China white epidemic: An eastern united states emergency department experience

ORIGINAL CONTRIBUTION China White; fentanyl

China White Epidemic: An Eastern United States Emergency Department Experience

Study objective: The purpose of this study was to isolate significant clinical or demographic findings concerning overdose patients treated during a China White (3-methyl fentanyl) epidemic and compare them with data for all unintentional narcotic overdose patients during a 24-month period.

Design: We reviewed charts from 85,246 patient visits to our emergency department during the 24-month period of January 1987 through Decem- ber 1988 to study this narcotic epidemic. Data from the Allegheny County Coroner's Office pertaining to unintentional drug overdose deaths that occurred during this same period also were reviewed.

Setting: The first outbreak of narcotic overdoses in the eastern United States involving China White occurred in Allegheny County, Pennsylva- nia, in 1988.

Type of participants: Patients were included if they met the criteria of a suspected unintentional narcotic overdose, but excluded if they were not given naloxone.

Interventions: Emergency physicians became suspicious of China White use after an unusual increase in narcotic overdoses presenting to the ED coupled with "routine drug of abuse" screens negative for opiates despite dramatic patient responses to naloxone. In most of the cases in which specific testing was done, there were positive indicators of fentanyl derivatives. Investigations found China White present in street drugs and paraphernalia.

Measurements and main results: A cluster was defined as a t ime period with a statistically significant increase in overdoses over the expected number for an interval of equal length. Although there were no significant clinical differences in case presentation during the 24-month period, there was a statistically significant 13-fold increase in overdoses during the Sep- tember through November 1988 cluster (mean, 13 vs 0.95 per month, P < .00i by Wilcoxon rank-sum test).* A dramatic increase in unintentional drug overdose deaths occurr.ed in the county during this cluster. A total of 18 fentanyl-positive unintentional drug overdose deaths, predominantly male (89%) and black (56%), with an age range of 19 to 44 years (mean, 34.9 years), were reported by the county coroner (13 during the cluster). Narcotic overdoses and unintentional drug overdose deaths declined sharply with confiscation of a clandestine China White laboratory,

Conclusions: China White was responsible for a dramatic rise in unintentional drug overdose deaths in Allegheny County in 1988. There were no significant clinical differences between China White overdose sur- vivors and other unintentional narcotic overdose victims. Overdoses re- sponsive to naloxone with inconsistent routine toxicologic screens may be due to a fentanyl analogue. [Martin M, Hecker J, Clark R, Frye J, Jehle D, Lucid El, Harchelroad F: China White epidemic: An eastern United States emergency department experience. Ann Emerg Med February 1991;20: 158-i64.]

Marcus Martin, MD, FACEP Janene Hecker, MD Richard Clark, MD Jeffrey Frye, MD Dietrich Jehle, MD Emily Jean Lucid, MD, FACEP Fred Harchelroad, MD Pittsburgh, Pennsylvania

From the Medical College of Pennsylvania, Allegheny Campus, Pittsburgh.

Received for publication May 24, 1989. Revision received June 7, 1990. Accepted for publication July 12, 1990.

Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989.

Address for reprints: Marcus Martin, MD, FACER Medical College of Pennsylvania, Allegheny Campus, 320 East North Avenue, Pittsburgh, Pennsylvania 15212.

*These numbers were incorrectly reported as mean 12 versus 1.05 per month in a previously published abstract. 1

70/158 Annals of Emergency Medicine 20:2 February 1991

CHINA WHITE Martin et al

Inclusion Criteria

Known or Suspected drug overdose Patient with a clinical response to naloxone (ie; improved respiratory, hemodynamic, or central nervous system status associated with administration of naloxone)

All patients with toxicologic screen positive for narcotics

Exclusion Criteria

Cardiac or respiratory arrest due to trauma or organic disease

Suicide attempt or homicide

Not given naloxone

FIGURE 1. Criteria used to determine un in ten t iona l narcot ic overdose victims.

INTRODUCTION A very noticeable increase in pa-

iients presenting with narcotic overdoses to our emergency department occurred during September through November 1988. Although heroin-related overdoses were not new to our 750-bed urban teaching hospital (Al- legheny Genera l , loca ted on the north side of Pittsburgh), the dramatic increase in narcotic overdose patients was quite disturbing to the community and attracted major me- dia attention. In addition, the number of drug-related deaths had increased substantially during previous months.

