SMART Policy Podcast
Podcast by the UT SMART Initiative. Host Jeremy Kourvelas speaks with experts from across the recovery ecosystem - representing healthcare, prevention, law enforcement and more - about local, state and federal drug policy to find out what is and isn't working to make this fight against addiction a little easier.
SMART Policy Podcast
Why a New Synthetic Opioid is Outsmarting Drug Tests
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There’s been growing attention to a new chemical in the illicit drug supply: N-Propionitrile Chlorphine, also known as cychlorphine. On top of being more potent than fentanyl, it’s also extremely hard to detect on toxicology tests. Currently, all deaths attributed to cychlorphine have been identified in the East Tennessee region around Knoxville, but experts believe it is in more areas already - we just haven’t been able to identify it.
Cychlorphine is an excellent example of why staying on top of new drug trends can be so challenging. This month I am joined by Chris Thomas of the Knox County Regional Forensic Center, Dr. Shravani Durbhakula of Vanberbilt University Medical Center, and Adam Gray of the Tennessee Bureau of Investigation to discuss the challenges of these new drugs from forensic, clinical, and law enforcement perspectives.
In this conversation we talk about several of the newer drugs in the supply, the technological and logistical limitations of testing for drugs, and of course, the policy options that could make this problem a little better.
Learn more:
CFSRE Summary of N-Propionitrile Chlorphine: https://www.cfsre.org/nps-discovery/monographs/n-propionitrile-chlorphine
Importance of Naloxone with Cychlorphine: https://www.tn.gov/health/news/2026/3/18/tdh-reinforces-importance-of-naloxone-with-rise-in-cychlorphine-fatalities.html
Knox County Regional Forensic Center: https://www.knoxcounty.org/rfc/
Dr. Shravani Durbhakula: https://www.shravanimd.com/about-dr-shravani-durbhakula/
SMART: www.smart.tennessee.edu
Cold Open Cyclorphine Emerges
SPEAKER_00You're listening to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. There's been growing attention to a new chemical in the illicit drug supply, N-probionitrile chlorphine, also known as cyclorphine.
SPEAKER_02That is the largest growth of any new substance that this office has seen in the last 10 years, with the exception of fentanyl. Not xalaze, not bromazolin. Nothing has had this many cases this quickly and killed this many people.
SPEAKER_00On top of being more potent than fentanyl, it's also extremely hard to detect on toxicology tests. Currently, all deaths attributed to cyclorphine have been identified in the East Tennessee region around Knoxville, but experts believe it is in more areas already. We just haven't been able to identify it.
SPEAKER_02You can tell them I've seen it all the way to the borders of my jurisdiction. So if I'm seeing it in as far north as Clavern and Granger County, then it has to be in Washington Green County. It has to be up there. And if I'm seeing it all the way down in McMing County, in Meggs County, it's got to be in Hamilton County. But they haven't found it yet.
SPEAKER_00Cyclorphine is an excellent example of why staying on top of new drug trends can be so challenging. This month I am joined by Chris Thomas of the Knox County Regional Forensic Center, Dr. Shravnider Bakala of Vanderbilt University Medical Center, and Adam Gray of the Tennessee Bureau of Investigation to discuss the challenges of these new drugs from forensic, clinical, and law enforcement perspectives.
SPEAKER_05As a clinician, we don't typically know what we're dealing with, right? My patients may also not know.
SPEAKER_02We've been finding it most often when we're looking for something else. Obviously, that makes our mind worry about what else is out there.
SPEAKER_01There might not even be a drug standard out there that they could purchase. And if you don't know to look for it, you're going to miss it. And when we decide, hey, we're going to look for this new drug, we have to go through a validation process that takes months to do.
SPEAKER_05Yeah, and I think that's interesting because you don't need very much to get a clinical effect with some of these substance because of how powerful they are. And then if we're not identifying them, but they are having clinical effects, you know, that's a that's something we need to figure out.
SPEAKER_01Sometimes it's kind of weird some of these drug pop-ups that we'll see that's regional, but then like some of them, you'll see them all across the state.
SPEAKER_00In this conversation, we talk about several of the newer drugs in the supply, the technological and logistical limitations of testing for drugs in multiple contexts, and of course, the policy options that could make this problem a little better. And as always, this episode is intended to be educational, showcases the personal opinions of the guests, and does not reflect any opinion or belief of the University of Tennessee.
Guest Introductions And Missions
SPEAKER_00So to get started, I'm going to go around and have you introduce yourself, what you do, and why you do it, and we'll go from there.
SPEAKER_02I'm Chris Thomas. Um I'm the Chief Administrative Officer and Director for the Knox County Regional Forensics Center. So I oversee all the day-to-day operations of the medical examiners at office for Knox, Anderson, and Blunt counties. And then we serve as performing autopsy services for an additional 20 counties when their county medical examiner determines an autopsy is needed either for criminal uh prosecution or for just understanding the cause and manner of death. I've always been a servant by nature. I'm uh a military veteran. I served the U.S. Army, uh, even in my private sector jobs. I always felt uh deep need to be involved in the community that I'm in because we live here. So if we live here, we want to make the place that we live better. We want to make this the best place that is possibly of anywhere to live. And I feel that uh my position allows me to share real-time information with uh people who can enact changes, whether it be law enforcement, legislation, or community leaders, to give them the tools that they need, give them data and information so that they can use that information to get the tools and resources they need to provide that best environment.
