New drugs and drug use trends often burst on the scene rapidly. NIDA’S Community Epidemiology Work Group (CEWG), which functioned through 2014, was a network of researchers in major metropolitan areas and some states across the United States that reported data on emerging trends and patters of drug use. NIDA’s National Drug Early Warning System (NDEWS) replaces the CEWG and reports on emerging trends and patterns of drug use in many of the same metropolitan areas and states as the CEWG, but also reports data from other areas of the nation, as problems arise. On this page we will provide periodic updates based on NDEWS reports and other reliable information, as well as links for where to go for more information.
FDA Investigates Multistate Outbreak of Salmonella Infections Possibly Linked to Kratom Products
Posted on February 21, 2018
The U.S. Food and Drug Administration (FDA) along with the Centers for Disease Control and Prevention (CDC) and state and local officials are investigating a multistate outbreak of Salmonella infections linked to products reportedly containing kratom. The CDC reports that 28 people ages 6 to 67 years in 20 states are infected, with 11 people who have been hospitalized. No deaths have been reported.
Salmonella bacteria cause the foodborne illness salmonellosis. Most people infected with Salmonella develop diarrhea, fever, and abdominal cramps. The illness usually lasts 4 to 7 days, and most people recover without treatment. However, in the current outbreak, an unusually high rate of cases have been hospitalized for their illness.
Kratom is a tropical deciduous tree native to Southeast Asia, with leaves that contain mitragynine, a psychoactive opioid. Kratom is consumed for mood-lifting effects, pain relief, and as an aphrodisiac. It is marketed in many forms, including leaves, pills, capsules, powder, and tea.
The FDA, CDC, and state and local officials are working to identify specific brand names or suppliers of products and will share more information as it becomes available. If you have questions about food safety, call 1-888-SAFEFOOD or consult the fda.gov website at http://www.fda.gov.
Posted on February 20, 2018
Betel quid usually includes a combination of the Areca nut (from the Areca catechu tree) and slaked lime (calcium hydroxide obtained by heating or harvesting sea shells or quarrying limestone) wrapped in a betel leaf. In some countries, when tobacco is added, the combination is called gutka; without tobacco, it’s called pan masala. Spices are also added in some cases for flavoring. It is the fourth most commonly self-administered psychoactive substance in the world after caffeine, alcohol, and tobacco and the most commonly used in Asia. It is estimated that more than 600 million people use betel quid worldwide.
The areca nut contains arecoline, muscarine, and pilocarpine, which can have stimulant and relaxation effects. The International Agency for Cancer Research has classified betel quid as being cancerous with or without tobacco. Other health effects include risk of having a low-birth weight baby if consumed while pregnant.
Although betel quid use disorder (BUD) is not formally identified as an addictive behavior, studies are looking at chronic use leading to myriad of health problems including oral health cancers. Read more in the Journal of the American Medical Association.
Iowa officials warn public about counterfeit oxycodone
Posted on July 18, 2017
Health and safety agencies in Iowa have issued an advisory to warn Iowans of counterfeit pain pills containing dangerous synthetic opioids. The Iowa Division of Criminal Investigation’s (DCI) laboratory analyzed pills made to resemble the prescription pain reliever oxycodone, finding them to contain more powerful and illicit synthetic opioids fentanyl and U-47700, putting users at higher risk of opioid overdose. Iowans with questions about synthetic opioids and emergency opioid reversal procedures can contact the Iowa Poison Control Center at 800-222-1222 or http://www.iowapoison.org.
More information is available from the Iowa Department of Public Health, Department of Public Safety, Poison Control Center and Office of Drug Control policy.
In Georgia: Sudden surge in overdoses related to street drugs sold as yellow opioid pain medication
Posted on June 29, 2017
The Georgia Department of Public Health has issued an alert about a dangerous, potentially lethal substance contained in street drugs surfacing in central and South Georgia. Patients reportedly purchased yellow pills alleged to be Percocet, an opioid pain medication. The substance has not yet been identified but it is extremely potent and has required massive doses of naloxone (Narcan) to counteract its effects. Dozens of patients have been hospitalized and there are reports of deaths that may be associated with the drugs. The overdoses have been reported over a 48-hour period in Centerville, Perry, Macon-Warner Robins, and Albany, but the drugs may also be sold on the street in other areas of the state. Testing is being done to identify the pills and the ingredients.