It was the ini t ial impress ion of most medical a/id law enforcement personnel that the apparent epidemic of overdoses and deathS was due to use of a more potent heroin than that to which area drug users were accus- tomed. Initial coroner's reports sug- gested that the deaths were heroin- related. However, routine toxicologic screens on the patients in the early stages of the epidemic were typically negative for opioids and revealed a variety of" other substances such as cocaine and quinine.

The overdose pat ients who were reached in t ime by the paramedics and those t rea ted in the ED re- sponded dramatical ly to naloxone. This typical patient presentation of narcosis coupled with negative rou-

20:2 February 1991

TABLE 1. Clinical presentations of cluster and noncluster cases for the 24-month study period

Demographics Cluster Noncluster P R a c e (%) (N - 38) (N = 20) .50

Black 58 45 White 42 55

Age (yr) (N = 39) (N = 20) .47 Mean 32.56 31.55 Median 32,0 31.0 SD 5.29 4.88 Range 22 -- 40 24 -- 42

Sex (%) (N = 39) (N = 20) .79 Male 7 4 75 Female 26 25

Chronic drug use (%) 69.2 65 .97

Paraphernalia with patient (%) 12.8 15 .55

Mode of arrival at ED (%) (N = 39) (N = 20) .44 Paramedic unit 74 80 Walk-in or automobile 26 20

Vital Signs Initial respirations (min -1) (N = 39) (N = 18) .93

Mean 7.79 7.61 Median 4.0 4,0 SD 7,10 7.85 Range 0 - - 22 0 - - 30

Initial heart rate (beats/min) (N = 36) (N - 15) .32 Mean 97.36 86.73 Median 100.00 98.00 SD 32.31 39.98 Range 0 180 0 150

Initial systolic blood pressure (mm Hg) (N = 39) (N = 20) .13 Mean 123.64 139.20 Median 124.06 133.00 SD 39.70 33.50 Range 0 -- 190 88 - - 198

Level of consciousness Comatose (%) 87 85 .35

Pupillary constriction (N = 31) (N - 16) .98 Before naloxone (%) 62 55

Clinical Course Total naloxone dose administered (mg) (N = 39) (N = 20) .22

Mean 4.04 5.!6 Median 4,00 4.00 SD 2.93 4.05 Range 0.4 - - 12 0.8 -- 16.8

Intubated (%) 12.8 15 .55

Length of stay in ED (excluding deaths and admissions) (min) (N = 35) (N = 13) .45

Mean 269.0 300 Median 288 320 SD 128.50 121.45 Range 69 - - 618 111 -- 515

tine toxicologic screens for narcotics raised our suspicion for a fentanyl ana logue as the causa t ive agent: Eventually, 3-methyl fentany! (China White) was de tec ted by rad io im- m u n o a s s a y t echn ique in bags of white powder and drug paraphernalia confiscated by law officials and in

Annals of Emergency Medic ine

the body fluids of overdose vict ims who died. After a clandestine opera- tion responsible for producing China White was shut down, the number of narcotic-related overdoses and deaths declined sharply.

The purpose of this study was to isolate significant clinical or demo-

!59/71


Cases per month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Months: January 1987=December 1988

Total deaths per month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Months January 1987 December1988

L m AI] ?ther un!?te,tioyal drug overdose deaths ( 9 1 ) ~ China Whi . . . . . . . . d (18) I

graphic findings concerning the overdose patients we treated during the 'China White epidemic and compare them with data for all other uninten- t ional narco t ic -overdose pat ients treated during a 24-month period. We elaborate on the uniqueness and rele- vant implications of overdoses and deaths caused by China White in this eastern US community.

MATERIALS A N D M E T H O D S A readily apparent increase in

overdoses and drug-related deaths in our area occurred in early October 1988, lasted for about six weeks, and then suddenly ended. An epidemic period seemed fairly well demar- cated, and our study began within two weeks after we treated the last overdose patient of the apparent epidemic. The study period was the 24 months between January 1, 1987, and December 31, 1988. Because the study was initiated in the beginning of December 1988, 23 months were audited retrospectively, and the 24th month was studied prospectively.

The ED log books containing multiple patient admission and discharge data were surveyed; 85,246 patient visits occurred during the study period. Inclusion and exclusion criteria were used to determine the cases considered unin tent ional narcotic overdoses (Figure 1).

