He bought what he believed to be Norco tablets from a friend a few days earlier and described the tablets as having the inscription “M367,” and looking exactly like Norco tablets that had been previously prescribed to him after a shoulder cartilage repair. Patient 2 was a man aged 36 years who went to the ED with his girlfriend (patient 3), concerned that he was experiencing an adverse reaction to an illicitly purchased drug. Promethazine use has recently been reported to be common among chronic opioid users and is thought to potentiate the “high” from opioids ( 3). Promethazine, a phenothiazine derivative, is routinely prescribed for the treatment of nausea, vomiting, and motion sickness. 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. 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 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). 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.Īlthough 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. 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 staff members at the California Poison Control System (CPCS) were alerted to increase vigilance for potential cases. 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). 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. The patients purchased the drug from a friend a few days earlier. 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. Collaborative efforts among public health, medical, and law enforcement officials are essential for a rapid and effective response. Health care providers should be aware of this and other concurrent outbreaks and notify local poison centers and health departments of suspected cases. The distribution of counterfeit tablets represents a major public health threat given the potentially lethal nature of the tablets. What are the implications for public health practice? Promethazine likely potentiates the opioid effect. 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. Whereas Norco typically contains acetaminophen and hydrocodone, these counterfeit tablets predominantly contained fentanyl and promethazine. 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.ĭuring 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. 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.
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