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MATT 2025 Recap: Ketamine

At this year’s MATT meeting, Dr. Laureen Marinetti spoke to attendees about how to differentiate between ketamine used illicitly versus ketamine used medically.  She also discussed the origin of medical and illicit ketamine. 

Ketamine was developed in 1962 for use as a veterinary anesthetic; it was not approved for human use until 1970.  Ketamine, [2-(ortho-chlorophenyl)-2-methylaminocyclohexanone], is an analog of phencyclidine (PCP), with two resolvable optical isomers, S(+) and R(-), S(+) is the more effective anesthetic, but exhibits a higher incidence of psychotic reactions, brings about a greater increase in blood pressure and pulse, and elicits a greater bronchodilatory response.  Clinically, ketamine is a dissociative anesthetic used to induce and maintain anesthesia and has also been used for severe agitation, excited delirium, acute pain control, acute asthma, and bronchospasm.  Ketamine was approved for the treatment of TRD, which is treatment resistant depression.  The product, Spravato® (S(+) or esketamine), was approved by the FDA in March of 2019.  It is administered as a nasal spray to be used in conjunction with oral antidepressant therapy.  Spravato® should be administered under the guidance of a healthcare provider.  In addition to treatment of TRD, there are other on-going investigative trials for the use of ketamine in post-traumatic stress disorder (PTSD), bipolar depression, cocaine/opiate/alcohol use disorder, and off-label for chronic pain at ketamine clinics.  Emergent reactions from ketamine use include recovery agitation characterized by hallucinations, vivid dreams, fear, severe confusion, laryngospasm, hypertension, tachycardia, emesis, psychoses, delirium, and cardiac arrest.   

Abuse of ketamine was first detected on the US West Coast in 1971.  This abuse continued into the 1980s moving internationally, and to include abuse by physicians.  In the 1990s and 2000s ketamine abuse was popular at Rave Parties where it became known as a club drug.  Nonmedical use of ketamine is becoming popular again.  Ketamine is available as a liquid, dried into crystalline white powder, and is self-administered by smoking, ingestion, insufflation, and as an IV administration when mixed as a solid-dose form with other drugs.  Some street names of illicit ketamine include: Vitamin K’, ‘Special K’, ‘Super K’, ‘Ket’, ‘K’, ‘Super C’, KitKat, ‘Tusi’, ‘Tucibi’, ‘Tuci’, ‘2-C or ‘2-CB’, the phonetic pronunciation of the number “2” and the letters “B”, “C” for “2” “C” “B”.  These products have not been found to contain phenethylamine 2CB.  Ketamine has also been detected in a pink dyed powder called pink cocaine that emerged in Latin America and Europe. This pink powder is a mixture that may contain, but is not limited to; ketamine, cocaine, opioids, methylenedioxymethamphetamine (MDMA), methamphetamine, novel psychoactive substances (NPS), or caffeine. 

Is the ketamine/norketamine in a toxicology report the result of legitimate medical use or is it because of illicit use?  Toxicology testing alone cannot answer this question; other information is needed, such as medicolegal death investigation and autopsy results.  Scene history, medical records, emergency medical services records as well as testing of solid dose form, powders or liquids found at the death scene may also be necessary.  For the data listed in this article, ketamine was screened by LC/QTOF/MS and confirmed by LC/MS/MS.  Toxicology results from ketamine cases containing both illicit and medical ketamine use are shown in the table below.  Group I is from the testing of postmortem blood determined to be from illicit ketamine use cases.  Group II is from the testing of postmortem blood determined to be from medical ketamine use.  Group III is from the testing of ante-mortem hospital blood determined to be from medical ketamine use.  Group IV is from the testing of one ante-mortem hospital serum determined to be from medical ketamine use.  The mean and median concentration of the illicit ketamine cases is significantly lower than that from the medical use ketamine, even though the ranges overlap.  This is not surprising since the medical use of ketamine is usually during an emergency to save the life of the patient.  In this situation there is likely not much time for the patient to metabolize ketamine if the patient does not survive. 

The table below shows the drugs found with illicit ketamine, the most common being fentanyl and fentanyl related.  More information from additional case work is needed to make a conclusion about expected ketamine and norketamine concentrations in illicit vs medical cases.  For more information regarding case demographics and history, please contact Axis Forensic Toxicology ([email protected]) to get a copy of the presentation. 