SPEAKER_05Well, I'm glad to be on this podcast. Thanks for having me, Jeremy. My name is Shravnin Dirvakala. I'm an anesthesiologist and pain physician. I direct the comprehensive pain service at Vanderbilt, where I also serve as an associate professor. I'm really interested in the gaps and surveillance that we're seeing with some of these newer compounds and drugs that are really in the illicit supply. I mean, I've enjoyed working with the smart policy group as well as Chris and Adam, who are on the podcast today, to better understand some of these things.
SPEAKER_01Yes, um, well, my name is Adam Gray. I am the Regional Crime Lab Administrator at the Knoxville Regional Crime Lab. And so we have, and that at this lab, we have like the DNA section or physiology, frenziochemistry, and toxicology. I oversee the day-to-day operations, make sure we're getting things done, getting cases out the door. And I think the reason why I do what I do is um I really love, feel like I'm contributing and helping society as a whole. We want to make like I like I'll just copy what Chris said, you know, we want to make this area safe and Tennessee safe and um love the idea of educating and and also and you know, you know, I like to always the TBI concept was uh, you know, you know, the innocent should not suffer, the guilt should not escape. And so I kind of that's why I really love what I do, and that's why I do it.
SPEAKER_00All right, thank
What New Drugs Are Appearing
SPEAKER_00you all. So to get us started, we're seeing some changes in the illicit drug market. You know, fentanyl obviously is still out there in large quantities, but there's even been some changes in how much is coming in and how. This will just be an open call, whoever's comfortable and you can bounce off each other. Uh, what are some of the new substances we're seeing, not only in drug seizures, but also in fatality data as well as in the clinical space?
SPEAKER_02I'll jump in since through the word fatality out there. So, of course, you know, fentanyl continues to be the number one drug of choice involved in the drug, fatal drug overdoses. And, you know, for several years we had a lot of these nidazines, benzodiazepines that were sort of introduced to the Tennessee market, and we caught on to those early on. And I think there were some legislative changes as well as just some surveillance from law enforcement agencies through the data. And it seemed last year that we had kind of peaked and we were kind of coming back down. Uh last year was a, I hate to use the term good year, but it was a relatively better year number wise compared to the previous few years that we had for drug-related deaths. And then late last fall, we started seeing some of these new substances again. We were introduced in proponitrile chlorophine or cycloraphine as it's commonly referred to, which now for my office alone, with you know the singular case in July and a singular case in October since that time period has been responsible, is now involved in 44 deaths in my location. That is the largest growth of any new substance that this office has seen in the last 10 years, with the exception of fanyl. Not xylazine, not bromazolin, nothing has had this many cases this quickly and killed this many people. And as if that wasn't enough. Now, for the last year or two, I think you and I have spoken as well as your partner uh Trevor has talked to me about the um, and I apologize when I pronounced these incorrectly, but meditative done, dean or dine. So now I've started seeing several cases. So I'm up to about six or seven cases with that. And as if that wasn't enough, now we're starting to see some trends. I've started in the last couple of months. I'm seeing metragenine analyses. I've got this metragenine pseudoendoxyl that has now been uh involved in about almost a dozen deaths now since uh the uh December of last year, mostly since this year. So we're seeing a lot of Kratum synthetic substances being mixed in. That's that's and that too, that both of those substances they're not currently detectable through standard toxicology procedures, which makes it more difficult. The NMS labs, which we use, they only because they have scientists and they have toxicologists that are familiar enough to recognize it, they said, Hey, we're pretty sure you have this, but you gotta go further. You got to go to a research laboratory to confirm this. And uh, we're starting to see that with more substances. So it's obviously that makes our mind worry about what else is out there that we're not aware of.
SPEAKER_00Yeah, I I want to put a pin in the difficulties with testing for it, that it has to be caught by an expert, because that's that's really worth diving into. Uh before we do so, what are some of the other substances that y'all are seeing? Uh Adam, Dr. Dabacola.
SPEAKER_01Chris did a great job explaining. So it's very interesting how the drug trends happen. So when we usually when you pass a law, they'll try to skirt the law by trying to add on the trying to be specific, might like replace a chlorine with a bromine or a fluorine, or just add on a functional group that'll change it, but it's pretty much structurally it's the same drug that or it attaches to the same receptors and causing the same reactions, or could be even worse. So, I mean, we had that happen with some stimulants a long time ago with the basalts, and now when fentanyl started coming and now it's starting to I guess people try to find a replacement for fentanyl, then you started getting these all these new MPS or novel cycle substances of opioids. And like I would say, like we're seeing uh we're seeing the proponitryl chlorophyll, and and I mean we're still seeing a lot of like fluoropentanols and parafluorfentanyls, but uh metatomidine is what he was saying. We're seeing a lot of those. But yeah, it's it's they they start to try to change these substances to get skirt the law or try to get it, it makes it a lot more lethal and or more dangerous. Our drug chemistry section usually detects it first before our toxicology section. And he did, like I said, we'll talk a little bit more about the testing later, but yeah, there is it is a it's a hard thing because it's ever changing, you gotta keep it up. And this is a great opportunity to share information. Uh so I'm I'm I'm really thankful. I I emailed Chris quite a bit uh over here and say, hey, you know, and I want to tell you that helps a lot. Communication and make sure we're at the look for
Treating Overdoses Without Clear Tests
SPEAKER_01and help people out and and and educate the you know the public of the dangers that are that are out there.
