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Accelerated AV junctional rhythm @75 bpm with right bundle branch block and probable retrograde P waves in lead V2.
Source publication
Adulterants "cut into" street heroin are common and often not detected by standard urine toxicology screening; however, their unwitting co-injection may have clinical consequences. We report a case of accelerated atrioventricular junctional arrhythmia that we determined to have been caused by quinine/quinidine cut into heroin. While identification...
Context in source publication
Context 1
... asymptomatic 31-year-old male participating in a clinical research study was found to have an accelerated atrioven- tricular (AV) junctional rhythm on routine electrocardiogram obtained per protocol (Fig. 1). He reported no recent change in his level of exertion or stress. His past medical history included intravenous heroin dependence, hepatitis C virus, and tobacco dependence. Previous electrocardiograms reviewed by a cardiologist showed sinus bradycardia with a QTc of 443 ms and right bundle branch block. His prescribed medications ...
Citations
... Adulterants found in opioids obtained within the United States include acetaminophen, diltiazem, dipyrone, and fentanyl [13]. These adulterants are believed to be linked to health-related issues such as bone marrow damage, cardiac arrhythmia, neutropenia, and renal failure, among other conditions [14]. Fentanyl, in particular, is highly deadly as it is 80-100 times stronger than morphine and thus may be deadly even at low doses [15]. ...
Purpose of Review
The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.
Recent Findings
Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles.
Summary
Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.
... Our analysis also revealed a significant number of other adulterants in syringe residue including caffeine, diphenhydramine, lidocaine, and quinine. The ongoing presence of quinine is important for clinicians to be aware of as overdoses of quinine can result in both cardiovascular toxicity and platelet disorders, including arrhythmias, chest pain, and thrombocytopenia [34]. Although levamisole has been historically documented as a common chemical adulterant of cocaine, of medical importance due to its ability to cause severe vasculitis [35], levamisole was present in only 1 sample. ...
Background
People who inject drugs (PWID) are at high risk of severe wounds, invasive infections and overdoses. To date there is little data on the bacterial and chemical contaminants PWID are exposed to when using illicitly manufactured fentanyls and stimulants.
Methods
Previously used injection drug use equipment were recovered in St. Louis, Missouri, USA by harm reduction organizations over a 12-month period. Syringe residue was analyzed for bacterial contaminants by routine culturing followed by whole genome sequencing of single bacterial isolates. Chemical adulterants in syringe residue were identified by liquid chromatography mass spectrometry.
Results
Bacteria were cultured from 58.75% of 160 syringes analyzed. Polymicrobial growth was common and was observed in 23.75% of samples. Bacillus cereus was the most common pathogen present, and was observed in 20.6% of syringe residues followed closely by Staphylococcus aureus at 18.8%.100 syringes underwent mass spectrometry which demonstrated that chemical adulterants were common and included caffeine, diphenhydramine, lidocaine, quinine, and xylazine.
Conclusion
Analysis of syringe residue from discarded drug use equipment demonstrates both chemical and biological contaminants including medically important pathogens and adulterants.
... Heroin has a strong dependence and can cause various degrees of damage to many human organs [1]. A large number of studies have shown that heroin addiction has serious effects on the cardiovascular system, can induce various arrhythmias, and cause intracellular calcium overload, affecting the normal physiological function of the heart [2,3]. Cardiac electrophysiological activity is closely related to myocardial calcium channels, and calcium channels are regulated by various calcium-dependent regulatory proteins. ...
Heroin can cause damage to many human organs, possibly leading to different types of arrhythmias and abnormal electrophysiological function of the heart muscle and the steady state of calcium-ion channels. We explored cardiomyocytes treated with heroin and the effect on calcium-ion channels. Transcriptomics and metabolomics were used to screen for differential genes and metabolite alterations after heroin administration to jointly analyze the effect of heroin on calcium channels in cardiomyocytes. Cardiomyocytes from primary neonatal rats were cultured in vitro and were treated with different concentrations of heroin to observe the changes in morphology and spontaneous beat frequency and rhythm by a patch clamp technique. Transcriptomic studies selected a total of 1,432 differentially expressed genes, 941 upregulated and 491 downregulated genes in rat cardiomyocytes from the control and drug intervention groups. Gene Ontology functional enrichment showed that 1,432 differential genes selected by the two groups were mainly involved in the regulation of the multicellular organismal process, response to external stimulus, myofibril, inflammatory response, muscle system process, cardiac muscle contraction, etc. Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis indicated that these genes were mainly concentrated in cardiac muscle contraction, osteoclast differentiation, adrenergic signaling in cardiomyocytes, dilated cardiomyopathy, hypertrophic cardiomyopathy, and other important pathways. Metabolomic testing further suggested that cardiomyocyte metabolism was severely affected after heroin intervention. After the treatment with heroin, the L-type calcium channel current I–V curve was up-shifted, the peak value was significantly lower than that of the control group, action potential duration 90 was significantly increased in the action potential, resting potential negative value was lowered, and action potential amplitude was significantly decreased in cardiomyocytes. In this study, heroin could cause morphological changes in primary cardiomyocytes of neonatal rats and electrophysiological function. Heroin can cause myocardial contraction and calcium channel abnormalities, damage the myocardium, and change the action potential and L-type calcium channel.
