A Descriptive Study of an Outbreak of Clenbuterol-Containing Heroin

• Published in: Annals of emergency medicine 2008-11, Vol.52 (5), p.548-553
• Main Authors: Hoffman, Robert S., MD, Kirrane, Barbara M., MD, Marcus, Steven M., MD
• Format: Article
• Language: English
• Subjects: Adolescent; Adrenergic beta-Agonists - blood; Adrenergic beta-Agonists - poisoning; Adrenergic beta-Agonists - urine; Adult; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Cardiomyopathies - chemically induced; Clenbuterol - blood; Clenbuterol - poisoning; Clenbuterol - urine; Disease Outbreaks; Drug Contamination - statistics & numerical data; Emergency; Female; Heroin Dependence; Humans; Hypnotics. Sedatives; Intensive care medicine; Male; Medical sciences; Mid-Atlantic Region - epidemiology; Middle Aged; Neuropharmacology; Pharmacology. Drug treatments; Poison Control Centers - statistics & numerical data; Psychology. Psychoanalysis. Psychiatry; Psychopharmacology
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2008.04.026

Study objective Illicit drugs may be adulterated with substances other than the sought-after substance of abuse. Although the true incidence and clinical effects of this practice are unknown, geographically disparate outbreaks of clinically significant adulteration continue to occur. We report on a recent outbreak of clenbuterol-adulterated heroin occurring along the East Coast of the United States. Methods After identification of index cases, 5 US poison centers collaborated with state and territorial health departments to alert the public of clenbuterol-tainted heroin. A case definition of clenbuterol-tainted heroin toxicity was promulgated, and emergency departments (EDs) were asked to contact poison centers when cases were identified. Results We identified 34 probable or confirmed ED presentations in 5 states during a 6-month period. Thirteen of the 34 patients met the criteria for “confirmed” exposures. Clenbuterol was identified in the blood and or urine of 12 of these 13 patients. Clenbuterol concentrations ranged from 2.4 to 26 ng/mL in the blood and 9.4 to 12,526 ng/mL in the urine. Symptoms included nausea, chest pain, palpitations, dyspnea, and tremor. Physical findings included significant tachycardia, hypotension, and laboratory evidence of hyperglycemia, hypokalemia, and increased lactate levels. Six patients demonstrated biochemical evidence of myocardial injury. Ten patients received β-adrenergic antagonists without adverse effect. Conclusion The adulteration of heroin by clenbuterol was associated with sympathomimetic effects, metabolic acidosis, and myocardial injury. The report also highlights how collaborative efforts among poison centers using the Centers for Disease Control and Prevention's Epi-X system rapidly identified a disease outbreak.