Trends in fentanyl and fentanyl analogue-related overdose deaths - Montgomery County, Ohio, 2015-2017.

INTRODUCTION: There is a lack of information on illicitly manufactured fentanyl and fentanyl analogue-related (IMF) unintentional overdose death trends over time. The study analyzes IMF-related unintentional overdose fatalities that occurred between July 2015 and June 2017 in Montgomery County, Ohio, an area with the highest rates of unintentional overdose mortality in Ohio. METHODS: LC-MS/MS-based method was used to identify fentanyl analogs and metabolites in 724 unintentional overdose death cases. The Chi-square statistic was used to assess differences over time in demographic and drug-related characteristics. RESULTS: The number of unintentional overdose death cases testing positive for IMFs increased by 377% between second half of 2015 and first half of 2017. The majority of decedents were white (82.5%) and male (67.8%). The proportion of fentanyl-only (no other analogs) cases declined from 89.2%-24.6% (p < 0.001), while proportion of fentanyl analogue-containing cases increased from 9.8%-70.3% (p < 0.001) between the second half of 2015 and first half of 2017. The most commonly identified fentanyl analogs were carfentanil (29.7%), furanyl fentanyl (14.1%) and acryl fentanyl (10.2%). Proportion of IMF cases also testing positive for heroin declined from 21.6% to 5.4% (p < 0.001), while methamphetamine positive cases increased from 1.4%-17.8% (p < 0.001) over the same time period. DISCUSSION: Emergence of fentanyl analogs contributed to substantial increases in unintentional overdose deaths. The data indicate a growing overlap between the IMF and methamphetamine outbreaks. Continuous monitoring of local IMF trends and rapid information dissemination to active users are needed to reduce the risks associated with IMF use.

Detection of diarrheic shellfish poisoning and azaspiracid toxins in Moroccan mussels: comparison of the LC-MS method with the commercial immunoassay kit.

Diarrheic shellfish poisoning (DSP) is a recurrent gastrointestinal illness in Morocco, resulting from consumption of contaminated shellfish. In order to develop a rapid and reliable technique for toxins detection, we have compared the results obtained by a commercial immunoassay-"DSP-Check" kit" with those obtained by LC-MS. Both techniques are capable of detecting the toxins in the whole flesh extract which was subjected to prior alkaline hydrolysis in order to detect simultaneously the esterified and non esterified toxin forms. The LC-MS method was found to be able to detect a high level of okadaic acid (OA), low level of dinophysistoxin-2 (DTX2), and surprisingly, traces of azaspiracids 2 (AZA2) in mussels. This is the first report of a survey carried out for azaspiracid (AZP) contamination of shellfish harvested in the coastal areas of Morocco. The "DSP-Check" kit was found to detect quantitatively DSP toxins in all contaminated samples containing only OA, provided that the parent toxins were within the range of detection and was not in an ester form. A good correlation was observed between the two methods when appropriate dilutions were performed. The immunoassay kit appeared to be more sensitive, specific and faster than LC-MS for determination of DSP in total shellfish extract.

Fatality Following Ingestion of Tetrahydrofuranylfentanyl, U-49900 and Methoxy-Phencyclidine.

Novel psychoactive substances (NPS), and specifically novel opioids, continue to cause adverse events, including death, within drug-using populations. As the number of opioid-related overdoses continues to increase, laboratories have identified the emergence of new fentanyl analogues and other synthetic opioid-related drugs. Tetrahydrofuranylfentanyl (THFF) has been identified in Europe and the United States as an emerging novel opioid, causing death in at least 15 drug-using individuals to date. THFF is structurally similar to furanylfentanyl, a previously characterized novel opioid responsible for numerous adverse events, including death. In this case report, THFF, U-49900 and methoxy-phencyclidine were identified in postmortem blood and urine specimens collected after a suspected overdose. As part of the death investigation, an unknown substance was collected from the scene and analytically confirmed as THFF and U-49900. To further assist laboratories in identifying THFF ingestion, metabolic profiling was conducted using pooled human liver microsomes. Characterized metabolites were then confirmed in the specimens collected during this investigation. In total, seven metabolites were identified for THFF, most notably THF-norfentanyl and hydroxyl-THFF. THF-norfentanyl provides utility as a biomarker because it is a unique metabolite of THFF. 4-Anilino-N-phenethylpiperidine (4-ANPP) and its metabolite, hydroxyl-4-ANPP, were identified in microsomal incubations and collected specimens, but usefulness as biomarkers is limited due to commonality between other fentanyl analogues and co-ingestion as a synthesis precursor. To our knowledge, this case report is the first to document a fatality after ingestion of THFF and U-49900 in the United States.

