Poster Presentation: Examination of Several Cases of Mitragynine Toxicity Resulting in Death From 2020-2023
By Stuart Kurtz, D-ABFT-FT,
This past October, I travelled to the annual meeting for the National Association of Medical Examiners (NAME) with our CEO, Phil Roberts, in San José, CA. While there, we had the pleasure of meeting with several of you and discussing how to best serve you and your offices going forward. We always look forward to these conversations both at conferences like NAME and throughout the year as your needs change.
This year I presented a poster that looked at 5 cases of mitragynine overdoses. Details of these cases were provided by the following offices and we thank them for their contributions.
Examination of Several Cases of Mitragynine Toxicity Resulting in Death From 2020-2023
- Office of the District Medical Examiner, District 15 FL, Dr. Wendolyn Sneed
- Office of the Coroner, Lorain County, OH, Dr. Frank P. Miller
- Forensic Medicine and Pathology, Big Horn County, WY, Dr. Thomas L. Bennett
- Office of the Coroner Stark County, OH, Dr. Ronald R. Rusnak
- St. Luke’s Hospital, IA, Dr. Ned Austin
Mitragynine is the primary alkaloid in the kratom plant. While not federally scheduled, some states have restrictions in place on the sale of kratom. At low doses, mitragynine acts as a “cocaine-like” stimulant while at higher doses users report “opioid-like” effects. An important thing to remember is that while mitragynine has activity at the mu opioid receptor, it does NOT affect the β-arrestin pathway. This is responsible for respiratory depression associated with compounds such as fentanyl, morphine, and the nitazenes.
There is no clinical data available for mitragynine so therapeutic, toxic, and fatal ranges are unknown. DUID case reports have found a range of 11-490 ng/mL. Internally, our cases have a median concentration of 76.4 ng/mL. Case circumstances and scene investigation are important in the interpretation of mitragynine levels. Low concentrations of mitragynine in blood are typically not of concern but we are happy to assist in the interpretation of the results.
Mitragynine is often not included in routine toxicology testing and most emergency departments, due to the nature of their testing procedures, will also not test for it. Comprehensive panels such as Axis’ Comprehensive Panel with Analyte Assurance™ will typically include testing for it. Because of the loose regulations regarding the sale of kratom, labelled bags of plant material or bottles of capsules can be identified at the scene. This can be vital in guiding testing recommendations if it’s suspected that it could be involved.
Please reach out to us if you have any questions regarding this poster, kratom in general, or interpretation of results for a case involving mitragynine. We can be reached at 317-759-4869 option 3 or toxicologist[email protected]. We can email a copy of the poster upon request
By Kevin Shanks, M.S., D-ABFT-FT
As mentioned in previous blog posts, novel psychoactive substances (NPS) come in different varieties and the Novel Emerging Compounds (NEC) Panel offered by Axis Forensic Toxicology helps to detect the most newly emerged NPS on the drug market and is meant to evolve over time as new drugs emerge on the street. In this series, we have taken a look at the recently emerged substances bromazolam, flubromazepam, alpha-PiHP, N,N-dimethylpentylone, phenibut, and tianeptine. In this fourth and final post in the series, we will take a brief look at two more recently emerged opioids: AP-237 and brorphine.
AP-237, also known as 1-butyryl-4-cinnamylpiperazine or Bucinnazine, is an opioid analgesic substance that is used as a prescription medication in China to treat pain. AP-237 is considered to be equipotent to morphine as an analgesic. AP-237 and a methylated derivative, 2-methyl-AP-237, recently emerged on the illicit drug market in the United States. AP-237 is currently unscheduled in the United States and not considered a controlled substance.
Brorphine is an opioid substance that was originally synthesized in 2018 by researchers who were investigating various opioids with the intention of finding safer analgesics that produce less respiratory depression than the typical prescription opioids used as medications. Brorphine was first detected on the illicit drug market in the United States in 2019 – 2020, but now has also been found in Europe. It is currently controlled as a Schedule I controlled substance in the United States.
Both of these substances function as opioid receptor agonists in the human body. Similar to other opioids, such as morphine and fentanyl, they bind to opioid receptors in the central nervous system (brain and spinal cord) and produce an analgesic effect. In overdose, they may cause severe central nervous system depression to include respiratory depression. When the breathing slows down, apnea can occur. Apnea leads to hypoxia – or lack of oxygen distribution to the surrounding tissues including the brain. Hypoxia can lead to cardiac arrest and death.
Axis qualitatively monitors both of these compounds in our NEC panel (order code 13710) and Comprehensive Panel, Blood with Analyte Assurance (order code 70510) using liquid chromatography with quadrupole time of flight mass spectrometry (LC-QToF-MS). Over the time range 01/30/2023 – 06/30/2023, Axis did not detect AP-237, but did detect brorphine in 1 blood specimen in Indiana. In Axis Forensic Toxicology casework, brorphine was detected alongside diphenhydramine, clonazolam, acetylfentanyl, fentanyl, morphine, 6-acetylmorphine, butonitazene, isotonitazene, metodesnitazene, metonitazene, and protonitazene.
