Adulterants present in the San Diego county fentanyl supply: a laboratory analysis of seized law enforcement samples

BACKGROUND

The opioid overdose crisis is one of the worst public health crises ever to face the US and emerging evidence suggests its effects are compounded by the presence of drug adulterants. Here we report our efforts to characterize the adulterants present within the local fentanyl supply of San Diego County, obtained from undifferentiated drug samples seized by local law enforcement over the calendar year 2021.

METHODS

Thirty-two participating local law enforcement agencies across San Diego submitted 4838 unknown individual illicit drug samples (total of 312 kg) to the San Diego County Sheriff's Department Regional Crime Laboratory for identification.

RESULTS

Qualitative analysis of these samples via FTIR and GC-MS identified methamphetamine (38.7%), fentanyl (20.8%), diacetylmorphine (heroin) (10.2%), codeine (5.8%) and alprazolam (4.3%) as the most common illicit substances and the presence of 52 unique adulterants. The most common adulterants included 4-methylaminoantipyrine (4-MAAP) (10.9%), mannitol (9%), acetaminophen (8.5%), methamphetamine (4.2%), diacetylmorphine (heroin) (3.6%), tramadol (1.9%), and xylazine (1.7%). Several additional pharmacologically active adulterants and contaminants of interest were also identified.

CONCLUSION

This analysis is vital for public health use and harm reduction efforts at the level of the individual consumer. Continued direct surveillance of the drug supply is necessary for the detection of potentially harmful adulterants that may pose serious threats to the public.

The first drug-related death associated with xylazine use in the UK and Europe

BACKGROUND AND AIMS

On November 8th^, 2022, the United States Food and Drug Administration (FDA) issued a statement alerting healthcare professionals to the increasing prevalence of xylazine in illicit drug overdoses in the country. Xylazine is a veterinary medicine with sedative, analgesic and muscle relaxant properties that is used as a heroin/fentanyl adulterant on the illicit drug market in North America. Here we report the first drug-related death associated with xylazine in the United Kingdom.

METHODS

The National Programme on Substance Abuse Deaths (NPSAD) receives reports on drug-related deaths from coroners In England, Wales and Northern Ireland on a voluntary basis. The NPSAD was searched for cases with xylazine detections in cases received by December 31, 2022.

RESULTS

One drug-related death associated with xylazine use was reported to NPSAD by December 31, 2022. The deceased was a 43-year-old male who was found dead at home with drug paraphernalia located at the property in May 2022. The post-mortem examination identified recent puncture wounds to the groin. Coronial documentation reports that the deceased had a history of illicit drug use. A number of drugs were detected by post-mortem toxicology and xylazine was implicated in death alongside heroin, fentanyl and cocaine.

CONCLUSIONS

To the best of our knowledge, this is the first death associated with xylazine use reported in the UK, and even Europe, and indicates the entry of xylazine into the UK drug supply. This report highlights the importance of monitoring changes in illicit drug markets and the emergence of new drugs.

Isolation and characterization of a new oxyphenisatin analogue, oxyphenisatin propionate, from a processed plum intended as a weight loss product

A new oxyphenisatin analogue was detected from a processed plum claiming to be a weight loss product without any side effects during the daily inspecting and monitoring of illegal adulterants in health supplements. An abundant peak caused our interest firstly owing to its identical fragments of m/z 224 and 196 in the MS/MS experiments with those of oxyphenisatin acetate. The chemical structure of the unknown compound was characterized by ultra-high performance liquid chromatography equipped with diode array detector and quadrupole time-of-flight tandem mass spectrometry (UHPLC-DAD-Q-TOF/MS), followed by nuclear magnetic resonance (NMR) and infrared (IR) spectroscopy experiments. Based on the data, it was defined that the two symmetrical acetyl groups in oxyphenisatin acetate were replaced by two propionyl groups for the unknown structure. Finally, the new oxyphenisatin analogue was identified as 3,3-bis[4'-(propionyloxy)phenyl]-1,3-dihydroindole-2-one and designated as oxyphenisatin propionate. Thereafter, the content of the new analogue was quantitatively determined to be 681 mg/kg, which would inevitably cause adverse health effect because there was not specification for daily consumption of this product. To the best of our knowledge, this is the first report for identification of oxyphenisatin propionate.

