By Anna Healey, MD
Emergency Medicine Resident
Case: A 20 year old female was brought in by EMS after being found combative on the street. She is agitated, violent, and yelling nonsense. Initial vital signs are HR 165, BP 170/99, T 101.4, RR 24, O2 sat 60%. After applying oxygen, the patient's saturation improves to 90% but she then has a generalized tonic-clonic seizure. She is intubated for airway protection and hypoxia.
Laboratory workup indicates acute renal insufficiency, elevated LFTs and acidosis. Her acetaminophen/aspirin levels are negative and her EKG shows only sinus tachycardia with normal intervals. Her boyfriend then presents to the ED, stating "all she did was take a tab of Molly tonight".
Emergency Medicine Resident
Case: A 20 year old female was brought in by EMS after being found combative on the street. She is agitated, violent, and yelling nonsense. Initial vital signs are HR 165, BP 170/99, T 101.4, RR 24, O2 sat 60%. After applying oxygen, the patient's saturation improves to 90% but she then has a generalized tonic-clonic seizure. She is intubated for airway protection and hypoxia.
Laboratory workup indicates acute renal insufficiency, elevated LFTs and acidosis. Her acetaminophen/aspirin levels are negative and her EKG shows only sinus tachycardia with normal intervals. Her boyfriend then presents to the ED, stating "all she did was take a tab of Molly tonight".
Adulterants in illicit street drugs are impressively common here in the US as well as abroad. They serve multiple purposes for the dealer, including reducing the amount of true drug needed for a given sample. This saves cost to the dealer while the user is often unaware of what they are actually getting and ingesting. Studies performed on samples of street cocaine and heroin have indicated the majority are less than 50% "pure".
Common adulterants are chosen because:
Recent studies have also shown that about 75% of the cocaine supply in the US has been cut with another agent, typically acetaminophen, caffeine, lidocaine, or aspirin. These drugs can have their own toxicities to be aware of as well. An adulterant becoming more common is the antihelminthic drug levamisole, which is mainly used in veterinary medicine. Levamisole can have some serious toxicity, including agranulocytosis, vasospasm causing limb ischemia, and leukoencephalopathy.
Heroin has not been immune to this phenomenon as well. It is well documented that samples of black tar heroin from Mexico have been cut with soil as a bulking agent and because of its color and consistency. Users who perform skin "popping" (subcutaneous injection of the drug) have developed wound botulism, as they are essentially injecting dirt into an anerobic environment. These patients may thus present with respiratory failure and muscle weakness, and often require mechanical ventilation and supportive care.
When a patient presents to the ED with drug ingestion, it is important to consider what else they may have ingested, either intentionally or unintentionally. Workup including EKG, serum acetaminophen and aspirin levels, electrolytes, and liver function studies are often warranted. Even in the most reliable historian, there is no way to determine the actual ingestion and objective data is the best and sometimes only way to manage and treat these patients.
Resources
Davis LE, King MK. Wound botulism from heroin skin popping. Curr Neurol Neurosci Rep. 2008;8(6):462-8.Buchanan JA, Lavonas EJ. Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole. Curr Opin Hematol. 2012;19(1):27-31.
Evrard I, Legleye S, Cadet-taïrou A. Composition, purity and perceived quality of street cocaine in France. Int J Drug Policy. 2010;21(5):399-406.
Pellegrini D, Young P, Grosso V, Massa M, Bruetman JE. [Agranulocytosis induced by levamisole in association to cocaine]. Medicina (B Aires). 2013;73(5):464-6.
Schneider S, Meys F. Analysis of illicit cocaine and heroin samples seized in Luxembourg from 2005-2010. Forensic Sci Int. 2011;212(1-3):242-6.
Common adulterants are chosen because:
- they look, smell, and taste like the intended drug
- have similar or enhancing effects to the intended drug
- cheap and readily available
Recent studies have also shown that about 75% of the cocaine supply in the US has been cut with another agent, typically acetaminophen, caffeine, lidocaine, or aspirin. These drugs can have their own toxicities to be aware of as well. An adulterant becoming more common is the antihelminthic drug levamisole, which is mainly used in veterinary medicine. Levamisole can have some serious toxicity, including agranulocytosis, vasospasm causing limb ischemia, and leukoencephalopathy.
Heroin has not been immune to this phenomenon as well. It is well documented that samples of black tar heroin from Mexico have been cut with soil as a bulking agent and because of its color and consistency. Users who perform skin "popping" (subcutaneous injection of the drug) have developed wound botulism, as they are essentially injecting dirt into an anerobic environment. These patients may thus present with respiratory failure and muscle weakness, and often require mechanical ventilation and supportive care.
When a patient presents to the ED with drug ingestion, it is important to consider what else they may have ingested, either intentionally or unintentionally. Workup including EKG, serum acetaminophen and aspirin levels, electrolytes, and liver function studies are often warranted. Even in the most reliable historian, there is no way to determine the actual ingestion and objective data is the best and sometimes only way to manage and treat these patients.
Resources
Davis LE, King MK. Wound botulism from heroin skin popping. Curr Neurol Neurosci Rep. 2008;8(6):462-8.Buchanan JA, Lavonas EJ. Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole. Curr Opin Hematol. 2012;19(1):27-31.
Evrard I, Legleye S, Cadet-taïrou A. Composition, purity and perceived quality of street cocaine in France. Int J Drug Policy. 2010;21(5):399-406.
Pellegrini D, Young P, Grosso V, Massa M, Bruetman JE. [Agranulocytosis induced by levamisole in association to cocaine]. Medicina (B Aires). 2013;73(5):464-6.
Schneider S, Meys F. Analysis of illicit cocaine and heroin samples seized in Luxembourg from 2005-2010. Forensic Sci Int. 2011;212(1-3):242-6.
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