Dose Makes the Poison: The Toxcast (Year 1)

Dose Makes the Poison: The ToxCast is ending its first year. There'll be more episodes coming soon in 2021. If you're a listener of the show, thank you! It is much appreciated.

In the meantime, if you want to go back and listen to prior episodes, please do.

Episode 1 - The Background

Episode 2 - A Brief Introduction to Forensic Toxicology 

Episode 3 - Toxicology in the Movies (Knives Out)

Episode 4 - A Few Drops Will Do Ya (Tetrahydrozoline)

Episode 5 - What's in the Bottle? (Cyanide)

Episode 6 - McGruff the Singing Crime Dog / Drugs in the News

Episode 7 - Not Your Parent's Heroin (Heroin, Fentanyl, and Fentalogs)

Episode 8 - How to Fix a Drug Scandal (Netflix) with Dr. Justin Brower

Episode 9 - Headed for a Heartbreak (The Cardiac Glycosides: Digoxin and Convallatoxin)

Episode 10 - A Very Special Toxisode: Yes, Pepper Spray is Tear Gas

Episode 11 - Quick Bites: The Case of Jagger the Irish Setter

Episode 12 - What in the Oleander is going on with the Benadryl Challenge?

Episode 13 - Tales on (Un)Poisoned Halloween Candy

Find the show on Anchor, Apple Podcasts, and Spotify.

If you like what you're hearing, please leave a review for the show over at Apple Podcasts. 

Email the show at dosemakesthepoisonpodcast@gmail.com if you'd like to contact me.

ETR - 2018, Quarter 2

A few days ago, the DEA released its Emerging Threats Report (ETR) for the second quarter of 2018. The agency touts this report as a "quarterly snapshot of the new psychoactive substance market in the United States". There are some interesting things of note which are included in this report.

Two new synthetic cannabinoids were detected for the first time - these were the alphabet soup 5F-EDMB-PINACA and 5F-MDMB-PICA. The top two most prevalent synthetic cannabinoids (which accounted for 50% of all detections) were FUB-AMB and 5F-ADB (also known as 5F-MDMB-PINACA) - both of these compounds have remained in the top two spots since 2016. Interestingly, they both were emergency scheduled by the Federal government in 2017, so I'm not quite sure what to make of their continued stay on the list.

Regarding designer opioids, the market has pretty much shifted back to fentanyl, which made up 75% of all designer opioid detections for the quarter. The compounds 4-ANPP and acetylfentanyl were detected a summed total of 74 times, while 13 other designer opioids (valerylfentanyl, parafluorobutyrylfentanyl, benzylfentanyl, 4'-methylacetylfentanyl, 3-methylfentanyl, U48800, furanylfentanyl, U47700, cyclopropylfentanyl, carfentanil, 4-fluoroisobutyrylfentanyl, butyrylfentanyl, and methoxyacetylfentanyl) accounted for 50 total detections or approximately 10% of all detections. Fentanyl analogs and other designer opioids are still out there in the wild, but they do not seem to be as prevalent as they were for the previous 1-2 years. Illicitly manufactured fentanyl continues to be the top dog in this category - ask any forensic toxicologist and she would tell you the same thing (and do please go talk to us forensic toxicologists, it can be very lonely working in a lab).

You get fentanyl! And you get fentanyl! We all get fentanyl!

There were only a total of 24 cathinones detected, of which 15 were N-ethylpentylone (62.5%). Older compounds such as MDPV, alpha-PVP, methylone, butylone, and ethylone are nowhere to be found.

The only designer benzodiazepine detected for the quarter was one identification of flubromazolam.


The Emerging Threats Report for Quarter 2 of 2018 can be found here.

Exposure to "Fentanyl" in the Field

It's in the news everywhere.

Fentanyl.

Fentanyl and secondary exposure.

Here are some of the news headlines from the last few weeks...

From KLTV7, a Harris County, TX police officer was hospitalized after coming in contact with a fentanyl-laced paper flyer. The officer "removed the flyer, got into her car and drove away. She soon began feeling lightheaded and had other symptoms". This story was also tweeted by the official handle of the Harris County, TX Sherriff's Office.

