1
|
Wu D, Fu L. Recent findings and advancements in the detection of designer benzodiazepines: a brief review. Arh Hig Rada Toksikol 2023; 74:224-231. [PMID: 38146763 PMCID: PMC10750316 DOI: 10.2478/aiht-2023-74-3771] [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: 08/01/2023] [Revised: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 12/27/2023] Open
Abstract
This review article takes a closer look at a new class of psychoactive substances called designer benzodiazepines (DBZs) and the challenges of their detection. These are adinazolam, clonazolam, deschloroetizolam, diclazepam, etizolam, flualprazolam, flubromazepam, flubromazolam, phenazepam, and pyrazolam. They are central nervous system depressants and sedatives that can cause psychomotor impairment and increase the overdose risk when combined with other sedatives. DBZs undergo phase I and II metabolism similar to traditional benzodiazepines, but their specific metabolic pathways and the influence of genetic polymorphisms are yet to be clarified. Advances in liquid chromatography-tandem mass spectrometry (LC-MS/MS) have enhanced the method's sensitivity for DBZs and their metabolites in biological samples and coupled with improved blood sampling methods require less blood for drug monitoring. Further research should focus on elucidating their pharmacokinetic properties and metabolism in humans, especially in view of genetic polymorphisms and drug interactions that could inform clinical treatment choices. Even though we have witnessed important advances in DBZ detection and measurement, further refinements are needed to expand the scope of detectable DBZs and their metabolites. All this should help toxicological research to better identify and characterise the risks of chronic and polydrug abuse and facilitate clinical, forensic, and regulatory responses to this growing issue.
Collapse
Affiliation(s)
- Dihua Wu
- Hangzhou Dianzi University College of Materials and Environmental Engineering, Hangzhou, China
| | - Li Fu
- Hangzhou Dianzi University College of Materials and Environmental Engineering, Hangzhou, China
| |
Collapse
|
2
|
Vekic N, Armstrong-Price D, Woodall K. Flualprazolam and flubromazolam: Blood concentrations and prevalence of two novel psychoactive substances in forensic case work in Ontario, Canada. J Anal Toxicol 2023; 47:762-769. [PMID: 37930844 DOI: 10.1093/jat/bkad058] [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: 03/17/2023] [Revised: 07/26/2023] [Accepted: 08/16/2023] [Indexed: 11/08/2023] Open
Abstract
Flualprazolam and flubromazolam are synthetic benzodiazepines that have not been approved for use in humans. They are categorized as novel psychoactive substances (NPS), and have been increasingly encountered in forensic case work. This report examines information from cases analyzed for flualprazolam and flubromazolam between July 1 and December 31, 2021 to identify the prevalence, trends and demographic data associated with these novel drugs in Ontario, Canada. Flualprazolam was identified in blood, serum or liver in 395 death investigations, 108 impaired driving and five sexual assault cases. Among all case types, blood concentrations were determined in 123 individuals aged 19-66 years. In impaired driving and sexual assault cases, flualprazolam blood concentrations ranged from <1.3 to 227 ng/mL (median 11.0 ng/mL), whereas a range of 3-59 ng/mL (median 6.8 ng/mL) was reported in death investigations. Flubromazolam was identified in blood, serum or liver in 137 death investigations, 55 impaired driving and one sexual assault case. Blood concentrations ranged from <1.3 to 323 ng/mL in 65 individuals, aged 14-61 years. In impaired driving and sexual assault cases, flubromazolam blood concentrations ranged from <1.3 to 323 ng/mL (median 7.7 ng/mL), which overlapped with the range of 2-220 ng/mL (median 8.0 ng/mL) reported in death investigations. Other drugs were frequently detected with flualprazolam and flubromazolam with opioids identified in more than 89% of positive flualprazolam and flubromazolam cases. These results demonstrated the prevalence of flualprazolam and flubromazolam in Ontario, Canada. Trends showed that over the 6-month period, as the number of flubromazolam cases decreased, the incidences of flualprazolam increased. An overlap in concentrations of these drugs was observed in both death investigations and cases involving living individuals. These data provide valuable information for the scientific community regarding the use of these drugs in antemortem and postmortem casework.
