CDC Issues Alert On Deadly New Designer Drug, Acetyl Fentanyl

Notes from the Field: Acetyl Fentanyl Overdose Fatalities — Rhode Island, March–May 2013

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6234a5.htm

August 30, 2013 / 62(34);703-704

In May 2013, the Rhode Island State Health Laboratories noticed an unusual pattern of toxicology results among 10 overdose deaths of suspected illicit drug users that had occurred during March 7–April 11, 2013. An enzyme-linked immunosorbent assay (ELISA) for fentanyl in blood was positive for fentanyl in all 10 cases, but confirmatory gas chromatography/mass spectrometry (GC/MS) did not detect fentanyl. The mass spectrum was instead consistent with acetyl fentanyl, a fentanyl analog. Acetyl fentanyl, a synthetic opioid, has not been documented in illicit drug use or overdose deaths, and is not available as a prescription drug anywhere. Animal studies suggest that acetyl fentanyl is up to five times more potent than heroin as an analgesic (1).

During May 14–21, 2013, CDC and Rhode Island public health officials conducted a field investigation to determine whether this cluster of 10 deaths represented an increase in the typical number of overdose deaths and what role might have been played by acetyl fentanyl. Data on illicit drug (cocaine, heroin, synthetic cathinones [bath salts], gamma-hydroxybutyric acid, and methamphetamine) overdose deaths during March 1, 2012–March 31, 2013 were abstracted from the Rhode Island Office of State Medical Examiners database and examined using Poisson regression. Data also were abstracted from autopsy reports, toxicology results, and medical records relating to the 10 deaths that were preliminarily positive for acetyl fentanyl. The state health laboratories performed all toxicology testing for acetyl fentanyl.

Investigators found that the number of illicit drug overdose deaths in Rhode Island was significantly higher in March 2013 (21, including 10 attributed to acetyl fentanyl), compared with the monthly average during March 2012&#8211;February 2013 (8.9, p<0.001). During the field investigation, two additional acetyl fentanyl overdose deaths were confirmed (dates of death: March 20 and May 16, 2013), bringing the total number of acetyl fentanyl deaths to 12. Among the 12 acetyl fentanyl decedents, ages ranged from 19 to 57 years, and eight were male. All but one of the deaths occurred in northern Rhode Island: six occurred in the same small city and none in the capital city, Providence. Evidence suggested that acetyl fentanyl was administered intravenously in at least four (33%) of the deaths. The route of acetyl fentanyl administration was undetermined for the remaining eight decedents.

The GC/MS toxicology results for 10 of the 12 decedents showed, in addition to acetyl fentanyl, various mixtures of other drugs, including cocaine (58%), other opioids (33%), ethanol (25%), and benzodiazepines (17%). None of the decedents tested positive for fentanyl by GC/MS. Toxicology results for one decedent showed only acetyl fentanyl. Since completion of the field investigation, two persons using acetyl fentanyl together died on May 26, 2013, increasing the number of acetyl fentanyl deaths to 14.

Acetyl fentanyl overdose deaths have recently been confirmed in Pennsylvania (2). If states observe clusters or increases in illicit opioid-related overdoses above expected levels, acetyl fentanyl could be involved and confirmatory testing will be needed. CDC encourages public health officials and laboratories, when feasible, to use an ELISA test to screen specimens from suspected illicit, nonpharmaceutical opioid overdose deaths. If an ELISA test is positive for fentanyl, CDC recommends laboratories conduct confirmatory testing by GC/MS; if no fentanyl is detected by GC/MS, then fentanyl analogs should be suspected, and subsequent testing should be considered.

Naloxone is an opioid antagonist that can reverse potentially fatal opioid-induced respiratory depression and is used as part of the initial treatment of suspected opioid overdose. Because of the increased potency of acetyl fentanyl, larger doses of naloxone might be needed to achieve reversal (3); health-care providers who administer naloxone in emergencies might consider increasing the amount they keep on hand. In addition, expansion of community-based programs that provide opioid-overdose prevention services, including distribution of and training in the use of naloxone, might be an effective strategy to help reduce opioid-related overdose deaths (4).

Reported by:

Laurie Ogilvie, MS, Rhode Island State Health Laboratories; Christina Stanley, MD, Rhode Island Office of State Medical Examiners. Lauren Lewis, MD, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Molly Boyd, MD, Div of Toxicology and Human Health Sciences, Agency for Toxic Substances & Disease Registry; Matthew Lozier, PhD, EIS officer, CDC. Corresponding contributor: Matthew Lozier, [email protected], 770-488-0794.

