〽️ Service Stats
As of Friday November 22, 2024.
9,122 samples analyzed
Serving 158 harm reduction programs
Reaching 228 counties in 39 states
356 unique substances identified
🚨 Upcoming Card & Data Changes
We will be shipping card version 9 in kits sometime starting in January 2025. The last update was in June 2023; we don't like changing this often. Based on your feedback and our detailed analysis of missingness, we made 3 substantial changes:
- Added nitazene and carfentanil to list of expected drugs
- Added stimulant / opioid type to OD panel
- Added test strip results for benzos, fent, xylazine, and meth
Click the link below to see all the smaller changes and data implications.
Nabarun Dasgupta
🕵🏼♀️ Solved! BTMPS FTIR Spectra
Mystery solved! A national team of experts has figured out why street samples and library FTIR spectra were not matching fully for BTMPS. If you're a FTIR tech, you'll want to read the blog post linked below. This is us, as a harm reduction community, doing the science to answer the questions that matter most to us. An excellent reminder that nobody is going to save us but ourselves.
Marya Lieberman
For the noobs, catch up here on all things BTMPS (also known as: bis(2,2,6,6-tetramethyl-4-piperidyl) sebacate).
The investigative team was Vikrant Jandev and Marya Liberman from Univ. of Notre Dame in Indiana, Blake Joachim from Outside In in Oregon, Ivy Sabal and Cole Altomare-Jarczyk from Brandeis University in Massachusetts. Y'all are great! 💞
👀 UNC Watchlist
Here are the trends in the drug supply we are keeping an eye on this month.
- BTMPS - industrial chemical added to plastics. See note above about new findings for FTIR spectra.
- Xylazine & (dex)medetomidine - strong sedatives mixed with fentanyl. We have a new tracker for these showing the uptick of (dex)medetomidine starting in June 2024. We're seeing a parallel increase in xylazine among our fentanyl samples too.
Opioid Data Lab
- Carfentanil - powerful opioid reemerges in a new way. We've seen carfentanil in samples from 7 states: FL, WI, NY, MI, WA, CA and NM
- Nitazenes - new-ish class of synthetic opioids. We have analyzed 112 samples containing nitazenes, from 14 states. The most common of these "benzimidazole opioids" we have see are protonitazene and metonitazene. Fentanyl is also found in about half the nitazene samples, and about the same for xylazine. These combos can be really sedating. On the other hand, nitazenes may find favor among those with big established fent habits. Nitazenes are the synthetic opioid most common in Europe (not fentanyl). Nitazenes have been in the US for years, for example in Wisconsin and Illinois in 2020 and Tennessee in 2019.
- 2-fluoro-2-oxo-PCE + fentanyl - international club drug mixed unexpectedly with fentanyl and others
- Shift to smoking - broad trend with implications for overdose prevention
- Decline in overdoses - it's happening, but why?
We also retired acetamiprid from the Watchlist. As our friend Eliza always reminds us, it's important to have expirations on drug alerts to prevent panic and distraction after the situation changes. 👏🏾
👩🏽🔬 New Substances Detected
We have a new live report app that shows which new-to-us substances detected recently. This app auto-updates the first of each month.
We detected 13 new substances in the drug supply in October 2024.
Many of these samples came from FTIR-based programs. These front line folks have way more local context and are the true experts. We make some speculations below based on our scientific and street knowledge. We're connecting dots nationally, but fully defer to the local programs. Let us know if we missed the mark at opioiddatalab@unc.edu.
Descriptions
- spironolactone and canrenone - Spironolactone is a second line medication for heart failure, and not a controlled substance. (Other medical uses.) Canrenone is a metabolic byproduct of spironolactone, so we hypothesize that this was a GCMS breakdown substance, or the pill may be old, or there could be some instability from pharma manufacturing. The index sample was a light yellow pill, assumed to be amphetamine. Allow us to speculate. There are pharmaceutical versions matching this description, and we can't help but notice the "AD" indicia may misdirect folks looking for amphetamine (aka Adderall). This sample was brought in before consumption, so kudos on trusting that spidey sense.