In cases included in the study, medical charts were obtained and reviewed for demographic data (age, sex, race, home address, location at which overdose occurred, employment); mode, time, and date of arrival at ED; time of discharge from the ED; clinical data (drug use history, clinical presentation, treatment,

72~60

length of stay in the ED, hospital admission, complications); and toxicologic test results (Table 1). In addition, data were abstracted from the Allegheny County coroner's office per ta in ing to un in t en t i ona l drug overdose deaths for the 24-month study period. Statistical methods used were X 2 test, Wilcoxon rank- sum tes t , S t u d e n t ' s t test , and Fisher's exact test.

RESULTS Application of the inclusion and

exclusion criteria to the 85,246 patient visits for the 24-month period revealed 59 cases that fit the clinical case definition of an unintentional narcotic overdose. As shown (Figure 2), 39 of those cases occurred in a "cluster" period between September 1 and November 30, 1988. The other 20 cases occurred during the remain- ing 21 months in the study period. A cluster is a time period with a statistically significant increase in overdoses above the expected number for an interval of equal length. There was a statistically significant (13- fold) increase in narcotic overdoses during the September through No- vember 1988 cluster (13 overdoses per month vs 0.95 overdoses per month for the remainder of the study period, P < .001 by Wilcoxon rank-sum test).

A dramatic increase in unintentional drug overdose deaths occurred in Allegheny County during the cluster (Figure 3). These unintentional or accidental deaths were related to a var ie ty of drugs, the major i ty of which were illicit; deaths related to trauma, suicide, or homicide were excluded.

A total of 18 China White-related

Annals of Emergency Medicine

FIGURE 2. Unintent ional narcotic overdose patients presenting to Alle- gheny General Hospital ED.

FIGURE 3. Unintentional drug overdose deaths in 1987 and 1988, Alie. gheny County, Pennsylvania.

unintentional drug overdose deaths were identified; three fourths oc. curred during the September through November cluster period. The China White-re la ted un in t en t i ona l drug overdose death patients were pre. dominantly male (89%) and black (56%) and had an age range of 19 to 44 years (mean, 34.9 years): Three fourths of the v ic t ims were pro. nounced dead at their homes or other locations at which the overdoses occurred. Some vict ims were found dead with the needle still in the in. jection site.

The clinical presentation of unin. tentional narcotic overdose patients presenting to the ED during the cluster period compared with the non. cluster periods is given (Table 1). The demographic profile of the clusta group did not differ significantly from that of the nonclustet group. In each group, the overdose cases were predominantly male. Known chronic drug users were equally likely to be black or white and were of the same average age. The majority of each group arrived at the ED by paramedic unit. Likewise, initial physical signs were not statistically different be. tween the two groups.

Most patients were initially comatose with constricted pupils and decreased mean respiratory rates, h the cluster group, 21% of patients

} 20:2 February 1991 ~

CHINA WHITE ~artin et al

were initially apneic compared with 17% of noncluster patients. Despite the high rate of respiratory arrest, 0niy two cluster patients presenting to the ED were in full cardiopulmo- Patient nary arrest, and neither could be resuscitated. No patient in the nonclu- 1 ster group was in full arrest on pre- 2 sentation. The majority of patients had normal mean heart rates and 3 mean systolic blood pressures when first evaluated. 5

Naloxone was administered to pa- 17 tients in both groups through multiple routes (eg, IV, IM, sublingual, and 26 endotracheal) by prehospital and hospital personnel. In both groups, the 31 IV route was used most frequently, followed by the IM and sublingual routes, with the endotracheal route the least frequent. The majority of patients in each group received mul- 6 tiple doses through the IV route, but 13 multiple administration routes also 17 were used in five cluster and three 20 a0ncluster patients. The mean total naloxone dosage in milligrams was not significantly different between the two groups; nor were the dosage ranges different. There was no clinical difference in pat ient response based on dosage of naloxone or route administered, except for the endotracheal route, which was not effective in re-establishing a normal respiratory rate or 'level of consciousness. The two patients given naloxone by endotracheal tube required repeated doses by IV and IM routes to effect a favorable response. A small percent- age of patients in each group required ~ntubation for airway management.