Health officials urge citizens to call 9-1-1 immediately if you have taken the pills or if you think someone has used the drug. Read the warning from the Georgia Department of Public Health.
New York City issues Health Advisory about overdoses from fentanyl added to cocaine
Posted on June 06, 2017
The New York City Health Department is warning citizens who use cocaine------even occasional users--- that the potent opioid fentanyl has been implicated in a growing number of cocaine-involved overdose deaths. In the past, fentanyl has been most commonly present in heroin-involved deaths, but fentanyl is increasingly being identified in overdose deaths involving other drugs. In 2016, 37 percent of overdose deaths involved cocaine and fentanyl without heroin, up from 11 percent in 2015.
Last year more than 1,300 New Yorkers died of a drug overdose, and nearly half (44 percent) of those deaths involved fentanyl In 2016. People who use cocaine occasionally and who are not used to taking opioids (i.e., have low tolerance) are considered to be at particularly high risk of overdose death. The NYPD Police laboratory testing data has confirmed the presence of fentanyl in with cocaine products as well as in counterfeit prescription sedatives (e.g., Xanax) and pain relievers purchased on the street, as well as in heroin, ketamine, and methamphetamine. Read the advisory from the New York City Health Department.
Gulf Coast HIDTA and the Georgia Bureau of Investigation Issue Synthetic Opioids Alert
Updated on May 16, 2017
There have been two new alerts issued related to synthetic opioids. The Gulf Coast High Intensity Drug Trafficking Area has issued an alert for a substance with the street name “Grey Death.” The substance appears similar to concrete mixing powder and varies in texture, which ranges from a chunky rock-like material to a fine powder. It is not a single drug, but typically contains several potent opioids, including whatever a drug dealer has on hand in varying proportions. It has a potency much higher than heroin and is reportedly administered via injection, ingestion, insufflation, and smoking. The analysis of each grey death sample collected in the gulf coast region so far revealed the presence of three opioids: U-47700, heroin, and fentanyl; though the amount of each drug within grey death varied from sample to sample. (See Gulf Coast HIDTA Emerging Trend Bulletin: Potent new opioid/opiate compound known as “Grey Death" (PDF, 164KB))
In addition, the Georgia Bureau of Investigation (GBI) is issuing a public safety alert regarding illegal synthetic opioids that have caused more deaths in the first four months of the year than all of last year. In 2017, 17 deaths have been caused by the opioids U-47700 and/or furanyl fentanyl. U-47700 and furanyl fentanyl are both Schedule I drugs and used in the same manner as heroin. The drugs are distributed in either powder or tablet form. Furanyl fentanyl is a fentanyl analog and has been sold as a “designer” drug. (See Press release - GBI Issues Synthetic Opioids Alert)
DEA Temporarily Bans Synthetic Opioid U-47700 ("Pink"), Linked to Nearly 50 Deaths
Posted on November 15, 2016
The U.S. Drug Enforcement Administration (DEA) has temporarily classified U-47700, nicknamed "Pink," a schedule I drug, which means it has a high potential for abuse and no approved medical use. Since last year, this dangerous synthetic opioid has been linked with at least 46 confirmed deaths—31 in New York and 10 in North Carolina. Law enforcement agencies have seized the drug in powder form and as counterfeit tablets that mimic pharmaceutical opioids. Earlier this year, law enforcement in Ohio seized 500 pills resembling a manufacturer's oxycodone immediate-release tablets. However, laboratory analysis confirmed that they contained Pink.
Pink belongs to a family of deadly synthetic opioids far more potent than morphine. It is usually imported to the United States, mainly from illicit labs in China. The drug can be toxic—even in small doses. It is typically taken by itself or combined with other drugs such as heroin and fentanyl.
Pink's name comes from the pinkish hue of the powder. It has been available for purchase over the internet and is misleadingly marketed as a "research chemical." Labels that state "not for human consumption" or "for research purposes only" are likely used in an effort to avoid legal restriction.
