Kathy T. Vo

Adverse Effects From Counterfeit Alprazolam Tablets.

Adverse Effects From Counterfeit Alprazolam Tablets From October 15 to December 31, 2015, the California Poison Control System–San Francisco division identified 8 patients who experienced adverse effects associated with the ingestion of counterfeit alprazolam tablets found to contain fentanyl and, in some cases, etizolam. The identification of these patients resulted in a coordinated response that included state and local public health departments, a toxicology laboratory, and media outlets, and resulted in an investigation by local law enforcement agencies.

Synthetic agents off the darknet: a case of U-47700 and phenazepam abuse

We read with interest the case report by A. Schneir and colleagues describing intoxication from the novel synthetic opioid U-47700.[1] In this report, a positive benzodiazepine (BZD) result on the initial urine drugs of abuse immunoassay was thought to be due to a BZD not tested for, or due to an unknown metabolite of U-47700. We suggest that the patient, who demonstrated an interest and use of synthetic agents, likely ingested a BZD derivative. In fact, the co-abuse of opioids and BZDs is well known and thought to result in a greater level of euphoria.[2] We present a case of a patient who used both opioid and BZD analogues. A 29-year old man was found unresponsive after intravenous injection of U-47700, but spontaneously regained consciousness before transport. In the emergency department (ED), he had no complaints other than feeling thirsty. Notable vital signs were blood pressure 157/105mmHg and heart rate 112 beats/min. Physical examination was unremarkable. A complete blood count was normal, though a differential showed elevated neutrophils at 79.6% (reference: 40.0–70.0%). A chemistry panel was notable for an elevated creatinine at 1.4mg/dL (reference: 0.7–1.2mg/dL) with normal estimated glomerular filtration rate. Urine drug screen by immunoassay was positive for BZDs only. After oral hydration, his vital signs improved. He was monitored for 3 h before discharge home. Biologic samples were analyzed using liquid chromatography-high resolution mass spectrometry.[3] Both phenazepam and U-47700 were definitively identified in serum and urine using reference standards purchased from Cayman Chemical (Ann Arbor, MI). Upon further testing, phenazepam also showed a high degree of cross-reactivity with our CEDIAR BZD assay (Thermo, Fremont, CA). The patient, in a discussion post-discharge, admitted to ingesting phenazepam a few days prior to his ED presentation and like U-47700, was purchased over the darknet using decentralized digital money. Serum quantification of the analogues revealed 1.4mg/L of phenazepam and 240 ng/mL of U-47700. Serum phenazepam concentrations of 0.04–3.2mg/L were found in patients with impaired driving, while deaths have been reported at levels 1.2 and 1.6mg/L.[4,5] Dose-dependent responses are largely unknown for U-47700. Phenazepam is a BZD derivative that was developed in the 1970s in the former USSR and has been used to treat anxiety, seizures, and alcohol withdrawal.[4] Phenazepam has a high abuse potential as the parent drug and its active metabolite, 3-hydroxyphenazepam, are both full GABA-A receptor agonists.[6] Pharmacokinetics of this drug have not been fully elucidated, though a summary of prior studies suggests its elimination half-life to be anywhere from 49 to 301 h,[6] explaining the persistence of phenazepam in our patient’s serum. In the United States, phenazepam is not currently controlled under the Controlled Substances Act and is sold on the Internet as a “research chemical”, effectively evading regulatory oversight.[7] Like U-47700, phenazepam’s accessibility puts it on the list of potentially life-threatening synthetic agents and should be considered in patients with drug abuse and an unknown source of a positive BZD screen on urine immunoassay.

Counterfeit Norco Poisoning Outbreak — San Francisco Bay Area, California, March 25–April 5, 2016

On March 28, 2016, two patients were evaluated at the Contra Costa Regional Medical Center emergency department (ED) in Contra Costa County, California, for nausea, vomiting, central nervous system depression, and respiratory depression, 30 minutes after ingesting what appeared to be Norco, a prescription opioid pain medication that contains acetaminophen and hydrocodone. The patients purchased the drug from a friend a few days earlier. The two cases of drug intoxication were reported to a Contra Costa County Health Department public health official who subsequently notified the California State Health Department.

