On the evening of June 23rd, 2016, 12 patients were brought to the emergency department (ED) at Yale-New Haven Hospital from a park in downtown New Haven, CT after using a white powder advertised as cocaine and showing signs and symptoms consistent with opioid overdose.1 Several patients required administration of multiple doses of naloxone (> 4 mg) to become alert again, and three patients died.
The white powder was identified as fentanyl, a drug 50 times more potent than heroin, and which most U.S. labs in 2016 could not detect by traditional screening assays. Over two years later on August 15th, 2018, emergency personnel responded to the same area, except this time to more than 49 overdoses from fentanyl-laced K2 (or Spice), which is made from a variety of dried plants and often sprayed with synthetic cannabinoids.2 This was part of the latest wave of new psychoactive substances (NPS) to hit the U.S. and the culprits were synthetic cannabinoids 5F-ADB, 5F-MDMB-PICA, and AMB-FUBINACA which was also responsible for the “Zombie” outbreak in New York City in 2016.3
Synthetic opioids and cannabinoids
Synthetic cannabinoids are the fastest growing class of NPS with over 177 identified by the United Nations Office on Drugs and Crime.4 While a few screening assays for detecting synthetic cannabinoids exist, the rapid development of NPS makes it very difficult for clinical laboratories to detect them using traditional screening and confirmatory methods. Then, what role can clinical laboratories play in the fight against synthetic opioid and cannabinoid use?
Clinical labs play a critical role in monitoring compliance with prescribed medication and abstinence from illicit compounds in pain management programs, so the first step is to ensure that they are up-to-date on best practices for monitoring drug therapy in pain management patients. Recently, the American Association for Clinical Chemistry (AACC) Academy released an executive summary and laboratory medicine practice guideline.5 This guideline compiled evidence-based recommendations for the use of laboratory and point-of-care urine drug tests for relevant medications (over-the-counter, prescribed/non-prescribed) and illicit substances in pain management patients. I strongly encourage that labs involved in pain management testing review this document and follow its recommendations.
Since the mass overdose event in 2016, our hospital lab responded by implementing a new fentanyl immunoassay to provide rapid results for the ED. However, it is important for clinical labs implementing these immunoassays to fully understand what their cross-reactivities are for different fentanyl analogues, and that these cross-reactivities are communicated to their ED physicians. Warrington et al.6 recently reviewed the performance of existing fentanyl immunoassays and they recommended that assays implemented should at least detect acetyl fentanyl, furanyl fentanyl, and carfentanil, based on recent trends in drug use and seizures.
On the other hand, immunoassays for synthetic cannabinoids are unreliable since the antibodies used do not provide sufficient cross-reactivities towards current synthetic cannabinoids.7 Simply put, the developers of these substances are introducing them at a much faster rate than IVD manufacturers and clinical labs can develop methods to detect them (Figure 1). This poses a big problem for most clinical labs who without an immunoassay cannot offer rapid detection of these substances in urine. Therefore, the only reliable option for testing is confirmation testing by either liquid chromatography-mass spectrometry (LC-MS) or high resolution LC-MS (HRMS).
LC-MS vs HRMS
Mass spectrometry (MS) has been in use in clinical labs since the 1980s, but has gained widespread use in recent years as the technology became cheaper and easier to use. Due to known sensitivity and specificity issues with immunoassays, all toxicology results should be considered presumptive unless confirmed by MS, which is the “gold standard” for quantification of small molecules in biological fluids.
The predominant form of MS used in clinical toxicology labs is the triple quadrupole. This type of MS is often employed in reference labs for confirmation testing and employs a “targeted” approach, which requires tuning the MS to detect specific substances of interest. While a “targeted” MS approach is reliable for detecting presence or absence of common drugs in urine, it is not as useful in the setting of the rapidly evolving world of NPS like synthetic cannabinoids. For that, a more versatile technology like HRMS, which can adopt an “untargeted” approach, is needed. The most common type of HRMS used in the clinical toxicology world are orbitrap and quadrupole-time of flight (QTOF).
A major advantage of using one of these platforms is that data collected in an “untargeted” mode can be retrospectively analyzed to detect additional compounds that were not identified as targets on the initial run.7 Major drawbacks of HRMS are the expense of the platforms, the need for experienced personnel to develop methods and operate these systems, and the turnaround time is slow. As a result, HRMS has been largely restricted to specialized toxicology reference labs. Our lab ended up sending urine samples to one of these labs to determine the identities of the NPS that caused the mass overdose event in 2018.
Overdoses from synthetic opioids and cannabinoids are rampant in North America, with reports of similar outbreaks reported from Fresno, CA to British Columbia, Canada.8 Sadly, the majority of clinical labs today are not equipped to deal with these outbreaks in real-time. Nevertheless, the clinical lab plays a key role in identifying the causative agents in an outbreak and disseminating this information to the public and other health providers. This information is critical for tailoring prevention and designing response strategies for future mass overdose events.
- Tomassoni AJ, Hawk KF, Jubanyik K, et al. Multiple Fentanyl Overdoses.New Haven, CT. June 23, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:107-111.
- Winston A. New Haven Overdoses Tied to Laced K2. The New York Times. https://www.nytimes.com/2018/08/15/nyregion/new-haven-overdose-k2.html. Accessed August 23, 2019.
- Adams AJ, Banister SD, Irizarry L, et al. “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. N Engl J Med. 2017;376:235-242.
- World drug report 2015. Vienna: United Nations Office on Drugs and Crime, 2015.
- Janetto PJ, Bratanow NC, Clark WA, et al. Executive Summary: American Association of Clinical Chemistry Laboratory Medicine Practice Guideline—Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients. J Appl Lab Med. 2018;2:489-826.
- Warrington JS, Walsh A, Baker E, et al. Keeping Up with Fentanyl: Failure to Do So Is Not an Option. J Appl Lab Med. 2018;3:148-151.
- Colby JM, Lynch KL. Drug Screening Using Liquid Chromatography Quadrupole Time-of-Flight (LC-QqTOF) Mass Spectrometry. Methods Mol Biol. 2019;1872:181-190.
- Armenian P, Whitman JD, Badea A, et al. Notes from the Field: Unintentional Fentanyl Overdoses Among Persons Who Thought They Were Snorting Cocaine. Fresno, CA. January 7, 2019. MMWR Morb Mortal Wkly Rep. 2019 Aug 9; 68(31): 687–688.