Persistent organochlorine chemicals in plasma and risk of non-Hodgkin's lymphoma.

Polychlorinated biphenyls (PCB) have been suspected as possible contributors to increasing non-Hodgkin's lymphoma incidence during the latter half of the 20th century based on their toxicologic properties and provocative epidemiologic reports. We investigated PCBs and other organochlorines and risk of non-Hodgkin's lymphoma in a population-based case-control study in the United States. Congeners of PCBs (including coplanar congeners), dioxins, furans and pesticides or pesticide metabolites were measured in plasma of 100 untreated cases and 100 control subjects. We used a multiple imputation procedure to fill in missing values of levels determined to be below the detection limits. Risks of non-Hodgkin's lymphoma associated with each analyte were estimated using conditional logistic regression for the continuous measure, exposure quartiles, trend across quartile categories, and exposures above the 95th percentile. Certain PCB congeners were associated with increased risk of non-Hodgkin's lymphoma, including coplanar PCBs 156, 180, and 194, with odds ratios for the highest versus lowest quartile ranging from 2.7 to 3.5, and significant trends. Each of the furan congeners was associated with risk of non-Hodgkin's lymphoma, as were total furans, with 3.5-fold increased risk for the highest versus lowest quartile and a significant trend across quartiles (P = 0.006). The toxic equivalency quotient (TEQ), a summed metric that weights congeners by their dioxin-like potency, was associated with non-Hodgkin's lymphoma, with 35% increased risk per 10 TEQ pg/g lipid (95% confidence interval, 1.02-1.79). Our results add to existing literature, which suggests that exposure to organochlorines contributes to non-Hodgkin's lymphoma risk; these risks were most apparent for certain PCBs and furans.

Postmortem and Toxicological Findings in a Series of Furanylfentanyl-Related Deaths.

Over the course of 4 months in 2015 and 2016, a cluster of seven fatal intoxications involving the opioid-analogue furanylfentanyl occurred in Sweden; toxicological analysis showed presence of furanylfentanyl either as the only drug or in combination with other illicit substances. Previous publications have only reported non-lethal furanylfentanyl intoxications. In the cases presented here, furanylfentanyl intoxication-alone or in combination with other drugs-was determined to be the cause of death by the responsible pathologist. All victims were young (24-37 years old) males, five of which had a well-documented history of drug abuse. Femoral blood concentration of furanylfentanyl ranged from 0.41 ng/g to 2.47 ng/g blood. Five cases presented a complex panel of drugs of abuse and prescription drugs. Moreover, in five cases the concurrent presence of pregabalin corroborates previous observations indicating pregabalin as a possible contributing factor in polydrug intoxications. We conclude that it is difficult to establish a specific lethal concentration of furanylfentanyl, due to incompletely known effects of possible pharmacokinetic and pharmacodynamic interactions with other drugs, as well as to the unknown degree of tolerance to opioids. We suggest that a full toxicological screening-to assess the possibility of drug interactions-together with segmental hair analysis regarding opioids-to estimate the level of opioid tolerance-be carried out to assist in the interpretation of cases involving synthetic opioids such as furanylfentanyl.

Ecological risk assessment for mink and short-tailed shrew exposed to PCBs, dioxins, and furans in the Housatonic River area.

A probabilistic risk assessment was conducted to characterize risks to a representative piscivorous mammal (mink, Mustela vison) and a representative carnivorous mammal (short-tailed shrew, Blarina brevicauda) exposed to PCBs, dioxins, and furans in the Housatonic River area downstream of the General Electric (GE) facility in Pittsfield, Massachusetts. Contaminant exposure was estimated using a probabilistic total daily intake model and parameterized using life history information of each species and concentrations of PCBs, dioxins, and furans in prey collected in the Housatonic River study area. The effects assessment preferentially relied on dose-response curves but defaulted to benchmarks or other estimates of effect when there were insufficient toxicity data. The risk characterization used a weight of evidence approach. Up to 3 lines of evidence were used to estimate risks to the selected mammal species: 1) probabilistic exposure and effects modeling, 2) field surveys, and 3) species-specific feeding or field studies. The weight of evidence assessment indicated a high risk for mink and an intermediate risk for short-tailed shrew.

