Improvements in Toxicology Testing to Identify Fentanyl Analogs and Other Novel Synthetic Opioids in Fatal Drug Overdoses, Connecticut, January 2016–June 2019

2021 ◽  
Vol 136 (1_suppl) ◽  
pp. 80S-86S
Author(s):  
Heather A. Clinton ◽  
Shobha Thangada ◽  
James R. Gill ◽  
Amy Mirizzi ◽  
Susan B. Logan
Keyword(s):  
Drug Overdose ◽  
Drug Market ◽  
Medical Examiner ◽  
Testing Methods ◽  
Synthetic Opioids ◽  
Postmortem Toxicology ◽  
Drug Overdoses ◽  
Fentanyl Analogs ◽  
Novel Synthetic Opioids ◽  
Overdose Deaths

Objectives Drug overdose deaths in Connecticut increasingly involve a growing number of fentanyl analogs and other novel nonfentanyl synthetic opioids (ie, novel synthetics). Current postmortem toxicology testing methods often lack the sophistication needed to detect these compounds. We examined how improved toxicology testing of fatal drug overdoses can determine the prevalence and rapidly evolving trends of novel synthetics. Methods From 2016 to June 2019, the Connecticut Office of the Chief Medical Examiner increased its scope of toxicology testing of suspected drug overdose deaths in Connecticut from basic to enhanced toxicology testing to detect novel synthetics. The toxicology laboratory also expanded its testing panels during this time. We analyzed toxicology results to identify and quantify the involvement of novel synthetics over time. Results From 2016 to June 2019, 3204 drug overdose deaths received enhanced toxicology testing; novel synthetics were detected in 174 (5.4%) instances. Ten different novel synthetics were detected with 205 total occurrences. Of 174 overdose deaths with a novel synthetic detected, most had 1 (n = 146, 83.9%) or 2 (n = 26, 14.9%) novel synthetics detected, with a maximum of 4 novel synthetics detected. Para-fluorobutyrylfentanyl/FIBF, furanylfentanyl, and U-47700 were most identified overall, but specific novel synthetics came in and out of prominence during the study period, and the variety of novel synthetics detected changed from year to year. Conclusions Enhanced toxicology testing for drug overdose deaths is effective in detecting novel synthetics that are not identified through basic toxicology testing. Identifying emerging novel synthetics allows for a timely and focused response to potential drug outbreaks and illustrates the changing drug market.

scholarly journals Improving risk factor identification for opioid overdose deaths in Tennessee

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Sarah J. Nechuta ◽  
Jenna Moses ◽  
Molly Golladay ◽  
Adele Lewis ◽  
Julia Goodin ◽  
...  
Keyword(s):  
Risk Factor ◽  
Drug Overdose ◽  
Medical Examiner ◽  
Prescription Opioid ◽  
Opioid Overdose ◽  
Prescription Opioids ◽  
Death Certificates ◽  
Postmortem Toxicology ◽  
Icd 10 ◽  
Overdose Deaths