... Known common adulterants of street drugs include acetaminophen, caffeine, diphenhydramine, methorphan, alprazolam, quetiapine, chloroquine, diltiazem, cocaine, procaine, lidocaine, quinine, quinidine, phenacetin, thiamine, and other substances. [8][9][10] Digging further into the overdose deaths, 2018 data noted that 75% of opioid deaths involved a non-methadone synthetic opioid, the most common of which was fentanyl. 7 Fentanyl, due to its high potency, has proven to be easy to produce and smuggle into the United States, saturating the illicit drug supply, and resulting in increased overdose deaths. ...
... 13 In summary, illicit drugs across the planet are constantly changing in terms of what is being used and what is cut or mixed into them, and our usual methods of drug testing are unable to detect them. 7,9,10 As medical providers, it is important to know what is in our local illicit drug supply so as to be able to know what might be causing drug dependence or overdoses in our local patient population as well as the appropriate treatment. ...
Background:
The United States is currently experiencing an unprecedented rise in fatal drug overdoses, which is in part due to the arrival of fentanyl, fentanyl analogs, and other synthetic drugs into the illicit drug supply. Traditional urine drug testing is often unable to detect fentanyl analogs and other novel synthetic drugs, which places physicians and first responders in the difficult position of treating patients who are intoxicated with or overdosing on unknown substances.
Design and methods:
We report, as a feasibility study, the development of a novel program to use a handheld Raman spectrometry device in our hospital's Emergency Department to surveil our local illicit drug supply in terms of what substances are being sold and used.
Results:
Using our novel program, we were able to detect 27 substances in our illicit drug supply over a 10 month period, including fentanyl analogues. We shared, through our local opioid safety coalition, real-time information to first responders, substance use treatment programs, and physicians about the novel substances we detected using the handheld Raman spectrometer.
Conclusions:
A community partnership of using handheld Raman spectrometry in our hospital's Emergency Department was successful in providing information to health care providers about novel substances in our illicit drug market. Additionally, the implementation of this program improved collaboration between local health care providers and local law enforcement.
... Adulterants are pharmacologically active substances added to mirror or enhance specific drug effects [30] and have been well-described in illicit drug supply studies. Adulterants in heroin have included scopolamine [31] and quinine [32,33], and more recently clenbuterol [34,35] and novel synthetic opioids [36,37]. Recent reports have described the adulterant role of xylazine as one that improves and prolongs opioid-associated euphoria [9]. ...
Introduction:
Illicit opioids, consisting largely of fentanyl, novel synthetic opioids, and adulterants, are the primary cause of drug overdose fatality in the United States. Xylazine, an alpha-2 adrenergic agonist and veterinary tranquilizer, is being increasingly detected among decedents following illicit opioid overdose. Clinical outcomes in non-fatal overdose involving xylazine are unexplored. Therefore, among emergency department patients with illicit opioid overdose, we evaluated clinical outcome differences for patients with and without xylazine exposures.
Methods:
This multicenter, prospective cohort study enrolled adult patients with opioid overdose who presented to one of nine United States emergency departments between 21 September 2020, and 17 August 2021. Patients with opioid overdose were screened and included if they tested positive for an illicit opioid (heroin, fentanyl, fentanyl analog, or novel synthetic opioid) or xylazine. Patient serum was analyzed via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect current illicit opioids, novel synthetic opioids, xylazine and adulterants. Overdose severity surrogate outcomes were: (a) cardiac arrest requiring cardiopulmonary resuscitation (primary); and (b) coma within 4 h of arrival (secondary).
Results:
Three hundred and twenty-one patients met inclusion criteria: 90 tested positive for xylazine and 231 were negative. The primary outcome occurred in 37 patients, and the secondary outcome occurred in 111 patients. Using multivariable regression analysis, patients positive for xylazine had significantly lower adjusted odds of cardiac arrest (adjusted OR 0.30, 95% CI 0.10-0.92) and coma (adjusted OR 0.52, 95% CI 0.29-0.94).
Conclusions:
In this large multicenter cohort, cardiac arrest and coma in emergency department patients with illicit opioid overdose were significantly less severe in those testing positive for xylazine.
... 12 Chloroquine possesses a bitter taste but is used as a diluent as it is similar to heroin. 13 The instrumental techniques for the confirmatory chemical analysis of narcotic substances are required. 14 The preliminary investigations followed by TLC and double dimension TLC for identifying and separating narcotic substances from others. ...