References:

1. Higashikawa Y, Suzuki S. Studies on 1-(2-phenethyl)-4-(N-propionylanilino) peperidine (fentanyl) and its related compounds. VI. Structure-analgesic activity relationship for fentanyl, methyl-substituted fentanyls and other analogues. Forensic Toxicol 2008;26:1&#8211;5.
   
2. Pennsylvania Department of Drug and Alcohol Programs. Department of Drug and Alcohol Programs warns about acetyl fentanyl: drug caused at least 50 fatalities this year in Pennsylvania. Harrisburg, PA: Pennsylvania Department of Drug and Alcohol Programs; 2013. Available at http://www.pa.gov/portal/server.pt/..._programs_warns_about_acetyl_fentanylExternal Web Site Icon.
   
3. Schumann H, Erickson T, Thompson TM, Zautcke JL, Denton JS. Fentanyl epidemic in Chicago, Illinois and surrounding Cook County. Clin Toxicol 2008;46:501&#8211;6.
   
4. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013;346:f174.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6234a5.htm

 

Note: very little info is available on this drug. There is not even a wiki stub on it. Here is the structural formula:

Here is the only Bluelight thread with "acetyl fentanyl" in the title:

http://www.bluelight.ru/vb/threads/615138-Need-information-on-Acetyl-Fentanyl-(AcetylFentanyl)

Acetyl fentanyl production by illicit chemists is a logical consequence of the Suspicious Substance List and the full frontal assault on any item that can be used in illicit methamphetamine production; there will likely be more acetyl fentanyl seen on the streets because propionyl chloride & propionic anhydride used to make fentanyl proper, are List 1 Suspicious Substances, requiring DEA notification in any amount; whereas acetic anhydride, which when substituted for the previously mentioned items makes acetyl fentanyl, is a List 2 Suspicious Substance and only requires DEA notification in over 55 gallons.

The name acetyl fentanyl is misleading and would, to a medicinal chemist, imply an additional acetyl group on the fentanyl molecule; whereas, the structure shown should be called desmethyl-fentanyl or nor-fentanyl because there is one less methyl group on the tertiary non-piperidinal nitrogen. I am not trying to be anal-retentive in the naming of this drug, but being on both sides of the fence so to speak, I have heard of and seen naming convention issues in less sophisticated chemists, become issues of small scale poisoning, and while I'm not suggesting that will be the case here, it should be nipped in the bud on general principle.

However, the reason for my post is this: there are gross over-exaggerations in opioid overdose deaths as well as other drug related deaths, for example, Michael Jackson, when multiple drugs are involved. These polydrug deaths, especially when an opioid is combined with a benzodiazepine, any other sedative-hypnotic or alcohol, that skew the data and have a net result ultimately of making it more difficult for pain patients to receive adequate analgesic dosages to relieve chronic pain. Michael Jackson cannot be said to have died of a propofol overdose when he had multiple sub-lethal (if administered alone) benzodiazepines in his system. He died from respiratory depression associated with a polydrug overdose with propofol contributing the major share. In these acetyl fentanyl deaths, without toxicology information in front of me, it is difficult to pick out which drug contributed which amount to the death in question. And even with the toxicology data, without a live patient or other individual, especially when one of the drugs involved is an opioid, it is virtually impossible to accurately view the data. When I was using fentanyl, I would routinely inject 150 mg not 150 mcg from 6-8 times a day. If I had died during this period of drug abuse, any medical examiner in the country would have said I took a lethal amount of fentanyl. And every single one of them would have been wrong. People who have long histories with opioids and other drugs, as well as atypical access, should not be the reason that people in chronic pain do not receive adequate analgesia. The fact still remains, when taken orally, as directed without additional drugs concomitantly, opioids are relatively safe. The usual course of action, especially with IR (as opposed to CR or SR) opioids, is to vomit the dose prior to lethal respiratory depression. Now this doesn't work in the case of parenterally administered opioids, but oral opioids rarely kill by themselves. Alcohol is often enough to push a sublethal oral dose into the lethal range, and it seems rare to find cases where absolutely no alcohol was consumed in the case of many deaths if adolescents or young adults. But let's stop naming polydrug overdose as opioid overdose because the data skew can and usually does, have far reaching implications and consequences.

MobiusDick

 

When I was using fentanyl, I would routinely inject 150 mg not 150 mcg from 6-8 times a day.

Are you a brachiosaurus?

 

Lol i was going to say elephant

 

More fake heroin on the streets. Awesome.


Good thing I'm over 4 months sober, and don't live on the east coast anymore.

 

New opioids besides desomorphine? Please tell me about these!!!!