ObjectiveTo examine specific drugs present based on postmortem toxicology for prescription opioid, heroin, and fentanyl overdoses classified based on ICD-10 coding. To compare drugs identified from postmortem toxicology with those listed on the death certificate for opioid overdoses.IntroductionUsing death certificates alone to identify contributing substances in drug overdose deaths may result in misclassification and underestimation of the burden of illicit and prescription opioids and other drugs in drug-related deaths. To enable timely and targeted prevention in Tennessee (TN), the identification and monitoring of new drugs and trends in use should utilize toxicology and medicolegal death investigation data directly, as recommended by others 1-3. These data can inform mortality outcome definitions for improved surveillance and risk factor identification 4-7. To our knowledge, this is the first analysis to use statewide linked toxicology and death certificate data in TN.MethodsWe identified 615 opioid involved overdose deaths in TN of unintentional (underlying ICD-10 codes: X40-X44) or undetermined (underlying ICD-10 codes: Y10-Y14) intent during June 1st to December 31st 2017. Utilizing the Interim Medical Examiner Database (I-MED), we identified postmortem toxicology reports for 454 cases, which were from one of three national laboratories used by a state Regional Forensic Center. Toxicology data were abstracted and independently verified by two co-authors and linked to the TN death statistical file that included cause of death information (literal text and ICD-10 codes) and demographics. The analysis focuses on cases with an available toxicology report.ResultsWe identified 171 prescription opioid overdoses, 221 fentanyl overdoses, and 113 heroin overdoses. Table 1 displays postmortem toxicology profiles for major drugs/classes. For prescription opioid deaths (excluding fentanyl and heroin), positive toxicology results for prescription opioids were as follows: methadone (11%), buprenorphine (14%), hydrocodone (14%), oxycodone (36%) and oxymorphone (also a metabolite, 47%). Benzodiazepines were present in close to 58% of prescription opioid overdoses; stimulants (cocaine, amphetamines, methamphetamines) in about 25%. For fentanyl and heroin deaths, prescription opioids were detected in about 26% and 34%, respectively; stimulants in about 57.9% and 52.2%, respectively, and benzodiazepines 36-37%. Fentanyl was present on toxicology in about half of heroin overdoses, and 6–monoacetylmorphine in 72.6%.ConclusionsUsing medical examiners’ data, including toxicology data, improves estimation of contributing drugs involved in opioid deaths. This analysis provides jurisdiction-specific data on drugs that can help with monitoring trends and informs risk factor identification. Future work includes adding information on prescribed opioid and benzodiazepines using TN’s Prescription Drug Monitoring Database and evaluating demographic variation in contributing drugs between toxicology and DC data to identify susceptible populations.References1. Slavova S, O'Brien DB, Creppage K, Dao D, Fondario A, Haile E, Hume B, Largo TW, Nguyen C, Sabel JC, Wright D, Council of S, Territorial Epidemiologists Overdose S. Drug Overdose Deaths: Let's Get Specific. Public Health Rep.2. Horon IL, Singal P, Fowler DR, Sharfstein JM. Standard Death Certificates Versus Enhanced Surveillance to Identify Heroin Overdose-Related Deaths. Am J Public Health. 2018;108(6):777-81.3. Mertz KJ, Janssen JK, Williams KE. Underrepresentation of heroin involvement in unintentional drug overdose deaths in Allegheny County, PA. J Forensic Sci. 2014;59(6):1583-5.4. Landen MG, Castle S, Nolte KB, Gonzales M, Escobedo LG, Chatterjee BF, Johnson K, Sewell CM. Methodological issues in the surveillance of poisoning, illicit drug overdose, and heroin overdose deaths in new Mexico. Am J Epidemiol. 2003;157(3):273-8.5. Davis GG, National Association of Medical E, American College of Medical Toxicology Expert Panel on E, Reporting Opioid D. Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. J Med Toxicol. 2014;10(1):100-6.6. Slavova S, Bunn TL, Hargrove SL, Corey T. Linking Death Certificates, Postmortem Toxicology, and Prescription History Data for Better Identification of Populations at Increased Risk for Drug Intoxication Deaths. Pharmaceutical Medicine. 2017;31(3):155-65.7. Hurstak E, Rowe C, Turner C, Behar E, Cabugao R, Lemos NP, Burke C, Coffin P. Using medical examiner case narratives to improve opioid overdose surveillance. Int J Drug Policy. 2018;54:35-42. 

Drug overdose deaths at work, 2011–2016

2019 ◽  
Vol 25 (6) ◽  
pp. 577-580 ◽  
Author(s):  
Hope M Tiesman ◽  
Srinivas Konda ◽  
Lauren Cimineri ◽  
Dawn N Castillo
Keyword(s):  
Drug Overdose ◽  
Negative Binomial ◽  
Occupational Injuries ◽  
Negative Binomial Regression ◽  
Opioid Overdose ◽  
Full Time ◽  
Demographic Groups ◽  
Drug Overdoses ◽  
The Impact ◽  
Overdose Deaths

