Dirty Drugs

A 25-year-old man presents to the emergency department with palpitations. He reports injecting heroin, which he obtained from a new source, and is concerned that it was “not just heroin.” His initial vital signs include blood pressure 150/90 mm Hg, heart rate 130 bpm, respiratory rate 16 breaths per minute, and pulse oximetry 99% on room air. The patient appears uncomfortable, but is alert and oriented. His physical exam is remarkable for tachycardia and agitation.   The concern for an altered illicit drug is not uncommon in the ED. Cases and epidemics of tainted illicit drugs have been reported historically; the first reported heroin adulterant was quinine. A New York City outbreak of malaria in the 1930s was linked to IV drug abuse, and quinine, the mainstay of treatment at the time, was added to heroin to protect heroin   An epidemic of heroin adulterated with scopolamine occurred in the Northeast in the 1990s. Hamilton, et al. described patients who presented with respiratory depression after using heroin and then manifested signs of anticholinergic toxicity following naloxone administration. Another epidemic on the East Coast in 2005 involved heroin adulterated with clenbuterol. These patients presented with tachycardia, tremor, diaphoresis, hyperglycemia, hypokalemia, and lactic acidosis secondary to the beta-2 agonist effects of clenbuterol instead of manifesting a pure opiate toxidrome.   Xylazine, an alpha-2 agonist, was found as an adulterant in heroin...
Source: The Tox Cave - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs