The purpose of this blog post is to take a look at some of our data regarding nitazene detections. For some background on nitazene compounds, take a look at our blog post of June 9, 2022 titled Drug Primer: Nitazenes. As a reminder, nitazenes are a structurally distinct class of opioids so non-specific tests such as color strips and immunoassays will not detect them.
For the SOFT 2022 meeting in Cleveland, Stuart Kurtz presented a poster titled Emergence of the Nitazene Class of Novel Synthetic Opioids in Postmortem Toxicology and Detection by LC-QToF-MS that looked at areas of detection as well as compounds found with nitazenes. Since that presentation, we examined the data through Q4 in 2022 to see what trends, if any, we could see in our casework. A big caveat is that the number of detections is a product of the testing being ordered. Nitazene screening is done as part of the comprehensive panel and not every case has comprehensive testing ordered.
One of the main takeaways from the poster was that only 11 out of the 128 cases examined had a nitazene present with no detection of fentanyl, morphine, methamphetamine, or cocaine. 83% of the cases had fentanyl detected with a nitazene. This is consistent with the trend of polysubstance overdose deaths rising and fentanyl being the dominate opioid detected.
Metonitazene was most commonly detected (n=102) with a big drop off to isotonitazene (n=22). Flualprazolam was the most common non-opioid NPS detected. Detection of opioids and NPS benzodiazepines has been an increasing trend in seized materials. Non-NPS detected included diphenhydramine (n=23) and gabapentin (n=16) which are suspected as cutting agents. It’s impossible to tell from postmortem toxicology work if a substance was cut with something but seized material data suggests that these are common cutting agents. Xylazine (n=7) has emerged as a common cutting agent and is gaining popularity in media. We will have more on xylazine in a future post. It is important to note that the presence of diphenhydramine or gabapentin does not necessarily mean they are a cutting agent since they are available over-the-counter and with a prescription respectively. Medical and prescription history is important in helping to determine where they may have come from.
The data from the SOFT poster was from June 2021 through May 2022. We went back and looked at the data through the end of 2022 to see if there were any trends regarding detection. We didn’t look at other drugs detected as we feel the sampling for the SOFT poster represents general trends well. We did see that the detections of nitazenes peaked in Q1 of 2022 and has dropped off through the end of 2022.
We updated the heat map regarding number of detections in each state. Keep in mind that Axis does not necessarily service the entirety of a state so actual numbers may be higher than what is shown. Indiana (n=130) is the leader in detections from our data. While the compounds that we test for may not be detected as often, that doesn’t mean that nitazenes as a class have completely disappeared.
The NPS landscape is always changing and requires us to adapt our testing scope. The best information we can have to help inform testing is testing unknown powders at the scene. A powder at a scene doesn’t mean that the person was exposed to it but it can be a big help in knowing what to look for and guiding you on future testing. The next best piece of information is knowing what is being found in seized materials in the region. Again, this doesn’t guarantee that a person was exposed to the NPS but helps make us aware of what we may need to test for.
As always, please feel free to reach out to us with any questions either by phone at 317-759-4869 option 3 or by email at [email protected].