As you can see from the prevalence data, both AP-237 and brorphine are rarely detected in blood by the toxicology laboratory, but it is still vital that we monitor them for the immediate future as NPS are a geographical and temporal phenomenon.
Axis also monitors other NPS in the following available panels of testing.
- The Novel Psychoactive Substances panel (order code 13610) include 25B-NBOMe, 25C-NBOMe, 25I-NBOMe, 2C-B, 2C-E, 2C-I, 5-MeO-DALT, adinazolam, alpha-PVP, butylone, clonazolam, dibutylone, dimethylone, ethylone, etizolam, eutylone, flualprazolam, flubromazolam, MDPV, mephedrone, methcathinone, methedrone, methoxetamine, methylone, N-ethylpentylone, pentylone, and TFMPP.
- The Designer Opioids panel (order code 13810) includes 4-ANPP, acetylfentanyl, acrylfentanyl, betahydroxythiofentanyl, butyrylfentanyl, carfentanil, cis-3-methylfentanyl, cyclopropylfentanyl, furanylfentanyl, isobutyrylfentanyl, methoxyacetylfentanyl, ocfentanil, parafluorobutyrylfentanyl, parafluoroisobutyrylfentanyl, tetrahydrofuranfentanyl, and U-47700.
- The Nitazenes Analog panel (order code 13910) includes butonitazene, etodesnitazene, etonitazene, flunitazene, isotodesnitazene, isotonitazene, metodesnitazene, metonitazene, N-pyrrolidinoetonitazene, and protonitazene.
As always, if you have questions about these substances and how they may play a role in your medical-legal investigation, please reach out to our subject matter experts by email ([email protected]) or phone (317-759-4869, Option 3).
By Denise Purdie Andrews
This October, Axis’ expert toxicologists can be found speaking in multiple venues, helping to educate our clients and share expertise with other forensic scientists.
At the upcoming National Association of Medical Examiner (NAME) 2023 Annual Meeting, which will be held in San Jose, California, from October 13-17, toxicologist Stuart Kurtz will be presenting a poster, Examination of Several Cases of Mitragynine Toxicity Resulting in Death From 2020-2023. Axis’ CEO, Phil Roberts, will also be in attendance to answer your product and service questions.
Shortly thereafter, the Society of Forensic Toxicology (SOFT) 2023 Conference will be held October 29 – November 3 in Denver, Colorado. Toxicologist Kevin Shanks will be making a poster presentation, Detection of the Substituted Cathinone Alpha-PiHP in Postmortem Toxicology Cases. Toxicologist Stuart Kurtz will also be in attendance at this event.
We will be sharing more information about the content of these posters in the coming months. If you have the good fortune to attend one of these sessions, please connect with your Axis experts. We’d like to thank you for your business and ensure that we are continuing to serve you well!
By Stuart A. K. Kurtz, M.S., D-ABFT-FT
Forensic science has always been the field I wanted to work in. I made my parents buy me a book at the Scholastic Book Fair in 3rd grade on forensic science. From there, I started looking at what areas interested me the most. I also loved chemistry so decided I would work as a drug chemist working with seized materials. While at IUPUI for grad school, I took a class with Kevin Shanks on designer drugs and knew that’s what I wanted to do.
Forensic toxicology combines many different aspects but the one that sticks out to me the most is science communication. I think that is the most impactful part of what I do. I have to be able to explain how we got the results including all steps from receiving a case, the review and release of the case, and, most importantly, what the results mean and don’t mean. Lawyers, juries, families, investigators, coroners, medical examiners, and pathologists all have very different levels of understanding when it comes to forensic toxicology. I have to be able to cater my explanations to each person and make sure that I am meeting them where they are in terms of their understanding.
Being able to talk to families and help them understand is my favorite part even if it is difficult at times to talk to someone experiencing tragedy. It can be as important to explain what something doesn’t mean as it is to explain what it does mean. Sometimes a family wants to pursue certain testing because they think it will give them the answers they need. I explain as well as I can the reasons for and against pursuing the testing. We never want to practice toxicology in a vacuum so I make sure to explain whether I can or cannot interpret the results and why. Ultimately, I want the results to be able to provide information that leads to the best closure possible for families.
Chief Deputy Coroner Alfarena McGinty of the Marion County IN Coroner’s Office came and gave a very moving presentation on her experiences and how that affects her daily work. She says, “We speak for the dead but we serve the survivors.” I say, “Behind every case there is a person. Behind every person there is a family.” Both of these mantras get at the fact that the families are central to how she and I go about our days in our respective jobs. While we arrived at those mantras separately, we have similar experiences that lead us there.
