The rise and rise of fentanyl in postmortem casework

Forensic toxicology laboratories are navigating a period of time with increasing drug overdose deaths, an opioid epidemic, the impact of the COVID-19 pandemic, and the illicit drug market flooded with novel psychoactive substances. In New York City, the Department of Forensic Toxicology has experienced a 56% increase in postmortem casework in the past decade with fentanyl detected in 80% of all overdose deaths. Over a period of 2.5 years, 15,638 postmortem cases were tested for the presence of fentanyl and fentanyl analogs using liquid-chromatography tandem mass spectrometry (LCMSMS). Fentanyl was detected in approximately one third of cases and of these 4447 cases with femoral blood. A twofold increase in cases with high concentrations of fentanyl (>100 ng/mL) was observed between 2021 and 2022. The minor metabolite and precursor chemical, 4-ANPP (4-anilino-N-phenethylpiperidine) may help differentiate between illicit and licit fentanyl. 4-ANPP blood concentrations were <10 ng/mL in 98% of the cases and the 4-ANPP:fentanyl ratio was <0.67 for 99.1% of blood specimens. Only six cases had 4-ANPP concentrations higher than the corresponding fentanyl blood concentration. This study also highlights, the changing fentanyl analogs found in postmortem cases since 2016 in NYC with the emergence of fluorofentanyl initially identified in 2020 and continuing to dominate in comparison with the prevalence of other analogs, many of which are no longer detected in casework. The detection of one of the latest drugs to be mixed with fentanyl, namely xylazine, has also increased in prevalence by 36.7% in 2022 compared with 2021.     

Investigation of Postmortem Absorption and Redistribution After the Application of a Fentanyl Patch

Fentanyl deaths have increased with availability of transdermal patches. Interpretation of postmortem fentanyl levels may be complicated by postmortem redistribution and absorption of fentanyl from a patch. We applied an unused 100‐μg/h fentanyl patch onto the lower abdomen of a decedent with no premortem fentanyl exposure. Ocular fluid, blood, and urine were collected prior to placement, and the decedent was refrigerated for 23 h. Prior to the autopsy, urine, subcutaneous tissue under the patch, and samples from the same anatomic sites were obtained. We observed no fentanyl in any postpatch placement samples (LOD: 0.1 ng/mL for blood and vitreous fluid, 1.0 ng/mL urine, 2.0 ng/g for tissues). Although we observed no postmortem absorption of fentanyl, this was only a single case; therefore, we recommend that patches be removed after receipt of a cadaver before initiation of an autopsy, with the location of removed patch documented.     

Evaluating the sensitivity,stability, and cross-reactivity of commercial fentanyl immunoassay test strips

Illicit fentanyl has flooded the United States' drug market, increasing the risk of overdose and poisonings throughout the general population and accidental exposure among law enforcement officers confiscating the increasing number of seizures. Fentanyl test strips (FTS) are used to obtain presumptive information about the presence of fentanyl in a suspected sample. However, their adoption by law enforcement personnel and seized-drug analysts has been limited because most products are advertised for urine testing, not for assays using water solutions. This study presents an evaluation of four commercial FTS: Rapid Response from BTNX, Inc.; T-Dip Fentanyl (FTY) Urine Dip Cards obtained from Amazon.com ; Premier BioDip FYL10 from Premier Biotech Inc.; and MobileDetect Fentanyl strips from DetectaChem, Inc. Performance characteristics curves were used to compare the products' sensitivity, showing that all can reliably detect fentanyl in aqueous solutions at concentrations below 1 μg/mL, with some of the tests able to reliably detect the drug at 200 ng/mL. A stability study demonstrates the performance of all four FTS brands was only slightly affected after 30 days of storage at two extreme environmental conditions. Fentanyl-related substances are also evaluated using the Rapid Response FTS, which showed high cross-reactivity with para-fluorofentanyl and acetylfentanyl, but lower with ortho-chlorofentanyl, carfentanil, and 4-ANPP. Users should be aware that FTS may give false-negative results even when potentially dangerous levels of carfentanil are present. When testing other common drugs, adulterants, and diluents frequently encountered in seized tablets, concentration-dependent results were obtained and multiple instances of false positives were recorded.     

