Journal of analytical toxicology最新文献

Accidental overdose cases continue to rise due to the opioid epidemic in the USA, namely, the widespread availability and use of fentanyl. Medical examiners and coroners across the country have been subsequently burdened, and with limited resources, some seek alternative triaging processes to identify overdoses. Point-of-care urine dipstick testing at autopsy is one such idea that may be used in various ways to instigate or negate the need for an autopsy or regular forensic toxicology laboratory testing. This study investigated the frequency and estimated quantitative fentanyl and norfentanyl concentrations in the postmortem urine of fentanyl-related accidental overdose deaths, as well as the effectiveness of commercially available point-of-care urine dipstick tests based on such concentrations. A total of 1550 fentanyl-related accidental overdose cases, where both the postmortem peripheral femoral blood and urine were tested, were reviewed. Of these, using sensitive liquid chromatography-tandem mass spectrometry (LC-MS-MS) laboratory testing, 82 cases (5%) had a positive fentanyl or norfentanyl detection in the blood, while fentanyl or norfentanyl remained undetected in the urine. Furthermore, a comparison of commercially available urine dipstick test cut-offs and authentic casework with estimated urine concentrations revealed that at a fentanyl/norfentanyl cut-off level of 5 ng/mL, 19% of these fentanyl-related accidental overdoses would result in a false negative, 24% at 10 ng/mL, 25% at 20 ng/mL, 51% at 50 ng/mL, and 61% at 100 ng/mL. The study found that the use of urine dipstick tests, as a decision-maker for the initiation of further comprehensive routine toxicology laboratory testing, or to support cause and manner of death determination, leads to both false-positive and false-negative predictions in fentanyl accidental overdoses.

In recent years, the use of 2-benzylbenzimidazole opioids ('nitazenes') has increased with them becoming one of the most prominent synthetic opioid subclasses of novel psychoactive substances. With the increased prevalence, there is also a concern of the dangers to public health with the use of nitazenes due to their high potency especially with polypharmacy. To aid in the detection of such compounds, it is important that forensic toxicology laboratories maintain up-to-date compound libraries for drug screening methods and that sensitive analytical instrumentation is available to detect the low blood/plasma concentrations of more potent drugs. This includes not only the compounds themselves but also potential metabolites and/or degradation products. Metonitazene is a 'nitro-nitazene' with a nitro group at position 5 of the benzimidazole ring. As a nitro-nitazene, there is a potential for bacterial degradation of metonitazene to 5-aminometonitazene, as occurs with nitro-benzodiazepines. In this study, we provide evidence from a postmortem (PM) case of degradation of metonitazene in unpreserved PM blood using liquid chromatography-triple quadrupole mass spectrometry (LC-QQQ-MS), and putative identification of the degradation/metabolic products 5-aminometonitazene and 5-acetamidometonitazene by liquid chromatography-quadrupole time-of-flight mass spectrometry. The results from LC-QQQ-MS analysis indicated that there did not appear to be such degradation in preserved (fluoride/oxalate) blood. These results suggest that nitro-nitazenes may be subject to similar in vitro stability/degradation issues as nitro-benzodiazepines. These breakdown products should be added to instrument libraries to aid in the detection of the use of nitro-nitazenes, and nitro-nitazenes should be quantified in preserved blood samples where available.

Recently, etomidate has been widely used as an alternative in illicit drug market. It is usually added to regular cigarette tobacco (commonly known as "cigarette powder") or mixed in e-cigarette oil sold through the Internet, retail stores, or entertainment outlets and other channels. An ultra-high performance liquid chromatography tandem mass spectrometry method was developed to quantify etomidate and etomidate acid in human blood and urine. The limit of detection (LOD) of etomidate and etomidate acid in blood is 0.5  and 2 ng/mL, respectively, and the lower limit of quantification (LLOQ) is 1  and 5 ng/mL, respectively. The LOD of etomidate and etomidate acid in urine is 1 and 2 ng/mL, respectively, and the LLOQ is 2  and 5 ng/mL, respectively. The precision, accuracy, recoveries, and matrix effects of etomidate and etomidate acid determinations in blood and urine met the requirements for methodological validation. The method was successfully applied to the identification and quantification of etomidate and etomidate acid in blood and urine of 62 forensic cases. The concentration of etomidate ranged from 1.52 to 8.41 ng/mL (positive cases, n = 5) and the concentration of etomidate acid ranged from 2.76 to 112 ng/mL (positive cases, n = 5) in blood. The concentrations of etomidate and etomidate acid in urine samples were 2.64-79,300 ng/mL (positive cases, n = 59) and 6.11-518,000 ng/mL (positive cases, n = 60), respectively. Therefore, the concentration of etomidate in blood and urine is mostly higher than that of etomidate.

