and website drug surveillance databases and abstracts published by professional forensic science organizations were also searched. Toxicological data and detailed case information were extracted, tabulated, analyzed and organized by drug category. Case reports included overdose fatalities (378 cases), clinical treatment and hospitalization (771 cases) and driving under the influence of drugs (170 cases) for a total of 1,319 cases providing details of adverse events associated with NPS. Confirmed adverse events with associated toxidromes of more than 60 NPS were reported including synthetic cannabinoid, NPS stimulant, NPS hallucinogen, NPS benzodiazepine and NPS opioid cases. Fifty of these NPS were reported for the first time in January 2017 through December 2020 as compared to the previous 4 years surveyed. This study provides insight and context of case findings described in the literature and in digital government surveillance databases and websites during a recent 4-year period. This review will increase the awareness of adverse events associated with NPS use to better characterize international emerging drug threats.
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Affiliation(s)
- Amanda L A Mohr
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA, 19090, USA
| | - Barry K Logan
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA, 19090, USA.,NMS Labs, 200 Welsh Rd, Horsham, PA, 19044, USA
| | - Melissa F Fogarty
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA, 19090, USA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA, 19090, USA
| | | | | | - Marilyn A Huestis
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA, 19090, USA.,Institute of Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Jeri D Ropero-Miller
- RTI International, Center for Forensic Sciences, 3040 East Cornwallis Rd, Research Triangle Park, NC, 27709, USA
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9
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Ametovski A, Cairns EA, Grafinger KE, Cannaert A, Deventer MH, Chen S, Wu X, Shepperson CE, Lai F, Ellison R, Gerona R, Blakey K, Kevin R, McGregor IS, Hibbs DE, Glass M, Stove C, Auwärter V, Banister SD. NNL-3: A Synthetic Intermediate or a New Class of Hydroxybenzotriazole Esters with Cannabinoid Receptor Activity? ACS Chem Neurosci 2021; 12:4020-4036. [PMID: 34676751 DOI: 10.1021/acschemneuro.1c00348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Synthetic cannabinoid receptor agonists (SCRAs) remain a prolific class of new psychoactive substances (NPS) and continue to expand rapidly. Despite the recent identification of hydroxybenzotriazole (HOBt) containing SCRAs in synthetic cannabis samples, there is currently no information regarding the pharmacological profile of these NPS with respect to human CB1 and CB2 receptors. In the current study, a series consisting of seven HOBt indole-, indazole-, and 7-azaindole-carboxylates bearing a range of N-alkyl substituents were synthesized and pharmacologically evaluated. Competitive binding assays at CB1 and CB2 demonstrated that all analogues except a 2-methyl-substituted derivative had low affinity for CB1 (Ki = 3.80-43.7 μM) and CB2 (Ki = 2.75-18.2 μM). A fluorometric functional assay revealed that 2-methylindole- and indole-derived HOBt carboxylates were potent and efficacious agonists of CB1 (EC50 = 12.0 and 63.7 nM; Emax = 118 and 120%) and CB2 (EC50 = 10.9 and 321 nM; Emax = 91 and 126%). All other analogues incorporating indazole and 7-azaindole cores and bearing a range of N1-substituents showed relatively low potency for CB1 and CB2. Additionally, a reporter assay monitoring β-arrestin 2 (βarr2) recruitment to the receptor revealed that the 2-methylindole example was the most potent and efficacious at CB1 (EC50 = 131 nM; Emax = 724%) and the most potent at CB2 (EC50 = 38.2 nM; Emax = 51%). As with the membrane potential assay, the indazole and other indole HOBt carboxylates were considerably less potent at both receptors, and analogues comprising a 7-azaindole core showed little activity. Taken together, these data suggest that NNL-3 demonstrates little CB1 receptor activity and is unlikely to be psychoactive in humans. NNL-3 is likely an unintended SCRA manufacturing byproduct. However, the synthesis of NNL-3 analogues proved simple and general, and some of these showed potent cannabimetic profiles in vitro, indicating that HOBt esters of this type may represent an emerging class of SCRA NPS.
