1
|
Berardinelli D, Taoussi O, Carlier J, Tini A, Zaami S, Sundermann T, Busardò FP, Auwärter V. In vitro, in vivo metabolism and quantification of the novel synthetic opioid N-piperidinyl etonitazene (etonitazepipne). Clin Chem Lab Med 2024; 62:1580-1590. [PMID: 38311816 DOI: 10.1515/cclm-2023-1360] [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: 12/01/2023] [Accepted: 01/21/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVES N-piperidinyl etonitazene (etonitazepipne) is a newly synthesized opioid related to the 2-benzylbenzimidazole analog class. Etonitazepipne has been formally notified and placed under intensive monitoring in Europe in January 2022. Nitazenes have high affinity at µ-opioid receptor (MOR). Etonitazepipne, specifically shows a EC50 of 2.49 nM, suggesting about 50 times higher potency combined with higher efficacy compared to morphine. Antinociceptive potency l ('hot plate test' with rats) was 192-fold greater than that of morphine. METHODS Here we report on a post-mortem case involving etonitazepipne and its quantification using a standard addition method (SAM) through liquid chromatography tandem mass spectrometry (LC-MS/MS). In addition, characterization and identification of phase I human metabolites using in vitro assay based on pooled human liver microsomes (pHLM) was performed along with the analysis of authentic urine samples by means of high-performance liquid chromatography high-resolution tandem mass spectrometry (LC-HRMS/MS). RESULTS The concentration of etonitazepipne in post-mortem blood and urine was 8.3 and 11 ng/mL, respectively. SAM was validated by assessing the following parameters: intraday and interday repeatability, matrix effect and recovery rate in post-mortem blood. A total of 20 and 14 metabolites were identified after pHLM incubation and urine analysis, respectively. Most pronounced in vitro and in vivo transformations were O-deethylation, hydroxylation, ketone reduction, and combinations thereof. CONCLUSIONS Considering small traces of the parent drug often found in real cases, the identification of metabolic biomarkers is crucial to identify exposure to this drug. O-deethylated, oxidated metabolites, and combination thereof are proposed as urinary biomarkers along with the parent compound.
Collapse
Affiliation(s)
- Diletta Berardinelli
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Forensic Toxicology, Institute for Legal Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Omayema Taoussi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Jeremy Carlier
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Anastasio Tini
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Tom Sundermann
- Institute of Forensic and Traffic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Francesco Paolo Busardò
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Volker Auwärter
- Forensic Toxicology, Institute for Legal Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
2
|
Taoussi O, Berardinelli D, Zaami S, Tavoletta F, Basile G, Kronstrand R, Auwärter V, Busardò FP, Carlier J. Human metabolism of four synthetic benzimidazole opioids: isotonitazene, metonitazene, etodesnitazene, and metodesnitazene. Arch Toxicol 2024; 98:2101-2116. [PMID: 38582802 PMCID: PMC11169013 DOI: 10.1007/s00204-024-03735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/08/2024]
Abstract
Following isotonitazene scheduling in 2019, the availability of alternative 2-benzylbenzimidazole opioids (nitazenes) on the global drug market increased, resulting in many fatalities worldwide. Nitazenes are potent µ-opioid receptor agonists with strong narcotic/analgesic effects, and their concentrations in biological matrices are low, making the detection of metabolite biomarkers of consumption crucial to document use in clinical and forensic settings. However, there is little to no data on the metabolism of the most recently available nitazenes, especially desnitro-analogues. The aim of the research was to assess isotonitazene, metonitazene, etodesnitazene, and metodesnitazene human metabolism and identify specific metabolite biomarkers of consumption. The four analogues were incubated with 10-donor-pooled human hepatocytes, and the incubates were analyzed by liquid chromatography-high-resolution tandem mass spectrometry and data mining with Compound Discoverer (Thermo Scientific); the analysis was supported by in silico metabolite predictions with GLORYx open-access software. Metabolites were identified in postmortem blood and/or urine samples from two metonitazene-positive and three etodesnitazene-positive cases following the same workflow, with and without glucuronide hydrolysis in urine, to confirm in vitro results. Twelve, nine, twenty-two, and ten metabolites were identified for isotonitazene, metonitazene, etodesnitazene, and metodesnitazene, respectively. The main transformations were N-deethylation at the N,N-diethylethanamine side chain, O-dealkylation, and further O-glucuronidation. In vitro and autopsy results were consistent, demonstrating the efficacy of the 10-donor-pooled human hepatocyte model to predict human metabolism. We suggest the parent and the corresponding O-dealkyl- and N-deethyl-O-dealkyl metabolites as biomarkers of exposure in urine after glucuronide hydrolysis, and the corresponding N-deethyl metabolite as additional biomarker in blood.
Collapse
Affiliation(s)
- Omayema Taoussi
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126, Ancona AN, Italy
| | - Diletta Berardinelli
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126, Ancona AN, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Tavoletta
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126, Ancona AN, Italy
| | - Giuseppe Basile
- Department of Trauma Surgery, IRCCS Galeazzi Orthopedic Institute, Milan, Italy
| | - Robert Kronstrand
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| | - Volker Auwärter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Francesco P Busardò
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126, Ancona AN, Italy.
| | - Jeremy Carlier
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126, Ancona AN, Italy
| |
Collapse
|
3
|
De Vrieze LM, Walton SE, Pottie E, Papsun D, Logan BK, Krotulski AJ, Stove CP, Vandeputte MM. In vitro structure-activity relationships and forensic case series of emerging 2-benzylbenzimidazole 'nitazene' opioids. Arch Toxicol 2024:10.1007/s00204-024-03774-7. [PMID: 38877156 DOI: 10.1007/s00204-024-03774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/24/2024] [Indexed: 06/16/2024]
Abstract
2-Benzylbenzimidazole 'nitazene' opioids are presenting a growing threat to public health. Although various nitazenes were previously studied, systematic comparisons of the effects of different structural modifications to the 2-benzylbenzimidazole core structure on μ-opioid receptor (MOR) activity are limited. Here, we assessed in vitro structure-activity relationships of 9 previously uncharacterized nitazenes alongside known structural analogues. Specifically, we focused on MOR activation by 'ring' substituted analogues (i.e., N-pyrrolidino and N-piperidinyl modifications), 'desnitazene' analogues (lacking the 5-nitro group), and N-desethyl analogues. The results from two in vitro MOR activation assays (β-arrestin 2 recruitment and inhibition of cAMP accumulation) showed that 'ring' modifications overall yield highly active drugs. With the exception of 4'-OH analogues (which are metabolites), N-pyrrolidino substitutions were generally more favorable for MOR activation than N-piperidine substitutions. Furthermore, removal of the 5-nitro group on the benzimidazole ring consistently caused a pronounced decrease in potency. The N-desethyl modifications showed important MOR activity, and generally resulted in a slightly lowered potency than comparator nitazenes. Intriguingly, N-desethyl isotonitazene was the exception and was consistently more potent than isotonitazene. Complementing the in vitro findings and demonstrating the high harm potential associated with many of these compounds, we describe 85 forensic cases from North America and the United Kingdom involving etodesnitazene, N-desethyl etonitazene, N-desethyl isotonitazene, N-pyrrolidino metonitazene, and N-pyrrolidino protonitazene. The low-to-sub ng/mL blood concentrations observed in most cases underscore the drugs' high potencies. Taken together, by bridging pharmacology and case data, this study may aid to increase awareness and guide legislative and public health efforts.
Collapse
Affiliation(s)
- Liam M De Vrieze
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Sara E Walton
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, PA, 19090, USA
| | - Eline Pottie
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, PA, 19090, USA
- NMS Labs, Horsham, PA, 19044, USA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, PA, 19090, USA
| | - Christophe P Stove
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
| | - Marthe M Vandeputte
- Laboratory of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
| |
Collapse
|
4
|
Ameline A, Gheddar L, Pichini S, Stove C, Aknouche F, Maruejouls C, Raul JS, Kintz P. In vitro characterization of protonitazene metabolites, using human liver microsomes, and first application to two urines collected from death cases. Clin Chim Acta 2024; 561:119764. [PMID: 38844019 DOI: 10.1016/j.cca.2024.119764] [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: 05/03/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
Protonitazene, or N,N-diethyl-5-nitro-2-[(4-propoxyphenyl)methyl]-1H-benzimidazole-1-ethanamine, is a novel synthetic opioid, which belongs to the nitazene family. Over the last four years, nitazenes have re-emerged on the new psychoactive substances market and have been reported in several fatal intoxication cases. The metabolism of several nitazene analogues have already been studied, but to date, no data exists regarding protonitazene. The aim of the study was the detection of protonitazene and its metabolites in authentic human urine collected in two fatal intoxication cases, comparing the data after in vitro incubation with human liver microsomes, and subsequent analysis by ultra-performance liquid chromatography-tandem mass spectrometry and ultra-performance liquid chromatography-high-resolution mass spectrometry. Protonitazene metabolites, including N-desethyl-protonitazene, 5-amino-protonitazene and 4-hydroxy-nitazene, were characterized in vitro and were identified in the urine of both cases. The ratios between metabolites and parent protonitazene, higher than 1, were calculated to estimate the proportionality of metabolites. The results suggest that testing protonitazene metabolites should increase the window detection of exposure to protonitazene.
