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Di Trana A, Di Giorgi A, Carlier J, Serra F, Busardò FP, Pichini S. "Tranq-dope": The first fatal intoxication due to xylazine-adulterated heroin in Italy. Clin Chim Acta 2024; 561:119826. [PMID: 38909977 DOI: 10.1016/j.cca.2024.119826] [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: 05/02/2024] [Revised: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND AND AIMS The number of xylazine-involved overdose deaths tremendously increased from 2019 onwards in the US. This is due to the "tranq-dope" trend consisting in mixing opioids with the sedative to reduce drug manufacturing costs and enhance their effects. In this study, we report the first fatality involving xylazine-adulterated heroin in the EU. MATERIALS AND METHODS The subject was a 33-year-old Caucasian male with a documented history of drug abuse who was found dead in a public area with puncture marks at the elbow. Peripheral blood and urine were collected at the autopsy and analyzed by liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) after protein precipitation. RESULTS 6-Monoacetylmorphine, total/free morphine, and codeine blood concentrations of 20.3, 236/105, and 38.3 ng/mL, respectively, indicated recent heroin consumption. Methadone blood concentration was below 10 ng/mL. Alprazolam, nordiazepam, and flurazepam blood concentrations were 23.9, 61.4, and 55.0 ng/mL, respectively. Benzoylecgonine blood concentration was below 5 ng/mL. Xylazine blood and urine concentrations were 105 and 72.6 ng/mL, respectively. CONCLUSION The combination of central nervous system depressants, i.e., opioids, benzodiazepines, and xylazine, was the principal cause of death by cardiorespiratory failure. The case was promptly reported to the UE Early Warning System on drugs.
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Affiliation(s)
- Annagiulia Di Trana
- National Centre on Addiction and Doping, National Institute of Health, Viale Regina Elena 299, 00161 Rome, Italy
| | - Alessandro Di Giorgi
- Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126 Ancona, Italy
| | - Jeremy Carlier
- Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126 Ancona, Italy.
| | - Francesco Serra
- Section of Legal Medicine, Department of Prevention, Sassari Hospital, via Rizzeddu 21/B, 07100 Sassari, Italy
| | - Francesco Paolo Busardò
- Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Tronto 10/a, 60126 Ancona, Italy
| | - Simona Pichini
- National Centre on Addiction and Doping, National Institute of Health, Viale Regina Elena 299, 00161 Rome, Italy
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La Maida N, Di Giorgi A, Pichini S, Pellegrini M, Di Trana A, Elmo MG, Polselli GM, Casella P, Di Stefano A, Ducci G. Comprehensive Monitoring of Psychoactive Substances in Psychiatric Patients Using Liquid Chromatography-High-Resolution Mass Spectrometry: A Key Tool for Treatment Planning and Understanding Consumption Patterns in Rome, Italy. Ther Drug Monit 2024; 46:203-209. [PMID: 38018870 DOI: 10.1097/ftd.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/05/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND The comprehensive monitoring of licit and illicit drug consumption plays a crucial role in understanding the complexities of patient conditions and designing effective treatment strategies. In this study, the prevalence of psychoactive prescription drugs, classical illicit drugs, and new psychoactive substances (NPS) were objectively assessed in individuals diagnosed with drug-related psychiatric disorders or episodes. METHODS Blood, urine, and hair samples were collected from psychiatric patients admitted to the Mental Health Department and Drug Addiction Service of the North Rome Local Health Authority with declared or suspected psychoactive drug use. Comprehensive drug screening was conducted for all samples using ultra-high-performance liquid chromatography-high-resolution mass spectrometry. RESULTS A total of 71 blood and urine and 50 hair samples were analyzed to confirm the suitability of the ultra-high-performance liquid chromatography-high-resolution mass spectrometry method for the study purposes. The main substances found in blood and urine were antipsychotics (71.8% and 66.2%) and benzodiazepines (62.0% and 59.2%), respectively, whereas cocaine (84.0%) and antipsychotics (74.0%) was more evident in hair. Z-drugs were detected in blood (7.0%), urine (5.6%), and hair (24%) samples; amphetamines were mainly detected in hair samples (14.0%). Synthetic cathinones were the most frequently detected NPS in hair specimens (8.0%), whereas synthetic cannabinoids were mainly found in blood samples (11.3%). These analyses showed that patients were polydrug users (77.5% detected in blood and urine, and 94.0% in hair). CONCLUSIONS Comprehensive screening enabled the assessment of past, recent, and actual consumption of psychoactive substances, including licit and illicit drugs and NPS, by psychiatric patients. A thorough understanding of substance consumption patterns can enhance therapeutic interventions and management of psychiatric disorders associated with psychoactive substance use.