References 

  1. Hoffman, RS, Howland, MA, Lewin, NA, Nelson, LS and Goldfrank, LR. Goldfrank’s Toxicologic Emergencies. 10th ed. New York: McGraw Hill Education; 2015
  2. Palamar, JJ. Tusi: a new ketamine concoction complicating the drug landscape. Am J Drug Alcohol Abuse 2023; May 10:1-5
  3. Palama, JJ, Wilkinson, ST, Carr, TH, Rutherford and Cottler, LB. Trends in illicit ketamine seizures in the US from 2017 to 2022. JAMA Psychiatry 2023; 80(7):750-751
  4. United Nations Office on Drugs and Crime, “Tuci”, “happy water-powdered milk” – is the illicit market for ketamine expanding? Global SMART Update, Vol. 27, December 2022
  5. National Drug Intelligence Center, U.S. Department of Justice, Intelligence Bulletin Ketamine, www.usdoj.gov/ndic, July 2004.
  6. 6. Mion, and Villevielle T., Ketamine Pharmacology: An Update (Pharmacodynamics and Molecular Aspects, Recent Findings), CNS Neurosci Ther. 2013 Apr 10;19(6):370–380. doi: 10.1111/cns.12099.
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MATT 2025 Recap: Nitazene Analogs

At this year’s MATT meeting, Stuart Kurtz spoke to attendees about the prevalence of nitazene analogs and the concentrations at which Axis detects them. We have previously discussed what nitazenes are in blog posts (see links below).  As a reminder, they are potent mu opioid receptor agonists that behave similarly to fentanyl & its analogs, morphine, heroin, hydrocodone, oxycodone, and other opioids. They are structurally distinct from these drugs and will not be detected using immunoassays designed for these other compounds. Isotonitazene and metonitazene were the first to emerge in 2019-2020. 

Metonitazene has remained our most popular analog detected in the areas we service. N-pyrrolidino metonitazene and N-pyrrolidino protonitazene have emerged in the last year with the latter nearly overtaking metonitazene in 2024. Unsurprisingly, fentanyl is the drug most commonly detected with them. 

Our method reports quantitative results for butonitazene, etodesnitazene, etonitazene, flunitazene, isotodesnitazene, isotnitazene, metodesnitazene, metonitazene, N-pyrrolidino etonitazene, and protonitazene. Our limit of detection for these is 1.0 ng/mL. Median concentrations of the available quantitative data show a range of 1.5-2.9 ng/mL. A good target for limit of detection for these compounds would be 0.5-1.0 ng/mL. There is no expected therapeutic range and the purity of drugs purchased on the street is highly variable. This can make it hard to determine what the expected blood concentrations should be. Given their potency is similar to fentanyl and its analogs, similar cutoffs to those compounds can be used as a starting point. 

Our project presented at AAFS 2025 highlighted that the nitazenes may be highly specific to various regions. Knowledge of seized material in your jurisdiction will tell you whether or not you should be considering nitazenes in otherwise negative toxicology cases. As new compounds emerge, we will remain current on the information available and use it to inform our testing scope. Nitazene Analogs are screened in Axis’ Comprehensive Panel with Analyte Assurance™ (70510) or as a standalone panel (13910) To discuss the potential impact of nitazenes in your casework or for more information about the presentation, please contact [email protected].

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Axis Experts Present at MATT 2025

Axis toxicologists Laureen Marinetti, PhD, F-ABFT, and Stuart Kurtz, M.S, D-ABFT-FT, will be presenting at the Midwest Association of Toxicology and Therapeutic Drug Monitoring (MATT) Annual Meeting in Milwaukee Wisconsin, April 2-4, 2025.  Their presentation topics are below and the presenter is highlighted.