全血中氯霉素的固相萃取方法

目的建立全血中氯霉素的固相萃取方法。方法在空白血中添加标准氯毒素,采用HLB、MCX固相柱萃取,HPLC法测定了线性范围、精密度、回收率。结果回收率分别为：HLB为69.1%,RSD为6.21%,MCX为70.1%,RSD为4.34%。标准工作曲线Y=18.1094X-0.4822,相关系数r=0.9999,线性范围1.0-20.0ug/L,最小检出量3ng。标准添加工作曲线Y=-2.1165X＋14.0459,相关系数r=0.9996,最小检出限0.5μg/mL（S/N=10∶1）。结论此二种萃取柱均可用于氯霉素的固相萃取。     

尿中氯胺酮及其代谢物盘鉴和GC/MS/SIM测定

目的 研究尿中氯胺酮(KET)及其代谢物去甲基氯胺酮(NKET)的盘鉴(Disk SPE)。方法 用含有化学键合C18和强酸型强阳离子交换(SCX)基团的萃取柱SPEC.C18 AR/MP3萃取,加入萃取柱前的尿样用0.1mol/L磷酸盐缓冲溶液(pH 6)稀释,洗脱溶剂为含2％(v/v)氨水的乙酸乙酯;以2,4,6-三硝基甲苯(TNT)为色谱内标,GC/MS/SIM检测。结果 在加标量为0.5μg/mL、2μg/mL和6μg/mL的控制尿样中,KET和NKET的平均回收率分别为91.5％和79.9％,6次测定的RSD均为8.7％;线性范围0.02-8μg/mL,线性相关系数分别为0.9819和0.9964;检出限(S/N=3)分别为6ng/mL和4ng/mL;总离子色谱图背景低,杂质少。同一根萃取柱重复使用8次以上未见性能下降;嫌疑尿样中检出KET和/或NKET,和常规的液液萃取结果相符。结论 该方法适用于尿中KET和NKET的同时测定。     

LC／MS／MS法测定全血中马钱子碱和士的宁的含量

目的建立定量分析人全血中马钱子碱和士的宁的高效液相色谱质谱联用法。方法应用Oasis^TM MCX小柱进行固相萃取法提取，XTerra^TM RP18色谱柱分离。结果在该条件下，人血中马钱子碱和士的宁的线性范围为0．01—5．0μg／ml，最小检出限为0．2ng／ml；马钱子碱和士的宁在0．01—5．0μg／ml浓度范围内的回收率均在80％以上。结论高效液相色谱质谱联用法可定量测定血中马钱子碱和士的宁。     

Simultaneous Determination of 13 Anticoagulant Rodenticidesin Human Blood by Liquid Chromatography–Tandem Mass Spectrometry and its Application in Three Poisoning Cases

Anticoagulant rodenticides are widely used for rodent control around the world. A rapid and sensitive method was developed and validated for the simultaneous determination of 13 anticoagulant rodenticides (coumafuryl, pindone, valone, warfarin, coumatetralyl, coumachlor, diphacinone, dicumarol, chlorophacinone, bromadiolone, difenacoum, flocoumafen, and brodifacoum) in human blood by liquid chromatography–tandem mass spectrometry. After liquid–liquid extraction, the anticoagulant rodenticides were separated on an Eclipse Plus C18 column. Linearities were observed for each analyte in blood ranging from 0.5 to 50 ng/mL, with correlation coefficients over 0.99. The limits of detection ranged from 0.01 to 0.2 ng/mL, and the limits of quantification were 0.5 ng/mL for all analytes. The intraday and interday precisions were <15%, and accuracies ranged from 80.3% to 111.0%. This validated method with high sensitivity has been applied in three anticoagulant rodenticide poisoning cases and has been used successfully in monitoring blood concentrations for months.     

HS-SPME-GC/MS法检测尿液及毛发中苯丙胺类毒品

目的采用顶空固相微萃取（HS-SPME）、GC/MS分析方法,对生物样品中苯丙胺（AM）、甲基苯丙胺（MAM）、3,4-亚甲二氧基苯丙胺（MDA）和3,4-亚甲二氧基甲基苯丙胺（MDMA）4种苯丙胺类毒品进行定性定量分析。方法在碱性和饱和盐处理状态下,采用100μm聚二甲基硅氧烷（PDMS）萃取纤维,于顶空瓶中进行生物样品AM、MAM、MDA、MDMA 4种毒品萃取,以2-甲基苯乙胺为内标,经气-质联用选择离子检测（GC/MS/SIM）模式进行定性定量分析。对HS-SPME条件优化,对方法的精密度、准确度和检出限进行测定。结果 AM、MAM、MDA、MDMA 4种毒品尿液中的最低检出限为5ng/mL,毛发中的最低检出限为0.5ng/mg。尿液中线性关系范围为0.05μg/mL~5μg/mL,r〉0.991,回收率为82%~108%,RSD为2.6%~6.1%（n=5）;毛发中线性关系范围为5ng/mg~500ng/mg,r〉0.992,回收率为80%~113%,RSD（%）为1.4%~6.8%（n=5）。结论 HS-SPME-GC/MS各项定量参数符合分析要求。该方法简单、灵活、经济、快速、无溶剂,适用于生物检材中该类毒品的分析。     