(HT: thanks to Dr. Ben Howell for the correction of what spirinolactone was prescribed for... not primarily for gout apparently, tho that may be for a few patients.)
- cyfluthrin - A common insecticide in the pyethroid family of chemicals, with limited toxicity to humans. At room temperature it has a "yellow-brown mass of oily to paste-like consistency" (source), which may explain the reported tan color of the sample. (PubChem) The sample also contained first-time-detected acetyl tributyl citrate (aka ATBC, tributyl acetylcitrate, PubChem), a nail polish additive, pharmaceutical pill coating, plasticizer, and fragrance that evoked thoughts of BTMPS. This sample was supposed to be heroin, and came to us from a used cotton. It was reported to cause a burning sensation, and did not provide a high. The sample also contained plenty of phenacetin, a OTC analgesic not sold in the USA. Could ATBC have come from the coating of the pill? Maybe, but we couldn't find an international excipient database that could definitively say so. Could the cyfluthrin have come from an insecticide used while growing the cotton? Possibly, but cyfluthrin isn't widely used in agriculture, was not in trace abundance, and the color of the sample suggests that the amount of the substance was non-trivial. How and why it ended up in this sample is a mystery. And could the recent emergence and publicity about BTMPS have led to experimentation with adding ATBC to the drug supply? Let's be clear, just by looking at molecules, we can't determine intentionality. We try to be objective scientists and not judgmental, but this sample is pretty fucked up.
- fluoxetine - Common SSRI anti-depressant Prozac (or generic). This sample was just a white powder, supposed to be a fentanyl, which turned out to be cocaine. There was a trace amount of fentanyl in it. Okay, so none of this is all that surprising given the time and place, and we don't know the full backstory. The sample had other common contaminants or breakdown products of cocaine: tropacocaine, levamisole, and methyl ecgonidine (MED), which makes us feel more confident that this was primarily a cocaine sample. But it was the fluoxetine that landed it on this list. Sometimes Rx medications get passed off as street-desirable pills, like the gout med above. In this case fluoxetine only shows up in trace abundance. Perhaps this was intentional, but just as likely to have been accidental. Part of a broader trend, we've detected other mental health meds in the drug supply: quetiapine (schizophrenia and bipolar disorder) and trazodone (anti-depressant), among others.
- atropine - an old pharmaceutical medicine with multiple uses, and not known to be psychoactive. It is on the WHO's List of Essential Medicines, and also occurs naturally in plants. In this sample, it only shows up in trace abundance. Like the fluoxetine sample above, these aren't substances that consistently produce an immediate euphoric high. So contamination is always the simplest possibility. Then again, if you've got crushed Rx tablets floating around when bagging up, maybe there's something else going on.
- N-desalkylflurazepam - (also called norfludiazepam) Infrequently seen benzo that's usually a metabolite of other benzos. Not much known about it in street drugs.
- etodesnitazene (also called etazene) - In the newer class of synthetic opioids called nitazenes. This particular one has been advertised in online forums with claims of relative safety. CSFRE reports "etodesnitazene was first reported in a case from Iowa collected in May 2021, with subsequent cases reported from Louisiana, West Virginia, and Iowa (n = 1)." The index sample we received was a messy brew that had fent, Benadryl, BTMPS, dex(medetomidine), gabapentin, and heroin, as well as trace xylazine and caffeine (and other substances). If that combo wasn't expected, we would expect this to be rather sedating. While the index sample was a white powder, WHO reports it has also been found in fake M30 pills. Etazene is expected to be more potent at the mu opioid receptor than the more historically common etonitazene.
- phenazolam (also called clobromazolam) - Another benzo, that CSFRE first saw in November 2022. It's been known in Sweden, Serbia, and Australia. It has some published lab papers, but not a ton is officially known.