For more information, see the DEA news release on its scheduling of Pink.
DEA Issues Nationwide Warning on Carfentanil
Posted on September 23, 2016
The Drug Enforcement Administration (DEA) has issued a nationwide warning to the public and law enforcement about human use of the potent animal opioid sedative carfentanil, one of the strongest opioids available. Carfentanil, a fentanyl analog with a potency approximately 10,000 times that of morphine, has been linked to a significant number of overdose deaths nationwide. It is used as a sedative or in general anesthesia for large animals, including elephants, but is not approved for use in humans. https://www.dea.gov/divisions/hq/2016/hq092216.shtml
In August 2016, NIDA posted carfentanil warnings by authorities in Ohio and Florida. As with many fentanyl analogs, it is likely that carfentanil is being added to mixtures of heroin and other street drugs, but it is not known how often carfentanil is being added to or substituted for other opioids in street drugs, underscoring its danger. More information can be seen under the August 23rd, 2016 posting below.
Fentanyl-Related Overdoses Prompt Alert from CDC
Posted on August 26, 2016
The Centers for Disease Control and Prevention (CDC) has released an alert to public health departments, health care professionals, first responders, and others through its Health Alert Network about the increase in fentanyl-related overdoses and deaths in many parts of the country. Fentanyl is an extremely potent synthetic opioid—50 times stronger than heroin. Traditionally, fentanyl and analogs such as carfentanil have been mixed with powder heroin. Fentanyl-laced heroin has been linked to a surge of overdoses in Indiana and Ohio in late August, 2016. Fentanyl and related compounds are also being found in counterfeit pills made to look like prescription pain relievers and sedatives (e.g., OxyContin®, Xanax®, Norco®). These counterfeit pills are also the subject of a recent Drug Enforcement Administration alert.
Those who use heroin or prescription drugs laced with fentanyl are at much higher risk of overdose and death. When emergency personnel are able to respond in time, they sometimes need multiple doses of naloxone to reverse fentanyl overdoses.
Alert Issued in Ohio for Human Use of Animal Sedative Carfentanil, with Cases Also Seen in Florida
Posted on August 23, 2016
Officials in the Cincinnati area (Cuyahoga County) have issued an alert about human use of the potent animal opioid sedative carfentanil, one of the strongest opioids on the market, with a potency approximately 10,000 times that of morphine and 100 times that of fentanyl. Carfentanil is an analog of the synthetic opioid analgesic fentanyl and is used as a sedative or in general anesthesia for large animals, including elephants. Side effects of fentanyl analogs in humans are similar to those of fentanyl itself, which include itching, nausea, and potentially serious respiratory depression, which can be life-threatening. Officials in Ohio have noted a high number of overdoses in a short period of time that are suspected to be from carfentanil. NIDA’s National Drug Early Warning System (NDEWS) reports several confirmed deaths in Akron and Columbus, and numerous seizures of the drug throughout Ohio. Read the public health warning from Cuyahoga County, Ohio.
In Florida (Manatee County), there was a recent seizure of carfentanil and a coincidental increase in overdoses and deaths. While more than a dozen fentanyl analogs are commonly flagged in postmortem testing in many states, it is difficult to assess how commonly carfentanil is being abused because states have few reference materials on this drug and few labs are equipped to test for it. The forensic toxicology laboratory researchers at the University of Florida are currently developing a new assay for the identification of carfentanil and will soon start including it in postmortem overdose death testing. Laboratory personnel are being warned about the potency of the drug and are advised to handle it with great care. Naloxone (Narcan®) should be available in the case of accidental exposure.
As with many fentanyl analogs, it is likely that carfentanil is being added to mixtures of heroin and other street drugs. Currently, it is unclear how often carfentanil is being added to or substituted for other opioids in street drugs, underscoring the risks of using illegal drugs.
More information can be found at the National Library of Medicine's Pubchem database – carfentanil.
