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Heroin: What’s In the Mix?

2007; Elsevier BV; Volume: 50; Issue: 3 Linguagem: Inglês

10.1016/j.annemergmed.2007.03.041

1097-6760

Allison A. Muller, Kevin C. Osterhoudt, William E. Wingert,

Poisoning and overdose treatments

Heroin abuse is a public health problem within the United States. Heroin intoxication has a well-recognized toxicity syndrome involving central nervous system depression, respiratory depression, and pupillary constriction. However, over the past decade, our poison control center has encountered several heroin adulterants that changed the toxicity syndrome observed after overdose.In the late 1990s, contamination of heroin with the anticholinergic drug scopolamine led to heroin overdose victims presenting with unusual manifestations of hallucination, mydriasis, tachycardia, and dry mucous membranes.1Perrone J. Hamilton R. Nelson L. et al.Scopolamine poisoning among heroin users—New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996.MMWR. 1996; 45: 457-460PubMed Google Scholar More recently, a heroin-laced acetaminophen and diphenhydramine mixture known as “cheese” has become a popularized heroin source for inexperienced users, and may also produce notable anticholinergic features.2Leinward D. Texas battles ‘starter heroin.’ USA Today, Apr 26 2006. Available at: http://www.usatoday.com/news/nation/2006-04-26-texas-heroin_x.htm. Accessed July 3, 2007.Google ScholarAn epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007. At our poison control center, xylazine, an alpha-2 adrenergic agonist which may produce pupil constriction and somnolence mimicking heroin effects, has also been found as an occasional contaminant of heroin.Most recently, clenbuterol, a long-acting beta-2 adrenergic agonist, has again surfaced in an epidemic of unusual heroin overdoses with symptoms and signs including tachycardia, tremor, diaphoresis, and laboratory findings of hyperglycemia, hypokalemia, and lactic acidosis.3Werder G. Arora G. Frish A. et al.Clenbuterol-contaminated heroin: cardiovascular and metabolic effects A case series and review.Conn Med. 2006; 70: 5-11PubMed Google Scholar, 4Hoffman R.S. Nelson L.S. Chan G.M. et al.Atypical reactions associated with heroin use—Five states, January—April 2005.MMWR. 2005; 54: 793-796PubMed Google Scholar Additionally, quinine has been detected in the urine of heroin abusers presenting with tinnitus.Many agents can be added to heroin to bulk its volume or to change or enhance its pharmacology. In the latter case, the heroin may be marketed on the street by attractive “brand” names such as Polo, Homicide, etc. Health care professionals confronted with atypical heroin overdoses are cautioned to consider the effects of potential adulterant drugs and chemicals, and to utilize regional poison control centers in epidemic surveillance. Heroin abuse is a public health problem within the United States. Heroin intoxication has a well-recognized toxicity syndrome involving central nervous system depression, respiratory depression, and pupillary constriction. However, over the past decade, our poison control center has encountered several heroin adulterants that changed the toxicity syndrome observed after overdose. In the late 1990s, contamination of heroin with the anticholinergic drug scopolamine led to heroin overdose victims presenting with unusual manifestations of hallucination, mydriasis, tachycardia, and dry mucous membranes.1Perrone J. Hamilton R. Nelson L. et al.Scopolamine poisoning among heroin users—New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996.MMWR. 1996; 45: 457-460PubMed Google Scholar More recently, a heroin-laced acetaminophen and diphenhydramine mixture known as “cheese” has become a popularized heroin source for inexperienced users, and may also produce notable anticholinergic features.2Leinward D. Texas battles ‘starter heroin.’ USA Today, Apr 26 2006. Available at: http://www.usatoday.com/news/nation/2006-04-26-texas-heroin_x.htm. Accessed July 3, 2007.Google Scholar An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007. At our poison control center, xylazine, an alpha-2 adrenergic agonist which may produce pupil constriction and somnolence mimicking heroin effects, has also been found as an occasional contaminant of heroin. Most recently, clenbuterol, a long-acting beta-2 adrenergic agonist, has again surfaced in an epidemic of unusual heroin overdoses with symptoms and signs including tachycardia, tremor, diaphoresis, and laboratory findings of hyperglycemia, hypokalemia, and lactic acidosis.3Werder G. Arora G. Frish A. et al.Clenbuterol-contaminated heroin: cardiovascular and metabolic effects A case series and review.Conn Med. 2006; 70: 5-11PubMed Google Scholar, 4Hoffman R.S. Nelson L.S. Chan G.M. et al.Atypical reactions associated with heroin use—Five states, January—April 2005.MMWR. 2005; 54: 793-796PubMed Google Scholar Additionally, quinine has been detected in the urine of heroin abusers presenting with tinnitus. Many agents can be added to heroin to bulk its volume or to change or enhance its pharmacology. In the latter case, the heroin may be marketed on the street by attractive “brand” names such as Polo, Homicide, etc. Health care professionals confronted with atypical heroin overdoses are cautioned to consider the effects of potential adulterant drugs and chemicals, and to utilize regional poison control centers in epidemic surveillance.