The Center for Forensic Science Research and Education (CFSRE) has issued two public alerts this month regarding next-generation opioids.
The latest, just released on Friday, warns of the emergence of protonitazene, an opioid that is approximately three times more potent than fentanyl. While its potency is similar to other nitazene opioids, protonitazene is actually a structural isomer of isotonitazene. However, it is dissimilar in structure to the synthetic opioids typically encountered in forensic casework, like fentanyl and heroin—necessitating increased analytical specificity during toxicological analysis.
Protonitazene was first reported by CFSRE’s NPS Discovery in May following in initial detection in a post-mortem toxicology case. Since then, eight more blood specimens have been associated with the opioid in postmortem death investigations in the U.S—in Iowa, Louisiana, New Jersey, Texas and Tennessee. Identifications of protonitazene have also been reported in Europe, as well as in British Columbia, Canada.
“The toxicity of protonitazene has not been examined or reported but recent association with death among people who use drugs leads professionals to believe this synthetic opioid retains the potential to cause widespread harm and is of public health concern,” writes CFSRE.
In a second public alert issued earlier this month, CFSRE noted the “unusual presentation” of drug-overdose symptoms in patients, especially for next-generation opioids.
For example, metonitazene was identified in toxicology samples collected from two female patients (in California and Michigan) who presented to their local emergency departments with signs and symptoms of suspected opioid overdose. However, unlike typical symptoms, both patients presented in cardiac arrest—a significant clinical finding not noted with other next generation opioids, according to CFSRE. While positive response to naloxone administration was noted for both patients, only one survived.
Also in Michigan, isotonitazene was identified in toxicology samples collected from two patients who presented to one emergency department experiencing depressed levels of consciousness. Both patients, male and female, reported the use of heroin prior to overdose. Each received two doses of naloxone and survived.
In Missouri, two patients presented to the ER with respiratory depression, one with decreased oxygen saturation. The male and female patients received 2 mg of naloxone each with a noted increase in respiratory rate and oxygenation. Toxicologists identified brorphine in the samples collected from both these patients.
“Understanding emerging drugs can help direct new or revised approaches to clinical treatment and harm reduction efforts,” writes CFSRE.
The new information regarding symptoms associated with specific next-generation opioids is part of a larger partnership between the American College of Medical Toxicology (ACMT) and CFSRE to comprehensively assess the role and prevalence of synthetic opioids and other drugs among suspected overdose events in the United States. The blood samples are collected from patients who present with a suspected opioid overdose to an ER at a participating site within ACMT’s Toxicology Investigators Consortium. The scope of testing, which is performed via liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS), targets more than 950 drugs among multiple classes.
“Our findings provide a near real-time assessment of the drug market and allude to resulting implications on clinical institutions,” said the forensic non-profit.