Suspected North Carolina counterfeit pill-involved deaths, 2020–2022.

This article focuses on the characteristics and toxicological findings of suspected counterfeit pill-involved deaths investigated by the North Carolina Office of the Chief Medical Examiner (NC OCME) from 2020 to 2022. The study analyzed 75 cases where decedents reportedly consumed prescription pills such as alprazolam, oxycodone, and hydrocodone, but toxicology revealed unexpected substances including fentanyl, fentanyl analogs, and novel benzodiazepines like flualprazolam and etizolam. Decedents ranged widely in age and obtained counterfeit pills through personal relationships, street sources, or online, with routes of administration primarily oral or nasal. The findings highlight the complexity and public health risks posed by counterfeit pills, emphasizing the need for detailed scene documentation, targeted toxicological testing, and coordinated information sharing among forensic, law enforcement, and public health entities to better understand and mitigate associated harms.