Flualprazolam Blood Concentrations in 197 Forensic Investigation Cases

Fake Xanax: Designer Emerging Benzodiazepine Epidemic Linked to Morbidity and Mortality a Narrative Review

Etizolam is a thienodiazepine derivative which produces an anxiolytic effect similar to benzodiazepines such as alprazolam (Xanax). Like classic benzodiazepines, etizolam has a high affinity towards the GABAA receptor, and allosterically potentiates the effects of GABA resulting in neuronal hyperpolarization related to chloride influx. When taken in therapeutic doses, etizolam produces a similar effect to Xanax. Counterfeit Xanax tablets contain variable amounts of etizolam. Tablets with high amounts of etizolam can cause toxicity if ingested, especially when combined with other substances. When toxic symptoms occur in patients, they may include severe sedation, unconsciousness, and depression of the medullary respiratory center. In this regard, there is the potential for death. Additionally, the rise in fake Xanax tablets containing etizolam and other counterfeit medications has been exacerbated by the difference in regulations regarding these substances in different countries as well as the illegal drug trade. Healthcare providers may also play a role through the over- or underprescribing of certain medications. Thus, in order to combat the rise in counterfeit medications such as fake Xanax, international cooperation, regulation, and enforcement of laws pertaining to the manufacture, prescription, and distribution of these substances are needed.

Toxicology findings from drivers suspected of drug-impaired driving in Ontario (2008-2019)

OBJECTIVE

This study examines the results of toxicological tests performed on blood and urine samples collected from suspected drug-impaired drivers in Ontario from 2008 to 2019. The report examines the results of toxicological analysis of the samples submitted, the characteristics of those drivers from whom samples were collected, and the temporal and situational circumstances that led to police investigations and sample collection to better understand drug-impaired driving behavior and to assist in the development and implementation of countermeasure strategies and programs.

METHODS

Blood and urine samples were sent to the Center of Forensic Sciences where they were analyzed using standardized comprehensive toxicological analysis to test for a wide variety of potentially impairing drugs. Demographic and temporal information for each case from which a sample was collected were also examined to describe the circumstances and characteristics of these driving incidents.

RESULTS

During the 12-year period examined, 5,388 samples collected from suspected drug-impaired drivers were analyzed. The number of samples collected increased substantially following the implementation of the Drug Evaluation and Classification Program (DECP) in July 2008, the enactment of legislation facilitating the collection of blood samples from suspects, and the legalization of cannabis for nonmedical purposes in 2018. The number of samples submitted shows temporal correlation with the number of police officers certified as Drug Recognition Experts (DRE) in the province. Over the 12-year period of this study, cannabis was the most frequently detected substance in drivers (52.8% of cases), followed by cocaine (44.3%) and methamphetamine (24.8%). In 80% of cases, more than one substance was detected.

CONCLUSIONS

Examining the characteristics of suspected drug-impaired drivers, the temporal circumstances, and the drug findings throughout the large geographic area of Ontario and over the extended period of this study enhances our understanding of drug-impaired driving behavior. These characteristics can assist in the development and/or evaluation of enforcement strategies and enhanced countermeasure activities.

Identification of clobromazolam in Australian emergency department intoxications using data-independent high-resolution mass spectrometry and the HighResNPS.com database

The proliferation of novel psychoactive substances (NPSs) continues to challenge toxicology laboratories. In particular, the United Nations Office on Drugs and Crime considers designer benzodiazepines to be a current primary threat among all NPSs. Herein, we report detection of a new emerging designer benzodiazepine, clobromazolam, using high-resolution mass spectrometry and untargeted data acquisition in combination with a "suspect screening" method built from the crowd-sourced HighResNPS.com database. Our laboratory first detected clobromazolam in emergency department presenting intoxications included within the Emerging Drugs Network of Australia-Victoria project in the state of Victoria, Australia, from April 2022 to March 2023. Clobromazolam was the most frequent designer benzodiazepine detected in this cohort (100/993 cases, 10%). No patients reported intentional administration of clobromazolam, although over half reported exposure to alprazolam, which was detected in only 7% of cases. Polydrug use was prevalent (98%), with phenazepam (45%), methylamphetamine (71%) and other benzodiazepines (60%) most frequently co-detected. This is the first case series published in the literature concerning clobromazolam in clinical patients. The identification of clobromazolam in patients presenting to emergency departments in Victoria demonstrates how high-resolution mass spectrometry coupled with the HighResNPS.com database can be a valuable tool to assist toxicology laboratories in keeping abreast of emerging psychoactive drug use.

