Wednesday, July 11, 2018

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.

Saturday, June 9, 2018

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.
 

 
 
 

Friday, June 8, 2018

RIP Anthony Bourdain

Anthony Bourdain has passed away from what is being reported as suicide. From all accounts, he was a fantastic person who spoke his truth wherever he went. He was honest and reveled in teaching people about new things through curiosity and humor; he was a gifted storyteller. And best of all, he was an advocate of world and its people. All people.

If you need help and/or are contemplating suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255. Please do not hesitate to call.



Tuesday, June 5, 2018

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 (2017)

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

Saturday, April 7, 2018

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

Tuesday, April 3, 2018

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.

Thursday, March 29, 2018

Bleeding and Coagulopathy Associated With Synthetic Cannabinoid Products

There have been warnings out of Chicago over the last couple days regarding users of synthetic cannabinoid products experiencing abnormal bleeding issues especially from the eyes and ears. As of today (Thursday, March 29), there have been 22 reports in the Chicago area since March 7. Vitamin K dependent severe coagulopathy has been observed in several cases which is consistent with exposure to a 4-hydroxycoumarin rodenticide (superwarfarin) such as brodifacoum.

 
Chemical Structure of Brodifacoum
Drawn by Kevin G. Shanks (2018)

A substance such as Brodifacoum inhibits the action of the vitamin K epoxide reductase enzyme. This enzyme inhibition interferes with the recycling of vitamin K epoxide to vitamin K and ultimately results in a steady decrease in blood vitamin K, which is a problem, because vitamin K is a vital part of the synthesis of prothrombin (coagulation factor II). Prothrombin is involved in the blood coagulation cascade, also known as blood clotting.

Low vitamin K means severely impacted blood clotting which can result in profuse bleeding.

Another effect of Brodifacoum is the increase in permeability of blood capillaries, leading to internal hemorrhaging, or when blood leaks from vessels. An individual can bleed internally progressively with time.

Brodifacoum is a highly lipophilic substance and has an extremely slow elimination pathway from the body. Biological half-life of the substance is 20-130 days. LD50 values for mammals are substantially less than 1.0 mg/kg. It is a potent substance with a long duration of action that can result in devastating effects in humans (and animals) - afterall, it's primary (only) use is to kill warfarin-resistant rodents (hence the class name superwarfarins).

Other superwarfarins include Bromadiolone, Coumatetralyl, Difenacoum, Flocoumafen, and Tioclomarol.

This is not the typical media hysteria/hyperbole that we all have grown accustomed to over the years with reporting on drugs. While no specific products have yet been implicated, my advice is that if you are a synthetic cannabinoid user (or know a user) in the Illinois area (including bordering states), discard your supply. Immediately.

Be safe.



References

Outbreak: severe coagulopathy associated with synthetic cannabinoids (K2/Spice)
http://myemail.constantcontact.com/Outbreak--Severe-coagulopathy-associated-with-Synthetic-Cannabinoids---K2-Spice--.html?soid=1100929526407&aid=_6hDV-Frs5Q; Accessed March 29, 2018.

Synthetic pot warning issued after 22 people in Illinois report bleeding from eyes, ears
http://www.chicagotribune.com/news/local/breaking/ct-met-fake-weed-synthetic-cannabis-warning-20180329-story.html; Accessed March 29, 2018.

Illinois health officials warn of synthetic pot after 17 people report of severe bleeding.
http://wgntv.com/2018/03/29/illinois-heath-officials-warn-of-synthetic-pot-after-17-people-report-severe-bleeding/; Accessed March 29, 2018.

IDPH issues warning about synthetic cannabinoids.
http://dph.illinois.gov/news/idph-issues-warning-about-synthetic-cannabinoids; Accessed March 28, 2018.