Droplet digital PCR for the identification of plant-derived adulterants in highly processed products

BACKGROUND

The high sensitivity of droplet digital PCR (ddPCR) contributes to its excellent performance in animal and microorganism identification, but the utilization of ddPCR is limited in plant adulterant identification of highly processed products for which effective methods are lacking.

PURPOSE

This study investigated the feasibility of ddPCR in the identification of plant adulterants in Chinese patent medicine (CPM) as groundwork to develop ddPCR assays for other highly processed goods.

METHODS

The original plant, processed and highly processed products of Mutong (Akebiae Caulis) and its two adulterants were used to analyze the specificity, sensitivity, and practical performance of the developed singleplex and triplex ddPCR assays.

RESULTS

The results revealed that the limit of detection (LOD) and limit of quantification (LOQ) for the selective ddPCR assays developed to identify Mutong and its adulterants were 0.00002 ng/μl and 0.00016 ng/μl, respectively, and that the regression equations representing the relationships between DNA concentration and target copy number all exhibited good linearity. Furthermore, the common adulterant of Mutong in three samples of Longdan Xiegan pills was successfully identified through ddPCR assays and confirmed by Sanger sequencing.

CONCLUSION

This work comprehensively revealed the great ability of ddPCR technology in detecting plant adulterants in traditional Chinese medicine (TCM), providing a method for the quality control of highly processed plant products with complex components for commonly used goods.

Infrared spectroscopy technique for quantification of compounds in plant-based medicine and supplement

Quality control of plant-based medicine and supplements must be carried out to ensure uniformity in quality and safety in their use, resulting in the need for effective and accurate analytical methods. Infrared spectroscopy is a method of qualitative and quantitative analysis that is fast, time-saving, cost-effective,accurate, and nondestructive. This method has been applied for quantitative analysis of compounds in complex matrices such as plant-based medicine and supplements supported by chemometrics techniques. The success of infrared spectroscopy applications for quantitative analysis of phytochemicals and adulterants content in plant-based medicine and supplement can happen by several factors. This article highlights the effect of spectral preprocessing and variable selection on quantitative analysis of phytochemical and adulterant in plant-based medicine and supplements using infrared spectroscopy. Literature search was conducted with PubMed, Google Scholar, and Science Direct by selecting quantitative analysis research on plant-based medicines and supplements that utilize spectral preprocessing techniques and variable selection in processing data analysis. The preprocessing spectra and variables selection can affect the accuracy and precision of infrared spectroscopy methods. The variable selection can be done using the wavenumber point technique, the wavenumber interval, or a combination thereof. Variable selection is more commonly used for near-infrared data than for IR data. The optimization of the preprocessing spectra and variables selection technique will be useful in increasing the ability of infrared spectroscopy in predicting compound levels.

Community Acceptance of Available Milk and Assessment of Its Quality in Peri-Urban Area of Southwest Delhi

Background:

Milk is considered to be a balanced food rich in fats, proteins, vitamins, and minerals, which is complete nutrition in a balanced proportion. However, most of milk sold in India does not match standards laid down by the Food Safety and Standards Authority of India.

Objective:

The objective was to understand the perception of community regarding the acceptance of packaged and unpackaged milk, to assess the quality of milk with respect to adulterants, and to assess the difference in the quality of milk at a level of vendor/hawker and end user.

Materials and Methods:

A cross-sectional study was conducted among 100 households in the peri-urban area of Kangan Heri, Delhi. A structured questionnaire and checklist were used for data collection. Purposive sampling was used. The analysis was done with the Statistical Package for the Social Sciences version 22. Descriptive statistics and cross tabulation were used.

