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Patocka J, Wu W, Oleksak P, Jelinkova R, Nepovimova E, Spicanova L, Springerova P, Alomar S, Long M, Kuca K. Fentanyl and its derivatives: Pain-killers or man-killers? Heliyon 2024; 10:e28795. [PMID: 38644874 PMCID: PMC11031787 DOI: 10.1016/j.heliyon.2024.e28795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Fentanyl is a synthetic μ-opioid receptor agonist approved to treat severe to moderate pain with faster onset of action and about 100 times more potent than morphine. Over last two decades, abuse of fentanyl and its derivatives has an increased trend, globally. Currently, the United States (US) faces the most serious situation related to fentanyl overdose, commonly referred to as the opioid epidemic. Nowadays, fentanyl is considered as the number one cause of death for adults aged 18-45 in the US. Synthesis and derivatization of fentanyl is inexpensive to manufacture and easily achievable. Indeed, more than 1400 fentanyl derivatives have been described in the scientific literature and patents. In addition, accessibility and efficacy of fentanyl and its derivatives can play a potential role in misuse of these compounds as a chemical weapon. In this review, the properties, general pharmacology, and overdose death cases associated with fentanyl and selected derivatives are presented. Moreover, current opioid epidemic in the US, Moscow theatre hostage crisis, and potential misuse of fentanyl and its derivatives as a chemical weapon are disclosed.
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Affiliation(s)
- Jiri Patocka
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
| | - Wenda Wu
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
- School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, China
| | - Patrik Oleksak
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
| | - Romana Jelinkova
- NBC Defence Institute, University of Defence, 68201 Vyskov, Czech Republic
| | - Eugenie Nepovimova
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
| | - Lenka Spicanova
- Philosophical Faculty, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
| | - Pavlina Springerova
- Philosophical Faculty, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
| | - Suliman Alomar
- Doping Research Chair, Zoology Department, College of Science, King Saud University, Riyadh-11451, Kingdom of Saudi Arabia
| | - Miao Long
- Key Laboratory of Zoonosis of Liaoning Province, College of Animal Science & Veterinary Medicine, Shenyang Agricultural University, Shenyang 110866, China
| | - Kamil Kuca
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003 Hradec Kralove, Czech Republic
- Biomedical Research Centre, University Hospital in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
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Syrjanen R, Schumann JL, Lyons T, McKinnon G, Hodgson SE, Abouchedid R, Gerostamoulos D, Koutsogiannis Z, Fitzgerald J, Greene SL. A risk-based approach to community illicit drug toxicosurveillance: operationalisation of the Emerging Drugs Network of Australia - Victoria (EDNAV) project. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104251. [PMID: 37952318 DOI: 10.1016/j.drugpo.2023.104251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The Emerging Drugs Network of Australia - Victoria (EDNAV) project is a newly established toxicosurveillance network that collates clinical and toxicological data from patients presenting to emergency departments with illicit drug related toxicity in a centralised clinical registry. Data are obtained from a network of sixteen public hospital emergency departments across Victoria, Australia (13 metropolitan and three regional). Comprehensive toxicological analysis of a purposive sample of 22 patients is conducted each week, with reporting of results to key alcohol and other drug stakeholders. This paper describes the overarching framework and risk-based approach developed within Victoria to assess drug intelligence from EDNAV toxicosurveillance. METHODS Risk management principles from other spheres of public health surveillance and healthcare clinical governance have been adapted to the EDNAV framework with the aim of facilitating a consistent and evidence-based approach to assessing weekly drug intelligence. The EDNAV Risk Register was reviewed over the first two years of EDNAV project operation (September 2020 - August 2022), with examples of eight risk assessments detailed to demonstrate the process from signal detection to public health intervention. RESULTS A total of 1112 patient presentations were documented in the EDNAV Clinical Registry, with 95 signals of concern entered into the EDNAV Risk Register over the two-year study period. The eight examples examined in further detail included suspected drug adulteration (novel opioid adulterated heroin, para-methoxymethamphetamine adulterated 3,4-methylenedioxymethamphetamine (MDMA)), drug substitution (25B-NBOH sold as lysergic acid diethylamide, five benzodiazepine-type new psychoactive substances in a single tablet, protonitazene sold as ketamine), new drug detection (N,N-dimethylpentylone), contamination (unreported acetylfentanyl) and a fatality subsequent to MDMA use. A total of four public Drug Alerts were issued over this period. CONCLUSIONS Continued toxicosurveillance efforts are paramount to characterising the changing landscape of illicit drug use. This work demonstrates a functional model for risk assessment of illicit drug toxicosurveillance, underpinned by analytical confirmation and evidence-based decision-making.
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Affiliation(s)
- Rebekka Syrjanen
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jennifer L Schumann
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Victorian Institute of Forensic Medicine, Toxicology Department, Southbank, Victoria, Australia; Monash University, Monash Addiction Research Centre, Frankston, Victoria, Australia
| | - Tom Lyons
- The Department of Health, Alcohol and Other Drugs Strategy Team, Victorian State Government, Melbourne, Victoria, Australia
| | - Ginny McKinnon
- The Department of Health, Alcohol and Other Drugs Strategy Team, Victorian State Government, Melbourne, Victoria, Australia
| | - Sarah E Hodgson
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rachelle Abouchedid
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Bendigo Health, Emergency Department, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Dimitri Gerostamoulos
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Victorian Institute of Forensic Medicine, Toxicology Department, Southbank, Victoria, Australia
| | - Zeff Koutsogiannis
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia
| | - John Fitzgerald
- The University of Melbourne, Melbourne School of Population and Global Health, Parkville, Victoria, Australia
| | - Shaun L Greene
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia.
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3
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Bergerhoff M, Moosmann B. Novel Receptor-Binding-Based Assay for the Detection of Opioids in Human Urine Samples. Anal Chem 2023; 95:2723-2731. [PMID: 36706344 DOI: 10.1021/acs.analchem.2c03516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Consumption of opioids is a growing global health problem. The gold standard for drugs of abuse screening is immunochemical assays. However, this method comes with some disadvantages when screening for a wide variety of opioids. Detection of the binding of a compound at the human μ-opioid receptor (MOR) offers a promising alternative target. Here, we set up a urine assay to allow for detection of compounds that bind at the MOR, thus allowing the assay to be utilized as a screening tool for opioid intake. The assay is based on the incubation of MOR-containing cell membranes with the selective MOR-ligand DAMGO and urine. After filtration, the amount of DAMGO in the eluate is analyzed by liquid chromatography tandem mass spectroscopy (LC-MS/MS). The absence of DAMGO in the eluate corresponds to a competing MOR ligand in the urine sample, thus indicating opiate/opioid intake by the suspect. Sensitivity and specificity were determined by the analysis of 200 consecutive forensic routine casework urine samples. A pronounced displacement of DAMGO was observed in 29 of the 35 opiate/opioid-positive samples. Detection of fentanyl intake proved to be the most challenging aspect. Applying a cut-off value of, e.g., 10% DAMGO binding would lead to a sensitivity of 83% and a specificity of 95%. Consequently, the novel assay proved to be a promising screening tool for opiate/opioid presence in urine samples. The nontargeted approach and possible automation of the assay make it a promising alternative to conventional methods.
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Affiliation(s)
- Maja Bergerhoff
- Institute of Forensic Medicine, Forensic Toxicology, Kantonsspital St. Gallen, St. Gallen 9007, Switzerland
| | - Bjoern Moosmann
- Institute of Forensic Medicine, Forensic Toxicology, Kantonsspital St. Gallen, St. Gallen 9007, Switzerland
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New Psychoactive Substances: Major Groups, Laboratory Testing Challenges, Public Health Concerns, and Community-Based Solutions. J CHEM-NY 2023. [DOI: 10.1155/2023/5852315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Across communities worldwide, various new psychoactive substances (NPSs) continue to emerge, which worsens the challenges to global mental health, drug rules, and public health risks, as well as combats their usage. Specifically, the vast number of NPSs that are currently available, coupled with the rate at which new ones emerge worldwide, increasingly challenges both forensic and clinical testing strategies. The well-established NPS detection techniques include immunoassays, colorimetric tests, mass spectrometric techniques, chromatographic techniques, and hyphenated types. Nonetheless, mitigating drug abuse and NPS usage is achievable through extensive community-based initiatives, with increased focus on harm reduction. Clinically validated and reliable testing of NPS from human samples, along with community-driven solution, such as harm reduction, will be of great importance, especially in combating their prevalence and the use of other illicit synthetic substances. There is a need for continued literature synthesis to reiterate the importance of NPS, given the continuous emergence of illicit substances in the recent years. All these are discussed in this overview, as we performed another look into NPS, from differentiating the major groups and identifying with laboratory testing challenges to community-based initiatives.
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Gjerde H, Bretteville-Jensen AL, Bache-Andreassen L, Hanoa K, Furuhaugen H, Brochmann GW, Vindenes V. Which illicit drugs are injected in Oslo? A study based on analysis of drug residues in used injection equipment and self-reported information. Scand J Public Health 2023; 51:21-27. [PMID: 34538164 PMCID: PMC9900188 DOI: 10.1177/14034948211043984] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND People who inject drugs (PWID) have a high risk of premature death due to fatal overdoses. Newly emerged fentanyls, much more potent than heroin and other opioids, may increase this risk further. Therefore, precise information on injected drugs is critical to improving prevention strategies. AIMS This study aimed to analyse drug residues in used injection equipment in order to determine drug and drug combinations and compare and complement findings with self-reported information. METHODS Used syringes and needles (n=766) were collected at the supervised drug consumption facilities, the needle exchange service and two low-threshold health services for problem drug users in Oslo, Norway. The material was collected every third month from June 2019 to June 2020 and analysed for 64 substances using highly specific analytical methods (ultra-high performance liquid chromatography tandem mass spectrometry). Additionally, a street-recruited sample of PWID was interviewed from 2017 to 2019 regarding their drug injection habits (n=572). RESULTS Heroin (65.5%) or amphetamines (59.8%), often in combination (30.5%), were commonly detected in drug residues. Other opioids, stimulants or benzodiazepines were rarely detected (6.1%). Fentanyl was detected in only one syringe. Heroin was the most reported drug (77.6% during the past four weeks, 48.3% daily/almost daily), followed by amphetamines (57.5% during the past four weeks, 23.1% daily or almost daily). Injection of methadone, buprenorphine and dissolved tablets was self-reported more frequently than determined in drug residue findings. CONCLUSIONS
Analysis of the injection equipment proved useful as a non-invasive, rapid and accurate means to obtain detailed information on injected drugs in Oslo and supplement traditional PWID survey information.
