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Giorgetti A, Große Perdekamp M, Franchetti G, Pircher R, Pollak S, Pelotti S, Auwärter V. Intoxications involving methoxyacetylfentanyl and U-47700: a study of 3 polydrug fatalities. Int J Legal Med 2024:10.1007/s00414-024-03263-7. [PMID: 38831139 DOI: 10.1007/s00414-024-03263-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/28/2024] [Indexed: 06/05/2024]
Abstract
Novel synthetic opioids (NSOs) represent an emerging group of novel psychoactive substances, acting as agonists at the opioid receptors. NSOs include fentanyl-related compounds, e.g. methoxyacetylfentanyl (MeACF), and non-fentanyl analogs, e.g. "U compounds" including U-47700. Here we present three cases of death involving MeACF and U-47700, with particular reference to preliminary data on pharmacokinetics and tissue distribution.After a complete post-mortem examination, general unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassays, gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry. To quantify the analytes of interest in post-mortem blood and tissues, the standard addition method was used. A toxicological significance score (TSS), weighing the role of the NSO in each death case, was assigned.Case 1 died at the hospital after consumption of U-47700, methadone (serum levels: 2,600 ng/ml and 37 ng/ml), tilidine and benzodiazepines. In case 2, U-47700 (204 ng/ml) together with methadone (290 ng/ml), flubromazepam (480 ng/ml) and diazepam (300 ng/ml) were detected in peripheral blood. In case 3, methoxyacetylfentanyl (266 ng/ml), furanylfentanyl (4.3 ng/ml) 4-ANPP (15 ng/ml) and alprazolam (69 ng/ml) were quantified in femoral blood. In all cases, the NSO likely contributed to the death (TSS = 3).NSOs appear to be often consumed in the setting of polydrug intoxications, especially in combination with other opioids and benzodiazepines, which often exert synergistic effects. The standard addition method remains the most reliable in post-mortem analysis and toxicological results should always be evaluated together with circumstantial and autopsy data.
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Affiliation(s)
- Arianna Giorgetti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy.
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Marcus Große Perdekamp
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Giorgia Franchetti
- Legal Medicine, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35121, Padua, Italy
| | - Rebecca Pircher
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Pollak
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susi Pelotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Reeves JJ, Brown AD, Collier BS. Designer benzodiazepine dependence and the difficulties of outpatient management; a case report. J Addict Dis 2024; 42:75-79. [PMID: 36112384 DOI: 10.1080/10550887.2022.2117510] [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] [Indexed: 10/14/2022]
Abstract
BACKGROUND Novel psychoactive substances, such as designer benzodiazepines (DBZD), are a growing public health concern. There are about 30 different DZBDs reported, which can vary widely in their effect and potential for harmful outcomes, ranging from agitation to confusion to coma. Despite the scope of this widespread phenomena, little information on the management of DBZD dependence is available in the literature. CASE In this case report, we present a patient with DBZD dependence requesting assistance tapering off the DBZD, clonazolam. He began self-medicating with clonazolam seven years prior for panic attacks to the point he was using 40 drops per day and having significant withdrawal during the day. He was prescribed gabapentin for his underlying anxiety while he tapered his clonazolam dose. Once he achieved a 75% reduction in his use of clonazolam, he had trouble managing withdrawal and anxiety symptoms and could not taper further. DISCUSSION We discuss the challenges of treating patients with DBZD use disorder in an outpatient setting. Switching a patient from a DZBD to a prescription benzodiazepine for the purposes of a taper can be dangerous as an outpatient due to the inability to monitor at-home DBZD usage and the resulting risk of overdose. DBZDs can also be highly potent and make it difficult to achieve success using current withdrawal guidelines.
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Affiliation(s)
- James J Reeves
- College of Community Health Sciences, University of Alabama, Tuscaloosa, AL, USA
| | - Andrew D Brown
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brent S Collier
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Syrjanen R, Greene SL, Weber C, Smith JL, Hodgson SE, Abouchedid R, Gerostamoulos D, Maplesden J, Knott J, Hollerer H, Rotella JA, Graudins A, Schumann JL. Characteristics and time course of benzodiazepine-type new psychoactive substance detections in Australia: results from the Emerging Drugs Network of Australia - Victoria project 2020-2022. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104245. [PMID: 37944339 DOI: 10.1016/j.drugpo.2023.104245] [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: 06/11/2023] [Revised: 09/28/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION The emergence of benzodiazepine-type new psychoactive substances (NPSs) are a growing international public health concern, with increasing detections in drug seizures and clinical and coronial casework. This study describes the patterns and nature of benzodiazepine-type NPS detections extracted from the Emerging Drugs Network of Australia - Victoria (EDNAV) project, to better characterise benzodiazepine-type NPS exposures within an Australian context. METHODS EDNAV is a state-wide illicit drug toxicosurveillance project collecting data from patients presenting to an emergency department with illicit drug-related toxicity. Patient blood samples were screened for illicit, pharmaceutical and NPSs utilising liquid chromatography-tandem mass spectrometry. Demographic, clinical, and analytical data was extracted from the centralised registry for cases with an analytical confirmation of a benzodiazepine-type NPS(s) between September 2020-August 2022. RESULTS A benzodiazepine-type NPS was detected in 16.5 % of the EDNAV cohort (n = 183/1112). Benzodiazepine-type NPS positive patients were predominately male (69.4 %, n = 127), with a median age of 24 (range 16-68) years. Twelve different benzodiazepine-type NPSs were detected over the two-year period, most commonly clonazolam (n = 82, 44.8 %), etizolam (n = 62, 33.9 %), clobromazolam (n = 43, 23.5 %), flualprazolam (n = 42, 23.0 %), and phenazepam (n = 31, 16.9 %). Two or more benzodiazepine-type NPSs were detected in 47.0 % of benzodiazepine-type NPS positive patients. No patient referenced the use of a benzodiazepine-type NPS by name or reported the possibility of heterogenous product content. CONCLUSION Non-prescription benzodiazepine use may be an emerging concern in Australia, particularly amongst young males. The large variety of benzodiazepine-type NPS combinations suggest that consumers may not be aware of product heterogeneity upon purchase or use. Continued monitoring efforts are paramount to inform harm reduction opportunities.