Results:

A total of 22.5% respondents preferred packaged milk over unpackaged milk. Only 8% of packaged milk samples contained no adulterant. Majority of the respondents were preferred unpacked milk for daily consumption.

Conclusion:

Community perceives good taste as traits of good quality milk followed by good smell, digestibility, and color and economical. The presence of neutralizer in packaged milk followed by detergent and urea. There was no difference in the presence of adulterants in packaged milk at the level of end user or vendor. There is a slight difference in the presence of adulterants in unpackaged milk at level of end user.

Adverse health risk from prolonged consumption of formaldehyde-preserved carps in eastern region of Indian population

Presence of formaldehyde as a preservative in commonly available fishes (Labeo rohita, Catla catla, Anabas testudineus and Clarias gariepinus) has become a serious health concern in the public health of eastern region of India. Formaldehyde content was determined using high-performance liquid chromatography (HPLC). Results showed high formaldehyde content in frozen carp (19.66 and 23.3 mg/kg in Labeo rohita and Catla catla, respectively); however, the amount of formaldehyde was significantly reduced in boiled and fried fish (80 °C and 100 °C for 5 min) in mustard, coconut, and sesame oils. However, formaldehyde contents in non-carp fishes (Anabas testudineus and Clarias gariepinus) were almost negligible, compared to those in L. rohita and C. catla. In vivo toxicity studies showed a time-dependent increase in blood formaldehyde levels in rats after they were fed formaldehyde-contaminated fish (23.3 mg/kg) for 7 days. Histopathological analysis of the stomach of rats fed contaminated fish showed destruction and granulation of the protective mucus layer and detachment from the secretory layer. Taken together, our results indicated that continuous consumption of formaldehyde-contaminated carps commonly available in the eastern region of India may be associated with adverse health effects.

Pine rosin identified as a toxic cannabis extract adulterant

Pine rosin (colophony) has been identified as a potentially new adulterant in cannabis oil. Its inhalation toxicity poses a significant health concern to users. For example, pine rosin fumes are released during soldering, and have been cited as a causative agent of occupational asthma. Symptoms also include desquamation of bronchial epithelium, which has also been observed in e-cigarette or vaping product used-associated lung injury (EVALI) patients. The sample analyzed herein was acquired from a cannabis industry source, also contains medium chain triglycerides and oleamide, the latter of which is a hypnotic that is commonly found in the synthetic marijuana product Spice, or K2. A combination of proton nuclear magnetic resonance (¹H NMR) and high pressure liquid chromatography-electrospray ionization mass spectrometry (HPLC-ESIMS) was used to unambiguously identify major pine rosin ingredients such as abietic and other resin acids. Comparison to commercial samples of pure pine rosin confirmed the assignment.

Authentication of Edible Bird's Nest (EBN) and its adulterants by integration of shotgun proteomics and scheduled multiple reaction monitoring (MRM) based on tandem mass spectrometry

Edible bird's nest (EBN) has been traditionally regarded as a kind of medicinal and healthy food in Asia. However, economically motivated adulteration (EMA) has been an issue in the EBN supply chain. To develop an accurate high-throughput approach for detecting EBN and its adulterants (exemplified by porcine skin, swim bladder, white fungus, and egg white), shotgun proteomics was applied for discovery of specific peptides that were subsequently converted into scheduled multiple reaction monitoring (MRM) transitions. Totally, 28 specific peptides were verified as unique to EBN and its adulterants by tandem mass spectrometry. Subsequently, 9 quantitative MRM-transitions of peptides from adulterants and 2 internal standard references from EBN were screened for the quantitative analysis of the adulterants, which allowed detection of adulterants in EBN matrix in the range of 1-80%. These results suggested that integration of shotgun proteomics and scheduled MRM had potential for the authentication of EBN and its adulterants.