SPEAKER_05Yeah, I would say, you know, as a clinician, we don't typically know what we're dealing with, right? Because it's not like our urine drug screens in the emergency rooms or the ones that I can even order on the outpatient side would tell me, for instance, that N propionitrile chlorophine is actually something that one of my patients took. And my patients may also not know that they took this substance. What we do know is, you know, this is not one of the ones that, you know, we've seen a lot of veterinary anesthetics and things from years ago or that are currently used in the veterinary space sort of surface in the illicit supply. This is not one of those. We don't really understand the human potency right now relative to fentanyl or nitazines, then naloxone responsiveness. We don't really have a clinical overdose phenotype right now. And, you know, this is something that we need to work to really understand. Because if someone comes in and we don't understand what they took, and we also don't even know how the drug works or you know what is required to reverse it, then that becomes problematic from a clinical standpoint. Uh, I did want to bring up Kratom. Chris brought this. Uh, kratom is definitely something that we're seeing. I have lots of patients who come in, some of them actually asking me for help to get off of this substance because they're using it, you know, to get off of opioids or to help them, but then they get addicted to this substance. And it can have negative effects too. You know, there are heavy metals that can be in these substances. FDA has identified heavy metals and in Kratum products. They can have a variety of effects that are dose-dependent, right? So at lower doses, they're stimulant-like, but at higher doses, they do have opioid-like effects. And the metabolite, the seven hydroxymetragenine, is actually 10 times or so more potent at the muopioid receptors than morphine. We do have patients coming in with this sort of kratom-associated blue skin that we're seeing. We don't completely understand the mechanism of this, but patients can really look quite blue. And there's a possible photosensitizing effect here because a lot of these patients that get the blue skin are working outside. And so we're not sure if there's some sort of deposition of like a melanin drug complex or what exactly is going on here. But it is worth understanding. I mean, people can go to a gas station and get this, but it can have significant side effects of nausea, tachycardia, hypertension, but even things like hepatotoxicity, which is damage to the liver, seizures, QT prolongation, which would impact the heart and cardiac arrhythmias. And then sometimes, you know, they are implicated in overdose deaths actually quite often because they might be, you know, involved with another substance as well, whether it's fentanyl or something else.
SPEAKER_00Wow, yeah, that there's quite a lot there. So a lot of different symptoms, a lot of different concerns. And that's that's what we're talking about with these cocktails of substances. Uh, you know, we're y'all all have all mentioned things mixed together, complications from that. And just as a a quick aside, you mentioning
Naloxone In A Mixed Drug Era
SPEAKER_00the blue skin at first, I think, you know, colloidal silver, but then with a photosensitivity aspect to it. Very strange. Very strange indeed. And and you know, something else too, uh with with so many of these substances, naloxone effectiveness is going to vary considerably, I suspect. Uh are we seeing something like that play out in clinical and death data? Is the effectiveness of naloxone being impacted?
SPEAKER_05Yeah, so we know that certain substances, for instance, nidosines and substances that are even more powerful than nitosines, like carfentinels, require multiple doses of naloxone. Uh, we're still trying to understand, you know, how many doses is it two, is it three? You know, it may depend, and it may depend on what else is mixed into that substance, or if they took another substance with it. So we want to be careful with using the word laced because that suggests it's one single substance. But it could also, in my case, there could be a situation where a patient of mine is being prescribed an opioid legitimately. So they have that opioid in their system, but then they additionally have, you know, something else in their system. So naloxone responsiveness is something we're still trying to understand. What's what's really interesting is I think Adam brought up metatomidine or Chris, or maybe both of you, but drugs like that, you know, those are not actually naloxone responsive. That's an alpha-2 aginergic agonist. It's a veterinary sedative that was usually used in dogs and cats. And it is very potent. It's more potent, uh, 200 to 300 times more potent than xylosine, actually. But it's not an opioid. So, of course, if it's not an opioid, it's not really going to respond to naloxone. You know, and you have these drugs mixed in with opioids, you might be able to reverse the opioid effects you're seeing, but with naloxone, but we're certainly not going to be able to reverse things that are not opioid. So it's a very complex question, and I think we're still trying to understand it. And in the context of not being able to test for these substances, to some extent it becomes a guessing gain.
SPEAKER_01I got a question. I know we we do see xylosine in a lot of our mixed drugs, especially with fentanyl. Does it have the same effect with naloxone?
SPEAKER_05Yeah, similar issue with xylosine, because again, you know, you can't really reverse xylosine necessarily with naloxone. But if it's xylosine plus fentanyl, maybe the fentanyl portion could be, you know, reversed with naloxone. So it's just a challenging, challenging thing. And xylosine has a lot of impacts in a public health sense and a medical sense, especially, you know, there are these crazy kind of necrotic skin ulcers that we see with xylosine, and that causes significant burden for our infectious disease physicians. You can have even like osteomyelitis, that's that's one that's has a significant impact. And we we see it kind of in pockets. I know that Philadelphia
Xylazine Fades Metatomidine Rises
SPEAKER_05had a cluster of cases, uh, but you guys would know better about that piece of it.
SPEAKER_02So, you know, it's interesting the conversation about xylazine versus metomodine. So we we saw, you know, xylazine, it came in hot and heavy for several years, and last year it pretty much dissipated, but I would still occasionally find it through some of our research labs. It's because the threshold or the quantification that used to be in most of these cases had had pretty much dropped below that minimum threshold for our standard toxicology program to pick up on it. And it's the same thing with this metomidine, and I know I'm probably pronouncing it incorrectly. It's used, we're we've been finding it most often when we're looking for something else. Because NMS has told me a couple of times they think they've saw it, but most of the cases I've gotten, it was, hey, we we see this cyclorphine or we see this other substance. So then we do the research and they're like, oh, we also found metomidine in there. So we report it and calculate on it. So it's it's it at least for us in fatal overdoses, it's coming through in either small enough quantities where it's not being picked up by the standard toxicology, or like you said, they haven't had enough experience with it yet to identify it.