Collapse
Affiliation(s)
- Alice Ameline
- Institut de Médecine Légale, 11 rue Humann, 67085 Strasbourg, France.
| | - Laurie Gheddar
- Institut de Médecine Légale, 11 rue Humann, 67085 Strasbourg, France
| | - Simona Pichini
- Istituto Superiore di Sanita, 299 viale Regina Elena, 00161 Roma, Italy
| | - Christophe Stove
- Laboratory of Toxicology, Campus Heymans, Ottergemsesteenweg 460, 9000 Gent, Belgium
| | - Frédéric Aknouche
- Laboratoire SYNLAB Réunion, 19 ter rue Balbolia, 97460 Saint-Paul, France
| | | | | | - Pascal Kintz
- Institut de Médecine Légale, 11 rue Humann, 67085 Strasbourg, France; X-Pertise Consulting, 42 rue Principale, 67026 Mittelhausbergen, France
| |
Collapse
|
5
|
Killoran S, McNamara S, Kavanagh P, O'Brien J, Lakes R. Identification of N-pyrrolidino protonitazene in powders sold as heroin and associated with overdose clusters in Dublin and Cork, Ireland. Drug Test Anal 2024. [PMID: 38769669 DOI: 10.1002/dta.3707] [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: 02/19/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/22/2024]
Abstract
Synthetic opioids have been associated globally with adverse effects in drug users. The nitazene group of drugs is a relatively new addition to the synthetic opioid class emerging in Europe in 2019. Some nitazenes have been shown to be more potent than fentanyl. Overdose clusters in heroin users in Dublin (57 cases) and Cork (20 cases), Ireland, in November and December 2023, respectively, prompted a rapid response from a number of Irish laboratories to identify the substance(s) of concern. Light brown (tan) powders were obtained from cases associated with overdoses, and the results from these analyses by collaboration of four laboratories are reported here. The samples were found to contain N-pyrrolidino protonitazene (protonitazepyne), caffeine, paracetamol, benzoic acid and mannitol.
Collapse
Affiliation(s)
| | - Sinéad McNamara
- HSE National Drug Treatment Centre Laboratory, Dublin, Ireland
| | - Pierce Kavanagh
- Discipline of Pharmacology and Therapeutics, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - John O'Brien
- School of Chemistry, Trinity College Dublin, Dublin, Ireland
| | | |
Collapse
|
6
|
Kozell LB, Eshleman AJ, Wolfrum KM, Swanson TL, Bloom SH, Benware S, Schmachtenberg JL, Schutzer KA, Schutzer WE, Janowsky A, Abbas AI. Pharmacologic Characterization of Substituted Nitazenes at μ, κ, and Δ Opioid Receptors Suggests High Potential for Toxicity. J Pharmacol Exp Ther 2024; 389:219-228. [PMID: 38453524 PMCID: PMC11026150 DOI: 10.1124/jpet.123.002052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
The benzimidazole opioids (substituted nitazenes) are highly potent μ opiod receptor (MOR) agonists with heroin- or fentanyl-like effects. These compounds have caused hospitalizations and fatal overdoses. We characterized the in vitro pharmacology and structure-activity relationships of 19 nitazenes with substitutions at three positions of the benzimidazole core. Affinities were assessed using agonist radioligand binding assays at human μ, κ, and Δ opioid receptors (MOR, KOR, and DOR, respectively) heterologously expressed in CHO cells. Notably, for MOR binding, nine substituted nitazenes had significantly higher affinities than fentanyl including N-pyrrolidino etonitazene, N-pyrrilidino isonitazene, and N-desethyl isotonitazene; 13 had subnanomolar affinities. Only metodesnitazene and flunitazene had significantly lower affinities than fentanyl. Affinities for the substituted nitazenes at KOR and DOR relative to MOR were 46- to 2580-fold and 180- to 1280-fold lower, respectively. Functional activities were assessed using [35S]GTPγS binding assays. Four nitazenes had subnanomolar potencies at MOR: N-pyrrolidino etonitazene, N-pyrrilidino isonitazene, N-pyrrilidino protonitazene and N-desethyl isotonitazene. Ten substituted nitazenes had significantly higher potencies than fentanyl. All tested nitazenes were full MOR agonists. Potencies at KOR and DOR relative to MOR were 7.3- to 7920-fold and 24- to 9400-fold lower, respectively. Thus, many of these compounds are high affinity/high potency MOR agonists with elevated potential to elicit toxicity and overdose at low doses. SIGNIFICANCE STATEMENT: Substituted nitazenes are a growing public health threat. Although the 19 nitazenes tested vary in their opioid receptor pharmacology, a number are very high affinity, high potency, and high efficacy compounds- higher than fentanyl. Their pharmacology suggests high potential for harm.
Collapse
Affiliation(s)
- Laura B Kozell
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Amy J Eshleman
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Katherine M Wolfrum
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Tracy L Swanson
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Shelley H Bloom
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Sheila Benware
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Jennifer L Schmachtenberg
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Kamryn A Schutzer
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - William E Schutzer
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Aaron Janowsky
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| | - Atheir I Abbas
- VA Portland Health Care System (L.B.K., A.J.E., K.M.W., T.L.S., S.H.B., S.B., J.L.S., K.A.S., W.E.S., A.J., A.I.A.), Departments of Psychiatry (L.B.K., A.J.E., T.L.S., W.E.S., A.J., A.I.A.), and Behavioral Neuroscience (L.B.K., A.J., A.I.A.), Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
7
|
Ververi C, Galletto M, Massano M, Alladio E, Vincenti M, Salomone A. Method development for the quantification of nine nitazene analogs and brorphine in Dried Blood Spots utilizing liquid chromatography - tandem mass spectrometry. J Pharm Biomed Anal 2024; 241:115975. [PMID: 38280237 DOI: 10.1016/j.jpba.2024.115975] [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: 10/29/2023] [Revised: 12/31/2023] [Accepted: 01/08/2024] [Indexed: 01/29/2024]
Abstract
The detection of nitazenes in biological fluids is increasingly needed as they are repeatedly reported in intoxication and overdose cases. A simple method for the quantification of low levels of nine nitazene analogs and brorphine in Dried Blood Spots (DBS) was developed and validated. 10 μL of spiked whole blood is deposited on a Capitainer®B card and allowed to dry. The spot is punched out, and extracted with 500 μL methanol:acetonitrile (3:1 v/v) added with 1.5 μL of fentanyl-D5 as the internal standard. After stirring, sonication, and centrifugation of the vial, the solvent is dried under nitrogen, the extract is reconstituted in 30 μL methanol, and 1 μL is injected into a UHPLC-MS/MS instrument. The method validation showed linear calibration in the 1-50 ng/mL range, LOD values ranging between 0.3 ng/mL (isotonitazene) and 0.5 ng/mL (brorphine), average CV% and bias% within 15 % and 10 % for all compounds, respectively. The matrix effect due to blood and filter paper components was within 85-115 % while recovery was between 15-20 %. Stability tests against time and temperature showed no significant variations for storage periods up to 28 days. Room temperature proved to represent the best samples storage conditions. UHPLC-MS/MS proved capable to reliably identify all target analytes at low concentration even in small specimen volumes, as those obtained from DBS cards, which in turn confirmed to be effective and sustainable micro-sampling devices. This procedure improves the efficiency of toxicological testing and provides an innovative approach for the identification of the nitazene class of illicit compounds.