Analysis of cocaine adulterants in human brain in cases of drug-related death

For different reasons, street cocaine is often diluted with pharmacologically active substances, the so-called adulterants such as levamisole or hydroxyzine. A controversial debate exists currently on the uptake of adulterants from cocaine preparations and drug-related death. Previous research convincingly argues that serious adverse side effects that affect the central nervous and cardiovascular systems can be a consequence of adulterated cocaine.

AIMS

Having identified the presence of adulterants in lung tissue and blood, the concentrations of these substances in brain, an important target location, was of interest. This provides an opportunity to assess their role in cases of drug-related deaths.

MATERIALS AND METHODS

We developed and validated a method for the analysis of cocaine, two cocaine metabolites and six adulterants, which can typically be found in cocaine preparations, and one adulterant metabolite in brain tissue by gas chromatography-mass spectrometry (GC-MS)¹. Ten brain samples which were tested positive for cocaine were analyzed. The homogenized brain tissue was embedded into drying paper for protein precipitation. During a subsequent solid-phase extraction (SPE), the eluate and one of the wash fractions were collected. After derivatization with N-Methyl-N-(trimethylsilyl)trifluoroacetamide (MSTFA) in pyridine and isooctane, the extracts were analyzed by GC-MS.

RESULTS AND DISCUSSION

The method was fully validated for cocaine (COC), benzoylecgonine (BZE), ecgonine methyl ester (EME), diltiazem (DIL), hydroxyzine (HYD), and levamisole (LEV) and partly validated for cetirizine (CET), lidocaine (LID), phenacetin (PHE), and procaine (PRO) in brain material. By analyzing post-mortem brain tissue of ten cocaine users, LEV, LID, and HYD as well as PHE were identified in contrast to DIL, PRO, and the HYD metabolite CET. HYD and LEV were found in moderate to high concentrations in some cases. Therefore, it cannot be excluded that they have caused adverse side effects.

CONCLUSION

Because adulterants can potentially affect the central nervous and cardiac systems, it is likely that they enhance COC toxicity.

Levamisole: A High Performance Cutting Agent

Levamisole is an imidazothiazole chemical most frequently used as an antihelminthic agent in cattle. Over the last decade, levamisole has been increasingly encountered as an additive in both powder and crack cocaine. A white powder with a "fish scale" appearance, the chemical is physically similar to powder cocaine. In vivo, levamisole is metabolized to aminorex, a compound with amphetamine-like psychostimulatory properties and a long half-life; a priori, this property allows levamisole to potentiate and prolong the stimulatory effects of cocaine while bulking up the drug to increase profit for the dealer. As use of cocaine cut with levamisole becomes more prevalent, complications directly attributable to the chemical are increasingly being recognized.

Cocaine adulteration

Cocaine is a naturally occurring and illicitly used psychostimulant drug. Cocaine acts at monoaminergic neurotransmitter transporters to block uptake of the monoamines, dopamine, serotonin and norepinephrine. The resulting increase of monoamines in the extracellular space underlies the positively reinforcing effects that cocaine users seek. In turn, this increase in monoamines underlies the development of addiction, and can also result in a number of severe side effects. Currently, cocaine is one of the most common illicit drugs available on the European market. However, cocaine is increasingly sold in impure forms. This trend is driven by cocaine dealers seeking to increase their profit margin by mixing ("cutting") cocaine with numerous other compounds ("adulterants"). Importantly, these undeclared compounds put cocaine consumers at risk, because consumers are not aware of the additional potential threats to their health. This review describes adulterants that have been identified in cocaine sold on the street market. Their typical pharmacological profile and possible reasons why these compounds can be used as cutting agents will be discussed. Since a subset of these adulterants has been found to exert effects similar to cocaine itself, we will discuss levamisole, the most frequently used cocaine cutting agent today, and its metabolite aminorex.