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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
| | - 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.
| | - Courtney Weber
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia; East Metropolitan Health Service, Department of Health, Perth, Australia
| | - Jennifer L Smith
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia; East Metropolitan Health Service, Department of Health, Perth, 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
| | - Jacqueline Maplesden
- St Vincent's Hospital Melbourne, Emergency Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Jonathan Knott
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia; Melbourne Health, Emergency Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Hans Hollerer
- Western Health, Emergency Department, Footscray Hospital, Footscray, Victoria, Australia
| | - Joe-Anthony Rotella
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia; Northern Health, Emergency Department, The Northern Hospital, Epping, Victoria, Australia
| | - Andis Graudins
- Monash Health, Monash Toxicology Unit, Emergency Service, Dandenong Hospital, Dandenong, Victoria, Australia; Monash University, Department of Medicine, Clinical Sciences at Monash Health, FMNHS
| | - 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
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Papsun DM, Chan-Hosokawa A, Lamb ME, Logan B. Increasing prevalence of designer benzodiazepines in impaired driving: A 5-year analysis from 2017 to 2021. J Anal Toxicol 2023; 47:668-679. [PMID: 37338191 DOI: 10.1093/jat/bkad036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/25/2023] [Accepted: 06/19/2023] [Indexed: 06/21/2023] Open
Abstract
Designer benzodiazepine (DBZD) use has been increasing over the past decade and poses a threat to human health and safety, particularly when involved in driving under the influence of drug (DUID) cases. Over a 5-year period between 2017 and 2021, there were 1,145 reported DBZDs in 805 blood samples submitted from law enforcement agencies for DUID testing. Eleven different DBZDs were detected, including three metabolite pairs: etizolam/alpha-hydroxyetizolam, clonazolam/8-aminoclonazolam, diclazepam/delorazepam, flualprazolam, flubromazolam, flubromazepam, bromazolam and bromazepam. Etizolam/alpha-hydroxyetizolam (n = 485) and flualprazolam (n = 149) were the most frequently detected DBZDs, at 60% and 18%, respectively. Driving behavior, standardized field sobriety test performance and physical observations of individuals suspected of DUIDs, whose blood sample was toxicologically confirmed for one or more DBZDs, were consistent with the effects caused by central nervous system depressants. Each DBZD has its own unique timeline, and toxicology testing had to be frequently updated to reflect the state of the novel psychoactive substance market. DBZDs play a role in impaired driving and can be the sole intoxicant in DUID cases.
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Affiliation(s)
| | | | | | - Barry Logan
- NMS Laboratories, 200 Welsh Rd, Horsham, PA 19044, USA
- Center for Forensic Science Research & Education, 2300 Stratford Ave, Willow Grove, PA 19090, USA
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Abstract
INTRODUCTION Designer benzodiazepines (DBs) are a subclass of novel psychoactive substances (NPS). DBs mimic the properties of approved and prescribed benzodiazepines. AREA COVERED A systematic search of literature on DB classification, structure-activity relationships, pharmacologic properties, and adverse effects. EXPERT OPINION The prevalence of DB use has increased substantially over the last decade. All DBs are full-agonist ligands at the gamma-aminobutyric acid type A-benzodiazepine (GABAA-BZ) receptor system. This is not surprising, since DBs largely represent either minor structural modifications, or well-recognized active metabolites, of existing approved benzodiazepines. As such, the pharmacologic profile and associated risks and hazards of DBs are similar or identical to clinically approved and legitimately prescribed benzodiazepines, most of which have been in use for decades. Concurrent use of DBs along with other abusable or recreational drugs (alcohol, opioids, cocaine, stimulants, hallucinogens, other sedative-hypnotics) represents the principal public health risk. The increasing illicit availability and use of DBs is of concern and requires regulatory attention, but DBs do not rank highly among designer psychotropic agents in terms of health risk to humans.
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Affiliation(s)
- Xiao Yu
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA, USA
| | - H Karl Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA, USA
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Metabolic profiling of clonazolam in human liver microsomes and zebrafish models using liquid chromatography quadrupole Orbitrap mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1216:123583. [PMID: 36621072 DOI: 10.1016/j.jchromb.2022.123583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/08/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Abstract
Clonazolam is a designer benzodiazepine with strong sedative and amnesic effects. As we all know, the detection of metabolites is the key to confirming the use of substances in the field of forensic toxicology. In order to better describe clonazolam metabolism completely, we performed the two different experiments exploiting the unique characteristics of the models used. In this study, in vivo and in vitro samples were analyzed with liquid chromatography-quadrupole/electrostatic field orbitrap mass spectrometry. The results showed that seven Phase I metabolites and one Phase II metabolite were detected in zebrafish model. The remaining Phase I and II metabolites were also found in the incubation solution of pooled human liver microsomes. The main types of metabolic reactions of clonazolam included hydroxylation, dealkylation, nitroreduction, dechlorination, N-Acetylation, and O-glucuronidation. In this paper, the main metabolites and metabolic pathways of clonazolam are clarified in detail in order to further improve the metabolic rule of clonazolam. Based on these results, to better detect and judge the abuse of clonazolam, we suggest that M1, its nitro reduction product, is used as its biomarker. The results of this study provide a theoretical basis for the pharmacokinetics and forensic medicine of clonazolam.
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Wille SMR, Bouazzati M, Rubbens J, Di Fazio V, Samyn N. Combined Use of Flubromazepam and Stimulants: Blood and Oral Fluid Concentrations and Impact on Driving Ability. J Anal Toxicol 2023; 46:e280-e284. [PMID: 36107733 DOI: 10.1093/jat/bkac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/10/2022] [Accepted: 09/12/2022] [Indexed: 01/26/2023] Open
Abstract
"Designer" benzodiazepines (DBZDs) are becoming increasingly available in Europe, with the European Monitoring Centre of Drugs and Drug Addiction currently monitoring ∼30 new benzodiazepines. The following driving under the influence of drug (DUID) case describes the oral fluid (OF) and blood concentrations, as well as the observed effects after the combined use of stimulants and flubromazepam. Both OF, collected via the Intercept i2 collector (Immunalysis, Pomona, CA, USA), and blood (collected in containers with various stabilizers) were screened using a liquid chromatographic (LC) time-of-flight (TOF) mass spectrometric (MS-MS) method. In addition, various LC-MS-MS methods in multi-reaction monitoring mode were applied for confirmation and quantification. The OF and blood samples were taken 2 h 25 min and 9 h 19 min after the accident, respectively. OF contained 789 ng/mL amphetamine, 5,173 ng/mL MDMA, 168 ng/mL benzoylecgonine, 492 ng/mL cocaine, 134 ng/mL 4-methylmethcathinone (4-MMC) and traces of flubromazepam (less than limit of quantification (LLOQ); 2 ng/mL). The sodium-fluoride blood samples contained 19 ng/mL amphetamine, 284 ng/mL MDMA, 20 ng/mL MDA, 38 ng/mL benzoylecgonine, 4 ng/mL methylecgonine, 161 ng/mL flubromazepam and traces of 4-MMC (<LLOQ; 2.5 ng/mL). The driver was observed to have an irregular speed driving pattern and could not keep his lane. He demonstrated the following effects after the accident: bloodshot eyes, red face, sweating, fatigue, disorientation in time and space and mental confusion. Even 24 h after the accident, the driver was confused, disoriented, had red spots on his face and could not keep his balance. The effects of flubromazepam combined with several stimulants are demonstrated. Moreover, this case illustrates well the pros and cons of the different biological matrices applied in a DUID context. Differences between the biological matrices are not only observed concerning the ease/practicality of (on-site) collection, but also in the final drug detectability due to the large variations in OF/blood drug concentration ratios and metabolism/elimination rates as a result of the different chemical entities of the compounds.