Fake Prescription Drugs Laced with Fentanyl
Updated on July 28, 2016
The Drug Enforcement Administration reports that the United States is in the midst of a fentanyl crisis, as traffickers are flooding the drug market with counterfeit prescription drugs containing fentanyl, an extremely powerful opioid. These pills, which look like legitimate prescription pain relievers or sedatives, are causing large numbers of fatal overdoses in many parts of the country. Because of its high potency, fentanyl is deadly in very small doses; it is even hazardous for law enforcement, as a lethal dose can be accidentally inhaled or absorbed through skin contact. For more information, see the DEA report - Counterfeit Prescription Pills Containing Fentanyls: A Global Threat (PDF, 3.1MB).
Media reports and official alerts in several U.S. communities (including Sacramento, CA and most recently, Carroll County, MD) are warning of counterfeit pain and anxiety medications that actually contain fentanyl, an extremely powerful, potentially deadly opioid. The pills, which are disguised as common prescription drugs like Norco (hydrocodone), Percocet (oxycodone), and Xanax (alprazolam), are responsible for a growing number of overdose deaths and non-fatal overdoses around the country. Fentanyl is 25 to 50 times stronger than heroin, so even a small amount can cause an overdose. (The Drug Enforcement Administration reports that some of these pills are manufactured in China and smuggled into the U.S. via Mexican drug cartels.)
The fake pills are much cheaper than the real versions. The public should be aware that drugs obtained on the street, even though they look like a real prescription pharmaceutical, may be deadly. It is always unsafe to take a prescription drug unless it comes from your own prescription and is dispensed by a reputable pharmacy.
Synthetic Cannabinoid Advisory in New York City
Posted on July 16, 2016
On July 14, 2016, New York City health officials issued an advisory about an increase in adverse events and emergency department visits related to synthetic cannabinoids (K2/Spice). From July 11 through July 13, 130 people were taken to emergency rooms after suspected ingestion of these drugs, which are sold under many street names including Geeked Up, Smacked, Scooby Snax, Green Giant, Red Giant, M. Bad Guy, Trippy, Ice Dragon, AK-47, and Kick. Synthetic cannabinoids, sometimes called "fake weed" or "herbal incense," are chemically related to THC, the active ingredient in marijuana, but they may be much more powerful. Their effects can be unpredictable and have caused death in some cases. In recent cases in New York City, some users' overdoses resemble opioid overdoses, including lethargy and suppression of breathing; in other cases they have exhibited agitated and violent behavior. The increase in emergency room admissions might indicate that the K2/Spice products circulating in the New York City area might be laced with other toxic chemicals. View Advisory (PDF, 61KB)
For more information on synthetic cannabinoids, see DrugFacts: K2/Spice ("Synthetic Marijuana")
Posted on June 09, 2016
Loperamide is an over-the-counter anti-diarrheal medication that is available in tablet, capsule, or liquid form under brand names such as Imodium, Kaopectate 1-D, Maalox Anti-Diarrheal, and Pepto Diarrhea Control. Because it acts at mu-opioid receptors, which regulate movement in the intestinal tract, it is an opioid medication, and there are reports of its being misused by drug users to stave off opioid withdrawal or possibly even to get high.
Misuse of loperamide has been reported since 2003; it is not common, but it has been reported all over the country. Nationwide, the number of calls to poison centers involving the intentional abuse or misuse of loperamide increased from 87 in 2010 to 190 in 2014 (AAPCC annual reports; http://www.aapcc.org/annual-reports/).
Effects of Loperamide
When taken as recommended, loperamide is designed not to enter the brain; but instructions available on the Internet purport to show how taking loperamide in very high quantities and combining it with other substances may help it produce psychoactive effects that resemble the euphoric effects of other opioids or that mitigate cravings and withdrawal symptoms.
Users’ reports of these effects (if any) are conflicting, but physical consequences of loperamide misuse may be severe, including fainting, abdominal pain, constipation, cardiovascular toxicity (including racing heart and even cardiac arrest), pupil dilation, and kidney failure from urinary retention. Anecdotes and case reports indicated that the potential harm is high.
There were also reports of opioid withdrawal symptoms when users stopped taking loperamide, including severe anxiety, vomiting, and diarrhea.
FDA issued a Safety Alert about Loperamide on 6/7/16: Loperamide (Imodium): Drug Safety Communication - Serious Heart Problems With High Doses From Abuse and Misuse
More information on loperamide is also availabe from the National Drug Early Warning System (NDEWS).