An old colleague of our Lab Director and Chief Toxicologist Dr. Behonick said to him “Someone has to make sense out of all this mess.” My goal is to help gather information that can be used to help the survivors make sense of the mess. No one person can clean up the mess but I can do my best to help others understand it.
By Kevin G. Shanks, M.S., D-ABFT-FT
I always had an interest in science and math at a young age. And for some reason, I was enamored with drugs and poisons too. Some of my favorite television shows as a teenager were Murder She Wrote and Quincy, M.E. – yes, I know I’m showing my age there. I also watched the now dreaded CSI television shows, including ever sunglasses-wearing Horatio in Miami. I also was a big fan of Agatha Christie or any work that involved poisons. Yes, I was (and still am) a big nerd.
My first role in the laboratory years ago was doing the analytical testing on a pharmaceutical drug: a urinary tract medication that had three active ingredients (methenamine, phenylsalicylate, and hyoscyamine). The pharmaceutical company had outsourced the regulated testing to my former lab and we had to test the tablets for regulatory compliance, which included content uniformity and testing for excipients and degradation in simulated gastric and intestinal fluids. It was very boring, monotonous work, but I learned a lot during that first year including how to make simulated gastric and intestinal fluid, which was quite interesting. I operated HPLC, flame photometers, and UV-VIS instruments. I also learned I didn’t like GMP testing very much. Just think of all the documentation you have to do in your job every day (it’s a lot, I know) and then multiply that by 1,000,000. I’m not joking. It was actually pretty stressful work too as it was all FDA-regulated work so we had multiple instances of FDA inspectors in the lab to watch us do the testing. And those FDA inspectors (at least the ones I’ve met) aren’t the nicest of people. After a year, an opportunity arose in method development and validation and I jumped at it. A few years went by and I got my hands on a LC-ToF in 2006 and I was hooked at that point. We became the first production forensic toxicology lab in the country to utilize an LC-ToF in screening. Around that time I also acquired the duty of handling the non-routine casework in the lab – things like syringes, tablets, liquids, drug paraphernalia, seized drug evidence, and foodstuffs. Also, another duty was developing methods for drugs that neither we nor a reference lab had a method for. A few more years later and a forensic toxicologist position opened up and I happily took it and as they say, that’s all she wrote. I’ve been in an official forensic toxicologist position for the last 12 years. If you ever want to know more, I’d gladly tell you more, but that’s enough about me in particular.
I’ve been lucky to see a lot of change in this field over the last 20 years. Firstly, instrumental analysis is quite different than it was a couple of decades ago. When I first was on the job we were using Thin Layer Chromatography, GC-MS, and immunoassay for screening. We had HPLC with UV and fluorescence detectors, GC-MS, and LC-single quadrupole MS instruments for confirmation testing – LC-triple quadrupole MS wasn’t really a thing yet in forensic toxicology. And no one inside of toxicology had even dreamt of using high resolution accurate mass instruments such as single stage time of flights or quadrupole time of flight mass spectrometers for anything at that point. But you look around the lab today and all you see is LC-QToFs and LC-MS/MS. It’s wild how much change has occurred in a relatively short amount of time.
Secondly, the sheer breadth of available drugs has substantially increased as well. In the early 2000s, novel psychoactive substance (NPS) wasn’t a term that was familiar. No one spoke about them. But sometime around 2008, NPS such as substituted cathinones, designer benzodiazepines, fentanyl analogs, synthetic opioids, and synthetic cannabinoids changed the toxicology landscape. We can no longer just worry about the classical drugs of abuse (such as methamphetamine or heroin or cocaine) or prescription medications (such as oxycodone, hydrocodone, or alprazolam). A challenge we face in forensic toxicology is what substances do we need to include in our scope of testing? In the early 2000s, most labs weren’t even testing for fentanyl. Can you imagine that? Illicit fentanyl is by far and away the most important drug that is driving overdoses in the United States these days and has been for the last several years. The next question after scope is how do we analyze them in the effective and efficient way as possible? And finally, after all that, the most pressing issue is the arduous challenge of results interpretation and expressing a scientific opinion in courts of law – how does the substance play a role in a medical-legal death investigation or human impairment? Does it play a role? Is it an incidental finding? Someone much smarter than me used to say, “Never practice toxicology in a vacuum”. And it’s truer today than it has ever been.
There’s that old adage that the only constant in life is change. It’s a saying for a reason. If this was social media, I’d end the sentence with #truth. That saying exactly describes the last 20 years of forensic toxicology.