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Affiliation(s)
- Hallvard Gjerde
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway,Hallvard Gjerde, Oslo University Hospital,
Department of Forensic Sciences, Section for Drug Abuse Research, P.O. Box 4950
Nydalen, NO-0424 Oslo, Norway. E-mail:
| | | | - Lihn Bache-Andreassen
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway
| | - Kristin Hanoa
- Department of Alcohol, Tobacco and
Drugs, Norwegian Institute of Public Health, Norway
| | - Håvard Furuhaugen
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway
| | - Gerd-Wenche Brochmann
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway
| | - Vigdis Vindenes
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway,Institute of Clinical Medicine, Faculty
of Medicine, University of Oslo, Norway
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6
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Papsun DM, Krotulski AJ, Logan BK. Proliferation of Novel Synthetic Opioids in Postmortem Investigations After Core-Structure Scheduling for Fentanyl-Related Substances. Am J Forensic Med Pathol 2022; 43:315-327. [PMID: 36103391 DOI: 10.1097/paf.0000000000000787] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
ABSTRACT New generations of novel synthetic opioids (NSOs) have emerged to fill a void in the illicit drug markets left by the decline in popularity of fentanyl analogs subsequent to core-structure scheduling of fentanyl-related substances in the United States and China. These new opioids include members of the 2-benzyl benzimidazole (eg, isotonitazene, metonitazene, N -pyrrolidino etonitazene, protonitazene, etodesnitazene), benzimidazolone (eg, brorphine), and cinnamylpiperazine (eg, AP-238, 2-methyl AP-237) subclasses. Novel synthetic opioids continue to be detected in opioid-related fatal overdoses, demonstrating the harms associated with exposure to these drugs. Between January 2020 and December 2021, 384 casework blood samples were reported by our laboratory to contain 1 or more of the prior listed 8 NSOs. Isotonitazene (n = 144), metonitazene (n = 122), and brorphine (n = 91) were the 3 most prevalent substances, with positivity for isotonitazene and brorphine peaking just before the announcement of emergency scheduling. These NSOs have been documented as significant drivers of drug mortality, and this case series described here highlights the challenges medical examiners and coroners face in staying current with emerging drugs. Challenges include regional differences, rapid turnover, short lifecycles, variable toxicology testing, and difficulty in assessing individual drug toxicity in polydrug cases.
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Affiliation(s)
| | - Alex J Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow, Grove, PA
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7
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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] [MESH Headings] [Grants] [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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8
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Simão AY, Antunes M, Cabral E, Oliveira P, Rosendo LM, Brinca AT, Alves E, Marques H, Rosado T, Passarinha LA, Andraus M, Barroso M, Gallardo E. An Update on the Implications of New Psychoactive Substances in Public Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:4869. [PMID: 35457736 PMCID: PMC9028227 DOI: 10.3390/ijerph19084869] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023]
Abstract
The emergence of new psychoactive substances has earned a great deal of attention, and several reports of acute poisoning and deaths have been issued involving, for instance, synthetic opiates. In recent years, there have been profound alterations in the legislation concerning consumption, marketing, and synthesis of these compounds; rapid alert systems have also been subject to changes, and new substances and new markets, mainly through the internet, have appeared. Their effects and how they originate in consumers are still mostly unknown, primarily in what concerns chronic toxicity. This review intends to provide a detailed description of these substances from the point of view of consumption, toxicokinetics, and health consequences, including case reports on intoxications in order to help researchers and public health agents working daily in this area.
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Affiliation(s)
- Ana Y. Simão
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
| | - Mónica Antunes
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Serviço de Química e Toxicologia Forenses, Instituto Nacional de Medicina Legal e Ciências Forenses, Delegação do Sul, 1150-219 Lisboa, Portugal
| | - Emanuel Cabral
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Patrik Oliveira
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Luana M. Rosendo
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Ana Teresa Brinca
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Estefânia Alves
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Hernâni Marques
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
| | - Tiago Rosado
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
| | - Luís A. Passarinha
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- UCIBIO—Applied Molecular Biosciences Unit, Departamento de Química, NOVA School of Science and Technology, Universidade NOVA, 2829-516 Caparica, Portugal
- Associate Laboratory i4HB-Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA, 2819-516 Caparica, Portugal
| | | | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto Nacional de Medicina Legal e Ciências Forenses, Delegação do Sul, 1150-219 Lisboa, Portugal
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
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9
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Bilel S, Azevedo Neto J, Arfè R, Tirri M, Gaudio RM, Fantinati A, Bernardi T, Boccuto F, Marchetti B, Corli G, Serpelloni G, De-Giorgio F, Malfacini D, Trapella C, Calo' G, Marti M. In vitro and in vivo pharmaco-dynamic study of the novel fentanyl derivatives: Acrylfentanyl, Ocfentanyl and Furanylfentanyl. Neuropharmacology 2022; 209:109020. [PMID: 35247453 DOI: 10.1016/j.neuropharm.2022.109020] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 02/16/2022] [Accepted: 02/24/2022] [Indexed: 01/21/2023]
Abstract
Fentanyl derivatives (FENS) belongs to the class of Novel Synthetic Opioids that emerged in the illegal drug market of New Psychoactive Substances (NPS). These substances have been implicated in many cases of intoxication and death with overdose worldwide. Therefore, the aim of this study is to investigate the pharmaco-dynamic profiles of three fentanyl (FENT) analogues: Acrylfentanyl (ACRYLF), Ocfentanyl (OCF) and Furanylfentanyl (FUF). In vitro, we measured FENS opioid receptor efficacy, potency, and selectivity in calcium mobilization studies performed in cells coexpressing opioid receptors and chimeric G proteins and their capability to promote the interaction of the mu receptor with G protein and β-arrestin 2 in bioluminescence resonance energy transfer (BRET) studies. In vivo, we investigated the acute effects of the systemic administration of ACRYLF, OCF and FUF (0.01-15 mg/kg i.p.) on mechanical and thermal analgesia, motor impairment, grip strength and cardiorespiratory changes in CD-1 male mice. Opioid receptor specificity was investigated in vivo using naloxone (NLX; 6 mg/kg i.p) pre-treatment. In vitro, the three FENS were able to activate the mu opioid receptor in a concentration dependent manner with following rank order potency: FUF > FENT=OCF > ACRYLF. All compounds were able to elicit maximal effects similar to that of dermorphin, with the exception of FUF which displayed lower maximal effects thus behaving as a partial agonist. In the BRET G-protein assay, all compounds behaved as partial agonists for the β-arrestin 2 pathway in comparison with dermorphin, whereas FUF did not promote β-arrestin 2 recruitment, behaving as an antagonist. In vivo, all the compounds increased mechanical and thermal analgesia with following rank order potency ACRYLF = FENT > FUF > OCF and impaired motor and cardiorespiratory parameters. Among the substances tested, FUF showed lower potency for cardiorespiratory and motor effects. These findings reveal the risks associated with the use of FENS and the importance of studying the pharmaco-dynamic properties of these drugs to better understand possible therapeutic interventions in the case of toxicity.
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Affiliation(s)
- Sabrine Bilel
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy
| | - Joaquim Azevedo Neto
- Department of Neuroscience and Rehabilitation, Section of Pharmacology, University of Ferrara, Via Fossato di Mortara 17/19, 44121, Ferrara, Italy
| | - Raffaella Arfè
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy
| | - Micaela Tirri
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy
| | - Rosa Maria Gaudio
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy; Center of Gender Medicine, University of Ferrara, Italy
| | - Anna Fantinati
- Department of Chemistry and Pharmaceutical Sciences, University of Ferrara, Italy
| | - Tatiana Bernardi
- Department of Chemistry and Pharmaceutical Sciences, University of Ferrara, Italy
| | - Federica Boccuto
- Department of Chemistry and Pharmaceutical Sciences, University of Ferrara, Italy
| | - Beatrice Marchetti
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy
| | - Giorgia Corli
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy
| | - Giovanni Serpelloni
- Neuroscience Clinical Center & TMS Unit Verona, Italy and Department of Psychiatry in the College of Medicine, Drug Policy Institute, University of Florida, Gainesville, FL, United States
| | - Fabio De-Giorgio
- Institute of Public Health, Section of Legal Medicine, Università Cattolica Del Sacro Cuore, Roma, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Davide Malfacini
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Italy
| | - Claudio Trapella
- Department of Chemistry and Pharmaceutical Sciences, University of Ferrara, Italy
| | - Girolamo Calo'
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Italy
| | - Matteo Marti
- Department of Translational Medicine, Section of Legal Medicine and LTTA Centre, University of Ferrara, Italy; Center of Gender Medicine, University of Ferrara, Italy; Collaborative Center of the National Early Warning System, Department for Anti-Drug Policies, Presidency of the Council of Ministers, Italy.
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10
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Koshute P, Hagan N, Jameson NJ. Machine learning model for detecting fentanyl analogs from mass spectra. Forensic Chem 2022. [DOI: 10.1016/j.forc.2021.100379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Zawadzki M, Wachełko O, Tusiewicz K, Szpot P. Severe poisoning after smoking a mixture of 4-fluoroisobutyryl fentanyl (4-FiBF) and alpha-pyrolidinoisohexaphenone (α-PiHP). J Forensic Leg Med 2021; 85:102287. [PMID: 34798437 DOI: 10.1016/j.jflm.2021.102287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/20/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
CONTEXT Intoxications after ingestion of new psychoactive substances are currently one of the most challenging issues in clinical toxicology. Synthetic cathinones represented the largest group of drugs seized in 2020, but the increasing distribution of fentanyl analogues is resulting in a growing global opioid crisis. In addition, synthetic opioids may be intentionally combined with psychostimulants by drug manufacturers to reduce depressive effects. We report a case of severe poisoning after smoking a mixture of 4-fluoroisobutyryl fentanyl (4-FiBF) and alpha-pyrrolidinoisohexaphenone (α-PiHP). CASE DETAILS A 29-year-old male was found out of conscious in his apartment and taken to the Intensive Care Unit. Examinations revealed pinpoint pupils, slight respiratory acidosis, leukocytosis as well as body temperature of 39.4 °C and increased creatinine with decreased eGFR level. Toxicological analysis of biological samples revealed presence of 4-FiBF and α-PiHP in concentrations: 87.7 ng/mL and 5.0 ng/mL (blood) and 2291.0 ng/mL and 722.2 ng/mL (urine), respectively. After 4 days, the patient was discharged home. DISCUSSION Unique combination of clinical symptoms was a result of a simultaneous 4-FiBF and α-PiHP intoxication. To our knowledge, this is the first case of ingestion such unusual mixture of new psychoactive substances with a full description of medical treatment.