Interference of the novel designer benzodiazepine 4'-chloro deschloroalprazolam with alprazolam analysis in toxicology and seized drug DUID casework

In recent years, the emergence of the novel designer benzodiazepine 4'-chloro deschloroalprazolam has presented a new challenge for forensic laboratories by interfering with the identification and quantitation of alprazolam. As an isomer of alprazolam, 4'-chloro deschloroalprazolam has similar physicochemical properties and can be misidentified in casework samples as alprazolam without a specific method to differentiate the two analytes. Starting in late 2021, the Houston Forensic Science Center (HFSC) received toxicological and seized drug evidence indicating the presence of 4'-chloro deschloroalprazolam. An interference study was performed to supplement the laboratory's validated benzodiazepines method for toxicological samples to differentiate alprazolam from 4'-chloro deschloroalprazolam. This study showed that while the isomers could not be chromatographically resolved using the current method, they could be differentiated based on their retention times relative to the internal standard, alprazolam-d5. Based on these findings, the HFSC toxicology laboratory reports test results as "unsuitable for analysis due to an interference" if a suspected alprazolam peak elutes before the alprazolam-d5 peak, even if all identification and quantification criteria (e.g., retention time) were acceptable. Additionally, the seized drug and toxicology laboratories re-evaluated previously analyzed alprazolam-positive casework to determine if suspected 4'-chloro deschloroalprazolam had been misidentified as alprazolam. This report presents three cases: one case with toxicological evidence indicating the presence of both 4'-chloro deschloroalprazolam and alprazolam, and two cases with both seized drug material and toxicology evidence indicating the presence of 4'chloro deschloroalprazolam with no detected alprazolam.

Flualprazolam and flubromazolam: Blood concentrations and prevalence of two novel psychoactive substances in forensic case work in Ontario, Canada

Flualprazolam and flubromazolam are synthetic benzodiazepines that have not been approved for use in humans. They are categorized as novel psychoactive substances (NPS), and have been increasingly encountered in forensic case work. This report examines information from cases analyzed for flualprazolam and flubromazolam between July 1 and December 31, 2021 to identify the prevalence, trends and demographic data associated with these novel drugs in Ontario, Canada. Flualprazolam was identified in blood, serum or liver in 395 death investigations, 108 impaired driving and five sexual assault cases. Among all case types, blood concentrations were determined in 123 individuals aged 19-66 years. In impaired driving and sexual assault cases, flualprazolam blood concentrations ranged from <1.3 to 227 ng/mL (median 11.0 ng/mL), whereas a range of 3-59 ng/mL (median 6.8 ng/mL) was reported in death investigations. Flubromazolam was identified in blood, serum or liver in 137 death investigations, 55 impaired driving and one sexual assault case. Blood concentrations ranged from <1.3 to 323 ng/mL in 65 individuals, aged 14-61 years. In impaired driving and sexual assault cases, flubromazolam blood concentrations ranged from <1.3 to 323 ng/mL (median 7.7 ng/mL), which overlapped with the range of 2-220 ng/mL (median 8.0 ng/mL) reported in death investigations. Other drugs were frequently detected with flualprazolam and flubromazolam with opioids identified in more than 89% of positive flualprazolam and flubromazolam cases. These results demonstrated the prevalence of flualprazolam and flubromazolam in Ontario, Canada. Trends showed that over the 6-month period, as the number of flubromazolam cases decreased, the incidences of flualprazolam increased. An overlap in concentrations of these drugs was observed in both death investigations and cases involving living individuals. These data provide valuable information for the scientific community regarding the use of these drugs in antemortem and postmortem casework.

