“Great complaint is made, and with justice, of the frequent adulteration of powdered drugs” (1) R.M. Huston, 1850 Dear Sir, Illicit drugs have always contained other substances in addition to the claimed active ingredient, leading to potential health threats or even to premature death. Adulterants are often intentionally added to bulk, dilute, complement or enhance the effects of drugs, but sometimes the explanation for their presence is simply poor manufacturing practice. The presence of adulterants has evolved over the years, mostly because new compounds have become available or consumer preference has changed. Most adulterants, normally found in cocaine and heroin and to some degree in all other abused drugs with potential adverse health effects, have been well characterized over time. Inactive bulking agents, such as sugars and talc, readily available compounds, like paracetamol, aspirin and caffeine, or pharmacologically active adulterants, which in large doses may have life-threatening side effects (e.g., phenobarbital, quinine, clenbuterol, phenacetin, lidocaine, levamisole, etc.) (2, 3). Moreover, the route of administration and adulterant concentration play a crucial even lethal role, from simple issues such as thrombophlebitis to more complex cases such as the one involving a 26-year-old man, who died after an intravenous administration of lidocaine, sold as cocaine (4). Phenacetin, diltiazem and hydroxyzine resulted to be the three cocaine adulterants that contributed most to hallucinatory and cardiac side effects (5), with levamisole adulterated cocaine causing pulmonary lymphocytic vasculitis-related fatalities (6). Similarly, the recent use of xylazine, a veterinary drug and used as a sedative, analgesic and muscle relaxant, as an adulterant of heroin and “speedball” (cocaine and heroin mixture) caused intoxications due to central nervous system depression, respiratory depression, bradycardia and hypotension leading to death in half of the cases (7, 8). The unpredictability of the effects caused by adulterated drugs, including unexpected synergistic reactions, together with the lack of standardized analyses and reporting makes it hard to compare adulteration practices over time and among different countries (2). Conversely, when death or serious illness due to adulteration occurs, circulation of information is particularly vital, such as in the USA regarding heroin and cocaine adulterated with fentanyl, and in Scotland recently regarding anthrax-contaminated heroin (2). The use of new psychoactive substances (NPS) as adulterants of controlled drugs has recently been documented in Spain as a new worrying phenomenon. Twenty-four NPS from several chemical classes have been identified in 173 samples smuggled as amphetamine, 3,4 methylenedioxymethamphetamine (MDMA), ketamine, mescaline, cocaine or methamphetamine between 2009 and 2012 (9). MDMA was the substance in which the greatest number of samples adulterated with NPS was observed, especially in tablets, followed by amphetamine. The compounds detected together with the controlled drugs belonged to several chemical classes such as phenethylamines, substituted cathinones, tryptamines and methoxetamine. 4-Bromo-2,5-dimethoxyphenethylamine (2C-B) was the most frequently observed NPS adulterant, especially in MDMA tablets, followed by 4-fluoroamphetamine in amphetamine. Substituted cathinones, such as mephedrone or methylone, were also reported as adulterants of MDMA, especially in crystal format. Since 2011, methoxetamine has been noticeably found in ketamine samples (9). The use of several NPS as adulterants of MDMA has also been documented in Switzerland, where in 2012 methylone was identified in 1.65% of MDMA tablets or in Austria where in the same year methylone, 4-methylethcathinone and mephedrone were identified in 8.84, 10.2, and 9.52%, respectively, of MDMA tablets (10, 11). It is imperative to acquire more knowledge about the toxicity associated with adulteration by NPS, since side effects of these new drugs and eventual synergic action with traditional drugs of abuse are in the majority of cases unknown (9). The aim should be to provide this knowledge not only to health professionals but also to drug users themselves as harm reduction advice. Indeed, it was recently reported a case of a suicide attempt trying to end a frightening experience following a presumptive lysergic acid diethylamide ingestion, which was analytically determined to be the substituted phenethylamine 2-(4-iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine (25I-NBOMe) (12). We wish to draw the attention of the whole scientific community to the injuries caused by drug adulterants and to emphasize the importance of improving surveillance and data sharing when new agents are detected. Many of the complications caused by adulterants are treatable and should not be ignored, but first “toxicologists and the medical community alike” need to know that they exist.
No takes yet. Share an insight, caveat, or question.
Busardò et al. (2016) studied this question.