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Affiliation(s)
- Marcin Zawadzki
- Wroclaw Medical University Department of Forensic Medicine, 4 J. Mikulicza-Radeckiego Street, Lower Silesia Province, Wroclaw, 50345, Poland; Institute of Toxicology Research, 45 Kasztanowa Street, Lower Silesia Province, Borowa, 55093, Poland.
| | - Olga Wachełko
- Institute of Toxicology Research, 45 Kasztanowa Street, Lower Silesia Province, Borowa, 55093, Poland.
| | - Kaja Tusiewicz
- Institute of Toxicology Research, 45 Kasztanowa Street, Lower Silesia Province, Borowa, 55093, Poland.
| | - Paweł Szpot
- Wroclaw Medical University Department of Forensic Medicine, 4 J. Mikulicza-Radeckiego Street, Lower Silesia Province, Wroclaw, 50345, Poland; Institute of Toxicology Research, 45 Kasztanowa Street, Lower Silesia Province, Borowa, 55093, Poland.
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12
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Adamowicz P, Nowak K. Blood concentrations of new synthetic opioids. Int J Legal Med 2021; 136:107-122. [PMID: 34676457 DOI: 10.1007/s00414-021-02729-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/15/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE Over the last decade, there has been a significant growth in the market and number of new psychoactive substances (NPS). One of the NPS groups that has grown rapidly in recent years, bringing a new set of problems, consists of new synthetic opioids. The extreme potency of these compounds poses a high risk of acute poisoning, as an overdose can cause respiratory depression. Most of the information regarding human pharmacokinetics of new opioids is based on toxicological case reports and the data on concentrations of new opioids in human blood are scarce. The interpretation of results usually requires a comparison to previously published cases; therefore, a referenced compilation of previously published concentration data would be useful. METHODS The data were collected by searching the PubMed and Scopus databases and by using the Google search engine. All the available data from articles and reports that measured new opioid concentrations in plasma, serum, or whole blood were included in the data analysis. RESULTS The presented tables list the observed concentrations in fatal and nonfatal cases involving 37 novel synthetic opioids. CONCLUSIONS Blood levels of new opioids are extremely difficult to interpret. Low blood concentrations of these substances do not rule out acute poisoning as their high potency creates a risk of respiratory depression even at low doses. Opioid tolerance, frequent presence of other drugs, and additional diseases make it impossible to define concentration ranges, especially the minimum fatal concentrations. This report provides quick access to the source articles quantifying novel synthetic opioids.
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Affiliation(s)
- Piotr Adamowicz
- Institute of Forensic Research, Westerplatte 9, 31-033, Krakow, Poland.
| | - Karolina Nowak
- Institute of Toxicology Research, Kasztanowa 45, 55-093, Borowa, Poland
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13
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Vearrier D, Grundmann O. Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids. J Clin Pharmacol 2021; 61 Suppl 2:S70-S88. [PMID: 34396552 DOI: 10.1002/jcph.1923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022]
Abstract
Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.
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Affiliation(s)
- David Vearrier
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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14
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Quantification and distribution of 4-fluoroisobutyryl fentanyl (4-FiBF) in postmortem biological samples using UHPLC–QqQ-MS/MS. Forensic Toxicol 2021. [DOI: 10.1007/s11419-021-00584-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Purpose
Development of ultra-high-performance liquid chromatography-triple quadrupole tandem mass spectrometry method for quantification of 4-fluoroisobutyryl fentanyl (4-FiBF) and its distribution in postmortem biological samples in four fatal intoxication cases, which occurred in September 2018, in Poland.
Methods
Biological fluids (blood, urine, vitreous humor, bile, gastric content) and tissues (brain, kidney, liver, stomach wall) were extracted with ethyl acetate from alkaline medium (pH 9). Fentanyl-d5 was used as internal standard.
Results
The validation parameters were as follows: lower limit of quantification: 0.1 ng/mL (biological fluids) and 0.1 ng/g (solid tissues), intra- and inter-day accuracies and precisions: not greater than 20%; recovery values: 86.9–110%; matrix effect: − 13.1–10.4%. Among all tested biological fluid, the highest concentration of 4-FiBF was found in bile (average concentration of 3390 ng/mL) while among the tissues, in liver (average concentration of 1650 ng/g). Furthermore, in collected specimens, there were also found other drugs and new psychoactive substances (NPS) e.g. N-ethylpentylon, 4-chloromethcathinone (4-CMC) and α-pyrrolidinoisohexanophenone (α-PiHP). Concentrations and distributions of these substances in postmortem samples have been also detailed. Examinations of seized drug (in case 4) revealed that it included the mix of 4-FiBF and α-PiHP.
Conclusions
The developed and fully validated method enabled for determination of 4-FiBF in postmortem biological fluids and tissues. To our knowledge, this is the first report of distribution study of 4-FiBF with other NPS (N-ethylpentylon, 4-CMC and α-PiHP) in authentic fatal intoxication cases.
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15
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Fast & fluorinated – Development and validation of a rapid benchtop NMR approach and other routine screening methods for the detection and quantification of synthesized fluorofentanyl derivatives. Forensic Chem 2021. [DOI: 10.1016/j.forc.2021.100321] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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16
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Abstract
Purpose of Review The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis. Recent Findings Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose. Summary The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.
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17
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Abstract
Illicit drugs and substances of abuse are increasingly used by adults and teenagers, with novel substances constantly becoming available. Many substances can cause ocular effects or visually threatening conditions. Current literature informing eye-care practitioners on these effects is scant. The present scoping review reports the ocular effects of most commonly used drugs and substances of abuse in the teenage and adult populations of North America. Ovid MEDLINE and Ovid EMBASE databases were searched for publications from 1980 to 2019 regarding ocular effects of drug use. The selected papers regarded human subjects, in either teenage or adult population and included all types of studies, including case reports. Publications in English or in French were included. Exclusion criteria were publications about the use of prescriptions drugs, drug withdrawal, and publications about the use of alcohol, tobacco, or cannabis. Some 241 papers were retained and analysed. The use of various drugs and substances can lead to damage to structures throughout the eye, including but not limited to corneal conditions, glaucoma and other optic neuropathies, maculopathies and endophthalmitis. The data presented in this review may help guide clinicians in their diagnosis and treatment of certain ocular conditions, which could otherwise not be linked to drug use.
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Affiliation(s)
- Valérie Proulx
- School of Optometry, University of Montreal, Montréal, Canada
| | - Benoit Tousignant
- School of Optometry, University of Montreal, Montréal, Canada.,School of Public Health, University of Montreal, Montréal, Canada
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18
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Rodriguez Salas J, Krotulski AJ, Newman R, Thogmartin JR, Mohr ALA, Logan BK. Concentrations of para-Fluorofuranylfentanyl (FFF) in Paired Central and Peripheral Blood Collected During Postmortem Death Investigations. J Anal Toxicol 2021; 46:358-373. [PMID: 33693685 DOI: 10.1093/jat/bkab025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/25/2021] [Accepted: 03/09/2021] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Judith Rodriguez Salas
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | | | | | - Amanda L A Mohr
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | - Barry K Logan
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA.,NMS Labs, Horsham, PA
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19
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Overview of the major classes of new psychoactive substances, psychoactive effects, analytical determination and conformational analysis of selected illegal drugs. OPEN CHEM 2021. [DOI: 10.1515/chem-2021-0196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Abstract
The misuse of psychoactive substances is attracting a great deal of attention from the general public. An increase use of psychoactive substances is observed among young people who do not have enough awareness of the harmful effects of these substances. Easy access to illicit drugs at low cost and lack of effective means of routine screening for new psychoactive substances (NPS) have contributed to the rapid increase in their use. New research and evidence suggest that drug use can cause a variety of adverse psychological and physiological effects on human health (anxiety, panic, paranoia, psychosis, and seizures). We describe different classes of these NPS drugs with emphasis on the methods used to identify them and the identification of their metabolites in biological specimens. This is the first review that thoroughly gives the literature on both natural and synthetic illegal drugs with old known data and very hot new topics and investigations, which enables the researcher to use it as a starting point in the literature exploration and planning of the own research. For the first time, the conformational analysis was done for selected illegal drugs, giving rise to the search of the biologically active conformations both theoretically and using lab experiments.
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20
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Blackwood CA, Cadet JL. The molecular neurobiology and neuropathology of opioid use disorder. CURRENT RESEARCH IN NEUROBIOLOGY 2021; 2. [PMID: 35548327 PMCID: PMC9090195 DOI: 10.1016/j.crneur.2021.100023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The number of people diagnosed with opioid use disorder has skyrocketed as a consequence of the opioid epidemic and the increased prescribing of opioid drugs for chronic pain relief. Opioid use disorder is characterized by loss of control of drug taking, continued drug use in the presence of adverse consequences, and repeated relapses to drug taking even after long periods of abstinence. Patients who suffer from opioid use disorder often present with cognitive deficits that are potentially secondary to structural brain abnormalities that vary according to the chemical composition of the abused opioid. This review details the neurobiological effects of oxycodone, morphine, heroin, methadone, and fentanyl on brain neurocircuitries by presenting the acute and chronic effects of these drugs on the human brain. In addition, we review results of neuroimaging in opioid use disorder patients and/or histological studies from brains of patients who had expired after acute intoxication following long-term use of these drugs. Moreover, we include relevant discussions of the neurobiological mechanisms involved in promoting abnormalities in the brains of opioid-exposed patients. Finally, we discuss how novel strategies could be used to provide pharmacological treatment against opioid use disorder. Brain abnormalities caused by opioid intoxication. Intoxication of opioids leads to defects in brain neurocircuitries. Insight into the molecular mechanisms associated with craving in heroin addicts.
