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.