Neptune's Elixir and ZaZa Red, obtained from a convenience store in North Carolina. Credit: CFSRE
Both the CDC and the Center for Forensic Science Research & Education (CFSRE) have now released warnings about a sudden increase in the use of tianeptine, also known as “gas station heroin.”
As an antidepressant, tianeptine is prescribed to treat depression and anxiety in some European, Asian, and South American countries, but it is not approved for medical use in the United States. Still, it can be found marketed as ZaZa, Tiana Red, Neptune’s Fix and more across many U.S. gas stations and convenience stores, especially in the southeast. These products are sold as dietary supplements or as “smart drugs” that allegedly enhance cognitive function. However, tianeptine has the potential to cause adverse opioid-like effects and has been linked to intoxication, overdoses and death.
According to CFSRE, Poison Control Center cases involving tianeptine exposure increased nationwide from 11 total cases between 2000 and 2013 to 151 cases in 2020.
Tianeptine induces euphoria at high doses via activation of mu-opioid and dopaminergic receptors. Its misuse shows effects similar to opioid toxicity including: respiratory depression, sedation, loss of consciousness and coma. Since tianeptine activates opioid receptors, naloxone can and should be used in the event of tianeptine overdose.
Tianeptine misuse has also been associated with psychosis in supratherapeutic doses, particularly in individuals with a history of substance abuse or psychotic disorders. There is also one documented report of intentional ingestion of tianeptine as part of a successful suicide attempt. In this case, a 26-
year-old man was found dead in his apartment next to multiple packets of 12.5-mg tianeptine tablets. Analytical testing revealed elevated tianeptine concentrations in the blood, urine, liver and stomach. The cause of death was attributed to suicidal ingestion of tianeptine in combination with alcohol consumption.
A Problem in New Jersey
From June 17 to Nov. 6, 2023, New Jersey’s Poison Center received 20 exposure calls from health care facilities regarding tianeptine use in 17 unique patients. These patients, who were distributed throughout the state, were aged 28–69 years.
Overall, 14 patients reported ingesting tianeptine in the form of Neptune’s Fix, a flavored elixir shot consisting of tianeptine and kavain, sold in small, colorful bottles in gas stations. All patients were described as having altered mental status upon evaluation. Other clinical effects included: tachycardia (11 patients); hypotension (10); seizure (8); cardiac arrest (1); and increased risk for ventricular arrhythmia (4). Among the 20 encounters, 13 of the 17 patients were admitted to an intensive care unit, and seven of the 17 underwent endotracheal intubation. There were no deaths.
Six samples of Neptune’s Fix from two of the reported cases were analyzed by CFSRE. Analysis identified variable compositions, most notably the presence of the two synthetic cannabinoid receptor agonists (SCRAs)—MDMB-4en-PINACA and ADB-4en-PINACA.
MDMB-4en-PINACA and ADB-4en-PINACA belong to the latest generation of structurally distinct synthetic cannabinoids. The clinical toxicity of MDMB-4en-PINACA remains poorly characterized; however, it demonstrates high potency in vitro and has been identified in postmortem forensic toxicology testing.
The Good News
Based on an analysis of seized drug samples from North Carolina drug investigations, the CFSRE does not believe tianeptine has entered the illicit drug supply at this time.
To make this determination, CFSRE researchers analyzed 59 random seized illicit drug samples from North Carolina. Twelve (20%) of the samples contained fentanyl, 16 (27%) were positive for cocaine, and 18 (30%) were positive for methamphetamine. One sample contained all three of those drugs in a mixture along with other opioids and/or adulterants. None of the samples, however contained tianeptine, suggesting that it is currently present in the specific products mentioned earlier.