The effect of disinfection by-products and mutagenic activity on birth weight and gestational duration.

Epidemiologic studies of disinfection by-products have traditionally focused on total trihalomethane (TTHM) concentration as a surrogate for maternal exposure during pregnancy. We used birth certificate data on 196,000 infants to examine the effect of third-trimester exposures on various indices of fetal development. We examined the effect of town-average concentrations of TTHM and additional exposure metrics in relation to mean birth weight, mean gestational age, small for gestational age (SGA) infancy, and preterm delivery. Trihalomethane data (TTHM, chloroform, and bromodichloromethane) from 1995-1998 were available for 109 towns in Massachusetts. Data from 1997-1998 on haloacetic acid (total haloacetic acids, dichloroacetic acid, and trichloroacetic acid), 3-chloro-4-(dichloromethyl)-5- hydroxy-2(5H)-furanone (MX), and mutagenicity were available for a limited number of towns. We observed reductions in mean birth weight (12-18 g) for maternal trihalomethane exposures > the 90th percentile compared with those < the 50th percentile. Birth weight reductions were detected for chloroform exposures > 20 microg/L and TTHM exposures > 40 microg/L. Elevated trihalomethanes were associated with increases in gestational duration and a reduced risk of preterm delivery. We found evidence of an exposure-response effect of trihalomethanes on risk of SGA, with odds ratios (ORs) ranging from 1.09 to 1.23 for bromodichloromethane exposures > 5 microg/L. Elevated mutagenic activity was associated with SGA [OR = 1.25; 95% confidence interval (CI), 1.04 to 1.51] and mean birth weight (-27 g; 95% CI, -54 to -1). Although smaller in magnitude, our findings are consistent with previous studies reporting associations between trihalomethanes and SGA. These data also suggest a relationship between fetal development indices and mutagenic activity independent of exposure to trihalomethanes, haloacetic acids, and MX.

First report of pectenotoxin-2 (PTX-2) in algae (Dinophysis fortii) related to seafood poisoning in Europe.

Pectenotoxin-2 (PTX-2), a polyether-lactone included in the neutral class of diarrhoetic shellfish poisoning (DSP) toxins, has been unambiguously detected in Dinophysis fortii collected in the northern Adriatic Sea (Emilia Romagna coasts). This is the first report of such a toxin in Europe. This lipid soluble toxin was identified both in crude methanolic phytoplankton extract and in the neutral fraction obtained by extract chromatography on a basic alumina column. The techniques used were reversed phase high-performance liquid chromatography followed either by UV diode-array detection (LC-UV-DAD) or by mass spectrometry (LC-MS) and tandem mass spectrometry (LC-MS-MS) using an atmospheric-pressure ionization source and an ionspray interface. Okadaic acid (OA) was also found in the D. fortii specimens and quantified as 15 pg/cell. Although quantitation of PTX-2 was not possible due to the lack of pure toxin, the high PTX-2:OA ratio suggested PTX-2 was significant in the D. fortii specimens. The presence of PTX-2 in a region with no previous report of DSP neutral toxic compounds may indicate a risk of human poisoning. Serious efforts should therefore be made to develop suitable routine methods capable of detecting the presence of PTXs in biological materials of marine origin, in order to assure the wholesomeness of seafood products.

Identification and quantitation of xenobiotics by 1H NMR spectroscopy in poisoning cases.

