Notes from the Field: Cluster of Severe Illness from Neptune’s Fix Tianeptine Linked to Synthetic Cannabinoids — New Jersey, June–November 2023

Investigation and Outcomes

Exposure calls involving tianeptine exposure identified in the New Jersey Poison Information and Education System’s Toxicall database during June 17–November 6, 2023, were retrospectively reviewed. Specialists in Poison Information record clinical and demographic information into Toxicall from exposure calls made by hospitals, health care providers, and the public. This study was reviewed and approved by the Rutgers Human Research Protection Program Institutional Review Board.* During this period, the center received 20 exposure calls from health care facilities regarding tianeptine use in 17 unique patients. These patients, who were distributed throughout the state, were aged 28–69 years. Overall, 14 patients reported ingesting tianeptine in the form of Neptune’s Fix, a flavored elixir shot, consisting of tianeptine and kavain (Piper methysticum root, prepared with water and reported to promote relaxation) sold in small colorful bottles. Nine patients reported previous use of tianeptine, and six reported coingesting other substances, including alprazolam (a benzodiazepine), kratom (leaves from the Mitragyna speciosa tree, which have opioid-like effects), tramadol (a synthetic opioid analgesic), trazodone (a serotonin reuptake inhibitor antidepressant medication), and gabapentin (an anticonvulsant sometimes used for neuropathic pain). All patients were described as having altered mental status upon evaluation. Other clinical effects included tachycardia (11 patients), hypotension (10), seizure (eight), prolonged QT interval (seven), prolonged QRS duration (four), and cardiac arrest (one); prolonged QT intervals and prolonged QRS durations are associated with an increased risk for ventricular arrhythmia (4). Among the 20 encounters, 13 of the 17 patients were admitted to an intensive care unit, and seven of the 17 underwent endotracheal intubation. There were no deaths.

Six samples of Neptune’s Fix from two reported cases were analyzed at the Center for Forensic Science Research and Education (https://www.cfsre.org) using an Agilent Technologies (https://www.agilent.com) gas chromatograph mass spectrometer and a Sciex (https://www.sciex.com) liquid chromatograph quadrupole time-of-flight mass spectrometer. Results were compared against an in-house database containing more than 1,100 targets, including recreational drugs, therapeutics, and novel psychoactive substances and were qualitatively confirmed by comparison to standard reference materials. All bottles were labeled as containing kavain and tianeptine; analysis identified variable compositions, including the presence of the two SCRAs methyl 3,3-dimethyl-2-(1-(pent-4-en-1-yl)-1H-indazole-3-carboxamido)butanoate (MDMB-4en-PINACA) and N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(pent-4-en-1-yl)-1H-indazole-3-carboxamide(ADB-4en-PINACA) (Table).