Heroin Adulterated with the Novel Synthetic Cannabinoid, 5F-MDMB-PINACA: A Case Series

Abstract

Introduction: Heroin can be adulterated with various substances that may or may not have pharmacological effects. Here we report a case series of 8 patients who presented to the emergency department after overdose with intravenous heroin preparation adulterated with the synthetic cannabinoid methyl 2-(1-(5-fluoropentyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate (5F-MDMB-PINACA). Case Series: Except for one patient, all of them presented with a typical initial opioid toxidrome consisting of central nervous system and respiratory depression along with pinpoint pupils. Naloxone was given to them, triggering severe agitation and combative behavior along with overlapping features of anticholinergic and sympathomimetic toxidrome. All patients required multiple doses of benzodiazepines. Three were successfully treated with physostigmine. Discussion: 5F-MDMB-PINACA is a synthetic cannabinoid that was added to heroin in samples obtained from patients reported in this case series. Patients demonstrated significant agitation after receiving naloxone for opioid toxidrome, presumably because of the removal of the depressant effect of opioids, which unmasked the excitatory effects of the synthetic cannabinoids. Three patients required physostigmine along with the benzodiazepines for control of their agitation, urine retention and abnormal vitals, suggesting the possibility of an anticholinergic toxidrome to have developed in these patients. Conclusion: Heroin contaminated with 5F-MDMB-PINACA exhibits variable severities of anticholinergic effects, some on presentation and others only after opiate antagonism.

Reports of Adverse Events Associated with Use of Novel Psychoactive Substances, 2017–2020: A Review

“…This is illustrated by the mass casualty incident reported by Ershad et al. ( Table I ) ( 33 ). Six heroin users had effects not typically associated with opioid use, including agitation and tonic-clonic seizures.…”

Detection of AP‐237 and synthetic cannabinoids on an infused letter sent to a German prisoner

“…In a case series, the most common clinical symptoms of opioid and SC co‐exposure were marked by a typical initial opioid toxidrome, consisting of central nervous system (CNS) and respiratory depression. In some cases, hallucinations and adrenergic stimulation with severe tachycardia appeared after treatment with naloxone 26–28 . Since both SCs and NSOs can exert a depressant effect on the CNS, their combination might lead to a synergistic toxicity.…”

Molecular Insights and Clinical Outcomes of Drugs of Abuse Adulteration: New Trends and New Psychoactive Substances

“…A total of 35 case reports of drug adulterants’ intoxications are included ( Table 2 ). Adulterants were analytically detected in biological matrices in only 15 cases and identified compounds were levamisole ( n = 7), 5F-MDMB-PICA ( n = 1); lead ( n = 1); sildenafil ( n = 1); etizolam and caffeine ( n = 1), and lysergic acid diethylamide (LSD) ( n = 4) [ 33 , 42 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ]. In the remaining 20 cases, adulterants were only hypothesized based on the observed symptoms, disease or indirect sequelae or confiscated drug analysis.…”

“…In the remaining 20 cases, adulterants were only hypothesized based on the observed symptoms, disease or indirect sequelae or confiscated drug analysis. Suspected substances were levamisole ( n = 10), methaqualone and several benzodiazepines, caffeine and acetaminophen ( n = 1), 5F-MDMB- PINACA ( n = 7) and phenethylamine ( n = 1), asbestos ( n = 1) [ 33 , 42 , 44 , 45 , 46 , 47 , 52 , 53 , 54 , 55 , 56 ]. Considering all of the reported cases, levamisole was the most prevalent adulterating agent in street cocaine ( n = 17 cases) [ 33 , 42 , 44 , 45 , 46 , 47 , 54 , 57 , 58 , 59 , 60 , 61 , 62 ].…”

“…Adulterated opioids were found in 10 intoxications. The most frequent adulterated opioid was heroin laced with 5F-MDMB-PINACA ( n = 8) [ 52 ], while methaqualone combined with oxazepam, ketazolam, nordiazepam, pinazepam, and alprazolam was detected in one heroin consumption case [ 55 ]. Lead was detected in one opium abuse case characterized by non-specific symptoms including nausea, acute/severe abdominal pain, and vomiting [ 49 ].…”