In order to analyse a wide range of xenobiotics and their metabolites present in biological fluids, NMR spectroscopy can be used. A large variety of xenobiotics (therapeutic agents, pesticides, solvents, alcohols) can be characterized and quantitated directly, without sample preparation. NMR investigations were applied to acute poisoning cases, involving drugs such as salicylates and valproic acid (VPA). In a salicylate poisoning case, the three major metabolites of acetylsalicylic acid have been detected in crude urine, and rapid identification of lysine revealed the origin of the intoxication, namely lysine acetylsalicylate (Aspegic). Valproic acid as its glucuronide was identified in urine samples from two poisoned patients. 1H NMR was also used to identify and quantitate paraquat (Gramoxone) in urine owing to its two aromatic signals at 8.49 and 9.02 ppm, in two acutely poisoned patients (183 and 93 mg/l). An intentional poisoning case with tetrahydrofuran (THF) was also investigated. Serum and urine samples were collected. THF was characterized by its resonances at 1.90 and 3.76 ppm, and quantified at 813 and 850 mg/l in the two biological fluids, respectively. Moreover, two other compounds were detected: lactate and gamma-hydroxybutyric acid (GHB). 1H NMR spectroscopic analysis of serum samples from three poisoned patients revealed methanol in one case and ethylene glycol in the two others. Moreover, in the same spectrum, the corresponding metabolites formate and glycolate were found. Compared with the reference chromatographic or spectrophotometric methods, requiring time-consuming extraction and/or derivatization steps, NMR spectroscopy allows the determination of many exogenous and endogenous compounds, without any pre-selection of the analytes.

1H NMR spectroscopic investigation of serum and urine in a case of acute tetrahydrofuran poisoning.

This article reports the investigation by 1H nuclear magnetic resonance (1H NMR) spectroscopy of biological fluids in a case of intentional poisoning with tetrahydrofuran (THF). Occupational exposures to this solvent are well documented, but acute poisoning cases are extremely rare, and the one presented here is the second known case of this kind. Urine and serum samples were collected. Without any pretreatment, the presence of THF was confirmed by characteristic resonances at 1.90 and 3.76 ppm; high lactate levels were also observed. The presence of gamma-hydroxybutyric acid (GHB) was noted. Quantitative analysis was performed by relative integration of peak areas. THF concentrations were 813 and 850 mg/L (11.3 and 11.8 mmol/L), and GHB concentrations 239 and 2,977 mg/L (2.3 and 28.6 mmol/L) in serum and urine, respectively. A gas chromatographic-mass spectrometric method confirmed 1H NMR observations. The origin of GHB detected in serum and urine is also discussed.

Counter-irritant and other medicinal uses of plants in Ranunculaceae by native peoples in British Columbia and neighbouring areas.

At least 20 species in Ranunculaceae, the buttercup family, are reported as having been used medicinally by 19 different groups of native peoples in British Columbia and adjacent areas. These species are known to contain the skin-irritating, blister-causing compound, protoanemonin, in their fresh state. Protoanemonin is almost certainly the active principle involved in many of these medicinal applications. A majority involved the use of the plants as external poultices for boils, cuts, abrasions and other skin sores. Other disorders having a high frequency of treatment with ranunculaceous species include: muscular aches, colds and other respiratory ailments, and general, unspecified illness. Native groups in other parts of North America also used many ranunculaceous species as poultices, and for colds, headaches and many other ailments. A number were used for stimulation and "revival" of unconscious persons. It is suggested that the protoanemonin contained in these plants may have, through several different mechanisms, positively influenced the healing process physiologically and not just psychologically. If future research confirms this, these protoanemonin containing plants may have potential in certain treatments in modern medicine.

Exposure and effects of chemical contaminants on tree swallows nesting along the Housatonic River, Berkshire County, Massachusetts, USA, 1998-2000.

Hatching success of tree swallows (Tachycineta bicolor) was assessed for three years in relation to chemical contamination along the Housatonic River, Berkshire County (MA, USA), in 1998, 1999, and 2000. Nest boxes were erected at five sites along the Housatonic River and its tributaries and at one reference location. Concentrations of total polychlorinated biphenyls (PCBs) were some of the highest ever reported in bird eggs. Mean concentrations at sites along the Housatonic River ranged between 32 and 101 microg/g wet weight. A significant negative relationship was observed between concentrations of total PCBs in clutches and hatching success. A significant negative relationship was also observed between hatching success and the sum of the total dioxins and furans and the associated toxic equivalents (TEQs) for dioxins and furans. In a combined model with PCB TEQs and dioxin/furan TEQs, PCB TEQs were not significantly correlated to hatching success, whereas dioxin/furan TEQs were. Contamination of tree swallows was from local food sources. Accumulation rates of total PCBs in 12-d-old nestlings averaged between 34 and 76 microg/d at the sites along the main stem of the Housatonic River compared to <1 microg/d at the reference location.