Novel benzodiazepine (NBz) detections in Victorian coronial cases started early in 2018 and have continued to increase in number and type up to December 2022. The 11 different NBz detections included etizolam (n = 82), flualprazolam (n = 43), clonazolam or 8-aminoclonazolam (n = 30), bromazolam (n = 15), clobromazolam (n = 13), phenazepam (n = 13), flubromazolam (n = 12), flubromazepam (n = 8), desalkylflurazepam (n = 6), diclazepam (n = 2), and estazolam (n = 1). The pattern of detections varied over the 5-year period, with different compounds appearing over different time frames. The most recent NBz to appear were bromazolam, clobromazolam, flubromazepam, and phenazepam, whereas etizolam had been seen regularly in case work since 2018. Of the total 133 deaths, 95 were considered drug-related deaths by forensic pathologists with at least one additional CNS depressant also present capable of contributing to death. All deaths involved other (non-benzodiazepine) CNS active drugs, although many involved multiple NBz, with five or more different benzodiazepines detected in eight cases.

With some exceptions, California Assembly Bill 2188 will preclude the use of ∆9-tetrahydrocannabinol-9-carboxylic acid (Δ9-THC-COOH) as a marker of cannabis use in urinary workplace drug testing. The bill allows for the use of psychoactive cannabis markers, which include Δ9-tetrahydrocannabinol (Δ9-THC) and the metabolite 11-hydroxy-Δ9-tetrahydrocannabinol (11-OH-Δ9-THC). Both analytes are present in urine mainly as conjugated metabolites and will require hydrolysis prior to analysis, but very little is known about expected concentrations in urine. The aim of this study was to report the concentrations from two large datasets comprising 1411 workplace drug-testing urine specimens that tested positive by immunoassay (50 ng/mL cutoff) and discuss strategies for using 11-OH-Δ9-THC and/or Δ9-THC to detect cannabis use. Median 11-OH-Δ9-THC and Δ9-THC concentrations were 28%-35% and 1.1%-1.6% of those of Δ9-THC-COOH, respectively, and correlations between the analytes were observed. To avoid the risk of positives from passive exposure, laboratories could use a cutoff with equivalent sensitivity to cannabis exposure. A 5 ng/mL cutoff for 11-OH-Δ9-THC showed 92% agreement with a 15 ng/mL cutoff for Δ9-THC-COOH, with only 0.9% of specimens being positive only for 11-OH-Δ9-THC. It was not possible to propose an estimated cutoff for Δ9-THC, due to the constraints of the limit of detection used in this study.

The designer benzodiazepine bromazolam is increasingly encountered in forensic casework, including impaired driving investigations. A series of suspected impaired driving cases that tested positive for bromazolam are described herein along with information about driving performance, driver appearance, and observed behavior. Bromazolam was indicated in casework either through screening by liquid chromatography-time of flight mass spectrometry (LC-TOF-MS) and/or a positive benzodiazepine immunoassay screen. Blood samples were forwarded for quantitative confirmatory analysis using a liquid chromatography-tandem mass spectrometry (LC-MS-MS) method with a reporting limit of 2.0 ng/mL. Bromazolam was reported in 98 impaired driving cases from samples reported between January 2021 and December 2023, with the earliest detection from September 2020. Mean and median blood concentrations were 125 ± 145 and 84 ng/mL respectively, with a range of 4.2-990 ng/mL. Additional positive findings were reported in almost all cases, with the highest result (990 ng/mL) being the only case in which bromazolam was the only finding. Fentanyl was the most frequent drug found in combination with bromazolam. Driving behaviors reported in these cases included erratic driving, errors in Standardized Field Sobriety Tests, and symptoms consistent with central nervous system depressants, including slurred speech, incoordination, and lethargic behavior. Based on its prevalence and demonstrated impairing effects, bromazolam should be included in the scope of impaired driving testing as long as it continues to be prevalent in the drug supply.