The last 3 examples above show is how chemical naming conventions have a big impact on our ability to retrieve additional health information. Current search engines are not nuanced enough to pick up on these chemical synonyms. And candidly, we wouldn't want to trust machines to do the name matching without human (chemist) oversight. Take the example of etodesnitazene vs. etazene. At the lab detection level, chemists often pick the name of a molecule given by the reference standard manufacturer because it is the most technically defensible; in the United States much of that is driven by Cayman Chemical. But, other labs in other countries will use other vendors, who may choose (completely legit) to name it differently. So, our job at the Street Drug Analysis Lab is to figure how to report out chemicals with multiple names in a way that returns the most useful clearweb search. If you search the scientific literature for "etodesnitazene" you'll get few hits. But, searching for "etazene" unlocks dozens of international studies and reports. So, in this case, we should probably switch to using "etazene." Before we do so, we will take time to verify that the chemical formula, and molecular structures and weights are the same. This is a careful process that will eventually become part of our (long-promised, but slow-going) Chemical Dictionary.
- pyrazolam - Established benzo in fake pills in Europe. May have less sedating properties than etizolam or bromazolam; there is a belief that pyrazolam may be helpful in reducing anxiety without as much of a hypnotic effect. The index sample was described as being a fine, tan power by itself, but the literature describes it more often in pill form. This interesting "netographic analysis" describes how pyrazolam is preferentially discussed on certain social media sites (but not others), and who's discussion volume is declining over time.
- delta-4(8)-iso-THC - impurity of synthetic THC production when being made from CBD. We don't know much about it's specific pharmacology (Wikipedia), but it's common in weed processing. The index sample had CBD, delta-8 and delta-9 THC, as well as cannabidiol, and was a brown oil/wax. Overall, this one is not a surprising find, but just new-to-us because we don't test a lot of weed.
- AB-MDMSBA - A less common synthetic cannabinoid. The index sample was expected to be a benzo, as a fine white powder, but wasn't. We are confident about the identification, but don't know much about this one. If anyone wants to enlighten us, we'd be happy to update this entry. The PubChem entry was only created in late 2021, so this is likely a newer syncann.
- N-(1-phenethyl-4-piperidyl)-N-benzylpropanamide - A fentanyl synthesis byproduct. (PubChem) We are expecting to see more of these novel impurities as production method shifts happen, driven by DTO infighting in Mexico, enforcement against precursors in China, and US-led trade wars. Stay tuned.
🦸🏽 Harm Reduction Heroes
Everyday heroes don’t always wear capes.” The truth is, the real champions are those rolling up their sleeves and making a difference on the ground daily. Their dedication and impact rival any superhero storyline—deserving all the spotlight and appreciation!
Learn more about these local heroes by clicking the links below!
National Black Harm Reduction Network
The National Black Harm Reduction Network is a powerful coalition dedicated to advancing health equity and justice for Black communities disproportionately impacted by systemic inequities. Rooted in the legacy of Black-led movements, the Network focuses on advocacy, mentorship, and building Black-centered harm reduction initiatives.
Illyana Massey
❤️🩹 Hurricane Update
Hurricane Helene’s aftermath has left harm reduction programs in western North Carolina stretched to their limits. Communities are continuing to face housing instability, rising overdose rates, all while essential supplies and stability vanishes overnight. Harm reduction workers are delivering aid in the hardest-hit areas, even on horseback, but the needs continue to far outweigh the resources. This is a critical moment for solidarity and action. Click here to learn how you can support these life-saving programs and help rebuild hope in WNC.
📖 Reading Room
A place for things that taught us something new and maybe you will learn something too!
When cities sweep homeless encampments, it’s not just tents and trash that are lost—it’s life-saving supplies like medications, IDs, and harm reduction tools. These sweeps devastate already vulnerable people, forcing them to start over with nothing. This cycle of displacement fuels instability and puts lives at greater risk. Learn how these policies impact communities and what can be done to support those most affected. Read more about this here from ProPublica.