Collapse
Affiliation(s)
- Nella Vekic
- University of Toronto, 3359 Mississauga Rd., Mississauga, ON L5L 1C6, Canada
| | - Delaney Armstrong-Price
- Toxicology Section, Centre of Forensic Sciences, 25 Morton Shulman Ave., Toronto, ON M3M 0B1, Canada
| | - Karen Woodall
- University of Toronto, 3359 Mississauga Rd., Mississauga, ON L5L 1C6, Canada
| |
Collapse
|
3
|
Cheng JYK, Hui JWS, Chan WS, So MH, Hong YH, Leung WT, Ku KW, Yeung HS, Lo KM, Fung KM, Ip CY, Dao KL, Cheung BKK. Interpol review of toxicology 2019-2022. Forensic Sci Int Synerg 2022; 6:100303. [PMID: 36597440 PMCID: PMC9799715 DOI: 10.1016/j.fsisyn.2022.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Bobbie Kwok-keung Cheung
- Corresponding author. Government Laboratory, 7/F, Homantin Government Offices, 88 Chung Hau Street, Ho Man Tin, Kowloon, SAR, Hong Kong, China. http://www.govtlab.gov.hk/
| |
Collapse
|
4
|
Pérez Orts M, van Asten A, Kohler I. The Evolution Toward Designer Benzodiazepines in Drug-Facilitated Sexual Assault Cases. J Anal Toxicol 2022; 47:1-25. [PMID: 35294022 PMCID: PMC9942444 DOI: 10.1093/jat/bkac017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/01/2022] [Accepted: 03/15/2022] [Indexed: 11/14/2022] Open
Abstract
Drug-facilitated sexual assault (DFSA) is a crime where the victim is unable to provide sexual consent due to incapacitation resulting from alcohol or drug consumption. Due to the large number of substances possibly used in DFSA, including illicit, prescription and over-the-counter drugs, DFSA faces many toxicological challenges. Benzodiazepines (BZDs) are ideal candidates for DFSA, as they are active at low doses, have a fast onset of action and can be easily administered orally. The last decade has seen the emergence of designer benzodiazepines (DBZDs), which show slight modifications compared with BZDs and similar pharmacological effects but are not controlled under the international drug control system. DBZDs represent an additional challenge due to the number of new entities regularly appearing in the market, their possibly higher potency and the limited knowledge available on their pharmacokinetic and pharmacodynamics properties. Many BZDs and DBZDs have a short half-life, leading to rapid metabolism and excretion. The low concentrations and short time windows for the detection of BZD in body fluids require the use of highly sensitive analysis methods to enable the detection of drugs and their respective metabolites. This review discusses the current state of the toxicological analysis of BZDs and DBZDs in forensic casework and their pharmacokinetic properties (i.e., absorption, distribution, metabolism, and elimination), as well as their analysis in biosamples typically encountered in DFSA (i.e., blood, urine and hair).
Collapse
Affiliation(s)
- Mireia Pérez Orts
- Van’t Hoff Institute for Molecular Sciences, University of Amsterdam, P.O. Box 94157, Amsterdam 1090 GD, The Netherlands
| | - Arian van Asten
- Van’t Hoff Institute for Molecular Sciences, University of Amsterdam, P.O. Box 94157, Amsterdam 1090 GD, The Netherlands,Co van Ledden Hulsebosch Center (CLHC), Amsterdam Center for Forensic Science and Medicine, 1098 XH Amsterdam, The Netherlands,Centre for Analytical Sciences Amsterdam (CASA), Science Park, 904, 1098 XH Amsterdam, The Netherlands
| | | |
Collapse
|
5
|
Characteristics of fatal 'novel' benzodiazepine toxicity in Australia. Forensic Sci Int 2021; 331:111140. [PMID: 34894611 DOI: 10.1016/j.forsciint.2021.111140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The study aimed to determine: 1. The characteristics of all recorded cases of fatal drug poisoning involving 'novel' benzodiazepines (NBZDs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings. METHODS Retrospective study of all deaths due to drug toxicity in Australia in which NBZDs were present in blood toxicology, retrieved from the National Coronial Information System (2000-2021). Information was collected on case characteristics, toxicology and major organ pathology. RESULTS A total of 40 cases were identified, the first occurring in 2015, with a median age of 26.5 years and 87.5% being male. Death was due to accidental toxicity in 92.5% of cases. There were extensive histories of substance use problems (80.0%) and mental health problems (32.5%). Etizolam was the most common NBZD (87.5%), followed by flubromazolam (15.0%), with other NBZDs detected in 20.0% (delorazepam, diclazepam, flualprazolam, flubromazepam, lormetazepam). Multiple NBZDs were present in 27.5%. Other drugs were present in 97.5%, most commonly opioids (70.0%), registered benzodiazepines (62.5%), psychostimulants (45.0%) and gabapentinoids (32.5%). A CNS depressant other than a NBZD was detected in 95.0% (n = 38). Autopsies were conducted and available for 30 cases, with pulmonary oedema (76.7%, n = 23), aspiration of vomitus (46.7%, n = 14) and acute bronchopneumonia (36.7%, n = 11) the most common diagnoses. CONCLUSIONS The 'typical' NBZD-related death was a young male who died due to accidental toxicity. Deaths most frequently involved etizolam and multiple substances, particularly depressants.