Drug overdose fatalities have risen sharply and the impact on US workplaces has not been described. This paper describes US workplace overdose deaths between 2011 and 2016. Drug overdose deaths were identified from the Census of Fatal Occupational Injuries and fatality rates calculated using denominators from the Current Population Survey. Fatality rates were compared among demographic groups and industries. Negative binomial regression was used to analyse trends. Between 2011 and 2016, 760 workplace drug overdoses occurred for a fatality rate of 0.9 per 1 000 000 full-time equivalents (FTEs). Workplace overdose fatality rates significantly increased 24% annually. Workplace overdose fatality rates were highest in transportation and mining industries (3.0 and 2.6 per 1 000 000 FTEs, respectively). One-third of workplace overdose fatalities occurred in workplaces with fewer than 10 employees. Heroin was the single most frequent drug documented in workplace overdose deaths (17%). Workplace overdose deaths were low, but increased considerably over the six-year period. Workplaces are impacted by the national opioid overdose epidemic.

scholarly journals Emerging Synthetic Fentanyl Analogs

2017 ◽  
Vol 7 (1) ◽  
pp. 36-40 ◽  
Author(s):  
Harold E. Schueler
Keyword(s):  
Illicit Drug ◽  
Forensic Toxicology ◽  
Drug Market ◽  
Medical Examiner ◽  
The Internet ◽  
Blood Concentrations ◽  
Fentanyl Analogs ◽  
Femoral Blood ◽  
Drug Traffickers ◽  
Death Investigation

Hundreds of synthetic substances have been introduced into the illicit drug market over the last ten years, but none of these drugs has had as poisonous a consequence as the emergence of the synthetic fentanyl analogs. Initially, pharmaceutical grade or illicit fentanyl was mixed with heroin, allegedly to boost the potency of the heroin. Then, the amounts of fentanyl spiked gradually increased until the proportion of fentanyl was greater than the proportion of heroin. Ultimately, many overdose cases began consisting of only fentanyl. The emergence of numerous synthetic fentanyl analogs, including acetylfentanyl, butyrylfentanyl, acrylfentanyl, furanylfentanyl and β-hydroxythiofentanyl, which are manufactured in China, were made available to the illicit drug traffickers over the Internet. In July of 2016, the most potent commercially available opioid, carfentanil, started appearing in illicit drug submissions and medical examiner death investigation cases in Northeast Ohio. Postmortem femoral blood carfentanil concentrations are in the picogram per milliliter (pg/mL) range, which is extremely low, and tests the limits of detection for most analytical forensic toxicology laboratories. The interpretation of these low carfentanil blood concentrations in antemortem and postmortem specimens is made difficult due to the overlap in the concentrations between these specimen types. The presence of these powerful synthetic fentanyl analogs presents a challenge to forensic toxicology laboratories preparing to analyze for these substances.

Accidental Overdose Deaths in Oklahoma, 2002–2017: Opioid and Methamphetamine Trends

2020 ◽  
Vol 44 (7) ◽  
pp. 672-678
Author(s):  
Rachel Bonk ◽  
Ross J Miller ◽  
Joshua Lanter ◽  
Cheryl Niblo ◽  
Jesse Kemp ◽  
...  
Keyword(s):  
Drug Overdose ◽  
Sharp Increase ◽  
The State ◽  
Prescription Opioids ◽  
Opioid Epidemic ◽  
Death Rates ◽  
Synthetic Opioids ◽  
Accidental Overdose ◽  
Overdose Deaths

Abstract To evaluate trends related to accidental overdose deaths in Oklahoma, with a focus on opioids and methamphetamine. All accidental drug overdose deaths in the state of Oklahoma from 2002 to 2017 were reviewed. Opioids were grouped into the following categories: all opioids, prescription opioids, synthetic opioids and heroin. Age-adjusted death rates for methamphetamine and each opioid category were calculated and analyzed. Accidental overdoses accounted for 9,936 deaths during the study period. Of these, opioids were seen in 62.9%, with prescription opioids comprising 53.8%, synthetic opioids 10.3% and heroin 2.8%. Synthetic opioids, despite a recent upward nationwide trend, showed a slight overall decrease (−6.8%) from 2009 to 2017. In contrast, methamphetamine showed a 402.2% increase from 2009 to 2017 and an overall increase of 1,526.7%. Methamphetamine was involved in the most overdoses (1,963), followed by oxycodone (1,724). Opioid-related deaths were most common among white individuals (90.3%) and showed a slight male predilection (56.9%). With the intent of assessing the opioid epidemic as it relates to accidental overdoses in Oklahoma, this study suggests that opioid-related overdoses have slowed in recent years amidst a sharp increase in methamphetamine deaths.

