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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.
Read MoreAxis 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.
Unpacking the Truth Behind “Pink Cocaine”
By Kevin Shanks, D-ABFT-FT
“Pink cocaine” has been in the news recently due to the death of Liam Payne, one of the vocalists from the pop music group, One Direction. He died after falling from the balcony of his hotel room in Buenos Aires, Argentina.
What exactly is “pink cocaine”?
It is literally just a bunch of drugs rolled into one powdery concoction and dyed the color pink. Drugs in “pink cocaine” may include ketamine, MDMA, methamphetamine, caffeine, or other novel psychoactive substances (NPS). And even though the name suggests it, “pink cocaine” most likely does not contain cocaine. Because of the lack of uniformity in illicit drugs, “pink cocaine” may differ in its makeup over time, from batch to batch. The mixture also goes by the name “tusi”, which may lead some people to believe that it may contain substituted/psychedelic phenethylamines such as 2C-B or 2C-I (which were originally synthesized by neuropharmacologist Alexander Shulgin), even though this has not been a reported as a regular constituent of the drug. According to the United States Drug Enforcement Administration (DEA), since 2020, they have seized a total of 960 pink powders. Four exhibits contained 2C-B and the other 956 contained other substances. And even though 2C-B has been detected in a few “pink cocaine”-related powders, Shulgin did not invent “pink cocaine” which has been previously erroneously reported by various media and news agencies.
Photograph of Pink Cocaine. DEA. https://www.dea.gov/pink-cocaine
The effects of “pink cocaine” are unpredictable due to the unknown nature of what specific substances are making up the concoction at the time of use. If it contains a dissociative anesthetic such as ketamine, the pharmacological effects may include sedation, dissociation, hallucinations, and delusions. If it contains a stimulant such as methamphetamine or MDMA, the effects may include tachycardia, hypertension, hyperthermia, and agitation. But again, the observed effects will be completely dependent on what specific substances are actually in the “pink cocaine” product.
Why is it dyed the color pink?
Most likely, the answer is to make it more memorable. Drug products are often dyed different colors to bring attention to them or to act as a branding mechanism. Bright colors are visually appealing and are often seen in the manufacturing of Ecstasy tablets. Brightly colored tablets of fentanyl, also known as rainbow fentanyl, were also a thing reported in the media a couple of years ago.
Liam Payne’s death was originally reported as being “pink cocaine”-related, but in November, officials in Argentina reported that the postmortem toxicology showed “traces of alcohol, cocaine, and a prescribed antidepressant”. He had used real cocaine, not “pink cocaine”.
In an unrelated story, “pink cocaine” has also been associated with the sexual assault and trafficking lawsuits involving rapper, record producer, and studio executive Sean “Diddy” Combs. Parts of the lawsuits claim that Diddy required employees to carry around “pink cocaine”, as well as other drugs, at all times for personal use.
Axis monitors for the compounds found in “pink cocaine”, as part of our Comprehensive Panel (order code 70510) with Analyte Assurance™. Screening is completed by liquid chromatography with quadrupole time of flight mass spectrometry (LC-QToF/MS) and confirmatory analyses are completed using liquid chromatography with triple quadrupole mass spectrometry (LC-MS/MS).
As always, if you have questions about “pink cocaine” or any other classical drug or NPS 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).
References
Liam Payne reportedly had ‘pink cocaine’ in his system when he died. NBC News. Hannah Peart. October 22, 2024. https://www.nbcnews.com/news/world/liam-payne-death-one-direction-pink-cocaine-toxicology-report-rcna176532
Tusi: a new ketamine concoction complicating the drug landscape. J.J. Palamar. Am J Drug Alcohol Abuse. September 2023. DOI: 10.1080/00952990.2023.2207716.
Pink Cocaine. United States Drug Enforcement Administration. https://www.dea.gov/pink-cocaine
Argentine prosecutors charge 3 people linked to the death of former One Direction star Liam Payne. AP News. Almudena Calatrava. November 8, 2024. https://apnews.com/article/argentina-payne-death-charged-e73f589a37a4a8f0e80e0b0e71d0f0f4
Diddy allegedly forced employees to carry pink cocaine at all times. VICE. Sammi Caramela. October 24, 2024. https://www.vice.com/en/article/diddy-pink-cocaine/
Read MorePoster Presentation: Not Your Typical TCA: A Review of Cases Involving Tianeptine
By Stuart Kurtz, D-ABFT-FT
At this year’s annual meeting of NAME, we presented a handful of case reports on tianeptine. We had previously provided some information on tianeptine in a blog post from September 18, 2023. The aim of this poster was to present cases where we detected tianeptine as the primary drug of interest. There were only 2 cases out of 6 presented where this was the case. One of these cases from District 14 Florida had contributing factors of acute pneumonia, chronic pancreatitis, and hepatic steatosis. The other case from Missouri had alcohol as a contributing factor.