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Affiliation(s)
- Adam Ametovski
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Elizabeth A. Cairns
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
| | - Katharina Elisabeth Grafinger
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany
| | - Annelies Cannaert
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Marie H. Deventer
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Shuli Chen
- Department of Pharmacology and Toxicology, University of Otago, Dunedin 9016, New Zealand
| | - Xinyi Wu
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Caitlin E. Shepperson
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
| | - Felcia Lai
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales 2050, Australia
| | - Ross Ellison
- Clinical Toxicology and Environmental Biomonitoring Laboratory, University of California, San Francisco, California 94143, United States
| | - Roy Gerona
- Clinical Toxicology and Environmental Biomonitoring Laboratory, University of California, San Francisco, California 94143, United States
| | - Karen Blakey
- Illicit Drug Group, Forensic Chemistry, QHFSS, Queensland Health, Coopers Plains, Brisbane, QLD 4108, Australia
| | - Richard Kevin
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
| | - Iain S. McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Psychology, The University of Sydney, Sydney, NSW 2006, Australia
| | - David E. Hibbs
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales 2050, Australia
| | - Michelle Glass
- Department of Pharmacology and Toxicology, University of Otago, Dunedin 9016, New Zealand
| | - Christophe Stove
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany
| | - Samuel D. Banister
- The Lambert Initiative for Cannabinoid Therapeutics, Brain and Mind Centre, The University of Sydney, Sydney, NSW 2050, Australia
- School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
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10
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Ivanov ID, Stoykova SS, Burdzhiev NT, Pantcheva IN, Atanasov VN. Synthetic Cannabinoids 5F-QUPIC and MDMB-CHMICA in Plant Material – Identification and Quantification by Gas Chromatography – Mass Spectrometry (GC-MS), Nuclear Magnetic Resonance (NMR), and High-Performance Liquid Chromatography with Diode Array Detection (HPLC-DAD). ANAL LETT 2021. [DOI: 10.1080/00032719.2021.1879109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Ivo D. Ivanov
- Faculty of Chemistry and Pharmacy, Department of Analytical Chemistry, Sofia University “St. Kl. Ohridski”, Sofia, Bulgaria
- Department of Toxicology, Military Medical Academy, Sofia, Bulgaria
| | - Silviya S. Stoykova
- Faculty of Chemistry and Pharmacy, Department of Analytical Chemistry, Sofia University “St. Kl. Ohridski”, Sofia, Bulgaria
- Department of Toxicology, Military Medical Academy, Sofia, Bulgaria
| | - Nikola T. Burdzhiev
- Faculty of Chemistry and Pharmacy, Department of Organic Chemistry and Pharmacognosy, Sofia University “St. Kl. Ohridski”, Sofia, Bulgaria
| | - Ivayla N. Pantcheva
- Faculty of Chemistry and Pharmacy, Department of Analytical Chemistry, Sofia University “St. Kl. Ohridski”, Sofia, Bulgaria
| | - Vasil N. Atanasov
- Faculty of Chemistry and Pharmacy, Department of Analytical Chemistry, Sofia University “St. Kl. Ohridski”, Sofia, Bulgaria
- Department of Toxicology, Military Medical Academy, Sofia, Bulgaria
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11
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Giorgetti A, Barone R, Pelletti G, Garagnani M, Pascali J, Haschimi B, Auwärter V. Development and validation of a rapid LC-MS/MS method for the detection of 182 novel psychoactive substances in whole blood. Drug Test Anal 2021; 14:202-223. [PMID: 34599648 PMCID: PMC9298299 DOI: 10.1002/dta.3170] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 12/31/2022]
Abstract
Introduction The analysis of novel psychoactive substances (NPS) represents a challenge in forensic toxicology, due to the high number of compounds characterized by different structures and physicochemical properties both among different subclasses and within a single subclass of NPS. The aim of the present work is the development and validation of a targeted liquid chromatography tandem mass spectrometry (LC‐MS/MS) method for the detection of NPS in whole blood. Materials and methods A protein‐precipitation based LC‐MS/MS method for the detection of more than 180 NPS was developed and validated by assessing the following parameters: selectivity, linearity, accuracy, precision, limit of detection (LOD) and of quantification (LOQ) recovery, and matrix effect. Then, the method was applied to real forensic samples. Results The method allowed the identification of 132 synthetic cannabinoids, 22 synthetic opioids, and 28 substances among synthetic cathinones, stimulants, and other drugs. Validation was successfully achieved for most of the compounds. Linearity was in the range of 0.25–10 ng/ml for synthetic cannabinoids and 0.25–25 ng/ml for other drugs. Accuracy and precision were acceptable according to international guidelines. Three cases tested positive for fentanyl and ketamine, in the setting of emergency room administration. Conclusions The present methodology represents a fast, not expensive, wide‐panel method for the analysis of more than 180 NPS by LC‐MS/MS, which can be profitably applied both in a clinical context and in postmortem toxicology.