Platform Presentation: An Update on Nitazene Detections: Where, When, and How Much?
Stuart A. K. Kurtz, M.S., D-ABFT-FT, Kevin G. Shanks, M.S., D-ABFT-FT, Laureen J. Marinetti, Ph.D., F-ABFT
This will expand the AAFS 2025 project (see blog post from February 28, 2025) by including quantitative data for the nitazenes we currently have validated. Nitazenes are an emerging class of synthetic opioids that were first detected in 2019. The compounds that are sticking around and emerging tend to be those with a higher potency than fentanyl or are in a similar range. Due to lack of approval for any medical use, clinical or veterinary, there is little known about expected concentrations in humans. By examining quantitative data when available, we can better understand what those mean in casework and what a target cutoff for qualitative reporting should be if quantitative methods prove too difficult to develop.
Platform Presentation: Differentiating Medical Ketamine from Illicit Abuse in Postmortem Cases
George S.Behonick, Ph.D., F-ABFT*, Catherine R. Miller, MD**, Natalia Belova, MD**, and Laureen J. Marinetti, Ph.D., F-ABFT*
*Axis Forensic Toxicology, ** District 15 ME Palm Beach County , FL.
Data review of 45 cases of illicit(8) and licit(37) ketamine findings.  Become familiar with the chemistry and pharmacology of ketamine.  Recognize the features and elements of medical ketamine use and illicit use.  Understand the principals involved with differentiating medical ketamine pharmacotherapy and illicit ketamine use.  Gain insight into the investigative details, decedent history, scene information, and toxicology of an illicit ketamine use case compared to a medical use case.

Axis is pleased to be able to share knowledge with other professionals in the fields of toxicology.  If you will be attending MATT, please make plans to connect with them and take in their presentations.

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Drug Primer: Difluoroethane (DFE)

By Kevin Shanks, D-ABFT-FT

1,1-Difluoroethane (DFE) is a chemical compound that belongs to the family of hydrofluorocarbons, also known as HFCs. DFE has a chemical formula C2H4F2 and is a colorless, odorless gas at room temperature and is commonly used as a refrigerant (HFC-152a or R-152a) in air conditioning and refrigeration systems. It is also used as a propellant in aerosol products, such as cleaning sprays for electronics, computer keyboards, and other sensitive equipment. DFE has a relatively low environmental toxicity and does not deplete the ozone layer, therefore is considered a more environmentally friendly alternative to older refrigerants like CFC-12 (dichlorodifluoromethane) because it has a lower global warming potential (GWP). 

Chemical Structure of 1,1-difluoroethane (DFE)
Drawn by Kevin G. Shanks (2025)

The pharmacology of DFE is primarily related to its toxicological effects, as it is not used for any therapeutic or medical application. It is often misused by individuals seeking to experience a high through inhalation, sometimes called “huffing”, which can be highly dangerous and lead to severe health consequences. The substance acts as a volatile anesthetic that depresses the central nervous system leading to a sedative effect via the GABAA and glutamate receptors. Symptoms of acute exposure to DFE are coughing, wheezing, difficulty breathing, drowsiness, dizziness, light-headedness, headache, nausea, euphoria, and loss of coordination. In more severe cases, it can cause slurred speech, altered judgement, unconsciousness, pulmonary edema, suffocation, and death. Chronic exposure to DFE may lead to more long-term effects, including potential neurological damage and heart damage, including coronary disease, angina, and arrhythmias, and potential psychological addiction. 

Electronic cleaning spray with DFE as an ingredient  Images by Kevin G. Shanks (2025)

There have been several case reports of DFE toxicity and fatality published in scientific literature over the years. In reports published by Broussard et al. and Hahn et al., 3 adults died in vehicle accidents and had blood DFE levels ranging from 35-86 mcg/mL. In another report published by Frazee et al., two men were found dead after using DFE – they had postmortem blood DFE concentrations of 61 and 230 mcg/mL. In another report published by Vance et al., 14 adults who died following acute ingestion of DFE had postmortem blood concentrations ranging from 3-380 mcg/mL.  

As DFE is not a pharmaceutical medication or substance approved for use in the human body, there is no amount considered safe for use, therefore, there is also no unequivocal corresponding postmortem blood concentration that is considered therapeutic, toxic, or fatal. All postmortem blood concentrations can and should be considered relevant in a medical-legal investigation surrounding impairment, toxicity, and/or fatality. 

