A mixed MDPV and benzodiazepine intoxication in a chronic drug abuser: Determination of MDPV metabolites by LC-HRMS and discussion of the case

We report on a case of repeated MDPV consumptions that resulted in severe psychosis and agitation prompting the concomitant abuse of benzodiazepines. A 27-year-old man was found irresponsive in his apartment and was brought to the emergency department (ED) of a local hospital. When in ED, he rapidly recovered and self-reported to have recently injected some doses of MDPV that he had bought in the Internet. He left the hospital withoutmedical cares. 15 days after, he was again admitted to the same ED due to severe agitation, delirium and hallucinations, and reported the use of MDPV and pharmaceutical drugs during the preceding week. He was sedated with diazepam and chlorpromazine. Urine samples collected in both occasions were sent for testing using liquid chromatography–high resolution mass spectrometry (LC–HRMS) and liquid chromatography–high resolution multiple mass spectrometry (LC–HRMS/MS) on an Orbitrap. The LC–HRMS analysis revealed the presence of MDPV and its phase I and phase II metabolites (demethylenyl-MDPV, demethylenyl-methyl-MDPV, demethylenylmethyl- oxo-MDPV, demethylenyl-hydroxy-alkyl-MDPV, demethylenyl-methyl-hydroxy alkyl-MDPV, demethylenyl-oxo-MDPV and their corresponding glucuronides), alprazolam and alprazolam metabolite at the first ED admission; at the time of the second ED access, the same MDPV metabolites, alprazolam, temazepam, and chlordiazepoxide were detected together with diazepam and metabolites. LC–HRMS/MS was use to determine the following concentrations, respectively on his first and second admission:MDPV 55 ng/mL, alprazolam 114 ng/mL, a-hydroxyalprazolam 104 ng/mL; MDPV 35 ng/mL, alprazolam 10.4 ng/mL, a -hydroxyalprazolam 13 ng/mL; chlordiazepoxide 13 ng/mL, temazepam 170 ng/mL, diazepam 1.3 ng/mL, nordiazepam 61.5, oxazepam 115 ng/mL. The toxicological findings corroborated the referred concomitant use of multiple pharmaceutical drugs and benzodiazepines. Confirmation of previous hypothesis on human metabolism of MDPV could be inferred by the analysis of urine.