Increasing prevalence of designer benzodiazepines in impaired driving: A 5-year analysis from 2017 to 2021

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.

Fentanyl concentrations in ligated femoral blood in the presence and absence of NPS benzodiazepine drugs. A review of over 1250 benzo-dope / fentanyl toxicity cases in Alberta, Canada

The drug combination referred to as 'benzo dope' has become prevalent in recent years, with an increasing number of fentanyl-related deaths reporting the concomitant presence of one or more benzodiazepine drug, such as etizolam, flualprazolam and flubromazepam. The central nervous system (CNS) depressant effects of these benzodiazepine drugs can exacerbate respiratory and CNS depressant effects resulting from the use/misuse of potent opioids such as fentanyl. This combined and enhanced drug-induced toxicity can pose a significant threat to life. Over a three-year period (2020-2022), the Office of the Chief Medical Examiner, Edmonton, Alberta, Canada issued 2812 case reports with fentanyl detected; of these cases, approximately 45% (1261) were positive for at least one benzodiazepine drug. This study presents concentrations of both fentanyl and benzodiazepine drugs in post mortem blood collected from a visualized, ligated femoral vein. The study demonstrates that the blood concentration of fentanyl in benzo-dope case reports is considerably higher than in cases where no benzodiazepine drug was detected.The median concentration of fentanyl in femoral blood for cases that also contained a benzodiazepine drug was 12.4 ng/mL (2020), 11.9 ng/mL (2021) and 14.0 ng/mL (2022). The median concentration of fentanyl in femoral blood for cases that did not contain a benzodiazepine drug was 8.5 ng/mL (2020), 7.0 ng/mL (2021) and 7.2 ng/mL (2022). The percent differences between the groups were similar with those observed from quantitative analysis of drug powders from unrelated police seizures in Alberta, Canada, suggesting the observed differences in blood fentanyl concentration may be due to the use of a drug substance with a higher concentration of fentanyl.Furthermore, the reported concentration of the benzodiazepine drug(s) is low, such that the role/contribution, if any, that this drug may have played in the decedents' death should be questioned and carefully considered by the certifying medical examiner/coroner.

New Psychoactive Substances Intoxications and Fatalities during the COVID-19 Epidemic

In January 2020, the World Health Organization (WHO) issued a Public Health Emergency of International Concern, declaring the COVID-19 outbreak a pandemic in March 2020. Stringent measures decreased consumption of some drugs, moving the illicit market to alternative substances, such as New Psychoactive Substances (NPS). A systematic literature search was performed, using scientific databases such as PubMed, Scopus, Web of Science and institutional and government websites, to identify reported intoxications and fatalities from NPS during the COVID-19 pandemic. The search terms were: COVID-19, SARS-CoV-2, severe acute respiratory syndrome coronavirus 2, coronavirus disease 2019, intox*, fatal*, new psychoactive substance, novel psychoactive substance, smart drugs, new psychoactive substance, novel synthetic opioid, synthetic opioid, synthetic cathinone, bath salts, legal highs, nitazene, bath salt, legal high, synthetic cannabinoid, phenethylamine, phencyclidine, piperazine, novel benzodiazepine, benzodiazepine analogue, designer benzodiazepines, tryptamine and psychostimulant. From January 2020 to March 2022, 215 NPS exposures were reported in Europe, UK, Japan and USA. Single NPS class intoxications accounted for 25, while mixed NPS class intoxications represented only 3 cases. A total of 130 NPS single class fatalities and 56 fatalities involving mixed NPS classes were published during the pandemic. Synthetic opioids were the NPS class most abused, followed by synthetic cathinones and synthetic cannabinoids. Notably, designer benzodiazepines were frequently found in combination with fentalogues. Considering the stress to communities and healthcare systems generated by the pandemic, NPS-related information may be underestimated. However, we could not define the exact impacts of COVID-19 on processing of toxicological data, autopsy and death investigations.