scholarly journals Fentanyl, fentanyl analogs and novel synthetic opioids: A comprehensive review

2018 ◽  
Vol 134 ◽  
pp. 121-132 ◽  
Author(s):  
Patil Armenian ◽  
Kathy T. Vo ◽  
Jill Barr-Walker ◽  
Kara L. Lynch
Keyword(s):  
Comprehensive Review ◽  
Synthetic Opioids ◽  
Fentanyl Analogs ◽  
Novel Synthetic Opioids

scholarly journals Impact of a Drug Overdose Decedent Toxicology Testing Legislative Mandate on Informing Coroner Death Investigation and Certification Practices

2019 ◽  
Vol 9 (1-2) ◽  
pp. 66-80
Author(s):  
Dana Quesinberry ◽  
Terry L. Bunn ◽  
Sarah Hargrove ◽  
Svetla Slavova
Keyword(s):  
Drug Overdose ◽  
Policy Implication ◽  
Influence Factors ◽  
Death Certificates ◽  
Postmortem Toxicology ◽  
Poisoning Deaths ◽  
Death Investigation ◽  
The Impact ◽  
Overdose Deaths ◽  
And Training

Objective: To (a) determine the impact of Kentucky’s (KY’s) mandate requiring postmortem toxicology testing of coroner cases; (b) identify the influence of coroner experience and training, jurisdiction size, budget, and location on postmortem testing requests; (c) identify facilitators/barriers for postmortem toxicology testing requests and listing the specific drugs involved in drug-poisoning deaths on death certificates. Methods: A modified Dillman approach was used to deliver the survey to KY’s elected coroners between April and May 2016. Responses stratified by identified influence factors were compared using χ2 tests and Fisher exact tests. Results: Fifty-eight percent of coroners reported that drug overdose investigations had changed since the mandate was enacted. Statistically significant differences in responses were found when stratified. Sixty-three percent of coroners reported always using testing results to complete death certificates. Conclusions: Uptake of the mandate for postmortem toxicology testing of all decedents is not yet complete. Policy Implication: Without uptake of the mandate, surveillance efforts may result in undercounting of drug overdose deaths and the involvement of specific drugs. Mandates for enhanced training and modification of funding structure for medico-legal death investigations could facilitate uptake.

scholarly journals Novel Synthetic Opioids and Overdose Deaths: Tip of the Iceberg?

2017 ◽  
Vol 43 (1) ◽  
pp. 216-217 ◽  
Author(s):  
Michael H Baumann ◽  
Gavril W Pasternak
Keyword(s):  
Synthetic Opioids ◽  
Novel Synthetic Opioids ◽  
Overdose Deaths

scholarly journals Adolescent prescription opioid misuse, illicit opioid use and overdose

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Michele K. Bohm ◽  
Heather Clayton
Keyword(s):  
Dose Response ◽  
Drug Overdose ◽  
Prescription Opioids ◽  
Response Relationship ◽  
Opioid Use ◽  
Dose Response Relationship ◽  
Heroin Use ◽  
Synthetic Opioids ◽  
Overdose Deaths ◽  
Illicit Opioid Use

