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http://www.cdc.gov/mmwr/volumes/65/wr/mm6516e1.htm?s_cid=mm6516e1_w
Counterfeit Norco Poisoning Outbreak — San Francisco Bay Area, California, March 25–April 5, 2016
Early Release / April 26, 2016 / 65
Kathy T. Vo, MD1,2; Xander M.R. van Wijk, PhD3; Kara L. Lynch, PhD3; Alan H.B. Wu, PhD3; Craig G. Smollin, MD1,2 (View author affiliations)
View suggested citation
Summary
What is already known about this topic?
The United States is experiencing an opioid epidemic with synthetic opioids such as fentanyl responsible for the highest rise in death rates in recent years. Fentanyl, a potent opioid receptor agonist, can cause significant central nervous system and respiratory depression and has been implicated in multiple outbreaks in the past decade.
What is added by this report?
During March 25–April 5, 2016, seven cases of counterfeit Norco ingestion and intoxication were identified by the San Francisco Division of the California Poison Control System. Whereas Norco typically contains acetaminophen and hydrocodone, these counterfeit tablets predominantly contained fentanyl and promethazine. Prior to this outbreak in the Bay Area, counterfeit or adulterated fentanyl-containing products had not previously been reported to include promethazine as an additive. Promethazine likely potentiates the opioid effect.
What are the implications for public health practice?
The distribution of counterfeit tablets represents a major public health threat given the potentially lethal nature of the tablets. Health care providers should be aware of this and other concurrent outbreaks and notify local poison centers and health departments of suspected cases. Collaborative efforts among public health, medical, and law enforcement officials are essential for a rapid and effective response.
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.
Three days earlier, the Sacramento County Division of Public Health had released a Drug Overdose Health Alert regarding multiple poisoning overdoses related to ingestion of fentanyl-contaminated counterfeit Norco in Sacramento County (1). All staff members at the California Poison Control System (CPCS) were alerted to increase vigilance for potential cases. In the subsequent 2 weeks, the CPCS San Francisco Division identified an additional five cases in three Bay Area counties (Alameda, San Francisco, and Santa Clara), including one case in a patient (patient 1) that was reported retrospectively (Table). All patients reported to the CPCS San Francisco Division had various signs and symptoms of opioid intoxication after ingestion of the illicit product, and all recovered without clinical sequelae within 24 hours.
Although analyses of product and patient specimens from Sacramento County were reported to have contained fentanyl, all cases in the Bay Area also contained promethazine, which had not been reported as an additive in previous counterfeit or adulterated fentanyl-containing products. Fentanyl is a synthetic opioid analgesic that is a full μ-opioid receptor agonist (one of the three opioid receptors through which opioids exert their pharmacologic actions) and has 100 times the potency of morphine (2). Fentanyl is available in many formulations, and its unique physicochemical properties, particularly its high lipophilicity, allow it to quickly enter the central nervous system and are responsible for its high potency (2) and high potential for abuse. Fentanyl is not currently formulated for oral administration in pill or tablet form, however, and its presence in pill form is a marker for an illicitly produced product. Promethazine, a phenothiazine derivative, is routinely prescribed for the treatment of nausea, vomiting, and motion sickness. Promethazine use has recently been reported to be common among chronic opioid users and is thought to potentiate the “high” from opioids (3).
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Corresponding author: Kathy T. Vo, [email protected], 415-643-3243.
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[paste:font size="5"]http://www.dhhs.saccounty.net/PUB/D...0160325-Health+Alert+-+Contaminated+Norco.pdf
TABLE. Laboratory findings from analyses of serum and urine specimens from seven patients reported to the California Poison Control System after exposure to counterfeit Norco — San Francisco Bay Area, California, March 25–April 5, 2016
Counterfeit Norco Poisoning Outbreak — San Francisco Bay Area, California, March 25–April 5, 2016
Early Release / April 26, 2016 / 65
Kathy T. Vo, MD1,2; Xander M.R. van Wijk, PhD3; Kara L. Lynch, PhD3; Alan H.B. Wu, PhD3; Craig G. Smollin, MD1,2 (View author affiliations)
View suggested citation
Summary
What is already known about this topic?
The United States is experiencing an opioid epidemic with synthetic opioids such as fentanyl responsible for the highest rise in death rates in recent years. Fentanyl, a potent opioid receptor agonist, can cause significant central nervous system and respiratory depression and has been implicated in multiple outbreaks in the past decade.
What is added by this report?