Online social networking and US poison control centers: Facebook as a means of information distribution

Abstract Background. Online social networking services such as Facebook provide a novel medium for the dissemination of public health information by poison control centers in the United States. We performed a cross-sectional study of poison control center Facebook pages to describe and assess the use of this medium. Methods. Facebook pages associated with poison control centers were identified during a continuous two-week period from December 24, 2012 to January 7, 2013. Data were extracted from each page, including affiliated poison control center; page duration, measured in years since registration; number of subscribers; number of postings by general toxicological category; and measures of user-generated activity including “likes”, “shares”, and comments per posting. Results. Among the 56 US poison control centers, 39 Facebook pages were identified, of which 29 were currently active. The total number of active pages has increased by 140% from 2009 to 2013 (average of 25% per year). The total number of all subscribers to active pages was 11,211, ranging from 40 to 2,456 (mean 387, SD 523), equal to 0.006% of all Facebook users in the United States. The number of subscribers per page was associated with page duration, number of postings, and type of postings. The types of toxicological postings were public education (45%), self-promotion (28%), childhood safety (12%), drugs of abuse (8%), environmental poisonings (6%), and general overdoses (1%). Conclusion. Slightly over half of all poison control centers in the United States are supplementing their outreach and education efforts through Facebook. In general, the more active the poison control center on Facebook, the more page followers and follower engagement gained.

Bismuth Subgallate Toxicity in the Age of Online Supplement Use.

Introduction: Bismuth salts have been used to treat gastroenterological disorders and are readily available over-the-counter and via the internet. Even though generally considered safe, bismuth compounds can cause a syndrome of subacute, progressive encephalopathy when taken in large quantities. Case Report: We present the case of woman who developed progressive encephalopathy, aphasia, myoclonus, and gait instability after chronically ingesting large amounts of bismuth subgallate purchased from a major online marketing website to control symptoms of irritable bowel syndrome. After extensive neurological work-up, elevated bismuth levels in her blood, urine, and cerebrospinal fluid confirmed the diagnosis of bismuth-related neurotoxicity. She improved slowly following cessation of exposure. Conclusion: This case highlights bismuth subgallate as a neurotoxic bismuth formulation and reminds providers of the potential for safety misconceptions of positively reviewed online supplements.

Cannabis Intoxication Case Series: The Dangers of Edibles Containing Tetrahydrocannabinol

Study objective: Cannabis and its principal active constituent, &Dgr;9‐tetrahydrocannabinol (THC), are increasingly available as edibles resembling commercially available food products. In this case series, we describe a population of predominantly pediatric patients who were inadvertently exposed to a THC‐containing product in San Francisco. Methods: Twelve children and 9 adults were identified, with 16 patients having detectable serum THC and THC metabolites. All patients presented to hospitals with a variety of constitutional symptoms and all were discharged home within 12 hours. Results: In general, pediatric patients had more severe symptoms and longer hospital length of stay, and, uniquely, a majority presented with leukocytosis and elevated lactic acid levels. Conclusion: We recommend that efforts be made to increase general public awareness in regard to the potential hazards of THC‐containing edibles resembling commercially available food products.

Alternating Ventricular Complexes After Overdose From an Herbal Medication

A woman in her 50s with no medical problems presented to the emergency department with complaints of chest burning, shortness of breath, diffuse paresthesias, and dizziness. She was in her normal state of health until an hour after drinking a home-brewed tea containing leaves and roots prescribed by a Chinese herbalist. She had normal mental status and vital signs. Seventeen minutes after arrival, the patient complained of feeling worse. An ECG was obtained (Figure 1). Question: What are the pertinent electrocardiogram (ECG) findings, and what is the likely cause?