Axis Forensic Toxicology tests for DFE by gas chromatography with flame ionization detection (GC-FID) under order code 46590, and has just added the screen to the Comprehensive Panel with Analyte Assurance™. Minimum sample size is 0.5 mL. Due to the previously mentioned lack of relevancy of postmortem blood concentrations, all results are reported as qualitative (positive or negative). No quantitation is performed. 

As always, if you have questions about DFE and how it may have played 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).

References

  • Randall C. Baselt. Fluorocarbons. Disposition of Toxic Drugs and Chemicals in Man.12th Edition. Pages 878-880. 
  • Larry Brousard, Barry S. Levine, Sarah Kerrigan. Chapter 31. Inhalants. Principles of Forensic Toxicology. 5th Edition. Pages 561-568. 
  • L. Brousard, T. Brustowicz, T. Pittman et al. Two traffic fatalities related to the use of difluoroethane. Journal of Forensic Science, 42: 1186-1187 (1997).
  • T. Hahn, J. Avella, and M. Lehrer. A motor vehicle accident fatality involving the inhalation of 1,1-difluoroethane. Journal of Analytical Toxicology, 30: 638-642 (2006).
  • C.C. Frazee III, S. Fleming, and U. Garg et al. Huffing: Two deaths involving 1,1-difluoroethane. Society of Forensic Toxicologists Annual Meeting, 2010. 
  • C. Vance, C. Swalwell, and I. McIntyre. Deaths involving 1,1-difluoroethane at the San Diego County Medical Examiner’s Office. Journal of Analytical Toxicology, 36: 626-633 (2012).
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Axis Adds 1,1-Difluoroethane to our Comprehensive Panel with Analyte Assurance™

We are excited to share some great news with you! Based on your valuable feedback and our ongoing efforts to improve our products, we are pleased to announce the addition of 1,1-Difluoroethane to our Comprehensive Panel with Analyte Assurance™, effective 3/10/2025.

Similar to other analytes included as part of Analyte Assurance™, if 1,1-Difluoroethane is noted as positive upon screening, our dedicated Lab Client Support team will contact you to determine if confirmation testing is desired.

At Axis Forensic Toxicology, we prioritize your needs and continuously work to improve our services to better meet your expectations. This new addition is a direct result of your input and our dedication to providing you with the most complete and reliable testing solutions.

If you have any questions or need further information about this update, please don’t hesitate to contact us at [email protected]. Our team is always ready to assist you.

Thank you for your continued trust and partnership. We look forward to delivering the highest quality service and testing solutions to support your needs.

Sincerely,
Matt Zollman
Director of Operations & Product Management

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Axis Experts Present at AAFS, February 2025

In mid-February 2025, two Forensic Toxicologists from Axis, Stuart Kurtz and Laureen Marinetti, attended the American Academy of Forensic Sciences annual meeting. While there, Stuart presented Axis’s data on nitazenes and Laureen presented Axis’s data on drug screening in vitreous fluid. For additional information please use this link to access previous Axis blog posts regarding nitazenes: https://axisfortox.com/?s=nitazene&post_type=post

As a refresher, nitazenes emerged after the scheduling of fentanyl analogs. This has largely lead to a decrease in new fentanyl analogs found in drug supplies but the rise in other opioids to fill their place. Isotonitazene was the first of these to emerge in 2019 with metonitazene emerging soon after. These are two of the original compounds described in drug patents from their initial clinical investigation. No nitazene compounds were ever approved for human or veterinary use. Nitazene compounds are structurally distinct from fentanyl analogs and morphine-based opioids such as morphine, hydrocodone, and oxycodone. This means that they will not cross-react in techniques that are immunoassay based. N-Pyrrolidino derivatives have emerged since 2023 which were not a part of the originally described compounds in the drug patents. A list of nitazene analogs that Axis can test for can be found in the Comprehensive Panel Specification Sheet here: https://axisfortox.com/test_catalog/comprehensive-drug-panel/

Graph by Stuart Kurtz

Above is a figure from Stuart’s poster that shows the trend of nitazenes by year. In 2024, metonitazene, N-pyrrolidino protonitazene, and N-pyrrolidino metonitazene are the top three by detections. Often times, two or three of these compounds will be detected together. Stuart will be expanding this data set for a presentation at the Midwest Association of Toxicology and Therapeutic Drug Monitoring in April 2025.