Initially, there was a third case that looked to be a tianeptine only fatality. Additional testing by the Lorain County OH crime lab revealed that 2 opened bottles of Neptune’s Fix Tianeptine Elixir found at the scene contained ADB-4en-PINACA and MDMB-4en-PINACA which are synthetic cannabinoids. Using this information, we were able to test the submitted specimens for these drugs via our 42130: Synthetic Cannabinoids panel and confirm the presence of both in the blood.
Due to the current gray area surrounding the sale of products containing tianeptine, scene evidence can be extremely useful. Tianeptine is screened in Axis’ 70510: Comprehensive Panel with Analyte Assurance™ in Blood and confirmed through the 13710: Novel Emerging Compounds Panel but may not be a part of routine screening in all labs. Awareness of what the lab is testing for is important when scene evidence indicates a particular drug. Labeled products can also be tested due to the inconsistent nature of the manufacturing of these products. In the above case from Lorain County OH, additional testing revealed that there were other drugs involved. Product labels are a good starting point but further testing is important to ensure that all factors can be accounted for. The FDA has urged manufacturers of Neptune’s Fix Tianeptine Elixir to recall all products and as of February 2024, all of them have done so.
We would like to thank the following offices for their contribution to this project.
- Office of the District Medical Examiner, District 15 FL, Dr. Terrell Tops & Dr. Natalia Belova
- Office of the District Medical Examiner, District 14 FL, Whit Majors & Dr. Jay Radtke
- Office of the Coroner, Lorain County, OH, Dr. Frank P. Miller
- Southwest Missouri Forensics, Nixa, MO, Carla Yoder & Dr. Ransom Ellis
If you have any questions about this post or want to request a copy of the poster, please reach out to us at 317-759-4869 option 3 or [email protected].
Read MoreAxis Experts Present, Fall 2024
By Denise Purdie Andrews
This Fall, Axis’ expert toxicologists can be found speaking in multiple venues, helping to educate our clients and share expertise with other forensic scientists.
The National Association of Medical Examiner (NAME) 2024 Annual Meeting, which will be held in Denver, Colorado, from September 19-23.
- Toxicologist Stuart Kurtz will be presenting a poster on Saturday, September 21st: Not Your Typical TCA: A Review of Cases Involving Tianeptine.
- Laboratory Director Laureen Marinetti will make a platform presentation on Monday, September 23rd at 14:15 local time: Differentiating Emergent Ketamine from Illicit Abuse in Postmortem Cases.
- Axis’ CEO, Phil Roberts, will also be in attendance to answer your product and service questions.
The Society of Forensic Toxicology (SOFT) 2024 Conference will be held October 27 – November 1 in St. Louis, MO.
- Toxicologist Stuart Kurtz will present a poster, An Analysis of Drug Detections in Carfentanil Cases from 2020-2024.
- Laboratory Director Laureen Marinetti will present a poster, The Comparison of Whole Blood and Vitreous Fluid Drug Findings in Fifty Postmortem Cases.
Toxicologist Kevin Shanks has a forthcoming paper in the Journal of Analytical Toxicology:
We will be sharing more information about the content of these presentations in the coming months. If you would like copies of any of the presentations, please email [email protected] and a copy will be provided after they have been presented. 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!
Read MoreDrug Primer: Designer Benzodiazepines
By Kevin Shanks, D-ABFT-FT
What are Designer Benzodiazepines?
Designer benzodiazepines are substances synthesized to mimic the effects of traditional benzodiazepines, which are commonly prescribed for anxiety, insomnia, and other conditions. Unlike their pharmaceutical counterparts, designer benzodiazepines are often created in clandestine laboratories with the intention of circumventing the controlled substances act and other legal restrictions. These benzodiazepine compounds have similar sedative and anxiolytic effects but may also come with unpredictable purity, potency, and adverse effects mainly due to their unregulated production. Their emergence and proliferation on the illicit market present significant challenges for public health officials, coroners and medical examiners, and law enforcement, as they can lead to substance abuse, pose serious health risks to users, and potentially cause death in overdose.
