Adulterated cocaine and lessons learned from the Jake walk blues.

The Substance Abuse and Mental Health Services Administration has posted a warning on their website and sent fliers to healthcare providers throughout the USA: Nationwide Pubic Health Alert Issued Concerning LifeThreatening Risk Posed by Cocaine Laced with Veterinary Anti-Parasite Drug. Similar reports have come out of Alberta, Canada and from Canadian public health advocacy groups—Alberta, Canada was one of the first locations where levamisoleadulterated cocaine was reported and first associated with severe health effects including death. Since consistently turning up in cocaine seizures in 2002, the amount of cocaine adulterated with levamisole has been steadily increasing. According to Drug Enforcement Agency (DEA) data levamisole was found in over 70% of all illicit cocaine as of July 2009 [1]. The amount of levamisole encountered in cocaine typically ranges from 6 to 9% of the drug by weight and according to a recent study from Seattle, Washington nearly 80% of individuals who tested positive for cocaine also tested positive for levamisole. Although it has been used historically as an immune modulator for diseases such as rheumatoid arthritis and as an adjuvant agent in anticancer therapy, levamisole is no longer approved for human use. It remains readily available, however, in pet stores throughout the USA and in Central and South America for sale as a deworming or anti-parasitic agent. A recent celebrity death brought attention to this issue. Adam Goldstein, aka DJ AM, a celebrated musician and pop DJ known for his ability to mix and blend songs together into what is referred to as ‘mashups’ was found dead in his apartment on August 28, 2009 of an apparent drug overdose. Although DJ AM was found to have oxycodone, cocaine, hydrocodone, alprazolam, and lorazepam in his system, toxicology results also included the chemical levamisole, presumed to have been present as a cocaine adulterant. Goldstein’s death, while most likely due to the combined effects of the cocaine, opioids, and benzodiazepines has created public awareness of the cocaine epidemic and drug adulteration [2]. The Annals of Internal Medicine published a report describing five cases of agranulocytosis associated with cocaine adulterated with levamisole [3] and in Alberta, where some of the first reports of levamisole appeared, over 20 confirmed or probable cases of agranulocytosis, including at least two deaths, have been reported due to adulterated cocaine as of this past August. While levamisole may cause reversible agranulocytosis in up to 20% of individuals exposed to it, the true threat to the public health is unclear. What also remains unclear is why levamisole in particular is being used as a cocaine adulterant. Reviewing similar epidemics from history may provide some insight and understanding into this current epidemic and drug adulteration or contamination in general. Jamaican ginger extract, also known as Jake, was a patent medicine with a high ethanol content that was available in the nineteenth and early twentieth century. Although not T. J. Wiegand (*) Northern New England Poison Center, Maine Medical Center, Portland, ME, USA e-mail: timothywiegand@yahoo.com