Collapse
|
6
|
Designer Benzodiazepines: A Review of Toxicology and Public Health Risks. Pharmaceuticals (Basel) 2021; 14:ph14060560. [PMID: 34208284 PMCID: PMC8230725 DOI: 10.3390/ph14060560] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 12/11/2022] Open
Abstract
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game between organized crime and law enforcement. Non-prohibited benzodiazepines are introduced onto the global drug market and scheduled as rapidly as possible by international authorities. In response, DBZD are continuously modified to avoid legal sanctions and drug seizures and generally to increase the abuse potential of the DBZD. This results in an unpredictable fluctuation between the appearance and disappearance of DBZD in the illicit market. Thirty-one DBZD were considered for review after consulting the international early warning database, but only 3-hydroxyphenazepam, adinazolam, clonazolam, etizolam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, phenazepam and pyrazolam had sufficient data to contribute to this scoping review. A total of 49 reports describing 1 drug offense, 2 self-administration studies, 3 outpatient department admissions, 44 emergency department (ED) admissions, 63 driving under the influence of drugs (DUID) and 141 deaths reported between 2008 and 2021 are included in this study. Etizolam, flualprazolam flubromazolam and phenazepam were implicated in the majority of adverse-events, drug offenses and deaths. However, due to a general lack of knowledge of DBZD pharmacokinetics and toxicity, and due to a lack of validated analytical methods, total cases are much likely higher. Between 2019 and April 2020, DBZD were identified in 48% and 83% of postmortem and DUID cases reported to the UNODC, respectively, with flualprazolam, flubromazolam and etizolam as the most frequently detected substances. DBZD toxicology, public health risks and adverse events are reported.
Collapse
|
7
|
Haden M, Cashman J, Ketchin A, Macfarlane R, Issa S, Eddleston M, Hines S, Hudson S, Hill SL, Thomas SHL. Detection of flubromazolam in patients with suspected non-medical drug use attending emergency departments in the United Kingdom. Clin Toxicol (Phila) 2021; 60:33-37. [PMID: 34080515 DOI: 10.1080/15563650.2021.1931692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Non-medical use of novel benzodiazepines has recently become common. Here, we describe the recent frequent detection of flubromazolam in patients attending United Kingdom emergency departments. METHODS Adults presenting to participating hospitals with toxicity after suspected drug misuse were studied between March 2015 and January 2021. Clinical features were recorded using consistent methodology and biological samples analysed using liquid chromatography-tandem mass-spectrometry. RESULTS Flubromazolam and/or its mono-hydroxylated metabolite were detected in samples from 14 of 957 patients, all presenting since July 2020. Reported clinical features included reduced level of consciousness (10), confusion/agitation (6) and acidosis (5) but multiple other substances were detected in all patients. All patients survived to discharge (length of hospital stay 3.0 to 213 h, median 24.1 h). There was no correlation between admission blood/serum flubromazolam concentrations (range 1.7-480.5 ng/ml, median 7.4 ng/ml) and Glasgow Coma Scale or length of hospital stay. In one patient who needed intubation and ventilation for five days, there was an exponential decline in flubromazolam concentrations with time (calculated half-life 39.8 h). Hydroxyl-flubromazolam was also identified at all time points. CONCLUSIONS Flubromazolam has been detected frequently in drug users presenting to UK emergency departments since July 2020. Prolonged toxicity may occur as a result of the long half-life of flubromazolam and the production of metabolites likely to be active.
Collapse
Affiliation(s)
- Mark Haden
- Emergency Department, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Josephine Cashman
- Emergency Department, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Ketchin
- Emergency Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Shabana Issa
- Emergency Department, Royal London Hospital, Barts Healthcare NHS Trust, London, UK
| | | | | | | | - Simon L Hill
- LGC Ltd, Fordham, UK.,Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon H L Thomas
- Clinical Toxicology, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| |
Collapse
|
8
|
|