Commentary. Fentanyl-related death and the underreporting risk

Atypical Fentanyl Transdermal Patch Consumption and Fatalities: Case Report and Literature Review

Fentanyl is a synthetic L-opioid receptor agonist, approximately 100 times more potent than morphine, that is experiencing an upward trend in the field of abuse. Fentanyl patches' abusive consumption can occur either by transdermal absorption or through other atypical and ingenious routes. In the present case, a 29-year-old man with a history of illicit drug use was found dead in a suburban neighborhood of an Italian city. At autopsy, lungs appeared increased in weight and showed minute subpleural hemorrhages. Airways contained abundant reddish foamy material; in addition, a fentanyl patch protective film was found inside the left main bronchus. Toxicological analysis revealed the presence of morphine, fentanyl, BEG and ethyl alcohol in peripheric blood; 6-MAM was also revealed in urine. Findings collected during post-mortem investigations allowed us to identify fentanyl consumption as the cause of death. Fentanyl consumption presumably took place by chewing of a transdermal patch, with subsequent aspiration of the protective film. The pathophysiology of death can be identified as combined respiratory failure-both central suppression and a fentanyl-induced increase in muscular stiffness; a further minor contribution may be identified in the mechanical airflow obstruction caused by the presence of the protective film at the bronchial level.

Determination of Nine Fentanyl Drugs in Hair Samples by GC-MS/MS and LC-MS/MS

We established GC-MS/MS and LC-MS/MS analysis methods for nine fentanyl drugs in hair samples. Human hairs were prepared by soaking in a solution of water-dimethyl sulfoxide with target analytes. The drugs were norfentanyl, acetyl fentanyl, para-fluorofentanyl, isobutyryl fentanyl, fentanyl, thiofentanyl, 4-fluoroisobutyr fentanyl, ocfentanil, and tetrahydrofuran fentanyl. For a single-factor experiment, a Box-Behnken design-response surface was used to optimize the pretreatment conditions of samples. The prepared samples were quantitatively analyzed by GC-MS/MS and LC-MS/MS. The working curve method was used for quantitative analysis with fentanyl-D5 as the internal standard. The concentrations of the nine fentanyl drugs in the samples were 1.488-6.494 ng mg^-1, RSDs < 5.0%. For GC-MS/MS, the linear range of the nine fentanyl drugs was 0.5-5.0 ng mg^-1, r ² > 0.999. The detection limits were 0.02-0.05 ng mg^-1, and the recovery rates were >86%. For LC-MS/MS, the nine fentanyl drugs had an excellent linear relationship within the concentration range of 3.0-220.0 pg mg^-1, r ² > 0.999. The detection limits were 0.05 pg mg^-1 and the recovery rates were >84%. The established methods were used for the detection of fentanyl drugs in human hairs, with high sensitivity, accuracy, and specificity. These two methods can be used for the certification of fentanyl certified reference substances (CRMs). In the experiment, the developed hair CRMs, which will continue to be studied in the future, are expected to be used in forensic drug abuse detection.

Fentanyl-related substance scheduling as an effective drug control strategy

Fentanyl is now the primary driver of the current opioid crisis. Fentanyl and its analogues are subject to the Controlled Substances Act of 1970, the Controlled Substances Analogue Enforcement Act of 1986 (Federal Analogue Act), state laws, international treaties, and the laws of foreign countries. The appearance of novel psychoactive substances led to further legislative developments in scheduling. New fentanyl analogues proliferated in a manner previously unseen since about 2016. Overdose deaths of these fentanyl analogues prompted the Drug Enforcement Administration to reactively emergency schedule each new fentanyl analogue as it appeared. The international community also acted. Finally, on February 6, 2018, a proactive temporary (emergency) class-wide scheduling of fentanyl-related substances was implemented based upon the fentanyl core structure to save lives. This action spurred a similar action in China. Fentanyl analogues fell dramatically in the marketplace, despite further increases in fentanyl itself. Congress temporarily extended this scheduling, but it will soon expire. Opposition to permanent class-wide was lodged due to concerns over law enforcement overreach, inadequate Health and Human Services input, and hindrance of research. This paper reaffirms the importance of a class-based scheduling strategy while also arguing for increased research of schedule I controlled substances.

