Tusi but not <scp>2C</scp>: A Miami‐Dade medical examiner case series highlighting the variable drug composition in colored powder paraphernalia

Eight fatalities between September 2020 and July 2024 in Miami-Dade County involving the ingestion of colored powders, referred to as "tusi," "tucibi," or "pink cocaine," are reported. For each case, a description of the terminal event, the postmortem toxicology findings, the cause and manner of death, and the chemical composition of the "tusi" powder(s) found on or near the decedent are summarized. Fourteen powders, mostly pink with a sweet or fruity aroma, were submitted for analysis. Ketamine was identified in all submissions, with the majority also containing methylenedioxymethamphetamine (MDMA). Other substances identified in the powders include stimulants (cocaine, methylenedioxyamphetamine [MDA], and methamphetamine), opioids (oxycodone), benzodiazepines (alprazolam), synthetic cathinones (eutylone), and over-the-counter medications (diphenhydramine and loratadine). Five of the powders contained cocaine; however, none contained fentanyl or 4-bromo-2,5-dimethoxyphenethylamine (2C-B). Five deaths were ruled as accidents, with four attributed to a drug overdose and one attributed to a fall from height. The remaining cases were classified as suicides (one fall from height, one hanging, and one self-inflicted gunshot wound). All cases reported multiple drugs in the decedent's postmortem blood in addition to ketamine and MDMA. The peripheral blood concentrations of ketamine and its metabolite, norketamine, ranged from 0.38-8.8 and 0.16-3.0 mg/L, respectively, and the concentration of MDMA and its metabolite, MDA, ranged from 0.10-3.0 and <0.01-0.27 mg/L, respectively. The medical examiner cases reported are the first to illustrate, through analytical testing, the variable drug composition of "tusi" powders and the impact its use may have in medicolegal death investigation.