- North Carolina News: Attorney General Josh Stein Finalizes $1.37 Billion Opioid Settlement with Kroger
- NY Times: What's Behind the Remarkable Drop in US Overdose Deaths (with one of our own quoted☺️)
- NY Times: Where Some See Taboos, They See Opportunity Explores how overdose defense is revolutionizing harm reduction
- Drugs+Hip-Hop: Slideshow: Opioid Advertisements From the Height Of the Crisis
- PAGroundhogs: PAG Surpasses 500 Samples Tested; Launches SAFER SMOKING Campaign
- KFF: 12 States Promised To Open the Books on Their Opioid Settlement Funds. We Checked Up on Them.
- Johns Hopkins blog: 10 Impactful ways to spend small opioid settlement allocations, check out Roxanne Saucier's handy list (with evidence)
🤓 Scientific Literature
The easiest way to get access to paywalled articles is to email the corresponding (or first) author.
- Coney L, et al. Comparison of strength and adulteration between illicit drugs obtained from cryptomarkets versus off-line. Addiction. 2024. [open access]
- Langford AV, Lin CC, Nielsen S. Global perspectives on opioid use: shifting the conversation from deprescribing to quality use of medicines. BMJ Quality & Safety. 2024 [open access]
- Lima, T. Y., et al. Temporal and spatial trends of fentanyl co-occurrence in the illicit drug supply in the United States: A serial cross-sectional analysis. The Lancet Regional Health – Americas, 24, Article 00225. 2024 [open access]
- Vivolo-Kantor, A. M., et al. Notes from the Field: Ketamine Detection and Involvement in Drug Overdose Deaths — United States, July 2019–June 2023. MMWR Morbidity and Mortality Weekly Report, 73(44), 1010–1012. 2024. [open access]
- Wilson P, et al. Safer supply and political interference in medical practice: Alberta's Narcotics Transition Services. International Journal of Drug Policy. 2024 [open access]
🤗 Opportunities for Impact
Job postings, conferences, and other events for you harm reduction baddies! If you have a job posting or event you'd like us to highlight, please be in touch.
Fireside Chat
Philomena Kebec, J.D., Economic Development Coordinator, Bad River Band of Lake Superior Chippewa invites you to the Brookings Institution launch of a major research initiative exploring the fentanyl epidemic in North America and globally:
Wednesday, December 4 from 9 AM to 12:30 PM EST, with in-person and virtual participation. I will be presenting at 9:50-10:35 with Peter Reuter and Beau Kilmer on domestic implications, sharing my research on the impact of fentanyl on American Indian and Alaska Native communities.
More information and a link to register is available here.
Panel Discussion
Watch a recap of "White faces, Black and Brown Lives: Racial Disparities in the OD Crisis." panel discussion last month.
Pain Patients as Casualties: Webinar
On December 3rd, join to explore how pain patients have become unintended casualties in the ongoing war on drugs and discuss compassionate solutions.
Call For Abstracts
Health Affairs is calling for abstracts on research and policy insights about the opioid crisis for a thematic issue to be published in September 2025. Submit your abstract by December 2, 2024, to contribute to this critical discussion and help shape future opioid policies. Click here to learn more.
📣 Team Voices
Check out monthly blog posts from members of our team!
Erin Tracy
Adams Sibley
🪩 Out and About
See what our team has been up to in the community!
👋 Meet our Team Members
Each month will feature different team members 😊
Colin Miller
Having joined the team in 2022, our Community Liaison Colin Miller brings a range of skill and lived and living experience from community organizing, to research, and to non-profit management. Colin is co-founder and initial Executive Director of Twin City Harm Reduction Collective in Winston-Salem and communicates with the animals in his spare time.
🏆 Box of the Month
Sometimes our amazing partners write us a warm message, doodle or draw a picture on the return boxes we send out. This is in no way a requirement (♻️ we reuse the boxes), but we love receiving the random surprises!
Each month, we will showcase boxes we love.
