The evolution of fentanyl-related substances: Prevalence and drug concentrations in postmortem biological specimens at the Miami-Dade Medical Examiner Department.

Since 2014, the Miami-Dade Medical Examiner Department (MDME) has observed a drastic increase in the number of fentanyl and fentanyl analog (fentanyl-related substances (FRSs)) fatalities since its introduction into the heroin and cocaine supply. Due to the prevalence of FRS in Miami-Dade County, the MDME toxicology laboratory began documenting each case in which fentanyl and/or a fentanyl analog was identified. Additional information monitored included demographics (age, race and sex), other drugs identified, cause of death (COD) and manner of death (MOD). From 2014 to 2022, the MDME toxicology laboratory analyzed a total of 1,989 cases that tested positive for FRS, of which 1,707 had detectable and/or quantifiable fentanyl concentrations in postmortem cases. The majority of decedents were white males (62%), and the predominant age range was 25-34 years. The most prevalent MOD was accident (93%) with the most common COD listed as acute combined drug toxicity of fentanyl in combination with other drugs (79%). Other drugs found in combination with fentanyl included heroin, cocaine (most prevalent), synthetic cathinones and ethanol. Of all FRS cases, 9% (170 cases) involved fentanyl alone as a COD, while 2% (38 cases) included only fentanyl analogs. Fentanyl concentrations ranged from 1.0 to 1,646 ng/mL in peripheral blood, 1.2 to 449 ng/mL in central blood, 3.2 to 28 ng/mL in donor blood (obtained during tissue harvesting), 1.1 to 108 ng/mL in antemortem blood, 8.5 to 1,130 ng/g in liver and 2.0 to 471 ng/g in brain. Drug concentrations were also reported for an additional eight fentanyl analogs. Considering the prevalence, high potency and constant evolution of FRS, it is important to continuously monitor trends and report drug concentrations in complex medical examiner casework in an effort to educate pathologists, law enforcement and local governments.

Comparison of Spectrophotometric Methods for the Determination of Carboxyhemoglobin in Postmortem Blood.

Carbon monoxide (CO) poisoning presents an interesting challenge for postmortem toxicology laboratories. The discontinuation of the CO-oximeter manufactured by Instrumentation Laboratories has left many forensic laboratories without this simple but reliable choice for the analysis of CO in blood. A comparable alternative that is quick and simple is analysis using a standard ultraviolet-visible spectrophotometer, which offers sufficient precision and accuracy for the measurement of percentage carboxyhemoglobin (%COHb) in postmortem blood. The hurdle for laboratories then becomes the selection of an appropriate spectrophotometric method since a variety of procedures have been published over the years. Four methods were evaluated based on literature findings and/or the appropriateness for postmortem testing. These methods are based on (i) relating %COHb to the ratio of COHb and Hb absorbance of a two-component system (two wavelengths), (ii) the multicomponent analysis of all hemoglobin species, (iii) the multicomponent analysis of a two-component system, and (iv) derivative spectroscopy. While all four methods performed similarly in terms of typical validation requirements, the ability to more effectively handle decomposed samples and the ease of sample preparation afforded (v) the multicomponent analysis of a two-component system-the most suitable for routine postmortem testing.

Method Validation of Seven Synthetic Cathinones by LC-MS/MS Analysis and the Prevalence of N-Ethylpentylone in Postmortem Casework.

N-ethylpentylone (NEP, ephylone, bk-EBDP) was the most prevalent synthetic cathinone detected by the Miami-Dade Medical Examiner Toxicology Laboratory from 2016-2018. There is limited information regarding the toxicity of NEP, however the few published reports suggest that NEP can cause serious toxic effects and sudden death. The purpose of this publication is to describe a validated LC-MS/MS method for seven synthetic cathinones (methylone, ethylone, butylone, dibutylone, α-PVP, pentylone, and NEP) and to present a detailed summary regarding the presence of NEP in postmortem casework at the Miami-Dade Medical Examiner Department. Post-mortem iliac blood, serum, liver, and brain specimens were prepared by solid-phase extraction with analysis by ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS-MS). Analyte linearity was established from 0.01 to 0.5 mg/L on a six-point calibration curve. A total of 101 NEP quantitations were performed using this method. Concentrations in postmortem case samples ranged from 0.01 mg/L to 2.7 mg/L. Iliac blood concentrations averaged 0.312 mg/L with a median of 0.137 mg/L (n=72) across all causes and manners of death. Approximately half of the cases were homicides in which the decedent was the victim of gunshot wounds or stabbing. Two of the three highest concentration cases of NEP (2.7 mg/L and 1.7 mg/L) involved 38-year old white males who were tasered by police prior to death. The psychostimulant effect of NEP may result in an excited delirium and/or hallucinogenic state. The concentration of NEP detected in accidental intoxication and polydrug cases overlapped with those attributed to other causes, including homicides and police involved deaths.

Qualitative Identification of Fentanyl Analogs and Other Opioids in Postmortem Cases by UHPLC-Ion Trap-MSn.

Since 2013, the Miami-Dade County Medical Examiner Department has experienced an increase in the number of opioid-related deaths. The majority of cases coincided with the introduction of fentanyl into the local heroin supply. From 2014 to 2015, Miami-Dade County experienced a near 600% increase in fentanyl-related deaths, followed by an additional 200% increase in 2016. In 2015, two novel fentanyl analogs were identified in medical examiner cases: beta-hydroxythiofentanyl and acetyl fentanyl. In 2016, four additional fentanyl analogs emerged: para-fluoroisobutyryl fentanyl, butyryl fentanyl, furanyl fentanyl and carfentanil, as well as the synthetic opioid U-47700. In order to address this epidemic, a method was developed and validated to identify 44 opioid-related and analgesic compounds in postmortem samples using ultra high performance liquid chromatography ion trap mass spectrometry with MSn capabilities. The limit of detection for all compounds ranged from 0.1 to 5 ng/mL, with a majority having MS3 spectral fragmentation. Blood, urine, liver or brain specimens from ~500 postmortem cases were submitted for analysis based on case history and/or initial screening results. Of those cases, 375 were positive for illicit fentanyl and/or one or more fentanyl analogs. Due to the potency of these compounds, they were almost always included in the cause of death. Worth emphasizing and extremely alarming is the detection of carfentanil in 134 cases, 104 of which were initially missed by gas chromatography mass spectrometry. By incorporating this sensitive, highly specific, and evolving screening procedure into the workflow, the toxicology laboratory continues to effectively assist the medical examiners in determining the cause and manner of death of decedents in Miami-Dade County.