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In recent years an increasing number of novel opioids have appeared on the illicit drug market and have been linked to the growing opioid crisis in the United States. It is suspected that synthetic-opioid-related deaths are underestimated since many laboratories either use a screening method that is not specific and sensitive enough for these compounds or testing is not performed for fentanyl and its related analogs in general. We describe a method for the analysis of 19 of the most current novel opioid drugs quantitatively in whole blood and serum, and 17 analytes qualitatively in urine using solid phase extraction with liquid chromatography-tandem mass spectrometry (LC-MS/MS). The limit of detection was determined to be at a minimum 0.25 ng/mL for beta-hydroxythiofentanyl, 0.05 ng/mL for butyryl/isobutyrylfentanyl, AH-7921, 2-furanylfentanyl, 4-ANPP, and U-47700; 0.025 ng/mL for MT-45, para-methoxybutyrylfentanyl, 4-methylphenethyl acetyl fentanyl, U-50488, acrylfentanyl, valerylfentanyl, and carfentanil; and 0.0125 ng/mL for para-fluorofentanyl, ortho-fluorofentanyl, para-fluorobutyrylfentanyl/FIBF, and alpha-methylfentanyl. The lower limit of quantitation was determined to be 0.1 ng/mL for all analytes except AH-7921, U-47700, U-50488 which were 0.05 ng/mL and beta-hydroxythiofentanyl which was 0.5 ng/mL. The method was validated successfully according to a Scientific Working Group in Forensic Toxicology (SWGTOX) compliant approach. This method was applied to the analysis of 2758 samples between October 2016 and September 2017. It was determined that 4-ANPP, furanylfentanyl, and carfentanil were the 3 most prevalent fentanyl related compounds detected: 56.1% of cases were positive for 4-ANPP, 44.5% were positive for furanylfentanyl, and 25.2% cases were positive for carfentanil.

BACKGROUND: Despite their well noted therapeutic benefits for heart failure (HF), angiotensin-converting enzyme (ACE) inhibitors may be underprescribed and underdosed among older nursing home patients. OBJECTIVES: To assess the use of ACE inhibitor therapy in older (≤70 years) nursing home residents with systolic heart failure (HF). DESIGN: A cross-sectional, retrospective analysis. SETTING: Five long-term care facilities in Providence, Rhode Island. SUBJECTS: Adults aged 70 years or older with left ventricular (LV) ejection fractions ≤40%. MEASUREMENTS: New York Heart Association (NYHA) class, comorbid diseases, and cardiac medications with logistic regression analysis to clarify their bearing on the prescription of ACE inhibitors. RESULTS: Of the 819 nursing home residents who were evaluated, 119 (24 men, 95 women) fulfilled exacting entry criteria, i.e., heart failure signs/symptoms and documented LV systolic dysfunction. Forty-one of these 119 (35%) older persons were receiving ACE inhibitor therapy, predominantly in doses (≤50 mg captopril/day or ≤5 mg enalapril/day) less than those of proven therapeutic efficacy. Compared with older residents not receiving ACE inhibitors, those receiving ACE inhibitors included fewer with NYHA Class I HF (0 vs 21%, P = .017), more men (58 vs 28%, P ≤ .01), and more people with hypertension (61 vs 35%, P ≤ .01). In contrast, diuretics were prescribed more frequently among those not receiving ACE inhibitors (83 vs 56%, P ≤ .001). CONCLUSIONS: ACE inhibitors are underprescribed and underdosed among elderly nursing home patients carefully screened to include systolic HF and no contraindications to the medication. ACE inhibitors are particularly underused in those elderly with NYHA Class I HF and in those receiving diuretics.