SPEAKER_05Yeah, and I think that's interesting because you don't need very much to get a clinical effect with some of these substance because of how powerful they are. And then if we're not identifying them, but they are having clinical effects, you know, that's uh that's something we need to figure out.
SPEAKER_01Yeah, I will tell you, um, I just looked at from from year to date. I was looking atomidine is actually one of the higher drugs that their forensic drug chemistry detected. So it's one of the more prominent ones that they're seeing in their in their drugs. And usually um when we get a solid dose in the drug chemistry unit, it's mixed. It's not really we very rarely see stuff by itself. If it's what you know, opioids. Now of course, you know, you do see cocaine and methamphetamine sometimes by itself, but I'm talking more talking about when we see these opioids.
SPEAKER_02Yeah, that that's I think it's we've had it in six deaths this year so far from our center.
SPEAKER_05I'm just looking at this CDC data, you know. I only have up to 2024 here, but at least for xylosine, it looks like the the count is really quite large in Tennessee. Like there's a map of all of the different states, and Tennessee is kind of a much darker color, indicating there were more than 150 deaths in Tennessee in 2024, at least. And you know, you guys obviously have much more up-to-date data, but xylosine, metatomidine, I mean, I think we're seeing these things kind of mixed into other substances. And like I said, that those numbers probably are not really reflecting the whole problem. If if it doesn't take much to get a death, and then we're not able to detect things that are, you know, present in small quantities.
SPEAKER_02What year did you say that report was for?
SPEAKER_052024.
SPEAKER_02It looks like 2024 was a huge year. My office alone, we found xylazine in 95 deaths. So it it was really in 2025 when it dropped off the radar for us. So I went from 95 deaths in 24 to only 19 in 2025. So we had been identifying it quite regularly, but it seems maybe the, like you said, the quantification has seemed to that and it seemed to drop right around the time the legislation changed. I think it was the summer of 24 when they actually changed the legislation to make that a scheduled substance where you couldn't purchase it without an actual veterinarian license versus just being on an open market. And it seemed to really decline in the later, latter part of 2024. And then 2025, it was very sporadic. And this year alone, I think, of course, last year was 19 cases. I've already identified it in 10 cases this year, and obviously we're only in the first two months as far as having data. So it looks like it's going to be back up in a trend again this year.
SPEAKER_05Yeah, and to that effect, I feel like it's very hard for you guys, right? Because as soon as something gets scheduled or you start identifying it, it's like they come up with something else and it's this cat and mouse situation for you.
SPEAKER_02Yeah, actually, so I have this. I know we're not on, but I pulled up this. This is the list of the um MPSs from the CSFRE. And each year, it's like all the new drugs they found each year. So I went through and I tried to actually list like the quantity of all these new drugs. Some of these I never I never saw, but it is kind of interesting. The NPSs that CSFRE have been tracking, like it this goes back to 2018. And I did, I'm and I looked at my data. I didn't have any of these new rare drugs from 18. In 2019, I had isotonidazine. That's when that came up. And I think we had like 20 cases. In 2020, there was a list and we started having more the brofenes, the metatonidazines, the fluorophentanyl, the U47700. You know, some of these that kind of came, had a few. Cases in and out. 21, you bring in etotinidazine. We had some of those. Then 22 was just new versions of it, the indexyl isotinidazines. And 23 and 24. So each year they have to go to the list of all the new drugs they're identifying that year. So it's like it just continues on.
SPEAKER_00So yeah, that's that's following global trends. We're seeing fentanyl decrease, not you know, in large enough quantities that we'd like to see, but we are seeing a decrease in response to changes in policies in China, in Mexico, uh, and markets appear to be shifting. You mentioned xylozine be getting scheduled as a controlled substance and quantities changing. That implies there was quite a bit of diversion from more traditional production routes. And now perhaps this year it's catching up with a illicit producer, maybe you know, clandestine labs somewhere shifting their production. There's all these broader global economic and policy changes. Locally, you mentioned metatomedine coming in in huge quantities as xylazine declines. Do we have any reason to believe that this is a similar trafficking route? Like are is it is it the same entities dealing in the same in these
Rural Resources And Undercounted Deaths
SPEAKER_00shifting substances, or are they are these different players constantly competing with each other? Like what can we infer from this?
SPEAKER_02Well, I'll tell you this so far in the fatal cases I've seen this year with metatamidon also had cycloraphine in it. Oh, wow. Yeah. That was common in every one of the deaths.
SPEAKER_05And that is so interesting because we can't really identify either of those, you know, when a patient comes in. And also for you guys, we you know, maybe some offices around the country can identify those, but most of the time, you know, those numbers I it really asks it gets me to question the numbers that we're seeing. Are we really seeing a decline in deaths, or are we seeing that they're evading detection and therefore it kind of looks like a decline in overdose deaths?