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Affiliation(s)
| | - Jean Lud Cadet
- Corresponding author.Molecular Neuropsychiatry Research Branch NIH/NIDA Intramural Research Program 251 Bayview Boulevard Baltimore, MD, USA
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21
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Shafi A, Berry AJ, Sumnall H, Wood DM, Tracy DK. New psychoactive substances: a review and updates. Ther Adv Psychopharmacol 2020; 10:2045125320967197. [PMID: 33414905 PMCID: PMC7750892 DOI: 10.1177/2045125320967197] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/26/2020] [Indexed: 12/19/2022] Open
Abstract
New psychoactive substances (NPS) are a heterogeneous group of substances. They are associated with a number of health and social harms on an individual and societal level. NPS toxicity and dependence syndromes are recognised in primary care, emergency departments, psychiatric inpatient and community care settings. One pragmatic classification system is to divide NPS into one of four groups: synthetic stimulants, synthetic cannabinoids, synthetic hallucinogens and synthetic depressants (which include synthetic opioids and benzodiazepines). We review these four classes of NPS, including their chemical structures, mechanism of action, modes of use, intended intoxicant effects, and their associated physical and mental health harms. The current challenges faced by laboratory testing for NPS are also explored, in the context of the diverse range of NPS currently available, rate of production and emergence of new substances, the different formulations, and methods of acquisition and distribution.
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Affiliation(s)
- Abu Shafi
- East London Foundation Trust, London, UK
| | - Alex J. Berry
- Division of Psychiatry, University College London, UK
| | | | - David M. Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Derek K. Tracy
- Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
- Department of Psychosis Studies, the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, DeCrespigny Park, London, SE5 8AF, UK
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22
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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Moeller K, Svensson B, Munksgaard R. Fentanyl analogs on the Swedish webforum flashback: Interest and impact of scheduling. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:103013. [PMID: 33181448 DOI: 10.1016/j.drugpo.2020.103013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sweden regulates new psychoactive substances, including fentanyl analogs, individually. This reactive scheduling procedure enabled the existence of a recreational market for unscheduled fentanyl analogs sold from surface webshops. We measure the interest in 24 named fentanyl analogs and the impact of scheduling. METHODS We scraped posts in threads on named fentanyl analogs from the Swedish internet forum Flashback.org, 2012-2019. The sample consists of 24 threads with a total of 8761 posts. We construct five measures of interest based on duration of threads, number of posts, and number of distinct posters, and fit a non-seasonal ARMA model to test if there was a change in mean activity after scheduling. RESULTS Across the five measures, there was most interest in acryl fentanyl, butyr fentanyl, and acetyl fentanyl. The number of daily posts was significantly reduced in nine out of 13 threads after scheduling. CONCLUSION The scheduling of fentanyl analogs impacted interest on Flashback.org. The biggest effect sizes were from the narcotics scheduling of 2-Me-MAF, acryl, and acetyl fentanyl, while furanyl fentanyl saw the biggest reduction after health scheduling. The reductions were bigger for narcotics scheduling compared to health scheduling.
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Affiliation(s)
- Kim Moeller
- Department of Criminology, Malmö University, Sweden.
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24
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Åstrand A, Vikingsson S, Jakobsen I, Björn N, Kronstrand R, Gréen H. Activation of the μ-opioid receptor by alicyclic fentanyls: Changes from high potency full agonists to low potency partial agonists with increasing alicyclic substructure. Drug Test Anal 2020; 13:169-174. [PMID: 32749741 PMCID: PMC7891621 DOI: 10.1002/dta.2906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/14/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022]
Abstract
Fentanyl analogs represent an important group of new psychoactive substances and knowing their efficacy and potency might assist in interpreting observed concentrations. The potency of fentanyl analogs can be estimated from in vitro studies and can be used to establish structure–activity relationships. In this study, recombinant CHO‐K1 cells (AequoScreen) expressing the human μ‐opioid receptor were used to establish dose–response curves via luminescent analysis for cyclopropyl‐, cyclobutyl‐, cyclopentyl‐, cyclohexyl‐, and 2,2,3,3‐tetramethylcyclopropylfentanyl (TMCPF), on three separate occasions, using eight different concentrations in an eight‐fold serial dilution in triplicates starting at ~60 μM. Fentanyl was used as a full agonist reference while morphine and buprenorphine were included for comparison. Cyclopropylfentanyl (EC50 = 4.3 nM), cyclobutylfentanyl (EC50 = 6.2 nM), and cyclopentylfentanyl (EC50 = 13 nM) were full agonists slightly less potent than fentanyl (EC50 = 1.7 nM). Cyclohexylfentanyl (EC50 = 3.1 μM, efficacy 48%) and TMCPF (EC50 = 1.5 μM, efficacy 65%) were partial agonists less potent than morphine (EC50 = 430 nM). Based on the results, cyclopropyl‐, cyclobutyl‐, and cyclopentylfentanyl would be expected to induce intoxication or cause fatal poisonings at similar concentrations to fentanyl, while the toxic or fatal concentrations of cyclohexylfentanyl and TMCPF would be expected to be much higher.
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Affiliation(s)
- Anna Åstrand
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Svante Vikingsson
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| | - Ingrid Jakobsen
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden
| | - Niclas Björn
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Robert Kronstrand
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| | - Henrik Gréen
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden.,Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
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25
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Chan WS, Wong GF, Hung CW, Wong YN, Fung KM, Lee WK, Dao KL, Leung CW, Lo KM, Lee WM, Cheung BKK. Interpol review of toxicology 2016-2019. Forensic Sci Int Synerg 2020; 2:563-607. [PMID: 33385147 PMCID: PMC7770452 DOI: 10.1016/j.fsisyn.2020.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022]
Abstract
This review paper covers the forensic-relevant literature in toxicology from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20.Papers%202019.pdf.
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26
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Helander A, Bäckberg M, Beck O. Drug trends and harm related to new psychoactive substances (NPS) in Sweden from 2010 to 2016: Experiences from the STRIDA project. PLoS One 2020; 15:e0232038. [PMID: 32324788 PMCID: PMC7179898 DOI: 10.1371/journal.pone.0232038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/06/2020] [Indexed: 01/15/2023] Open
Abstract
Background In the past decade, hundreds of new psychoactive substances (NPS) have been introduced as unclassified alternatives to the illicit drugs. The NPS represent a growing health concern by causing adverse effects and deaths but are usually undetectable by conventional drug tests. This report summarizes results and experiences from analytically confirmed drug-related acute intoxications in emergency departments (ED) and intensive care units (ICU) enrolled in the Swedish STRIDA project on NPS in 2010–2016. Methods and findings ED/ICU intoxications suspected to involve NPS were enrolled in the project, after initial contact with the Poisons Information Centre (PIC). Serum/plasma and urine samples, and sometimes drug products, were subjected to a comprehensive toxicological investigation, and the PIC retrieved information on associated clinical symptoms and treatment. Between January 2010-February 2016, 2626 cases were enrolled. The patients were aged 8–71 (mean 27, median 24) years and 74% were men. Most biological samples (81%) tested positive for one, or more (70%), psychoactive drugs, including 159 NPS, other novel or uncommon substances, classical recreational and illicit drugs, and prescription medications. When first detected, most NPS or other novel substances (75%) were not banned in Sweden, but they usually disappeared upon classification, which however often took a year or longer. Some NPS were found to be especially harmful and even fatal. Conclusions The STRIDA project provided a good overview of the current drug situation in Sweden and demonstrated a widespread use and rapid turnover of many different psychoactive substances. The accomplishment of the project can be attributed to several key factors (close collaboration between the PIC and laboratory to identify suspected poisonings, free analysis, continuous updating of analytical methods, evaluation of adverse effects, and sharing information) that are useful for future activities addressing the NPS problem. The results also illustrated how drug regulations can drive the NPS market.
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Affiliation(s)
- Anders Helander
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Clinical Pharmacology, Karolinska University Laboratory, Stockholm, Sweden
- * E-mail:
| | | | - Olof Beck
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Clinical Pharmacology, Karolinska University Laboratory, Stockholm, Sweden
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden
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27
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Gampfer TM, Wagmann L, Park YM, Cannaert A, Herrmann J, Fischmann S, Westphal F, Müller R, Stove CP, Meyer MR. Toxicokinetics and toxicodynamics of the fentanyl homologs cyclopropanoyl-1-benzyl-4´-fluoro-4-anilinopiperidine and furanoyl-1-benzyl-4-anilinopiperidine. Arch Toxicol 2020; 94:2009-2025. [PMID: 32249346 PMCID: PMC7303074 DOI: 10.1007/s00204-020-02726-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/26/2020] [Indexed: 12/16/2022]
Abstract
The two fentanyl homologs cyclopropanoyl-1-benzyl-4´-fluoro-4-anilinopiperidine (4F-Cy-BAP) and furanoyl-1-benzyl-4-anilinopiperidine (Fu-BAP) have recently been seized as new psychoactive substances (NPS) on the drugs of abuse market. As their toxicokinetic and toxicodynamic characteristics are completely unknown, this study focused on elucidating their in vitro metabolic stability in pooled human liver S9 fraction (pHLS9), their qualitative in vitro (pHLS9), and in vivo (zebrafish larvae) metabolism, and their in vitro isozyme mapping using recombinant expressed isoenzymes. Their maximum-tolerated concentration (MTC) in zebrafish larvae was studied from 0.01 to 100 µM. Their µ-opioid receptor (MOR) activity was analyzed in engineered human embryonic kidney (HEK) 293 T cells. In total, seven phase I and one phase II metabolites of 4F-Cy-BAP and 15 phase I and four phase II metabolites of Fu-BAP were tentatively identified by means of liquid chromatography high-resolution tandem mass spectrometry, with the majority detected in zebrafish larvae. N-Dealkylation, N-deacylation, hydroxylation, and N-oxidation were the most abundant metabolic reactions and the corresponding metabolites are expected to be promising analytical targets for toxicological analysis. Isozyme mapping revealed the main involvement of CYP3A4 in the phase I metabolism of 4F-Cy-BAP and in terms of Fu-BAP additionally CYP2D6. Therefore, drug-drug interactions by CYP3A4 inhibition may cause elevated drug levels and unwanted adverse effects. MTC experiments revealed malformations and changes in the behavior of larvae after exposure to 100 µM Fu-BAP. Both substances were only able to produce a weak activation of MOR and although toxic effects based on MOR activation seem unlikely, activity at other receptors cannot be excluded.