The drug trafficking problem in Rajasthan is quite common as Rajasthan is the largest state in India, and many international and interstate borders surround it. Illicit traffickers can add unlimited diluents and adulterants to heroin. Only 5% or less than that alkaloid is present; the rest is of diluents and adulterants. Adulterants can associate with a significant risk of overdose, which may lead to death due to severe poisoning. Thus, the purity of drugs may vary, and the presence and percentage of diluents and adulterants depend on the region. The present article aims to identify and separate diluents and adulterants from diacetylmorphine drug samples. The illicit drug samples were deposited for investigations in the narcotics division of the state forensic science laboratory, Jaipur. During studies, sophisticated instruments like GCMS confirmed the preliminary results obtained from TLC and color tests. The variety and quantity of adulterants and diluents differ in all the samples, but the pattern is similar. The extensive and widespread cutting agent of illicit drugs used to analyze these drug samples.
... Most of the detected toxic adulterants have been associated with adverse effects, including blood disorders (neutropenia, anemia), multifocal inflammatory leukoencephalopathy, hemolytic uremic syndrome, renal failure, liver toxicity, multiple malignancies, infectious diseases, respiratory depression, life-threatening cardiac arrhythmias, and cardiac arrest. 32,33,39,40 Specifics of heroin and cocaine adulteration are discussed in the following sections. ...
... Quinine is sometimes used to adulterate heroin or heroin and cocaine. 40,68,87 Quinine mimics the "rush" caused by the hypotensive effect of heroin as well as heroin's bitter taste. 40,68 Quinine can also induce QT prolongation, which can lead to life-threatening cardiac arrhythmias as noted above. ...
... 40,68,87 Quinine mimics the "rush" caused by the hypotensive effect of heroin as well as heroin's bitter taste. 40,68 Quinine can also induce QT prolongation, which can lead to life-threatening cardiac arrhythmias as noted above. 40,68 Metamizole. ...
Use of US Food and Drug Administration–approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.
... 3 IV use of the drug is difficult to evaluate since the injection is generally performed together with other chemical substances named adulterants. 4 Heroin addiction is a serious social health problem. We evaluated patients who smoked heroin and aimed to investigate its effect on right heart function since not much is known about the cardiac effect of heroin addiction. ...
Objective:
The aim of this study was to investigate the effects of heroin addiction, which is an important social and health problem, on right cardiac function.
Methods:
A total of 85 individuals were included in the study. The study group comprised 45 patients smoking heroin and the control group was 40 healthy individuals with no drug addiction. Patients injecting heroin were excluded. Echocardiographic evaluation of patients using heroin was performed and compared with those in the control group.
Results:
The right ventricle and pulmonary artery diameters in the heroin group were found to be higher compared to the control group. The myocardial performance index (MPI) was higher and more abnormal in the heroin group (0.48 ± 0.22 vs 0.39 ± 0.11, p < 0.05) whereas isovolumic acceleration (IVA) of the right ventricle was significantly lower in the heroin group (2.92 ± 0.69 vs 3.4 ± 0.68 m/s2, p < 0.01). No significant difference was observed between the groups with regard to the right ventricular ejection fraction (RVEF) (59.6 ± 2.5 vs 60.6 ± 2.3%, p = 0.08), tricuspid annular plain systolic excursion (TAPSE) (24.1 ± 4.2 vs 24.5 ± 2.4 mm, p = 0.7), tissue Doppler imaging S wave (TDI-S) (13.7 ± 2.1 vs 13.8 ± 2.1 cm/s, p = 0.86) and right ventricular fractional area change (RVFAC) (42.7 ± 8.3 vs 43.9 ± 3.5%, p = 0.4). Multivariate and univariate regression analyses revealed independent correlation between the pulmonary artery diameter and RVIVA, and heroin addiction.
Conclusions:
Heroin addiction negatively affected right ventricular function and more attention should be paid to the cardiac function of these patients.
... Health issues reported in the United States to be related to these adulterants include anemia, bone marrow damage, cancers, cardiac arrhythmias, hemolytic uremic syndrome, leukopenia, multifocal inflammatory leukoencephalopathy, neutropenia, and renal failure. 22,23 Yet the danger lies not only in the direct toxicity of these adulterants but also in their unpredictability and their potential for unknown or unanticipated synergistic reactions with the opioid or other nonopioid components, all of which increase the risk for adverse health consequences, including death. 4 ...
... ). Ambas sustancias pueden ocasionar trastornos de la conducción cardíaca evidenciándose en el ECG como una prolongación del segmento QRS o QT, o por un bloqueo aurículo-ventricular. La limitación en dicho reporte es el uso concomitante de metadona por parte del consumidor, la cual también puede ocasionar algunas alteraciones de la conducción miocárdica(Phillips et al., 2012).Barbera et al., (2013) describen 5 casos forenses analizando las posibles causas de muertes por sobredosis en consumidores de cocaína o heroína. En tres de ellos surge la presencia de dextrometorfano como adulterante de la heroína, opioide sintético con efecto agonista sobre receptores mu y efecto antagonista sobre los receptores glutamatérgicos N-metil-D-aspartato (NMDA). ...