SPEAKER_02I'll jump on that one too. So we have well, I've been noticing too this year, I have a rather significant downward trend in autopsies ordered by rural county medical examiners. There's been several medical examiners in State Tennessee and the regions that I serve that have retired and the new medical examiners have come along. And they're doing one thing really well, is that they want a team of death investigators who can go to the scene versus just allowing law enforcement to be the only provider on scene that does this scene investigation. However, and I I would have to defer to Adam on if he's seeing a larger request and toxicology request for these rural counties because you know, and I talked to some of the state, and everybody asked me how many counties have I seen the cyclorphine of the 20 I served. And I said 11. And they're like, oh, well, that's kind of good. That's only half the counties. I said, no, you don't understand. I probably have 10 counties who have never ordered a drug-related death autopsy. It's pretty much just babies, children, homicides, and they internally investigate their own drug-related deaths. Now, you're talking about finances and resources and personnel and motivation when you're getting into that. So if a if an individual goes into an ED and they run a they run a urine drug screen and they say they tested positive for fentanyl or opiates, the medical examiner has the right to say, okay, fentanyl, you know, probable fentanyl overdose on the death certificate and never do an additional blood test. They don't have to. There's no requirement. They can simply just take the information they got from the ED, sign off on the death certificate, no additional cost to the county taxpayer. Done.
unknownRight.
SPEAKER_01There was something else you guys were talking about. We were mentioning like the drug trends, and a lot of times they'll do like a temporary schedule, and then and then by the time it goes around and becomes, you know, oh, now it's temporary schedule, move to something else. It was like, and sometimes these trends happen regionally, like nitazines. Um I remember seeing Chris and them put out a paper about nitazines in the Knoxville area, and we were talking about writing a paper too, and we were like, and then we went and pulled the stats, and like, well, the rest of the state hasn't really seen it yet. And so it was, but it's kind of spread, and that's a little bit sometimes it's kind of weird some of these drug pop-ups that we'll see that's regional, but then like some of them you'll see them all across the state. So I don't it maybe it's more like you were talking about Jeremy, of its distribution of way that's going on, maybe wherever these drugs are coming from. It does, I I
Why Toxicology Misses Novel Compounds
SPEAKER_01can't speak to that, but it does seem fairly odd, is to say.
SPEAKER_00And speaking of fairly odd, I think coming back to something Chris said early on, how easy it is to miss an indication of a substance on a test. So, like being that it is technically possible to detect on conventional equipment, but for a phrase Adam, I've heard you say before, is uh sending out for confirmation and concentration, which is a useful pair of words to think about. So but that also necessitates kind of already looking for it. If it can be from what I understand, from what you know, limited exposure, when you do a test of a chemical substance, you get these, you say it's chromatography or some other test like that, you get these peaks and troughs along a band. And uh sometimes it could look like noise, sometimes it might be a substance requiring a more intensive investigation. I know that's a gross simplification, but what's going on here? Why, why, why is it that it can be easy to miss these drugs sometimes?
SPEAKER_01Well, I'll let you know. So let's say if it's a brand new drug and it's it comes in let's say the drug chemistry section, they'll see it and they're like, huh, this is odd. I wonder what this is. And there might not even be a drug standard out there that they could purchase. So we usually to be able to identify a substance, we have to have a drug standard to compare it to. So we have a couple of different companies that we purchase drug standards from that are certified. We bring we buy them, we run it on their instrumentation, we do and we make sure that the that that matches what they're seeing. Eventually, though, you'll start saying, Okay, this is something because we're c we're starting to see a little bit more often. And then they'll purchase a standard, try to do what what we do, and we have to do a presumptive confirmatory, then we just usually do two different tests to confirm it in the drug chemistry section. And then that's one way to do it. Now, toxicology, it's kind of interesting. A lot of toxicology, even hospitals, they use a lot of uh screening techniques, and and some of that screening techniques is it looks for a class of drugs, not really a let's say drug-specific, like, oh yeah, it looks for fentanyl, but it looks for all the opioids or opiates. And so sometimes those tests are sensitive for a different types of opioids, and sometimes some are a little bit less sensitive, but sometimes they'll be sensitive, and then you run the confirmatory test, which is you have all these drug standards, you run them, and you're saying, All right, did anything show up that we see? And if you don't know to look for it, you're gonna miss it, or it'll pop up and you're like, I don't even know what this is. So that's how a lot of times it gets missed, or the certain kind of confirmation test in toxicology is not specific enough for that type of drug. Um so and that's one way, but also the biggest thing that's and I Chris can back me up on this one too, because we talked about this before. So TBI, we're accredited lab, so we have to go through a lot of checks and balances. And when we decide, hey, we're gonna look for this new drug, we have to go through a validation process that takes months to do. I mean, we gotta make sure what we're gonna report out, not only are we gonna identify it, but also quantify it, that we can say, hey, this drug is definitely that drug. So we have to go through this huge process, and it takes months. Yeah, then you gotta think, okay, is this a drug that's gonna stay around long enough? And by the time I get my method, it's already gone. Yeah. We you know, that happened with basalts, you know, we their bath assaults was really big, and we're like, boom, it's it was. I mean, there's still sometimes they show up, but it's not as often. But then when you get to the like he was talking about the CFSRE people, they will try or the DEA lab, they will try to tell how they say, okay, we'll we'll identify it, but it's they have what would you say, Chris?
