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

Alleged drug only

No alleged drug

Drug and substitutes

Cocaine 58.3% 19.2% 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 5-fluorouracil 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 lymphocytesas 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?