Surge in Fentanyl Overdose Deaths
Posted on July 09, 2015
A surge in overdose deaths related to fentanyl, an opioid 30 to 50 times more potent than heroin, has prompted Baltimore health officials to launch a public health campaign to raise awareness among drug users. Hundreds of people have overdosed on fentanyl across the nation since 2013, often as a result of using heroin that has been laced with the much stronger substance. A quarter of drug overdose deaths in Maryland now involve fentanyl, up from 4 percent in 2013. Opioid overdose can stop a person's respiration, and fentanyl can have this effect very quickly. Other parts of the country such as Detroit and surrounding suburbs are also seeing major surges in fentanyl use and fentanyl-related deaths. In some cases users are unknowingly taking fentanyl in what they believe to be pure heroin, but a growing number of opioid users are deliberately taking fentanyl.
Fentanyl and other opioid overdoses can be reversed if the drug naloxone (Narcan) is administered promptly. In a growing number of states, naloxone is being distributed to injection drug users and other laypersons to use in the event of overdose. For example, Baltimore's Staying Alive Drug Overdose Prevention and Response plan issues naloxone and training in its use.
Increasing Overdoses From Synthetic Cannabinoids (“Spice,” "K2,” etc.) in Several States
Updated on May 08, 2015
Recent surges in hospitalizations and calls to poison control centers linked to consumption of synthetic cannabinoid products--sold under brand names like “Spice,” “K2,” "No More Mr. Nice Guy," and others--are being reported in several southern and northeastern U.S. states and have prompted officials to issue health warnings. After a surge in synthetic cannabinoid exposures and poison center calls in April and May, 2015, the Maryland Poison Center issued an urgent notice about the dangers of these drugs. New York Governor Andrew Cuomo issued an alert after more than 160 patients were hospitalized following synthetic cannabinoid use in under two weeks in mid April, 2015.
Synthetic cannabinoids are chemically related to THC, the active ingredient in marijuana, and are sometimes called “synthetic marijuana” or “legal marijuana,” but actually the effects can be considerably more powerful and more dangerous than marijuana. Users can experience anxiety and agitation, nausea and vomiting, high blood pressure, shaking and seizures, hallucinations and paranoia, and they may act violently.
The Maryland notice lists several chemical compounds in materials from crime labs, including MAB-/AB-CHMINACA, FUBINACA, FUB-PB-22, and XLR11. Besides the brand names above, the New York State health alert lists other common names: Blonde, Summit, Standard, Blaze, Red Dawn X, Citron, Green Giant, Smacked, Wicked X, AK-47; recent reports have involved products with the names Geeked Up, Ninja, Caution, Red Giant, and Keisha Kole.
For more information on synthetic cannabinoids, see DrugFacts: K2/Spice ("Synthetic Marijuana")
Updated on April 06, 2015
Use of a dangerous synthetic cathinone drug called alpha-pyrrolidinopentiophenone (alpha-PVP), popularly known as "Flakka," is surging in Florida and is also being reported in other parts of the country, according to news reports.
Alpha-PVP is chemically similar to other synthetic cathinone drugs popularly called "bath salts," and takes the form of a white or pink, foul-smelling crystal that can be eaten, snorted, injected, or vaporized in an e-cigarette or similar device. Vaporizing, which sends the drug very quickly into the bloodstream, may make it particularly easy to overdose. Like other drugs of this type, alpha-PVP can cause a condition called "excited delirium" that involves hyperstimulation, paranoia, and hallucinations that can lead to violent aggression and self-injury. The drug has been linked to deaths by suicide as well as heart attack. It can also dangerously raise body temperature and lead to kidney damage or kidney failure.
U.S. and British Columbia Issue Alerts on Fentanyl
Updated on March 18, 2015
The U.S. Drug Enforcement Agency (DEA) has issued a nationwide alert about the dangers of fentanyl and related compounds (fentanyl analogues). Fentanyl, an opioid that is 50-100 times more powerful than morphine, is both abused on its own and commonly added to heroin to increase its potency. Fentanyl and fentanyl-laced heroin have been a concern for over a decade and have caused numerous overdose deaths among injection drug users in several U.S. cities.
