3 December 2021 - Adverse effects linked to next generation opioids reported in patients presenting to emergency departments after suspected opioid overdose

The objective of this announcement is to notify public health and safety, clinicians, law enforcement, first responders, medical examiners and coroners, forensic and clinical laboratory personnel, and all other related communities about new information surrounding new generation synthetic opioids in clinical settings after suspected opioid overdoses and presentation to emergency departments, including: metonitazene, N-piperidinyl etonitazene, isotonitazene, and brorphine.

Drug use can lead to adverse events and overdose scenarios where individuals present to emergency departments for clinical evaluation and/or treatment. The culprit can be traditional drugs (e.g., heroin, fentanyl, cocaine, methamphetamine) or novel psychoactive substances (NPS); however, proper drug testing methodologies must be employed for accurate identification and characterization. A partnership between the American College of Medical Toxicology (ACMT) and the Center for Forensic Science Research and Education (CFSRE) was established to comprehensively assess the role and prevalence of synthetic opioids and other drugs among suspected overdose events in the United States. Patients with a suspected opioid overdose presented to an emergency department at a participating site within ACMT’s Toxicology Investigators Consortium (ToxIC). Residual, discarded biological samples were obtained for testing against an expansive library of drugs and other substances...

10 December 2021 - New synthetic opioid protonitazene increasing in prevalence as “nitazenes” gain traction across the United States and Canada 

Protonitazene is a new, potent synthetic opioid bearing structural resemblance to etonitazene, a synthetic opioid that is nationally and internationally controlled. Protonitazene is dissimilar in structure to synthetic opioids typically encountered in forensic casework (e.g., fentanyl, heroin); however, protonitazene is a structural isomer of isotonitazene, requiring increased analytical specificity during toxicological analysis. In vitro pharmacological data suggest that this new opioid exhibits potency similar to other recently emergent “nitazene” opioids, and is approximately three times more potent than fentanyl. Protonitazene was first reported by NPS Discovery in May 2021 following initial detection in a toxicology case. To date, nine blood specimens associated with postmortem death investigations in the U.S. were confirmed to contain protonitazene; however, at least six additional cases have been discovered through toxicological surveillance by NPS Discovery as of December 2021. Identifications of protonitazene have also been reported from organizations in Europe. 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...

22 December 2021 - Etodesnitazene — New synthetic opioid identified during forensic death investigations in the United States and Canada

Etodesnitazene is a new synthetic opioid bearing structural resemblance to etonitazene, a synthetic opioid that is nationally and internationally controlled. Etodesnitazene is dissimilar in structure to synthetic opioids typically encountered in forensic casework (e.g., fentanyl, heroin); however, several analogues of this series (known as “nitazenes”) have recently emerged in several countries around the world. In vitro pharmacological data show that etodesnitazene is an active opioid agonist which is approximately four times less potent than fentanyl (a common phenomenon for analogues missing the 5-nitro group) but approximately six times more potent than morphine. Etodesnitazene was first reported by NPS Discovery in February 2021 following initial detection in a toxicology case. To date, ten blood and/or urine specimens associated with postmortem death investigations or clinical intoxications in the United States and Canada were confirmed to contain etodesnitazene. Identifications of etodesnitazene have also been reported from organizations in Europe. The toxicity of etodesnitazene 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 harm and is of public health concern.