ObjectiveGiven the evolving opioid overdose epidemic, we examined the interrelationships between nonmedical use of prescription opioids and illicit opioid use in adolescents.IntroductionThe number of overdose deaths involving illicit opioids such as heroin and illicitly-manufactured fentanyl (IMF) is now higher than deaths involving prescription opioids. Adolescents misusing prescription opioids are more likely to use heroin. Although nonmedical use of prescription opioids (NUPO) among adolescents is decreasing,there is still relatively high prevalence of this behavior. Such high prevalence, along with the evolving epidemiology of the drug overdose epidemic as well as the association between NUPO and heroin use, signal that NUPO in adolescents is still an important issue. Understanding the interrelationships between NUPO and illicit opioid use in adolescents can inform prevention efforts. The purpose of this study is to: 1) present the magnitude of the drug overdose problem in adolescents, 2) compare the prevalence of heroin use and injection drug use (IDU) between students reporting NUPO and those not reporting NUPO, and 3) determine whether a dose-response relationship exists between these behaviors among adolescents. This information will be beneficial when focusing on adolescents at risk for heroin use by helping to determine whether any NUPO is associated with heroin use or if such risk is only noted at a higher frequency of NUPO behavior.MethodsWe analyzed data from two surveillance sources to capture adolescent overdose mortality and behavioral risk factors. Overdose death data for decedents aged 15 to 19 years were obtained for 2010 and 2016 from CDC WONDER, an online database with national mortality data based on death certificates for U.S. residents. We identified deaths involving prescription and illicit opioids using International Classification of Disease, 10th revision (ICD-10) codes for drug overdose deaths. Each death is assigned one underlying cause of death code and the following identified overdoses: X40-44 (unintentional), X60-64 (intentional), X85 (homicide), or Y10-14 (undetermined intent). Additionally, for overdose deaths attributed to specific drugs or drug categories, ICD-10 multiple cause of death codes were used to determine the number of deaths involving any opioid, either prescription or illicit (T40.1-T40.4 and T40.6), prescription opioids (T40.2 or T40.3), heroin (T40.1), and heroin and/or synthetic opioids (e.g., fentanyl) excluding methadone (T40.1 or T40.4). We compared the proportion of overdose deaths involving prescription opioids that also involved heroin or synthetic opioids in 2010 and 2016. The second data source, the 2017 national Youth Risk Behavior Survey (YRBS), a nationally representative cross-sectional survey of high school students, was analyzed to look at behavioral risk factors. We assessed lifetime NUPO (LNUPO) and calculated frequency of LNUPO by heroin use, injection drug use (IDU), and heroin/IDU using logistic regression models to generate adjusted prevalence ratios (aPR) and corresponding 95% confidence intervals (CI). We used linear contrast analysis to determine dose-response relationships between frequency of LNUPO and heroin use, IDU and heroin/IDU.ResultsThe number of adolescents aged 15 to 19 years who died of drug overdose increased from 831 in 2010 (3.8 per 100,000) to 873 in 2016 (4.1 per 100,000). While the proportion of overdose deaths involving prescription opioids declined during this time period, the proportion involving heroin and/or synthetic opioids, such as fentanyl increased. In 2016, two-thirds of overdose deaths among decedents aged 15 to 19 years involved either a prescription or illicit opioid. The percent of deaths involving prescription opioids that also involved heroin and/or synthetic opioids, such as fentanyl increased from 5% in 2010 to 25% in 2016. Using the 2017 YRBS sample, we estimate that 14% of high school students nationwide have ever used prescription opioids nonmedically in their lifetime. Compared to students reporting no LNUPO, students reporting LNUPO were more likely to report heroin use (9.2% vs. 0.4%), IDU (7.8% vs. 0.4%), and heroin/ IDU (10.1% vs. 0.7%). We observed a positive dose-response relationship with frequency of LNUPO. Adjusted prevalence ratios for heroin, IDU and heroin/IDU increased with increasing frequency of LNUPO and were even significantly higher among those reporting just one or two occasions of LNUPO than among those reporting no LNUPO.ConclusionsOur findings on opioid-involved drug overdose mortality and opioid use patterns confirm NUPO is still a concern for adolescents. We report a five-fold increase, from 2010 to 2016, in the percent of adolescent overdose deaths involving prescription opioids that also involved illicit opioids such as heroin and/or IMF. This may reflect deliberate polysubstance use among adolescents using prescription opioids nonmedically, but should also be considered in the context of stable prevalence of reported heroin use in YRBS and the National Survey on Drug Use and Health. In addition to issues with self-report bias, adolescents may not self-identify as a person who uses heroin, for example, if they unknowingly use counterfeit prescription pills that contain heroin or IMF. Health risk behaviors established in adolescence often continue into young adulthood and understanding associations between opioid initiation, misuse, and overdose is critical for prevention efforts. Although we found a dose-response relationship between the frequency of LNUPO and the prevalence of heroin and IDU, we also report significantly higher heroin use and IDU among students reporting just one or two occasions of LNUPO compared to students reporting no LNUPO. This underscores the importance of prevention efforts aimed at all adolescents who use prescription opioids nonmedically, with particular emphasis on those frequently misusing them. Clinical, community, and school-based efforts can address NUPO, noting these associations. 