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Affiliation(s)
- Sarah M R Wille
- Unit Toxicology, National Institute for Criminalistics and Criminology (NICC), Vilvoordsesteenweg 100, Brussels 1120, Belgium
| | - Malika Bouazzati
- Unit Toxicology, National Institute for Criminalistics and Criminology (NICC), Vilvoordsesteenweg 100, Brussels 1120, Belgium
| | - Jari Rubbens
- Unit Toxicology, National Institute for Criminalistics and Criminology (NICC), Vilvoordsesteenweg 100, Brussels 1120, Belgium
| | - Vincent Di Fazio
- Unit Toxicology, National Institute for Criminalistics and Criminology (NICC), Vilvoordsesteenweg 100, Brussels 1120, Belgium
| | - Nele Samyn
- Unit Toxicology, National Institute for Criminalistics and Criminology (NICC), Vilvoordsesteenweg 100, Brussels 1120, Belgium
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Hong E, Gu SM, Kim JM, Yoon KS, Lee JM, Kim YH, Suh SK, Lee D, Eom H, Yun J, Cha HJ. The designer benzodiazepine, flubromazepam, induces reward-enhancing and cardiotoxic effects in rodents. Toxicol Res (Camb) 2022; 11:644-653. [DOI: 10.1093/toxres/tfac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/10/2022] [Accepted: 06/10/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
The use of many benzodiazepines is controlled worldwide due to their high likelihood of abuse and potential adverse effects. Flubromazepam—a designer benzodiazepine—is a long-acting gamma-aminobutyric acid subtype A receptor agonist. There is currently a lack of scientific evidence regarding the potential for flubromazepam dependence or other adverse effects. This study aimed to evaluate the dependence potential, and cardiotoxicity via confirmation of the QT and RR intervals which are the factors on the electrical properties of the heart of flubromazepam in rodents. Using a conditioned place preference test, we discovered that mice treated intraperitoneally with flubromazepam (0.1 mg/kg) exhibited a significant preference for the flubromazepam-paired compartment, suggesting a potential for flubromazepam dependence. In addition, we observed several cardiotoxic effects of flubromazepam; 100-μM flubromazepam reduced cell viability, increased RR intervals but not QT intervals in the electrocardiography measurements, and considerably inhibited potassium channels in a human ether-à-go-go-related gene assay. Collectively, these findings suggest that flubromazepam may have adverse effects on psychological and cardiovascular health, laying the foundation for further efforts to list flubromazepam as a controlled substance at both national and international levels.
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Affiliation(s)
- Eunchong Hong
- College of Pharmacy , Chungbuk National University, 194-31 Osongsaengmyeong 1-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Republic of Korea
| | - Sun Mi Gu
- College of Pharmacy , Chungbuk National University, 194-31 Osongsaengmyeong 1-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Republic of Korea
| | - Jin Mook Kim
- Pharmacological Research Division , National Institute of Food and Drug Safety Evaluation (NIFDS), Ministry of Food and Drug Safety (MFDS), 187 Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28159, Republic of Korea
| | - Kyung Sik Yoon
- Pharmacological Research Division , National Institute of Food and Drug Safety Evaluation (NIFDS), Ministry of Food and Drug Safety (MFDS), 187 Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28159, Republic of Korea
| | - Jin-Moo Lee
- Pharmacological Research Division , National Institute of Food and Drug Safety Evaluation (NIFDS), Ministry of Food and Drug Safety (MFDS), 187 Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28159, Republic of Korea
| | - Young-Hoon Kim
- Pharmacological Research Division , National Institute of Food and Drug Safety Evaluation (NIFDS), Ministry of Food and Drug Safety (MFDS), 187 Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28159, Republic of Korea
| | - Soo Kyung Suh
- Pharmacological Research Division , National Institute of Food and Drug Safety Evaluation (NIFDS), Ministry of Food and Drug Safety (MFDS), 187 Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28159, Republic of Korea
| | - Dohyun Lee
- Laboratory Animal Center , Osong Medical Innovation Foundation, 123 Osongsaengmyeong-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Republic of Korea
| | - Heejong Eom
- Laboratory Animal Center , Osong Medical Innovation Foundation, 123 Osongsaengmyeong-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Republic of Korea
| | - Jaesuk Yun
- College of Pharmacy , Chungbuk National University, 194-31 Osongsaengmyeong 1-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Republic of Korea
| | - Hye Jin Cha
- Deputy Director General for Narcotics Safety Planning , Pharmaceutical Safety Bureau, Ministry of Food and Drug Safety (MFDS), 187 Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28159, Republic of Korea
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Ling J, Zhang W, Yan X, Liu W, Wang Y, Ding Y. Sensitive detection and primary metabolism analysis of flualprazolam in blood. J Forensic Leg Med 2022; 90:102388. [PMID: 35691207 DOI: 10.1016/j.jflm.2022.102388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/04/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022]
Abstract
Flualprazolam, a new benzodiazepine psychoactive substance recently made available online, and outside the controlled substance list, is often used by criminals for rape and robbery. In this paper, flualprazolam was successfully identified by gas chromatography-mass spectrometry (GC-MS), liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-Q-TOF-MS) and nuclear magnetic resonance (NMR). Moreover, LC-Q-TOF-MS analysis method was proposed for the determination of flualprazolam in whole blood using the rabbit perfusion model. After metabolism analysis, a monohydroxylated metabolite 3-hydroxy-flualprazolam was found in the primary mass spectrum of metabolites. Meanwhile, the time effect curve of the flualprazolam in rabbit's blood was explored and the detection window was about 36 h. Moreover, the sensitivity of the established LC-Q-TOF-MS method was investigated with the limit of detection of 0.03 ng/mL. The successful analysis of an actual forensic case with this established method suggests that it might provide a reference method for drug detection or supervision in law enforcement agencies and identification institutions.
