The rise and rise of fentanyl in postmortem casework

Abstract

Forensic toxicology laboratories are navigating a period of time with increasing drug overdose deaths, an opioid epidemic, the impact of the COVID‐19 pandemic, and the illicit drug market flooded with novel psychoactive substances. In New York City, the Department of Forensic Toxicology has experienced a 56% increase in postmortem casework in the past decade with fentanyl detected in 80% of all overdose deaths. Over a period of 2.5 years, 15,638 postmortem cases were tested for the presence of fentanyl and fentanyl analogs using liquid‐chromatography tandem mass spectrometry (LCMSMS). Fentanyl was detected in approximately one third of cases and of these 4447 cases with femoral blood. A twofold increase in cases with high concentrations of fentanyl (>100 ng/mL) was observed between 2021 and 2022. The minor metabolite and precursor chemical, 4‐ANPP (4‐anilino‐N‐phenethylpiperidine) may help differentiate between illicit and licit fentanyl. 4‐ANPP blood concentrations were <10 ng/mL in 98% of the cases and the 4‐ANPP:fentanyl ratio was <0.67 for 99.1% of blood specimens. Only six cases had 4‐ANPP concentrations higher than the corresponding fentanyl blood concentration. This study also highlights, the changing fentanyl analogs found in postmortem cases since 2016 in NYC with the emergence of fluorofentanyl initially identified in 2020 and continuing to dominate in comparison with the prevalence of other analogs, many of which are no longer detected in casework. The detection of one of the latest drugs to be mixed with fentanyl, namely xylazine, has also increased in prevalence by 36.7% in 2022 compared with 2021.

Introduction to the JFS Special Section on Fentanyl and its Analogs in Forensic Science

“…The final articles are on forensic pathology and forensic toxicology [13][14][15][16][17][18][19]. There is a Case Report [20] that serves as a path forward in the detection of "fentanyls," other novel synthetic opioids (NSO), and novel psychoactive substances (NPS).…”

Xylazine Poisoning in Clinical and Forensic Practice: Analysis Method, Characteristics, Mechanism and Future Challenges

“…Recently, a xylazine-related death was first reported in Europe [ 10 ]. Indeed, xylazine poisoning is emerging in clinical and forensic practice; whereas most of them are case reports and they are often combined with other toxins or drugs, the pathological changes in xylazine poisoning cases have seldom been reported [ 10 , 11 , 12 , 13 , 14 , 15 ]. Therefore, the lethal concentration of xylazine in blood and other organs is far from identified and the underlying mechanism in the cause of death in xylazine-related deaths needs further study to be demonstrated.…”