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Affiliation(s)
- Nunzia La Maida
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | - Alessandro Di Giorgi
- Department of Excellence of Biomedical Science and Public Health, University "Politecnica delle Marche" of Ancona, Ancona, Italy
| | - Simona Pichini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | - Manuela Pellegrini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | - Annagiulia Di Trana
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Giuseppa Elmo
- Department of Mental Health, Azienda Sanitaria Locale (ASL) Roma 1-Servizio Psichiatrico di Diagnosi e Cura (SPDC), San Filippo Neri Hospital, Rome, Italy
| | - Gian Marco Polselli
- Department of Mental Health, Azienda Sanitaria Locale (ASL) Roma 1-Servizio Psichiatrico di Diagnosi e Cura (SPDC), San Filippo Neri Hospital, Rome, Italy
- Department of Mental Health, Azienda Sanitaria Locale (ASL) Roma 1-Servizio Psichiatrico di Diagnosi e Cura (SPDC), S. Spirito Hospital, Rome, Italy
| | - Pietro Casella
- Department of Mental Health, Azienda Sanitaria Locale (ASL) Roma 1-Drug Dipendence and Addiction Unit, Rome, Italy; and
| | - Adele Di Stefano
- Department of Mental Health, Azienda Sanitaria Locale (ASL) Roma 1-Mental Health and Drug Dipendence Unit in prison, Rome, Italy
| | - Giuseppe Ducci
- Department of Mental Health, Azienda Sanitaria Locale (ASL) Roma 1-Servizio Psichiatrico di Diagnosi e Cura (SPDC), San Filippo Neri Hospital, Rome, Italy
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Palamar JJ, Massano M, Salomone A. Five cases of unintentional exposure to BZO-4en-POXIZID among nightclub attendees in New York City. J Anal Toxicol 2024; 48:75-80. [PMID: 37952092 PMCID: PMC10981447 DOI: 10.1093/jat/bkad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/29/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023] Open
Abstract
A new class of synthetic cannabinoids called OXIZIDs has emerged in recent years. This class consists of compounds with oxindole cores and hydrazide/hydrazone linker moieties and has often been described as being designed to circumvent a Chinese class-wide ban that was effective as of 1 July 2021. However, through hair testing of nightclub attendees in New York City-a high-risk population for recreational drug use-we have evidence suggesting exposures to an OXIZID called BZO-4en-POXIZID (4en-pentyl MDA-19) prior to the effective ban. Through analysis of 6 cm segmented hair samples from attendees collected in 2021, we detected five cases of exposure. Specifically, we detected a cluster of three cases based on hair samples collected on 20 June 2021, and then two additional cases from samples collected on 16 July 2021. Four of these hair samples were long enough to analyze two 6 cm hair segments (representing approximately two 6-month timeframes) and three of four of these cases tested positive for repeated exposure (for an estimated exposure over 6 months prior to hair collection). All cases included young adult females reporting past-year cannabis use but all tested negative for tetrahydrocannabinol exposure. Three cases also reported past-year use of cocaine, ecstasy, and/or ketamine, and four cases tested positive for exposure to cocaine, 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxyamphetamine (MDA), methamphetamine and/or eutylone. These subjects were exposed to BZO-4en-POXIZID-likely as an adulterant in other drugs, and these cases are among the first documented cases which occurred approximately half a year before the Chinese legislative ban.