Collapse
Affiliation(s)
| | | | - Marta Massano
- Department of Chemistry, University of Turin, Turin, Italy
| | | | - Marco Vincenti
- Department of Chemistry, University of Turin, Turin, Italy; Centro Regionale Antidoping, Orbassano, Turin, Italy
| | - Alberto Salomone
- Department of Chemistry, University of Turin, Turin, Italy; Centro Regionale Antidoping, Orbassano, Turin, Italy
| |
Collapse
|
8
|
Bade R, Nadarajan D, Driver EM, Halden RU, Gerber C, Krotulski A, Hall W, Mueller JF. Wastewater-based monitoring of the nitazene analogues: First detection of protonitazene in wastewater. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 920:170781. [PMID: 38360322 DOI: 10.1016/j.scitotenv.2024.170781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/23/2024] [Accepted: 02/05/2024] [Indexed: 02/17/2024]
Abstract
Synthetic opioids, particularly the nitazene analogues class, have become a public health concern due to their high potency. Wastewater-based epidemiology can detect community use of these compounds. The objective of this work was to detect nitazene analogues in wastewater from samples collected from eight sites in the United States. Influent wastewater samples were collected from eight sites in seven states (Arizona, Oregon, New Mexico, Illinois, New Jersey, Washington and Georgia) in the United States. Samples were collected from each site on three days between 27 December 2022 and 4 January 2023, acidified on collection, stored frozen and shipped to Arizona State University (Tempe, AZ) for sample processing. Samples were then shipped to The University of Queensland (Brisbane, Australia) for sample analysis. Protonitazene was found in samples collected from two sites in Washington and Illinois. The concentration was estimated up to 0.5 ng/L, with estimated excreted mass loads up to 0.3 mg/day/1000 people. This work has shown that it is possible to detect nitazene analogues in wastewater using a combination of sample pre-concentration and sensitive instrumentation, thereby further expanding the utility of wastewater-based epidemiology.
Collapse
Affiliation(s)
- Richard Bade
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, 20 Cornwall Street, Woolloongabba, Queensland 4102, Australia.
| | - Dhayaalini Nadarajan
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, 20 Cornwall Street, Woolloongabba, Queensland 4102, Australia
| | - Erin M Driver
- Biodesign Center for Environmental Health Engineering, Biodesign Institute, Arizona State University, 1001 S. McAllister Ave., Tempe, AZ 85281, USA
| | - Rolf U Halden
- Biodesign Center for Environmental Health Engineering, Biodesign Institute, Arizona State University, 1001 S. McAllister Ave., Tempe, AZ 85281, USA; School of Sustainable Engineering and Built Environment, Arizona State University, Tempe, AZ 85281, USA; OneWaterOneHealth, Arizona State University Foundation, 1001 S. McAllister Avenue, Tempe, AZ 85287-8101, USA
| | - Cobus Gerber
- Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5001, South Australia, Australia
| | - Alex Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, PA 19090, United States
| | - Wayne Hall
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, 20 Cornwall Street, Woolloongabba, Queensland 4102, Australia; National Centre for Youth Substance Use Research, The University of Queensland, St Lucia, Queensland, Australia
| | - Jochen F Mueller
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, 20 Cornwall Street, Woolloongabba, Queensland 4102, Australia
| |
Collapse
|
9
|
Schneider KE, Martin EM, Allen ST, Morris M, Haney K, Saloner B, Sherman SG. Volatile drug use and overdose during the first year of the COVID-19 pandemic in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104371. [PMID: 38447262 PMCID: PMC11056297 DOI: 10.1016/j.drugpo.2024.104371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Overdose deaths in the United States rose substantially during the COVID-19 pandemic. Disruptions to the drug supply and service provision introduced significant instability into the lives of people who use drugs (PWUD), including volatility in their drug use behaviors. METHODS Using data from a multistate survey of PWUD, we examined sociodemographic and drug use correlates of volatile drug use during COVID-19 using multivariable linear regression. In a multivariable logistic regression model, we assessed the association between volatile drug use and past month overdose adjusting for sociodemographic and other drug use characteristics. RESULTS Among participants, 52% were male, 50% were white, 29% had less than a high school education, and 25% were experiencing homelessness. Indicators of volatile drug use were prevalent: 53% wanted to use more drugs; 45% used more drugs; 43% reported different triggers for drug use, and 23% used drugs that they did not typically use. 14% experienced a past-month overdose. In adjusted models, hunger (β=0.47, 95% CI: 0.21-0.72), transactional sex (β=0.50, 95% CI: 0.06-0.94), and the number of drugs used (β=0.16, 95% CI: 0.07-0.26) were associated with increased volatile drug use. Volatile drug use was associated with increased overdose risk (aOR=1.42, 95% CI: 1.17-1.71) in the adjusted model. CONCLUSIONS Volatile drug use during the COVID-19 pandemic was common, appeared to be driven by structural vulnerability, and was associated with increased overdose risk. Addressing volatile drug use through interventions that ensure structural stability for PWUD and a safer drug supply is essential for mitigating the ongoing overdose crisis.
Collapse
Affiliation(s)
- Kristin E Schneider
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Emily M Martin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Miles Morris
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Katherine Haney
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| |
Collapse
|
10
|
Stangeland M, Lunde T, Fossan KO, Berg JA. Non-fatal overdose with a new synthetic opioid. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2024; 144:23-0464. [PMID: 38349109 DOI: 10.4045/tidsskr.23.0464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
A young man experienced respiratory arrest at home, and cardiopulmonary resuscitation was performed. The patient received naloxone with good effect and was admitted to hospital. He disclosed opioid use, but no substances were detected in routine drug screenings.
Collapse
Affiliation(s)
- Marcus Stangeland
- Avdeling for medisinsk biokjemi og farmakologi, Haukeland universitetssjukehus
| | | | - Kjell Ove Fossan
- Avdeling for medisinsk biokjemi og farmakologi, Haukeland universitetssjukehus
| | - Jon Andsnes Berg
- Avdeling for medisinsk biokjemi og farmakologi, Haukeland universitetssjukehus
| |
Collapse
|
11
|
Bade R, Hall W. The use of wastewater based epidemiology to detect synthetic opioids in the community. BMJ 2024; 384:q5. [PMID: 38171576 DOI: 10.1136/bmj.q5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Richard Bade
- Queensland Alliance for Environmental Health Sciences, University of Queensland, Woolloongabba, Queensland, Australia
| | - Wayne Hall
- National Centre for Youth Substance Use Research, University of Queensland, St Lucia, Queensland, Australia
| |
Collapse
|
12
|
Pucci M, Singh Jutley G, Looms J, Ford L. N-desethyl isotonitazene detected in polydrug users admitted to hospital in Birmingham, United Kingdom. Clin Toxicol (Phila) 2024; 62:19-25. [PMID: 38353737 DOI: 10.1080/15563650.2024.2309321] [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: 11/13/2023] [Accepted: 01/18/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION Nitazenes are potent synthetic opioids and N-desethyl isotonitazene, a metabolite of isotonitazene, has emerged as a drug in its own right. METHODS This is an observational case series of patients with suspected or declared substance use who were admitted to hospitals in the Sandwell and West Birmingham National Health Service Trust between July and October 2023. All patients were found on toxicological screening to have been exposed to N-desethyl isotonitazene. RESULTS Twenty presentations involving 19 patients who tested positive for N-desethyl isotonitazene were included in the study. In 19 presentations, multiple substances were detected on toxicological screening. The number of patients testing positive for other substances were: 19 for cocaine and its main metabolite benzoylecgonine, 13 for morphine, 11 for the heroin-specific metabolite 6-monoacetylmorphine, ten for xylazine, eight for gabapentinoids (pregabalin and/or gabapentin), seven for methadone and/or the metabolite, 2-ethylidene-1, 5-dimethyl-3, 3-diphenylpyrrolidine, six for benzodiazepines and five for the synthetic cannabinoid MDMB-4en-PINACA. Only one patient had no other substances detected apart from N-desethyl isotonitazene. This patient presented with coma, miosis, bradypnoea and hypercapnia and responded to naloxone. In this cohort, the median concentration of N-desethyl isotonitazene was 1.53 µg/L (n = 14; range 0.59-5.48) in whole blood and 27.75 µg/L (n = 16; range 0.51-91.53) in urine. DISCUSSION The majority of the patients in this cohort presented with features typical of an opioid overdose, which is unsurprising as they were all experienced users of diamorphine. Although these features are also consistent with the known effects of N-desethyl isotonitazene, in only one case is it possible to attribute the patient's features to N-desethyl isotonitazene toxicity alone. CONCLUSIONS This case series highlights the need for toxicovigilance in the illicit drug market as patterns of substance misuse evolve and novel psychoactive substances continue to emerge.
