title: Fentanyl and a Novel Synthetic Opioid U-47700 Masquerading as Street "Norco" in Central California: A Case Report.
abstract: In 2013 and 2014, more than 700 deaths were attributed to fentanyl and fentanyl analogues in the United States. Of recent concern is the cluster of unintentional fentanyl overdoses because of tablets thought to be "Norco" purchased on the street in Northern California. U-47700 (trans-3,4-dichloro-N-[2-(dimethyl-amino)cyclohexyl]-N-methylbenz-amide) is a nonfentanyl-based synthetic opioid with 7.5 times the binding affinity of morphine to μ-opioid. We report a case of fentanyl and U-47700 intoxication from what was thought to be illicitly purchased Norco. A 41-year-old woman presented to the emergency department (ED) for altered mental status shortly after ingesting 3 beige Norco pills bearing a Watson imprint. She had pinpoint pupils and respiratory depression, which reversed after 0.4 mg naloxone administration intravenously. She had complete recovery and was discharged from the ED after a 4-hour observation period. Serum testing with liquid chromatography-quadrupole time-of-flight mass spectrometry (LC 1260 QTOF/MS 6550; Agilent, Santa Clara, CA) confirmed the presence of the medications the patient reported receiving, and additionally fentanyl (15.2 ng/mL) and U-47700 (7.6 ng/mL). In this case report, street Norco purchased in Central California resulted in altered mental status requiring naloxone reversal because of fentanyl and the novel synthetic opioid U-47700. Because these compounds are not detected by routine urine drug testing and physical examination findings are similar to those of a traditional opioid toxidrome, emergency providers should use the patient's history and other circumstantial details to aid in diagnosis. In cases with suspicion of opioid or opioid analogue cause, we recommend that emergency providers contact their local poison control center, medical toxicologist, or public health department to aid in the investigation.
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA. Electronic address: parmenian@fresno.ucsf.edu.
authors.forename: Patil
authors.initials: P
authors.lastname: Armenian
authors.affiliation: Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Olson
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA.
authors.forename: Andres
authors.initials: A
authors.lastname: Anaya
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA.
authors.forename: Alicia
authors.initials: A
authors.lastname: Kurtz
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA.
authors.forename: Rawnica
authors.initials: R
authors.lastname: Ruegner
authors.affiliation: Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA.
authors.forename: Roy R
authors.initials: RR
authors.lastname: Gerona
mesh_terms: D000328:Adult; D001549:Benzamides / Q000633:toxicity*; D002140:California; D015198:Designer Drugs / Q000633:toxicity*; D004347:Drug Interactions; D004636:Emergency Service, Hospital; D005260:Female; D005283:Fentanyl / Q000633:toxicity*; D006801:Humans; D009294:Narcotics / Q000633:toxicity*; D009293:Opioid-Related Disorders / Q000150:complications / Q000175:diagnosis
chemical_list: D001549:Benzamides; D015198:Designer Drugs; D009294:Narcotics; C000614521:U-47700; D005283:Fentanyl