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Affiliation(s)
- Joseph J Palamar
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, Room 1752, New York, NY 10016, USA
| | - Marta Massano
- Department of Chemistry, University of Turin, via Giuria 5, Turin 10125, Italy
| | - Alberto Salomone
- Department of Chemistry, University of Turin, via Giuria 5, Turin 10125, Italy
- Centro Regionale Antidoping, Regione Gonzole 10, Orbassano (TO) 10043, Italy
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Henion J, Hao C, Eikel D, Beck O, Stambeck P. An analytical approach for on-site analysis of breath samples for Δ9-tetrahydrocannabinol (THC). JOURNAL OF MASS SPECTROMETRY : JMS 2024; 59:e4987. [PMID: 38108556 DOI: 10.1002/jms.4987] [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: 10/03/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 12/19/2023]
Abstract
Increased acceptance of cannabis containing the psychoactive component, Δ9-tetrahydrocannabinol (THC), raises concerns about the potential for impaired drivers and increased highway accidents. In contrast to the "breathalyzer" test, which is generally accepted for determining the alcohol level in a driver, there is no currently accepted roadside test for THC in a motorist. There is a need for an easily collectible biological sample from a potentially impaired driver coupled with an accurate on-site test to measure the presence and quantity of THC in a driver. A novel breath collection device is described, which includes three separate sample collectors for collecting identical A, B, and C breath samples from a subject. A simple one-step ethanol extraction of the "A" breath collector sample can be analyzed by UHPLC/selected ion monitoring (SIM) liquid chromatography/mass spectrometry (LC/MS) to provide qualitative and quantitative determination of THC in breath sample in less than 4 min for samples collected up to 6 h after smoking a cannabis cigarette. SIM LC/MS bioanalyses employed d3-THC as the stable isotope internal standard fortified in negative control breath samples for quantitation including replicates of six calibrator standards and three quality control (QC) samples. Subsequent confirmation of the same breath sample in the B collectors was then confirmed by a reference lab by LC/MS/MS analysis. Fit-for-purpose bioanalytical validation consistent with pharmaceutical regulated bioanalyses produced pharmacokinetic (PK) curves for the two volunteer cannabis smokers. These results produced PK curves, which showed a rapid increase of THC in the breath of the subjects in the first hour followed by reduced THC levels in the later time points. A simpler single-point calibration curve procedure with calibrators and QC prepared in ethanol provided similar results. Limitations to this approach include the higher cost and operator skill sets for the instrumentation employed and the inability to actually determine driver impairment.
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Affiliation(s)
- Jack Henion
- Advion Interchim Scientific, Ithaca, New York, USA
- Cornell University, Ithaca, New York, USA
| | | | - Daniel Eikel
- Advion Interchim Scientific, Ithaca, New York, USA
| | - Olof Beck
- Karolinska Institutet, Solna, Stockholm, Sweden
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Trobbiani S, Stockham P, Kostakis C. A method for the sensitive targeted screening of synthetic cannabinoids and opioids in whole blood by LC-QTOF-MS with simultaneous suspect screening using HighResNPS.com. J Anal Toxicol 2023; 47:807-817. [PMID: 37632762 DOI: 10.1093/jat/bkad063] [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: 04/24/2023] [Revised: 08/11/2023] [Accepted: 08/25/2023] [Indexed: 08/28/2023] Open
Abstract
A sensitive method for the qualitative screening of synthetic cannabinoids and opioids in whole blood was developed and validated using alkaline liquid-liquid extraction (LLE) and liquid chromatography-time-of-flight mass spectrometry (LC-QTOF-MS). Estimated limits of detection for validated compounds ranged from 0.03 to 0.29 µg/L (median, 0.04 µg/L) for the 27 opioids and from 0.04 to 0.5 µg/L (median, 0.07 µg/L) for the 23 synthetic cannabinoids. Data processing occurred in two stages; first, a targeted screen was performed using an in-house database containing retention times, accurate masses and MS-MS spectra for 79 cannabinoids and 53 opioids. Suspect screening was then performed using a database downloaded from the crowd sourced NPS data website HighResNPS.com which contains mass, consensus MS-MS data and laboratory-specific predicted retention times for a far greater number of compounds. The method was applied to 61 forensic cases where synthetic cannabinoid or opioid screening was requested by the client or their use was suspected due to case information. CUMYL-PEGACLONE was detected in two cases and etodesnitazine, 5 F-MDMB-PICA, 4-cyano-CUMYL-BUTINACA and carfentanil were detected in one case each. These compounds were within the targeted scope of the method but were also detected through the suspect screening workflow. The method forms a solid base for expansion as more compounds emerge onto the illicit drug market.