Collapse
Affiliation(s)
- Mark Pucci
- West Midlands Poisons Unit, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | | | - Jonathan Looms
- West Midlands Poisons Unit, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Loretta Ford
- Toxicology Laboratory, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| |
Collapse
|
13
|
Di Trana A, Montana A, Lo Faro AF, Busardò FP, Pichini S. Molecular Insights of New Psychoactive Substances (NPS) 2.0. Int J Mol Sci 2023; 24:17492. [PMID: 38139320 PMCID: PMC10743891 DOI: 10.3390/ijms242417492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 11/24/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
The New Psychoactive Substances (NPS) phenomenon represents an ever-changing global issue, with a number of new molecules entering the illicit market every year in response to international banning laws [...].
Collapse
Affiliation(s)
- Annagiulia Di Trana
- National Centre on Addiction and Doping, National Institute of Health, 00161 Rome, Italy;
| | - Angelo Montana
- Department of Biomedical Science and Public Health, University Politecnica delle Marche, 60121 Ancona, Italy; (A.M.); (A.F.L.F.)
| | - Alfredo Fabrizio Lo Faro
- Department of Biomedical Science and Public Health, University Politecnica delle Marche, 60121 Ancona, Italy; (A.M.); (A.F.L.F.)
| | - Francesco Paolo Busardò
- Department of Biomedical Science and Public Health, University Politecnica delle Marche, 60121 Ancona, Italy; (A.M.); (A.F.L.F.)
| | - Simona Pichini
- National Centre on Addiction and Doping, National Institute of Health, 00161 Rome, Italy;
| |
Collapse
|
14
|
Schüller M, Lucic I, Øiestad ÅML, Pedersen-Bjergaard S, Øiestad EL. High-throughput quantification of emerging "nitazene" benzimidazole opioid analogs by microextraction and UHPLC-MS-MS. J Anal Toxicol 2023; 47:787-796. [PMID: 37700512 PMCID: PMC10714918 DOI: 10.1093/jat/bkad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
Benzimidazole opioids, often referred to as nitazenes, represent a subgroup of new psychoactive substances with a recent increase in fatal overdoses in the USA and Europe. With a variety of analogs emerging on the illicit drug market, forensic laboratories are challenged to identify these potent drugs. We here present a simple quantitative approach for the determination of nine nitazene analogs, namely, clonitazene, etodesnitazene, etonitazene, etonitazepyne, flunitazene, isotonitazene, metodesnitazene, metonitazene and protonitazene in whole blood using liquid-phase microextraction and electromembrane extraction in a 96-well format and liquid chromatography-tandem mass spectrometry. Green and efficient sample preparation was accomplished by liquid-phase microextraction in a 96-well format and resulted in high extraction yields for all analytes (>81%). Here, blood diluted with buffer (1:1, %v) was extracted from a donor compartment across a thin organic liquid membrane and into an aqueous acceptor solution. The acceptor solution was collected and directly injected into the analysis platform. Chromatographic separation was accomplished with a biphenyl column, allowing for a baseline separation of the structural isomers isotonitazene and protonitazene before detection by multiple reaction monitoring. Validation was performed according to Scientific Working Group of Forensic Toxicology guidelines. The calibration range was from 0.5 to 50 nM (except for protonitazene and clonitazene from 0.1 nM) with good linearity and limits of detection down to 0.01 nM. An AGREEprep assessment was performed to evaluate sample preparation greenness, with a final score of 0.71. Nitazenes represent a current threat to public health, and analytical methods that cover a wide range of these analogs are limited. Here, the described method may assist in the detection of nitazenes in whole blood and prevent these substances from being missed in postmortem investigations.
Collapse
Affiliation(s)
- Maria Schüller
- Department of Pharmacy, University of Oslo, P.O. Box 1068 Blindern, Oslo 0316, Norway
| | - Ivana Lucic
- Department of Pharmacy, University of Oslo, P.O. Box 1068 Blindern, Oslo 0316, Norway
| | - Åse Marit Leere Øiestad
- Department of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, P.O. Box 4459 Nydalen, Oslo 0424, Norway
| | - Stig Pedersen-Bjergaard
- Department of Pharmacy, University of Oslo, P.O. Box 1068 Blindern, Oslo 0316, Norway
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, Copenhagen 2100, Denmark
| | - Elisabeth Leere Øiestad
- Department of Pharmacy, University of Oslo, P.O. Box 1068 Blindern, Oslo 0316, Norway
- Department of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, P.O. Box 4459 Nydalen, Oslo 0424, Norway
| |
Collapse
|
15
|
Meyer M, Westenberg JN, Jang KL, Choi F, Schreiter S, Mathew N, King C, Lang UE, Vogel M, Krausz RM. Shifting drug markets in North America - a global crisis in the making? Int J Ment Health Syst 2023; 17:36. [PMID: 37880722 PMCID: PMC10598952 DOI: 10.1186/s13033-023-00601-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023] Open
Abstract
Understanding drug market dynamics and their underlying driving factors is paramount to developing effective responses to the overdose crisis in North America. This paper summarises the distinct drug market trends observed locally and internationally over the past decade to extrapolate future drug market trajectories. The emergence of fentanyl on North American street markets from 2014 onwards led to a shift of street drug use patterns. Previously perceived as contaminants, novel synthetic opioids became the drugs of choice and a trend towards higher potency was observed across various substance classes. The diversification of distribution strategies as well as the regionalisation and industrialisation of production followed basic economic principles that were heavily influenced by prosecution and policy makers. Particularly, the trend towards higher potency is likely most indicative of what to expect from future illicit drug market developments. Nitazenes and fentanyl-analogues, several times more potent than fentanyl itself, are increasingly detected in toxicological testing and have the potential of becoming the drugs of choice in the future. The dynamic of drug import and local production is less clear and influenced by a multitude of factors like precursor availability, know-how, infrastructure, and the success of local drug enforcement strategies. Drug market dynamics and the current trajectory towards ultrapotent opioids need to be recognised by legislation, enforcement, and the health care system to prepare effective responses. Without significant improvements in treatment access, the implementation of preventative approaches and early warning systems, the mortality rate will continue to increase. Furthermore, there is no mechanism in place preventing the currently North American focused overdose crisis to spread to other parts of the globe, particularly Europe. A system of oversight, research, and treatment is needed to address mortality rates of historic proportions and prevent further harm.
Collapse
Affiliation(s)
- Maximilian Meyer
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland.
| | - Jean N Westenberg
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Kerry L Jang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Fiona Choi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Stefanie Schreiter
- Department of Psychiatry and Neurosciences, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nickie Mathew
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Conor King
- Victoria Police Department, Victoria, Canada
| | - Undine E Lang
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Marc Vogel
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - R Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| |
Collapse
|
16
|
Amaducci A, Aldy K, Campleman SL, Li S, Meyn A, Abston S, Culbreth RE, Krotulski A, Logan B, Wax P, Brent J, Manini AF. Naloxone Use in Novel Potent Opioid and Fentanyl Overdoses in Emergency Department Patients. JAMA Netw Open 2023; 6:e2331264. [PMID: 37642962 PMCID: PMC10466160 DOI: 10.1001/jamanetworkopen.2023.31264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/23/2023] [Indexed: 08/31/2023] Open
Abstract
Importance Synthetic opioids, such as the fentanyl analogue and nitazene drug class, are among the fastest growing types of opioids being detected in patients in the emergency department (ED) with illicit opioid overdose (OD). However, clinical outcomes from OD of novel potent opioids (NPOs), specifically nitazenes, are unknown aside from small case series. Objective To determine naloxone administration and clinical sequelae of patients who were in the ED with NPO overdose compared with fentanyl OD. Design, Setting, and Participants This is a cohort study subgroup analysis of adults admitted to the ED and tested positive for NPOs among in the ongoing nationwide ToxIC Fentalog cohort study from 2020 to 2022. Patients who were in the ED with a presumed acute opioid OD and residual blood samples were included, and those testing positive for NPOs were analyzed. Patients were included in this analysis if their confirmatory testing was positive for an NPO analyte, such as brorphine, isotonitazene, metonitazene, and/or N-piperidinyl etonitazene. A comparison group included patients that were positive for fentanyl and devoid of any other analytes on toxicologic analysis. Exposures Patients were exposed to NPOs, including brorphine, isotonitazene, metonitazene and/or N-piperidinyl etonitazene. Main Outcomes and Measures The primary outcome was the total number of naloxone doses and total cumulative naloxone dose administered as part of routine clinical care following the OD. Naloxone requirements and clinical sequelae of NPO-positive patients were compared with those testing positive for fentanyl only. Results During the study period, 2298 patients were screened, of whom 717 met inclusion criteria, 537 had complete laboratory testing data, with 11 (2.0%) positive for only fentanyl and 9 (1.7%) positive for NPOs (brorphine, isotonitazene, metonitazene, or N-piperidinyl etonitazene). The age range of patients was aged 20 to 57 years (4 males [44.4%] and 5 females [55.6%]). The NPO group received a statistically significantly higher mean (SD) number of naloxone boluses in-hospital (1.33 [1.50]) compared with the fentanyl group (0.36 [0.92]) (P = .02), which corresponded to a moderately large effect size (Cohen d = 0.78). Metonitazene overdose was associated with cardiac arrest and more naloxone doses overall. Metonitazene cases had a mean (SD) number of 3.0 (0) naloxone doses, and 2 of 2 patients (100%) with metonitazene overdoses were administered cardiopulmonary resuscitation. Conclusions and Relevance In this cohort study of patients admitted to the ED with confirmed opioid overdose testing positive for NPOs, in-hospital naloxone dosing was high compared with patients who tested positive for fentanyl alone. Further study is warranted to confirm these preliminary associations.