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Affiliation(s)
- Jiang Ling
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, 410013, Changsha, Hunan, China
| | - Wenqi Zhang
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, 410013, Changsha, Hunan, China
| | - Xiaojun Yan
- Institute of Forensic Science, Public Security Department of Hunan Province, 410013, Changsha, Hunan, China
| | - Wenlong Liu
- Institute of Criminal Science and Technology of Changsha Public Security Bureau, 410013, Changsha, Hunan, China
| | - Yanyan Wang
- Key Laboratory of Forensic Toxicology, Ministry of Public Security, People's Republic of China, 100192, Beijing, China
| | - Yanjun Ding
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, 410013, Changsha, Hunan, China.
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Pan M, Rasmussen BS, Dalsgaard PW, Mollerup CB, Nielsen MKK, Nedahl M, Linnet K, Mardal M. A New Strategy for Efficient Retrospective Data Analyses for Designer Benzodiazepines in Large LC-HRMS Datasets. Front Chem 2022; 10:868532. [PMID: 35692684 PMCID: PMC9175026 DOI: 10.3389/fchem.2022.868532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
The expanding and dynamic market of new psychoactive substances (NPSs) poses challenges for laboratories worldwide. The retrospective data analysis (RDA) of previously analyzed samples for new targets can be used to investigate analytes missed in the first data analysis. However, RDA has historically been unsuitable for routine evaluation because reprocessing and reevaluating large numbers of forensic samples are highly work- and time-consuming. In this project, we developed an efficient and scalable retrospective data analysis workflow that can easily be tailored and optimized for groups of NPSs. The objectives of the study were to establish a retrospective data analysis workflow for benzodiazepines in whole blood samples and apply it on previously analyzed driving-under-the-influence-of-drugs (DUID) cases. The RDA workflow was based on a training set of hits in ultrahigh-performance liquid chromatography–quadrupole time-of-flight–mass spectrometry (UHPLC-QTOF-MS) data files, corresponding to common benzodiazepines that also had been analyzed with a complementary UHPLC–tandem mass spectrometry (MS/MS) method. Quantitative results in the training set were used as the true condition to evaluate whether a hit in the UHPLC-QTOF-MS data file was true or false positive. The training set was used to evaluate and set filters. The RDA was used to extract information from 47 DBZDs in 13,514 UHPLC-QTOF-MS data files from DUID cases analyzed from 2014 to 2020, with filters on the retention time window, count level, and mass error. Sixteen designer and uncommon benzodiazepines (DBZDs) were detected, where 47 identifications had been confirmed by using complementary methods when the case was open (confirmed positive finding), and 43 targets were not reported when the case was open (tentative positive finding). The most common tentative and confirmed findings were etizolam (n = 26), phenazepam (n = 13), lorazepam (n = 9), and flualprazolam (n = 8). This method efficiently found DBZDs in previously acquired UHPLC-QTOF-MS data files, with only nine false-positive hits. When the standard of an emerging DBZD becomes available, all previously acquired DUID data files can be screened in less than 1 min. Being able to perform a fast and accurate retrospective data analysis across previously acquired data files is a major technological advancement in monitoring NPS abuse.
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Affiliation(s)
- Meiru Pan
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | - Michael Nedahl
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristian Linnet
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Mardal
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Pharmacy, The Arctic University of Norway, Tromsø, Norway
- *Correspondence: Marie Mardal,
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11
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Pérez Orts M, van Asten A, Kohler I. The Evolution Toward Designer Benzodiazepines in Drug-Facilitated Sexual Assault Cases. J Anal Toxicol 2022; 47:1-25. [PMID: 35294022 PMCID: PMC9942444 DOI: 10.1093/jat/bkac017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/01/2022] [Accepted: 03/15/2022] [Indexed: 11/14/2022] Open
Abstract
Drug-facilitated sexual assault (DFSA) is a crime where the victim is unable to provide sexual consent due to incapacitation resulting from alcohol or drug consumption. Due to the large number of substances possibly used in DFSA, including illicit, prescription and over-the-counter drugs, DFSA faces many toxicological challenges. Benzodiazepines (BZDs) are ideal candidates for DFSA, as they are active at low doses, have a fast onset of action and can be easily administered orally. The last decade has seen the emergence of designer benzodiazepines (DBZDs), which show slight modifications compared with BZDs and similar pharmacological effects but are not controlled under the international drug control system. DBZDs represent an additional challenge due to the number of new entities regularly appearing in the market, their possibly higher potency and the limited knowledge available on their pharmacokinetic and pharmacodynamics properties. Many BZDs and DBZDs have a short half-life, leading to rapid metabolism and excretion. The low concentrations and short time windows for the detection of BZD in body fluids require the use of highly sensitive analysis methods to enable the detection of drugs and their respective metabolites. This review discusses the current state of the toxicological analysis of BZDs and DBZDs in forensic casework and their pharmacokinetic properties (i.e., absorption, distribution, metabolism, and elimination), as well as their analysis in biosamples typically encountered in DFSA (i.e., blood, urine and hair).