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Affiliation(s)
- Stephen Trobbiani
- Forensic Science SA, GPO Box 2790, Adelaide, South Australia 5001, Australia
| | - Peter Stockham
- Forensic Science SA, GPO Box 2790, Adelaide, South Australia 5001, Australia
- Flinders University of South Australia, Sturt Road, Bedford Park, Adelaide, South Australia 5042, Australia
| | - Chris Kostakis
- Forensic Science SA, GPO Box 2790, Adelaide, South Australia 5001, Australia
- Flinders University of South Australia, Sturt Road, Bedford Park, Adelaide, South Australia 5042, Australia
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Avram M, Bodinger CA, Clark MA, Stuckey DG, Mathews SE, Stogsdill SN, Barna EC, Williams DK, McGill M, Fantegrossi WE, Liebelt EL, James LP, Endres GW, Moran JH. Hands-Free Analytical Urine Testing Technology Validated for Drug-Facilitated Crime Investigations. Chem Res Toxicol 2023. [PMID: 37703190 DOI: 10.1021/acs.chemrestox.3c00136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Forensic laboratories need quick and simple technology to improve turnaround times, while delivering reliable results. The goal of this study is first to create a simplified workflow to meet new Academy Standards Board requirements for urine testing in drug-facilitated crime investigations and, second, to create "ready-to-go", "hands-free" testing technology to further streamline analytical procedures. A first of its kind, the ToxBox forensic test kit is used to validate a single analytical procedure for opioids, benzodiazepines, cannabinoids, antidepressants, and several other drug classes. Method performance indicators follow accreditation requirements and include accuracy, precision, measurement uncertainty, calibration models, reportable range, sensitivity, specificity, carryover, interference, ion suppression/enhancement, and analyte stability. "Hands-free" testing platforms require the use of new suspended-state technology to stabilize NIST-traceable standards premanufactured at precise concentrations in the presence of sample preparation reagents. By suspending all reaction components in the solid state, with air gaps between the phases, reference standards and process controls are built in a "ready-to-go" format and stabilized for long-term storage in the presence of a sample matrix, β-d-glucuronidase, and enzymatic buffers. "Hands-free" test kits are removed from storage, incubated at either ambient temperature or 60 °C, and assayed using validated methods. This is the first example of how complex forensic testing workflows can be streamlined with new "hands-free" testing strategies to meet analytical challenges associated with quantitative and confirmatory analyses.
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Affiliation(s)
- Marina Avram
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
- Department of Pharmacology & Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | | | - Madeline A Clark
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
| | - Daniel G Stuckey
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
| | - Samuel E Mathews
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
| | | | - Elyse C Barna
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
| | - David K Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | - Mitchell McGill
- Department of Pharmacology & Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
- Department of Environmental Health Sciences, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | - William E Fantegrossi
- Department of Pharmacology & Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | - Erica L Liebelt
- Department of Pediatrics, Section of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | - Laura P James
- Department of Pediatrics, Section of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | - Gregory W Endres
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
| | - Jeffery H Moran
- PinPoint Testing, LLC, Little Rock, Arkansas 72202, United States
- Department of Pharmacology & Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
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Peters FT, Wissenbach D. Current state-of-the-art approaches for mass spectrometry in clinical toxicology: an overview. Expert Opin Drug Metab Toxicol 2023; 19:487-500. [PMID: 37615282 DOI: 10.1080/17425255.2023.2252324] [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: 05/16/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Hyphenated mass spectrometry (MS) has evolved into a very powerful analytical technique of high sensitivity and specificity. It is used to analyze a very wide spectrum of analytes in classical and alternative matrices. The presented paper will provide an overview of the current state-of-the-art of hyphenated MS applications in clinical toxicology primarily based on review articles indexed in PubMed (1990 to April 2023). AREAS COVERED A general overview of matrices, sample preparation, analytical systems, detection modes, and validation and quality control is given. Moreover, selected applications are discussed. EXPERT OPINION A more widespread use of hyphenated MS techniques, especially in systematic toxicological analysis and drugs of abuse testing, would help overcome limitations of immunoassay-based screening strategies. This is currently hampered by high instrument cost, qualification requirements for personnel, and less favorable turnaround times, which could be overcome by more user-friendly, ideally fully automated MS instruments. This would help making hyphenated MS-based analysis available in more laboratories and expanding analysis to a large number of organic drugs, poisons, and/or metabolites. Even the most recent novel psychoactive substances (NPS) could be presumptively identified by high-resolution MS methods, their likely presence be communicated to treating physicians, and be confirmed later on.
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Affiliation(s)
- Frank T Peters
- Institute of Forensic Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Daniela Wissenbach
- Institute of Forensic Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
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Heinsvig PJ, Noble C, Dalsgaard PW, Mardal M. Forensic drug screening by liquid chromatography hyphenated with high-resolution mass spectrometry (LC-HRMS). Trends Analyt Chem 2023. [DOI: 10.1016/j.trac.2023.117023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Busardò FP, Zaami S. Current Design of New Psychoactive Substances. Curr Pharm Des 2022; 28:1211-1212. [PMID: 35899910 DOI: 10.2174/138161282815220624141644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Francesco Paolo Busardò
- Department of Excellence of Biomedical Science and Public Health, University "Politecnica delle Marche", Ancona, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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