CDC Morbidity and Mortality Weekly Report June 7, 1996 / Vol. 45 / No. 22 Scopolamine Poisoning among Heroin Users --New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996 Heroin is mixed ("cut") frequently with other substances primarily to increase its weight for retail sale (e.g., mannitol and starch) and to add pharmacologic effects (e.g., dextromethorphan and lidocaine). During 1995 and 1996, health departments and poison-control centers in New York City (NYC); Newark, New Jersey; Philadelphia; and Baltimore reported at least 325 cases of drug overdoses requiring medical treatment in persons who had used "street drugs" sold as heroin that pr obably also contained scopolamine, an anticholinergic drug. This report summarizes the clinical and epidemiologic features of these cases, which represent a new type of drug overdose. New York City On March 16, 1995, eight persons were treated in the emergency department (ED) of a Bronx hospital for acute onset of agit ation and hallucinations approximately 1 hour after " snorting" heroin. On physical examination, all these persons had clinical manifestations of anticholinergic toxicity (i.e., tachycardia, mild hypertension, dilated pupils, dry skin and mucous membranes, and diminished or absent bowel sounds); five had urinary retention. All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours. During March 17-April 5, 1995, a total of 10 persons who reported using heroin presented with similar clinical findings to hospital EDs in the Bronx and Manhattan. Seven patients reported having used heroin with the street names "Point on Point" or "Sting." Specimens of " Sting" heroin obtained from two patients on April 5 and analyzed by gas chro matography-mass spectrophotometry (GC-MS) by the Bureau of Laboratories, New York City Department of Health (NYCDOH), contained heroin and scopolamine. The GC-MS patterns of the scopolamine suggested it was synthetic rather than derived from a plant source. As a result of this finding, these patients were treated for suspected scopolamine poisoning with physostigmine (an antidote for anticholinergic toxicity). While receiving physostigmine intravenously for 5-10 minutes, their paranoia, hallucinations, and agitation resolved (1 ). During March 17-April 10, 1995, NYCDOH issued pr ess releases warning of scopolamine-adulterated heroin sold under the street names "Point on Point" and "Sting." During March 16, 1995-May 27, 1996, the New York City Poison Control Center (NYPCC) recorded 121 cases that met a case definition of both historical or clinical evidence of heroin use and clinical manifestations consistent with anticholinergic toxicity. NYPCC continues to receive several reports each week of presumed combined heroin/scopolamine overdoses that respond to physostigmine treatment. Newark During a 24-hour period on December 28-29, 1995, a Newark hospital ED treated 22 persons who, approximately 30 minutes after using heroin with the street name "Polo," developed clinical manifestations of anticholinergic toxicity. Naloxone treatment increased agitation and hallucinations, and physostigmine treatment resolved the signs of toxicity. On December 29, the New Jersey Poison Center (NJPC) informed all EDs in the state about the syndrome of severe anticholinergic toxicity associated with the use of "Polo" heroin. Later that day, after GC-MS testing of a sample of heroin obtained from a patient identified both heroin and scopolamine, the New Jersey Department of Health (NJDOH) held an emergency press conference to alert the pub lic to this drug combination. NJDOH and NJPC identified a total of 61 persons with 1) recent histories of snorting or ingesting heroin with the street name " Polo" and 2) clinical manifestations of anticholinergic toxicity for which treatment had been provided at 13 EDs in the Newark metropolitan area during December 28-30, 1995. During December 31, 1995-June 1, 1996, NJPC was consulted 2-3 times each week about patients with similar conditions. Philadelphia During February 19-21, 1996, a total of 12 patients who had injected or snorted heroin and had clinical manifestations of anticholinergic toxicity were treated in EDs at four hospitals in northeastern Philadelphia and reported to the Delaware Valley Poison Control Center (DVPCC). DVPCC estimated that in the Philadelphia area, during February 19-21, a total of 35 persons were treated for apparent combined scopolamine/ heroin overdose, and during March 15-May 5, six persons were treated. On May 9, a total of 27 persons presented to one Philadelphia hospital ED between 4:30 p.m. and 11 p.m. because of drug overdoses after taking heroin (mostly by injection). Of these, 16 were admitted to the hospital for observation because of tachycardia, hallucinations, or semi-coma. In addition to these cases, DVPCC was consulted about apparent anticholinergic toxicity among 72 heroin users during May 9-11, and among 12 during May 22-23. Baltimore During May 10-12, 1996, a total of 22 persons presented to one hospital ED with clinical manifestations of anticholinergic toxicity. Al though these persons reported taking heroin with street names of "Homicide" and "Super Buick," GC-MS testing of a specimen identified scopolamine, quinine, and dextromethorphan but no heroin. Testing of Heroin by the Drug Enforcement Administration The Drug Enforcement Administration monitors the purity of and adulterants in heroin through " street" purchases of heroin (i.e., the " Domestic Monitor Program" [DMP]) and testing of heroin obtained during criminal justice operations. From June 1979 through February 1996, DMP did not detect scopolamine in specimens sold as heroin. During 1995, DMP made a total of 806 purchases, including 195 from Maryland, New Jersey, New York, and Pennsylvania; none contained scopolamine. During 1996, of the 147 DMP purchases, including 46 from Maryland, New Jersey, New