Lethal Fentanyl and Cocaine Intoxication

The New England Journal of Medicine reported an outbreak of opioid intoxication in patients who had not used opioids previously and who had non-opioid substance use disorder. Eighteen patients over four days presented to the ER by EMS for suspected drug intoxication after smoking “crack “cocaine. All patients had arrived from the same Zip code.

The average age was 53 years of age and 67% were men. All patients were examined and found to be unresponsive with signs of opioid overdose: lethargy, pinpoint pupils, and respiratory distress. Initial urine drug screens confirmed cocaine but no other opioids. A total of 3 patients out of 18 expired. Fentanyl testing was not part of the initial drug screen

Urine testing for opioids was completed in 16 of the 18 patients using more sophisticated testing such as immunoassay and liquid chromatography. These tests were positive for cocaine and its metabolites and 15 patients confirmed fentanyl including the 3 that had expired. The results of these tests confirmed severe poisoning.

Further investigation could not ascertain whether the poisoning was due to intentional adulteration or unintentional contamination of fentanyl.
All patients were treated aggressively with Naloxone in different forms. More aggressive urine drug testing may or may not have made a difference in three of the cases which died for failure to diagnose another opioid involved in this situation.

Unintended exposure to fentanyl poses extraordinary risks of respiratory depression and death. This especially holds true among patients without opioid tolerance. Drug users must beware.

NEJM 379:18 NOV 1 2018

Dr. Gilreath

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