@HCSOTexas

From KATC3, police officers in Lafayette, LA responded to a call of an unresponsive man at a residence. Upon observing the scene, two officers "showed symptoms of being exposed to the potent drug [fentanyl]".

 

From ABC13 Eyewitness News, a Houston, TX police officer checked a person's hotel room and found 50-100 pills in a plastic bag. The officer "put the baggie in the patrol car" and "he started feeling ill, shortness of breath and feeling dizzy, and he was no getting better".

From the Belleville News Democrat, two police officers were responding to a series of overdoses at a Brooklyn, IL strip club when they came into contact with fentanyl and began to feel ill. "The thing with fentanyl is the smallest amount, like if you put just less than a gram in a room, it can knock out everyone in the room. It's a pretty hardcore substance, and it's happening everywhere."

There are other stories out there.

It goes without saying that fentanyl is a potent mu-opioid receptor agonist substance that produces central nervous system depression. That is true.

 

Chemical structure of Fentanyl

Drawn by Kevin G. Shanks (2017)

It's been used as a pharmaceutical in the USA since 1968. Intravenous and intrathecal fentanyl is used for anesthesia and analgesia in a hospital setting. It is also available as a transdermal patch for chronic pain management, or as a lozenge for oral transmucosal absorption which is intended for opioid tolerant people and in the treatment of breakthrough pain in cancer. It can also be used intranasally and sublingually.

But can stories like this really happen?

No. Not from dermal absorption of powder. It's not possible. NOT. POSSIBLE.

NOT POSSIBLE.

Let's go to the facts.

The American College of Medical Toxicology (ACMT) (a really smart group of medical doctors) has issued a position paper on this topic and they brought math, science, and some much needed damned common sense to the table.

You can read their position here via the Clinical Toxicology journal website.

Go read it.

Now.

It's good. I promise.

...
...
...
...
...
...

OK. You read it?

Notice the lack of hyperbole and hysteria?

No. Not that Hysteria.

Notice the logical viewpoints?

Notice the use of math and science?

 

Lots o' numbers! You're making my head explode!
http://dx.doi.org/10.1080/15563650.2017.1373782

TL;DR.

It is impossible to dermally absorb enough powder fentanyl to produce any sort of pharmacological effect. There needs to be some sort of mechanism in place to move that fentanyl through the skin. Pharmaceutical companies invested a large amount of time, effort, and money to develop transdermal delivery systems to administer drug (e.g. transdermal patch to place on the skin). If you were to find yourself in a situation where you had powdered fentanyl on your skin, calmly walk over to the sink and wash your hands with soap and water.

Let's use facts in our discussions about drugs. Hysteria and hyperbole is not helpful to anyone. At all. In fact, it makes things worse. Much worse.

PS.

The flyers from Harris County, TX mentioned above were tested in a lab and contained no fentanyl or any other drug. Imagine that!

PPS.

Now there's this gem of a story in the news today...

From the Northwest Indiana Times, a paramedic was attempting to intubate an unresponsive man when the man coughed and snorted in his face. After doing his job and returning to the fire station, the paramedic "began to feel unwell an fell unconscious". The paramedic suspected he "was exposed to a powerful synthetic opioid, such as fentanyl".

Yeah..no.

Semi Charmed Life (1997)

Third Eye Blind's song 'Semi Charmed Life' debuted as the first single on the band's 1997 self-titled album. 

Third Eye Blind album cover art (1997)

It quickly became one of the most well known (and most played) songs of the late 90s as it made its way up the charts peaking at number 4 on the US Billboard Hot 100. The song was featured in several movies including Dirty Work (1998), Wild Things (1998), American Pie (1999), and A Lot Like Love (2006). A snippet of it can also be heard in Contact (1997). 

 

 

Music Video, Semi Charmed Life (1997), YouTube

 

It’s an upbeat catchy song right from the opening line, so much so that I can recognize the song by only 1-2 seconds being played of it.

 

Doo doo doo, doo doo-doo doo... 

 

It’s a happy song...or is it?

 

Have you really listened to the lyrics? Read them below. You'll soon find out that it isn't a happy song after all.