Benzodiazepines work by affecting the central nervous system, primarily through action via gamma-aminobutyric acid (GABA). GABA is an inhibitory neurotransmitter that helps reduce excitability of neurons and essentially calms the brain’s activity. When the substance binds to the GABA receptor, chloride channels in the receptor open – this allows chloride ions to enter the nerve cell. This influx of chloride ions makes the neuron more negatively charged, which makes it less likely to relay a signal and slows down brain activity, which results in sedative, muscle relaxant, and anxiety reducing effects. While effective for their intended pharmaceutical uses as medications, benzodiazepines can also lead to tolerance, dependence, and withdrawal symptoms if used for prolonged periods or at high doses. Common adverse effects of the use of these compounds include drowsiness, tiredness, sedation, loss of motor coordination, slurred speech, amnesia, and respiratory depression.
Some examples of designer benzodiazepines are:
- Bromazolam – Bromazolam is a drug that has a history in pharmaceutical drug development as it was first synthesized in the 1970s as XLI-268, but it was never approved for medicinal use. The first emergence of bromazolam on the illicit drug market in the United States was in 2019, but it did not become prevalent until more recently. The substance is the brominated analog of alprazolam, meaning it has a bromine atom in the place of the typical chlorine atom. It is not currently considered a controlled substance by the United States Federal government.
- Clonazolam – Clonazolam is a drug that was first reported in 1971 in scientific research, but it did not become a pharmaceutical medication. Reports include strong sedative effects. It has recently been sold online as a novel psychoactive substance and in 2023, it was made a Schedule I controlled substance in the United States by the Federal government.
- Etizolam – Etizolam is a substance that was first patented in 1972, but is currently used as a pharmaceutical medication for the treatment of anxiety and insomnia in Italy and India. It is not authorized for use as a medicine in the United States and was first detected in the States in 2015-2016. It became a Schedule I controlled substance at the Federal level in 2023.
- Flubromazepam – Flubromazepam is a drug that also has a history in pharmaceutical drug development. It was first synthesized in 1960, but it did not receive any further study as a medicine. It appeared on the illicit drug market in 2012, but didn’t gain any traction for several years. Flubromazepam is a fluorinated analog of phenazepam, a benzodiazepine used as a medicine in Russia, meaning it has a fluorine atom in the place of the typical chlorine atom. It is not currently considered a controlled substance by the United States Federal government.
- Gidazepam (Desalkylgidazepam) – Gidazepam is a benzodiazepine used in Russia as a pharmaceutical medication for anxiety and certain cardiovascular disorders such as cardiac arrhythmias. Gidazepam acts as a prodrug and is rapidly metabolized to an active metabolite, desalkylgidazepam, which has a very long half-life (87 hours). Gidazepam is not currently considered a controlled substance by the United States Federal government.
Chemical Structure of the Designer Benzodiazepine Bromazolam Drawn by Kevin G. Shanks (2024)
The most recent data from the Drug Enforcement Administration’s (DEA) National Forensic Laboratory Information System in 2022 showed that the designer benzodiazepines clonazolam (5th), bromazolam (6th), etizolam (8th), flualprazolam (10th), and flubromazepam (14th) were now in the top 15 reported tranquilizers and depressants in the United States. Each of these compounds have been previously implicated in human intoxication cases involving driving motor vehicles as well as being involved in or associated with toxicity leading to fatality.
Because of these trends, Axis recently introduced an all-encompassing Designer Benzodiazepines panel of testing. This panel scope includes adinazolam, bromazolam, clonazolam and metabolite 8-aminoclonazolam, etizolam, flualprazolam, flubromazepam, flubromazolam, gidazepam (as desalkylgidazepam). This streamlined panel allows for easier potential identification of designer benzodiazepines in your medical-legal investigation.
As always, if you have questions about these substances and how they may apply to your toxicology casework or investigation, please reach out to our forensic toxicology experts by email ([email protected]) or phone (317-759-4869, Option 3).
Read MoreAxis Forensic Toxicology Confirms Transition of Chief Toxicologists and Appointment of New Laboratory Director Effective June 1, 2024
Axis Recognizes Postdoctoral Fellows
Axis is pleased to recognize the four Forensic Medicine Fellows that recently completed Axis’ toxicology rotation. The rotation is a week-long virtual program where participants reviewed many aspects of a modern forensic toxicology operation, including the instrumentation and methods, critical processes, and a survey of major illicit and pharmaceutical drugs and emerging compounds, their action upon the body and relevance to cause of death.
