Moscow hostage crisis chemical agent
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The chemical agent used in the Moscow theatre hostage crisis of 23 October 2002 has never been definitively revealed by the Russian authorities, though many possible identities have been speculated. An undisclosed incapacitating agent was used by the Russian authorities in order to subdue the Chechens militants who had taken control of a crowded theater.
At the time, the agent was surmised to be some sort of surgical anesthetic or chemical weapon. Immediately after the siege, Western media speculated widely as to the identity of the substance that was used to end the siege, and chemicals such as the tranquilizer diazepam (Valium), the anticholinergic BZ, the highly potent oripavine-derived Bentley-series opioid etorphine, another highly potent opioid, such as a fentanyl or an analogue thereof, such as 3-methylfentanil, and the anaesthetic halothane were proposed. Foreign embassies in Moscow issued official requests for more information on the gas to aid in treatment, but were publicly ignored. While still refusing to identify the gas, on October 28, 2002 the Russian government informed the U.S. Embassy of some of the gas's effects. Based on this information and examinations of victims, doctors concluded the gas was a morphine derivative. The Russian media reported the drug was Kolokol-1, either mefentanyl or α-methylfentanil dissolved in a halothane base.
Why it was used
It was reported that efforts to treat victims were complicated because the Russian government refused to inform doctors what type of gas had been used. In the records of the official investigation of the act, the agent is referred to as a certain "gaseous substance", in other cases it is referred to as an "unidentified chemical substance". 
Two days after the incident, on October 30, 2002, Russia responded to increasing domestic and international pressure with a statement on the unknown gas by Health Minister Yuri Shevchenko. He identified it as a fentanyl derivative, an extremely powerful opioid. Boris Grebenyuk, the All-Russia Disaster Relief Service chief, said the services used trimethyl phentanylum (3-methylfentanyl, a fentanyl analog that is about 1000 times more potent than morphine, which was manufactured and abused in the former Soviet Union); New Scientist pointed out that 3-methylfentanyl is not a gas but an aerosol. The research made by American scientists into fentanyl derivatives shows that their lethality level surpasses the efficiency of traditional lethal methods: the lethality degree of the chemical weapons used in World War I was 7%, while in the Dubrovka theater it exceeded 15%.
A German toxicology professor who examined several German hostages said that their blood and urine contained halothane, a once-common inhalation anaesthetic which is now seldom used in Western countries, and that it was likely the gas had additional components. No other unusual chemical substances have been detected. However, halothane has a strong odor (although often defined as "pleasant" by comparison with other anesthetic gases). Thus, by the time the whole theatre area would be filled with halothane to a concentration compatible with loss of consciousness (0.5% - 3%), it is likely that Chechens inside would have realized they were being attacked. Additionally, recovery of consciousness is rapid after the flow of gas is interrupted, unlike with high-dose fentanyl administration. Therefore, although halothane might have been a component in the aerosol, it was probably not a major component, or perhaps it was a metabolite of another drug.
Writing in the Moscow daily Komsomolskaya Pravda, Viktor Baranets, a former Russian Defense Ministry official, stated that the Ministry of the Interior knew that any normal riot control agent, such as pepper spray or tear gas, would allow the Chechens time to harm the hostages. They decided to use the strongest agent available. The paper identified the material as a KGB-developed "psycho-chemical gas" known as Kolokol-1, and reported that "the gas had such an influence on [Chechen siege leader Movsar] Barayev that he couldn't get up from [his] desk". Russian doctors who helped hostages in the first minutes after the siege used a common antidote to fentanyl, naloxone, by injection. But the effects of the fentanyl derivative's application, which can exacerbate chronic diseases, grew acute for the hostages, who had stayed in a closed space without water and food for several days.
Although the exact nature of the active chemical has not been verified, the Russian language newspaper Gazeta.ru claimed that the chemical used had been 3-methylfentanyl, attributing this information to "experts from the Moscow State University chemistry department."
Zilker and Wheelis
Thomas Zilker: It seems to be different from fentanyl, carfentanil and sufentanil but it has to be, it has to have the potency of carfentanil at least because otherwise it wouldn’t work in these circumstance. So the Russians obviously have designed a new fentanyl which we cannot detect in the west.
Mark Wheelis: The fact that the Russians did it and got away with a lethality of less than twenty percent suggests to me that very likely there may have been a novel agent with a higher safety margin than normal fentanyl.
Riches et al.
In 2012, Riches et al. found evidence from liquid chromatography-tandem mass spectrometry analysis of extracts of clothing from two British survivors, and urine from a third survivor, that the aerosol was a mixture carfentanil and remifentanil the exact proportions of which they could not determine. Assuming that these were the only active constituents (which has not been verified by the Russian military), the primary acute toxic effect to the theatre victims would have been opioid-induced apnea; in this case mechanical ventilation and/or treatment with naltrexone, the specific antidote for poisoning with carfentanil in humans would have been life-saving for many or all victims.