 

I'm packed and I'm holding

I'm smiling, she's living, she's golden

She lives for me, says she lives for me

Ovation, her own motivation

She comes round and she goes down on me

And I make her smile, like a drug for you

Do ever what you wanna do, coming over you

Keep on smiling, what we go through

One stop to the rhythm that divides you

 

And I speak to you like the chorus to the verse

Chop another line like a coda with a curse

Come on like a freak show takes the stage

We give them the games we play, she said...

 

I want something else, to get me through this

Semi-charmed kinda life, baby, baby

I want something else, I'm not listening when you say good-bye

 

Doo doo doo, doo doo-doo doo...

 

The sky was gold, it was rose

I was taking sips of it through my nose

And I wish I could get back there, someplace back there

Smiling in the pictures you would take

Doing crystal meth, will lift you up until you break

It won't stop, I won't come down

I keep stock with the tick-tock rhythm, I bump for the drop

And then I bumped up, I took the hit that I was given

Then I bumped again, then I bumped again

I said...

 

How do I get back there, to the place where I fell asleep inside you

How do I get myself back to the place where you said...

 

I want something else, to get me through this

Semi-charmed kinda life, baby, baby

I want something else, I'm not listening when you say good-bye

 

 

I believe in the sand beneath my toes

The beach gives a feeling, an earthy feeling

I believe in the faith that grows

And the four right chords can make me cry

When I'm with you I feel like I could die

And that would be alright, alright

 

 

And when the plane came in, she said she was crashing

The velvet it rips in the city, we tripped on the urge to feel alive

Now I'm struggling to survive, those days you were wearing that velvet dress

You're the priestess, I must confess

Those little red panties they pass the test

Slide up around the belly, face down on the mattress

 

One

And you hold me, and we're broken

Still it's all that I wanna do, just a little now

Feel myself, heading off the ground

I'm scared, I'm not coming down

No, no

And I won't run for my life

She's got her jaws now, locked down in a smile

But nothing is alright, alright

 

And I want something else, to get me through this life

Baby, I want something else

Not listening when you say...

Good-bye, good-bye, good-bye, good-bye

 

Doo doo doo, doo doo-doo doo...

 

The sky was gold, it was rose (Doo doo doo, doo doo-doo doo...)

I was taking sips of it through my nose (Doo doo doo, doo doo-doo doo...)

And I wish I could get back there (Doo doo doo, doo doo-doo doo...)

Someplace back there, in the place we used to start (Doo doo doo, doo doo-doo doo...)

 

 

I want something else (Doo doo doo, doo doo-doo doo...)

Lyrics as written by Stephan Jenkins.

____________________________________________________________

Semi Charmed Life is the happiest sounding song you'll ever hear about doing methamphetamine and drug addiction.

 

 

 

 

The beat goes on...

The US Federal government has moved to control five new synthetic cannabinoids as Schedule I controlled  substances.

Synthetic cannabinoid herbal incense

Image by Kevin G. Shanks (2015)

These newer alphabet soup synthetic cannabinoids include:

4-CN-CUMYL-BUTINACA
1-(4-cyanobutyl)-N-(1-methyl-1-phenylethyl)-1H-indazole-3-carboxamide

5F-AB-PINACA
N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(5-fluoropentyl)-1H-indazole-3-carboxamide

4-CN-CUMYL-BUT7AICA
1-(4-cyanobutyl)-N-(1-methyl-1-phenylethyl)-1H-pyrrolo[2,3-b]pyridine-3-carboxamide

MMB-CHMICA
Methyl(1-(cyclohexylmethyl)-1H-indole-3-carbonyl)-L-valinate

NM2201
Napthalen-1-yl 1-(5-fluoropentyl)-1H-indole-3-carboxylate

Chemical Structures of Newly Controlled Cannabinoids

Drawn by Kevin G. Shanks (2018)

With the inclusion of these five substances, the Federal government has now scheduled 38 synthetic cannabinoids since 2011. In case you want to learn more about synthetic cannabinoids, I wrote a 2.5 minute primer on them quite a while ago. It's a quick read and is still more than applicable -  you can find it here.