Collapse
Affiliation(s)
- Alexandra Amaducci
- Lehigh Valley Health Network-USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Kim Aldy
- American College of Medical Toxicology, Phoenix, Arizona
- Baylor University Medical Center, Dallas, Texas
| | | | - Shao Li
- American College of Medical Toxicology, Phoenix, Arizona
| | - Alison Meyn
- American College of Medical Toxicology, Phoenix, Arizona
| | | | | | - Alex Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, Pennsylvania
| | - Barry Logan
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, Pennsylvania
- NMS Labs, Horsham, Pennsylvania
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, Arizona
- University of Texas Southwestern Medical Center, Dallas
| | | | - Alex F. Manini
- NYC Health and Hospitals, Elmhurst, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
17
|
de Oliveira MC, Vides MC, Lassi DLS, Torales J, Ventriglio A, Bombana HS, Leyton V, Périco CDAM, Negrão AB, Malbergier A, Castaldelli-Maia JM. Toxicity of Synthetic Cannabinoids in K2/Spice: A Systematic Review. Brain Sci 2023; 13:990. [PMID: 37508922 PMCID: PMC10377539 DOI: 10.3390/brainsci13070990] [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: 05/17/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Synthetic cannabinoids (SCs) are emerging drugs of abuse sold as 'K2', 'K9' or 'Spice'. Evidence shows that using SCs products leads to greater health risks than cannabis. They have been associated with greater toxicity and higher addiction potential unrelated to the primary psychoactive component of marijuana, Δ9-tetrahydrocannabinol (Δ9-THC). Moreover, early cases of intoxication and death related to SCs highlight the inherent danger that may accompany the use of these substances. However, there is limited knowledge of the toxicology of Spice ingredients. This systematic review intends to analyze the toxicity of SCs compounds in Spice/K2 drugs. (2) Methods: Studies analyzing synthetic cannabinoid toxicity and dependence were included in the present review. We searched the PubMed database of the US National Library of Medicine, Google Scholar, CompTox Chemicals, and Web of Science up to May 2022. (3) Results: Sixty-four articles reporting the effects of synthetic cannabinoids in humans were included in our review. Ten original papers and fifty-four case studies were also included. Fourteen studies reported death associated with synthetic cannabinoid use, with AB-CHMINACA and MDMB-CHMICA being the main reported SCs. Tachycardia and seizures were the most common toxicity symptoms. The prevalence of neuropsychiatric symptoms was higher in third-generation SCs. (4) Conclusion: SCs may exhibit higher toxicity than THC and longer-lasting effects. Their use may be harmful, especially in people with epilepsy and schizophrenia, because of the increased risk of the precipitation of psychiatric and neurologic disorders. Compared to other drugs, SCs have a higher potential to trigger a convulsive crisis, a decline in consciousness, and hemodynamic changes. Therefore, it is crucial to clarify their potential harms and increase the availability of toxicology data in both clinical and research settings.
Collapse
Affiliation(s)
- Mariana Campello de Oliveira
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - Mariana Capelo Vides
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - Dângela Layne Silva Lassi
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - Julio Torales
- Department of Psychological Medicine, School of Medical Sciences, National University of Asuncion, San Lorenzo 111421, Paraguay
| | - Antonio Ventriglio
- Department of Experimental Medicine, Medical School, University of Foggia, 71122 Foggia, Italy
| | - Henrique Silva Bombana
- Department of Legal Medicine, Medical School, São Paulo University, São Paulo 05508-090, SP, Brazil
| | - Vilma Leyton
- Department of Legal Medicine, Medical School, São Paulo University, São Paulo 05508-090, SP, Brazil
| | | | - André Brooking Negrão
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - André Malbergier
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
| | - João Maurício Castaldelli-Maia
- Interdisciplinary Group of Alcohol and Drug Studies (GREA), Institute Perdizes, Department of Psychiatry Medical School, São Paulo University, São Paulo 05403-903, SP, Brazil
- Department of Neuroscience, Medical School, FMABC University Center, Santo André 09060-870, SP, Brazil
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| |
Collapse
|
18
|
Norman C, Marland V, McKenzie C, Ménard H, Nic Daéid N. Evaluation of fentanyl immunoassay test strips for rapid in-situ detection of fentanyl and fentanyl analogs in seized samples and alternative matrices. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 118:104102. [PMID: 37343365 DOI: 10.1016/j.drugpo.2023.104102] [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: 03/28/2023] [Revised: 05/23/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Ion mobility spectrometry is used for the rapid detection of drugs at points of security but are unable to differentiate some drugs leading to the instrument alarming for a drug not present in the sample. This can be particularly problematic for samples that alarm for fentanyl. In this study, fentanyl immunoassay strips were evaluated for use as a secondary test for fentanyl, including for the testing of alternative matrices, such as powders, e-liquids, and infused papers and textiles. METHODS The limit of detection of fentanyl immunoassay strips was examined along with their selectivity to 18 fentanyl analogsand 72 other drugs and cutting agents. The effectiveness of the test strips at the detection of fentanyl in the presence of other drugs was examined by testing a series of concentrations of fentanyl in solution in combination with other drugs. The testing of alternative matrices was explored with laboratory prepared samples through sampling with cotton buds and extraction in water. RESULTS The fentanyl immunoassay strips detected fentanyl at concentrations of 45 ng/mL and reacted with 16 of 18 tested fentanyl analogs with carfentanil and norfentanyl being the only analogs to not react. There was no reactivity with other drugs or cutting agents. The effectiveness of the fentanyl test strips was not reduced when fentanyl was mixed with other drugs. Fentanyl was successfully detected with high sensitivity in all alternative matrices. CONCLUSION The fentanyl immunoassay strips were found to be an effective secondary test for fentanyl and at least 16 fentanyl analogs in seized drug samples, including when mixed with other drugs. The effectiveness of the sampling methods for alternative matrices should be further evaluated using fentanyl and fentanyl analog casework samples. The use of this method by law enforcement and other agencies should be examined to assess its effectiveness and ease of use in operational settings.
Collapse
Affiliation(s)
- Caitlyn Norman
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK.
| | - Victoria Marland
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Craig McKenzie
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK; Chiron AS, Stiklestadveien 1, 7041 Trondheim, Norway
| | - Hervé Ménard
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| | - Niamh Nic Daéid
- Leverhulme Research Centre for Forensic Science, School of Science and Engineering, University of Dundee, Dundee, UK
| |
Collapse
|
19
|
Abstract
OBJECTIVE This article informs and updates the practicing neurologist on the current landscape of known neurologic injuries linked to the use of illicit drugs, focusing on emerging agents. LATEST DEVELOPMENTS Synthetic opioids such as fentanyl and similar derivatives have exploded in prevalence, becoming the leading cause of overdose fatalities. The higher potency of synthetic opioids compared with semisynthetic and nonsynthetic opiates poses an increased risk for unintentional overdose when found as an adulterant in other illicit drug supplies such as heroin. Conversely, misinformation about the risk of symptomatic exposure to fentanyl through casual contact with the skin and ambient air has led to misdirected fear and stigma that threatens to impede valid harm-reduction measures for fentanyl users at risk of actual overdose. Finally, during the COVID-19 pandemic, overdose rates and deaths continued to climb, especially among those who use opioids and methamphetamine. ESSENTIAL POINTS A variety of potential neurologic effects and injuries can occur with illicit drug use owing to the diverse properties and mechanisms of action of the various classes. Many high-risk agents are not detected on standard drug screens, including so-called designer drugs, and the practicing neurologist is best served by recognizing the clinical features of the traditional toxidrome and other potential idiosyncratic effects of various illicit agents.