Vitreous fluid is located in the eye between the retina and the lens.  It is made up of mostly water with trace amounts of inorganic salts, ascorbic and hyaluronic acids.  Laureen’s presentation looked at the utility of screening for drugs using vitreous fluid and how this data compared to the same drug screening in blood.  The data was from over 120 cases tested by Axis in the normal course of business wherein both blood and vitreous fluid were screened.  The table below shows the drug class, the number of drug detections where the drug confirmed in blood in that drug class, and the percentage of time that the drug also confirmed in the vitreous fluid from the same case.

Chart by Laureen Marinetti, PhD

As shown in this table, all drugs did not confirm the same in each class.  Drug entry into the vitreous fluid is dependent upon several factors; drug potency, time of death in relation to drug consumption, the chemical and pharmacological properties of the drug, drug volume of distribution, protein binding of the drug, and the drugs ability to cross the blood retinal barrier (BRB).  Drugs may diffuse passively or be actively transported across the BRB.  Although there are some advantages to testing vitreous fluid, for example it is isolated from blood and other tissues, it is less susceptible to postmortem redistribution and putrefactive changes, vitreous fluid is not a good specimen for general drug screening.  Vitreous fluid is a great matrix for testing for electrolytes, glucose, urea nitrogen, creatinine and volatiles.

For more details on both the nitazenes poster and the vitreous fluid presentation, please reach out to us at 317-759-4869 option 3 or [email protected]. 

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Limitations of the Use of Reference Ranges to Interpret Toxicology Results in a Medicolegal Death Investigation

By Laureen Marinetti, PhD, F-ABFT

A therapeutic reference range like those listed on the Axis Forensic Toxicology report (Schulz, M., et al.) is provided as a starting point.  These ranges are derived from the clinical literature regarding an effective range of therapy for a drug, a therapeutic range.  Since they are from clinical data they are commonly measured in plasma or serum and collected from healthy subjects in a controlled study.  These subjects are not infants, children, elderly or individuals in poor health or who abuse drugs.  The samples are not whole blood and are not collected from the heart or a central cavity and they are not decomposed or from an embalmed body.  Changes to drug levels after death are inevitable and unavoidable.  Therefore, trying to compare postmortem concentrations to these clinical data is not comparing apples to apples so to speak.  This is why any value given for a therapeutic, toxic, or lethal blood concentration is not considered absolute, but is to be used as a frame of reference or guideline in evaluating a specific case in its context.   

What about postmortem data from case studies that provide toxic and lethal ranges?  While a reference text such as Baselt is useful in a general sense, these data are not controlled for the many variables inherent in postmortem toxicology.  These variables may include; collection site of the blood (concentrations from central sites may be affected by postmortem redistribution or PMR), the presence of other drugs (may add to or subtract from the toxic effects), tolerance state of the decedent, bacterial activity, genetic polymorphisms, resuscitation efforts, condition of the blood (decomposed or embalmed may lead to a lower concentration than at the time of death), manner of death (suicide vs accidental, the former potentially having an “overkill” drug concentration due to the intent of drug use), survival time (allows for drug metabolism thus lowering the postmortem measured concentration), and time of testing in relation to the sample collection (unstable drugs may degrade before they are tested, especially if the sample is not stored properly).  Therefore, to help answer the million-dollar question; is the concentration and/or combination of drug(s) measured or detected significant to the cause of death, or is it an incidental finding.   

The Academy Standards Board (ASB) developed a guideline for Forensic Toxicologists called Guidelines for Opinions and Testimony in Forensic Toxicology, ANSI/ASB 037.  It states in part that opinions be based on the totality of information available, including case history, observations, circumstances, and other relevant information, and not based solely on analytical results (4.3.c).    To follow the guidelines, the Forensic Toxicologist requires more information such as medical history, autopsy results, and death investigation.  Having this information allows the toxicology results to be put in context of the specific case, thus giving the best answer to the question posed.  Blood drug concentration and drug effects can be affected by the dose of the substance used, length of time between the dose and death, drug metabolism, drug absorption differences, route of administration, how long the drug has been used (tolerance), did the subject stop using the drug and then start again (loss of tolerance), age and sex of the individual, underlying pathology or observed disease states, individual drug stability in blood, postmortem redistribution or PMR (collect a peripheral blood to help minimize PMR), protein binding, and the accumulation of active metabolites.  There is also the first Academy Standards Board standard for Medicolegal Death Investigation entitled, Organizational and Foundational Standard for Medicolegal Death Investigation, ANSI/ASB 125 First Edition, 2021.