The ED clinical courses of cluster and noncluster patients were also compared regarding length of stay in the ED, admission to the hospital, death, clinical complications, and ad- ditiOnal t reatment required. Mean lengths of stay in minutes were not significantly different, and the ranges of stay were comparable. Two cluster patients were pronounced dead in the ED after attempted resuscitation, and there were no ED deaths in the noncluster group. Admission to the hospital was required for two cluster patients - one for management of hy- p0kalemia and one to ru le ou t myocardial infarction in the presence of ECG changes (hyperacute T waves) and mild elevation in total CPK and •g fraction. Three noncluster patients were admitted: one each for ECG change (diffuse T wave laver-

TABLE 2. Clinical complications: Cluster versus noncluster

Cluster Group Complication Admitted Treatment

Hypokalemia Yes Potassium chloride Hyperacute T waves, elevated Yes Clonidine

creatine phosphokinase Pulmonary edema No Furosemide, metoprolol,

aminophy[line Seizure No Phenytoin Hypertension, atrial fibrillation No Labetolo]

Lanoxin

Hypoglycemia No Dso

Atrial fibrillation, ischemia in No Lidocaine inferior leads

Noncluster Group

Complication Admitted Treatment

T wave inversion (diffuse) Yes Seizure Yes Phenytoin, diazepam Seizure, tachycardia No Inderal Pulmonary edema Yes Furosemide

sions), management of seizures, and treatment for pulmonary edema.

The occurrence of clinical complications was 17.9% (seven of 39 patients) for the c luster group and 20.0% (four of 20 patients) for the nonclus ter group; therefore, there was no difference in rate between the two groups. Complications, admissions, and treatments given are listed (Table 2). In the cluster group, two pat ients left w i thou t comple t ing t reatment ; no nonclus ter patients left without completing treatment.

Rout ine toxicologic screens on urine and blood specimens were obtained in the majority of patients in each group and were positive for one or more drugs in 80% of cluster sc reens and 75% of n o n c l u s t e r screens. There was an average of 3.29 drugs per positive screen in cluster patients and 3.08 drugs per positive screen in noncluster patients, with cocaine and quinine occurring more frequently in the cluster group and opiates predominating in the noncluster group.

Twenty of the 39 overdose cases that occurred during the cluster period had specific testing for fentanyl derivatives. In 16 of the 20, there were positive indicators for the presence of a fentanyl analogue using gas chromatography-mass spectrometry (GO-MS).

DISCUSSION Fentanyl and Analogues

Fentanyl citrate N-(1-phenethyl-4- piperidinyl) propionani l ide dihy- drogen citrate (Figure 4) is a synthetic narcotic analgesic and sedative used perioperatively and is commercially available as Sublimaze ® (fentanyl) and Innovar ® (fentanyl plus droperi- dol, a n e u r o l e p t i c m a j o r t r an - quilizer). 2 Fentanyl was synthesized in the 1960s, used for medicinal purposes in Europe, and then introduced in the United States as Sublimaze ® in 1968.

A 100-~g (0.1 mg) dose of fentanyl is approximately equal in analgesic activity to 10 mg morphine or 75 mg meperidine. 2 It is suited for anesthesia because of its high potency, rapid onset, and short duration of action. 3 When given intravenously, onset of action is almost immediate. Fentanyl may produce signs of narcosis char- acteristic of and indistinguishable from those of natural opioids, includ- ing euphoria, miosis, bradycardia, and respiratory depression.2, 3 The narcotic potency of fentanyl is reported to be 200- to 300-fold that of morphine.g, 4 A single 100-~g IV dose may induce analgesia for 30 to 60 minutes. 2 Large doses of fentanyl may produce apnea, and the respiratory depression (alterations in respirations and alveolar ventilation and

20:2 February 1991 Annals of Emergency Medicine 161/73


Fentanyl

3-Methyl fentanyl

o~-Methyl fentanyl

O

II - - O H 2 - - N~ ~---- N - - C - - O H 2 - - OH 3

0

II - - C H 2 - - N~ ' ) ~ N - - C - - O H 2 - - OH s

0

II --CH2cH31 - - N ~ - - - ~ - - C - - C H 2 - - CH s

4

diminished sensitivity to CO 2 stimu- lation) may last longer than the analgesic effect.