During March 25–April 5, 2016, seven cases of counterfeit Norco ingestion and intoxication were identified by the San Francisco Division of the California Poison Control System. Whereas Norco typically contains acetaminophen and hydrocodone, these counterfeit tablets predominantly contained fentanyl and promethazine. Prior to this outbreak in the Bay Area, counterfeit or adulterated fentanyl-containing products had not previously been reported to include promethazine as an additive. Promethazine likely potentiates the opioid effect.
What are the implications for public health practice?
The distribution of counterfeit tablets represents a major public health threat given the potentially lethal nature of the tablets. Health care providers should be aware of this and other concurrent outbreaks and notify local poison centers and health departments of suspected cases. Collaborative efforts among public health, medical, and law enforcement officials are essential for a rapid and effective response.
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.
Three days earlier, the Sacramento County Division of Public Health had released a Drug Overdose Health Alert regarding multiple poisoning overdoses related to ingestion of fentanyl-contaminated counterfeit Norco in Sacramento County (1). All staff members at the California Poison Control System (CPCS) were alerted to increase vigilance for potential cases. In the subsequent 2 weeks, the CPCS San Francisco Division identified an additional five cases in three Bay Area counties (Alameda, San Francisco, and Santa Clara), including one case in a patient (patient 1) that was reported retrospectively (Table). All patients reported to the CPCS San Francisco Division had various signs and symptoms of opioid intoxication after ingestion of the illicit product, and all recovered without clinical sequelae within 24 hours.
Although analyses of product and patient specimens from Sacramento County were reported to have contained fentanyl, all cases in the Bay Area also contained promethazine, which had not been reported as an additive in previous counterfeit or adulterated fentanyl-containing products. Fentanyl is a synthetic opioid analgesic that is a full μ-opioid receptor agonist (one of the three opioid receptors through which opioids exert their pharmacologic actions) and has 100 times the potency of morphine (2). Fentanyl is available in many formulations, and its unique physicochemical properties, particularly its high lipophilicity, allow it to quickly enter the central nervous system and are responsible for its high potency (2) and high potential for abuse. Fentanyl is not currently formulated for oral administration in pill or tablet form, however, and its presence in pill form is a marker for an illicitly produced product. Promethazine, a phenothiazine derivative, is routinely prescribed for the treatment of nausea, vomiting, and motion sickness. Promethazine use has recently been reported to be common among chronic opioid users and is thought to potentiate the “high” from opioids (3).
Top
[paste:font size="5"]Top
[paste:font size="5"]Top
[paste:font size="5"]Figure).
Top
Corresponding author: Kathy T. Vo, [email protected], 415-643-3243.
Top
Top
[paste:font size="5"]http://www.dhhs.saccounty.net/PUB/D...0160325-Health+Alert+-+Contaminated+Norco.pdf
- Lötsch J, Walter C, Parnham MJ, Oertel BG, Geisslinger G. Pharmacokinetics of non-intravenous formulations of fentanyl. Clin Pharmacokinet 2013;52:23–36. CrossRef PubMed
- Lynch KL, Shapiro BJ, Coffa D, Novak SP, Kral AH. Promethazine use among chronic pain patients. Drug Alcohol Depend 2015;150:92–7. CrossRef PubMed
- Thoren KL, Colby JM, Shugarts SB, Wu AH, Lynch KL. Comparison if information-dependent acquisition on a tandem quadrupole TOF vs a triple quadrupole linear ion trap mass spectrometer for broad-spectrum drug screening. Clin Chem 2016;62:170–8. CrossRef PubMed
- Peng PW, Sandler AN. A review of the use of fentanyl analgesia in the management of acute pain in adults. Anesthesiology 1999;90:576–99. CrossRef PubMed
- CDC. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012;61:10–3. PubMed
- CDC. Nonpharmaceutical fentanyl-related deaths—multiple states, April 2005–March 2007. MMWR Morb Mortal Wkly Rep 2008;57:793–6. PubMed
- Drug Enforcement Administration. DEA issues nationwide alert on fentanyl as a threat to health and public safety, March 18, 2015. http://www.dea.gov/divisions/hq/2015/hq031815.shtml
- Arens AM, Vo KT, van Wijk X, Lemos N, Olson KR, Smollin C. Adulterated Xanax: a case series from San Francisco [Abstract]. From: abstracts from the 2016 American College of Medical Toxicology (ACMT) Annual Scientific Meeting, March 18–20, 2016, Huntington Beach, CA.