A review of the significance of animal food products as potential pathways of human exposures to dioxins.

The polychlorinated dibenzo-p-dioxins and dibenzofurans (dioxins) are groups of compounds with similar chemical and toxicological properties. Carcinogenicity was considered the most serious toxic end point when setting previous regulatory policies, but recent concerns have focused on the possible endocrine-disrupting activities of the dioxins. Toxicity is related to the 2,3,7,8 pattern of chlorine substitution, a pattern that also leads to chemical and metabolic stability. Dioxins are practically insoluble in water and concentrate in lipids of biological systems, leading to low background concentrations in fat of the general human population. Major environmental sources of dioxins are emissions from industrial chlorination processes and combustion of materials containing chlorine. Inhalation and water have been ruled out as significant exposure pathways, which suggests that food is the primary source. Pathways of entry into food chains are atmospheric transport of emissions and their subsequent deposition on plants, soils, and water. The major food sources seem to be fat-containing animal products and some seafoods. This conclusion is based on evaluations of potential environmental pathways involving dioxins and related compounds. Generally, dioxins and other lipophilic compounds are not taken up and translocated by plants, so residues in foods and feeds derived from seeds should be negligible. Animals on high-roughage diets, or those that ingest contaminated soil, are the most likely to accumulate dioxin residues from the environment. The conclusion that animal products are a major source of human exposure requires verification by appropriate food sampling programs and animal metabolism studies. If it is desirable to reduce human exposure to dioxins via the food supply, reduction of sources would be a more effective strategy than changing agricultural practices and food consumption patterns.

Ultrastructural observations in ponies after treatment with monensin.

Ultrastructural studies were made of myocardium, diaphragm, appendicular muscle, liver, and kidney of 3 ponies acutely poisoned with a single oral dose of monensin (4 mg/kg of body weight). These ponies developed severe signs of toxicosis and were killed 28 to 72 hours after treatment. Severe mitochondrial damage (swelling) and lipoidosis in myocardial tissues were observed in 2 of the 3 ponies; similar, but less severe, changes were observed in the 3rd pony. The hepatocytes of the 3 ponies were characterized by increased amounts of smooth endoplasmic reticulum, large numbers of lipid droplets, vacuoles bounded by fibrous material, and a 2-fold increase in the number of peroxisomes per cell. Some hepatocytes also contained a membrane-bounded protein-like body. The observations indicate that heart mitochondria are primary targets of monensin poisoning in ponies.

Effect of pretreatment with selenium-vitamin E on monensin toxicosis in cattle.

Ten female beef calves weighing approximately 180 kg each were allotted to 2 groups of 5 each before they were given (orally) monensin (50 mg/kg of body weight). In group A, the calves were given (IM) a commercial selenium-vitamin E (Se-E) preparation (0.25 mg of Se and 17 IU of alpha-tocopherol/kg of body weight) at 72 and 24 hours before monensin was given. The calves in group B were injected at the 2 times with isotonic saline solution. Clinical signs of monensin toxicosis, including lethargy and recumbency, appeared on day 2 in the calves given the Se-E pretreatment, compared with the onset on day 1 in the saline solution-pretreated calves. All calves in the 2 groups died, but mean survival time was longer in group A (4.4 vs 2.2 days). Lesions of monensin toxicosis were myocardial necrosis, skeletal myonecrosis, pulmonary congestion, and rumenitis. The frequency and severity of the lesions were similar for both groups of calves. The results of the present study indicate that Se-E pretreatment modifies the development of monensin toxicosis in cattle.

Clinical, clinicopathologic, and pathologic alterations in acute monensin toxicosis in cattle.

