Adulterated Xanax: A Case Series From San Francisco

Arens A1,2; Vo K1,2; Van Wijk X3,; Lemos N3; Olson K2,4; Smollin C1,2 1 Department of Emergency Medicine, University of California San Francisco; 2 California Poison Control System, San Francisco Division; 3 Department of Laboratory Medicine, University of California San Francisco; 4 Departments of Medicine & Clinical Pharmacy, University of California San Francisco

Introduction Pill Analysis Public Health Alert 21M was found down “in a wheelbarrow” by friends Illicit drugs can be adulterated, or substituted with alternative Within one week of the presentation and identification of the medications, which can result in outbreaks of poisoning. after using ‘Xanax’ purchased off the street. first patients, CPCS and the San Francisco Department of A series of patients in the Bay Area, including two fatalities, A friend arrived with the ‘Xanax’ tab (Image 1a). Public Health issued a health advisory and press release to were referred to the San Francisco division of the California • Pill was sent for analysis at the Zuckerberg San Francisco alert both health care providers and potential consumers of Poison Control System (CPCS) for complications after General (ZSFG) Clinical Chemistry Laboratory this potential life-threatening adulterated product. ingesting adulterated ‘Xanax’ tabs purchased illegally off the • Liquid Chromatography - Mass Spectrometry Image 1a. Pill submitted for Image 1b. Image of analysis to the ZSFG Clinical commercially available 2mg street. was used to determine the contents. Xanax® tab. Chemistry Laboratory: white Contents: rectangular pill stamped ‘2’ on one Analysis of the initial pills found large quantities of fentanyl side and ‘XANAX’ on the other with and etizolam. Fentanyl 3.4 mg 3 score marks on each side. Total Etizolam 10.6 mcg weight: 212 mg. Index Cases Date Age Sex Clinical Serum levels Comprehensive Drug Screen Three patients were evaluated by EMS after drinking Cases to Date Cocaine, Benzoylecgonine, Demand cardiac ischemia, rhabdomyolysis, Fentanyl 1.55 ng/mL alcohol, using cocaine, and ingesting ‘Xanax’ purchased 10/15 27 M Cocaethylene, Norfentanyl, compression neuropathy, acute kidney injury Etizolam 0.60 ng/mL off the street. Levamisole, Cotinine Cocaine, Benzoylecgonine, Patient 1. 34F last seen normal at midnight was found Demand cardiac ischemia, rhabdomyolysis, Fentanyl 0.61 ng/mL 10/15 38 F Cocaethylene, Norfentanyl, unresponsive by friends at 0800. Patient was asystolic on compression neuropathy Etizolam <0.24 ng/mL Discussion Levamisole, Diphenhydramine EMS arrival with rigor of the jaw. A ‘Xanax’ tablet found in patient’s purse was sent to the medical examiner’s office. Found deceased by friends after ingesting Pending autopsy 10/15 34 F Pending autopsy The SF division of the California Poison Control System and Table 1. Patients referred ‘Xanax’ the SF medical examiner’s office identified ten patients and to CPCS – San Francisco Patient 2. 37F with a h/o Crohn’s Disease presented to the Obtundation requiring intubation, two fatalities exposed to an adulterated ‘Xanax’ product cardiogenic pulmonary edema, and Fentanyl 1.39 ng/mL ED with complaints of right lower extremity weakness. Division 10/17 21 M Benzoylecgonine, Norfentanyl biventricular heart failure. Symptoms Etizolam 0.26 ng/mL identified to contain potentially lethal concentrations of • All cases were referred improved after 5 days. fentanyl and etizolam. VS: T 37.1, BP 90/50, HR 112, RR 16, SpO2 100% RA from 10/15 –12/31/2015 Found deceased on scene with pills marked 10/26 42 M Pending autopsy Pending autopsy Neuro: A&Ox3, CN II-XII intact ‘Xanax’ found nearby A health advisory and press release were created to alert • Five patients were treated Decreased motor strength and sensation in RLE both health care providers and potential consumers of this Lethargy after ingesting chlordiazepoxide, distal to the knee. at ZFSG 10/26 45 M Etizolam 22 ng/mL Chlordiazepoxide, Demoxepam alcohol and 3 ‘Xanax’ bought from a friend potential life-threatening adulterated product. Comprehensive drug screen: Cocaine, Benzoylecgonine, • Biological samples were Cocaethylene, Fentanyl, Norfentanyl, Levamisole, analyzed at the ZSFG Fentanyl 0.15 ng/mL Diphenhydramine 11/4 19 M Lethargy and ataxia after ingesting ‘Xanax’ Etizolam 55 ng/mL Norfentanyl, Cotinine Clinical Chemistry Alprazolam 101 ng/mL Conclusion Laboratory Patient 3. 27M with no past medical history presented to the Norfentanyl, Cotinine, ED with complaints of left upper extremity weakness. 11/15 19 M CNS/resp depression requiring naloxone Fentanyl 2.6 ng/mL Diphenhydramine, Naloxone, Clusters of patients with unexpected effects after ingestion of Sertraline illicit or illegally obtained substances should alert health care Norfentanyl, Midazolam, Alpha- providers of a potential epidemic of adulterated products. VS: T 37.8, BP 96/76, HR 124, RR 11, SpO2 sat 96% RA Urine only – Fentanyl 11/28 8mo M CNS depression requiring intubation hydroxymidazolam, Atropine, identified Neuro: A&Ox3, CN II-XII intact Lorazepam Decreased motor strength and sensation in LUE Norfentanyl, Diazepam, Cardiac arrest after ingesting ‘Xanax’ distal to the elbow. Nordiazepam, Temazepam, 12/31 25 M purchased on the street (recovered fully Fentanyl 1.4 ng/mL Comprehensive drug screen: Cocaine, Benzoylecgonine, Oxazepam, Naloxone, after 2 days) Cocaethylene, Fentanyl, Norfentanyl, Levamisole, Cotinine Acetaminophen