Collapse
|
20
|
Pergolizzi J, Raffa R, LeQuang JAK, Breve F, Varrassi G. Old Drugs and New Challenges: A Narrative Review of Nitazenes. Cureus 2023; 15:e40736. [PMID: 37485167 PMCID: PMC10361140 DOI: 10.7759/cureus.40736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
Nitazenes are a group of compounds developed in the 1950s as opioid analgesics, but they were never approved to market. As such, they are not well known outside of academic research laboratories. A characteristic of nitazenes is their high potency (e.g., hundreds to thousands fold more potent than morphine and other opioids and tenfold more potent than fentanyl). In the past few years, several nitazenes, including "designer analogs," have been detected in the illicit drug supply and have been implicated in overdose mortality, primarily due to their exceptionally high potency. In the street drug supply, nitazenes are often found mixed with fentanyl or other agents but their presence is not always disclosed to drug buyers, who may not even be familiar with nitazenes. These drugs pose a particular challenge since there is little experience in how to reverse a nitazene overdose or potential drug-drug or drug-alcohol interactions. Public health efforts are needed to better inform street drug consumers, first responders, healthcare professionals, and the general public about these "new old drugs" that are infiltrating the recreational drug supply.
Collapse
Affiliation(s)
| | - Robert Raffa
- School of Pharmacy, Temple University (Emeritus), Philadelphia, USA
| | | | - Frank Breve
- Pharmacy, Temple University, Philadelphia, USA
| | | |
Collapse
|
21
|
Resnik KN, Babb KN, Bekenstein LW, Moeller FG, Peace MR, Alves EA. Case report: Identification of AP-238 and 2-fluorodeschloroketamine in internet available powder samples sold as bucinnazine. Forensic Sci Int 2023; 348:111732. [PMID: 37216788 DOI: 10.1016/j.forsciint.2023.111732] [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: 01/27/2023] [Revised: 05/08/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
Novel synthetic opioids (NSOs) are a class of opioid agonists that include analogs of fentanyl and structurally distinct non-fentanyl compounds normally used as standalone products, heroin adulterants, or constituents of counterfeit pain pills. Most NSOs are not currently scheduled in the U.S., are predominantly illegally synthesized, and sold on the Darknet. Among them, the cinnamylpiperazine derivatives such as bucinnazine (AP-237), AP-238, and 2-methyl-AP-237 and the arylcyclohexylamine derivatives, analogs of ketamine, such as 2-fluoro-deschloroketamine (2 F-DCK) have appeared in several monitoring systems. Two white powders purchased on the internet as bucinnazine were first analyzed with polarized light microscopy followed by direct analysis in real time-mass spectrometry (DART-MS) and gas chromatography-mass spectrometry (GC-MS). Both powders were white crystals with no other significant microscopic properties. The DART-MS analysis showed the presence of 2-fluorodeschloroketamine in powder #1, and AP-238 in powder #2. Identification was confirmed by GC-MS. The purity of each substance was 78.0% for powder #1, and 88.9% for powder #2, respectively. The toxicological risk associated with the misuse of NSOs still needs further study. The absence of bucinnazine and the presence of different active compounds in internet purchased samples raises public health and safety concerns.
Collapse
Affiliation(s)
- Karissa N Resnik
- Special Forensic Toxicology Drug Testing Laboratory, Division of Forensic Toxicology, Armed forces Medical Examiner System, Dover, DE, United States; Department of Forensic Science, Virginia Commonwealth University, Richmond, VA, United States
| | - Kala N Babb
- Department of Forensic Science, Virginia Commonwealth University, Richmond, VA, United States
| | - Lori W Bekenstein
- University Student Health Services, Virginia Commonwealth University, Richmond, VA, United States
| | - F Gerard Moeller
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, United States
| | - Michelle R Peace
- Department of Forensic Science, Virginia Commonwealth University, Richmond, VA, United States
| | - Emanuele Amorim Alves
- Department of Forensic Science, Virginia Commonwealth University, Richmond, VA, United States; National School of Public Health Sérgio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
| |
Collapse
|
22
|
Daziani G, Lo Faro AF, Montana V, Goteri G, Pesaresi M, Bambagiotti G, Montanari E, Giorgetti R, Montana A. Synthetic Cathinones and Neurotoxicity Risks: A Systematic Review. Int J Mol Sci 2023; 24:ijms24076230. [PMID: 37047201 PMCID: PMC10093970 DOI: 10.3390/ijms24076230] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
According to the EU Early Warning System (EWS), synthetic cathinones (SCs) are the second largest new psychoactive substances (NPS) class, with 162 synthetic cathinones monitored by the EU EWS. They have a similar structure to cathinone, principally found in Catha Edulis; they have a phenethylamine related structure but also exhibit amphetamine-like stimulant effects. Illegal laboratories regularly develop new substances and place them on the market. For this reason, during the last decade this class of substances has presented a great challenge for public health and forensic toxicologists. Acting on different systems and with various mechanisms of action, the spectrum of side effects caused by the intake of these drugs of abuse is very broad. To date, most studies have focused on the substances’ cardiac effects, and very few on their associated neurotoxicity. Specifically, synthetic cathinones appear to be involved in different neurological events, including increased alertness, mild agitation, severe psychosis, hyperthermia and death. A systematic literature search in PubMed and Scopus databases according to PRISMA guidelines was performed. A total of 515 studies published from 2005 to 2022 (350 articles from PubMed and 165 from Scopus) were initially screened for eligibility. The papers excluded, according to the criteria described in the Method Section (n = 401) and after full text analyses (n = 82), were 483 in total. The remaining 76 were included in the present review, as they met fully the inclusion criteria. The present work provides a comprehensive review on neurotoxic mechanisms of synthetic cathinones highlighting intoxication cases and fatalities in humans, as well as the toxic effects on animals (in particular rats, mice and zebrafish larvae). The reviewed studies showed brain-related adverse effects, including encephalopathy, coma and convulsions, and sympathomimetic and hallucinogenic toxidromes, together with the risk of developing excited/agitated delirium syndrome and serotonin syndrome.
Collapse
Affiliation(s)
- Gloria Daziani
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Alfredo Fabrizio Lo Faro
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Vincenzo Montana
- Dipartimento di Anestesia, Rianimazione e Emergenza-Urgenza, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Goteri
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Mauro Pesaresi
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Giulia Bambagiotti
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Eva Montanari
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Raffaele Giorgetti
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
| | - Angelo Montana
- Department of Excellence Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy; (G.D.); (A.F.L.F.); (G.G.); (M.P.); (G.B.); (E.M.); (R.G.)
- Correspondence:
| |
Collapse
|
23
|
Morioka F, Fujii S, Kamata H, Shima N, Tsuboi K, Katagi M, Sato T. Postmortem examination and toxicological analysis for acute metonitazene intoxication in Japan: A case report. Leg Med (Tokyo) 2023; 61:102216. [PMID: 36801590 DOI: 10.1016/j.legalmed.2023.102216] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
Benzoimidazole analgesics (Nitazenes, NZs) are opioid receptor agonists that exhibit very strong pharmacological effects at minute doses, and their abuse has recently become a concern worldwide. Although no deaths involving NZs had been reported in Japan to date, we recently experienced an autopsy case of a middle-aged man who was determined to have died from poisoning by metonitazene (MNZ), a type of NZs. There were traces of suspected illegal drug use around the body. Autopsy findings were consistent with acute drug intoxication as the cause of death, but it was difficult to identify the causative drugs by simple qualitative drug screening. Analysis of compounds recovered from the scene where the body was found identified MNZ, and its abuse was suspected. Quantitative toxicological analysis of urine and blood was performed using a liquid chromatography high-resolution tandem mass spectrometer (LC-HR-MS/MS). Results showed that MNZ concentrations in blood and urine were 6.0 and 5.2 ng/mL, respectively. Other drugs detected in blood were within therapeutic ranges. Quantitated blood MNZ concentration in the present case was in the similar range as those reported in overseas NZs-related deaths. There were no other findings that could have contributed to the cause of death, and the decedent was judged to have died of acute MNZ intoxication. Emergence of NZs distribution has been recognized in Japan similarly to overseas; early investigation of their pharmacological effects as well as crackdown on their distribution is strongly desired.