Fentanyl is very !ipophilic and acts on w-receptors in the brain, where m a x i m u m concen t r a t ion may be reached in one minute, s Distribution half-life is one tO two minutes, and elimination half-life is ten minutes with 50% excretion in the urine and 50% excretion in the bile. s

Fentanyl has been used to narco- tize race horses6, z and abuse by healthcare professionals, especially anesthesia personnel, has been reported~8, 9 Legal derivatives of fentanyl used as anesthetics o r immo- bilizing agents include sufentanyl, al- fentanyl , lofentany! , and carfen- tanyl.S,

China White is a name given to the family of the illicit potent ana- 10gues of fentanyl that first appeared on the s t r e e t s of Ca l i fo rn i a in 1979.1°, 11 Originally, the name was used in reference to a pure form of heroin processed in Southeast Asia that is White. 12,13 California drug dealers and addicts applied this name or "synthetic heroin" to illicit fentanyl. TM Although classic narcosis is common for China White, investiga- tors typically do not find heroin in the street samples3 o

At least ten different illicit fentanyl analogues have been identified and more than 110 deaths have been

reported in the West since late De- cember 1979. All of the deaths occurred in California with the excep- tion of two in Portland, Oregon, one in Tempe, Arizona, and one in Reno, Nevada. lo The Drug Enforcement Admin i s t r a t ion in i t ia l ly reported that 3-methyl fentanyl caused the early California deaths but later cor- rectly reported a -methy l fentanyl (Figure 4) as the cause. Is

A succession of new fentanyl analogues appeared after the restriction Of c~-methyl f e n t a n y l . In 1984, 3-methyl fentanyl (probably the most potent analogue of fentanyl) surfaced and accounted for the majority of illicit fentanyl deaths in the West in 1984 and 1985 and for 18 deaths in the East in 1988. 3-Methyl fentanyl may be more than 6,000-fold as potent as morphine and 1,000- to 2,000- fold as potent as heroin.4;]O, ll, 16 In a California study, seasoned heroin Users who had also used illicit fentanyl analogues indicated that they could not physically distinguish between the two drugs but that true heroin gives more o f an in tense "rush" (onset). 12 In contrast, fentanyl gives a longer "nod" (painless, sleepy euphoria). Eighty-nine percent of the respondents preferred true heroin to fentanyl. 12

In our study, 74% of the China White overdose victims presenting to the ED were male and 26% were re-

FIGURE 4. Chemical structures of fentanyl, 3-methyl fentanyl, and R-methyl fentanyl.

male. A similar male-to-female ratio was reported for the western China White overdoses, lo Further compari- son reveals that the mean age of the victims was in the early 30s for all overdoses. The western overdoses typica l ly occurred among white, blue-collar workers in suburban areas compared with the urban occurrence of the eastern overdoses in slightly more blacks than whites, with a 20% employment rate. In the West, there most often was a history of heroin abuse but many claims of no recent abuse. The eastern cases were pre- dominant ly chronic drug abusers. Large amounts of lactose were used as adulterants in the West, and quinine was used in the East. There were some reports of cocaine use in combination with China White in the West.l~ Cocaine was almost rou- tinely combined with China White in the East. Alcohol use was common to both western and eastern Overdose cases.

A usual dose of 3-methyl fentanyl is a few micrograms compared with 8 to 16 mg per dose of street heroin. 14 The minimum lethal dose reportedly is 250 p~g fentanyl and a few micrograms for 3-methyl fentanyl.S, I0 Be- cause fentanyls mix poorly with cutting agents, the risks of error and fatal overdoses are increased.lL ~7 Drug dealers in Pittsburgh were sell- ing China White in quarter bags (about one fourth the usual powdei amount for street heroin but the same price)~ Large amounts of cutting agents are used, so the actual amount of active drug is small (less than 1%) and therefore does not generally in- fluence taste, color, or odor, to mak- : ing distinction between drugs impos- sible.

Naloxone Although the cluster period of this

study is remarkable for an increase in unintentional overdose deaths, it is apparent that the death toll may have been greater were it not for the opiate antagonist naloxone. Naloxone is a synthetically produced N-allyl deriv- ative of oxymorphone, which antago- nizes narcotic effects at three sepa- rate opioid receptors in the brain. 18 In doing so, naloxone reverses the

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0HINA WHITE Martin et al

major effects of narcotics: miosis, euphoria, analgesia, respiratory depression, and sedation39

The dosage of naloxone required for complete reversal of symptoms varies according to the opioid being antagonized and patient profile. For adult overdose patients, at least 2 mg should be used to constitute an ade- quate trial, but many protocols begin with an initial dose of 0.4 rag. This can be repeated every two to three minutes. If there is no response ob- served after a 10-rag total dose, the diagnosis of a pure narcotic overdose should be questioned (Narcan ® pack- age insert). The above dosing sched- ule is for IV administrat ion. Sub- cutaneous and IM routes are effective, but the onset of action is not as rapid.2O, 21 Although the endotracheal application of naloxone has been found to be effective, 22 such was not the case in two of our patients.