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Affiliation(s)
- Mireia Pérez Orts
- Van’t Hoff Institute for Molecular Sciences, University of Amsterdam, P.O. Box 94157, Amsterdam 1090 GD, The Netherlands
| | - Arian van Asten
- Van’t Hoff Institute for Molecular Sciences, University of Amsterdam, P.O. Box 94157, Amsterdam 1090 GD, The Netherlands,Co van Ledden Hulsebosch Center (CLHC), Amsterdam Center for Forensic Science and Medicine, 1098 XH Amsterdam, The Netherlands,Centre for Analytical Sciences Amsterdam (CASA), Science Park, 904, 1098 XH Amsterdam, The Netherlands
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12
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Essink S, Nugteren-van Lonkhuyzen JJ, van Riel AJHP, Dekker D, Hondebrink L. Significant toxicity following an increase in poisonings with designer benzodiazepines in the Netherlands between 2010 and 2020. Drug Alcohol Depend 2022; 231:109244. [PMID: 34998250 DOI: 10.1016/j.drugalcdep.2021.109244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/05/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Designer benzodiazepines (DBs) are an emerging class of new psychoactive substances. While structurally derived from pharmaceutical benzodiazepines, their toxicological profile is less clear. We investigated time trends in the rate of DB poisonings and their clinical toxicity. METHODS A retrospective observational study was performed on the incidence rate of DB poisonings, relative to all recreational drug poisonings reported to the Dutch Poisons Information Center (DPIC) from 2010 to 2020. Time-trend analysis was performed using Poisson regression. A prospective cohort study was performed on toxicity of DBs, including the Poisoning Severity Score, from January 2016-June 2019. Data was collected through telephone interviews. RESULTS Between 2010 and 2020, the DPIC was consulted on 142 DB exposures. The incidence rate of DB exposures increased from 0.1% to 4.3%, with a year effect estimate of 1.35 (95% CI [1.14;1.54]). Twenty different DBs were reported, mostly etizolam (33%), clonazolam (17%), and flunitrazolam (8%). During consultation (often shortly after exposure), poisoning was graded moderate-severe in 29% of cases (n = 146). In the prospective cohort sample with follow-up (n = 22), 86% of cases (n = 19) showed a moderate-severe poisoning. The severity of poisoning did not differ between mono- and mixed intoxications. Frequently reported symptoms in the prospective cohort sample included drowsiness (86%), confusion (59%), and agitation (55%). Coma was observed in seven cases (32%) and respiratory depression requiring mechanical ventilation in five cases (23%). CONCLUSION The rate of DB poisonings reported to the DPIC strongly increased from 2010 to 2020, indicating increased (ab)use of DBs. Most DB exposures resulted in moderate-severe toxicity with neurological effects.
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Affiliation(s)
- Sharon Essink
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Johanna J Nugteren-van Lonkhuyzen
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Antoinette J H P van Riel
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Douwe Dekker
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Laura Hondebrink
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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13
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Characteristics of fatal 'novel' benzodiazepine toxicity in Australia. Forensic Sci Int 2021; 331:111140. [PMID: 34894611 DOI: 10.1016/j.forsciint.2021.111140] [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: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The study aimed to determine: 1. The characteristics of all recorded cases of fatal drug poisoning involving 'novel' benzodiazepines (NBZDs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings. METHODS Retrospective study of all deaths due to drug toxicity in Australia in which NBZDs were present in blood toxicology, retrieved from the National Coronial Information System (2000-2021). Information was collected on case characteristics, toxicology and major organ pathology. RESULTS A total of 40 cases were identified, the first occurring in 2015, with a median age of 26.5 years and 87.5% being male. Death was due to accidental toxicity in 92.5% of cases. There were extensive histories of substance use problems (80.0%) and mental health problems (32.5%). Etizolam was the most common NBZD (87.5%), followed by flubromazolam (15.0%), with other NBZDs detected in 20.0% (delorazepam, diclazepam, flualprazolam, flubromazepam, lormetazepam). Multiple NBZDs were present in 27.5%. Other drugs were present in 97.5%, most commonly opioids (70.0%), registered benzodiazepines (62.5%), psychostimulants (45.0%) and gabapentinoids (32.5%). A CNS depressant other than a NBZD was detected in 95.0% (n = 38). Autopsies were conducted and available for 30 cases, with pulmonary oedema (76.7%, n = 23), aspiration of vomitus (46.7%, n = 14) and acute bronchopneumonia (36.7%, n = 11) the most common diagnoses. CONCLUSIONS The 'typical' NBZD-related death was a young male who died due to accidental toxicity. Deaths most frequently involved etizolam and multiple substances, particularly depressants.
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14
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Giorgetti A, Sommer MJ, Wilde M, Perdekamp MG, Auwärter V. A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues. Forensic Toxicol 2021; 40:180-188. [DOI: 10.1007/s11419-021-00591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose
Designer benzodiazepines (DBZDs) increasingly emerged on the novel psychoactive substance (NPS) market in the last few years. They are usually sold as readily available alternatives to prescription benzodiazepines (BZDs) or added to counterfeit medicines. BZDs are generally considered relatively safe drugs due to the low risk of serious acute adverse effects in mono-intoxication, though e.g., alprazolam seems to display an elevated risk of respiratory depression. Here we report on a fatal intoxication involving the novel DBZD flualprazolam.
Methods
A complete postmortem examination was performed. General unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassay, gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. The standard addition method was employed to quantify flualprazolam in postmortem blood and tissues. Finally, a toxicological significance score (TSS) was assigned.
Results
Flualprazolam was detected in heart serum (25.4 ng/mL) and peripheral blood (21.9 ng/mL) as well as in urine, stomach contents, brain, liver and kidney (65.2–323 ng/g). The cause of death was deemed as central nervous system (CNS) and respiratory depression with agonal aspiration of stomach contents, in the setting of a multiple drug intake. Given the concentration levels of the co-consumed CNS depressants, the contribution of flualprazolam to the death was considered likely (TSS of 3).
Conclusions
Our results support that highly potent DBZDs like flualprazolam carry an elevated risk for unintended toxicity, especially in association with other CNS depressants. A multidisciplinary evaluation of fatalities remains mandatory, especially when pharmacological/toxicological data on intoxicating compounds are lacking. To our knowledge this is the first report of flualprazolam concentrations in solid tissues in human.
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15
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Designer Benzodiazepines: A Review of Toxicology and Public Health Risks. Pharmaceuticals (Basel) 2021; 14:ph14060560. [PMID: 34208284 PMCID: PMC8230725 DOI: 10.3390/ph14060560] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 12/11/2022] Open
Abstract
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game between organized crime and law enforcement. Non-prohibited benzodiazepines are introduced onto the global drug market and scheduled as rapidly as possible by international authorities. In response, DBZD are continuously modified to avoid legal sanctions and drug seizures and generally to increase the abuse potential of the DBZD. This results in an unpredictable fluctuation between the appearance and disappearance of DBZD in the illicit market. Thirty-one DBZD were considered for review after consulting the international early warning database, but only 3-hydroxyphenazepam, adinazolam, clonazolam, etizolam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, phenazepam and pyrazolam had sufficient data to contribute to this scoping review. A total of 49 reports describing 1 drug offense, 2 self-administration studies, 3 outpatient department admissions, 44 emergency department (ED) admissions, 63 driving under the influence of drugs (DUID) and 141 deaths reported between 2008 and 2021 are included in this study. Etizolam, flualprazolam flubromazolam and phenazepam were implicated in the majority of adverse-events, drug offenses and deaths. However, due to a general lack of knowledge of DBZD pharmacokinetics and toxicity, and due to a lack of validated analytical methods, total cases are much likely higher. Between 2019 and April 2020, DBZD were identified in 48% and 83% of postmortem and DUID cases reported to the UNODC, respectively, with flualprazolam, flubromazolam and etizolam as the most frequently detected substances. DBZD toxicology, public health risks and adverse events are reported.