York, and Pennsylvania, only two (made in March 1996 in Elizabeth and Passaic, New Jersey) contained scopolamine. In addition, four of 23,288 non-DMP specimens believed to be heroin and obtained through criminal justice operations contained scopolamine. The earliest was obtained in October 1995 in Bohemia, New York; two in March 1996 in Philadelphia; and one in March 1996 in NYC. Reported by: J Perrone, MD, R Hamilton, MD, L Nelson, MD, F DeRoos, MD, J Brubacher, MD, WJ Meggs, MD, RS Hoffman, MD, New York City Poison Control Center; P Ravikumar, PhD, S Reimer, PhD, A Ramon, MD, Bur of Laboratories; B Mojica, MD, New York City Dept of Health.RD Shih, MD, SM Marcus, MD, New Jersey Poison Center; E Karkevandian, DO, PM Podrazik, MD, JJ Calabro, DO, Newark Beth Israel Medical Center; JL York, MD, Clara Maass MedicalCenter, Newark; JW Farrell, JF French, T O'Connor, New Jersey Dept of Health. F Henretig, MD, Delaware Valley Poison Control Center, Philadelphia; W Thompson, Philadelphia CoordinatingOffice for Drug and Alcohol Abuse Programs; R Kastner, L Tri mmer, Lancaster County Drug and Alcohol Commission, Lancaster, Pennsylvania. G Kelen, MD, K Nordenholtz, MD, B Blok, MD,G Green, MD, Dept of Emergency Medicine, Johns Hopkins Univ Hospital, Baltimore; TM Muller, S Soni, PhD, Laboratory Div, Baltimore City Police Dept; P Beilenson, MD, Baltimore City HealthDept; G Benjamin, MD, J Smialek, MD, Maryland State Dept of Health and Mental Hygiene. S Springer, C Heilig, Drug Enforcement Administration, US Dept of Justice. Div of Health Effectsand Hazard Evaluatio n, National Center for Environmental Health; National Center for HIV, STD, and TB Prevention (proposed), CDC. Editorial Note: Scopolamine is pharmacologically similar to atropine and other belladonna drugs; it occurs naturally in plants, such as henbane, and can be manufactured. Scopolamine and other anticholinergic drugs are components of some over-thecounter and prescription medications used to prevent nausea, vomiting, and motion sickness (e.g. scopolamine transdermal patches) or in combination with other medications. The cases described in this report underscore one of the multiple risks associated with use of illegal drugs (2,3 ). Before the reports of these cases in the Northeast, scopolamine contamination of heroin was usually not considered in the evaluation of persons with drug overdose. In the initial clusters of anticholinergic toxicity, some EMS staff and clinicians did not recognize the manifestations suggesting scopolamine poisoning and treated some patients for drug overdose with the opioid antagonist naloxone, which was associated with increased severity of agitation, hallucinations, and other manifestations of anticholinergic toxicity. Following the identification of scopolamine in the street drugs sold as heroin, notices and publicity from poisoncontrol centers, health departments, drug-treatment programs, syringe-exchange programs, and other community agencies were used to rapidly inform clinicians, drug users, and others in the community about the scopolamine contamination of heroin. The use of multiple drugs and alcohol complicates assessment of the causes of the acute mental status changes in drug users. Many of the cases described in this report probably were associated with use of at least two drugs--heroin and scopolamine. Overdose of heroin and other opioids usually is characterized by lethargy, respiratory depression, and pinpoint pupils. In comparison, overdose with scopolamine and other anticholinergic medicines is characterized by dilated pupils, flushing, dry skin and mucous membranes, absent bowel sounds, rapid heart rate, and altered mental status (4 ). Interaction between scopolamine and heroin or other drugs (e.g., cocaine) may obscure the classical effects and differ ences. Al though some of these patients improve dramatically with intrav enous physostigmine therapy, such treatment should be administered only by experienced staff and with appropriate patient monitoring because of the potential for serious side effects, including seizures, bronchospasm, and bradycardia. For many patients, treatment may be restricted to sedation and observation, and manifestations may resolve over a period of hours. Naloxone remains the treatment of choice for coma and severe respiratory distress associated with possible drug overdose. Because of the complexities of both the diagnosis and treatment of patients with mental status changes and possible drug overdose, practitioners caring for such patients should consult their local poison-control center. Surveillance based on data from the system of poison-control centers in the Northeast was critical in recognizing the cause of this new type of drug overdose among heroin users and alerting health departments. The impact of the effects of these drug overdoses was limited further by timely recognition of the combined heroin and anticholinergic toxicity, use of sedation or physostigmine to treat the patients, and prompt investigation and reporting by state and local health departments. The continued occurrence of drug overdoses associated with use of scopolamine-containing heroin indicates the need for cl inicians, pub lic health programs, and organizations working with drug users to be aware of this problem; new cases should be reported promptly to the local poison-control center and health department. References 1. Hamilton R, Perrone J, Meggs WJ, et al. Epidemic anticholinergic poisoning from scopolamine tainted heroin [Abstract]. J Toxicol Clin Toxicol 1995;33:502. 2. CDC. AIDS associated with injecting-drug use--United States, 1995. MMWR 1996;45:392-8. 3. Kaa E. Impurities, adulterants and diluents of illicit heroin: changes during a 12-year period. Forensic Sci International 1994;64:171-9. 4. CDC. Anticholinergic poisoning associated with an herbal tea--New York City, 1994. MMWR 1995;44:193-5.