Recently, a number of intravenous drug users have overdosed on a new, non-prescription injected synthetic opioid, acetyl fentanyl. Acetyl fentanyl is a fentanyl analog previously undocumented in illicit drug use that is up to five times more potent than heroin. CDC recommends increased vigilance by public health agencies, emergency departments, state laboratories, medical examiners, and coroners for patients with symptoms consistent with opioid overdose and laboratory results showing an enzyme-linked immunosorbent assay (ELISA) positive for fentanyl.
CDC also recommends that public health officials work with laboratories to carry out ELISA screens for fentanyl, and if the results of these screens are positive for fentanyl, conduct gas chromatography-mass spectrometry (GC/MS) confirmatory testing on specimens to confirm or rule out fentanyl and its analogs, including acetyl fentanyl.
Since March 6, 2013, 14 overdose deaths related to a novel, injected non-prescription synthetic opioid have occurred among intravenous drug users in Rhode Island. Ten of those deaths occurred in March. On May 30, 2013, Rhode Island Department of Health confirmed that the implicated synthetic opioid is acetyl fentanyl, a fentanyl analog previously undocumented in illicit drug use. Acetyl fentanyl is not available as a prescription drug in the U.S.
The age of the persons who died from an acetyl fentanyl overdose ranged from 19 – 57 years, and 10 of the decedents were male. The toxicology testing results for most of the decedents showed, in addition to acetyl fentanyl, varying mixtures of drugs, including cocaine, heroin (morphine), ethanol, and benzodiazepines. However, none of these additional substances were present in all decedents and none of these persons tested positive for fentanyl by GC/MS after testing positive for fentanyl by ELISA. Toxicology results for one decedent showed only acetyl fentanyl (by GC/MS) and no other substances. These deaths represent a significant increase in the number of illicit drug overdose deaths compared with the number of cases typically reported in one month in Rhode Island.
There have been unconfirmed reports from other states of increases in illicit opioid-related overdose events seen in emergency departments. Media stories have associated these events with “fentanyl-contaminated heroin” or, in some cases, to fentanyl alone. It is possible that these events are related to acetyl fentanyl, but confirmatory testing is needed. States other than Rhode Island have not informed CDC that they are testing for acetyl fentanyl.
Because of these reports of increases in illicit opioid-related overdose events, CDC encourages emergency departments and emergency response services to exercise increased vigilance in promptly identifyingsuspected opioid overdose patients and taking appropriate action. Because acetyl fentanyl is a synthetic opioid, it is believed that naloxone will have the same reversal effect as it does for fentanyl and other synthetic opioids. We recommend that emergency departments and emergency medical services treat suspected opioid overdosesaccording to standard protocols. In addition, larger doses of naloxone may be required to reverse the opioid induced respiratory depression because of the higher potency of fentanyl and acetyl fentanyl compared to heroin. CDC advises that emergency departments and emergency medical services ensure that they have adequate naloxone available, as some agencies have run out of naloxone in the face of increased numbers of overdoses and administering higher doses of naloxone in a short period of time.
Since acetyl fentanyl might be the substance of interest in cases in which the result of the ELISA screen is positive for fentanyl but GC/MS is not conducted, toxicology laboratories should conduct both ELISA screens and GC/MS confirmatory testing on samples from illicit opioid-related overdose patients where possible. The following information can assist in identifying acetyl fentanyl.
Chemical name: N-Phenyl-N-[1-(2-phenylethyl)-4-piperidinyl] acetamide
Chemical formula: C21H26N2O
Molecular weight: 322.205 g/mol
CAS Number: 003258-84-2
Extraction: Recovered by routine n-butyl chloride liquid: liquid basic drug extraction, including an acid back extraction. Sensitivity of method not yet established.
Detection: GC/MS EI Scan
Ions 231, 146, 188 m/z and earlier eluter metabolite/breakdown ANPP 146, 189 m/z
Elution order: Citalopram, ANPP, Paroxetine, ACETYL FENTANYL, Fentanyl, Zolpidem
See chromatographic peak, mass spectrum, and chemical structure of acetyl fentanyl in the exhibit below.
Public health agencies, state laboratories, medical examiners, coroners, and emergency departments should contact CDC if they have seen any of the following:
Please contact one of the following CDC epidemiologists for more information:
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