Funtabulously Frivolous Friday Five 360

Smoking heroin

The practice of ‘chasing the dragon’ was first recognized in Hong Kong in the 1950s. Heroin is placed on a piece of aluminium foil, heated with a flame from below, and the resulting vapour is “chased” and inhaled with a straw or other tube. The rippling effect of the drug fumes in the air is often likened to a dragon’s tail.

The first heroin smoking originated in Shanghai in the 1920s and involved use of porcelain bowls and bamboo tubes, thereafter spreading across East Asia and to the United States over the next decade. ‘Chasing the dragon’ was a later refinement of this form of heroin smoking.

Reference:

• Strang J, Griffiths P, Gossop M. Heroin smoking by ‘chasing the dragon’: origins and history. Addiction. 1997 Jun;92(6):673-83; discussion 685-95

Protonitazene.

2-benzyl benzimidazole, nitazene, opioids were first developed in the 1950s as analgesics, but were found to be so potent they were never approved or marketed as medicines​​. Since 2019, they have re-emerged within illegal drug supplies in the United States, UK and other European countries.

Relative potency to heroin

Relatively cheap to produce, nitazenes can range from tens to many hundreds of times more potent than morphine, thus create a profoundly high risk of overdose. Though nitazenes are structurally unrelated to other opioids, they bind with the mu-opioid receptor; thus create the predictable analgesia and euphoria. Nitazenes also suppress the respiratory system, which can result in death, but the effects are seen at much lower doses.

Caroline Copeland, senior lecturer in pharmacology and toxicology and director of the National Programme on Substance Abuse Deaths at King’s College London, says steps taken by the Taliban to dramatically cut opium production in Afghanistan prompted the appearance of nitazenes on the European heroin market. She adds that nitazenes have also been detected in cocaine and synthetic cannabis, known commonly as ‘spice’, as well as counterfeit medicines, including benzodiazepines and oxycodone.

That is quite a different demographic, … so it’s a much wider risk.

Reference:

• Holland A, Copeland CS, Shorter GW, Connolly DJ, Wiseman A, Mooney J, Fenton K, Harris M. Nitazenes-heralding a second wave for the UK drug-related death crisis? Lancet Public Health. 2024 Feb;9(2):e71-e72.
• Wilkinson E. Everything you need to know about nitazenes. The Pharmaceutical Journal, 2024

Clobromazolam (phenazolam)

Clobromazolam was the most frequent designer benzodiazepine detected in a Victorian cohort (100/993 cases, 10%). No patients reported intentional administration of clobromazolam. Over half of patients reported exposure to alprazolam, however it was detected in only 7% of cases, highlighting the risks of substances present occultly in recreational drugs.

In this cohort of patients presenting to emergency departments with polydrug use was prevalent (98%), with phenazepam (45%), methylamphetamine (71%) and other benzodiazepines (60%) most frequently co-detected.

Reference:

• Castle JW, Syrjanen R, Di Rago M, Schumann JL, Greene SL, Glowacki LL, Gerostamoulos D. Identification of clobromazolam in Australian emergency department intoxications using data-independent high-resolution mass spectrometry and the HighResNPS.com database. J Anal Toxicol. 2024 Jun 11;48(5):273-280. 
• Polívka, Z.ěk; Holubek, J.; Metyš, J.; Šedivý, Z.ěk; Protiva, M. Potential hypnotics and anxiolytics: 8-Chloro-6- (2-chlorophenyl) -1-[4- (2-methoxyethyl) piperazino]-methyl-4H-s-triazolo[4,3-a]-1,4-benzodiazepine and related compounds. Collection of Czechoslovak Chemical Communications 1983; 48(12): 3433-3443
  
  

Sample B

Those in the know can tell that the barcode numbers and front of label ‘NDC’ numbers do not match; and that the QR Code and Lot/Expiry/Serial Number are absent.

‘Street xanax’ use is quite common in Australia, and alprazolam is rarely detected in this context.  Counterfeit Alprazolam may contain a range of undeclared substances in different combinations and dosages, such as etizolam, cyproheptadine, promethazine, flubromazepam, amantadine and MMTMP.

Here are two more challenging examples:

Example 1

Sample A is real. The label is missing the manufacturer’s image in Sample B.

Example 2

Reference:

• Grigg J, Peacock A, Lenton S, Salom C, Agramunt S, Thomas N, Lyons T, Sutherland R. Real or fake? Sourcing and marketing of non-prescribed benzodiazepines amongst two samples of people who regularly use illicit drugs in Australia. Drug Alcohol Rev. 2023 Sep;42(6):1559-1565. 
• Queensland Drug Warning: Fake Xanax® tablets containing a strong opioid. 2023 [PDF]