Benzoylecgonine (cocaine metabolite) detection in hair samples of jail detainees using radioimmunoassay (RIA) and gas chromatography/mass spectrometry (GC/MS)

Benzoylecgonine (BE) was detected in hair samples using nonproprietary extraction methodology and modifications of well-established radioimmunoassay (RIA) screening/quantitative gas chromatography/mass spectrometry (GC/MS) confirmation procedures. Samples collected anonymously from a population of 48 jail detainees weighed between 5.3 and 61.2 mg. All of the 22 hair samples which had RIA results indicating the presence of BE or immunologically similar substances above a cutoff amount of 1.25 ng/sample (50 ng/mL) were confirmed by GC/MS. Several varieties of hair color and texture were tested, although in each general category there were samples which contained BE as well as other samples which did not reveal detectable amounts of BE. The range of concentrations in 22 hair extracts that screened positive were 0.26 to 18 ng/mg hair as determined by GC/MS. In comparison with other reports of cocaine-related substances in hair, these data show consistent concentrations.     

Emergence of fentanyl-related deaths in Travis County,Texas and surrounding areas: A retrospective review of postmortem fentanyl-related drug toxicities from 2020 to 2022

The opioid epidemic has affected the United States (US) for decades with fentanyl and its analogs accounting for a recent surge in morbidity and mortality. Currently, there is a relative lack of information characterizing fentanyl-related fatalities specifically in the Southern US. A retrospective study was conducted to examine all postmortem fentanyl-related drug toxicities in Travis County, Texas, encompassing Austin (one of the fastest-growing cities in the US), from 2020 to 2022. Fentanyl contributed to 2.6% and 12.2% of deaths submitted for toxicology between 2020 and 2022, respectively, representing a 375% increase in fentanyl-related deaths over this 3-year period (n = 517). Fentanyl-related fatalities primarily occurred in males in their mid-30s. Fentanyl and norfentanyl concentrations ranged from 0.58 to 320 ng/mL and 0.53 to 140 ng/mL with mean (median) concentrations of 17.2 ± 25.0 (11.0) and 5.6 ± 10.9 (2.9) ng/mL, respectively. Polydrug use was present in 88% of cases, with methamphetamine (or other amphetamines) (25%), benzodiazepines (21%), and cocaine (17%) representing the most frequently identified concurrent substances. Co-positivity rates of various drugs and drug classes widely varied over time. Scene investigations reported illicit powder(s) (n = 141) and/or illicit pill(s) (n = 154) in 48% (n = 247) of fentanyl-related deaths. Illicit oxycodone (44%, n = 67) and illicit “Xanax” (38%, n = 59) pills were frequently reported on scene; however, toxicology only identified oxycodone and alprazolam in 2 and 24 of these cases, respectively. The results of this study provide a better understanding of the fentanyl epidemic in this region creating an opportunity to promote increased awareness, shift focus to harm reduction, and aid in minimizing public health risks.     

人毛发中36种芬太尼类物质的HPLC-MS/MS检测方法

建立了同时对人毛发中36种芬太尼类物质快速定性定量检测方法,并成功应用于实际案件的检测。利用高效液相色谱-串联质谱(HPLC-MS/MS)技术,采用MRM(多反应监测)模式,用Waters ACQUITY BEH C18(100 mm×2.1 mm,1.7μm)色谱柱,柱温50℃,流动相为甲醇-0.1%甲酸的水溶液(V/V),梯度洗脱。毛发样品采用0.1%SDS、水、丙酮依次清洗后,研磨成粉末,称取约20 mg,加1 mL甲醇浸泡18 h,后再加入1 mL去离子水,混匀后过滤膜,用液相色谱-串联质谱进行检测。36种芬太尼类物质的检出限均为0.01 ng·mg^-1,保留时间RSD均小于0.33%。对芬太尼和阿芬太尼进行了定量分析,在0.01~2 ng·mg^-1范围内均具有良好的线性关系,判定系数R2分别为0.997和1,在0.05、0.2和1 ng·mg^-1的添加水平的回收率为89.34%~104.80%,基质效应为96.95%~112.59%,准确度范围为91.92%~102.34%,日内精密度范围为0.49%~6.84%,日间精密度范围为1.21%~7.00%。该方法简单、高效、准确、灵敏,可作为芬太尼类物质滥用情况的监测方法。     

