Life (and death) in Pink: The dangerous rise of synthetic opioids in the new psychoactive substances panorama

Concentrations of para-Fluorofuranylfentanyl (FFF) in Paired Central and Peripheral Blood Collected During Postmortem Death Investigations

The opioid epidemic in the United States (U.S.) has been associated with an increasing mortality rate in large part due to the emergence and proliferation of synthetic opioids over the last fifteen years. Fentanyl and its analogues have played a large part in these statistics due to their potency and toxicity. Fluorofuranylfentanyl (FFF) is a fentanyl analogue that emerged in the U.S. in 2018 and was associated with numerous adverse events and deaths. During this study, a liquid chromatography tandem mass spectrometry (LC-MS/MS) workflow was developed to accurately identify the isomer of FFF present (ortho- vs. meta- vs. para-) in medicolegal death investigation cases from Pinellas County, Florida. FFF was quantified in central and peripheral blood samples collected at autopsy. In addition, the metabolism of FFF was studied using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). para-FFF was quantitatively confirmed in 29 postmortem cases; no other isomer of FFF was detected. Central blood concentrations ranged between 0.66 and 73 ng/mL (mean = 11±14 ng/mL, median = 10 ng/mL) and peripheral blood concentrations ranged between 0.53 and 23 ng/mL (mean = 5.7±6.4 ng/mL, median = 2.7 ng/mL). Comparison of central to peripheral blood concentrations were evaluated to determine the possibility of postmortem redistribution (PMR). The metabolism of ortho-FFF was studied and found to undergo metabolic processes similar to fentanyl, producing ortho-fluorofuranyl-norfentanyl, fluoro-4-ANPP, and hydroxylated species. The results of this study demonstrate the toxicity of FFF and its implication in medicolegal death investigations. Laboratories must remain aware of new or re-emerging fentanyl analogues, as they pose significant risks to public health and public safety.

Psychopharmacological characterization of an emerging drug of abuse, a synthetic opioid U-47700, in adult zebrafish

3,4-Dichloro-N-[2-(dimethylamino)cyclohexyl]-N-methylbenzamide (U-47700) is a selective μ-opioid receptor agonist originally synthesized as a prospective analgesic drug. Several times more potent than morphine, U-47700 has high abuse potential and may cause clinical neurotoxicity, euphoria, respiratory depression and occasional mortality. U-47700 also evokes analgesia, sedation and euphoria-like states in both humans and rodents. Despite the growing use and abuse of U-47700, its psychopharmacological and toxicological profiles in vivo remain poorly understood. The zebrafish (Danio rerio) is rapidly becoming a popular aquatic model organism for central nervous system (CNS) disease modeling and drug discovery. Here, we examine acute (1, 5, 10, 25 and 50 mg/L for 20-min) and chronic (0.1, 0.5 and 1 mg/L for 14 days) effects of U-47700 in adult zebrafish. Overall, we found overt sedation evoked in fish by acute, and hyperlocomotion with an anxiolytic-like action by chronic, drug treatments. Acute treatment with 1 and 10 mg/L U-47700 also resulted in detectable amounts of this drug in the brain samples, supporting its permeability through the blood-brain barrier. Collectively, these findings emphasize complex dose- and treatment-dependent CNS effects of U-47700 following its acute and chronic administration. Our study also supports high sensitivity of zebrafish to U-47700, and suggests these aquatic models as promising in-vivo screens for probing potential CNS effects evoked by novel synthetic opioid drugs.

