Simultaneous Fatal Poisoning Of Two Victims With 4F-MDMB-BINACA And Ethanol

Due to the unknown toxicity of newly emerging SCRAs, forensic assessments of cases involving these substances are challenging. According to the reported cases and reviews of the scientific literature, concurrent ethanol consumption should amplify the toxicity of SCRAs. The concentration of 4F-MDMB-BINACA in the postmortem blood was 2.50 and 2.34 ng/mL, and blood alcohol concentration was 2.11 and 2.49 g/L, respectively. Two fatal cases are reported caused by simultaneous consumption of 4F-MDMB-BINACA and ethanol.
Fig. 2.
4F-MDMB-BINACA was hydrolysed via ester hydrolysis forming the 4F-MDMB-BINACA ester hydrolysis metabolite (B22). Data obtained from the twenty urine samples were retrospectively analysed and processed using TraceFinder software based on the identification criteria of mass errors less than ± 5 ppm for full MS peaks and MS/MS peaks from the theoretical mass and matching of MS/MS spectra. The mixture was vortex-mixed and 500 µL of this mixture and 500 µL of methanol were loaded onto the Clean Screen FASt® tube. After incubation, the mixture was cooled at room temperature, and 150 µL of purified water was added. High-resolution QTOF-MS data were acquired on an Agilent 6510 Accurate Mass QTOF mass spectrometer (Agilent Technologies) equipped with dual electrospray ionization (ESI) source operated in both positive and negative ion modes, to determine accurate masses of the metabolites. Chromatographic separation was performed on an Agilent 1290 LC system with a Poroshell 120 EC-C18 analytical column (2.7 μm, 75 × 2.1 mm; Agilent Technologies, Santa Clara, CA, USA).
Fig. 1.
Monitoring metabolism of synthetic cannabinoid 4F-MDMB-BINACA via high-resolution mass spectrometry assessed in cultured hepatoma cell line, fungus, 4F ADB liver microsomes and confirmed using urine samples The threshold for fatal overdose of combined use of SCRAs and ethanol can be estimated as a little ng/mL (0.37–4.1 ng/mL according to the reported cases) of SCRA and 1.5–2.5 g/L of ethanol. The reported cases and reviews of the scientific literature suggest a possible synergistic effect between SCRAs and ethanol, because their combined use clearly increases their toxicity. The victim died due to severe necrotizing pancreatitis and acute kidney injury evolving into multi-organ failure 11 days after hospital admission . Studies have found no unequivocal synergistic effect between THC and ethanol at low or moderate ethanol doses [29, 30], but no data on high doses of ethanol are available. Given that THC and ethanol act on the same receptors, data on their simultaneous use may yield important insights in this regard.
Fungus C. elegans
Concentrations of 4F-MDMB-BINACA in the postmortem blood samples were 2.50 and 2.34 ng/mL, which are in line with published data. Although the lethal dose of 4F-MDMB-BINACA is unknown, its concentration in postmortem blood samples was found to range between 0.10 and 2.90 ng/mL . In SCRA-related cases in which the deceased suffered from heart disease, the SCRA concentration in the postmortem blood was less than 1 ng/mL . Concentrations of SCRAs in postmortem cases cover a wide range ; however, some reports of survival have also been published—even at relatively high blood SCRA concentrations [19, 20


A limitation of this case report is that we did not have a urine sample available for additional NPS testing. Point-of-care DOA tests using urine to screen for misuse of multiple substances, regularly include cannabis, amphetamines, cocaine, opioids, benzodiazepines and methadone. THC, methamphetamine, SRCA, lysergic acid diethylamide (LSD), gamma-hydroxybutyrate (GHB) and ketamine are likely to become volatile under the temperature of current e-cigarettes, while crack cocaine is hard to vaporise. A systematic review including data of 114 patients of which the majority was intoxicated due to SCRA smoking revealed that 45 % of the patients who present at the ER after an intoxication due to SCRA smoking recovered within 24 hours .
Data availability
Moreover, a study conducted in the United Kingdom investigated components of e-liquids in 112 samples originating from prisoners, teenagers and test purchases of commercially available e-cigarettes taken between 2014 and 2021 . This is the first case report that describes the toxicological symptoms of vaping ADB-BUTINACA. Results of the DOA test (including testing for amphetamines, methamphetamines, barbiturates, benzodiazepines, cocaine, methadone, opioids, cannabis, tricyclic antidepressants) were available within 30 minutes and were all negative. We report a case of an involuntary intoxication of the SCRA ADB-BUTINACA after vaping. There are several pitfalls in the detection of SCRA in samples taken from the patien


As synthetic cannabinoid receptor agonists (SCRA) are gaining popularity globally, clinicians have to understand that intoxication caused by vaping SCRA is not detected by commonly available tests. He confirmed that he had been vaping an electronic cigarette (e-cigarette) earlier that day just before the onset of his symptoms. Metabolic acidosis (1/3, 0/7) and respiratory acidosis (1/3, 0/7), All 10 patients recovered with supportive care, including intubation and ventilation for one case. In 3 cases ADB-BUTINACA was the only substance detected, while in seven other substances of misuse were also detected including other SCRA, opioids, benzodiazepines cocaine and pregabali