Rapid quantitative determination of fentanyl in human urine and serum using a gold-based immunochromatographic strip sensor

Fentanyl is a typical opioid that is used in surgical anesthesia. However, when abused, fentanyl can lead to addiction and even death. To better control the use of fentanyl, it is necessary to develop rapid and sensitive detection methods. In this study, an ultrasensitive monoclonal antibody (mAb) was prepared and used to develop an indirect competitive enzyme-linked immunosorbent assay (ic-ELISA) and a colloidal gold-based immunochromatographic strip (CG-ICS) for the analysis of fentanyl in urine and serum. Under optimum conditions, the anti-fentanyl mAb belonging to the subtype of IgG2b showed a half-maximal inhibitory concentration (IC50) of 0.11 ng mL-1 and a linear range of detection of 0.020-0.50 ng mL-1. Fenanyl-spiked original urine and serum diluted eight times were used for the analysis of fentanyl by ic-ELISA and CG-ICS. IC50 from the standard curves was 0.46 ng mL-1 for urine and 2.6 ng mL-1 for serum in ic-ELISA and 1.6 ng mL-1 for urine and 6.27 ng mL-1 for serum in CG-ICS. The recovery test revealed that the ic-ELISA and CG-ICS, with a recovery rate of 87.0-108.4% and a coefficient of variation of 3.3-10.9%, were the same reliable tools as the liquid chromatography tandem mass spectrometry for fentanyl analysis in real samples.

Potential Role of Serum S-100β Protein as a Predictor of Cardiotoxicity and Clinical Poor Outcome in Acute Amphetamine Intoxication

Cardio- and neurotoxicity of amphetamines play an important role in worsening morbidity, making the initial evaluation of the patient's status a potentially lifesaving action. The current study hypothesized that the S-100β serum level could predict the severity of acute amphetamine toxicity and the in-hospital outcome. The current study is a prospective cohort study conducted on 77 patients diagnosed with acute amphetamine exposure and referred to Aseer Poison Control Center, Saudi Arabia. The patients admitted to ICU showed significantly higher serum levels of S-100β in comparison to those not admitted (p < 0.05). Moreover, the S-100β level was significantly elevated among patients with prolonged QTc intervals. Receiver-operating characteristic curve of S-100β serum level as an in-hospital outcome predictor showed that at a cutoff value > 0.430 ug/L, the sensitivity of S-100β serum level as severity predictor was 100%, and the specificity was 74.1%. In conclusion, the current study revealed that the S-100β serum level could be used as an outcome predictor in hospital admission cases due to toxic amphetamine exposure and offers an idea about the cardiac and neuronal involvement. This can help select patients who will benefit most from ICU admission and early management and assess the severity of cases in settings where GC-MS is not available.

Novel Opioids: Systematic Web Crawling Within the e-Psychonauts' Scenario

Background

A wide range of novel psychoactive substances (NPSs) are regularly searched and discussed online by e-psychonauts. Among NPSs, the range of prescription/non-prescription opioids (fentanyl and non-fentanyl analogs) and herbal derivatives currently represents a challenge for governments and clinicians.

Methods

Using a web crawler (i.e., NPS.Finder^®), the present study aimed at assessing psychonaut fora/platforms to better understand the online situation regarding opioids.

Results

The open-web crawling/navigating software identified some 426 opioids, including 234 fentanyl analogs. Of these, 176 substances (162 were very potent fentanyls, including two ohmefentanyl and seven carfentanyl analogs) were not listed in either international or European NPS databases.

Conclusion

A web crawling approach helped in identifying a large number, indeed higher than that listed by European/international agencies, of unknown opioids likely to possess a significant misuse potential. Most of these novel/emerging substances are still relatively unknown. This is a reason of concern; each of these analogs potentially presents with different toxicodynamic profiles, and there is a lack of docking, preclinical, and clinical observations. Strengthening multidisciplinary collaboration between clinicians and bioinformatics may prove useful in better assessing public health risks associated with opioids.