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Affiliation(s)
- Tanja M Gampfer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421, Homburg, Germany
| | - Lea Wagmann
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421, Homburg, Germany
| | - Yu Mi Park
- Department of Microbial Natural Products (MINS), Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Saarland University, 66123, Saarbrücken, Germany
- Environmental Safety Group, Korea Institute of Science and Technology (KIST) Europe, 66123, Saarbrücken, Germany
| | - Annelies Cannaert
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000, Ghent, Belgium
| | - Jennifer Herrmann
- Department of Microbial Natural Products (MINS), Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Saarland University, 66123, Saarbrücken, Germany
| | - Svenja Fischmann
- State Bureau of Criminal Investigation Schleswig-Holstein, 24116, Kiel, Germany
| | - Folker Westphal
- State Bureau of Criminal Investigation Schleswig-Holstein, 24116, Kiel, Germany
| | - Rolf Müller
- Department of Microbial Natural Products (MINS), Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Saarland University, 66123, Saarbrücken, Germany
| | - Christophe P Stove
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, 9000, Ghent, Belgium
| | - Markus R Meyer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421, Homburg, Germany.
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Luethi D, Liechti ME. Designer drugs: mechanism of action and adverse effects. Arch Toxicol 2020; 94:1085-1133. [PMID: 32249347 PMCID: PMC7225206 DOI: 10.1007/s00204-020-02693-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 12/18/2022]
Abstract
Psychoactive substances with chemical structures or pharmacological profiles that are similar to traditional drugs of abuse continue to emerge on the recreational drug market. Internet vendors may at least temporarily sell these so-called designer drugs without adhering to legal statutes or facing legal consequences. Overall, the mechanism of action and adverse effects of designer drugs are similar to traditional drugs of abuse. Stimulants, such as amphetamines and cathinones, primarily interact with monoamine transporters and mostly induce sympathomimetic adverse effects. Agonism at μ-opioid receptors and γ-aminobutyric acid-A (GABAA) or GABAB receptors mediates the pharmacological effects of sedatives, which may induce cardiorespiratory depression. Dissociative designer drugs primarily act as N-methyl-D-aspartate receptor antagonists and pose similar health risks as the medically approved dissociative anesthetic ketamine. The cannabinoid type 1 (CB1) receptor is thought to drive the psychoactive effects of synthetic cannabinoids, which are associated with a less desirable effect profile and more severe adverse effects compared with cannabis. Serotonergic 5-hydroxytryptamine-2A (5-HT2A) receptors mediate alterations of perception and cognition that are induced by serotonergic psychedelics. Because of their novelty, designer drugs may remain undetected by routine drug screening, thus hampering evaluations of adverse effects. Intoxication reports suggest that several designer drugs are used concurrently, posing a high risk for severe adverse effects and even death.
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Affiliation(s)
- Dino Luethi
- Center for Physiology and Pharmacology, Institute of Pharmacology, Medical University of Vienna, Währinger Strasse 13a, 1090, Vienna, Austria.
- Institute of Applied Physics, Vienna University of Technology, Getreidemarkt 9, 1060, Vienna, Austria.
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
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29
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Systematic review of the clinical consequences of butyrfentanyl and corresponding analogues. Interdiscip Toxicol 2020; 12:83-88. [PMID: 32206028 PMCID: PMC7071838 DOI: 10.2478/intox-2019-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 07/08/2019] [Indexed: 11/21/2022] Open
Abstract
Butyrfentanyl and its analogues are being increasingly used throughout the United States and Europe. Currently, lethal cases are emerging across the United States, England, and Europe without any end in sight. We therefore performed a systematic review of existing case reports on the literature of butyrfentanyl and similar analogs. We searched PubMed and Embase for articles (up until September 2018) using terms such as “butyrfentanyl” or “butyrylfentanyl.” In total, our search found 271 articles and identified 10 for inclusion in this review. A total of 33 cases were found with 61% of those being fatal. The most common route of administration was intravenous, but other routes of administration were readily used such as oral, intranasal, and inhalation. Most cases reported use of concomitant licit and illicit pharmacological agents. The toxidrome was consistent with other opioid overdoses, and naloxone was successfully used in nine of 10 patients. We encourage toxicology screenings of novel fentanyl analogs such as butyrfentanyl or 4-fluorobutyrfentanyl when an opioid overdose of unknown nature presents.
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Gampfer TM, Wagmann L, Richter MJ, Fischmann S, Westphal F, Meyer MR. Toxicokinetic Studies and Analytical Toxicology of the New Synthetic Opioids Cyclopentanoyl-Fentanyl and Tetrahydrofuranoyl-Fentanyl. J Anal Toxicol 2020; 44:449-460. [DOI: 10.1093/jat/bkaa010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/10/2019] [Accepted: 12/26/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
The growing number of new synthetic opioids (NSO) on the new psychoactive substances (NPS) market bears new challenges in toxicology. As their toxicodynamics and particularly their toxicokinetics are usually unknown, impact on human health is not yet fully understood. Detection of the 2 NSO cyclopentanoyl-fentanyl (CP-F) and tetrahydrofuranoyl-fentanyl (THF-F) was first reported in 2016. Both were involved in several fatal intoxication cases, but no detailed information about their toxicological characteristics is available so far. The main purpose of this study was therefore to investigate the in vitro toxicokinetics and in vivo analytical toxicology of CP-F and THF-F by means of liquid chromatography high-resolution tandem mass spectrometry (LC-HRMS/MS). These studies included metabolic stability, phase I and II metabolism, isozyme mapping, plasma protein binding and detectability in LC-HRMS/MS standard urine screening approaches (SUSA) using rat urine samples. In total, 12 phase I metabolites of CP-F and 13 of THF-F were identified, among them 9 metabolites described for the first time. Overall, N-dealkylations, hydroxylations and dihydroxylations were the main metabolic reactions. The cytochrome P450 (CYP) isozymes mainly involved were CYP2D6 and CYP3A4, leading to elevated drug levels and intoxications in CYP2D6 poor metabolizers. CP-F showed a high plasma protein binding of 99%, which may increase the risk of toxicity by simultaneous intake of other highly bound drugs. Detectability studies showed that neither the parent compounds nor their metabolites were detectable in rat urine using LC-HRMS/MS SUSA. However, a more sophisticated analytical strategy was successfully applied and should be used for analytical confirmation of an intake of CP-F and/or THF-F.
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Affiliation(s)
- Tanja M Gampfer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421 Homburg, Germany
| | - Lea Wagmann
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421 Homburg, Germany
| | - Matthias J Richter
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421 Homburg, Germany
| | - Svenja Fischmann
- State Bureau of Criminal Investigation Schleswig-Holstein, 24116 Kiel, Germany
| | - Folker Westphal
- State Bureau of Criminal Investigation Schleswig-Holstein, 24116 Kiel, Germany
| | - Markus R Meyer
- Department of Experimental and Clinical Toxicology, Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Molecular Signaling (PZMS), Saarland University, 66421 Homburg, Germany
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Evaluation of 4-fluoroisobutyrylfentanyl in blood samples from 247 authentic cases submitted to the New York City Office of Chief Medical Examiner in 2017–2018. Forensic Toxicol 2020. [DOI: 10.1007/s11419-019-00518-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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32
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Thylstrup B, Hesse M, Jørgensen M, Thiesen H. One opioid user saving another: the first study of an opioid overdose-reversal and naloxone distribution program addressing hard-to-reach drug scenes in Denmark. Harm Reduct J 2019; 16:66. [PMID: 31805969 PMCID: PMC6896775 DOI: 10.1186/s12954-019-0328-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/06/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Overdose education and naloxone distribution programs decrease opioid overdose deaths. However, no studies of such programs have been carried out in Denmark. The aim of this study was to evaluate the feasibility and the effect of a broader "training-the-trainers" model in low-threshold settings after participation in the "Danish Save Lives" [SL] program. METHODS Between May 2013 and November 2015, 552 participants from four municipalities took part in the SL program. The program is built on the train-the-trainers model where a central trainer trains others (trainers), who in turn train others (helpers). Participants were 30 police officers (5%), 188 people who use opioids (34%), 23 significant others (4%), and 217 social workers (39%). Ninety-four participants could not be classified (17%). At follow-up, participants were interviewed to determine the number and outcomes of opioid overdoses. Logistic regression was used to assess predictors of treating an overdose. RESULTS In all, 37 (7%) participants had intervened in 45 opioid overdose events (two trainers and 35 helpers). Detailed descriptions of the overdose event were available from 32 follow-up interviews (70%). In 16 cases, the person who intervened was already present at the site when the overdose occurred, and in 17 cases, the overdose victim recovered without complications. All overdose victims survived except one. People who used opioids were more likely to have treated an overdose than other participants (adjusted odds ratio [AOR] = 8.50, p = 0.001), and the likelihood of treating and overdose declined over time AOR = 0.37 (0.13, 0.93), p = 0.034). CONCLUSIONS Prevention programs that target people who use opioids are more likely to be effective than programs that target professionals, especially in high-risk settings that can be hard for paramedics to reach. A future goal is to explore how prevention programs can be adapted to new user groups. TRIAL REGISTRATION The Danish Data Protection Agency, 2015-57-0002, Aarhus University, 2016-051-000001, 184, retrospectively registered.