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Affiliation(s)
- Arianna Giorgetti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Bologna, Italy
| | - Rossella Barone
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Bologna, Italy
| | - Guido Pelletti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Bologna, Italy
| | - Marco Garagnani
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Bologna, Italy
| | - Jennifer Pascali
- Department of Legal and Occupational Medicine, Toxicology and Public Health, University Hospital of Padova, Padova, Italy
| | - Belal Haschimi
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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12
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Norman C, McKirdy B, Walker G, Dugard P, NicDaéid N, McKenzie C. Large-scale evaluation of ion mobility spectrometry for the rapid detection of synthetic cannabinoid receptor agonists in infused papers in prisons. Drug Test Anal 2021; 13:644-663. [PMID: 33058556 DOI: 10.1002/dta.2945] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 11/10/2022]
Abstract
Synthetic cannabinoid receptor agonists (SCRAs), colloquially known as "spice," are commonly used in prisons and enter establishments via the mail in the form of infused papers. Many prisons use benchtop ion mobility spectroscopy (IMS) instruments to screen mail and seized materials for the presence of SCRAs and other controlled substances. The selectivity and sensitivity of Rapiscan Itemiser® 3E and Itemiser® 4DN Ion Trap Mobility Spectroscopy™ (ITMS™) systems were evaluated using 21 SCRA reference standards. Some differences in the SCRA reduced mobility (K0 ) values were observed between this study and those reported previously using IMS detection systems, particularly for cumyl and quinolinyl SCRAs (e.g., 5F-PB-22, Cumyl-4CN-BINACA, and 5F-Cumyl-PEGACLONE), although this was found to have little effect at an operational level. Operational reliability of the systems was evaluated by analyzing 392 paper and card samples with known drug content. ITMS™ system results (e.g., detect or nondetect) were in agreement with gas chromatography-mass spectrometry (GC-MS) analysis in up to 95% of samples tested. Overall, this study found the ITMS™ systems tested to be effective instruments when deployed for the rapid detection of SCRA-infused papers. Used effectively and with up-to-date substance libraries, they will help reduce the supply of SCRAs into prisons and identify emerging threats as they arise. Several emerging SCRAs (5F-MPP-PICA, 5F-EMB-PICA, and 4F-MDMB-BICA) were detected for the first time in Scottish prisons between May and August 2020 as a result of routine monitoring, and all were detected using the ITMS™ systems tested.
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Affiliation(s)
- Caitlyn Norman
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Brian McKirdy
- HMP Inverness, Scottish Prison Service, Inverness, UK
| | - Gillian Walker
- Public Protection Unit, Scottish Prison Service, Edinburgh, UK
| | - Pat Dugard
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Niamh NicDaéid
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Craig McKenzie
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
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13
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Tiemensma M, Rutherford JD, Scott T, Karch S. Emergence of Cumyl-PEGACLONE-related fatalities in the Northern Territory of Australia. Forensic Sci Med Pathol 2020; 17:3-9. [PMID: 33185835 DOI: 10.1007/s12024-020-00334-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/11/2022]
Abstract
Suspected unnatural or unexpected deaths in the Northern Territory of Australia are reportable to the coroner, and investigation of such cases typically includes a post-mortem examination with comprehensive toxicological screening. An autopsy case series of five Cumyl-PEGACLONE-related fatalities over a recent eighteen-month period is presented. Databases of the Northern Territory coroner's office and the Royal Darwin Hospital Forensic Pathology Unit were searched to identify deaths related to synthetic cannabis use between July 1, 2018 and December 31, 2020. Toxicological analysis was performed at Forensic Science South Australia using a combination of liquid chromatography, gas chromatography and mass spectrometry. Cumyl-PEGACLONE, a synthetic cannabinoid receptor agonist (SCRA) with a gamma-carbolinone core, was detected in five cases (range in post-mortem blood 0.73-3.0 μg/L). Concurrent alcohol use and underlying cardiovascular disease were considered relevant factors in most cases. Toxicological Significance Scoring was carefully considered in all five cases, and in four cases, the presence of Cumyl-PEGACLONE was considered to be highly significant (TSS = 3). Synthetic cannabis use has not previously been identified in Northern Territory drug trends, and only one fatality related to the use of gamma-carbolines was identified in a recent Australia-wide study on synthetic cannabinoid-related fatalities. Deaths related to Cumyl-PEGACLONE use are emerging in the Northern Territory of Australia; this has public health implications. Although the exact mechanism(s) of death related to Cumyl-PEGACLONE are not fully established, this additional descriptive case series reaffirm an association with underlying cardiovascular disease, and suggest that concurrent use with alcohol may be relevant.