Designer benzodiazepines: an update

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 (GABA_A-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.

A Two-Year Evaluation of Flualprazolam Concentrations in Orange County Drivers: Effects on Driving and Field Sobriety Test Performance

Starting in early 2017, flualprazolam was detected in toxicology and seized drug cases across the USA. Due to the addition of fluorine to alprazolam, flualprazolam's chemistry was enough to bypass targeted toxicology confirmations, and it has become increasingly available for purchase both on the dark web and in counterfeit pills. Flualprazolam was added to the exact mass screening regiment of the Orange County forensic laboratory in December 2018. Through data mining of previously analyzed cases, data were evaluated beginning from August 2018. Flualprazolam was subsequently added to the laboratory's validated quantitative liquid chromatography dual mass spectrometry method in the summer of 2020, and all driving cases from August 2018 to June 2020 were re-analyzed to obtain concentrations. The police and drug recognition evaluation (if available) reports were collected and reviewed for all cases where flualprazolam was detected. Of the 203 cases containing quantifiable drug, the average flualprazolam concentration (median, range) was 22.8 ng/mL (15.4 ng/mL, 4.0-133.3 ng/mL). Only two cases had flualprazolam detected with no other drugs. The other most common drugs detected were cannabinoids (62%), ethanol (20%) and cocaine and/or methamphetamine (32%). The most common reason for the police investigation was an accident/collision (50%), and the most common time of officer contact was evening (18:00 to 23:59). The field sobriety test (FST) results were evaluated and showed a higher frequency of impaired performance in cases of flualprazolam in combination with other drugs. No conclusion could be made regarding the effect of flualprazolam alone on FST performance.

A Fatal Case Report Resulting from the Abuse of the Designer Benzodiazepines Clonazolam and Flualprazolam in Conjunction with Dried Opium Poppy Pods‡

Toxicologists are often confronted with the abuse of multiple drugs and are obliged to decide which compound may have been the cause of death. We report on a 21-year-old man (182 cm, 84 kg), who was found unconscious in his bed. Beside him, the police found several controlled substances, among them were dried opium poppy pods containing thebaine, codeine and morphine, a clear liquid with the designer benzodiazepines flualprazolam and clonazolam and a white powder with the imprint SGT-25, instead of SGT-78 (CUMYL-4CN-BINACA). These compounds were also found in the urine sample following a non-targeted gas chromatography-mass spectrometry and a targeted liquid chromatography-tandem mass spectrometry (LC-MS-MS) screening approach. Subsequently, these compounds were quantified in whole femoral blood and scalp hair. Based on the concentrations measured in femoral blood in particular, we assume that the deceased had taken a lethal dose of the designer benzodiazepines-flualprazolam (0.74 mg/L) and clonazolam (2.08 mg/L), an extremely high dose of the opiates-thebaine (0.81 mg/L), codeine (0.23 mg/L) and morphine (0.13 mg/L ) and a high dose of the synthetic cannabinoid-CUMYL-4CN-BINACA (0.01 mg/L). Besides postmortem concentrations, we also present electron impact and electrospray ionization mass spectra of compounds found in the vicinity of the decedent, namely the tryptamines-4-hydroxy-N-isopropyl-N-methyltryptamine (4-HO-MIPT), 4-hydroxy-N-ethyl-N-methyltryptamine (4-HO-MET) and 4-acetoxy-N,N-diethyltryptamine (4-ACO-DET), the amphetamines-3-fluoroethamphetamine (3-FEA) and 2-fluoromethamphetamine (2-FMA) and the arylcyclohexylamines-N-ethyldeschloroketamine (O-PCE), 3-methoxyphencyclidine (3-MeO-PCP) and 3-methoxyeticyclidine (3-MeO-PCE).