Annals of Emergency Medicine
An article in the Annals of Emergency Medicine discusses the relative therapeutic indices (the difference between the medically effective dose and the toxic or lethal dose of a given medication) of all the possible drugs similar to fentanyl, concluding that while the biological half-life is dramatically shorter and the therapeutic index higher for carfentanil and remifentanil (accounting for the Russian claim that the gas alone could not have caused the deaths of 16% of the hostages rescued), both of those drugs are highly lipophilic (readily taken up into the body's fatty tissues) and can be released into the circulation long after the first symptoms of overdose are treated, causing severe delayed effects and even death if the correct antidote is not administered quickly when the patient shows renewed symptoms of poisoning by these drugs. This might account for the large number of deaths following use of large amounts of the agent in a closed space, where local concentrations of the gas might be unexpectedly high.
The authors of this article go on to quote an article in the Washington Post quoting one Russian physician who treated survivors of the hostage rescue who stated that toxicology testing to identify the agent used was not performed because “to conduct such tests we have to know approximately what we're looking for, and we didn't know what to look for. Besides, we didn't have the technical means to conduct such tests.” This supports the United States Ambassador to Russia's allegation that information on the composition of the gas used during the hostage rescue was only given after unacceptable delay, when prompt information on the exact drugs, or the proper antidotes to those drugs used might have saved lives.
Under the heading "Lessons Learned," the authors state "It seems likely that the 800 hostages were about to be killed by Chechen rebels. To rescue them, the Russian military used a calmative agent in an attempt to subdue the rebels. The intent was likely to win control of the theater with as little loss of life as possible. Given the large number of explosives in the hands of the hostage takers, a conventional assault or the use of more toxic chemical agents might have significantly increased the number of casualties. Although it may seem excessive that 16% of the 800 hostages may have died from the gas exposure, 84% survived. We do not know that a different tactic would have provided a better outcome."
The authors concluded by saying
- The extremely high therapeutic indices of the fentanyl derivatives may have inappropriately reduced concern about the potential lethality of these agents.
- Factors such as the lipophilicity of the fentanyl derivatives, the health status of those exposed, great uncertainty regarding the dose each of the people present in the theater received, and the resulting potential for overdose should have been addressed more thoroughly.
- Opioid intoxication is a relatively simple poisoning to treat, and many of the deaths after the Moscow theater hostage crisis could have been avoided if trained rescuers and medical teams with the proper antidotes were made ready in advance.
- In the United States, naloxone, for a long time a critical antidote to treat heroin overdose and iatrogenic opioid toxicity, has now become a crucial chemical warfare antidote."
- Conclusions of forensic examination commission, Volumes 30-33 of the criminal case.
- "News Chronology (August through October 2002)". THE CBW CONVENTIONS BULLETIN (Issue 58). 2002. pp. 27–46.
- Russia Confirms Suspicions About Gas Used in Raid - Potent Anesthetic Pumped Into Theater - 2 More Hostages Die From Drug's Effects, Susan B. Glasser and Peter Baker, Washington Post, 2002-10-31 A.15
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- Peterson, Scott. (October 29, 2002). Gas enters counterterror arsenal - The unprecedented use of a secret toxic gas leaves 400 still hospitalized, and starts a debate about Russian tactics. The Christian Science Monitor, WORLD; p. 1.
- CHECHEN-NORTH-OST SPECIAL FORCE OF RUSSIA N 11 (74) NOVEMBER 2002 in Russian, last three paragraphs[unreliable source?]
- "BBC - Science & Nature - Horizon - The Moscow Theatre Siege". Retrieved 23 June 2016.
- Riches JR, Read RW, Black RM, Cooper NJ, Timperley CM. Analysis of Clothing and Urine from Moscow Theatre Siege Casualties Reveals Carfentanil and Remifentanil Use. J Anal Toxicol. 2012 Sep 20. (Epub ahead of print). Riches, J. R.; Read, R. W.; Black, R. M.; Cooper, N. J.; Timperley, C. M. (2012). "Analysis of Clothing and Urine from Moscow Theatre Siege Casualties Reveals Carfentanil and Remifentanil Use". Journal of Analytical Toxicology 36 (9): 647–656. doi:10.1093/jat/bks078. PMID 23002178..
- Wax, Paul; et al. (May 2003). ""Unexpected “gas” casualties in Moscow: A medical toxicology perspective"". Annals of Emergency Medicine Volume 41, Issue 5,. Elsevier Science Direct. pp. 700–705. Retrieved 19 September 2015.
- , Researchgate, December 2014.
- Gas 'killed Moscow hostages', BBC News, 27 October 2002
- Hostages given military's nerve gas antidote, The Guardian, October 28, 2002
- What was the gas?, BBC News, 28 October 2002
- Gas enters counterterror arsenal, The Christian Science Monitor, October 29, 2002
- German doctors identify gas used in Russian hostage rescue, CBC News, October 29, 2002
- US identifies deadly Moscow siege gas, BBC News, 29 October 2002
- Russia names Moscow siege gas, CNN, October 30, 2002