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Laws concerning the growing, selling and consuming of cannabis and its related products have been changing considerably over the last few years. The legalization of hemp in 2018 sparked an interest in ∆9-tetrahydrocannabinol (∆9-THC) isomers and analogs that are derived from hemp and sold with minimal oversight. One example is ∆8-tetrahydrocannabinol (∆8-THC). Although less potent than ∆9-THC, ∆8-THC is gaining popularity and can easily be found where cannabis-related products are sold. The Forensic Toxicology Laboratory at the University of Florida routinely tested decedents for 11-nor-∆9-tetrahydrocannabinol-9-carboxylic acid (∆9-THC-acid), the primary metabolite of ∆9-THC. Urine samples from ∼900 decedents were received by the laboratory between mid-November 2021 and mid-March 2022 and subjected to CEDIA™ immunoassay testing. Subsequent confirmation of 194 presumptive positive samples was performed by gas chromatography--mass spectrometry. A peak eluting immediately after ∆9-THC-acid was identified as 11-nor-∆8-tetrahydrocannabinol-9-carboxylic acid (∆8-THC-acid), a metabolite of ∆8-THC, in 26 of those samples (13%). Six of the samples were positive for ∆8-THC-acid only. Other toxicological findings were consistent with poly-drug use including fentanyl/fentanyl analogs, ethanol, cocaine and methamphetamine. There has been an emergence of ∆8-THC use as indicated by the presence of ∆8-THC-acid in 26 of 194 presumptive positive cases during a four-month period. The majority of individuals were White males with a history of drug and/or alcohol use. ∆9-THC-acid, as well as other drugs, was often present. Given the psychoactive potential and availability of ∆8-THC, monitoring ∆8-THC-acid in decedents is important to characterize the risk and prevalence of ∆8-THC use.

BACKGROUND: Fentanyl-related deaths continue to increase in the United States; however, most national studies focus on fatal overdose. More research, including data on nonfatal overdose, is needed. OBJECTIVE: We examined trends in characteristics of fatal and nonfatal fentanyl-related poisonings (“exposures”) in the US. METHODS: National Poison Control data were examined to estimate trends in characteristics of reported exposures between 2015 and 2021 (N = 15,391; 38.7% female). We also delineated correlates of experiencing a major adverse effect or death. RESULTS: The proportion of exposures increased among all age groups between ages 13 and 39 (ps < .05) with the largest increase among those age 13–19 (a 127.8% increase). With respect to reasons for use, the proportion of cases involving fentanyl “abuse” increased by 63.8% (p < .001). The proportion involving fentanyl inhalation increased 427.6% from 5.7% to 29.9% and injection increased from 6.7% to 9.6%, a 42.3% increase (ps < .01). The proportion also increased for co-use of methamphetamine (by 669.0%), cocaine (by 374.0%), and heroin (by 159.5%). The proportion of major adverse effects increased from 15.5% to 39.6% (p < .001). In the multivariable model, “abuse”, suspected suicide attempts, and use via inhalation were risk factors for experiencing a major effect or death, and misuse, ingestion, dermal use, and co-use of methamphetamine were associated with lower risk. CONCLUSION: Poison Control data suggest that characteristics of individuals exposed to fentanyl continue to shift, with use via inhalation increasing and medical outcomes of nonfatal poisonings becoming more severe. These results complement mortality data and inform prevention and harm reduction efforts.

The opioid epidemic continues to evolve in the USA, with fentanyl the most prevalent synthetic opioid in fatal drug overdoses. Following the scheduling of fentanyl’s core structure in 2018, there was a notable decline in the prevalence of fentanyl analogs in decedents; however, fluorofentanyl began being reported in casework in the winter of 2020. Fluorofentanyl has three positional isomers (para-fluorofentanyl (p-FF), ortho-fluorofentanyl (o-FF) and meta-fluorofentanyl (m-FF)), with the most predominant isomer that has recently emerged in the USA being p-FF. The goal of this study was to identify p-FF in postmortem cases between October 2020 and April 2021. Urine and blood were extracted using UCT Clean Screen® extraction columns and then screened using an Agilent 1290 Infinity liquid chromatograph (LC) coupled to an Agilent 6545 accurate mass time-of-flight mass spectrometer (TOF-MS) and quantified using an Agilent 6890N GC system coupled with an Agilent 5973 MS. The limit of quantitation (LOQ) for fentanyl, acetyl fentanyl, butyryl fentanyl, p-FF, o-FF and m-FF was 2.5 ng/mL. The screening method could not differentiate the three positional isomers of fluorofentanyl. Suspected overdose cases (n = 370) received from October 2020 through April 2021 from four Medical Examiner Districts in the state of Florida were analyzed for the presence of fluorofentanyl. The LC–QTOF-MS screen yielded 27 decedents positive for fluorofentanyl, with a majority being Caucasian (93%) and male (70%) with ages ranging from 27 to 63 years. Analysis of the blood and urine by GC–MS yielded 14 decedents positive for p-FF, nine of which were positive in the blood. The blood concentrations (n = 9) for p-FF ranged from