Drug checking services as a surveillance tool for clinical laboratories: Examining trends in the unregulated fentanyl supply

OBJECTIVES

Timely assessment and understanding of drug trends is essential for clinical laboratories to effectively respond to the overdose epidemic. In this proof-of-concept study, we sought to determine whether information obtained through Toronto's Drug Checking Services (DCS) and cross-provincial urine drug testing (UDT) data can be used as a surveillance tool for clinical laboratories and discuss the value of collaboration between the clinical laboratory, clinicians, and community partners to optimize patient care.

DESIGN & METHODS

Mass spectrometry-based UDT data from LifeLabs Ontario (n = 127,529) and British Columbia (n = 14,848), and drug checking data from Toronto DCS (n = 3,308 drugs or used paraphernalia) was collected between August 2020 and October 2021. Fentanyl co-positivity with toxic adulterants such as benzodiazepine-related drugs and fentanyl analogues were examined.

RESULTS

The percent co-positivity of fentanyl with etizolam, flualprazolam, flubromazolam, carfentanil, and acetylfentanyl in both Ontario UDT and DCS drugs/used paraphernalia showed similar trends. Regional differences in co-positivity with etizolam and fentanyl analogues were noted between Ontario and British Columbia UDT with patterns consistent over the entire 15-month collection period.

CONCLUSIONS

Clinical laboratories should connect with their local DCS, if available, to understand and monitor unregulated drug trends. These data can be used as an important tool to help clinical laboratories tailor their UDT menus and thereby provide a community-focused service to improve patient care.

Pharmacological evaluation and forensic case series of N-pyrrolidino etonitazene (etonitazepyne), a newly emerging 2-benzylbenzimidazole 'nitazene' synthetic opioid

Novel synthetic opioids continue to emerge on recreational drug markets worldwide. In response to legislative bans on fentanyl analogues, non-fentanyl structural templates, such as 2-benzylbenzimidazoles ('nitazenes'), are being exploited to create new μ-opioid receptor (MOR) agonists. Here, we pharmacologically characterize an emerging cyclic analogue of etonitazene, called N-pyrrolidino etonitazene (etonitazepyne), using in vitro and in vivo methods. A series of analytically confirmed fatalities is described to complement preclinical findings. Radioligand binding assays in rat brain tissue revealed that N-pyrrolidino etonitazene has high affinity for MOR (Ki = 4.09 nM) over δ-opioid (Ki = 959 nM) and κ-opioid (Ki = 980 nM) receptors. In a MOR-β-arrestin2 activation assay, N-pyrrolidino etonitazene displayed high potency (EC₅₀ = 0.348 nM), similar to etonitazene (EC₅₀ = 0.360 nM), and largely exceeding the potencies of fentanyl (EC₅₀ = 14.9 nM) and morphine (EC₅₀ = 290 nM). When administered s.c. to male Sprague Dawley rats, N-pyrrolidino etonitazene induced opioid-like antinociceptive, cataleptic, and thermic effects. Its potency in the hot plate test (ED₅₀ = 0.0017 mg/kg) was tenfold and 2,000-fold greater than fentanyl (ED₅₀ = 0.0209 mg/kg) and morphine (ED₅₀ = 3.940 mg/kg), respectively. Twenty-one overdose fatalities associated with N-pyrrolidino etonitazene were found to contain low blood concentrations of the drug (median = 2.2 ng/mL), commonly in the context of polysubstance use. N-Pyrrolidino etonitazene was reported as a cause of death in at least two cases, demonstrating toxicity in humans. We demonstrate that N-pyrrolidino etonitazene is an extremely potent MOR agonist that is likely to present high risk to users. Continued vigilance is required to identify and characterize emergent 2-benzylbenzimidazoles, and other non-fentanyl opioids, as they appear in the marketplace.