Also, there are many posts about these substances on this blog. Please read some of them as these are substances of extreme toxicological importance. These substances are cheap. They are used for convenience and to evade drug tests for THC. They are easy to get ahold of. Yet, they are complete pharmacological and toxicological unknowns. As I usually say, when people consume products containing synthetic cannabinoids, they are ingesting substances of unknown identification with unknown pharmacological and toxicology properties in unknown dosages in unknown combinations. It's a recipe for disaster.


And the beat goes on...

Stay safe.


References

United States DEA (2018) Notice of Intent: Schedules of Controlled Substances: Temporary Placement of NM2201, 5F-AB-PINACA, 4-CN-CUMYL-BUTINACA, MMB-CHMICA, and 5F-CUMYL-P7AICA Into Schedule I.
Federal Register, Volume 83, Number 103
https://www.deadiversion.usdoj.gov/fed_regs/rules/2018/fr0530.htm

CDC Warning - Vitamin K Dependent Antagonist Coagulopathy Associated With Synthetic Cannabinoid Use

Looks like the issue has spread - which isn't all that surprising. But is frightening.

The Center for Disease Control (CDC) issued a warning regarding the surge in severe bleeding cases associated with synthetic cannabinoid use from Illinois. From March 10 to April 5, 2018, ninety-four (94) people have presented to the hospital with severe bleeding symptoms after exposure to herbal incense/potpourri synthetic cannabinoid products. Eighty nine (89) of the cases are in Illinois, with the remaining five (5) originating in Indiana, Maryland, Missouri, and Wisconsin. There has been positive analytical confirmation of Brodifacoum in at least eighteen (18) individuals, with two (2) fatalities. Brodifacoum has been identified as a constituent in three (3) synthetic cannabinoid products.

Read here and here for previous my updates on this issue as well as a quick explainer as to what Brodifacoum actually is.

If you are on Twitter, check out Dr. Steve Aks (@ERtox) and Cook County Medical Examiner's Office (@CookCountyME) for updates.

Be safe.


References

Outbreak Alert: Potential Life-Threatening Vitamin K Dependent Antagonist Coagulopathy Associated With Synthetic Cannabinoid Use
https://content.govdelivery.com/accounts/USCDC/bulletins/1e6dac3
Accessed: April 7, 2018

Tainted Synthetic Pot Eyed As Cause Of Another Illinois Death As Store Owner Accused Of Selling Substance Held Without Bail
http://www.chicagotribune.com/news/local/breaking/ct-met-fake-pot-poison-cook-county-20180406-story.html
Accessed: April 7, 2018

Bleeding and Coagulopathy Associated with Synthetic Cannabinoid Products
https://dosemakespoison.blogspot.com/2018/03/bleeding-and-coagulopathy-associated.html

Update of an Outbreak of Severe Bleeding Cases / Synthetic Cannabinoid Use
http://dosemakespoison.blogspot.com/2018/04/update-of-outbreak-of-severe-bleeding.html

Update of an Outbreak of Severe Bleeding Cases / Synthetic Cannabinoid Use

As I wrote about the other day, there was a mass outbreak of severe bleeding cases associated with synthetic cannabinoid use in Illinois during March. As of March 29, there were 22 reports of vitamin K dependent severe coagulopathy.

Five days later and there have been 56 affected individuals. Symptoms include coughing up blood, blood in the urine, severe bloody nose, and/or bleeding gums. Nine people have tested positive for the vitamin K antagonist Brodifacoum (see my last post for explanation of its effects). Two people have died.

Three people have been arrested in Chicago in connection to selling some herbal incense/potpourri products that (according to police) have detectable amounts of Brodifacoum.

Dump your product if you have any.

Stay safe out there.


References

Bleeding and Coagulopathy Associated with Synthetic Cannabinoid Products
https://dosemakespoison.blogspot.com/2018/03/bleeding-and-coagulopathy-associated.html

Second Death of An Individual Who Used Synthetic Cannabinoids
http://www.dph.illinois.gov/news/second-death-individual-who-used-synthetic-cannabinoids
Accessed April 3, 2018.

3 Chicago Store Clerks Charged With Selling Synthetic Pot Laced With Rat Poison
http://abcnews.go.com/US/chicago-store-clerks-charged-selling-synthetic-pot-laced/story?id=54197525
Accessed April 3, 2018.