Pharmacokinetic and pharmacodynamic considerations in developing a response to the opioid epidemic

Introduction: Opioids continue to be used widely for pain management. Widespread availability of prescription opioids has led to opioid abuse and addiction. Besides steps to reduce inappropriate prescribing, exploiting opioid pharmacology to make their use safer is important.Areas covered: This article discusses the pathology and factors underlying opioid abuse. Pharmacokinetic and pharmacodynamic properties affecting abuse liability of commonly abused opioids have been highlighted. These properties inform the development of ideal abuse deterrent products. Mechanisms and cost-effectiveness of available abuse deterrent products have been reviewed in addition to the pharmacology of medications used to treat addiction.Expert opinion: The opioid crisis presents unique challenges to managing pain effectively given the limited repertoire of strong analgesics. The 5-point strategy to combat the opioid crisis calls for better preventive, treatment, and recovery services, better data, better pain management, better availability of overdose-reversing drugs and better research. There is an urgent need to decrease the cost of abuse deterrent opioids which deters their cost-effectiveness. In addition, discovery of novel analgesics, further insight into central and peripheral pain mechanisms, understanding genomic risk profiles for efficient targeted efforts, and education will be key to winning this fight against the opioid crisis.

Trends in severe opioid-related poisonings and fatalities reported to the Paris poison control center - a 10-year retrospective observational study

France is experiencing an increase in the number of opioid prescriptions and related fatalities. We carried out a retrospective observational study using data from the Paris PCC over a 10-year period. The main objective was to obtain an epidemiological description of the severe reported cases. The secondary objectives were to assess the evolution of the number of these cases and their severity defined by the use of fentanyl and its derivatives, the use of the opioid-poisoning treatment naloxone, and the number of fatalities. During 2008-2017, 268 511 cases were recorded, including 1 122 cases of opioid-related poisoning that required medical management. These poisonings involved tramadol (43%), codeine (25%), dextropropoxyphene (13%), and morphine (8%); most resulted from self-exposure (60%). During the 10-year study period, 130 opioid-related fatalities were recorded in the Paris area, mainly resulting from suicides (39%) in men and were attributed to morphine (27%), tramadol (24%), and methadone (21%). We did not identify an increase in the number of severe opioid-related poisonings or fatalities or in the use of fentanyl or its derivatives. Conversely, we observed an increase in the use of naloxone, suggesting an increase in the severity of opioid poisonings. Our findings show that, until 2017, the opioid overdose epidemiology in the Paris area is different to that in the USA. The systematic analysis of data from the PCCs could be a good tool for health monitoring. To assess trends in France, a national study over a longer period would also be useful.

Fentanyl overdoses and pharmacogenetics

Fentanyl has been implicated as a major contributor to the increased number of opioid overdose deaths. Surprisingly, little is known about the pharmacogenetic influences on fentanyl pharmacokinetics or pharmacodynamics. Pharmacogenetic studies of fentanyl are based largely on small sample sizes and have examined the potential association of only a small number of high frequency variants in selected candidate genes primarily with postoperative pain. Few data are available on low frequency variants, variants from racially/ethnically diverse populations, or on other phenotypes. Given the genetic diversity of low frequency variants, DNA sequencing may be needed to determine whether pharmacogenetic differences may contribute to lethal opioid overdoses.

Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose

PURPOSE OF REVIEW

Effective responses to the US opioid overdose epidemic rely on accurate and timely drug overdose mortality data, which are generated from medicolegal death investigations (MDI) and certifications of overdose deaths. We identify nuances of MDI and certification of overdose deaths that can influence drug overdose mortality surveillance, as well as recent research, recommendations, and epidemiological tools for improved identification and quantification of specific drug involvement in overdose mortality.