scholarly journals The Opioid Epidemic: Moving Toward an Integrated, Holistic Analytical Response

2018 ◽  
Vol 43 (1) ◽  
pp. 1-9 ◽  
Author(s):  
Jayne B Morrow ◽  
Jeri D Ropero-Miller ◽  
Megan L Catlin ◽  
Agnes D Winokur ◽  
Amy B Cadwallader ◽  
...  
Keyword(s):  
Law Enforcement ◽  
Real Time ◽  
Drug Toxicity ◽  
Analytical Data ◽  
Medical Examiner ◽  
Opioid Epidemic ◽  
Potential Health ◽  
Synthetic Opioids ◽  
Analytical Response ◽  
Novel Synthetic Opioids

Abstract In many jurisdictions, public safety and public health entities are working together to enhance the timeliness and accuracy of the analytical characterization and toxicology testing of novel synthetic opioids. The improved sharing and early detection of these analytical data are intended to inform surveillance, interdiction efforts, patient intervention and treatment, all of which are critical to curbing the opioid epidemic. Forensic practitioners working to identify novel synthetic opioids struggle to provide timely results when encountering new or unknown substances, such as the fentanyl analogs. These compounds, which mimic heroin in pharmacologic effect but can be far more potent, are inconsistently present in chemical identification libraries, and are currently largely unavailable as reference materials for analytical comparison. Additionally, federal, state and local governments as well as nongovernmental organizations require potency, toxicity and potential-for-abuse data to evaluate the potential health risks of emerging drug threats. Subsequent scheduling efforts and criminal prosecutions also require these thorough drug characterization studies. Pilot programs have demonstrated that early communication of real-time drug toxicity and analytical data significantly impacts the successful response to emerging opioids. High-quality, real-time, national-level data on chemical composition, toxicological test data, drug toxicity and overdoses, and analysis of seized materials by law enforcement are needed to track drug trends. However, the USA still lacks a national system to coordinate and communicate toxicology, medical and medical examiner and coroner data with the broader medical and law enforcement communities. Opportunities to address these gaps as well as recent advancements collected through interagency efforts and technical workshops in the toxicology and analytical chemistry communities are presented here. Opportunities for partnership, increased communication and expanding best practices to move toward an integrated, holistic analytical response are also explored.

scholarly journals Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health

2019 ◽  
Vol 16 (2) ◽  
pp. 177 ◽  
Author(s):  
Barbara Lovrecic ◽  
Mercedes Lovrecic ◽  
Branko Gabrovec ◽  
Marco Carli ◽  
Matteo Pacini ◽  
...  
Keyword(s):  
Public Health ◽  
Current Knowledge ◽  
Drug Market ◽  
Progressive Increase ◽  
Designer Drugs ◽  
New Psychoactive Substances ◽  
Opioid Overdose ◽  
Synthetic Opioids ◽  
Psychoactive Effects ◽  
Novel Synthetic Opioids

Background: In the last decade there has been a progressive increase in the use of new psychoactive substances (NPSs) that are not yet under international control. In particular, novel synthetic opioids (NSOs) have reappeared on the recreational drug market in the last few years. As a result, the use of NSOs has increased rapidly. This poses an emerging and demanding challenge to public health. Aim: To raise awareness among clinicians and other professionals about NPSs, especially NSOs, to summarize current knowledge about pharmacological properties, forms of NSO on the market, pattern of use, effects and consequences of use. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms. Results: Some NPSs are already controlled, while others can be legally sold directly on the drug market (mainly via internet, less so by drug dealers) or be used as precursors for the synthesis of other designer drugs that mimic the psychoactive effects of controlled substances. Potential side-effects of NSOs include miosis, sedation, respiratory depression, hypothermia, inhibition of gastrointestinal propulsion, death (from opioid overdose). Conclusions: The severity of the opioid crisis has intensified with the introduction of highly potent NSOs on the drug market. As long as addicts are dying from overdose or similar causes, there is something more constructive to do than waiting for addicts to overdose on heroin at a place located near a remedy, as if to say, within reach of naloxone.

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