LC-MS/MS分析人全血中五氟利多

目的建立人体全血中五氟利多浓度的液相色谱-质谱联用法（LC-MS/MS）分析方法。方法全血中五氟利多和利培酮（内标）经正己烷液-液提取后,采用Capcell Pak C18色谱柱（250mm×2.0mm5,μm）进行分离,流动相为乙腈：20mmol/L乙酸胺和0.1%甲酸溶液（75∶25,V/V）,流速为0.2mL/min,然后以MS/MS电喷雾正电离的多反应监测扫描方式（MRM）测定。用于定量分析的离子为m/z 524→109（五氟利多）和m/z 411→191（内标）。结果五氟利多的最低检测限为0.2ng/mL,在0.4～400ng/mL浓度范围内线性良好（r=0.9994）,低、中、高浓度（1ng/mL、10ng/mL、100ng/mL）准确度分别为97%,108%和95%,日内和日间RSD均小于15%。结论该方法简便、快速、灵敏,适用于全血中五氟利多浓度的测定。     

固相萃取-液相色谱-质谱法检验人全血中的地塞米松

目的采用固相萃取结合液相色谱-质谱法检验人全血中地塞米松。方法采用SPE提取全血,用UPLC-MS/MS方法测定,采用ESI离子源,MRM方式监测。结果地塞米松的检出限为0.05ng/mL,线性范围1ng/mL~100ng/mL,方法回收率大于78.1%,日内、日间精密度均小于15%。结论 SPE-UPLC/MS/MS检验人全血中地塞米松的方法简单、高效,可应用于人全血中地塞米松的检验。     

Oral abuse of fentanyl patches (Duragesic): seven case reports

In order to increase the understanding regarding the oral abuse and potential toxicity of fentanyl patches seven cases were identified over a 3-year period where fentanyl, either alone or in combination with other factors, contributed to death following the oral abuse of Duragesic patches. The decedents comprised three females and four males with ages ranging from 20 to 51 years. Postmortem blood fentanyl concentrations were determined in all cases and ranged from 7 to 97 ng/mL. Two deaths were classified as a fentanyl overdose, three deaths were classified as a fentanyl and ethanol overdose, one death was considered a mixed drug intoxication and the remaining death was determined to be a combination of fentanyl and medical causes. These cases represent the largest reported series of deaths following the oral administration of transdermal fentanyl patches and provide detailed information on the potential for the abuse of transdermal Duragesic patches via this route. The postmortem blood fentanyl concentrations detected for each of the decedents demonstrate the potentially fatal blood concentrations that can arise after this relatively rare route of administration.     

Fatalities associated with fentanyl and co-administered cocaine or opiates

Fatalities associated with fentanyl hydrochloride are increasingly seen in Massachusetts. Between September 2005 and November 2006, 5009 medicolegal investigations associated 107 deaths with licit or illicit fentanyl use, along with a co-detection of an opiate/opioid or cocaine/benzoylecognine, or both. Deaths associated with illicit fentanyl use occur in younger people (39.4 vs. 61.5 years) with higher fentanyl (17.1 ng/mL vs. 4.4 ng/mL) and lower morphine (76.9 ng/mL vs. 284.2 ng/mL) postmortem blood concentrations, and more frequent cocaine co-intoxication (65% vs. 3%), than deaths associated with illicit fentanyl use. A wide range of postmortem blood concentrations of fentanyl was detected (trace-280 ng/mL), with a minimum concentration of 7 ng/mL of fentanyl strongly associated with illicit use of fentanyl in poly-drug cases. The most commonly detected opiates/opioids in illicit fentanyl users were: morphine (29%), oxycodone (14.5%), and methadone (14.5%). Ethanol, cannabinoids, diazepam, citalopram, and diphenhydramine were each detected in greater than 10% of the licit fentanyl cases. Most fentanyl abusers died at their own home and their deaths were most often classified as accidental. Mapping of primary residences of decedents revealed conspicuous clustering of the illicit fentanyl use cases, as opposed to the random pattern in licit use cases. Fentanyl misuse is a public health problem in Massachusetts.     

