LAUSR

Fentanyl and its analogs are used to produce extremely potent drugs that are fueling striking increases in US overdose deaths. Surveillance for these fentanyl analogs is challenging due to limitations of currently available drug testing; additionally, users are frequently unaware of the individual opioids to which they are exposed in overdose [1]. Online cryptomarkets facilitate the purchase of high-potency opioids by individuals who are seeking to conceal their drug purchases from law enforcement; new strategies to obscure these transactions allow individuals to obtain home delivery of illicit opioids via the United States Postal Service. A previously healthy 23-year-old man was found unresponsive in bed. First responders observed symptoms consistent with opioid toxicity; they immediately administered supplemental oxygen and 4 mg of intramuscular (IM) naloxone. Following naloxone administration, the patient awoke, becoming tremulous and tachycardic (180/min). He subsequently received 2 mg of IM lorazepam for agitation and tremor. In the emergency department (ED), the patient’s initial vital signs were notable for a heart rate of 155 beats per min, respiratory rate of 36 breaths per min, and oxygen saturation of 90% on a non-rebreather mask. His physical examination was consistent with mild precipitated opioid withdrawal. He had no stigmata of recent injection drug use. His chest radiograph showed perihilar haziness consistent with pulmonary edema. A urinary catheter was placed 5 h following ED presentation due to urinary retention and an inability to void. Two simultaneous urine specimens were obtained; one went to the hospital lab for clinical purposes, while the other was sent to a reference laboratory for advanced analytical testing. The patient was admitted to a critical care setting for hypoxic respiratory failure and non-cardiogenic pulmonary edema. With supportive care his clinical status improved and he was discharged on hospital day 3. Our team contacted the patient after discharge to ascertain the circumstances by which he obtained the furanyl fentanyl. He reported purchasing “Synthetic China White Heroin #4” from the cryptomarket, AlphaBay, with the intent to purchase fentanyl. His knowledge of AlphaBay and the “Dark Web” stemmed from news articles about the discovery and termination of the original Silk Road marketplace. This patient used reddit.com as an educational resource to access cryptomarkets securely and privately. Based on his investigations, he downloaded “The Onion Router” (TOR, an anonymizing proxy network) and purchased a Virtual Private Network (VPN) to further obscure his IP address and true location. To complete the transaction, he purchased a cryptocurrency, Bitcoin, from coinbase.com. The Bitcoin was transferred through a series of online wallets until ultimately being deposited to AlphaBay, where the purchase was made. He specifically described researching and undertaking these steps to conceal the transaction and avoid criminal prosecution. The patient specifically sought drugs from a domestic seller to prevent his purchase from being seized by United States Customs and Border Protection. He bought 1 g of “Synthetic China White Heroin #4” for the equivalent of $40 in Bitcoin. The package was shipped from a New York post office using United States Postal Service Priority Mail, containing a “dime bag” of white powder that “looked like * Kavita M. Babu [email protected]