Transcript Cocaína y sus adulterantes

Cocaína y Sus Adulterantes
Robert S. Hoffman, MD
Cocaine Synthesis
• You begin with a plant
• You end up with a drug
• Materials can be added:
– Intentionally
– Unintentionally
ADICCIONES, 2010;22(3):227-232
Definitions
• Drugs can be altered through 4 different
processes:
– Dilution
– Substitution
– Contamination
– Adulteration
Caveat emptor:
No siempre se consigue lo que quiere
Substance
purchased
Cocaine
Alleged No alleged
drug only drug
58.3%
19.2%
Drug and
substitutes
22.5%
Amphetamines
27.1%
49.9%
23%
Methamphetamine 32.9%
63.2%
3.9%
Klat: J Toxicol Clin Toxicol 1986: 1163 specimens
Contamination
• A product of the synthetic process is
unintentionally allowed to remain in the
finished drug
– Solvents
– Acids or bases
– Plant material
Dilution
• An inert material is added to cocaine to
increase the weight
– Similar Color
– Similar Consistency
Substitution
• A pharmacologically active substance is
replaces cocaine
• It also has properties similar to cocaine to
deceive the user into thinking cocaine is
present
– Sympathomimetics
– Local anesthetics
Common Substances Found in
Street Cocaine
Color
Anesthetic
Sympathomimetic
Starch
Lidocaine
Ephedrine
Sugar
Tetracaine
Phenylpropanolamine
Talc
Benzocaine Pseudoephedrine
Ground Glass
Shannon M. Clinical toxicity of cocaine adulterants.
Ann Emerg Med. 1988 Nov;17(11):1243-7
Addiction. 2009 May;104(5):798-805.
• Analysis of materials VOLUNTARILY
handed in by drug consumers
• 1999-2007
Fucci N. Unusual adulterants in cocaine
seized on Italian Clandestine market.
Forensic Sci Int. 2007; 25;172(2-3):e1.
• Hydroxyzine
– An anticholinergic
• Levamisole
Substitution With Intended Harm
Am J Emerg Med 1986;4:545-548
Levamisole
Levamisole
• Originally used to treat parasitic infections
in humans and cattle
• 1970s, levamisole was used as an
immunomodulator for rheumatoid arthritis
and nephrotic syndrome
• Later it became an adjuvant to 5fluorouracil in colon cancer.
Levamisole
• Beginning in 2003, levamisole was
identified as a new cocaine adulterant.
• By July 2009, the United States Drug
Enforcement Administration (DEA)
estimated that 69% of the cocaine seized
contained
Zhu NY, Legatt DF, Turner AR. Ann Intern Med. 2009 Feb 17;150(4):287-9.
• 21 cases
• Usually presented with a febrile illness
• White blood cell count increased when
cocaine was stopped
• Agranulocytosis returned on re-exposure
Now Known As Retiform Purpura
Medicine 2006;85:203–213
aggregates of foamy histiocytes
(arrows), reactive astrocytes
(arrow heads), and perivascular
cuffing of small lymphocytes
as well as neutrophils
Prevalence of Levamisole in Urine
Toxicology Screens in Denver
• 300 specimens were positive for cocaine
• 249 positive for cocaine
– 194 of 249 cocaine positive samples tested
positive for levamisole (78%)
• 51 negative for cocaine
– 9 of 51 positive for levamisiole
JAMA, April 27, 2011—Vol 305, No. 16 1657
Predispositions
• Levamisole toxicity seems to be related to
the auto-immune system
– Many unaffected individuals
– High prevalence of HLAB27 in affected
individuals
– Perinuclear antineutrophil cytoplasmic
antibodies (p-ANCA) often found in patients
with vasculitis
– Repeat exposure associated with recurrence
Why Is Levamisole Added To
Cocaine?
• Increases biogenic amines
– Similar to cocaine
• Increases addiction in animals
• Is converted to a stimulant Aminorex in
horses
Treatment
• Stop the cocaine
• Agranulocytosis
– Colony stimulating factors, antibiotics
• Vasculitis
– Steroids?
• Leukoencephalopathy
– Steroids?