Concentrations of unconjugated morphine, codeine and 6-acetylmorphine in urine specimens from suspected drugged drivers

Concentrations of unconjugated morphine, codeine and 6-acetylmorphine (6-AM), the specific metabolite of heroin, were determined in urine specimens from 339 individuals apprehended for driving under the influence of drugs (DUID) in Sweden. After an initial screening analysis by immunoassay for 5-classes of abused drugs (opiates, cannabinoids, amphetamine analogs, cocaine metabolite and benzodiazepines), all positive specimens were verified by more specific methods. Opiates and other illicit drugs were analyzed by isotope-dilution gas chromatography-mass spectrometry (GC-MS). The limits of quantitation for morphine, codeine and 6-AM in urine were 20 ng/mL. Calibration plots included an upper concentration limit of 1000 ng/mL for each opiate. We identified the heroin metabolite 6-AM in 212 urine specimens (62%) at concentrations ranging from 20 ng/mL to > 1000 ng/mL. The concentration of 6-AM exceeded 1000 ng/mL in 79 cases (37%) and 31 cases (15%) were between 20 and 99 ng/mL. When 6-AM was present in urine the concentration of morphine was above 1000 ng/mL in 196 cases (92%). The concentrations of codeine in these same urine specimens were more evenly distributed with 35% being above 1000 ng/mL and 21% below 100 ng/mL. These results give a clear picture of the concentrations of unconjugated morphine, codeine and 6-acetylmorphine that can be expected in opiate-positive urine specimens from individuals apprehended for DUID after taking heroin.     

紫外分光光度法和二阶导数光谱法测定水样中的敌草快

目的建立测定水样中的敌草快的分析方法。方法采用紫外分光光度法和二阶导数光谱法测定水样中的敌草快。结果紫外分光光度法直接测定水样中的敌草快,在0.1~50μg/mL范围内线性关系良好,日内,日间精密度均小于2.6%。二阶导数光谱法在0.1~10μg/mL线性关系良好,日内、日间精密度均小于1.29%。结论该两种方法快速、简单、灵敏,适用于环境监测工作。     

血液中64种常见有机氯菊酯类农药的快速筛查

目的建立人体血浆中64种有机氯菊酯类农药多残留的气相色谱（GC）快速筛查分析方法。方法空白人体静脉抗凝血用乙腈沉淀蛋白,乙酸乙酯∶环己烷（v/v,3∶1）进行液液萃取净化,使用HP-5色谱柱,采用气相色谱进行定性、定量分析。对方法进行优化并进行方法学评价。结果 64种农药在0.001~0.1μg/mL范围内线性关系均良好,相关系数在0.990 1~0.999 9之间。检出限在0.001~0.15μg/mL范围内,方法定量限在0.001~0.5μg/mL之间,回收率总体于80%~110%之间,相对标准偏差小于15%,方法检出限总体于0.01μg/mL以下,日内精密度在1.5%~11.5%之间,日间精密度在2.9%~13.9%之间。结论本文建立的人体血浆的农药多残留快速筛查测定法,符合农药残留分析方法的要求,可在相关研究和实践中选用。     

GC/MS法检测全血中的奥氮平

目的采用乙睛-甲醇混合溶剂提取、气质联用分析法检测全血中奥氮平。方法针对奥氮平特性,在加入稳定剂硫代硫酸钠条件下采用乙睛-甲醇混合溶剂提取法,采用GC/MS分析法,对全血中的奥氮平进行定性、定量分析。并对提取介质、酸碱度、稳定剂种类及用量进行了考察。结果采用本文方法在奥氮平为1～400μg/mL浓度范围内呈良好的线性关系(r2=0.999 8,n=5),检出限为1.0ng,方法平均回收率可达66.5%(RSD=2.5%)。日内RSD为2.1%～3.9%,日间RSD为2.9%～4.5%。选择乙腈∶甲醇(V∶V=8∶2)混合溶剂进行液-液提取,稳定剂为300mg硫代硫酸钠。结论本文方法可用于全血中奥氮平检测,在相关案件检验中选择使用。