Adulterants in Urine Drug Testing

Urine drug testing plays an important role in monitoring licit and illicit drug use for both medico-legal and clinical purposes. One of the major challenges of urine drug testing is adulteration, a practice involving manipulation of a urine specimen with chemical adulterants to produce a false negative test result. This problem is compounded by the number of easily obtained chemicals that can effectively adulterate a urine specimen. Common adulterants include some household chemicals such as hypochlorite bleach, laundry detergent, table salt, and toilet bowl cleaner and many commercial products such as UrinAid (glutaraldehyde), Stealth® (containing peroxidase and peroxide), Urine Luck (pyridinium chlorochromate, PCC), and Klear® (potassium nitrite) available through the Internet. These adulterants can invalidate a screening test result, a confirmatory test result, or both. To counteract urine adulteration, drug testing laboratories have developed a number of analytical methods to detect adulterants in a urine specimen. While these methods are useful in detecting urine adulteration when such activities are suspected, they do not reveal what types of drugs are being concealed. This is particularly the case when oxidizing urine adulterants are involved as these oxidants are capable of destroying drugs and their metabolites in urine, rendering the drug analytes undetectable by any testing technology. One promising approach to address this current limitation has been the use of unique oxidation products formed from reaction of drug analytes with oxidizing adulterants as markers for monitoring drug misuse and urine adulteration. This novel approach will ultimately improve the effectiveness of the current urine drug testing programs.

Qualitative, quantitative and temporal study of cutting agents for cocaine and heroin over 9 years

Forensic laboratories mainly focus on the qualification and the quantitation of the illicit drug under analysis as both aspects are used for judiciary purposes. Therefore, information related to cutting agents (adulterants and diluents) detected in illicit drugs is limited in the forensic literature. This article discusses the type and frequency of adulterants and diluents detected in more than 6000 cocaine specimens and 3000 heroin specimens, confiscated in western Switzerland from 2006 to 2014. The results show a homogeneous and quite unchanging adulteration for heroin, while for cocaine it could be characterised as heterogeneous and relatively dynamic. Furthermore, the results indicate that dilution affects more cocaine than heroin. Therefore, the results provided by this study tend to reveal differences between the respective structures of production or distribution of cocaine and heroin. This research seeks to promote the systematic analysis of cutting agents by forensic laboratories. Collecting and processing data related to the presence of cutting agents in illicit drug specimens produces relevant information to understand and to compare the structure of illicit drug markets.

Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature

Xylazine is not a controlled substance; it is marketed as a veterinary drug and used as a sedative, analgesic and muscle relaxant. In humans, it could cause central nervous system depression, respiratory depression, bradycardia, hypotension, and even death. There have been publications of 43 cases of xylazine intoxication in humans, in which 21 (49%) were non-fatal scenarios and 22 (51%) resulted in fatalities. Most of the non-fatal cases required medical intervention. Over recent years xylazine has emerged as an adulterant in recreational drugs, such as heroin or speedball (a cocaine and heroin mixture). From the 43 reported cases, 17 (40%) were associated with the use of xylazine as an adulterant of drugs of abuse. Its chronic use is reported to be associated with physical deterioration and skin ulceration. Literature shows some similar pharmacologic effects between xylazine and heroin in humans. These similar pharmacologic effects may create synergistic toxic effects in humans. Therefore, fatalities among drug users may increase due to the use of xylazine as an adulterant. Xylazine alone has proven harmful to humans and even more when it is combined with drugs of abuse. A comprehensive review of the literature of non-fatal and fatal xylazine intoxication cases including those in which the substance was used as adulterant is presented, in order to increase the awareness in the forensic community, law enforcement, and public health agencies.

