title: A descriptive study of an outbreak of clenbuterol-containing heroin.
abstract: OBJECTIVE
  Illicit drugs may be adulterated with substances other than the sought-after substance of abuse. Although the true incidence and clinical effects of this practice are unknown, geographically disparate outbreaks of clinically significant adulteration continue to occur. We report on a recent outbreak of clenbuterol-adulterated heroin occurring along the East Coast of the United States.
  
  
  METHODS
  After identification of index cases, 5 US poison centers collaborated with state and territorial health departments to alert the public of clenbuterol-tainted heroin. A case definition of clenbuterol-tainted heroin toxicity was promulgated, and emergency departments (EDs) were asked to contact poison centers when cases were identified.
  
  
  RESULTS
  We identified 34 probable or confirmed ED presentations in 5 states during a 6-month period. Thirteen of the 34 patients met the criteria for "confirmed" exposures. Clenbuterol was identified in the blood and or urine of 12 of these 13 patients. Clenbuterol concentrations ranged from 2.4 to 26 ng/mL in the blood and 9.4 to 12,526 ng/mL in the urine. Symptoms included nausea, chest pain, palpitations, dyspnea, and tremor. Physical findings included significant tachycardia, hypotension, and laboratory evidence of hyperglycemia, hypokalemia, and increased lactate levels. Six patients demonstrated biochemical evidence of myocardial injury. Ten patients received beta-adrenergic antagonists without adverse effect.
  
  
  CONCLUSIONS
  The adulteration of heroin by clenbuterol was associated with sympathomimetic effects, metabolic acidosis, and myocardial injury. The report also highlights how collaborative efforts among poison centers using the Centers for Disease Control and Prevention's Epi-X system rapidly identified a disease outbreak.
authors.affiliation: New York City Poison Center, New York University School of Medicine, New York, NY, USA.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.forename: Barbara M
authors.initials: BM
authors.lastname: Kirrane
authors.forename: Steven M
authors.initials: SM
authors.lastname: Marcus
mesh_terms: D000293:Adolescent; D000318:Adrenergic beta-Agonists / Q000097:blood / Q000506:poisoning* / Q000652:urine; D000328:Adult; D009202:Cardiomyopathies / Q000139:chemically induced; D002976:Clenbuterol / Q000097:blood / Q000506:poisoning* / Q000652:urine; D004196:Disease Outbreaks; D004340:Drug Contamination / Q000706:statistics & numerical data*; D005260:Female; D006556:Heroin Dependence; D006801:Humans; D008297:Male; D008873:Mid-Atlantic Region / Q000453:epidemiology; D008875:Middle Aged; D011039:Poison Control Centers / Q000706:statistics & numerical data*
chemical_list: D000318:Adrenergic beta-Agonists; D002976:Clenbuterol