Let’s look at some specific drugs and case histories to illustrate the difficulty with the interpretation of toxicology findings.  These examples are nowhere near all inclusive.    

Examples of two drugs that need to be interpreted in context are fentanyl and ketamine.  Both of these drugs are commonly used medically therefore if a decedent is in the hospital or had emergency treatment prior to death, it would be important to have medical records, especially if the case is a suspected drug overdose.  Tolerance or lack of tolerance is one, but not the only, important variable to consider.  Two drugs that result in high tolerance are methadone and fentanyl.  During the time of methadone clinics for heroin treatment, methadone concentrations in tolerant subjects were documented up to 3000 ng/mL, range of 30 to 3000, and ranged from 20 to 2000 in impaired drivers.  Blood concentrations found in the postmortem blood of people who died from methadone toxicity ranged from 60 to 3100 ng/mL.  These large, overlapping ranges can possibly be explained by tolerance, but PMR and the presence of other central nervous system (CNS) depressant drugs can also play a role.  Also, underlying disease can result in a subject being more sensitive to a drug’s toxic effects. Methadone is cardio-toxic therefore those with cardiac disease may be more sensitive to methadone toxicity than those that do not have cardiac disease. 

Fentanyl was predominately used in a medical setting; the first abuse of fentanyl was diversion of the medical product.  In that time a fentanyl therapeutic range from clinical data was 0.3 to 3.8 ng/mL, therefore a value of 8 ng/mL or more was thought to be a possible cause or at least contributory to death.  However since the mass abuse of the illicitly manufactured fentanyl, the concentration of fentanyl in ante-mortem toxicology case work has been increasing.  Driving under the influence of drugs data is a great way to gain an appreciation of tolerance in the user population.  In a study of 186 living subjects from driving under the influence of drugs case work, showed fentanyl concentrations ranging from 0.5 to 303 ng/mL, with a mean of 11.8 and median of 5.5 ng/mL (hospital records were reviewed to exclude those cases in which fentanyl was administered).  In this same study there were 238 central blood samples from postmortem cases where fentanyl was listed in the COD which showed a range of 0.7 to 636 ng/mL with a mean of 32.5 and a median of 19.3, and 58 peripheral blood samples from postmortem cases which showed a range of 0.9 to 78 ng/mL with a mean of 14 and a median of 10.  As shown by this data, fatal and impairing concentrations of fentanyl overlap and the clinical therapeutic range determined years ago no longer applies to most fentanyl cases today.  A review of the autopsy and investigation findings is important for fentanyl positive cases.   

For those decedents with a history of respiratory conditions, opioids like fentanyl and other drugs that cause central nervous system depression can be fatal at lower concentrations.  Decedents with cardiovascular or hypertensive disease are more sensitive to the toxic effects of stimulant drugs like cocaine, methamphetamine, MDMA, pseudoephedrine, caffeine, etc.  Drugs whose toxic effects include seizures can lower the threshold of toxicity if the decedent already has a seizure disorder. While the drug may not be the direct cause of death, it may be contributory to the death in combination with the underlying disease state.  There are many variables to consider in each case and there is no one size fits all type of reference range for forensic toxicology testing nor should there be.  The interpretation hinges on the context and circumstances of the specific case. Axis Forensic Toxicology understands that one should never practice toxicology strictly by the numbers and we are able to help with interpretation of the toxicology results in your case work.  If you have any questions or concerns regarding a substance’s role in your medicolegal death investigation, please reach out to our subject matter experts at [email protected]. 

“All things are poisons, for there is nothing without poisonous qualities.  It is only the dose which makes a thing poison.” (Paracelsus).   