Collapse
Affiliation(s)
- Fumiya Morioka
- Department of Legal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan.
| | - Shihoko Fujii
- Forensic Science Laboratory, Osaka Prefectural Police HQ, Osaka, Japan
| | - Hiroe Kamata
- Forensic Science Laboratory, Osaka Prefectural Police HQ, Osaka, Japan
| | - Noriaki Shima
- Forensic Science Laboratory, Osaka Prefectural Police HQ, Osaka, Japan
| | - Kento Tsuboi
- Department of Legal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Munehiro Katagi
- Department of Legal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Takako Sato
- Department of Legal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| |
Collapse
|
24
|
Schumann JL, Syrjanen R, Alford K, Mashetty S, Castle JW, Rotella J, Maplesden J, Greene SL. Intoxications in an Australian Emergency Department Involving 'Nitazene' Benzylbenzimidazole Synthetic Opioids (Etodesnitazene, Butonitazene and Protonitazene). J Anal Toxicol 2023; 47:e6-e9. [PMID: 35983900 DOI: 10.1093/jat/bkac062] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/24/2022] [Accepted: 08/18/2022] [Indexed: 11/12/2022] Open
Abstract
Benzimidazole synthetic opioids are highly potent μ-opioid receptor agonists with heroin-like effects, including dose-dependent respiratory depression and a high risk of abuse and toxicity. Benzimidazoles were first detected in 2019 in Europe and Canada, with analytical confirmation of etodesnitazene, protonitazene and butonitazene in 2021. We report the first detections of these compounds in Australia, in two patients presenting with drug toxicity to Emergency Departments (EDs) in the state of Victoria. Case 1 was a female in her 20s who rectally administered etodesnitazene and was found unconscious with respiratory depression and hypotension. Case 2 was a female in her 30s who presented to the ED in a sedated state after taking a formulation of protonitazene that also contained butonitazene, in addition to methylamphetamine. She responded positively to naloxone. Novel synthetic opioids were used with prior experience of the formulations purchased; however, the unpredictability of their effects was demonstrated by the acute toxicity experienced with this occasion of use. Toxicosurveillance of ED presentations with analytical confirmation of drugs is crucial in identifying emerging drugs in the community and informing harm reduction strategies.
Collapse
Affiliation(s)
- Jennifer L Schumann
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia.,Monash Addiction Research Centre, Eastern Clinical School, Moorooduc Hwy, Frankston 3199, Australia.,Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Rebekka Syrjanen
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia.,Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Katherine Alford
- Department of Emergency Medicine, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| | - Srujana Mashetty
- Department of Emergency Medicine, Dandenong Hospital, 135 David Street, Dandenong, Victoria 3175, Australia
| | - Jared W Castle
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Joe Rotella
- Department of Emergency Medicine, Northern Hospital, 185 Cooper Street, Epping, Victoria 3076, Australia.,Department of Emergency Medicine, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia.,Department of Critical Care, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia
| | - Jacqueline Maplesden
- Department of Emergency Medicine, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| | - Shaun L Greene
- Department of Emergency Medicine, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia.,Department of Critical Care, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia.,Victorian Poisons Information Centre, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| |
Collapse
|
25
|
New Psychoactive Substances Intoxications and Fatalities during the COVID-19 Epidemic. BIOLOGY 2023; 12:biology12020273. [PMID: 36829550 PMCID: PMC9953068 DOI: 10.3390/biology12020273] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
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.
Collapse
|
26
|
White A, Seah V, Brown J, McDonald C, Tran J, Roberts DM. Acute metonitazene poisoning reversed by naloxone. Clin Toxicol (Phila) 2023; 61:137-138. [PMID: 36763346 DOI: 10.1080/15563650.2022.2164505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Adam White
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Vincent Seah
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Jared Brown
- NSW Poisons Information Centre, Children's Hospital Westmead, Westmead, NSW, Australia
- Centre for Alcohol and Other Drugs, NSW Ministry of Health, St Leonards, NSW, Australia
| | - Catherine McDonald
- Forensic Toxicology Laboratory, NSW Health Pathology, Forensic and Analytical Science Service, Lidcombe, NSW, Australia
| | - Jason Tran
- Forensic Toxicology Laboratory, NSW Health Pathology, Forensic and Analytical Science Service, Lidcombe, NSW, Australia
| | - Darren M Roberts
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- NSW Poisons Information Centre, Children's Hospital Westmead, Westmead, NSW, Australia
- Edith Collins Centre, Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| |
Collapse
|
27
|
Brunetti P, Lo Faro AF, Di Trana A, Montana A, Basile G, Carlier J, Busardò FP. β'-Phenylfentanyl Metabolism in Primary Human Hepatocyte Incubations: Identification of Potential Biomarkers of Exposure in Clinical and Forensic Toxicology. J Anal Toxicol 2023; 46:e207-e217. [PMID: 36029472 DOI: 10.1093/jat/bkac065] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/24/2022] [Accepted: 08/26/2022] [Indexed: 01/26/2023] Open
Abstract
From 2014 onwards, illicit fentanyl and analogues have caused numerous intoxications and fatalities worldwide, impacting the demographics of opioid-related overdoses. The identification of cases involving fentanyl analogues is crucial in clinical and forensic settings to treat patients, elucidate intoxications, address drug use disorders and tackle drug trends. However, in analytical toxicology, the concentration of fentanyl analogues in biological matrices is low, making their detection challenging. Therefore, the identification of specific metabolite biomarkers is often required to document consumption. β'-Phenylfentanyl (N-phenyl-N-[1-(2-phenylethyl)-4-piperidinyl]-benzenepropanamide) is a fentanyl analogue that was first detected in Sweden in 2017 and has recently reemerged onto the American illicit drug market. There is little data available on β'-phenylfentanyl effects and toxicokinetics and its metabolism is yet to be studied. We aimed to investigate β'-phenylfentanyl human metabolism to identify potential biomarkers of use. To assist in β'-phenylfentanyl metabolite identification, a list of putative reactions was generated using in silico predictions with GLORYx freeware. β'-phenylfentanyl was incubated with cryopreserved 10-donor-pooled human hepatocytes, analyses were performed by liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS-MS) and data were processed using a partially automated targeted/untargeted approach with Compound Discoverer. We identified 26 metabolites produced by N-dealkylation, oxidation, hydroxylation, O-glucuronidation, O-methylation and combinations thereof. We suggest β'-phenylnorfentanyl (N-phenyl-N-4-piperidinyl-benzenepropanamide) and further metabolites 1-oxo-N-phenyl-N-4-piperidinyl-benzenepropanamide and 1-hydroxy-N-phenyl-N-4-piperidinyl-benzenepropanamide as major biomarkers of β'-phenylfentanyl use. In silico predictions were mostly wrong, and β'-phenylfentanyl metabolic fate substantially differed from that of a closely related analogue incubated in the same conditions, highlighting the value of the experimental assessment of new psychoactive substance human metabolism. In vivo data are necessary to confirm the present results. However, the present results may be necessary to help analytical toxicologists identify β'-phenylfentanyl-positive cases to provide authentic samples.