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Affiliation(s)
- Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000 Aarhus C, Denmark
| | - Marian Jørgensen
- HealthTeam for Homeless, Save Lives Program, Sundholmsvej 18, 2300 København S, Denmark
| | - Henrik Thiesen
- HealthTeam for Homeless, Save Lives Program, Sundholmsvej 18, 2300 København S, Denmark
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview. Biomarkers 2019; 25:9-19. [PMID: 31735069 DOI: 10.1080/1354750x.2019.1694994] [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] [Indexed: 10/25/2022]
Abstract
Acute intoxications account for a significant proportion of the patient population in intensive care units and sedative medications, ethanol, illicit drugs, inhalable poisons and mixed intoxications are the most common causes. The aim of this article is to describe biomarkers for screening and diagnosis of acute intoxications in critically ill patients. For this purpose, a survey of the relevant literature was conducted, and guidelines, case reports, expert assessments, and scientific publications were reviewed. In critical care, it should always be attempted to identify and quantify the poison or toxin with the assistance of enzyme immunoassay (EIA), chromatography, and mass spectrometry techniques and this section is critically appraised in this publication. The principles for anion gap, osmol gap and lactate gap and their usage in intoxications is shown. Basic rules in test methodology and pre-analytics are reviewed. Biomarkers in general are presented in part one and biomarkers for specific intoxications including ethanol, paracetamol, cardiovascular drugs and many others are presented in part two of these publications.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Wilde M, Sommer MJ, Auwärter V, Hermanns-Clausen M. Acute severe intoxication with cyclopropylfentanyl, a novel synthetic opioid. Toxicol Lett 2019; 320:109-112. [PMID: 31778775 DOI: 10.1016/j.toxlet.2019.11.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/19/2019] [Accepted: 11/23/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Since 2016 an increase has been observed in the availability of new synthetic opioids (NSO) in Europe. Cyclopropylfentanyl is a very potent and selective μ-opioid agonist, which was reported for the first time in August 2017 in Europe. METHODS The case was included in a prospective observational study of patients treated in emergency departments after the intake of novel psychoactive substances (NPS). Clinical features were acquired using a structured questionnaire for physicians. Serum and/or urine samples of ED patients were analyzed using liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS) screening methods for NPS. CASE REPORT Within 10 min after intranasal intake of fentanyl, a 25-year-old male developed nausea, profuse sweating and dyspnoe. Because soon afterwards coma and respiratory insufficiency was noticed, the patient was admitted to hospital. After administration of naloxone (0.8 mg) breathing stabilized. However, the patient displayed recurrent decreases of oxygen saturation for 12 h. The intake of cyclopropylfentanyl was analytically confirmed. CONCLUSION The constantly growing diversity of NSO still poses a high risk for drug users and can be a challenging task for clinicians and forensic toxicologists. Clinicians treating opioid overdoses should be aware of the potentially long lasting respiratory depression induced by fentanyl analogs.
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Affiliation(s)
- Maurice Wilde
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, University of Freiburg, Freiburg, Germany; Hermann Staudinger Graduate School, University of Freiburg, Freiburg, Germany
| | - Michaela J Sommer
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, University of Freiburg, Freiburg, Germany; Hermann Staudinger Graduate School, University of Freiburg, Freiburg, Germany
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maren Hermanns-Clausen
- Faculty of Medicine, 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.
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Tabarra I, Soares S, Rosado T, Gonçalves J, Luís Â, Malaca S, Barroso M, Keller T, Restolho J, Gallardo E. Novel synthetic opioids - toxicological aspects and analysis. Forensic Sci Res 2019; 4:111-140. [PMID: 31304442 PMCID: PMC6609355 DOI: 10.1080/20961790.2019.1588933] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/16/2019] [Accepted: 02/26/2019] [Indexed: 01/14/2023] Open
Abstract
Over the past few years, there has been an emerging number of new psychoactive drugs. These drugs are frequently mentioned as "legal highs", "herbal highs", "bath salts" and "research chemicals". They are mostly sold and advertised on online forums and on the dark web. The emerging new psychoactive substances are designed to mimic the effects of psychoactive groups, which are often abused drugs. Novel synthetic opioids are a new trend in this context and represent an alarming threat to public health. Given the wide number of fatalities related to these compounds reported within the last few years, it is an important task to accurately identify these compounds in biologic matrices in order to administer an effective treatment and reverse the respiratory depression caused by opioid related substances. Clinicians dealing with fentanyl intoxication cases should consider that it could, in fact, be a fentanyl analogue. For this reason, it is a helpful recommendation to include synthetic opioids in the routine toxicological screening procedures, including analysis in alternative matrices, if available, to investigate poly-drug use and possible tolerance to opioids. To address this public health problem, better international collaboration, effective legislation, effective investigation, control of suspicious "research chemicals" online forums and continuous community alertness are required. This article aims to review diverse reported fatalities associated with new synthetic opioids describing them in terms of pharmacology, metabolism, posology, available forms, as well as their toxic effects, highlighting the sample procedures and analytical techniques available for their detection and quantification in biological matrices.
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Affiliation(s)
- Inês Tabarra
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
| | - Sofia Soares
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
- Laboratório de Fármaco-Toxicologia - UBIMedical, Universidade da Beira Interior, Covilhã, Portugal
| | - Tiago Rosado
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
- Laboratório de Fármaco-Toxicologia - UBIMedical, Universidade da Beira Interior, Covilhã, Portugal
| | - Joana Gonçalves
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
| | - Ângelo Luís
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
| | - Sara Malaca
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
- Laboratório de Fármaco-Toxicologia - UBIMedical, Universidade da Beira Interior, Covilhã, Portugal
| | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto Nacional de Medicina Legal e Ciências Forenses, Delegação do Sul, Lisboa, Portugal
| | - Thomas Keller
- Departament of Toxicology, Institute of Forensic Medicine, Salzburg, Austria
| | - José Restolho
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
- nal von minden GmbH, Regensburg, Germany
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã, Portugal
- Laboratório de Fármaco-Toxicologia - UBIMedical, Universidade da Beira Interior, Covilhã, Portugal
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Abstract
The Swedish STRIDA project on new psychoactive substances (NPS) monitored the occurrence and health hazards of novel recreational drugs in Sweden through evaluation of analytically confirmed adverse events presenting in emergency departments and intensive care units. During a ~6-year period from 2010 to early 2016, about 2,600 cases of suspected NPS intoxications were included in the project. About 75% of patients were men and the total age range was 8-71 (median 24) years and 57% were 25 years or younger. A large number of NPS belonging to many different drug classes were identified in project samples of urine and blood (serum/plasma) submitted for free drug testing, including synthetic cannabinoid receptor agonists, stimulants, cathinones, hallucinogens, dissociative drugs, benzodiazepines, and opioids, and also in drug materials from the cases forwarded to the laboratory along with the biological samples. The STRIDA project has been shown to serve as an effective early warning system for NPS by collecting data on incidence, distribution, and adverse effects and has supported healthcare professionals in the knowledge and critical care of intoxications caused by a wide range of novel substances. The results of the STRIDA project have also illustrated how drug regulations can drive the NPS market.
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Pravetoni M, Comer SD. Development of vaccines to treat opioid use disorders and reduce incidence of overdose. Neuropharmacology 2019; 158:107662. [PMID: 31173759 DOI: 10.1016/j.neuropharm.2019.06.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/01/2019] [Accepted: 06/02/2019] [Indexed: 02/06/2023]
Abstract
Vaccines offer a promising therapeutic strategy to treat substance use disorders (SUD). Vaccines have shown extensive preclinical proof of selectivity, safety, and efficacy against opioids, nicotine, cocaine, methamphetamine, and designer drugs. Despite clinical evaluation of vaccines targeting nicotine and cocaine showing proof of concept for this approach, no vaccine for SUD has yet reached the market. This review first discusses how vaccines for treatment of opioid use disorders (OUD) and reduction of opioid-induced fatal overdoses fit within the current medication assisted treatment (MAT) portfolio, and then summarizes ongoing efforts toward translation of vaccines targeting heroin, oxycodone, fentanyl, and other opioids. This article is part of the Special Issue entitled 'New Vistas in Opioid Pharmacology'.
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Affiliation(s)
- Marco Pravetoni
- University of Minnesota Medical School, Departments of Pharmacology and Medicine, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
| | - Sandra D Comer
- Columbia University Irving Medical Center, Department of Psychiatry, The New York State Psychiatric Institute, New York, NY, USA
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Varshneya NB, Walentiny DM, Moisa LT, Walker TD, Akinfiresoye LR, Beardsley PM. Opioid-like antinociceptive and locomotor effects of emerging fentanyl-related substances. Neuropharmacology 2019; 151:171-179. [PMID: 30904478 PMCID: PMC8992608 DOI: 10.1016/j.neuropharm.2019.03.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/27/2019] [Accepted: 03/16/2019] [Indexed: 10/27/2022]
Abstract
The emergence of several fentanyl-related substances in the recreational drug marketplace has resulted in a surge of opioid overdose deaths in the United States. Many of these substances have never been examined in living organisms under controlled conditions. In the present study, seven fentanyl-related substances were tested in adult male Swiss Webster mice for their effects on locomotion and antinociception and compared to those of fentanyl and morphine. In locomotor activity tests, fentanyl (1, 10 mg/kg), morphine (100, 180 mg/kg), isobutyrylfentanyl (10 mg/kg), crotonylfentanyl (10 mg/kg), para-fluorobutyrylfentanyl (10, 100 mg/kg), para-methoxybutyrylfentanyl (10 mg/kg), thiophenefentanyl (100 mg/kg), and benzodioxolefentanyl (0.1 mg/kg) produced significant (p ≤ 0.05) dose-dependent increases in locomotion. Valerylfentanyl, however, was without effects on locomotion up to 100 mg/kg. In warm-water tail-withdrawal tests, all substances produced significant (p ≤ 0.05) dose-dependent increases in antinociception with increasing ED50 values (CI) of isobutyrylfentanyl [0.0768 mg/kg (0.044-0.128)] > fentanyl [0.0800 mg/kg (0.0403-0.164)] > para-methoxybutyrylfentanyl [0.106 mg/kg (0.0516-0.195)] > crotonylfentanyl [0.226 mg/kg (0.176-0.292)] > para-fluorobutyrylfentanyl [0.908 mg/kg (0.459-1.58)] > thiophenefentanyl [4.66 mg/kg (3.65-5.95)] > valerylfentanyl [6.43 mg/kg (3.91-10.5)] > morphine [7.82 mg/kg (5.42-11.0)] > benzodioxolefentanyl [46.3 mg/kg (25.8-83.4)]. Naltrexone (1 mg/kg) increased antinociceptive ED50 values several fold in decreasing magnitudes of isobutyrylfentanyl (233x) > para-methoxybutyrylfentanyl (37.7x) > thiophenefentanyl (34.6x) > valerylfentanyl (11.9x) > para-fluorobutyrylfentanyl (10.9x) > benzodioxolefentanyl (8.42x) > crotonylfentanyl (6.27x) > fentanyl (3.95x) > morphine (1.48x). These findings establish that locomotor and antinociceptive effects of several fentanyl-related substances are similar to those of morphine and fentanyl and are mediated by opioid receptors.