By George S. Behonick, Ph.D. F-ABFT
In recognition of National Forensic Science Week (NFSW), September 18-22, 2023, I am putting pen to paper to capture some thoughts on what this means to Axis Forensic Toxicology. The euphemism, “Dead men tell no tales”, is oft used as a metaphor. To be certain, it is an exaggerated phrase, but it does get a point across. Similarly, medical examiners (ME), forensic pathologists and coroners hold as a credo, “We speak for the dead”. It is a creed extending to other members of the medico-legal death investigation team, chiefly the men and women who comprise the ranks of the various disciplines within the field of forensic science. We at Axis Forensic Toxicology are part of that team and we are charged with the responsibility of trying to provide answers and context to what often are the final moments, or acts, of a person before departing this planet. Forensic postmortem toxicology is uniquely set apart from the other forensic science specialties. Think about this for a moment, it is the only branch within forensic science that provides the ME, coroner or forensic pathologist with explanation for, or reason for a decedent’s demise; that is, a cause of death (COD). All of the other forensic science disciplines may provide supporting evidence integral to unraveling the circumstances and details of a death. For example, DNA and latent fingerprint scientists provide definitive proof in establishing a decedent’s identity, or likewise may be able to establish the identity of a subject who may have had close contact with the decedent before or at the time of death. Criminalist analysts may categorize and document trace evidence such as hairs and fibers, for eventual comparison to known materials from a death scene or decedent. Firearms examiners provide weapon function tests in cases of suicide by suspected self-inflicted gunshot wound (that is, was it an accident or was it self-intentional?). Projectile fragments and bullets recovered at autopsy can be matched to a specific weapon. Note however, that none of these examples provide potential for COD. Postmortem forensic toxicology can offer plausible reason and evidence for the pathophysiological mechanisms to cause one’s death (e.g. the respiratory depression and accompanying apneic and anoxic pathology associated with an opioid poisoning or intoxication).
The past quarter century has borne witness to rapid change and advancement in the field of forensic toxicology. Toxicologists and analysts were at the forefront of the nationwide epidemic of prescription drug abuse and misuse which ignited in the mid to late 1990s with OxyContin® (dubiously dubbed “Hillbilly Heroin” because of its scourge inflicted to middle Appalachia) and then morphed to other opioids such as methadone and prescription derived fentanyl. Within the first decade of the new millennium, the United States experienced a re-emergence in heroin. Heroin-related deaths surged for a brief period 2010-15, to be followed by the nationwide infiltration of illicitly manufactured fentanyl (IMF) into the street drug supply chain. The synthetic modification and manipulation of IMF then resulted in the proliferation of potent fentanyl analogs such as carfentanil and furanylfentanyl. More recently, other designer opioids, novel psychoactive substances, and clandestinely manufactured psychotropic substances such as synthetic cannabinoids (‘K2 Spice’), cathinone compounds (‘bath salts’), nitazene compounds and designer benzodiazepines such as bromazolam and flualprazolam have come to make their mark in the United States. Not to mention, mitragynine (‘kratom’) and the adulterant drug xylazine (‘Tranq’). Fortuitously, forensic toxicology has enjoyed a golden age in the last twenty-five years with respect to technology. This encompasses not only new and improved methods for the extraction and recovery of drugs and drug metabolites from postmortem blood and other fluids and tissues, but also a robust cavalcade of sophisticated instrumentation and automation. Utility and versatility of high-resolution mass spectrometry (HRMS) which empowers laboratories with the ability to detect and identify, in real time fashion, literally hundreds of drug compounds and drug metabolites of interest is astounding. Liquid Chromatography-Quadrupole Time of Flight HRMS imbues laboratories with a tool to meet the challenges of an ever-changing illicit drug landscape. Indeed, working as a forensic scientist, technician, or analyst in a modern forensic toxicology laboratory is both exciting and rewarding; moreover, it is imperative we also acknowledge all of the actors in this play. It is not an exaggeration in stating that it takes a village to do what we do day to day, so it is we recognize during this NFSW 2023 the executive and administrative clerical staff, the logistics staff, the IT support, managers and supervisors, the accessioning staff, and everyone associated with Axis Forensic Toxicology.
In closing, I leave you with the sage words of a grizzled ME whom I had the pleasure of working with in Virginia. His name is Dr. William Massello III, recently retired in the last several years as the Chief Medical Examiner for the state of North Dakota. He once posited to me, “Someone has to make sense out of all of this mess”. Words I have never forgotten, but still echo today. Despite some of the most horrific, tragic circumstances that can befall a human being, we are called upon to do our jobs. Be proud of what you do, realize the essential contributions you make to the public at large, the criminal justice system and to the decedent families and next of kin we indirectly serve. Be proud to work in forensic science!