Quality analysis of commercial samples of Ziziphi spinosae semen (suanzaoren) by means of chromatographic fingerprinting assisted by principal component analysis

Due to the scarcity of resources of Ziziphi spinosae semen (ZSS), many inferior goods and even adulterants are generally found in medicine markets. To strengthen the quality control, HPLC fingerprint common pattern established in this paper showed three main bioactive compounds in one chromatogram simultaneously. Principal component analysis based on DAD signals could discriminate adulterants and inferiorities. Principal component analysis indicated that all samples could be mainly regrouped into two main clusters according to the first principal component (PC1, redefined as Vicenin II) and the second principal component (PC2, redefined as zizyphusine). PC1 and PC2 could explain 91.42% of the variance. Content of zizyphusine fluctuated more greatly than that of spinosin, and this result was also confirmed by the HPTLC result. Samples with low content of jujubosides and two common adulterants could not be used equivalently with authenticated ones in clinic, while one reference standard extract could substitute the crude drug in pharmaceutical production. Giving special consideration to the well-known bioactive saponins but with low response by end absorption, a fast and cheap HPTLC method for quality control of ZSS was developed and the result obtained was commensurate well with that of HPLC analysis. Samples having similar fingerprints to HPTLC common pattern targeting at saponins could be regarded as authenticated ones. This work provided a faster and cheaper way for quality control of ZSS and laid foundation for establishing a more effective quality control method for ZSS.

Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters

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We quantified adulterants in street drugs sold as cocaine.

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We analyzed effects of the most common adulterant levamisole, on neurotransmitter transporters.

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Differences in the selectivity of levamisole can be explained by homology modelling and docking.

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Aminorex, a metabolite of levamisole, modulates neurotransmitter transporters directly.

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Depending on the transporter, aminorex acts as a blocker or as a releaser.

Psychostimulants such as amphetamine and cocaine are illicitly used drugs that act on neurotransmitter transporters for dopamine, serotonin or norepinephrine. These drugs can by themselves already cause severe neurotoxicity. However, an additional health threat arises from adulterant substances which are added to the illicit compound without declaration. One of the most frequently added adulterants in street drugs sold as cocaine is the anthelmintic drug levamisole. We tested the effects of levamisole on neurotransmitter transporters heterologously expressed in HEK293 cells. Levamisole was 100 and 300-fold less potent than cocaine in blocking norepinephrine and dopamine uptake, and had only very low affinity for the serotonin transporter. In addition, levamisole did not trigger any appreciable substrate efflux. Because levamisole and cocaine are frequently co-administered, we searched for possible allosteric effects; at 30 μM, a concentration at which levamisole displayed already mild effects on norepinephrine transport it did not enhance the inhibitory action of cocaine. Levamisole is metabolized to aminorex, a formerly marketed anorectic drug, which is classified as an amphetamine-like substance. We examined the uptake-inhibitory and efflux-eliciting properties of aminorex and found it to exert strong effects on all three neurotransmitter transporters in a manner similar to amphetamine. We therefore conclude that while the adulterant levamisole itself has only moderate effects on neurotransmitter transporters, its metabolite aminorex may exert distinct psychostimulant effects by itself. Given that the half-time of levamisole and aminorex exceeds that of cocaine, it may be safe to conclude that after the cocaine effect “fades out” the levamisole/aminorex effect “kicks in”.

Important Considerations in the Interpretation of Forensic Urine Drug Test Results

With sound analytical methodology, good laboratory practice, and intact specimen chain-of-custody, test result interpretation is the final element dictating the action to be taken following drug urinalysis. From a technical viewpoint, false test results may be reported as a result of adulteration, including the alteration of metabolic process through the intentional use of foreign material, or the outright addition of adulterants to specimens. Unintended exposure through contact or inhalation may result in the detection of targeted drug analytes at low levels, while the use of certain licit food and medicinal items, such as a salad dressing, a bagel containing poppy seeds, and Tylenol® III, may produce positive results using commonly reporting cutoff levels. For those specimens that test positively, the following factors should be considered when interpreting the meaning of a quantitative result: analyte stability, urine water content, and time lapse between drug exposure and specimen collection.