Twenty beef calves weighing approximately 180 kg were allotted to 3 groups. In group A, 6 calves were given 25 mg of mycelial monensin/kg of body weight orally and were evaluated at 1, 2, and 4 days for clinical, ECG, clinicopathologic, and pathologic alterations. In group B, 7 calves were given a single dose of monensin (40 mg/kg) and 5 were given a 2nd 40 mg/kg dose on day 7; calves were evaluated at days 1, 2, 4, 7, 8, 9, and 11. In group C, 2 calves served as controls. Monensin-treated calves developed anorexia, diarrhea, and lethargy after day 1. One group B calf died on day 7 with lesions of congestive heart failure. Electrocardiographic abnormalities were not observed in group A calves; in group B, prolongation of Q-T and QRS intervals occurred from days 2 to 11 and first degree heart block was seen from days 7 to 11. Clinicopathologic alterations included: increased serum activities of aspartate aminotransferase and creatine kinase in group B calves after day 2; decreased serum K+, Na+, and Ca2+ concentrations in both groups, and postdosing occurrence of leukocytosis. Calves were euthanatized sequentially and the lesions of monensin toxicosis were present in the heart, skeletal muscles, and rumen in groups A and B. Disseminated pale yellowish-brown areas of necrosis were present in the ventricular myocardium of 6 of 12 group B calves. Gross lesions were not present in the skeletal muscles or rumen. Microscopically, the myocardial and skeletal muscular lesions were characterized by sarcoplasmic vacuolation from mitochondrial swelling and lipid accumulation in calves killed after day 1 in groups A and B, and by myocardial necrosis with contraction bands, but without calcification, in group B calves killed by day 4. Acute rumenitis was present in groups A and B calves. Myotoxic effects of monensin may be related to its action as an ionophore producing altered intracellular ion concentrations and initiating degeneration and necrosis in striated muscle fibers.

Accidental monensin sodium intoxication of feedlot cattle.

Of 1,994 yearling and 2-year-old cattle in a winter feeding program, 117 died within 42 days of being fed toxic amounts of monensin sodium in a liquid protein supplement. Death losses commenced on the third day after ingestion of a toxic amount in the feed. Clinical signs in cattle that died in less than 9 days included anorexia, pica, diarrhea, depression, mild hindlimb ataxia, and dyspnea. Gross necropsy findings in cattle dying in the acute phase of the illness included hydrothorax, ascites, and pulmonary edema, as well as petechial hemorrhages, edema, and yellow streaking in skeletal and cardiac muscle. Cattle dying after 9 days had gray streaks in heart and skeletal muscle, generalized ventral edema, enlarged, firm, bluish discolored liver, and enlarged heart. Microscopic changes in cattle dying in the acute phase (less than 9 days) consisted of pulmonary edema, congestion, and hemorrhage. Cardiac and skeletal muscle had localized areas of edema, hemorrhage, and coagulative necrosis. In cattle dying after 9 days of illness, the changes included lymphocytic infiltration, sarcolemmal nuclear proliferation, and fibrosis in skeletal and cardiac muscle. Lungs contained increased alveolar macrophages and a few neutrophils. Centrilobular necrosis and mild fibrosis were found in the liver. Changes varied somewhat according to the area of heart or skeletal muscle that was affected. Active muscles, eg, those in the heart ventricles and diaphragm, were altered most severely. Intoxication appeared to be a result of sedimentation of monensin in the molasses carrier to give remarkable concentrations of the substance at the bottom of the holding tank.

[Massive poisoning by naftidrofuryl with severe disorders of rhythm and conduction]. / Intoxication massive par le naftidrofuryl avec troubles sévères du rythme et de la conduction.

The authors report the case of a 35-year old woman with normal heart who voluntarily poisoned herself by swallowing 6 grams of naftidrofuryl. She developed disorders of atrioventricular conduction and a ventricular-like arrhythmia with collapse which resolves after mechanical ventilation. Data from the literature indicate that naftidrofuryl possesses class I electrophysiological properties which must not be ignored and which account for the cardiac effects observed in this particular case and in cases of parenteral overdosage already reported. By analogy with class I antiarrhythmic agents, treatment of naftidrofuryl poisoning with disorders of conduction could include the administration of molar sodium lactate.

An outbreak of monensin poisoning in adult turkeys.

Monensin, fed in excess of 200 ppm caused mortality in Triple 5 and Triple 6 turkeys aged 25 weeks old and over. Mortality commenced three to four days after administering feed containing monensin and ceased three to five days after it was removed. This concentration of drug did not have any detectable adverse effects on Triple 5 turkeys fed from day old, four weeks old, or 11 weeks old for periods of two weeks.

Outbreak of monensin poisoning in cattle.

Following accidental overdosage with monensin, nine deaths occurred in a batch of 40, four-to-seven-month-old calves. A description of the incident is given including the findings on post mortem examination. Inaccurate on-farm feed mixing can present problems as was highlighted by this outbreak.