Objective
Determine if a combination of substances involved in overdose in Philadelphia are of immediate concern in North Carolina.
Report published May 8, 2024. Sharing permitted.
Summary
The combination of fentanyl+bromazolam+xylazine is not unexpected. Out of 63 samples form NC since April 1, 2024, none have contained all three substances together. Further monitoring is warranted before assuming this report from Philadelphia is an immediate threat in North Carolina. However, general education about xylazine is recommended, as is the danger of respiratory depression from potent benzodiazepines combined with fentanyl in the unregulated drug supply.
Source
The analysis below was conducted by the UNC Street Drug Analysis Lab.
Background
This analysis was initiated on May 8, 2024 based on an alert from the Philadelphia Poison Center (on April 29, 2024). 10 cases of hospitalizations were described, including one death, where a combo of fentanyl, bromazolam, and xylazine were implicated. Quinine and caffeine were also listed, but the alert was ambiguous: it did not specify if all 5 substances were found in the sample sample, or if this was a collection of cases where subset of combos of the substances were identified.
Time frame for case origination was reported to be April 4, 2024 to May 3, 2024.
Limitations: No supporting data were provided to support the claims, nor was any methodology described as to how the substances were identified, although our colleagues at CFSRE was reported to have been involved. It is unclear if these findings were based on blood or urine testing, or if solid drug samples were analyzed. It is unclear if these cases resulted in unique calls to the poison center, or if the PC was involved in the hospital consults. Poison center data do not usually have detailed toxicological findings unless there was physical medical intervention, suggesting that these are hospital cases where more information is available even if it had not been disclosed in the alert. Despite considerable limitations to credibility, the reputational position of some of the involved entities was sufficient to warrant further consideration.
We were asked to see if this combination had been detected in North Carolina. Analysis was conducted with all data (~5,300 samples) completed by 4pm on May 8, 2024.
Methods
We obtain drug samples from 34 harm reduction programs, clinics, hospitals, health departments, and drug user unions across North Carolina. Mailed-in samples are analyzed using exactive GCMS, with untargeted search, and pure standard verification of identified substances. See Laboratory methods and codebook for full details.
Raw data used in this analysis are available here. We analyzed our sample database to identify the specific presence of the 5 substances, as well as a subset analysis of the 3 potent psychoactives (fentanyl/bromazolam/xylazine).
Spectra and details for each described substance can be found using the links at the bottom of the page.
Analysis were conducted by Nabarun Dasgupta at the UNC Street Drug Analysis Lab.
Use of AI
Python code was generated by AI based on human prompts, within a Deepnote environment, using CHAT-GPT. Blocks below with purple side bar are the AI prompts provided by humans, and the text below in green are the AI-generated responses. All AI-generated responses were reviewed and verified by a human. Text in black was generated by humans. All Python code used in this analysis and this notebook are available on the UNC institutional archive.
Analysis
list all samples from merged df where state==NC and substance ==bromazolam
The query for samples from North Carolina (NC) where the substance is bromazolam returned 16 samples. Due to the large number of columns in the dataframe, only a selection of the results is displayed here.
any samples (uniquely identified by 'sampleid') where the following substances were identified? (watch out for inconsistent capitalization) - all within ONE sampleid - meaning they have to have all of them? Fentanyl Bromazolam Xylazine Quinine Caffeine
There are no samples (uniquely identified by 'sampleid') in the dataset where all of the specified substances (Fentanyl, Bromazolam, Xylazine, Quinine, Caffeine) were identified together within a single sample.
how about bromazolam fentanyl and xylazine, all 3 together only
The query for samples containing all three substances (Bromazolam, Fentanyl, and Xylazine) together returned multiple entries, indicating that there are samples in the dataset that contain all three specified substances. The results include a variety of sample IDs, each listed with one of the substances, showing that these substances co-occur within the same samples.
how many unique sampleid?
There are 28 unique sample IDs in the dataset that contain all three specified substances (Bromazolam, Fentanyl, and Xylazine) together.
NC distribution
any from north carolina?
