Cocaína y Sus Adulterantes Robert S. Hoffman, MD.
-
Upload
rudolf-day -
Category
Documents
-
view
215 -
download
0
Transcript of Cocaína y Sus Adulterantes Robert S. Hoffman, MD.
![Page 1: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/1.jpg)
Cocaína y Sus Adulterantes
Robert S. Hoffman, MD
![Page 2: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/2.jpg)
Cocaine Synthesis
• You begin with a plant
• You end up with a drug
• Materials can be added:
– Intentionally
– Unintentionally
![Page 3: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/3.jpg)
![Page 4: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/4.jpg)
![Page 5: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/5.jpg)
ADICCIONES, 2010;22(3):227-232
![Page 6: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/6.jpg)
![Page 7: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/7.jpg)
![Page 8: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/8.jpg)
Definitions
• Drugs can be altered through 4 different processes:
– Dilution
– Substitution
– Contamination
– Adulteration
![Page 9: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/9.jpg)
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
![Page 10: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/10.jpg)
Contamination
• A product of the synthetic process is unintentionally allowed to remain in the finished drug
– Solvents
– Acids or bases
– Plant material
![Page 11: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/11.jpg)
Dilution
• An inert material is added to cocaine to increase the weight
– Similar Color
– Similar Consistency
![Page 12: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/12.jpg)
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
![Page 13: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/13.jpg)
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
![Page 14: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/14.jpg)
![Page 15: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/15.jpg)
Addiction. 2009 May;104(5):798-805.
• Analysis of materials VOLUNTARILY handed in by drug consumers
• 1999-2007
![Page 16: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/16.jpg)
![Page 17: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/17.jpg)
Fucci N. Unusual adulterants in cocaine seized on Italian Clandestine market.
Forensic Sci Int. 2007; 25;172(2-3):e1.
• Hydroxyzine
– An anticholinergic
• Levamisole
![Page 18: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/18.jpg)
Substitution With Intended Harm
Am J Emerg Med 1986;4:545-548
![Page 19: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/19.jpg)
Levamisole
![Page 20: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/20.jpg)
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.
![Page 21: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/21.jpg)
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
![Page 22: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/22.jpg)
Zhu NY, Legatt DF, Turner AR. Ann Intern Med. 2009 Feb 17;150(4):287-9.
![Page 23: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/23.jpg)
• 21 cases
• Usually presented with a febrile illness
• White blood cell count increased when cocaine was stopped
• Agranulocytosis returned on re-exposure
![Page 24: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/24.jpg)
![Page 25: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/25.jpg)
![Page 26: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/26.jpg)
Now Known As Retiform Purpura
![Page 27: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/27.jpg)
Medicine 2006;85:203–213
![Page 28: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/28.jpg)
aggregates of foamy histiocytes (arrows), reactive astrocytes (arrow heads), and perivascular cuffing of small lymphocytesas well as neutrophils
![Page 29: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/29.jpg)
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
![Page 30: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/30.jpg)
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
![Page 31: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/31.jpg)
Why Is Levamisole Added To Cocaine?
• Increases biogenic amines
– Similar to cocaine
• Increases addiction in animals
• Is converted to a stimulant Aminorex in horses
![Page 32: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/32.jpg)
![Page 33: Cocaína y Sus Adulterantes Robert S. Hoffman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022062500/56649f095503460f94c1dc1b/html5/thumbnails/33.jpg)
Treatment
• Stop the cocaine
• Agranulocytosis– Colony stimulating factors, antibiotics
• Vasculitis– Steroids?
• Leukoencephalopathy– Steroids?