Patients in this s tudy predominantly received IV naloxone, and 87% of the patients in the cluster group and 85% of the patients in the n0ncluster group presented in coma. Mean respirations were less than eight for both cluster and noncluster patients. Only two of the China White 'overdose victims were pronounced dead in our ED, and they had no vital signs on arrival. The other victims who died were pronounced where they were initially found or at another medical facility. All other overdose patients in the cluster and noncluster groups in our ED were resuscitated using naloxone. This experience shows naloxone to be very effective in the treatment of China White overdoses.

Testing for Fentanyl and Analogues

A drug synthesized in a clandestine laboratory and distributed for illicit purposes may be so novel and miniscule in amount (especially after heavy cutting) that its structure and source can be elusive. Before m-methyl fentanyl was identified by Drug Enforcement Administration forensic scientists, they could find 0nly lactose in the powder samples of China White. is

Polydrug use is also a pressing problem, and diagnosis may require more than one laboratory method. 22 Because the level of sensitivity for detecting drugs by thinqayer chromatography (TLC) is in the low mi-

crogram range, a negative screen may turn out to be positive by radioimmunoassay or GC-MS. TLC false- negat ive results occur more frequently than do false-positive ones. 23 The levels of sensitivity by radioimmunoassay and GC-MS may be 50- to 100-fold and 1,000-fold those of TLC, respectively. Drug identification by GC-MS is more reliable and definitive than other methods and more expensive . However , even when laboratories use GC-MS for general screening, drug identification may be reliable only 50% to 70% of the time. ~4 This may be due in part to technical limitations, laboratory error, or inadequate specimens (ie, not enough serum, or no accompany- ing urine specimen).

Because of its high potency, the fentanyl analogue concentration in body fluids is expected to be low and unlikely to be detected by routine or general toxicologic screens. Fentanyl may appear in the plasma in quan- tities of less than 1 ng/mL. Therefore, use of sensitive and selective detection methods free from interfering endogenous compounds is neces- sary. 25 Because the fentanyls and opiates are chemical ly unrelated, there is no cross reaction with re- agents used in opiate screens. Immu- noassays are generally less specific than GC-MS, but the capabilities to interact with drug and metabolites may increase the drug detection sensitivity.

Henderson et al developed a very sensitive and specific radioimmuno- ass~ty for fentanyl soon after its introduction into US clinical medicine. 26 The radioimmunoassay for fentanyl is believed to be very specific for measuring the parent drug, and the antisera have very low affinity for metabolites and no cross reactivity with other drugs. 27 Henderson mod- ified the rad io immunoassay tech- n i q u e and was able to d e t e c t c~-methyl fentanyl in powder samples at levels of 1 ~g/g and between l and 10 ng/mL in the body fluids of China White overdose victims.lO, 2s Hender- son also reported finding concentrations of China White in body fluids of overdose victims at or below the 1-ng level. 10 A commercial radioimmunoassay for fentanyl is available, but it is for veterinary use only. GC- MS techniques have been described and used for confirmation of fentanyl and various analogues. 15,18,25

CONCLUSION We report the first outbreak of a

narcot ic overdose in the eastern U n i t e d Sta tes i n v o l v i n g Ch ina White. An epidemic of China White overdoses clearly occurred in the last calendar quarter of 1988 in Allegheny County, Pennsylvania. There were no significant clinical differences between the China White overdose victims and other unintentional narcotic overdose victims treated at our facility.

Death may occur quickly after IV injection of China White due to its extreme potency. Naloxone favorably reverses its narcotic effects. Because China White is difficult to detect by routine toxicologic screens, specific drug testing is recommended in overdose cases suspicious for fentanyl analogues. Our experience illustrates the importance of emergency medicine in early detection of epidemics.

The authors acknowledge the following persons for their support: John Alvin, PhD, Associate Professor, Department of Pharmacology, University of Pittsburgh, Director, Pharmakon Laboratories, Pitts- burgh; Jonathan Hibbs, MD, Bureau of Ep- idemiology, Department of Health, Har- risburg, Pennsylvania; Joshua Perper, MD, Allegheny County Coroner, Pittsburgh; Charles L Winek, PhD, Director, Depart- ment of Laboratories, Allegheny County Coroner's Office, Pittsburgh; and Susan Schober, PhD, Medical Epidemiologist, National Institute of Drug Abuse, Rock- ville, Maryland.

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China white epidemic: An eastern united states emergency department experience

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