There are 8 unique sample IDs from North Carolina that contain all three specified substances (Bromazolam, Fentanyl, and Xylazine) together.
list those 8 please
The list of the 8 unique sample IDs from North Carolina that contain all three specified substances (Bromazolam, Fentanyl, and Xylazine) together is provided, along with additional substances found in these samples. Due to the length of the list and the presence of multiple substances per sample ID, only a selection of the entries is displayed here for brevity.
list just the sampleid for those
The unique sample IDs from North Carolina that contain all three specified substances (Bromazolam, Fentanyl, and Xylazine) together are: '300512', '300551', '400581', '400619', '400652', '500388', '500661', and '500807'.
how many samples from merged df have date_collect or date_complete after April 1, 2024 and state==NC?
There are 63 unique sample IDs from North Carolina in the merged dataframe that have either the `date_collect` or `date_complete` after April 1, 2024.
OD involvement
were any of the NC samples involved in overdose? show 'od', overdose notes, sensations, sensation_notes in a table, with unique sampleid as the leftmost column
The table above lists the unique sample IDs from North Carolina that contain all three specified substances (Bromazolam, Fentanyl, and Xylazine) together, along with their overdose involvement (`od`), overdose notes, sensations experienced, and sensation notes.
Conclusions
The combo of substances identified by the Delaware Poison Center is not at all surprising. The hospitalizations and death are still tragic.
Substances
We've had 28 samples nationwide that have xylazine, fent and bromazolam. Quinine and caffeine are common too, but that specific 5 substance combo we haven't seen. But again, zero percent surprised.
We have analyzed 63 samples from North Carolina collected or completed since April 1, 2024. Focusing in on the main psychoactives (fent/analogues, xylazine, bromazolam), we have 8 samples from NC with that combo. Interestingly showing up in cocaine and substituted cathinone samples too (as trace) – meaning this is not a rare combo as evidenced by other products getting contaminated with them. For cocaine and substituted cathinones, those samples may well have been sent to us exactly because it caused unexpected sensations.
NC Geography
Distribution of the 3 psychoactive-combos includes eastern NC (Greenville), southern (Charlotte), central (Wake Co.), and west (Asheville).
Greenville, Nov 2023 https://www.streetsafe.supply/results/p/400581
Asheville, March 2023 https://www.streetsafe.supply/results/p/400619
Asheville, April 2023 https://www.streetsafe.supply/results/p/400652
Greenville, Nov 2023 - as trace in a cocaine sample https://www.streetsafe.supply/results/p/500388
Wake County, June 2023 https://www.streetsafe.supply/results/p/500661
Greenville, Nov 2023 - bromazolam, heroin, xylazine, caffeine, fentanyl https://www.streetsafe.supply/results/p/500807
Primarily N,N-dimethylpentylone (as substitued cathinone) but also with traces of xyl, bromazolam, and fent (Charlotte, April 2023), likely from the same batch: https://www.streetsafe.supply/results/p/300512 and https://www.streetsafe.supply/results/p/300551
NC Overdoses
Two samples 400652 and 500661 were reported to be involved in overdoses, Wake County and Asheville. The Wake County sample was sourced from the darkweb (online).
Sensations
Sensations for 3 of the 8 samples were described to be stronger, weird, and unpleasant.
Interpretation
Framing these cases as being caused by a unique, static drug named "demon" rather than as bags of fetty/dope branded with a "Demon" stamp could potentially cause unnecessary panic and confusion among both PWUD and the general public. This is not a "drug called demon", this is a fentanyl mix containing xylazine, bromazolam, and two very common cuts/bulking agents, quinine and caffeine. In this age of mis- and disinformation, it is imperative that we be as careful as possible with how we characterize these kind of things so as to not confuse and mislead the general population, but especially so we don't confuse or mislead the target audience.
Recommendation
Further monitoring is warranted before assuming this report from Philadelphia is an immediate threat in North Carolina. However, general education about xylazine is recommended, as is the danger of respiratory depression from potent benzodiazepines combined with fentanyl in the unregulated drug supply.