Confirmed reports of bupropion sold as crack cocaine in the illicit drug supply

Abstract

In July 2020, the Massachusetts Drug Supply Data Stream (MADDS) encountered two drug samples sold in a community as cocaine (one as “crack” and one as “white rock”) that contained bupropion as the only psychoactive substance [1]. Identification of bupropion was conducted by Fourier-transform infrared spectroscopy (FTIR) and Gas chromatography– mass spectrometry (GC/MS). Both samples were in the form of rocks or chunks of compressed powder, along with cookers, containers used by the donor to mix and heat drugs, suggesting that the putative cocaine had been injected. To our knowledge, this represents the first confirmed report of bupropion sold as crack cocaine in the illicit drug supply. Bupropion is an FDA-approved medication for the indications of smoking cessation and depression. Its pharmacology includes inhibition of reuptake of dopamine and norepinephrine while antagonizing acetylcholine at neuronal nicotine receptors [2]. Bupropion sold as crack cocaine poses heightened risk to people who unwittingly ingest it because it has a distinct toxicity profile. Bupropion’s structure shares important similarities to cathinone and stimulating synthetic cathinone analogues, including substances sold as “bath salts”. Research suggests bupropion is peripherally and centrally stimulating. Case reports and internet posts document its potential for use as a stimulant or euphoriant outside of its prescribed indications [3]. Unapproved use of bupropion documented in the medical literature is mostly limited to populations without ready access to more traditional psychoactive drugs, for example people who are incarcerated [4,5]. However, individuals who use bupropion in this way highlight that they can easily obtain the drug from physicians under the guise of seeking an antidepressant or smoking cessation aid [6]. Since antidepressants are generally not included in most national surveys of drug use the true extent of this use of bupropion is unknown. Use of bupropion in this way is known to occur via oral ingestion, insufflation, and intravenous routes, and patients report experiencing a mood elevating and stimulant effect [6–8]. Bupropion in overdose can cause refractory seizures, dysrhythmias, cardiac arrest, and death. In prior reports of the non-prescription use of bupropion, patients knowingly and purposefully consumed the bupropion, whereas, donors providing remnant drug materials for testing to MADDS reported at the time of donation that they thought they were buying crack cocaine when they in fact received bupropion with no cocaine. It is also notable that these cases were detected in a location with a well-established drug distribution hub and during the COVID-19 pandemic, when illicit drug supply chains may have been strained or disrupted, with as-yet-unknown health impacts for people who use drugs for their psychoactive effects. To facilitate broader dissemination of communications about this risk, the MADDS team developed written and video-based notifications to the public. Drug supply surveillance such as that conducted by MADDS is critical for early detection and community response.