By Kevin Shanks, M.S., D-ABFT-FT
As mentioned in previous blog posts, novel psychoactive substances (NPS) come in different varieties and the Novel Emerging Compounds (NEC) Panel offered by Axis Forensic Toxicology helps to detect the most newly emerged NPS on the drug market and is meant to evolve over time as new drugs emerge on the street. In the first post in the series, we took a look at two of the more recently emerged NPS benzodiazepines, bromazolam and flubromazepam, and in the second post, we looked at two of the most recently detected stimulants, alpha-PiHP and N,N-dimethylpentylone. In this third post in the series, we will take a brief look at two more recently emerged compounds: phenibut and tianeptine.
Phenibut is a substance that was originally developed in the Soviet Union in the 1960s and is currently marketed as a medication in Belarus, Kazakhstan, Latvia, Russia, and Ukraine and used in the treatment of anxiety and insomnia, as well as many other disease states and disorders. Phenibut is not approved for use in the United States, but it has been sold on the internet as a dietary supplement and nootropic and has been used recreationally. The name phenibut is derived from the chemical name (B-phenyl-y-aminobutyric acid). It is an analog of the neurotransmitter gamma-aminobutyric acid (GABA) and is thought to act as a GABA receptor agonist (similar to baclofen), but it also has dopaminergic effects. Reported effects of the substance include sedation, tiredness, drowsiness, nausea, headache, irritability, agitation, and euphoria. Phenibut is currently considered an uncontrolled substance in the United States.
Tianeptine is a drug that was developed by the French Society of Medical Research in the 1960s and is currently approved as a prescription medication in France and other European and Asian countries. It is used for the treatment of major depressive disorder, as well as anxiety, irritable bowel syndrome, and asthma. Tianeptine is not approved for use in the United States as a medication. It has been found as a drug of abuse throughout the years in Russia and has become an emerging public health risk in the United States as a recreational drug. Tianeptine is a mu opioid receptor agonist and also has glutamate receptor activity via the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and N-methyl-D-aspartate (NMDA) receptors. Reported effects of tianeptine use include headache, drowsiness, nausea, agitation, anxiety, and euphoria. Tianeptine is not a controlled substance in the United States, but has been controlled at the state level in Alabama, Michigan, Ohio, and Tennessee as either a Schedule I or II substance.
As both substances are not controlled substances at the Federal level, the Drug Enforcement Administration (DEA) has not released any detection or prevalence data via the National Forensic Laboratory Information System (NFLIS), but both phenibut and tianeptine have been implicated in human toxicity which have led to hospitalizations and have also been associated with fatalities in the United States.
Axis qualitatively monitors both of these compounds in our NEC panel (order code 13710) and Comprehensive Panel, Blood with Analyte Assurance (order code 70510) using liquid chromatography with quadrupole time of flight mass spectrometry (LC-QToF-MS). Over the time range 01/30/2023 – 06/30/2023, Axis has detected phenibut in 5 blood specimens in 5 states (Arizona, Florida, Indiana, Ohio, and Tennessee) and tianeptine in 6 cases in 4 states (Florida, Indiana, Kentucky, and Tennessee). In Axis Forensic Toxicology casework, phenibut was typically found alongside THC/THC-COOH (n=2), tianeptine (n=2), caffeine (n=2), dextromethorphan (n=1), and fentanyl/norfentanyl (n=1). Tianeptine was simultaneously detected with bromazolam (n=2), phenibut (n=2), cotinine (n=2), fentanyl/norfentanyl (n=1), and methamphetamine (n=1).
Axis also monitors other NPS in our Novel Psychoactive Substances panel (order code 13610). These additional compounds include 25B-NBOMe, 25C-NBOMe, 25I-NBOMe, 2C-B, 2C-E, 2C-I, 5-MeO-DALT, adinazolam, alpha-PVP, butylone, clonazolam, dibutylone, dimethylone, ethylone, etizolam, eutylone, flualprazolam, flubromazolam, MDPV, mephedrone, methcathinone, methedrone, methoxetamine, methylone, N-ethylpentylone, pentylone, and TFMPP.
As always, if you have questions about these substances and how they may play a role in your medical-legal investigation, please reach out to our subject matter experts by email ([email protected]) or phone (317-759-4869, Option 3).
Be on the lookout for the fourth and final post in the NEC Panel series! To round out the panel, we will take a brief look at three more recently emerged novel compounds: AP-237, brorphine, and fluorofentanyl.