A Forward-Thinking Approach to Addressing the New Synthetic Opioid 2-Benzylbenzimidazole Nitazene Analogues by Liquid Chromatography Tandem Quadrupole Mass Spectrometry (LC-QQQ-MS)

Novel psychoactive substances (NPS) continue to represent a threat to public health and safety. The number of new drugs in the latest emergent synthetic opioid class—the 2-benzylbenzimidazole analogs—also called the nitazenes—has begun to dominate the current new synthetic opioid (NSO) subclass of NPS. We describe a liquid chromatography–tandem quadrupole mass spectrometry method for the quantification of nine analogs and/or metabolites of drugs in this series: isotonitazene, metonitazene, protonitazene, etonitazene, clonitazene, flunitazene, N-desethyl isotonitazene, 5-amino isotonitazene and 4ʹ-hydroxy nitazene in human whole blood, urine, and tissue. Samples were prepared for analysis using a basic liquid–liquid extraction. Chromatographic separation was achieved using a C-18 analytical column. Multiple reaction monitoring mode was used for detection. The calibration range for the analytes was 0.5–50 ng/mL (except for 5-amino isotonitazene, which was 1.0–50 ng/mL). The limit of detection was 0.1 ng/mL, and the limit of quantitation was 0.5 ng/mL. The method had no carryover or interferences. Ionization enhancement was observed but did not affect quantitation. All analytes passed the method validation assessment. Authentic human samples suspected of containing NSOs were obtained from a medical examiner and coroner offices, as well as partnering forensic toxicology laboratories. Isotonitazene was confirmed in 92 blood samples, and its metabolites were confirmed across various matrices. Metonitazene (n = 35), flunitazene (n = 5), protonitazene (n = 3), etodesnitazene (n = 2) and butonitazene (n = 1) were also detected in cases. These newly emerging 2-benzylbenzimidazole analogs were commonly found in combination with NPS benzodiazepines and opioids (e.g., flualprazolam, fentanyl). Nitazene analogs are potent esoteric drugs that may not be identified during routine toxicological screening, and specialized assays based on sensitive instrumentation are needed to accurately characterize these NSOs.

Flualprazolam distribution in postmortem samples

The constant emergence of novel psychoactive substances is troubling to both public health officials and legislators. Additionally, sufficient data collection for each new compound can take months up to years. Flualprazolam, a triazolobenzodiazepine, quickly garnered attention as a sedative drug that likely expresses adverse reactions similarly to alprazolam. This study focuses on the distribution of flualprazolam in multiple common postmortem matrices. Central blood, vitreous humor, liver homogenate, brain homogenate, gastric contents, and urine samples from death investigation cases were quantitated when available. Samples were screened with liquid chromatography quadrupole time-of-flight with limit of detection set at 4 ng/ml and quantitated on liquid chromatography tandem mass spectrometry, with concentration range from 4 to 256 ng/ml. From August 2018 to September 2020, 24 central blood samples were quantitated for flualprazolam. Central bloods of 22 cases had concentrations above the limit of quantitation. The average flualprazolam central blood concentration was 16.3 ng/ml with a median of 9.95 ng/ml (4.24-48.0). Additional analyses for unconjugated flualprazolam were performed on at a total of 15 urine samples ( x ¯  = 14.4, 4.07-36.1 ng/ml), 23 brain homogenates ( x ¯  = 23.2, 3.99-69.3 ng/g), 23 liver homogenates ( x ¯  = 50.7, 13.6-156 ng/g), five vitreous humor samples ( x ¯  = 7.70, 4.03-12 ng/ml), and 12 gastric contents samples ( x ¯  = 0.36, 0.02-2.51 mg). The cause of death for 13 of the 24 cases listed flualprazolam as a contributing factor of death.

Driving under the Influence of Flualprazolam: 11 Case Reports

Eleven cases of suspected driving under the influence (DUI) of flualprazolam are presented. Data from police reports and drug recognition examinations (DRE), when available, were evaluated. In all cases, significant driving impairments were observed including weaving, driving slowly, stopping in the roadway, or collisions. Objective signs of impairment in all cases were generally consistent with those expected from central nervous system depressants. Both the mean and median blood flualprazolam concentrations were less than 15 ng/mL. Though comprehensive analysis was not performed on each specimen, the data from this study support the conclusion that flualprazolam at low concentrations may significantly impair the ability to safely drive.