References 

  • ANSI/ASB 037, Guidelines for Opinions and Testimony in Forensic Toxicology, 2019. https://www.aafs.org/asb-standard/guidelines-opinions-and-testimony-forensic-toxicology 
  • ANSI/ASB 125, Organizational and Foundational Standard for Medicolegal Death Investigation, 2021.  https://www.aafs.org/asb-standard/organizational-and-foundational-standard-medicolegal-death-investigation
  • Baselt, Randall C., Disposition of Toxic Drugs and Chemicals in Man, 12th Edition, Biomedical Publications, 2020.  
  • Havro, V., Casassa, N., Andera, K., and Mata, D., A Two-Year Review of Fentanyl in Driving under the Influence and Postmortem Cases in Orange County, CA, USA., Journal of Analytical Toxicology, Vol. 46, Issue 8, October 2022, pp. 875-881. 
  • Rohrig, Timothy P., Postmortem Toxicology Challenges and Interpretive Considerations, Elsevier Academic Press, 2019. 
  • Schulz, M., Iwersen-Bergmann, S.,Andresen, H.,and Schmoldt, A. Therapeutic and toxic blood concentrations of nearly 1,000 drugs and other xenobiotics, Critical Care, 2012, 16:R136. 
  • Stephenson, L., Van Den Heuvel, C., Scott, T., and Byard, R.W., Difficulties Associated with the Interpretation of Postmortem Toxicology, Journal of Analytical Toxicology, Vol. 48, Issue 6, July 2024, pp. 405-412. 
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Axis Offers Training Opportunities for Forensic Pathology Medicine Fellows

By Kevin G. Shanks, M.S., D-ABFT-FT  

Axis Forensic Toxicology prides itself in its ability and willingness to provide continuing education and training for our forensic toxicology clients. One of these educational avenues is the Axis forensic medicine fellow training rotation program. We are planning now for our Spring 2025 program.

In this weeklong virtual training program, a Forensic Medicine Fellow will be introduced to the set-up and operation of the modern postmortem forensic toxicology laboratory, alongside descriptions of the analytical instrumentation and analytical methods employed by the laboratory. Board certified forensic toxicologists will discuss the importance of toxicology specimen collection and present a survey of the major illicit and pharmaceutical drugs (e.g. ethanol, cocaine, methamphetamine, MDMA, heroin, fentanyl, and prescription opioids) with respect to mechanisms of actions, their detection, and their relevance to cause of death determination. Novel psychoactive substances (NPS), to include designer benzodiazepines, synthetic cannabinoids, substituted cathinones, fentanyl analogs, nitazene derivatives, xylazine, and mitragynine (kratom) are also discussed in depth. 

The forensic toxicology forensic medicine fellow training rotation instills the Fellow with confidence in interpreting the significance of toxicological findings with respect to cause and manner of death classification. Peer reviewed scientific references provided to the Fellow lay a foundation for a body of knowledge that may aid in the resolution of drug-related deaths by the forensic pathologist. One-on-one toxicology case review with a forensic toxicologist surveying completed cases by the laboratory will be undertaken and is intended to give the Fellow an overview of how a “toxicology pending conference” is conducted between forensic pathologists and forensic toxicologists. 

If you are a forensic pathology fellow or a pathologist who directs forensic pathology fellows and are interested in learning more about this training opportunity, please reach out to Axis Forensic Toxicology’s toxicologists at [email protected] or call us on the phone at (317) 759 – 4869. 

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Poster Presentation: An Analysis of Drug Detections in Carfentanil Cases from 2020-2024

By Stuart Kurtz, D-ABFT-FT

This year at the annual meeting for the Society of Forensic Toxicologists (SOFT), we presented data looking at the detections of other drugs in cases with carfentanil detected. This was a continuation of data presented at the Midwest Association of Toxicology and Therapeutic Drug Monitoring (MATT) annual meeting earlier this year. The presentation at MATT focused on where the cases were and how many we were seeing over time. This post can be found at the link below. 

https://axisfortox.com/carfentanil-through-the-years-a-look-at-data-from-2016-2024/ 

During the Q&A portion of that presentation, I was asked if carfentanil is seen by itself or is it usually with other drugs. That prompted the creation of the SOFT presentation. I expanded the number of detections graph to include 2024 through the end of September. We have had 82 detections of carfentanil during that time period. Kentucky (42) and Indiana (21) have the highest number of detections with no other state having more than 5 during the same time period. 