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16
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Haden M, Cashman J, Ketchin A, Macfarlane R, Issa S, Eddleston M, Hines S, Hudson S, Hill SL, Thomas SHL. Detection of flubromazolam in patients with suspected non-medical drug use attending emergency departments in the United Kingdom. Clin Toxicol (Phila) 2021; 60:33-37. [PMID: 34080515 DOI: 10.1080/15563650.2021.1931692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Non-medical use of novel benzodiazepines has recently become common. Here, we describe the recent frequent detection of flubromazolam in patients attending United Kingdom emergency departments. METHODS Adults presenting to participating hospitals with toxicity after suspected drug misuse were studied between March 2015 and January 2021. Clinical features were recorded using consistent methodology and biological samples analysed using liquid chromatography-tandem mass-spectrometry. RESULTS Flubromazolam and/or its mono-hydroxylated metabolite were detected in samples from 14 of 957 patients, all presenting since July 2020. Reported clinical features included reduced level of consciousness (10), confusion/agitation (6) and acidosis (5) but multiple other substances were detected in all patients. All patients survived to discharge (length of hospital stay 3.0 to 213 h, median 24.1 h). There was no correlation between admission blood/serum flubromazolam concentrations (range 1.7-480.5 ng/ml, median 7.4 ng/ml) and Glasgow Coma Scale or length of hospital stay. In one patient who needed intubation and ventilation for five days, there was an exponential decline in flubromazolam concentrations with time (calculated half-life 39.8 h). Hydroxyl-flubromazolam was also identified at all time points. CONCLUSIONS Flubromazolam has been detected frequently in drug users presenting to UK emergency departments since July 2020. Prolonged toxicity may occur as a result of the long half-life of flubromazolam and the production of metabolites likely to be active.
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Affiliation(s)
- Mark Haden
- Emergency Department, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Josephine Cashman
- Emergency Department, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Ketchin
- Emergency Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Shabana Issa
- Emergency Department, Royal London Hospital, Barts Healthcare NHS Trust, London, UK
| | | | | | | | - Simon L Hill
- LGC Ltd, Fordham, UK.,Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon H L Thomas
- Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
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17
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Maskell PD, Parks C, Button J, Liu H, McKeown DA. Clarification of the Correct Nomenclature of the Amino Metabolite of Clonazolam: 8-Aminoclonazolam. J Anal Toxicol 2021; 45:e1-e2. [PMID: 33150945 DOI: 10.1093/jat/bkaa169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Peter D Maskell
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Claire Parks
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
| | - Jenny Button
- Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Huiling Liu
- Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Denise A McKeown
- Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, UK
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18
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Degreef M, Vits L, Berry EM, Maudens KEK, van Nuijs ALN. Quantification of 54 Benzodiazepines and Z-Drugs, Including 20 Designer Ones, in Plasma. J Anal Toxicol 2021; 45:141-153. [PMID: 32507898 DOI: 10.1093/jat/bkaa059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/03/2020] [Accepted: 04/19/2020] [Indexed: 02/07/2023] Open
Abstract
Benzodiazepines are widely used in the treatment of sleep and anxiety disorders, as well as epileptic seizures and alcohol withdrawal because of their broad therapeutic index and low cost. Due to their central nervous system depressant effects they are also often implicated in traffic accidents and drug-related intoxications. With an increasing number of designer benzodiazepines used in a recreational setting, there is a need for analytical methods to be able to quantify both the prescribed and designer benzodiazepines. A liquid chromatography-triple quadrupole mass spectrometry method was developed for the quantification of 34 prescribed and 20 designer benzodiazepines in plasma. Different sample preparation strategies, including protein precipitation, liquid-liquid extraction, solid-phase extraction and mini-QuEChERS, were tested. The best recoveries for all compounds of interest were obtained with a liquid-liquid extraction using methyl-tertiary-butyl-ether and 500 μL plasma. The method was fully validated according to the European Medicines Agency guidelines for all compounds, except pivoxazepam, which is included for qualitative purposes only. In-sample stability issues were observed for cloxazolam, both at ambient temperature and during long-term storage at -20°C. Due to the large number of compounds included, the simple and time-efficient sample preparation and the relatively inexpensive instrumentation used, the presented method can be readily implemented in both therapeutic drug monitoring and forensic analyses.
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Affiliation(s)
- Maarten Degreef
- Toxicological Centre, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Lore Vits
- Toxicological Centre, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Eleanor M Berry
- Toxicological Centre, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
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19
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Laing MK, Ti L, Marmel A, Tobias S, Shapiro AM, Laing R, Lysyshyn M, Socías ME. An outbreak of novel psychoactive substance benzodiazepines in the unregulated drug supply: Preliminary results from a community drug checking program using point-of-care and confirmatory methods. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 93:103169. [PMID: 33627302 DOI: 10.1016/j.drugpo.2021.103169] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND From mid-2018, an increase in novel psychoactive substance (NPS) benzodiazepines was noted on surveillance of the unregulated drug market around Vancouver, British Columbia, Canada. The rise was concordant with an outbreak of atypical overdoses suspicious for benzodiazepine adulteration of unregulated opioids. This study sought to describe the number and type of NPS benzodiazepines in a sample drawn from a community drug checking program during this period, and to explore accuracy of point-of-care drug checking technologies when compared to confirmatory methods in this sample. METHODS Point-of-care drug checking data using fentanyl and benzodiazepine test strips as well as Fourier transform infrared spectroscopy were gathered at harm reduction sites in the Vancouver area from October 2018 to January 2020. A convenience subsample underwent confirmatory testing with gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or quantitative nuclear magnetic resonance spectroscopy. RESULTS Of 159 samples with both point-of-care and confirmatory results, 24 (15.1%) contained at least one NPS benzodiazepine, including etizolam (n = 18), flubromazolam (n = 3), flualprazolam (4), and flubromazepam (n = 1). Of 114 confirmatory samples expected by participants on self-report to contain opioids, 18 (15.8%) contained some NPS benzodiazepine, with 16 (14.0%) containing both an NPS benzodiazepine and an opioid, always fentanyl. False positive and negative rates were 15.5% and 37.5% for test strips, and 3.9% and 91.7% for FTIR, respectively. Combined together, false positive and negative rates of point-of-care methods were 17.8% and 29.2%. CONCLUSIONS NPS benzodiazepine adulteration in an unregulated drug supply sample reveals new risks compounding ongoing harms associated with the synthetic opioid epidemic. Given substantial false positive and false negative rates noted in our sample for point-of-care detection methods, cautious use of combined point-of-care methods, routinely paired with confirmatory drug checking may aid in early detection and monitoring of unregulated drug markets and inform targeted harm reduction strategies and health policy approaches.