By George S. Behonick, Ph.D., F-ABFT, Laboratory Director, Chief Toxicologist
Synthetic compounds designed to mimic the pharmacology of various illegal drug classes infiltrated the illicit drug market during the last decade plus; this includes synthetic cannabinoids (“K2 Spice”), cathinones (“Bath Salts”), hallucinogens, and designer fentanyl analogs and opioids (examples such as fluorofentanyl, brophine and the nitazene compounds). In particular, the fentanyl analogs, along with illicitly manufactured fentanyl (IMF), imposed significant impact to the morbidity and mortality of drug-related exposures. Heroin cases experienced a dramatic resurgence around 2010; in large part, its unprecedented purity (users could ‘snort’ or insufflate the drug) and its relative low cost compared to prescription opioids (e.g. OxyContin®) fueled its unbridled demand as an alternative among opioid addicts and neophyte users. Gradually with time, solid dose materials (paraphernalia) and autopsy specimens began to demonstrate the concomitant presence of heroin and IMF. Ostensibly, the addition of IMF was designed to increase the potency of the product. Eventually, beginning in 2014 the proportion of IMF became greater than heroin in these mixtures. By 2015 the greater number of drug-involved cases included fentanyl, and not heroin. Simultaneous to this trend, numerous synthetic fentanyl analogs were being manufactured outside of the United States, but made available to illicit drug traffickers over the Internet. In 2016-17, carfentanil began appearing in seized solid dose drug products and medical examiner death investigation cases .
Carfentanil is a mu (µ) opioid receptor agonist; it is about 10,000 times more potent than morphine and demonstrates 30-100 times the potency of fentanyl . Between September 1, 2016 and January 1, 2017, Axis Forensic Toxicology detected carfentanil in 262 postmortem blood specimens . We described the specific details of 13 fatalities, from Indiana, Michigan, Kentucky and Ohio in this data set. Other investigators reported the detection of carfentanil in blood specimens obtained from impaired drivers and postmortem toxicology submissions [7, 4]. In response, state and federal agencies issued health alerts in 2018 which detailed the rising numbers of deaths involving fentanyl and fentanyl analogs to include carfentanil [2, 1].
2016 and 2017 demonstrated a surge increase in the number of drug-related deaths in the United Sates; that is, ↑11,228 (+21.4%) in 2016 and ↑6605 (+10.4%) in 2017; however, notably in 2018, drug-related deaths declined by 2,870 or -4.1%. The rise and fall coincided with increases, and then, decreases of carfentanil detections in seizure exhibits from 2015-2018. The overall availability of carfentanil was attributed to be a major factor in the accelerated, then diminished rate of drug-related deaths in the period 2016-2018 . China banned carfentanil on March 1, 2017.
In CY 2022 Axis Forensic Toxicology detected carfentanil in two cases. Carfentanil was detected in one case in February 2023 however, in late spring and summer (May 26 – Aug 18), Axis Forensic Toxicology detected carfentanil in blood specimens from 9 postmortem cases. The time span being four months with the cases originating from four different states: Indiana (4), Wisconsin (2), Kentucky (2), and Ohio (1). A cursory review of a subset of these cases (n = 7) indicated 6 of 7 decedents to be male, with an age range of 29-61 years and median age of 41 years. Carfentanil postmortem blood concentrations exhibited a range of 47.2 to 409 picograms per milliliter (pg/mL); carfentanil was identified qualitatively in two of the cases. Multiple drugs were detected in all but one case. Fentanyl was detected in all cases with multiple drug detections. Methamphetamine and amphetamine was detected in 5 of the 7 cases. Other detections included: Acetylfentanyl (4 cases), 4-ANPP (4 cases), fluorofentanyl ( 1case) and morphine (1 case).
The aforementioned case accounts underscore the continued awareness and vigilance medico-legal death investigators and forensic toxicology laboratories must demonstrate to surveilling the drug carfentanil. In one case reported herein, the decedent, a 61 year old male, was found deceased in his vehicle at a truck stop that he was known to frequent on a near daily basis. The sole toxicological finding in this case was a carfentanil postmortem blood concentration of 403 pg/mL. In the two Wisconsin cases, the deaths occurred in two males who apparently knew each other and were suspected to have secured drugs from the same supplier within a close approximate time to each other. And in one Indiana case, investigators believed there was an association or a link to two other cases with respect to the source of the carfentanil. All three deaths occurred proximate to each other in time with a belief that the carfentanil supplier was one of the decedents. Detecting carfentanil in blood is a challenge because of the low (sub nanogram/mL or picogram/mL) presenting concentrations of the drug. Axis Forensic Toxicology presumptively screens for carfentanil in the Comprehensive panel (order code 70510) and the Indiana State Department of Health panel (test code 70575); this is accomplished by high resolution mass spectrometry ( Liquid Chromatography Quadrupole Time of Flight Mass Spectrometry) via the Analyte Assurance™ feature of the Comprehensive panel. Confirmation and quantitation of carfentanil is accomplished by LC-MS/MS (Liquid Chromatography Tandem Mass Spectrometry) in the Designer Opioids panel (order code 13810) with a carfentanil Lower Limit of Quantitation (LLOQ) of 10 pg/mL , or 0.010 ng/mL. Of note, carfentanil is not presumptively screened in the Drugs of Abuse panel (order code 70530), or in the customized Drugs of Abuse panel (Kentucky, order code 70555).