Is it fucked up i want some of this stuff, bad? Though, when i tried plain fentanyl (cut open a patch and shot a pea sized gel ball after dissolving in water), i was bummed. i was getting the OP-OC40s for $no prices a piece then... and would have preferred one of those over the $no prices patch i bought with a friend. i've heard fentanyl is just no euphoria and all OD. Or have i been informed incorrectly and didn't prep that shot correct? i get 90 Oxymorphone 10mg IR pills a month and bang them, so my tolerance is kinda absurd.

Peace&Love,
~f.xy

Edit: Sorry about the prices, mods... I've been on a hiatus. What about a comparative price, i.e.- I could have had four Oxy for what I paid for the Fentanyl?

1. 90 x 10mg oxymorphone for the whole month??? So just 3 a day? That's really not much of a tolerance at all. I've never had the chance to bang oxymorphone, but when the good Opanas were still around I would snort 2 of the 40mg stop signs at a time to get off, and around that time when I would pick up oxycodone I would pick up like 30 or 40 30mgs and bang 12 x 30 mg at a time to get off.

Fuck that shit was expensive, but I was "taking a break" from heroin, once I started slamming the oxy though I realized I was just wasting my money and if I wanted opiates I should just be buying dope, instead of trying to achieve a dope high with pricier, weaker drugs.

Let me say though, I wish like fuck those stop signs (opana) were still around! Those were miracle workers, both to get high and for pain relief. When they reformulated those they really fucked over all the sick people who depended on opana for legit pain relief from cancer, etc. I read sooo many complaints on WebMD, RXlist, drugs.com, etc. Those pills were the best competition for a shot of heroin. Closest thing I believe, even closer/better than what a crushed 80mg OC would do back in the early honeymoon days.

2. Shot prep could probably be better, I'm not sure exactly how to go about it better, as I've only had the lollipops and if I had a patch I'd prob just cut it up and chew pieces. Be careful shooting that GEL buddy! Anything with gel in it, ie suboxone films, etc. is a definite no-no.

 

The Lab here in Montreal probably made their own precursors.

Funnily enough, I've been searching around for bromadol lately and found a forum poster from the U.S. who purportedly supplied bromadol and acetylfentanyl to the Montreal group that got busted.

 

No, it's not even possible for the government to "keep up" because something has to exist before it can be classified as illegal. Therefor there is anywhere from a 4 - 12 month period when new RC's are not illegal. Until the recent passing of a "blanket" law that made all "synthetic marijuana" the Gov has never before passed preemptive drug legislation. In fact, that blanket law has all kinds of issues because what is "synthetic marijuana?" The definition is murky and the constitutionality is highly in question. SUPREME COURT won't hear that case, at least not yet and probably not till 1/2 the country has legalized marijuana. Still 20 years away(best guess). People in Colorado blazing legally on their front porches and people in Kansas are still facing mandatory minimum sentences for simple possession. SWIM got locked up in Delaware for 6 months for possessing 1oz. (should say second time busted for possession but still. We have created a class of Felons that are for the most part, non-violent personal users. Felony convictions, violent or not are a killer when looking for a job. Now attitudes are changing fast even though we have known that alcohol is FAR more dangerous than marijuana. The private prison industry lobbies to keep or raise mandatory Min's. Exactly what they wan't is to have fully occupied prisons with easier to control populations. i.e. non-violent drug offenders. No-one should profit from the misery of another. Simple moral law says... Do no harm to others. If you aren't hurting anyone other than yourself(maybe you are or maybe your not so much) then why do we have simple possession laws. Do I not get to direct my life in the direction I wish it to go? I certainly cannot direct others lives in the way I wan't theirs to be lived. Can I not have myself. At least my own body to do with as I please so long as what I choose to do does not infringe upon others living their lives as they please, or are trying. If I haven't harmed you then leave me alone and I will grant you the same respect. BTW good molly/methylone crystals all over the north east. about 40% pure as it took 300mgs and it felt like about 120-130mg MDMA. Mostly white and Tan Crystals. 1G rolled 3 people hard(could have rolled 4-5). Like two pills pupils. Peace and Love all my Narcophiles.

 

Anyone have any theories on why China hasn't gotten into the designer opiate business yet?

Because China remembers the peril of opium (and as shown by Hong Kong until recently, would have a taste for it).
Tolerance for illegal (and even legal prescription) opiate use is very low.

 

I think people should read up on all of the analogues George Mardquandt went through. The DEA talk about 'the Seigfried Route' from Rhodium.

Fentanyl - awful stuff. Scared it's heading to the UK since the police don't even LOOK for it in powder samples so if mixed with H, we would never know...

 

Had no idea Fentanyl itself was so powerful. Figured it was right down there with a potency equivalent of Advil after hearing about someone using the patches with zero pain relief for chronic back and neck pain.

Interesting article.