Flualprazolam: Report of an Outbreak of a New Psychoactive Substance in Adolescents

Abstract

Flualprazolam is a nonregistered drug in the benzodiazepine family and constitutes a new psychoactive substance (NPS). Since 2014, a growing number of designer benzodiazepines have become available over the Internet and on the counterfeit drug market. In June 2019, a cluster of patients intoxicated with flualprazolam was identified by the Oregon Poison Center. As an emerging drug of abuse, the clinical characteristics of flualprazolam have been poorly characterized thus far. Over a one-week period, 6 teenagers presented to local emergency departments after ingesting illegally obtained counterfeit alprazolam, which led to sedation. Other symptoms included slurred speech, confusion, and mild respiratory depression. All 6 patients had resolution of their symptoms within 6 hours of ingestion. Blood and urine samples, as well as a tablet fragment, were obtained from 3 patients. The tablet and biological samples were analyzed by using liquid chromatography–quadrupole time-of-flight mass spectrometry and were found to contain the NPS flualprazolam without other drugs or intoxicants. With this case series, we add to the medical literature a clinical description of an emerging drug of abuse. Flualprazolam appears to share the clinical properties of other benzodiazepines. As flualprazolam and other NPSs become more common, physicians must be aware of their availability and characteristics. Sedation lasting <6 hours was observed in 6 of 6 patients exposed to flualprazolam. No effects that would be unexpected from benzodiazepine intoxication were seen among the patients. Specifically, none developed prolonged symptoms or required intubation and mechanical ventilation, ICU admission, or antidotal therapy.

A fluorine turns a medicinal benzodiazepine into NPS: the case of flualprazolam

“…In three patients, flualprazolam was detected in their urine samples. All symptoms reported subsided within 6 h [11].…”

“…Flualprazolam shares a similar structure with other controlled benzodiazepines, such as alprazolam and triazolam as well as other novel benzodiazepines, such as flubromazolam (Fig. 1) [11].…”

“…The number of forensic cases, where flualprazolam is involved, is continuously increasing, along with the number of drivers under the influence of flualprazolam. Cases of clinical intoxications have also been reported in the literature [11].…”

“…It is also sold as Xanax bars, alone or in combination with other NPS benzodiazepines, such as etizolam, adinazolam or other unidentified substances. Pellets, blotters and a liquid form of flualprazolam also exist in the market, while powders containing flualprazolam also contain other harmful substances, such as fentanyl, cocaine or MDMA [11,26]. A mixture of flualprazolam with diphenhydramine, quinine, fentanyl and cocaine is sold as a powder under the name 'Dope' [26].…”

“…Blumenberg et al [11] described the first confirmed clinical flualprazolam case where six teenagers consumed flualprazolam, after receiving the drug as a free sample, believing that it was commercial Xanax. Flualprazolam was identified by the analysis of a fragment of a not consumed tablet and it was concluded that the whole tablet contained approximately 2.75-3 mg of flualprazolam.…”