In summary, carfentanil exhibited a significant nationwide prevalence in postmortem cases in 2016-17; subsequent scheduling of the drug in the United States and a ban in China in 2017 resulted, in part, to a precipitous decline in positive postmortem cases. Axis Forensic Toxicology recognized a re-emergence of carfentanil in postmortem case work notably beginning the latter part of May 2023 and extending into August 2023 with a total of 9 detections from four states (IN, WI, KY and OH). Medico-legal death investigators, medical examiners, coroners and law enforcement agencies are urged to be alert to this observation. Death scene investigation, decedent social/drug history, autopsy and an appropriate scope of toxicology testing are of paramount importance in suspected drug-related cases. Drug intelligence trends in a given jurisdiction or region, as provided by local sources such as the Drug Enforcement Agency (DEA), law enforcement drug task forces together with information from state and federal drug testing laboratories are essential tools in identifying real time drug patterns in a specific location. Thus far in 2023, with the exception of 1 case from the total of 10, all of the carfentanil detections noted in the laboratory were punctuated by the parallel detections of IMF; likewise, methamphetamine and amphetamine was detected in 5 of the 7 cases reviewed as a subset to the ten case total observed thus far in 2023. Axis Forensic Toxicology will continue to monitor carfentanil case trends in the remainder of 2023.
The following individuals and jurisdictions are recognized for their contributions to this article by the provision of case investigative details, circumstances and decedent histories: Amy Lay, Medicolegal Death Investigator/Pathology Assistant, Lake County Coroner’s Office, IN; Steve Lockyear, Vanderburgh County, IN Coroner; Joe Hudson, Grayson County, KY Coroner; Josh Garvey, Iowa County, WI Deputy Coroner, and Dr. Robert F. Corliss, Professor and Autopsy Director-Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison.
 Centers for Disease Control Health Update, CDCHAN-00413, Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. July 11, 2018
 Delaware General Health District, Delaware County, Ohio Health Alert, Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. July 12, 2018
 Jalal, H, Burke, DS. Carfentanil and the rise and fall of overdose deaths in the United States. Addiction. 2021 Jun; 116(6):1593-1599
 Papsun, D, Isenschmid, D, Logan, BK. Observed carfentail concentrations in 355 blood specimens from forensic investigations. J Analytical Tox. 2017; 41:777-778
 Schueler, HE. Emerging synthetic fentanyl analogs. Acad Forensic Path. 2017 7(1):36-40
 Shanks, KG, Behonick, GS. Detection of carfentanil by LC-MS-MS and reports of associated fatalities in the USA. J Analytical Tox. 2017; 41:466-472
 Tiscione, NB, Alford, I. Carfentanil in impaired driving cases and the importance of drug seizure data. J Analytical Tox. 2018; 42:476-484
 Wilde, M, Pichini, S, Pacifici, R, Tagliabracci, A, Paolo Busardo, F, Auwarter, V, Solimini, R. Metabolic pathways and potencies of new fentanyl analogs. Frontiers in Pharmacology. 2019 10:1-16
By Kevin Shanks, M.S., D-ABFT-FT
Novel psychoactive substances (NPS) are compounds designed or consumed to mimic the effects of typical recreational substances such as diacetylmorphine (heroin), cocaine, methamphetamine, cannabis, or even prescription medications. As these NPS emerge and become prevalent, the United States Federal government can use its scheduling powers to effectively ban the substances as Schedule I controlled substances.
Schedule I controlled substances are defined as a substance that has a high potential for abuse and no currently accepted medical use in the United States.
Effective July 26, 2023, the United States Federal government controlled the following NPS as Schedule I controlled substances: etizolam, flualprazolam, clonazolam, flubromazolam, and diclazepam. Over the past few years, each of these drugs have been associated with or implicated in numerous cases of driving under the influence of drugs as well as toxicity and fatality.
Axis tests for clonazolam, etizolam, flualprazolam, and flubromazolam in the Novel Psychoactive Substance panel (order code 13610) as well as the Comprehensive Panel with Analyte AssuranceTM (order code 70510). Diclazepam (as metabolites delorazepam and lorazepam) is also included in order code 70510. If you have questions about these substances and how they may apply to your casework, please reach out to our subject matter experts by email ([email protected]) or phone (317-759-4869, Option 3).
Department of Justice, Drug Enforcement Administration, 21 CFR Part 1309, Docket No. DEA-989. Federal Register. Volume 88, No. 142. Schedules of Controlled Substances: Temporary Placement of Etizolam, Flualprazola, Clonazolam, Flubromazola, and Diclazepam in Schedule I. July 26, 2023.