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Affiliation(s)
- Matthew K Laing
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Lianping Ti
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Allison Marmel
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Samuel Tobias
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Aaron M Shapiro
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial Toxicology Centre, 655W 12th Ave, Vancouver, BC, Canada
| | - Richard Laing
- Strategic Research and Science Development: Drug Analysis Service
- Stratégique et Développement Scientifique: Service d'analyse des drogues, Health Canada, 3155 Willingdon Green, Burnaby, BC, V5G 4P2, Canada
| | - Mark Lysyshyn
- School of Population and Public Health, University of British Columbia, 2206 E. Mall, Vancouver, BC, V6T 1Z3, Canada; Vancouver Coastal Health Authority, 801-601 West Broadway, Vancouver, BC, V5Z 4C2, Canada
| | - M Eugenia Socías
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
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20
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Heide G, Høiseth G, Middelkoop G, Øiestad ÅML. Blood Concentrations of Designer Benzodiazepines: Relation to Impairment and Findings in Forensic Cases. J Anal Toxicol 2020; 44:905-914. [PMID: 32369173 PMCID: PMC7733327 DOI: 10.1093/jat/bkaa043] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The use of designer benzodiazepines appears to be increasing in many countries, but data concerning blood concentrations are scarce, making interpretation of concentrations difficult. The aim of this study was to report blood concentrations of clonazolam, diclazepam, etizolam, flualprazolam, flubromazepam, flubromazolam and phenazepam and to investigate the relationship between blood concentrations and impairment. The concentration data are from blood samples collected from living cases (apprehended drivers and other drug offences) and medico-legal autopsies. The blood samples were analysed for the seven designer benzodiazepines mentioned above by ultra high performance liquid chromatography–tandem mass spectrometry. Positive cases from between 1 June 2016 and 30 September 2019 were included. Blood concentrations and the conclusion from a clinical test of impairment (when available) are reported. The presented seven benzodiazepines were detected in a total of 575 cases, where 554 of these cases concerned apprehended drivers or other criminal offenders. The number of findings and the median (range) concentrations were as follows: clonazolam, n = 22, 0.0041 mg/L (0.0017–0.053 mg/L); diclazepam, n = 334, 0.0096 mg/L (0.0016–0.25 mg/L); etizolam, n = 40, 0.054 mg/L (0.015–0.30 mg/L); flualprazolam, n = 10, 0.0080 mg/L (0.0033–0.056 mg/L); flubromazepam, n = 5, 0.037 mg/L (0.0070–0.70 mg/L); flubromazolam, n = 20, 0.0056 mg/L (0.0004–0.036 mg/L); and phenazepam, n = 138, 0.022 mg/L (0.0018–0.85 mg/L). A designer benzodiazepine was the only drug detected with relevance for impairment in 25 of the 554 living cases. The physician concluded with impairment in 19 of the 25 cases. Most of the concentrations in these cases were relatively similar to or higher than the median reported concentrations. The most frequent other drugs detected were amphetamine, tetrahydrocannabinol, clonazepam and methamphetamine. The presented blood concentrations can be helpful with the interpretation of cases involving one or more of these seven benzodiazepines. The results indicate that concentrations commonly observed in forensic cases are associated with impairment.
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Affiliation(s)
- Gunhild Heide
- Department of Forensic Sciences, Oslo University Hospital, 0424 Oslo, Norway
| | - Gudrun Høiseth
- Department of Forensic Sciences, Oslo University Hospital, 0424 Oslo, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, 0319 Oslo, Norway
| | - Gerrit Middelkoop
- Department of Forensic Sciences, Oslo University Hospital, 0424 Oslo, Norway
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21
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Mullins ME. Fentanyl, Inc.. Clin Toxicol (Phila) 2020. [DOI: 10.1080/15563650.2020.1736299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Michael E. Mullins
- Section of Medical Toxicology; Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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22
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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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23
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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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Nielsen S, McAuley A. Etizolam: A rapid review on pharmacology, non‐medical use and harms. Drug Alcohol Rev 2020; 39:330-336. [DOI: 10.1111/dar.13052] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research CentreMonash University Melbourne Australia
| | - Andrew McAuley
- School of Health and Life SciencesGlasgow Caledonian University Glasgow UK
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Xia M, Huang D, Tong Y, Lin J. Pearl powder reduces sleep disturbance stress response through regulating proteomics in a rat model of sleep deprivation. J Cell Mol Med 2020; 24:4956-4966. [PMID: 32220128 PMCID: PMC7205811 DOI: 10.1111/jcmm.15095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/04/2019] [Accepted: 01/06/2020] [Indexed: 12/24/2022] Open
Abstract
Aims This study aimed to explore whether pearl could help prevent cognitional morbidity and improve the metabolic processes of hippocampus. Methods Rats were divided into group of control (CTL), sleep deprivation (SD) and pearl powder (PP). The sleeplessness was introduced to all rats except control. Before and after administration with vehicle or pearl powder, cognition was evaluated by Morris water maze (MWM). The protein expression in hippocampus among all groups was examined using iTRAQ‐based global proteomic analysis. Results Morris water maze tests revealed improvements of insomnia‐induced cognitive deficit in both PP‐ and ES‐treated rats, as compared to SD rats. However, proteomic analysis indicates that the pharmacological impact on gene expression of these two medicines is quite different: pearl is more capable of correcting aberrant gene expression caused by SD than estazolam. Therefore, pearl is more suitable for treatment of insomnia. These data, together with protein‐protein interaction analysis, indicate that several pathways, affected by sleep deprivation, may be rescued by pearl powder: retrograde endocannabinoid signalling pathway, and the protein interaction or network enrich in oxidative phosphorylation Parkinson's disease and Huntington disease, etc Conclusions Sleep deprivation can mimic cognition decline caused by insomnia with altered protein expression in the hippocampus; such behavioural and pathological changes can be significantly ameliorated by pearl powder.
