Adulterated Xanax: A Case Series From San Francisco

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