The 2024 follows were:
- Joshua Smith, DO, from the Jackson County, MO, Medical Examiner’s Office is a graduate of the Texas College of Osteopathic Medicine in Fort Worth, TX. He is board certified in anatomic and clinical pathology. At the conclusion of his fellowship, he will be serving as a deputy medical examiner with the Jackson County MEO.
- Shamaya Creagh Winters, MD, from the Fulton County, GA, Medical Examiner’s Office is a graduate of Wayne State University School of Medicine in Detroit, MI. She took her anatomic pathology exam this month. At the conclusion of her fellowship training, she will join the Fulton County MEO as an Associate Medical Examiner.
- Geunyoung Jung, MD, from the Marion County, IN, Coroner’s Office is a graduate of Pusan National University College of Medicine in Busan, South Korea. He is board certified in anatomic pathology. At the conclusion of his fellowship, he will join the Bexar County Medical Examiner’s Office (San Antonio, TX) as a deputy medical examiner.
- Ryan Bruhns, MD, from the Forensic Science Center (Pima County) in Tucson, AZ, is a graduate of the University of Arizona College of Medicine in Tucson, AZ. He is board certified in anatomic and clinical pathology. At the conclusion of his fellowship, he will remain with the Forensic Science Center.
Our fellows were very engaged in the presentations and topics. We are confident that they will serve our industry well and we wish them the best in their careers!
Axis is pleased to be able to offer this program to its clients in support of a well-functioning death investigation system. The rotation is typically offered each Spring. If you have or anticipate having a Fellow in your office and would like to participate, please contact our toxicologists at [email protected].
Read MoreChange to Third Party Storage Requests
Axis Forensic Toxicology has historically offered a service to store casework for a third party (typically a family member or law office) once our clients authorize a release. This has effectively been a behind-the-scenes service that benefits third parties, but creates a great deal of complexity for case transfer and storage on our end.
We wanted to communicate that we will no longer be offering this service for third parties. If our submitting client requests additional storage beyond the 1-year of storage that is provided with all cases, we will continue to offer that service as we always have. This change is specific to storage for third parties only.
The options that will be provided to those third parties will be to perform testing (which would also provide 12 months of storage) or to ship the case to a location of the third party’s choosing (either a dedicated storage facility that they have coordinated with or any other location they choose).
If you have any questions, please contact us at [email protected].
We look forward to serving you.
Sincerely,
Matt Zollman
Director of Operations & Product Management
Read MoreCarfentanil Through the Years: A Look at Data From 2016-2024
By Stuart Kurtz, D-ABFT-FT Last month, Axis was represented at the Midwest Association for Toxicology and Therapeutic Drug Monitoring’s annual meeting. Toxicologist Stuart Kurtz gave a presentation on the lab’s detections of carfentanil since Axis started testing for it in 2016. The focus of this presentation was on the increase in detections Axis noticed in 2023 and where Axis has been detecting carfentanil. This data is only representative of casework Axis has done. In a previous blog post, we wrote about a minor surge in detections in early to mid-2023. Due to the potent nature of carfentanil and implications for public health concerns, we wanted to refresh everyone’s minds that this drug can still be found in casework. 
*2024 is evaluated for 01/01/2024-04/26/2024 In the last month and a half since we looked at our 2024 data, Axis now has 61 detections for carfentanil. This puts 2024 on pace to be the 2nd highest year for detections since Axis started testing for it. It should be noted that prior to 2020, carfentanil was not included in Axis’ routine screening. It’s now a part of our 70510: Comprehensive Panel with Analyte Assurance or as part of the 13810: Designer Opioids Panel. While carfentanil detections represent a small percentage of total casework, ~1% in 2024 so far, its recent increase in detections was noticed in June 2023. Axis had 4 cases that month with a 5th case at the end of May. At this point, Axis’ toxicologists began to monitor the increase in detections to see if it continued. The number of detections held steady until a large increase November 2023. The main areas where this occurred were Florida and Kentucky. In a meeting with other members of Florida toxicology labs, they mentioned that they also saw an increase in detections of carfentanil around that time. In January 2024, detections in Florida decreased almost to zero while Kentucky remained steady. Kentucky continues to be the area with the most detections in 2024. Other states such as Indiana, Ohio, and Kansas are also seeing detections in 2024. 
*April 2024 is evaluated through 04/26/2024. As always, please reach out to Axis’ toxicologists with any questions regarding this data or help interpreting your results. You can email us at [email protected] or call us at 317-759-4869 option 3.