Protonitazene is a synthetic benzimidazole opioid of the nitazenes class, developed in the 1950s as an effective analgesic, but never released on the market due to severe side effects and possible dependence. Despite its increasing use as a new psychoactive substance starting in 2019, its detection in human hair of intoxicated and deceased consumers has never been reported. We present the development and validation of a specific procedure to identify protonitazene in hair by liquid chromatography with tandem mass spectrometry. Drugs were incubated overnight at 40°C in 1 mL borate buffer, pH 9.5 with 20 mg pulverized hair and 1 ng/mg fentanyl-d5 used as internal standard. Drugs were then extracted with a mixture of organic solvents. The chromatographic separation was performed using an HSS C18 column with a 15-min gradient elution. Linearity was verified from 1 to 100 pg/mg. The limit of detection was estimated at 0.1 pg/mg. No interference was noted from a large panel of natural and synthetic opioids, fentanyl derivatives, or other new synthetic opioids. Protonitazene was identified at 70 and >7600 pg/mg in the whole head hair specimens of two male subjects deceased from an acute drug overdose in jail. Protonitazene was also identified at 14 and 54 pg/mg in two living co-prisoners. As nitazenes represent a growing threat to public health in various parts of the world, this method was developed in response to the challenges posed by the identification of this class of substances.

One of the quickest-growing subclasses of novel psychoactive substances is novel synthetic opioids (NSOs), which are categorized as fentanyl analogs (fentalogs) or nonfentanyl opioids that bind to the mu-opioid receptor. Increased detections of NSOs have been observed in the USA. However, limited information on their prevalence outside of the East Coast is available. This study details the prevalence of NSOs, specifically fluorofentanyl, in the biological and drug paraphernalia specimens of accidental overdose deaths in San Francisco in 2022. A recently developed and validated liquid chromatography with tandem mass spectrometry method was utilized for the analysis of >250 NSOs. Out of the 649 accidental overdose deaths in 2022, 617 cases were available for blood analysis, with at least 1 NSO detected in 48 cases (7.8%). Fentalogs were detected in all 48 cases, with fluorofentanyl being detected in 40 cases. In postmortem femoral blood, estimated concentrations of fluorofentanyl ranged from 0.1 to 8.9 ng/mL, and 0.05 to 85 ng/mL in urine. Polysubstance use with NSO was seen with fentanyl (89.6%), methamphetamine (70.8%), cocaine (33.3%), and heroin (18.8%). NSOs, mainly fluorofentanyl, were observed in matched drug paraphernalia. This report documents the migration of fluorofentanyl to the West Coast, specifically California.

For the past 60 years, benzodiazepines such as chlordiazepoxide, diazepam, and alprazolam have been used as pharmaceutical medications for the treatment of myriad conditions including anxiety, seizures, and insomnia. In more recent years, novel benzodiazepine derivatives have emerged as illicit substances in powders and counterfeit tablets on the illicit drug market. In 2016, bromazolam, a brominated derivative of alprazolam, emerged on the illicit drug market in Europe, but the substance was not reported in the USA until 2019-2020. In this study, we report the emergence and subsequent prevalence of bromazolam in postmortem blood in the state of Indiana during 2023. Analysis was completed by a solvent protein precipitation extraction with acetonitrile and detection by liquid chromatography with quadrupole time of flight mass spectrometry. During 2023, bromazolam was detected in 94 cases across 25 counties in Indiana. It was never the sole substance detected and was commonly detected alongside fentanyl (83 cases), norfentanyl (77 cases), 4-anilino-N-phenethylpiperidine (76 cases), acetylfentanyl (49 cases), methamphetamine (32 cases), naloxone (25 cases), 11-nor-9-carboxy-tetrahydrocannabinol (24 cases), and benzoylecgonine (20 cases). After official query with the Indiana Department of Health, it was found that bromazolam was specifically included in the cause of death certification in 31 fatalities (32.9%). Due to the scarcity of information regarding this novel benzodiazepine derivative in postmortem toxicology and its involvement in fatalities, it is important that forensic toxicology laboratories consider adding bromazolam to their comprehensive scope of analysis.