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Affiliation(s)
- Marianne Tiemensma
- Forensic Pathology Unit, Royal Darwin Hospital, Darwin, Australia. .,College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | | | - Timothy Scott
- Forensic Science South Australia, Adelaide, Australia.,College of Science and Engineering, Flinders University, Adelaide, Australia
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14
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YETER O. Simultaneous determination of 4F-MDMB BINACA, a new synthetic cannabinoid, and its metabolites in human blood samples by LC-MS/MS. JOURNAL OF THE TURKISH CHEMICAL SOCIETY, SECTION A: CHEMISTRY 2020. [DOI: 10.18596/jotcsa.770427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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15
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Dybowski MP, Holowinski P, Typek R, Dawidowicz AL. Comprehensive analytical characteristics of N-(adamantan-1-yl)-1- (cyclohexylmethyl)-1H-indazole-3-carboxamide (ACHMINACA). Forensic Toxicol 2020. [DOI: 10.1007/s11419-020-00547-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Abstract
Purpose
The aim of this study was to clarify the most essential analytical features of N-(adamantan-1-yl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (one of the newest cannabimimetics called ACHMINACA), to make them useful for analytical identification of this compound.
Methods
The compound was analyzed by gas chromatography–mass spectrometry, high-resolution liquid chromatography–mass spectrometry, crystal X-ray diffraction and spectroscopic methods such as nuclear magnetic resonance, Raman, and infrared spectroscopies.
Results
Detailed and comprehensive analytical data have been acquired for ACHMINACA.
Conclusions
Although brief descriptions of the partial data of ACHMINACA have appeared recently, this article provides the most detailed and comprehensive analytical data of ACHMINACA to our knowledge. Our data will significantly broaden the knowledge about the compound structure extending the possibility of its orthogonal analysis. The gathered data are useful for forensic, toxicological, and clinical purposes.
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16
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Affiliation(s)
- Piotr Adamowicz
- Department of Forensic Toxicology, Institute of Forensic Research, Kraków, Poland
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17
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Giorgetti A, Busardò FP, Tittarelli R, Auwärter V, Giorgetti R. Post-Mortem Toxicology: A Systematic Review of Death Cases Involving Synthetic Cannabinoid Receptor Agonists. Front Psychiatry 2020; 11:464. [PMID: 32523555 PMCID: PMC7261860 DOI: 10.3389/fpsyt.2020.00464] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/06/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Synthetic cannabinoid receptor agonists (SCRAs) have become the largest group of new psychoactive substances monitored by the European Union Early Warning System. Despite the wide diffusion on the market, data regarding effects, toxicities, and mechanisms as well as toxic/lethal doses are still scarce. METHODS A comprehensive literature search for articles published up to January 2019 was performed in multiple electronic databases. Only cases of death in which toxicological analyses revealed the presence of SCRAs in blood or urine and at least an external examination was performed, including those occurred in emergency departments, were included. RESULTS Of 380 studies identified, 354 were excluded, while 8 additional manuscripts were included through the screening of relevant references cited in the selected articles. A total number of 34 manuscripts (8 case series and 26 case reports) were included. CONCLUSIONS Typical toxic ranges for SCRAs have not been so far identified, and the results of toxicological analyses should be interpreted with caution. In death cases involving SCRAs, a thorough post-mortem examination is a prerequisite to assess the role of the substance use in the deceased and to identify a probable mechanism of death. Even after a comprehensive analysis of clinical, circumstantial, toxicological, and autoptic data, the cause and manner of death remain unclear in some cases.
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Affiliation(s)
- Arianna Giorgetti
- Legal Medicine and Toxicology, University-Hospital of Padova, Padova, Italy
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Francesco Paolo Busardò
- Section of Legal Medicine, Department of Excellence SBSP, University Politecnica delle Marche of Ancona, Ancona, Italy
| | - Roberta Tittarelli
- Unit of Forensic Toxicology, SAIMLAL Department, Sapienza University of Rome, Rome, Italy
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Raffaele Giorgetti
- Section of Legal Medicine, Department of Excellence SBSP, University Politecnica delle Marche of Ancona, Ancona, Italy
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