Collapse
Affiliation(s)
- Pietro Brunetti
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, Ancona AN 60126, Italy
| | - Alfredo F Lo Faro
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, Ancona AN 60126, Italy
| | - Annagiulia Di Trana
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, Ancona AN 60126, Italy
| | - Angelo Montana
- Health Service Department, Italian State Police, Piazza Sant'Ambrogio 5, Milan MI 20123, Italy
| | - Giuseppe Basile
- IRCCS Galeazzi Orthopedic Institute, Via Riccardo Galeazzi 4, Milan MI 20161, Italy
| | - Jeremy Carlier
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, Ancona AN 60126, Italy
| | - Francesco P Busardò
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, Ancona AN 60126, Italy
| |
Collapse
|
28
|
Kimani MM, Kern S, Lanzarotta A, Thatcher M, Lorenz LM, Smith SW, Collins M, Howe GW, Wetherby AE. Rapid screening of 2-benzylbenzimidazole nitazene analogs in suspect counterfeit tablets using Raman, SERS, DART-TD-MS, and FT-IR. Drug Test Anal 2023; 15:539-550. [PMID: 36648419 DOI: 10.1002/dta.3440] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023]
Abstract
Developing methods to rapidly screen for novel synthetic 2-benzylbenzimidazole opioids, also known as nitazenes, has become increasingly important due to their high potency. These compounds have potency comparable or exceeding that of fentanyl by up to 10 times and have been implicated in approximately 5% of all drug overdose deaths in the United States in 2021. This paper details the authenticity determination of suspect tablets and the identification of three nitazene analogs (N-pyrrolidino etonitazene, isotonitazene, and etodesnitazene) in suspect tablets seized at a mail facility using Raman and surface-enhanced Raman scattering (SERS) with handheld devices, portable Fourier transform infrared spectrometer (FT-IR), and a direct analysis in real-time ambient ionization coupled to a thermal desorption unit and a mass spectrometer (DART-TD-MS). These methods are rapid and excellent for screening opioids in suspect tablets but could not fully determine the exact structure of some of the nitazene analogs present due to spectral similarities or similar fragmentation patterns. Liquid chromatography-mass spectrometry (LC-MS) confirmed the presence of these nitazene compounds in addition to other opioids/drugs that were in trace quantities. The quantitative high-performance liquid chromatography coupled with ultraviolet (HPLC-UV) detection experiments determined that the suspect tablets contained an average of 0.817 mg of N-pyrrolidino etonitazene per tablet. The results obtained reveal that the simultaneous deployment of these complementary and orthogonal portable analytical techniques as part of a workflow allows suspect tablets to be screened and nitazene-type drugs to be identified in suspect counterfeit tablets at remote sampling sites.
Collapse
Affiliation(s)
- Martin M Kimani
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Sara Kern
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Adam Lanzarotta
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Michael Thatcher
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Lisa M Lorenz
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Skyler W Smith
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Melissa Collins
- Office of Regulatory Affairs, Office of Regulatory Science, Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, Ohio, USA
| | - Gregory W Howe
- Office of Regulatory Affairs, Office of Regulatory Science, Pacific Southwest Medical Products Laboratory, US Food and Drug Administration, Irvine, California, USA
| | - Anthony E Wetherby
- Office of Regulatory Affairs, Office of Regulatory Science, Winchester Engineering Analytical Center, US Food and Drug Administration, Winchester, Massachusetts, USA
| |
Collapse
|
29
|
Walton SE, Krotulski AJ, Glatfelter GC, Walther D, Logan BK, Baumann MH. Plasma pharmacokinetics and pharmacodynamic effects of the 2-benzylbenzimidazole synthetic opioid, isotonitazene, in male rats. Psychopharmacology (Berl) 2023; 240:185-198. [PMID: 36526866 DOI: 10.1007/s00213-022-06292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
RATIONALE Isotonitazene is an illicit synthetic opioid associated with many intoxications and fatalities. Recent studies show that isotonitazene is a potent µ-opioid receptor (MOR) agonist in vitro, but little information is available about its in vivo effects. OBJECTIVES The aims of the present study were to investigate the pharmacokinetics of isotonitazene in rats, and relate pharmacokinetic parameters to pharmacodynamic effects. METHODS Isotonitazene and its metabolites were identified and quantified by liquid chromatography tandem quadrupole mass spectrometry (LC-QQQ-MS). Male Sprague-Dawley rats with jugular catheters and subcutaneous (s.c.) temperature transponders received isotonitazene (3, 10, 30 µg/kg, s.c.) or its vehicle. Blood samples were drawn at 15, 30, 60, 120, and 240 min post-injection, and plasma was assayed using LC-QQQ-MS. At each blood draw, body temperature, catalepsy scores, and hot plate latencies were recorded. RESULTS Maximum plasma concentrations of isotonitazene rose in parallel with increasing dose (range 0.2-9.8 ng/mL) and half-life ranged from 23.4 to 63.3 min. The metabolites 4'-hydroxy nitazene and N-desethyl isotonitazene were detected, and plasma concentrations were below the limit of quantitation (0.5 ng/mL) but above the limit of detection (0.1 ng/mL). Isotonitazene produced antinociception (ED50 = 4.22 µg/kg), catalepsy-like symptoms (ED50 = 8.68 µg/kg), and hypothermia (only at 30 µg/kg) that were significantly correlated with concentrations of isotonitazene. Radioligand binding in rat brain tissue revealed that isotonitazene displays nM affinity for MOR (Ki = 15.8 nM), while the N-desethyl metabolite shows even greater affinity (Ki = 2.2 nM). CONCLUSIONS In summary, isotonitazene is a potent MOR agonist whose pharmacodynamic effects are related to circulating concentrations of the parent drug. The high potency of isotonitazene portends substantial risk to users who are exposed to the drug.
Collapse
Affiliation(s)
- Sara E Walton
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, 2300 Stratford Avenue, Willow Grove, PA, 19090, USA
- College of Life Sciences, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA, 19107, USA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, 2300 Stratford Avenue, Willow Grove, PA, 19090, USA.
- College of Life Sciences, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA, 19107, USA.
| | - Grant C Glatfelter
- Designer Drug Research Unit, Intramural Research Program (IRP), National Institute On Drug Abuse (NIDA), National Institutes of Health, 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| | - Donna Walther
- Designer Drug Research Unit, Intramural Research Program (IRP), National Institute On Drug Abuse (NIDA), National Institutes of Health, 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, 2300 Stratford Avenue, Willow Grove, PA, 19090, USA
- College of Life Sciences, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA, 19107, USA
- NMS Labs, 200 Welsh Road, Horsham, PA, 19044, USA
| | - Michael H Baumann
- Designer Drug Research Unit, Intramural Research Program (IRP), National Institute On Drug Abuse (NIDA), National Institutes of Health, 333 Cassell Drive, Suite 4400, Baltimore, MD, 21224, USA
| |
Collapse
|
30
|
Delaney SR, Konforte D, Stefan C, Palaty J, Sun D, McDonald K, Thompson H, Werb D, Beriault DR. Drug checking services as a surveillance tool for clinical laboratories: Examining trends in the unregulated fentanyl supply. Clin Biochem 2023; 111:11-16. [PMID: 36379241 DOI: 10.1016/j.clinbiochem.2022.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/26/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sarah R Delaney
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada; Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, Canada; Toronto's Drug Checking Service, Canada.
| | | | - Cristiana Stefan
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada; Toronto's Drug Checking Service, Canada; Clinical Laboratory and Diagnostic Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | | | | | - Karen McDonald
- Toronto's Drug Checking Service, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Hayley Thompson
- Toronto's Drug Checking Service, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Dan Werb
- Toronto's Drug Checking Service, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Division of Infectious Diseases and Global Public Health, University of California San Diego, USA
| | - Daniel R Beriault
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada; Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, Canada; Toronto's Drug Checking Service, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| |
Collapse
|
31
|
Cao SY, Zhou Y, Ma YX, Cheng SX, Tang GM, Wang YT. Syntheses, crystal structure, luminescent behaviors and Hirshfeld surface of salts with imidazole and benzimidazole-yl scaffolds. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2022.134764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
32
|
Molecular Insights and Clinical Outcomes of Drugs of Abuse Adulteration: New Trends and New Psychoactive Substances. Int J Mol Sci 2022; 23:ijms232314619. [PMID: 36498947 PMCID: PMC9739917 DOI: 10.3390/ijms232314619] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Adulteration is a well-known practice of drug manufacturers at different stages of drug production. The intentional addition of active ingredients to adulterate the primary drug may enhance or mask pharmacological effects or may produce more potent drugs to increase the number of available doses and the dealer's profit. Adulterants found in different drugs change over time in response to different factors. A systematic literature search in PubMed and Scopus databases and official international organizations' websites according to PRISMA guidelines was performed. A total of 724 studies were initially screened, with 145 articles from PubMed and 462 from Scopus excluded according to the criteria described in the Method Section. The remaining 117 records were further assessed for eligibility to exclude articles without sufficient data. Finally, 79 studies were classified as "non-biological" (n = 35) or "biological" (n = 35 case reports; n = 9 case series) according to the samples investigated. Although the seized samples analyses revealed the presence of well-established adulterants such as levamisole for cocaine or paracetamol/acetaminophen for heroin, the reported data disclosed new adulteration practices, such as the use of NPS as cutting agents for classic drugs of abuse and other NPS. For example, heroin adulterated with synthetic cannabinoids or cocaine adulterated with fentanyl/fentalogues raised particular concern. Notably, adulterants play a role in some adverse effects commonly associated with the primary drug, such as levamisole-adulterated cocaine that may induce vasculitis via an autoimmune process. It is essential to constantly monitor adulterants due to their changing availability that may threaten drug consumers' health.
Collapse
|