![]() ![]() The patients purchased the drug from a friend a few days earlier. On March 28, 2016, two patients were evaluated at the Contra Costa Regional Medical Center emergency department (ED) in Contra Costa County, California, for nausea, vomiting, central nervous system depression, and respiratory depression, 30 minutes after ingesting what appeared to be Norco, a prescription opioid pain medication that contains acetaminophen and hydrocodone. Collaborative efforts among public health, medical, and law enforcement officials are essential for a rapid and effective response. Health care providers should be aware of this and other concurrent outbreaks and notify local poison centers and health departments of suspected cases. The distribution of counterfeit tablets represents a major public health threat given the potentially lethal nature of the tablets. What are the implications for public health practice? Promethazine likely potentiates the opioid effect. Prior to this outbreak in the Bay Area, counterfeit or adulterated fentanyl-containing products had not previously been reported to include promethazine as an additive. Whereas Norco typically contains acetaminophen and hydrocodone, these counterfeit tablets predominantly contained fentanyl and promethazine. Fentanyl, a potent opioid receptor agonist, can cause significant central nervous system and respiratory depression and has been implicated in multiple outbreaks in the past decade.ĭuring March 25–April 5, 2016, seven cases of counterfeit Norco ingestion and intoxication were identified by the San Francisco Division of the California Poison Control System. The United States is experiencing an opioid epidemic with synthetic opioids such as fentanyl responsible for the highest rise in death rates in recent years. ![]()
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