A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues

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.

Online surveillance of novel psychoactive substances (NPS): Monitoring Reddit discussions as a predictor of increased NPS-related exposures

BACKGROUND

Novel psychoactive substances (NPS) present continuous and growing challenges for the scientific, medical, and interventional communities as emerging substances on recreational drug markets change national and international drug landscapes. NPS account for an increasing proportion of adverse events, hospitalizations, and deaths due to increasing potency and unanticipated biological effects compared to predecessors. This study evaluated the utility of drug use forums as an early indicator or predictor of impending intoxications with potentially harmful or lethal outcomes prior to their occurrences.

METHODS

Eight NPS were selected for evaluation to assess the relationship between online mentions of drugs and their involvement in toxic exposures or overdoses. Mentions on Reddit drug forum discussions were tallied and toxicology testing results from forensic investigations in the US were assessed. The selected NPS covered several subclasses and a predetermined time range (2013-2020). They included carfentanil, U-47700, eutylone, flualprazolam, N-ethylpentylone, 5F-MDMB-PICA, isotonitazene, and brorphine.

RESULTS

Seven NPS (excluding 5F-MDMB-PICA) appeared in discussions on Reddit prior to their implication in poisonings or intoxications. Distinct increases and decreases in number of mentions and number of exposures were observed. For most substances (n = 5, 63%), a rise in Reddit mentions was soon followed by a corresponding rise in toxicology positivity. Peak positivity for carfentanil and flualprazolam, however, preceded peak Reddit mentions.

CONCLUSIONS

This study demonstrated the utility of social media sites, such as Reddit, as a predictor for future trends in NPS-related exposures. These results provide confirmation that activity on drug use forums in the virtual world can help predict changes in exposures associated with new or re-emerging NPS in the real world. The results warrant further evaluation as a strategy for inclusion in early warning systems.

Designer Benzodiazepines: A Review of Toxicology and Public Health Risks

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.

A fluorine turns a medicinal benzodiazepine into NPS: the case of flualprazolam

Purpose

The purpose of this review is to summarize the existing knowledge on flualprazolam, a novel ‘designer’ benzodiazepine that derives from the fluorination of the phenyl moiety in the ortho-position of alprazolam.

Methods

An extensive literature search was carried out in PubMed, Google Scholar and World Wide Web using relevant keywords. All articles found were gathered, and the available information is presented.

Results

This article reviews the existing knowledge on chemistry, pharmacology, toxicology, prevalence and current legal status of flualprazolam. Moreover, forensic and clinical cases where flualprazolam was involved worldwide, as well as flualprazolam seizures, along with the methods for its determination in biological samples are presented.

Conclusions

The recent flualprazolam-related cases have raised concerns to regulatory authorities and international stakeholders suggesting that flualprazolam should be under international control. The urgent international control of flualprazolam, despite the limited information on clinical effects and pharmacologic characteristics available, is an important measure for the prevention of its increasing abuse worldwide.

Analysis of the Illicit Opioid U-48800 and Related Compounds by LC-MS/MS and Case Series of Fatalities Involving U-48800

We report a method for the detection and quantitation of twelve drugs and two metabolites in the same structural class as the illicit mu-opioid agonist U-47700 in human whole blood. These substances are either known or suspected to be present as potential novel opioids in illicit drug markets. The general class of these drugs was developed in pharmaceutical research programs in the 1970's but have recently become of concern for overdoses and death in opioid users in the United States and internationally. The scope of analysis included the following compounds: methylenedioxy U-47700, ethylenedioxy U-47700, ethylenedioxy U-51754, U-69593, U-47931E (Bromadoline), U-47700, U-48800, U-49900, U-51754, U-50488, propyl U-47700, and isopropyl U-47700. Additionally, two metabolites, N,N-didesmethyl U-47700, desmethyl U-47700 were also included in the scope. Drugs were extracted from human whole blood using solid phase extraction (SPE) and the extracts were analyzed by liquid chromatography tandem mass spectrometry (LCMSMS). The assay was validated with respect to bias, carryover, interference, and within run and between run precision, and accuracy. Eight medicolegal death investigation cases which had screened positive for U-48800 by liquid chromatography time-of-flight mass spectrometry (LCTOF) were successfully confirmed and quantified using this method. The mean and median concentrations of U-48800 in these cases were 2.5 (±2.1) ng/mL and 1.8 ng/mL, respectively, with a range of concentrations of 0.27-6.2 ng/mL. Case history information including the presence of other drugs in combination are described and discussed.