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Affiliation(s)
- Neil B Varshneya
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - D Matthew Walentiny
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Lea T Moisa
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Teneille D Walker
- Diversion Control Division, Drug Enforcement Administration, United States Department of Justice, Springfield, VA, USA
| | - Luli R Akinfiresoye
- Diversion Control Division, Drug Enforcement Administration, United States Department of Justice, Springfield, VA, USA
| | - Patrick M Beardsley
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA.
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Klingberg J, Cawley A, Shimmon R, Fu S. Collision-Induced Dissociation Studies of Synthetic Opioids for Non-targeted Analysis. Front Chem 2019; 7:331. [PMID: 31139620 PMCID: PMC6527801 DOI: 10.3389/fchem.2019.00331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/24/2019] [Indexed: 01/30/2023] Open
Abstract
The continual introduction of a large number of new psychoactive substances, along with the large turnover of these substances, necessitates the development of non-targeted detection strategies to keep pace with the ever-changing drug market. The production of certified reference materials often lags behind the introduction of new substances to the market, therefore these detection strategies need to be able to function without relying on reference materials or library spectra. Synthetic opioids have recently emerged as a drug class of particular concern due to the health issues caused by their incredibly high potency. A common method which has been used for non-targeted analysis in the past involves the identification of common product ions formed as a result of the fragmentation of the parent molecule. These common fragments can then potentially be used as markers to indicate the presence of a particular class of compounds within a sample. In this study, standards of a number of different synthetic opioids, including 14 fentanyl derivatives, 7 AH series opioids, 4 U series opioids, 4 W series opioids and MT-45, were subjected to collision-induced dissociation studies to determine how the compounds fragment. The spectra obtained from these studies included a number of diagnostic fragments common to the different opioid classes that, when used in combination, show potential for use as class predictors. By using simple data processing techniques, such as extracted ion chromatograms, these diagnostic product ions identified can be applied to a non-targeted screening workflow.
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Affiliation(s)
- Joshua Klingberg
- Centre for Forensic Science, University of Technology Sydney, Ultimo, NSW, Australia
| | - Adam Cawley
- Australian Racing Forensic Laboratory, Racing NSW, Sydney, NSW, Australia
| | - Ronald Shimmon
- Centre for Forensic Science, University of Technology Sydney, Ultimo, NSW, Australia
| | - Shanlin Fu
- Centre for Forensic Science, University of Technology Sydney, Ultimo, NSW, Australia
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41
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Palmquist KB, Swortwood MJ. Data-independent screening method for 14 fentanyl analogs in whole blood and oral fluid using LC-QTOF-MS. Forensic Sci Int 2019; 297:189-197. [DOI: 10.1016/j.forsciint.2019.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/28/2019] [Accepted: 02/04/2019] [Indexed: 11/28/2022]
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Müller D, Neurath H, Neukamm MA, Wilde M, Despicht C, Blaschke S, Grapp M. New synthetic opioid cyclopropylfentanyl together with other novel synthetic opioids in respiratory insufficient comatose patients detected by toxicological analysis. Clin Toxicol (Phila) 2019; 57:806-812. [DOI: 10.1080/15563650.2018.1554187] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Dieter Müller
- Clinical Toxicological Laboratory, GIZ-Nord Poisons Centre, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Hartmud Neurath
- Clinical Toxicological Laboratory, GIZ-Nord Poisons Centre, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Merja A. Neukamm
- Faculty of Medicine, Department of Forensic Toxicology, Institute of Forensic Medicine, Medical Center – University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Maurice Wilde
- Faculty of Medicine, Department of Forensic Toxicology, Institute of Forensic Medicine, Medical Center – University of Freiburg, University of Freiburg, Freiburg, Germany
- Hermann Staudinger Graduate School, University of Freiburg, Freiburg, Germany
| | - Caroline Despicht
- Faculty of Medicine, Department of Forensic Toxicology, Institute of Forensic Medicine, Medical Center – University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Sabine Blaschke
- Emergency Department, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Marcel Grapp
- Forensic Toxicological Laboratory, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
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43
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Schifano F, Chiappini S, Corkery JM, Guirguis A. Assessing the 2004-2018 Fentanyl Misusing Issues Reported to an International Range of Adverse Reporting Systems. Front Pharmacol 2019; 10:46. [PMID: 30774595 PMCID: PMC6367955 DOI: 10.3389/fphar.2019.00046] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/14/2019] [Indexed: 01/15/2023] Open
Abstract
Objective: A recent, global, increase in the use of opioids including the prescribing, highly potent, fentanyl has been recorded. Due its current popularity and the potential lethal consequences of its intake, we aimed here at analyzing the fentanyl misuse, abuse, dependence and withdrawal-related adverse drug reactions (ADRs) identified within the European Medicines Agency (EMA), the United Kingdom Yellow Card Scheme (YCS), and the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) databases. Methods: Descriptive analysis of both ADRs and related cases. Results: The analysis of fentanyl-related misuse, abuse, dependence and withdrawal cases reported during years 2004-2018 to the EMA, the YCS, and the FAERS showed increasing levels overtime, specifically, EMA-related data presented two peaks (e.g., in 2008 and 2015), whilst the FAERS dataset was characterized by a dramatic increase of the ADRs collected over the last 18 months, and particularly from 2016. Some 127,313 ADRs (referring to n = 6,161 patients/single cases) related to fentanyl's misuse/abuse/dependence/withdrawal issues were reported to EMA, with 14,287 being judged by the reporter as "suspect." The most represented ADRs were: "drug dependence "(76.87%), "intentional product misuse" (13.06%), and "drug abuse" (7.45%). Most cases involved adult males and the concomitant use of other prescribing/illicit drugs. A range of idiosyncratic (i.e., ingestion/injection of transdermal patches' fentanyl) and very high-dosage intake cases were here identified. Significant numbers of cases required either a prolonged hospitalization (192/559 = 34.35%) or resulted in death (185/559 = 33.09%). Within the same time frame, YCS collected some 3,566 misuse/abuse/dependence/withdrawal ADRs, corresponding to 1,165 single patients/cases, with those most frequently reported being "withdrawal," "intentional product misuse," and "overdose" ADRs. Finally, FAERS identified a total of 19,145 misuse/abuse/dependence/withdrawal-related cases, being "overdose," withdrawal, and "drug use disorder/drug abuse/drug diversion" the most represented ADRs (respectively, 43.11, 20.80, and 20.29%). Conclusion: Fentanyl abuse may be considered a public health issue with significant implications for clinical practice. Spontaneous pharmacovigilance reporting systems should be considered for mapping new trends of drug abuse.
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Affiliation(s)
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Jannetto PJ, Helander A, Garg U, Janis GC, Goldberger B, Ketha H. The Fentanyl Epidemic and Evolution of Fentanyl Analogs in the United States and the European Union. Clin Chem 2019; 65:242-253. [DOI: 10.1373/clinchem.2017.281626] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/26/2018] [Indexed: 01/13/2023]
Abstract
Abstract
BACKGROUND
Since 2013, an unprecedented surge in fentanyl overdose deaths has been caused by heroin laced with illicitly produced fentanyl and/or fentanyl analogs (FAs) sold as heroin. The US Drug Enforcement Agency's National Forensic Laboratory Information System reported a >300% increase in fentanyl encounters from 4697 in 2014 to 14440 in 2015. In 2015, the CDC reported 9580 deaths caused by synthetic opioids, primarily fentanyl, a 72% increase from 2014. The European Monitoring Centre for Drugs and Drug Addiction has also encountered several new FAs in the heroin supply. Counterfeit pharmaceuticals containing mixtures of fentanyl and FAs continue to be a poorly recognized worldwide problem despite the WHO classifying several FAs as a serious threat to public health.
CONTENT
This review covers the epidemiology of fentanyl abuse and discusses the clinical practice implications of widespread fentanyl abuse. It includes a historical perspective on the illicit FAs that have appeared in the US and European Union and reviews the methods available to identify FAs and emerging technologies useful for identifying previously undescribed analogs. A compilation of structural and mass spectral data on FAs reported thus far is provided.
SUMMARY
Fentanyl and FAs have evolved into a global public health threat. It is important to understand the analytical, clinical, and regulatory efforts underway to assist communities affected by the current fentanyl epidemic.
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Affiliation(s)
- Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Anders Helander
- Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Laboratory, Stockholm, Sweden
| | - Uttam Garg
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Gregory C Janis
- MedTox Laboratories, Laboratory Corporation of America Holdings, St. Paul, MN
| | - Bruce Goldberger
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Hemamalini Ketha
- Mass Spectrometry and Toxicology, Laboratory Corporation of America Holdings, Burlington, NC
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Lovrecic B, Lovrecic M, Gabrovec B, Carli M, Pacini M, Maremmani AGI, Maremmani I. Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020177. [PMID: 30634521 PMCID: PMC6352208 DOI: 10.3390/ijerph16020177] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 01/28/2023]
Abstract
Background: In the last decade there has been a progressive increase in the use of new psychoactive substances (NPSs) that are not yet under international control. In particular, novel synthetic opioids (NSOs) have reappeared on the recreational drug market in the last few years. As a result, the use of NSOs has increased rapidly. This poses an emerging and demanding challenge to public health. Aim: To raise awareness among clinicians and other professionals about NPSs, especially NSOs, to summarize current knowledge about pharmacological properties, forms of NSO on the market, pattern of use, effects and consequences of use. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms. Results: Some NPSs are already controlled, while others can be legally sold directly on the drug market (mainly via internet, less so by drug dealers) or be used as precursors for the synthesis of other designer drugs that mimic the psychoactive effects of controlled substances. Potential side-effects of NSOs include miosis, sedation, respiratory depression, hypothermia, inhibition of gastrointestinal propulsion, death (from opioid overdose). Conclusions: The severity of the opioid crisis has intensified with the introduction of highly potent NSOs on the drug market. As long as addicts are dying from overdose or similar causes, there is something more constructive to do than waiting for addicts to overdose on heroin at a place located near a remedy, as if to say, within reach of naloxone.