SPEAKER_02And I'm gonna say less, I don't say less criteria, but so they as no one as part of a regional forensic center, we have to be name accredited, which means our primary toxicology has to be done with the American Board of Forensic Toxicologists board certified laboratory, which NMS is our primary toxicology, is the DEA toxicology, they are a research facility. So they are not an accredited laboratory, which means that we cannot use them solely for the purposes of toxicology, which is why we say these are supplemental reports that go along with our toxicology. The CSFRE is a research laboratory and they are accredited for the from the American Board of Forensic Toxicologists. Something Adam said there too is about the timing that it takes. And I will say I have the benefit of being smaller. If you're ever doing any kind of training with you know, any kind of female mass disaster, they always say you start local, you end local. And we are as local as it gets, which means I have less red tape than maybe a state agency or a federal agency. So as of today, you know, and I would say that I am you know investigating 44 deaths now from the cycloraphene in my office. Now, 15 of those have not been confirmed because as Adam said, it takes time. When my toxicologist company says, hey, we think we've found some of these on it, but then I got to go to DEA or CSFRE. I'm talking, I've already been in it three weeks, maybe two to three weeks with D with NMS. Now I'm going another three weeks with DEA and CSFRE is unfortunately even further because they're six to eight weeks out. I can't be waiting four months to tell the public what happened now. Right. So I do have the freedom and the ability with other agencies don't to say I can go off and tell the public, listen, I am dealing with 44 cyclorphine deaths. Is it confirmed? Absolutely not. And if I'm off by five, will I take the beating later on? Sure, absolutely. But you need to know now, not six months from now.
SPEAKER_00Especially given
Tracking Spread Across Tennessee
SPEAKER_00the likelihood that all of these numbers are likely an underrepresentation, given that the rate of missing them seems so high. Extremely unrepresented.
SPEAKER_02Since we I've gotten another email from I've started getting emails from areas in the tri-cities and the Chattanooga and national markets, because they're like, we're not seeing, you know, how far are you seeing it? And I can tell them I've seen it all the way to the borders of my jurisdiction. So I mean, if I'm seeing it in as far north as Claiborne and Granger County, right, then it has to be in Washington Green. It has to be up there. Right. But they've not found it there. And if I'm seeing it all the way down in McMinn County, in Megs County, it's got to be in Hamilton County. But they haven't found it yet.
SPEAKER_05Is it that like they don't have the ability to test for it? Is it that they don't have the personnel? Like, why do you think they're not finding it? I mean, obviously, we know that people can drive and get to Nashville or wherever from.
SPEAKER_02I think it's a combination of all the things. You have each county's medical examiner is different. You have most medical examiners in rural counties, they are clinical physicians. They're they're they're ER doctors or they have their own private practice. They sort of do this as a courtesy to the county government on the side. They might get a per diem per death certificate or cremation permit, but it's a lot. And I don't know, I can't say to their resources of what they get, but it's a lot. I mean, I know that they have pressure from county government on controlling expenses, controlling expenses. So I have heard it myself from another medical examiner before when we found early on, before I had these research resources and we were having to pay for some of this stuff, and we had a menatonidizine. And I remember reaching out to a county medical examiner and a DA, and I said, Do you want to pay this amount to confirm this? And the response I got was, there's already enough drugs to kill them with. That's all I need. That's our job. Okay. So as understanded, understood by most medical examiners, their job is to determine the cause of manner of death.
SPEAKER_00So the widespread availability of fentanyl in and of itself is clouding this.
SPEAKER_02There was some, there was some legislation change about fentanyl about requiring it to be on the death certificate. If you see so there was some legislation that kind of pushed, you know, this, which you know, then created the necessity for, you know, confirming it, which is why, you know, you have UDSs and you have, you know, blood draws in hospitals that can confirm fentanyl now. You know, uh 10 years ago we couldn't do that. We couldn't say fentanyl. We could say there's an opioid positive, but we couldn't tell you it's fentanyl. So what we need is another push like that to have the resources available. And once again, this is you know, more of I'll say Adam's area, but technology can improve to increase to have devices eventually where you can detect these strange substances. But you have to build profiles, you have to have research, and it takes time.
SPEAKER_00And in a clinical sense, we're dealing often with point of care testing right there at the bedside. And, you know, Chris and Adam, like you're saying, months or weeks to wait for some of these results. If you're a healthcare provider, especially in an emergency setting, you cannot wait that amount of time. So what are some of the considerations there?
SPEAKER_05Yeah, so I mean, if you see depressed breathing, the pinpoint pupils, pretty much no matter what you see, right, you you want to give the naloxone. It's relatively safe, it can save a life. Even if it's combined with something that's not reversible with naloxone, there's likely a fentanyl or something, some sort of opioid component to the mixture of drugs that someone has ingested. And so that's a good thing to do. Again, it's important to understand that one dose might not be enough. And so if you don't see someone responding to a single dose, it doesn't mean there's not an opioid in the system, you know, give another dose. And that's something that we really have to reinforce. It's easy to kind of do this elimination game, right? So, okay, naloxone didn't work, it must not be an opioid, let's try something else. But that's not really necessarily the case with the strength of the substances that we're seeing and the substances that we are not seeing. We don't even know what else might be out there or starting to surface. We're just starting to see, you know, the n proprio nitrile chlorphine. Who knows what's next? And unfortunately, I feel like we haven't figured out how to be sort of proactive and get in front of the illicit manufacturers yet. And it's kind of like they come out with something and then we're chasing it. It's hard. I mean, I don't know if we can track the precursors and how they're getting in. And I'm sure there are people who are doing research on all this, but that is certainly a challenge.
SPEAKER_01So I will let you know. Um, one thing that I do know a lot of times it's interesting, and I don't know if this happened. I didn't really look for this on the cyclochlorofin uh this time, but a lot of times some of this starts out in Europe first. And then like a year or two later, it it's over here in the States. That we used to look at that a lot, but lately it seems like some of the stuff is getting here a little first or about the same time. Some not all not all things, don't get me wrong. Um, on some of it, especially if you're talking about like the NPS benzos. A lot of times those directly kind of like, all right, you saw it in Europe, it's gonna be come over here. So I just it's it's really hard to stay ahead of it. A lot of people are playing guessing games. I know there was I saw a paper where someone was using AI to try to figure out what functional groups could be changed to make the newest drugs from like from nidosines and and interesting, they even suggested brofin was going to be the next big thing, but they that was a couple of years ago, but guess what? It's we're saying cyclochlorphin. So it's very interesting that someone thought about brofin a long time ago, but it ends up being this one, is what we're seeing now.