Brorphine-Investigation and quantitation of a new potent synthetic opioid in forensic toxicology casework using liquid chromatography-mass spectrometry

New synthetic opioids continue to appear as novel psychoactive substances (NPS) on illicit drug markets. Isotonitazene emerged in mid-2019, becoming the most prevalent NPS opioid in the United States within a few months. Notification by the Drug Enforcement Administration of its intent to schedule isotonitazene in mid-2020 led to its decline in popularity and replacement with a new NPS opioid: brorphine. Brorphine is a potent synthetic opioid, but little information was previously available regarding its toxicity or involvement in impairment and death. Our laboratory developed an assay for the identification and quantitative confirmation of brorphine using standard addition. Quantitative analysis was performed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). In vitro and in vivo metabolism studies were performed using pooled human liver microsomes and authentic biological specimens, respectively, with analysis by liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). Brorphine was confirmed in 20 authentic forensic cases, commonly found in combination with fentanyl (100%) and flualprazolam (80%). The average concentration of brorphine in blood was 2.5 ± 3.1 ng/mL (median: 1.1 ng/mL, range: 0.1-10 ng/mL). The average concentration of brorphine in urine was 4.6 ± 7.6 ng/mL (median: 1.6 ng/mL, range: 0.2-23 ng/mL). The majority of cases originated from Midwestern states. Metabolism was verified to included N-dealkylation and hydroxylation. Detailed case histories and autopsy findings are presented herein. The prevalence of brorphine continues to increase in the United States. Forensic scientists should remain aware of the ongoing emergence of new opioids, especially those outside a standard scope of toxicology testing.

Steep increases in fentanyl-related mortality west of the Mississippi River: Recent evidence from county and state surveillance

BACKGROUND

Overdose deaths from synthetic opioids (e.g., fentanyl) increased 10-fold in the United States from 2013 to 2018, despite such opioids being rare in illicit drug markets west of the Mississippi River. Public health professionals have feared a "fentanyl breakthrough" in western U.S. drug markets could further accelerate overdose mortality. We evaluated the number and nature of western U.S. fentanyl deaths using the most recent data available.

METHODS

We systematically searched jurisdictions west of the Mississippi River for publicly available data on fentanyl-related deaths since 2018, the most recent Centers for Disease Control and Prevention (CDC) statistics. Using mortality data from 2019 and 2020, we identified changes in fentanyl-related mortality rate and proportion of fatal heroin-, stimulant, and prescription pill overdoses involving fentanyl.

RESULTS

Seven jurisdictions had publicly available fentanyl death data through December 2019 or later: Arizona; California; Denver County, CO; Harris County, TX; King County, WA; Los Angeles County, CA; and Dallas-Fort Worth, TX (Denton, Johnson, Parker, and Tarrant counties). All reported increased fentanyl deaths over the study period. Their collective contribution to national synthetic narcotics mortality increased 371 % from 2017 to 2019. Available 2020 data shows a 63 % growth in fentanyl-mortality over 2019. Fentanyl-involvement in heroin, stimulant, and prescription pill deaths has substantially grown.

DISCUSSION

Fentanyl has spread westward, increasing deaths in the short-term and threatening to dramatically worsen the nation's already severe opioid epidemic in the long-term. Increasing the standard dose of naloxone, expanding Medicaid, improving coverage of addiction treatment, and public health educational campaigns should be prioritized.