Figure 1: Number of detections of carfentanil in casework from 2016 through September 30, 2024. The table below the graph expresses the detections of carfentanil as a percentage of total cases tested for the same time period. Carfentanil was added to our 70510: Comprehensive Panel, Blood in 2020 and is screened in cases where this panel is ordered. 

In Figure 1, 2021 and 2022 had very few detections of carfentanil. This could be used to justify the removal of carfentanil from testing. The increase of cases starting in mid-2023 shows that caution should be taken when considering this. There is no guarantee that other novel psychoactive substances (NPS) will follow this pattern. NPS can have a cyclical nature to them where they may come and go from the drug supply over a period of years. If a lab validates a method to test for an NPS, they should consider keeping it as part of their testing scope even if the number of detections drops to 0 for an extended period of time. 

In cases where carfentanil was detected with xylazine (5), bromazolam (6), and fluorofentanyl (22), fentanyl was detected in all of those cases. Overall, carfentanil and fentanyl were detected in 153 cases. Carfentanil was detected in 79 cases without fentanyl. The top detections in those cases were 4ANPP (20), cocaine as benzoylecgonine (11), methamphetamine (11), and acetylfentanyl (9). 7 of the 247 cases since 2020 had carfentanil as the only drug of interest. While this is a small number, the circumstances of those cases may not account for cause of death (COD) without knowing carfentanil is present. 

Even though carfentanil is rarely the only drug of interest, it may help to explain COD. A history of use of drugs like heroin, methamphetamine, or fentanyl may indicate a high tolerance. Toxicology results with low to moderate amounts may not give a clear indication of COD but the presence of a drug like carfentanil, with its high potency, may tie it all together. Carfentanil is available with Analyte Assurance™ as part of the 70510: Comprehensive Panel, Blood and as a directed test in the 13810: Designer Opioids Panel, Blood. Awareness of seized drugs in a jurisdiction is a huge help in determining whether a seemingly negative toxicology report needs an additional look. 

If you have any questions about this presentation, need help with the interpretation of results, or want to request a copy of the poster, please contact us at [email protected] or 317-759-4869 option 3. 

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Axis Forensic Toxicology Announcement: Dr. Laureen Marinetti Appointed to Medicolegal Death Investigation Consensus Body

Axis Forensic Toxicology is pleased to announce that our Chief Toxicologist, Dr. Laureen Marinetti, has been appointed to the Medicolegal Death Investigation Consensus Body under the American Academy of Forensic Sciences’ Academy Standards Board (ASB). This appointment reflects Dr. Marinetti’s dedication to advancing forensic toxicology and her commitment to enhancing the standards and practices in the field.

The Medicolegal Death Investigation Consensus Body is a key component of the ASB, focused on developing, approving, and enforcing recognized standards in forensic science. These standards play a critical role in ensuring accuracy, reliability, and integrity in death investigations.

Dr. Marinetti brings a wealth of experience and expertise to this important group. With over two decades of leadership in forensic toxicology, she has been instrumental in addressing emerging trends, advancing methodologies, and contributing to public health and safety. Her role at Axis has consistently underscored the importance of scientific rigor and collaboration in forensic investigations.

At Axis, we are proud to support professionals like Dr. Marinetti, who contribute to the development of best practices across the forensic community. Her appointment to the Medicolegal Death Investigation Consensus Body highlights her contributions to the field and Axis’ ongoing commitment to supporting advancements in forensic science.

Please join us in congratulating Dr. Laureen Marinetti on this significant achievement. Her work with the Consensus Body will help shape the future of medicolegal death investigations and further strengthen the standards that serve our communities.

For more information about Dr. Marinetti’s work and Axis Forensic Toxicology’s services, visit http://axisfortox.com.

About Axis Forensic Toxicology
Axis Forensic Toxicology is a leading provider of comprehensive toxicology services, specializing in postmortem, criminal, and clinical testing. With a commitment to scientific excellence, accuracy, and timely reporting, Axis supports medical examiners, coroners, and law enforcement agencies across the country. Our state-of-the-art laboratory, highly trained professionals, and dedication to quality assurance ensure reliable results that meet the highest standards. At Axis, we are driven by innovation and collaboration, helping our clients address complex toxicological challenges and make informed decisions that protect public health and safety.

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