SPEAKER_00So for some background, borphine was the first of the cyclorphines we saw, right? And now it now, and propionotrial chlorophine being the being the predominant one now. So they they weren't that far off then.
SPEAKER_02They were they were tracking brofene from this MPS list back in 2020. We didn't see it until 2023. And between 23 and 24, we saw six cases of it. They did kind of come in all at the same time, and I remember because I actually handed over those cases to the drug death death task force because uh they was in three counties, because I remember saying these have to be from a singular substance. It killed six people within this like you know, four-week time period. I said these cases have to be connected. I don't know if you know law enforcement was able to get that. I noticed something too about the psychoporphine. We talked about the clinical settings. So, you know, I've said I'm I'm investigating 44 deaths right now, only five of them came out of hospital settings. The other 39 were all scene deaths. So that that does me question uh are there is anybody surviving? Huh? Do we know of have we has anyone been tested that was a surviving person that took this? Or is it I'd say is it a 100% fatal rate?
SPEAKER_05You know, we wouldn't be able to know, right? Like if they survived and there's no forensic testing, we don't have the capacity to test for it. So that's why I think it might be more prevalent than we actually think. You know, and and Jeremy, I think we were talking about earlier how the cause of death, Chris said actually that all you have to do is say it's it's an opioid overdose or it's it's an overdose, a drug overdose. You don't necessarily need to say it's you know X drug or Y drug. So, you know, if there was legislation that said you need to at least know the category of drug, um, that might be helpful.
SPEAKER_02So it's interesting one thing about that. So there's five forensic centers in Tennessee. And if you look at the state map of where the you know largest drug, you know, potents it is always right in those five. There is a name accreditation requirement that the forensic centers, and it does state in name accreditation that you have to individually list any drug that could be possibly considered part of the drug death on the death certificate and the autopsy report. So it's another reason why I think you see it's not just because the areas that surround those forensic centers are the hottest spots, but because there is a regulatory requirement, not a state law, not a state statute, but there's actually in a name accreditation that holds us to a higher standard on quality. And that's why you see those
Breaking Data Silos With Networks
SPEAKER_02red marks that more deeply penetrate around the forensic centers, because for us, it is a requirement to put on the death certificate.
SPEAKER_00We've talked before on this show about the importance of overdose fatality review, which brings together different sources of data. It has healthcare providers represented, law enforcement, medical examiners, anybody who interacts with a patient that is found to have d to have died. It's basically a way to find where did we miss our chance. And you frequently see things like, oh, this person was arrested three or four times and then started showing up in the emergency room a couple of times, and then finally they expired. It's like there look at all those points where some intervention could have been had. And that seems like probably the only way to break down uh data silos in this way, because otherwise, we're talking about lags in data, complexity of data, also just an overwhelming volume that reduces the ability to, in a timely way, keep everybody connected in the same conversation. You know, these big state reports from Department of Health or Mental Health, they do a good job of compiling all these data, but it it takes a couple of years to put it all together at that large of a level. So that that's something that I've been thankful for seeing in this region at least, that conversations like the one we're having. Adam, you you saying that you and Chris are emailing all the time. I know the the the
Hospital Samples And Survivor Signals
SPEAKER_00four of us are frequently communicating. We've got our smart policy network. This is the kind of thing, these regional networks, that really seems to break down these silos.
SPEAKER_01I don't know. I'm gonna tell you, I've learned something new pretty much every time we talk. One thing I'm interested in in the hospital setting, you said that they are missing a lot. Is it are they just doing like some kind of screen test and that's it that just looks for classes of drugs? Or are they doing more specific drug testing? And I'm just curious if they have like a what kind of they're using.
SPEAKER_02We get a lot of fatal drug deaths from the hospitals, unfortunately. And basically in the medical records, we just get UDS was performed, you know, fentanyl, opiate. Methamphetamine or amphetamine was detected. Sometimes we see cocaine, but it's really just your basic one. So I can't tell you, I know the instrumentation devices of every facility in Knox County or Blunt County or Anderson County, but I I don't think we've ever received like blood. They we they have to hold admission samples. So most hospitals have like a seven-day pause, a seven-day policy on emission samples. And many of the overdose individuals do not, you know, make it past seven days. Some do. So they toss them at seven days. But what we do is we take the admission sample. So if they're if someone dies three days after being in a hospital, we tell the hospital, we subpoena the hospital, we like, we want your, you know, the blood draw, because they do an initial blood draw at whenever they admit them. And we take that sample, and that's what we use to test for toxicology. We're not doing post-mortem in those situations because we want the earliest sample that they went in, because that's going to give us the best information. Some hospitals lose it, misplace it, discard it, or if the you know individual makes it past the seven days, they've then it's discarded. And then sometimes we'll we'll do a post-mortem, but obviously with the weight metabolization rates and everything, it it's just not as good information. So that's why in our toxicology reports, it always does. Where do we get the blood from and when do we get it? So chain of custody, you know, record of investigation, all that stuff, the timelines they do matter. So it's all reported on those documents. But that's why we'll see some of my drug deaths don't have toxicology listed because we weren't able to do it. So we just have to take the medical record hospital and the UDS information on it. But that's on the lower spectrum, but that's on the death. So the survivors, don't know.