RECENT FINDINGS

Death certificates are the foundation of drug overdose mortality surveillance. Accordingly, counts and rates of specific drug involvement in overdose deaths are only as accurate as the drug listed on death certificates. Variation in systematic approaches or jurisdictional office policy in drug overdose death certification can lead to bias in mortality rate calculations. Recent research has examined statistical adjustments to improve underreported opioid involvement in overdose deaths. New cause-of-death natural language text analysis tools improve quantification of specific opioid overdose mortality rates. Enhanced opioid overdose surveillance, which combines death certificate data with other MDI-generated data, has the potential to improve understanding of factors and circumstances of opioid overdose mortality.

SUMMARY

The opioid overdose crisis has brought into focus some of the limitations of US MDI systems for drug overdose surveillance and has given rise to a sense of urgency regarding the pressing need for improvements in our MDI data for public health action and research. Epidemiologists can stimulate positive changes in MDI data quality by demonstrating the critical role of data in guiding public health and safety decisions and addressing the challenges of accurate and timely overdose mortality measures with stakeholders. Education, training, and resources specific to drug overdose surveillance and analysis will be essential as the nation's overdose crisis continues to evolve.

Detection of fentanyl and fentanyl analogues in biological samples using liquid chromatography-high resolution mass spectrometry

BACKGROUND

Fentanyl and analogues such as butyrylfentanyl, carfentanil, 4-fluorobutyrylfentanyl, and furanylfentanyl may be either added to, or sold as, heroin. Fentanyl and carfentanil have approximately 100 and 10,000 times the potency of morphine, respectively, and there is thus a high risk of death with the use of these drugs.

METHODS

We looked for fentanyl/fentanyl analogues using liquid chromatography-high resolution mass spectrometry (LC-HRMS) in selected biological samples obtained post-mortem February 2017-end January 2018. Suspicion of fentanyl poisoning arose from the circumstances of death, a history of heroin use, and the geographical area in which the deceased was discovered, supplemented by drugs intelligence data.

RESULTS

Of the 84 deaths investigated, fentanyl and/or a fentanyl analogue were detected in 40 (48%). The fentanyls encountered were carfentanil (N = 17), fentanyl (9), carfentanil and fentanyl together (12), and fentanyl, carfentanil, 4-fluorobutyrylfentanyl, and butyrylfentanyl together (2). The median (range) post-mortem blood fentanyl concentration was 2.66 (0.21-107) μg/L and the median (range) carfentanil concentration was 0.24 (0.03-1.66) μg/L. The most prevalent compounds present together with fentanyls were ethanol [N = 28, median (range) post-mortem blood concentration: 44 (<10-249) mg/dL)], benzoylecgonine [N = 22, 0.64 (<0.05-3.17) mg/L] and free morphine [N = 20, 0.05 (<0.05-0.34) mg/L]. Deaths in hospital excluded, median blood free morphine, and ethanol concentrations were significantly lower in deaths where fentanyl/fentanyl analogues were present, but there was much overlap with the blood concentrations of these analytes in the non-fentanyl related deaths. A routine drugs of abuse assay using LC-HRMS identified fentanyl with 100% sensitivity and carfentanil with 89% sensitivity.

CONCLUSIONS

Given their potency, misuse of fentanyl and its analogues is likely to cause severe toxicity. A simple LC-HRMS method detected all cases in which fentanyl was identified post-mortem and most of the cases in which carfentanil was detected.

After NAS

Mothers have used opioids for thousands of years but neonatal abstinence syndrome (NAS) or rather, survivors of NAS, is a modern phenomenon. Unrecognized and/or untreated opioid withdrawal was almost always fatal but with greater awareness and standardization of treatment, NAS is now an uncommon direct cause of infant death. However, opioids are now increasingly accessible and potent and the outcomes of children after the neonatal period are of great concern, especially when coupled with multiple other social and health risks. Complex individual, environmental and genetic factors need to be considered when assessing outcomes or future research for babies with NAS. Any intervention or research efforts must address these multifactorial complexities. This review will discuss pertinent post neonatal outcomes, including mortality, physical and mental health and social functioning of children with a history of NAS.