Early Identification of Locally Emerging Trends in Psychoactive Substance Use - Experience and Best Practice in Four European Localities

Background: Timely information about trends in psychoactive substance use could yield tailored interventions and reduce potential harms. However, conventional epidemiological tools might have limited capacity to detect trends emerging on a local level. Objectives: The aim of this study was to explore best practice in the identification of new drug trends at the local level. Methods: A total of 33 key informants from seven European municipalities/regions were interviewed to describe trends in substance use in their locality and to provide expert insights on how these were identified. Semi-structured interviews were analyzed with open coding method. Results: Four case studies that described local trends and responses were compiled: onset of problematic GHB use in the Dutch municipality of Breda (1); emerging retail shops selling new psychoactive substances (NPS) across the regions of Czech Republic (2) and in the Portuguese Agueda and Coimbra (3); and use of drugs with unknown content in the Italian region of Emilia Romagna, and its city Bologna (4). "Early identifiers" in the four case studies were organizations that work directly with people who use drugs (PWUD), emergency departments, and local police. Efficient methods of horizontal and vertical information sharing, sometimes facilitated by communication platforms, were in place, such that included early warning systems on local, national, and supra-local level. Local-level identification systems appeared as best suited to provide locally relevant information. Conclusions: Best practice in identifying emerging trends should involve all relevant "early identifiers", should consist of supra-local exchange platforms, integrate the qualities of local-level identification, and be facilitated by local-level coordinators.

Substance misuse-related poisoning deaths, England and Wales, 1993–2016

Context

In recent years there has been an increase in the availability of ‘novel psychoactive substances (NPS)’ or ‘legal highs’. In turn, there is concern as to the risks these compounds pose as compared to those posed by traditionally misused substances such as illicit diamorphine (heroin), methadone, cocaine, and amfetamines.

Methods

We reviewed deaths where opiates/opioids, stimulants, hypnosedatives, hallucinogens, or volatile substances were mentioned on the death certificate in England and Wales, 1993–2016 as recorded on the Office for National Statistics drug poisoning deaths database. Deaths were analysed by year of registration of death, age, sex, intent, drug(s) involved, and the presence of alcohol (ethanol).

Results

There were 68,347 drug-related deaths in England and Wales (includes both licit and illicit substances), of which 15,457 were either coded as, or had mention of, drug dependent/non-dependent substance abuse on the death certificate. Opioids, particularly diamorphine/morphine and methadone, featured in most deaths. Diamorphine/morphine-related deaths (17,402) increased from 155 in 1993 to 981 in 2001, and then remained relatively stable until 2010 (791). Thereafter, annual numbers of deaths fell to 579 in 2012, but have since increased to 1,209 (2016). Deaths in the age group 20–29 years declined from 46% (1993), to 13% (2016), whereas in those aged 40–49 years the percentage of deaths increased from 13% (1993) to 33% (2016). Methadone was mentioned in 7,894 deaths (1993–2016). Annual numbers of such deaths increased from 206 to 437, 1993–7, then declined, but have since increased, reaching 413 in 2016. As to age, a similar pattern as to diamorphine/morphine-related deaths is apparent. Annual numbers of deaths involving cocaine (1993–2016: 3,342), reached 235 in 2008, declined, but have since increased (2011: 112, 2016: 371). Annual numbers of deaths involving methylenedioxyamfetamine/ methylenedioxyethamfetamine/ methylenedioxymetamfetamine (‘ecstasy’) (1993–2016: 853), have also increased steadily in recent years (2010; 8, 2016: 65). There were relatively few mentions of ‘novel stimulants’ (1993–2016: 386) on death certificates and such deaths have declined in recent years (2015: 88, 2016: 57). Mephedrone was most frequently mentioned (122), as was para-methoxyamfetamine/ para-methoxymetamfetamine (88). Conversely, although synthetic cannabinoids were mentioned infrequently (1993–2016: 37), such deaths have increased recently (2015: 8, 2016: 26).

Conclusions

Illicit diamorphine (heroin) and methadone continue to be the principal drugs of abuse involved in fatal poisonings in England and Wales. The increase in such deaths in recent years has been largely due to an increase in deaths amongst older users, although the role of potent synthetic opioids such as carfentanil is a cause for concern. Overall, stimulants and related compounds have been implicated in an increasing number of deaths annually. The impact of the plethora of NPS that have appeared in recent years on fatal poisonings may have been mitigated by legislation.