Flualprazolam Overdose

[Captin]

My 19 year old son recently died. The coroner listed cause of death as a drug interaction between Tylenol PM and Flualprazolam. His toxicology report listed a therapeutic dose of Tylenol. There was .02 mg/liter of Flualprazolam in his femoral blood sample. He was also pretty beat up. His usual dosage of alprazolam was 5 hulks so I find it hard to believe that the small amount of Flualp did him in. How does one convert the residual in the blood sample back to the dose that he took? He weighed 140 lbs and had taken the Flualp about 10 hours prior to being found. How much is metabolized in 10 hours?

 

[deficiT]

My condolences on your loss. I can't imagine.

I'm not sure how one would do that... But hopefully someone comes along and has a better answer

 

[dalpat077]

My 19 year old son recently died. The coroner listed cause of death as a drug interaction between Tylenol PM and Flualprazolam. His toxicology report listed a therapeutic dose of Tylenol. There was .02 mg/liter of Flualprazolam in his femoral blood sample. He was also pretty beat up. His usual dosage of alprazolam was 5 hulks so I find it hard to believe that the small amount of Flualp did him in. How does one convert the residual in the blood sample back to the dose that he took? He weighed 140 lbs and had taken the Flualp about 10 hours prior to being found. How much is metabolized in 10 hours?

Unfortunately Tylenol PM just happens to be a combination drug of Acetaminophen and Diphenhydramine. Diphenhydramine (Benadryl) is an antihistamine and has a moderately unsafe interaction with Xanax (Alprazolam) i.e. additive or synergistic effects increased. Both have central nervous system and/or respiratory-depressant effects. Unfortunately it depends on where you look i.e. there's a load of conflicting information on this (and for some sites to purport that there's no danger is ludicrous).

With the above in mind: Flualprazolam is an analog of Alprazolam, is more potent than Alprazolam, has a long duration of action (6 - 14 hours) compared to Alprazolam. and a longer elimination half-life compared to Alprazolam (varies greatly and based on an individual's metabolism and various other factors). This information courtesy of the DEA.

Interestingly enough: the so-called "Hulks" strictly speaking referred to (used to refer to) green Xanax (Alprazolam) 2mg bars. But sold as fakes can contain any number of substances including, ironically, and as has been reported (drug seizures), Flualprozolam and Diphenhydramine in the same pill (not to mention sometimes another benzodiazepine also just for good measure). Needless to say it's pot luck as to how much of each is contained in an illicit pill.

As for metabolism and working backwards to determine the initial dose: at best anything I work out would be highly speculative (and that aside from the fact that this well above my pay grade and I'm no coroner nor medical professional). For what it's worth though see the below in reference to Xanax (Alprazolam) and Diphenhydramine. Unfortunately there's not much research and studies pertaining to Flualprazolam so I'm just using Alprazolam as a sort of baseline or reference point.

"Pharmacokinetics (Xanax) (Alprazolam)

Absorption Following oral administration, alprazolam is readily absorbed. Peak concentrations in the plasma occur in 1 to 2 hours following administration. Plasma levels are proportionate to the dose given; over the dose range of 0.5 to 3.0 mg, peak levels of 8.0 to 37 ng/mL were observed. Using a specific assay methodology, the mean plasma elimination half-life of alprazolam has been found to be about 11.2 hours (range: 6.3-26.9 hours) in healthy adults."

Unfortunately it doesn't seem quite as clear cut or agreed upon when it comes to Diphenhydramine.

"Pharmacokinetics (Diphenhydramine)

Oral bioavailability of diphenhydramine is in the range of 40% to 60%, and peak plasma concentration occurs about 2 to 3 hours after administration.

The elimination half-life of diphenhydramine has not been fully elucidated, but appears to range between 2.4 and 9.3 hours in healthy adults. A 1985 review of antihistamine pharmacokinetics found that the elimination half-life of diphenhydramine ranged between 3.4 and 9.3 hours across five studies, with a median elimination half-life of 4.3 hours. A subsequent 1990 study found that the elimination half-life of diphenhydramine was 5.4 hours in children, 9.2 hours in young adults, and 13.5 hours in the elderly. A 1998 study found a half-life of 4.1 ± 0.3 hours in young men, 7.4 ± 3.0 hours in elderly men, 4.4 ± 0.3 hours in young women, and 4.9 ± 0.6 hours in elderly women. In a 2018 study in children and adolescents, the half-life of diphenhydramine was 8 to 9 hours."

I suppose it's a question of when peak levels for both were reached and what the combined effect was at the time. Whether or not the coroner took this into account or was able to determine the same I obviously know not.

I guess my point is that I can understand (logically) how the coroner came to that conclusion this in spite of the levels detected. Now whether or not this was a simple and quick off-of-the-cuff conclusion and default position taken (given that Flualprazolam is now an Internationally banned substance as of March 2021) for the sake of expediency I know not and it's not for me to say.

I don't really know what "his usual dosage of Alprazolam" actually means i.e. daily or now and then for recreational purposes? Was Alprazolam detected in addition to Flualprazolam and Diphenhydramine is my point (bearing in mind that Alprazolam too doesn't simply disappear without a trace)? Whichever way you slice it (and assuming legit pharma.) 5 x "Hulks" equals 10mg Alprazolam.

"He was also pretty beat up"?

None of the above changes the outcome though unfortunately but that's the science (as I see it and interpret it anyway).

 

[dalpat077]

For the sake of interest I thought this worth a mention on this thread. I am not saying that it's applicable in this particular instance as the OP didn't provide much information. But as noted: worth a mention.

Much to my surprise it came to my attention just today that in certain states and counties a coroner does not even need a medical qualification and can be an elected official and nothing more. The only requirement is that AFTER they have been elected they are to take a basic course within the first year of their being in the job.

In other words: a coroner is not necessarily a qualified medical professional and may not be even close to being a forensic pathologist in some instances.

Why applicable on this thread?

Depending on location: who says that the coroner in this instance didn't just make an assumption i.e. just assumed that this was drug related and that was the end of it. No autopsy and based his finding purely on a toxicology report. Not making accusations. And have no idea where this happened. But worth knowing about. Came as a big surprise to me anyway that a general practitioner and even a mortician or funeral director can be elected a coroner.

For the greater audience: just saying that in some handful of states and in some counties there can be a very big difference between a coroner and who may be left to their own devices. They can ask for the assistance of a state medical examiner and also a forensic pathologist if they're in doubt but they're under no obligation legally to do so. And if in doubt: Joe Public can enlist the services of a professional private forensic pathologist (at a cost of course).

This practice has it roots going back decades from what I gather. And given the costs involved and the small number of cases that some coroners will deal with on an annual basis it's just not cost justified to have qualified forensic pathologists on hand 24/7. And not to mention that there's apparently just not enough of them to go around the country anyway.

There's a lot more to this issue and there's been several moves to correct this issue but that's going too far down the rabbit hole for the purposes of this thread.

 

[TheOriginalChair]

My deepest condolences, ive had a lot a young friends go recently and myself been close to death a couple times, Benzos these days are known killers, even in the PsychonautWiki Flualp has a big warning, but from what i read he had quite a tolarence to benzos, i really im baffled how with a threshold going to common dose he passed away, does tylenol PM suppresses that much the system, do you believe the body just was really relaxed and when you goin a sleep since body is lowering its respiratory sytem do you believe the combination made that happen? Is that what the Coroner is sayin? So i can understand correctly? Cause i take tylenol PM with my bars, i know these are legit but sometimes i get fakies and have had rough nights waking up in the E.R. without the tylenol PM... Again my deepest condolences my friend, he is in peace now in a place full of love.