By Kevin Shanks, M.S., D-ABFT-FT
As mentioned in the previous post, novel psychoactive substances (NPS) come in different flavors – and opioids, cannabinoids, stimulants, hallucinogens, and benzodiazepines are just a few of them. The Novel Emerging Compounds (NEC) Panel offered by Axis Forensic Toxicology helps to detect the most newly emerged NPS on the drug market and is meant to continually evolve over time as new substances emerge on the street.
In the first post in this series, we took a look at two of the more recently emerged NPS benzodiazepines, and in this second post, we are looking at two of the most recently detected stimulants: alpha-PiHP and N,N-dimethylpentylone.
Alpha-PiHP, also known as 4-methyl-1-phenyl-2-(pyrrolidin-1-yl)pentan-1-one or alpha-pyrrolidinoisohexanophenone, is a substituted cathinone that is a positional isomer of the prescription medication pyrovalerone, a norepinephrine-dopamine reuptake inhibiting drug that is used for the treatment of chronic fatigue and as an appetite suppressant. Alpha-PiHP was first reported as being a drug sold on the illicit drug market in 2016 by the National Forensic Laboratory of Slovenia when it was detected in an off-white colored powder. In the United States in 2018, the Center for Forensic Science Research and Education (CFSRE) first reported the detection of the substance in a white solid material via the Department of Homeland Security.
N,N-dimethylpentylone is also known as 1-(1,3-benzodioxol-5-yl)-2-(dimethylamino)pentan-1-one or dipentylone and is a substituted cathinone that is a positional isomer of a previously reported cathinone, N-ethylpentylone, a norepinephrine-dopamine-serotonin reuptake inhibitor. Pentylone is a common metabolite produced by the body via de-ethylation after consumption of N,N-dimethylpentylone. The drug was first identified in Sweden in 2014, but didn’t emerge in the United States until 2021-2022.
Similar to other classical stimulants such as methamphetamine and amphetamine, these two compounds act pharmacologically as central nervous system stimulants with activity involving the neurotransmitters serotonin, norepinephrine, and dopamine. While the human pharmacology of these substances hasn’t been readily tested, it is surmised that they act as either direct releasers of the neurotransmitters or as transporter inhibitors. Reported effects after use of substances such as these include increased alertness, increased energy, euphoria, feelings of well-being, restlessness, and hallucination. Other physiological effects are hyperthermia, tachycardia, hypertension, mydriasis, diaphoresis, dehydration, and hyponatremia.
While not explicitly listed as controlled substances in the United States, both of the substances may be considered positional isomers of already controlled drugs and therefore be considered “analogues”. According to the Drug Enforcement Administration’s (DEA) National Forensic Laboratory Laboratory Information System (NFLIS) 2022 Midyear Drug Report, N,N-dimethylpentylone was the third most common phenethylamine detected by the DEA – behind only methamphetamine and amphetamine. Alpha-PiHP was the sixth most commonly detected phenethylamine in 2022. Alpha-PiHP and N,N-dimethylpentylone have been implicated in human toxicity which have led to numerous hospitalizations and fatalities in the USA.
Axis qualitatively monitors both of these compounds in our NEC panel (order code 13710) and Comprehensive Panel, Blood with Analyte Assurance (order code 70510) using liquid chromatography with quadrupole time of flight mass spectrometry (LC-QToF-MS). Over the time range 01/30/2023 – 06/30/2023, Axis has detected alpha-PiHP in 11 blood specimens with all detections located in Florida and N,N-dimethylpentylone in 42 cases with 41 cases in Florida and 1 case in Indiana. The reason why these compounds have been predominately found in Florida is not known, but NPS and classical drug trends tend to be regional phenomena.
In Axis Forensic Toxicology casework, Alpha-PiHP was typically found alongside fentanyl/norfentanyl (n=6), 4-ANPP (n=5), N,N-dimethylpentylone (n=5), cocaine/benzoylecgonine (n=3), and naloxone (n=3). N,N-dimethylpentylone was simultaneously detected with fentanyl/norfentanyl (n=30), 4-ANPP (n=29), pentylone (n=21), cocaine/benzoylecgonine (n=18), and naloxone (n=14).
Axis also monitors other NPS stimulants in our Novel Psychoactive Substances panel (order code 13610). These additional compounds include alpha-PVP, butylone, dibutylone, dimethylone, eutylone, MDPV, mephedrone, methcathinone, methedrone, methylone, N-ethylpentylone, pentylone, and TFMPP. As always, if you have questions about these substances and how they may play a role in your medical-legal investigation, please reach out to our subject matter experts by email ([email protected]) or phone (317-759-4869, Option 3).
Stay tuned for the third post in the NEC Panel series! We will take a look at two more recently emerged novel compounds: phenibut and tianeptine.