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Affiliation(s)
| | - Mercedes Lovrecic
- National Institute of Public Health, 1000 Ljubljana, Slovenia.
- Centre for Psychiatry and Addiction Medicine, Izola Health Centre, 6310 Izola, Slovenia.
| | - Branko Gabrovec
- National Institute of Public Health, 1000 Ljubljana, Slovenia.
| | - Marco Carli
- Department of Translational Research and New Technologies, University of Pisa, 56100 Pisa, Italy.
| | - Matteo Pacini
- G. De Lisio Institute of Behavioral Sciences, 56100 Pisa, Italy.
| | - Angelo G I Maremmani
- Department of Psychiatry, North-Western Tuscany Region NHS Local Health Unit, Versilia Zone, 55049 Viareggio, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
| | - Icro Maremmani
- G. De Lisio Institute of Behavioral Sciences, 56100 Pisa, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
- Vincent P. Dole Dual Disorder Unit, Santa Chiara University Hospital, University of Pisa, 56100 Pisa, Italy.
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46
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Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 63:122-128. [PMID: 30292493 DOI: 10.1016/j.drugpo.2018.08.007] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/25/2018] [Accepted: 08/09/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND In 2016, the number of overdose deaths involving illicitly-manufactured fentanyl (IMF) surpassed heroin and prescription opioid deaths in the United States for the first time, with IMF-involved overdose deaths increasing more than 500% across 10 states from 2013 to 2016. IMF is an extremely potent synthetic opioid that is regularly mixed with heroin and often sold to unwitting consumers. Community-based organizations have started to distribute fentanyl test strips (FTS) as a strategy to identify IMF in street purchased products. We investigated the association between FTS use and changes in drug use behavior and perceived overdose safety among a community-based sample of people who inject drugs (PWID) in the United States. METHODS Between September-October 2017, a total of 125 PWID completed an online survey about their most recent FTS use in Greensboro, North Carolina. Our first outcome of interest included whether PWID engaged in any of the following changes in drug use behavior after using FTS: used less than usual, administered tester shot, pushed syringe plunger slower than usual, and snorted instead of injected. Our second outcome of interest was whether PWID felt that FTS use made them feel better able to protect themselves from overdose. We conducted bivariate and multivariate analyses to determine the association between FTS use and these two outcomes. RESULTS Overall, 63% of the sample reported a positive FTS test result and 81% reported using FTS prior to consuming their drugs. For the outcomes, 43% reported a change in drug use behavior and 77% indicated increased perceived overdose safety by using FTS. In multivariable models adjusting for demographic and FTS correlates, PWID with a positive FTS test result had five times the odds of reporting changes in drug use behavior compared to those with a negative result. PWID who used the FTS after drug consumption were 70% less likely to report behavioral changes at subsequent drug consumption compared to those who used it before consumption. PWID who were not existing clients of the syringe services program had four times higher odds than existing clients to report increased overdose safety from using FTS. CONCLUSIONS We found that using FTS and receiving a positive test result was associated with changes in drug use behavior and perceptions of overdose safety. FTS may represent an effective addition to current overdose prevention efforts when included with other evidence-based strategies to prevent opioid overdose and related harm.
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Affiliation(s)
- Nicholas C Peiper
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States
| | - Sarah Duhart Clarke
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States
| | - Louise B Vincent
- Urban Survivors Union, Piedmont Chapter, Greensboro, NC, United States
| | - Dan Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, CA, United States
| | - Alex H Kral
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States
| | - Jon E Zibbell
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States.
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47
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Addressing the Fentanyl Analogue Epidemic by Multiplex UHPLC-MS/MS Analysis of Whole Blood. Ther Drug Monit 2018; 40:738-748. [DOI: 10.1097/ftd.0000000000000564] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Abstract
Illicit fentanyl and its analogues are very dangerous synthetic opioids, with high abuse potential and severe adverse effects including coma and death. They are used as adulterants in street heroin, cocaine, and methamphetamine, or as heroin substitutes sold to unaware users with a high risk of overdoses. Fentanyl and its analogues have also been identified in counterfeit medicinal products, such as oxycodone, hydrocodone, and alprazolam tablets, or as components of speedball mixtures together with cocaine or other stimulants. In recent years, a number of epidemics involving acute intoxications and deaths related to illicit fentanyl or its analogues have occurred in the United States, Europe, Canada, Australia, and Japan. In several cases, fatalities involved polysubstance use. A review of the most recent case reports or case series of acute intoxications and fatalities involving illicit fentanyl and its newest analogues is herein provided, together with the available information on intoxication symptoms, eventual death cause, and metabolites detected in different biological fluids and reported concentrations.
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Correlations between metabolism and structural elements of the alicyclic fentanyl analogs cyclopropyl fentanyl, cyclobutyl fentanyl, cyclopentyl fentanyl, cyclohexyl fentanyl and 2,2,3,3-tetramethylcyclopropyl fentanyl studied by human hepatocytes and LC-QTOF-MS. Arch Toxicol 2018; 93:95-106. [PMID: 30361799 PMCID: PMC6342890 DOI: 10.1007/s00204-018-2330-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023]
Abstract
Recently, a number of fentanyl analogs have been implicated in overdose deaths in Europe and in the US. So far, little is known of the molecular behavior of the structurally related subgroup; the alicyclic fentanyls. In this study, reference standards of cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and 2,2,3,3-tetramethylcyclopropyl fentanyl (TMCPF) at a final concentration of 5 µM were incubated with cryopreserved human hepatocytes (1 × 106 cells/mL) for 0, 1, 3 and 5 h. The metabolites formed were identified by liquid chromatography-quadrupole time-of-flight mass spectrometry analysis. The most abundant biotransformation found was N-dealkylation (formation of normetabolites) and oxidation of the alicyclic rings. As ring size increased, the significance of N-dealkylation decreased in favor of alicyclic ring oxidation. An example of this was cyclopropyl fentanyl, with a three-carbon ring, whose normetabolite covered 82% of the total metabolic peak area and no oxidation of the alicyclic ring was observed. In contrast, TMCPF, with a seven-carbon ring structure, rendered as much as 85% of its metabolites oxidized on the alicyclic ring. Other biotransformations found included oxidation of the piperidine ethyl moiety and/or the phenethyl substructure, glucuronidation as well as amide hydrolysis to form metabolites identical to despropionyl fentanyl. Taken together, this study provides a base for understanding the metabolism of a number of structurally related fentanyl analogs formed upon intake.
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Baruffaldi F, Kelcher AH, Laudenbach M, Gradinati V, Limkar A, Roslawski M, Birnbaum A, Lees A, Hassler C, Runyon S, Pravetoni M. Preclinical Efficacy and Characterization of Candidate Vaccines for Treatment of Opioid Use Disorders Using Clinically Viable Carrier Proteins. Mol Pharm 2018; 15:4947-4962. [PMID: 30240216 DOI: 10.1021/acs.molpharmaceut.8b00592] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Vaccines may offer a new treatment strategy for opioid use disorders and opioid-related overdoses. To speed translation, this study evaluates opioid conjugate vaccines containing components suitable for pharmaceutical manufacturing and compares analytical assays for conjugate characterization. Three oxycodone-based haptens (OXY) containing either PEGylated or tetraglycine [(Gly)4] linkers were conjugated to a keyhole limpet hemocyanin (KLH) carrier protein via carbodiimide (EDAC) or maleimide chemistry. The EDAC-conjugated OXY(Gly)4-KLH was most effective in reducing oxycodone distribution to the brain in mice. Vaccine efficacy was T cell-dependent. The lead OXY hapten was conjugated to the KLH, tetanus toxoid, diphtheria cross-reactive material (CRM), as well as the E. coli-expressed CRM (EcoCRM) and nontoxic tetanus toxin heavy chain fragment C (rTTHc) carrier proteins. All vaccines induced early hapten-specific B cell expansion and showed equivalent efficacy against oxycodone in mice. However, some hapten-protein conjugates were easier to characterize for molecular weight and size. Finally, heroin vaccines formulated with either EcoCRM or KLH were equally effective in reducing heroin-induced antinociception and distribution to the brain of heroin and its metabolites in mice. This study identifies vaccine candidates and vaccine components for further development.
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Affiliation(s)
- Federico Baruffaldi
- Hennepin Healthcare Research Institute (HHRI, formerly Minneapolis Medical Research Foundation or MMRF) , 701 Park Avenue , Minneapolis , Minnesota 55415 , United States
| | - April Huseby Kelcher
- Hennepin Healthcare Research Institute (HHRI, formerly Minneapolis Medical Research Foundation or MMRF) , 701 Park Avenue , Minneapolis , Minnesota 55415 , United States
| | - Megan Laudenbach
- Hennepin Healthcare Research Institute (HHRI, formerly Minneapolis Medical Research Foundation or MMRF) , 701 Park Avenue , Minneapolis , Minnesota 55415 , United States
| | - Valeria Gradinati
- Hennepin Healthcare Research Institute (HHRI, formerly Minneapolis Medical Research Foundation or MMRF) , 701 Park Avenue , Minneapolis , Minnesota 55415 , United States.,Dipartimento di Chimica e Tecnologie Farmaceutiche, Socrates Program , Universitá degli Studi di Milano , Milan 20122 , Italy
| | - Ajinkya Limkar
- University of Minnesota , Minneapolis , Minnesota 55455 , United States
| | | | - Angela Birnbaum
- University of Minnesota , Minneapolis , Minnesota 55455 , United States
| | - Andrew Lees
- Fina Biosolutions, LLC , Rockville , Maryland 20850 , United States
| | - Carla Hassler
- RTI International , Research Triangle Park , North Carolina 27709-2194 , United States
| | - Scott Runyon
- RTI International , Research Triangle Park , North Carolina 27709-2194 , United States
| | - Marco Pravetoni
- Hennepin Healthcare Research Institute (HHRI, formerly Minneapolis Medical Research Foundation or MMRF) , 701 Park Avenue , Minneapolis , Minnesota 55415 , United States.,Departments of Medicine and Pharmacology, Center for Immunology , University of Minnesota , Minneapolis , Minnesota 55455 , United States
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