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Affiliation(s)
- Meng Xia
- School of Basic Medicine, Guangxi University of Chinese Medicine, Nanning, China
| | - Delun Huang
- School of Basic Medicine, Guangxi University of Chinese Medicine, Nanning, China
| | - Yuangming Tong
- Information Center, Guangxi Institute of Chinese Medicine and Pharmaceutical Science, Nanning, China
| | - Jiang Lin
- School of Basic Medicine, Guangxi University of Chinese Medicine, Nanning, China
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Orsolini L, Corkery JM, Chiappini S, Guirguis A, Vento A, De Berardis D, Papanti D, Schifano F. 'New/Designer Benzodiazepines': An Analysis of the Literature and Psychonauts' Trip Reports. Curr Neuropharmacol 2020; 18:809-837. [PMID: 31933443 PMCID: PMC7569319 DOI: 10.2174/1570159x18666200110121333] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/08/2019] [Accepted: 01/09/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND NPS belonging to the benzodiazepine (BZD) class, e.g., 'legal/designer BZDs'/'research chemicals', have recently emerged in the drug (mainly online/virtual) market. OBJECTIVE While certain NPS belonging to the BZD class possess pharmacological profiles similar to controlled pharmaceutical BZDs, clinical and pharmacological profiles of current emerging BZDs are still not well-described. Therefore, there is a need to increase clinicians'/public health knowledge/awareness, to incentive harm reduction strategies. METHOD A comprehensive overview was carried out by using the EMCDDA/EDND database regularly monitored by our research team, by specifically looking at the 'new BZDs' so far notified. Furthermore, given the limitation of peer-reviewed data published so far, a nonparticipant multilingual qualitative netnographic study was conducted to obtain further clinical/pharmacological/ toxicological data, including psychonauts' online trip reports. RESULTS First designer BZDs appeared as NPS around 2007. So far, 29 designer BZDs have been notified to the EMCDDA, being some of them extremely powerful, also at lower dosages. They are sold as tablets/powder/pellets/capsules/blotters/liquids, at very affordable prices, and variably administered. Some are also sold on the illicit drugmarket as counterfeit forms of traditional BZDs or as either adulterants or diluents in heroin or other synthetic opioids/cannabinoids. Nowadays, there is no guarantee of the quality of designer BZDs composition/purification and, hence, most NPS consumers may be inadvertently exposed to unsafe and harmful compounds. CONCLUSION Given the limited information on their pharmacology/toxicity, variations in dosage, onset of effects, combination of substances, potency, and general patient or individual variability, the concomitant use of these substances with other drugs entails several and unpredictable risks.
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Affiliation(s)
- Laura Orsolini
- Address correspondence to this author at the Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, AL10 9AB, Herts, UK; Villa Jolanda Hospital, Neomesia Mental Health, Villa Jolanda, Italy; Polyedra, Teramo, Italy; Tel: (+39) 392 3244643; E-mail:
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Murphy L, Melamed J, Gerona R, Hendrickson RG. Clonazolam: a novel liquid benzodiazepine. TOXICOLOGY COMMUNICATIONS 2019. [DOI: 10.1080/24734306.2019.1661568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Lauren Murphy
- Toxicology, Oregon Health & Science University, Portland, OR, USA
- Oregon Poison Center, Portland, OR, USA
| | | | - Roy Gerona
- University of California, San Francisco, San Francisco, CA, USA
| | - Robert G. Hendrickson
- Toxicology, Oregon Health & Science University, Portland, OR, USA
- Oregon Poison Center, Portland, OR, USA
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Bühler T, Schmid Y, Liechti ME. [Knockout Drugs: Diagnostics in the Emergency Unit and Clinical Practice]. PRAXIS 2019; 108:869-876. [PMID: 31571536 DOI: 10.1024/1661-8157/a003306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Knockout Drugs: Diagnostics in the Emergency Unit and Clinical Practice Abstract. Every now and then, physicians are challenged with date rape drugs. If there is a suspicion of substance administration, the question of involving forensic medicine is commonly raised. In obscure situations or questionable offences, however, patients may wish for an initial diagnosis in the emergency department or the private practice. The physicians are often greatly challenged by the variety of substances, the limited analytical methods and difficulties with the interpretion of results. The major goal of this article is to present diagnostic options including their limitations. An overview of frequently involved substances is provided. Particular focus will be placed on practical aspects, including questions regarding pre-analytics and health insurance coverage.
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Affiliation(s)
- Tim Bühler
- Abteilung für Klinische Pharmakologie & Toxikologie, Universitätsspital Basel
| | - Yasmin Schmid
- Abteilung für Klinische Pharmakologie & Toxikologie, Universitätsspital Basel
| | - Matthias E Liechti
- Abteilung für Klinische Pharmakologie & Toxikologie, Universitätsspital Basel
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Ligon ES, Nawyn J, Jones LV, Allred BM, Reinhardt DV, France S. Synthesis of Flubromazepam Positional Isomers for Forensic Analysis. J Org Chem 2019; 84:10280-10291. [PMID: 31328518 DOI: 10.1021/acs.joc.9b01433] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Designer benzodiazepines have recently appeared in many forensic cases as legal alternatives to federally scheduled drugs such as diazepam (Valium) and alprazolam (Xanax). Though current forensic instrumental techniques are often sufficient for identifying novel psychoactive substances, they may not readily differentiate between potential positional isomers. Additionally, characterization data for positional isomers of known designer benzodiazepines are widely nonexistent. In this study, flubromazepam, a recognized designer benzodiazepine since 2012, was targeted for synthesis and characterization due to its potential for federal scheduling and current legal status within the United States. A practical synthetic method was developed to prepare purified reference materials for each positional isomer of flubromazepam in which the positions of the bromine and fluorine substituents were varied. Possible isomers (9 of the 12) were successfully prepared and used for further analysis.
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Van Wijk XMR, Goodnough R, Colby JM. Mass spectrometry in emergency toxicology: Current state and future applications. Crit Rev Clin Lab Sci 2019; 56:225-238. [DOI: 10.1080/10408363.2019.1585415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Xander M. R. Van Wijk
- Department of Pathology, Pritzker School of Medicine, University of Chicago, Chicago, IL, US
| | - Robert Goodnough
- California Poison Control System, San Francisco Division, San Francisco, CA, US
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, US
| | - Jennifer M. Colby
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, US
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