A Fatal Case Report Resulting from the Abuse of the Designer Benzodiazepines Clonazolam and Flualprazolam in Conjunction with Dried Opium Poppy Pods

A 21-year-old man was found unconscious in his bed with multiple controlled substances nearby, including opium poppy pods and designer drugs. Toxicological analysis of his blood and urine revealed lethal concentrations of the designer benzodiazepines flualprazolam (0.74 mg/L) and clonazolam (2.08 mg/L), along with high levels of opiates (thebaine 0.81 mg/L, codeine 0.23 mg/L, morphine 0.13 mg/L) and the synthetic cannabinoid CUMYL-4CN-BINACA (0.01 mg/L). The combination of these substances, especially the benzodiazepines, likely caused his death. The report also includes mass spectra of additional compounds found at the scene, such as several tryptamines, amphetamines, and arylcyclohexylamines.

Study at a glance

Abstract

Toxicologists are often confronted with the abuse of multiple drugs and are obliged to decide which compound may have been the cause of death. We report on a 21-year-old man (182 cm, 84 kg), who was found unconscious in his bed. Beside him, the police found several controlled substances, among them were dried opium poppy pods containing thebaine, codeine and morphine, a clear liquid with the designer benzodiazepines flualprazolam and clonazolam and a white powder with the imprint SGT-25, instead of SGT-78 (CUMYL-4CN-BINACA). These compounds were also found in the urine sample following a non-targeted gas chromatography-mass spectrometry and a targeted liquid chromatography-tandem mass spectrometry (LC-MS-MS) screening approach. Subsequently, these compounds were quantified in whole femoral blood and scalp hair. Based on the concentrations measured in femoral blood in particular, we assume that the deceased had taken a lethal dose of the designer benzodiazepines-flualprazolam (0.74 mg/L) and clonazolam (2.08 mg/L), an extremely high dose of the opiates-thebaine (0.81 mg/L), codeine (0.23 mg/L) and morphine (0.13 mg/L ) and a high dose of the synthetic cannabinoid-CUMYL-4CN-BINACA (0.01 mg/L). Besides postmortem concentrations, we also present electron impact and electrospray ionization mass spectra of compounds found in the vicinity of the decedent, namely the tryptamines-4-hydroxy-N-isopropyl-N-methyltryptamine (4-HO-MIPT), 4-hydroxy-N-ethyl-N-methyltryptamine (4-HO-MET) and 4-acetoxy-N,N-diethyltryptamine (4-ACO-DET), the amphetamines-3-fluoroethamphetamine (3-FEA) and 2-fluoromethamphetamine (2-FMA) and the arylcyclohexylamines-N-ethyldeschloroketamine (O-PCE), 3-methoxyphencyclidine (3-MeO-PCP) and 3-methoxyeticyclidine (3-MeO-PCE).