Anodyne by Design; Detecting Designer in Pain Management

Anna M Miller, Gregory C Janis, Melissa M Goggin MedTox Laboratories, Laboratory Corporation of America® Holdings

I. Introduction Figure 1: Structures of Representative Designer Opioids III. Results Figure 3: Distribution of Opioids in 6-MAM Positive Samples In an effort to combat opiate abuse, tighter restrictions have been 1104 samples from suspected users (6-MAM positive) enrolled in chronic pain implemented regarding the use of prescribed opiates and opioids in pain clinics were surveyed for designer opioids. 48% of surveyed contain and/or management. While these changes have undoubtedly reduced the prevalence norfentanyl which may be from prescription or clandestine sources. Furanyl fentanyl, of prescription opiate abuse, they have also left a subset of individuals p-fluorobutyrylfentanyl, acetyl fentanyl, U-47700, (as norcarfentanil), searching for alternatives to satiate addictions or to assuage other - , fluorofentanyl, butyryl fentanyl, 3-methylfentanyl, and kratom were all seeking motivations, potentially contributing to a notable increase in heroin found in heroin positive samples as presented in Table 2 and Figure 3. use as well as a rapid proliferation of designer opioids. Multiple classes of designer opioids exist stemming from basic academic research and drug In a separate survey of 3009 samples from a general pain management population, development projects, and each compound has the potential for clandestinely 5.6% were confirmed positive for fentanyl and metabolites. Clandestine opioids were applied structural permutations. In order to assess the true prevalence of also identified, but at a much lower incidence than in the heroin positive population; these drugs we surveyed a population of individuals abusing opiates within the 0.3% furanyl fentanyl, 0.1% p-fluorobutyrylfentanyl, 0.2% acetyl fentanyl, and 0.2% pain management setting to estimate the frequency of designer opioid abuse. kratom. Almost all of the designer opioids are invisible to standard opioid testing Table 2: Designer Opioids Confirmed in 1104 6-MAM Positive methodologies, thus requiring targeted screening analysis followed by full Urine Samples confirmation analysis. Mean & (top) (bottom) Figure 2: Screen and Confirm Chromatography Analytes (metabolites) Count (%) Concentration N=1104 (738) * Range (ng/mL) II. Methods Fentanyl (norfentanyl) 535 (48.5%) 30.2 (0.1 – 624.5) Independent, fully validated screen and confirmation LC-MS/MS methods are Furanyl fentanyl ( dihydrodiol) 147 (13.3%) 29.0 (0.1 – 565.0) utilized to detect and verify the presence of 25 designer opioids in human urine. p-Fluorobutyrylfentanyl (fluorobutyryl norfentanyl) 108 (9.8%) 26.2 (0.1 – 459.0) IV. Conclusion Method preparation and instrument parameters are summarized in Table 1. Examples of monitored opioids are shown in Figure 1 and example Acetyl fentanyl (acetylnorfentanyl) 87 (7.9%) 2.4 (0.1 – 91.0) Results indicate designer opioid use in pain management patients exists, but chromatograms of the screen and confirm are shown in Figure 2. U-47700 & (desmethyl- & didesmethyl-U-47700) 14 (1.3%) 46.5 (0.2 – 483.0) their use is not widespread. Use of fentanyl and fentanyl analogs dominate within this population, whereas use of the more esoteric designer opioids (Norcarfentanil) * carfentanil 12 (1.6%) 8.6 (1.7 – 28.9) Table 1: Extraction and LC-MS/MS Parameters occurs at a lower frequency. Furthermore, the prevalence of designer opioids in Acrylfentanyl * (acryl norfentanyl) 8 (1.1%) 16.6 (0.2 – 95.4) Screen Method Confirm Method the general population is less than one percent. Kratom (7-hydroxy-) 7 (0.6%) 418.9 (2.7 – 965.0) Designer opioid abuse of a single compound tends to be short lived before a Extraction Organic Solvent Dilution Liquid-liquid Extraction Fluorofentanyl (fluoro norfentanyl) 7 (0.6%) 0.9 (0.3 – 3.3) different or new drug is abused leading to challenges for the testing industry to Butyryl fentanyl (butyryl norfentanyl) 5 (0.5%) 0.8 (0.3 – 1.4) remain abreast of current trends. However, based on our findings, designer Waters ACQUITY UPLC® HSS T3 Agilent Pursuit XRs Ultra Diphenyl opioids are more frequently abused in combination with heroin which may Column 3-Methylfentanyl (3-methylnorfentanyl) 4 (0.4%) 9.6 (0.3 – 21.5) 50 x 2.1 mm, 1.8 µm 100 x 2.0 mm, 2.8 µm allow for some of the clandestine opioid abuse to be detected via traditional AH-7921 (desmethyl- & didesmethyl-AH-7921) 0 0 Mobile Phase A 10 mM Ammonium Acetate with 0.1% Formic Acid means of opiate screening. IC-26 (desmethyl- & didesmethyl-IC-26) 0 0 Mobile Phase B Acetonitrile Methanol MT-45 (nor-MT-45) 0 0 Flow Rate 550 µL/min 600 µL/min W-15 (nor-W-15) 0 0 V. References W-18 (nor-W-18) 0 0 Gradient 10 – 75% B in 1.20 minutes 30 – 95% B in 3.30 minutes 1. Vardanyan RS, Hruby VJ. Fentanyl related compounds and derivatives: Ocfentanil (norocfentanil) 0 0 current status and future prospects for pharmaceutical applications. Analytical Sciex Triple Quad TM 5500 Sciex Triple Quad TM 5500 Future Med Chem. 2014; 6: 385-412. Instrument Valeryl fentanyl (valeryl norfentanyl) 0 0 2. Katselou M, Papoutsis I, Nikolaou P, et al. AH-7921: the list of new -4-methylphenethyl (acetylnorfentanyl) 0 0 psychoactive opioids is expanded. Forensic Toxicol. 2015; 33: 195-201. Positive mode Positive mode β-OH-thiofentanyl (norfentanyl) 0 0 MS Parameters Single MRM per Analyte Quant and Qual MRM per Analyte 3. Goggin M, Nguyen A, Janis G. Identification of Unique Metabolites of the 52 Monitored MRMs 93 Scheduled MRMs 4-Methoxybutyrylfentanyl (4-methoxybutyryl norfentanyl) 0 0 Designer Opioid Furanyl Fentanyl. J Anal Tox. 2017; 41: 367-375. ©2016 Laboratory Corporation of America® Holdings All rights reserved. 00000-0000 Detected Not Detected