Heroin is not the only drug that can be laced with fentanyl, however. Officials in Vancouver, British Columbia, Canada, recently issued public warnings about a wide range of fentanyl-laced drugs causing overdose deaths among users. They warn that fentanyl is now being concealed in non-injection drugs, including oxycodone and various "party drugs" in powder or pill form, as well as in marijuana (although no deaths have been confirmed from fentanyl-laced marijuana). Because of this new threat, British Columbia officials are urging all recreational drug users to "know their source."
HIV Outbreak in Indiana Linked to Abuse of Opana
Posted on February 27, 2015
Health officials in Indiana have announced a fast-spreading outbreak of new HIV cases in the southeastern portion of the state that are linked to injection drug abuse of the powerful prescription opioid painkiller Opana. Injecting drugs and sharing injection equipment is one of the main routes of transmitting HIV. Also, a few new HIV cases in southeastern Indiana were transmitted sexually.
Officials advise that people in southeastern Indiana who have engaged in needle sharing or unprotected sex should get tested for HIV and then re-tested after 2-3 months, as HIV may not appear on tests immediately when the virus is contracted. To reduce risk of contracting HIV, avoid injection drug use, sharing or re-using needles, and having unprotected sex or sex with commercial sex workers.
Posted on July 23, 2014
The death of an Ohio high school senior caused by an overdose of powdered caffeine has prompted the FDA to issue a safety advisory about caffeine powders. Bulk bags of pure caffeine powder are readily available online, and these products may be attractive to young people looking for added caffeine stimulation or for help losing weight, but they are extremely dangerous. Just a teaspoon of pure caffeine powder is equivalent to about 25 cups of coffee—a lethal amount. Besides death, severe caffeine overdose can cause fast and erratic heartbeat, seizures, vomiting, diarrhea, and disorientation—symptoms much more extreme than those of drinking too much coffee or tea or consuming too many sodas or energy drinks.
Although caffeine is generally safe at the dosages contained in popular beverages, caffeine powder is so potent that safe amounts cannot be measured with ordinary kitchen measuring tools, making it very easy to overdose on them even when users are aware of their potency. The FDA thus recommends that consumers avoid caffeine powder altogether, and wishes to alert parents to the existence of these products and their hazards.
Posted on November 08, 2013
“Krokodil,” a toxic homemade opioid that has been used as a cheap heroin substitute in poor rural areas of Russia, has recently been featured in news reports alleging its appearance in parts of the United States. The CEWG is investigating, although the DEA has not yet confirmed any krokodil in this country.
Krokodil is a synthetic form of a heroin-like drug called desomorphine that is made by combining codeine tablets with various toxic chemicals including lighter fluid and industrial cleaners. Desomorphine has a similar effect to heroin in the brain, although it is more powerful and has a shorter duration. Krokodil gets its name from the scaly, gray-green dead skin that forms at the site of an injection. The flesh destroyed by krokodil becomes gangrenous, and, in some cases, limb amputation has been necessary to save a user’s life.
We will update this page with any further information on krokodil in the U.S., if cases are found.
Posted on September 30, 2013
“N-bomb” refers to any of three closely related synthetic hallucinogens (25I-NBOMe, 25C-NBOMe, and 25B-NBOMe) that are being sold as legal substitutes for LSD or mescaline. Also called “legal acid,” “smiles,” or “25I,” they are generally found as powders, liquids, soaked into blotter paper (like LSD) or laced on something edible.
These chemicals act on serotonin receptors in the brain, like other hallucinogens, but they are considerably more powerful even than LSD. Extremely small amounts can cause seizures, heart attack or arrested breathing, and death. At least 19 young people are reported to have died after taking 25I- 25C- or 25B-NBOMe between March 2012 and August 2013. People may ingest one of these drugs unknowingly, believing it to be LSD; a young man in one medical case report published in late 2014 experienced severe hallucinations and panic and attempted suicide after such an ingestion.
For more information, see http://www.deadiversion.usdoj.gov/drug_chem_info/nbome.pdf (PDF, 217KB)