SPEAKER_05I think the survivor part is really interesting because you there are probably a lot of signals in survivors that if we could capture those signals, you know, that may be a way for us to be proactive rather than reactive. But like you say, you know, the urine drug screens, they're they have some degree of specificity. I know if there's fentanyl, I know if there's you know cocaine, I know if there's buprenorphine and the urine, but it's not going to tell me about these novel kind of substances that we're seeing.
SPEAKER_01Okay. One thing I do know a lot of the I know a lot of TBI agents and some of the other agents are using for solid dose drugs is the MX908. But it's got Leno, it's a useful and useful tool, but you whatever the has in the library you can identify. I always think it'd be interesting, like some of these people that go to the hospital who end up, let's say, surviving, and let's say, hey, can you bring this in? And we'll test it and see what's in what's really going on. I mean, to me, like to me, the
Policy Ideas Better Surveillance Tools
SPEAKER_01more information we have out there and educate people on the dangers of going out there is I think is more sometimes more important.
SPEAKER_00All right. So there's a a lot to digest from this conversation. Dr. Drabacola, you mentioned earlier a potential policy that would require more clarity on overdose deaths, requiring some specificity of substances involved. That's one policy option. In that same vein, I would like to know uh this group's thoughts on other policy options to consider to improve this overall situation. This could be federal, state, local, or even a soft policy, like just a depart internal departmental thing.
SPEAKER_02Jeremy, it was interesting. You told us on one of the earlier SMART calls that legislation that was looking to change in Tennessee that required any death suspected of Kratom to have a test for metrogeny. Well, that requires an expanded panel, which cannot be done. And I quote and I if I'm incorrect, I'm incorrect, but I don't know if UDS's pick up on kratom alkaloids and of those substances. I've not, you know, seen those in UDSs. I've never seen Kratom on UDSs. But if if if there's going to be a law passed that says, hey, if you suspect Kratom, then you have to do, you know, this extra toxicology. Why are we why are we just going to Kratom? I mean, we we skipped a bunch of major drugs before we went to Kratom. Kratom is is definitely, especially with the alkaloids that are out there, it's important. But it seems like there should already be a law that says, hey, if you suspect fennel, you need to do a toxicology to find out what other substances are in there.
SPEAKER_01Well, I my opinion, too, and Erisa, you said about uh Kratom, you know, there's even thoughts that there might be other active metabolites or uh active drugs that are in there that we only know about these. We're only really talking about these two mainly. And so that could be more of a testing that has to be included on top of that. Um but and my I want to tell you, and I have to tell you, this is my opinion on some of the testing. Right. I do know, like in toxicology, there are some techniques um for like screening for on the LCMS MS screens, a lot of these labs have. You know, we talked about doing it here before with the TBI, but those instruments are kind of kind of expensive, and we would have to have those across those type of instruments to be able to have those at all three of our labs. And and they're and it's very it would be a useful tool. I would say some of the screening tests out there, analysis, or when they actually do these kind of testing, if they don't have a kit that matches the drug type, you're just totally missing it. So like in a hospital setting, I I have I really I I I wouldn't know how much what how much they would want to go for like like even the same thing, do some kind of LCMSMS screen where they could do high significations of drugs. And one there are some um instruments out there right now, it's really cool. Like let's say if uh we're talking about uh cyclochlorofin, you can go say, oh man, we've been seeing cyclochlorofin, we found it, and you can actually they they can go back in time and look all right a few months previously, and you can look through your data and say, Hey, this is what this drug looks like. Did we miss it? How long, how long, how far back did we start originally starting to see it the first time? You could actually go back in time, which would be very useful information. And and so that that would be a very useful. But again, like I said, that's expense. But like I said, that's my Adam Gray, not TBI approved wish list.
SPEAKER_05I I want to go back to the survival data. If we could use some of these tools that Adam is mentioning for survivors when there's an overdose, not necessarily a death, and see, you know, how much that might give us in terms of signals. And I wonder if there could be some policy initiative around that.
SPEAKER_01I think that was really interesting because there are some and like to see the compare the difference I could between survival and fatalities. Um I I don't Chris shared some information with me, and it was surprising how much of those had met meth methamphetamine with the fatalities and fentanyl with the cyclorofin.
SPEAKER_04Yeah.
SPEAKER_01Um, so yeah, I thought that was a very interesting uh combo. Um, so is that is that most likely um because I know methamphetamine on the back end when you have a high dose, you correct me I'm wrong, on the it has a depressant effect when you're coming off. So um it could exasperate when you're having
Closing Thanks And Subscribe
SPEAKER_01another opioid on top of that.
SPEAKER_00That's actually a really good observation. Uh I'm definitely glad you brought that up. Well, uh thank you all so very much. Uh Dr. Shravani Drabakala, uh Adam Gray, Chris Thomas. I really thank you all for being on the Smart Policy Podcast. I truly appreciate it.
SPEAKER_05Thank you. Great conversation.
SPEAKER_00Thanks for having us.
SPEAKER_01Thank you for doing this. I always learn a lot more from other people. I'm really thankful for everyone here.
SPEAKER_00For more episodes on in depth discussions on Tennessee policies related to substance use disorder by a range of local experts. Please subscribe to us wherever you get podcasts and visit our website at smart.tennessee.edu. I'm Jeremy Corvellis. Thank you for listening, and see you next month.