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Drug that killed Prince – street drug not as labeled

July 28, 2016

Short Attention Span Summary

An important case series from California found fentanyl-adulterated tablets sold on the street this year in March as hydrocodone/acetaminophen.  Tablets had from 600-6900 micrograms of fentanyl per tablet but looked just like regular hydrocodone/acetaminophen tablets.  18 people were included in this series and had serious effects.  At the time of writing, 56 cases had already been reported to the county and there were 15 deaths.  Be on the lookout for opiate toxicity.  These patients required higher than normal doses of naloxone and prolonged infusion of naloxone.  Fentanyl is what caused the death of pop singer Prince.  See this CNN report.



Acad Emerg Med. 2016 Jun 20. doi: 10.1111/acem.13034. [Epub ahead of print]

Fatal Fentanyl: One Pill Can Kill.

Sutter ME1,2, Gerona R3, Davis MT1,2, Roche BM1,2, Colby DK1,2, Chenoweth JA1,2, Adams AJ4, Owen KP1,2, Ford JB1,2, Black H2,5, Albertson TE2,5, Heard KJ.

Author information:

1University of California, Davis, Division of Medical Toxicology, Department of Emergency Medicine, PSSB 2100, Sacramento, CA 95817.

2Veterans Affairs Norther California, Mather, Mather, CA, 95655.

3University of California San Francisco, Division of Laboratory Medicine, 1001 Potrero Avenue, NH 2M16, San Francisco, CA, 94110.

4University of California, San Francisco School of Medicine, San Francisco, CA, 94143.

5University of California, Davis, Division of Pulmonary and Critical Care, Patient Services Support Building, 3400, Sacramento, CA, 95817.




The current national opioid epidemic is a public health emergency. We have identified an outbreak of exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on the street as hydrocodone/acetaminophen.


Over an 8-day period in late March 2016, 18 patients presented to our institution with exaggerated opioid toxicity. The patients provided a similar history: ingesting their “normal dose” of hydrocodone/acetaminophen tablets but with more pronounced symptoms. Toxicology testing and analysis was performed on serum, urine, and surrendered pills.


One of the 18 patients died in hospital. Five patients underwent cardiopulmonary resuscitation; 1 required extracorporeal life support; 3 required intubation; and 2 received bag-valve mask ventilation. One patient had recurrence of toxicity after 8 hours after naloxone discontinuation. Seventeen of 18 patients required boluses of naloxone, and 4 required prolonged naloxone infusions (26-39 hours). All 18 patients tested positive for fentanyl in the serum. Quantitative assays conducted in 13 of the sera revealed fentanyl concentrations of 7.9 to 162 ng/mL (mean, 52.9 ng/mL). Pill analysis revealed fentanyl amounts of 600-6900 μg/pill. The pills are virtually indistinguishable from authentic hydrocodone/acetaminophen tablets and are similar in weight. To date, our county has reported 56 cases of fentanyl opioid toxicity, with 15 fatalities. In our institution, the outbreak has stressed the capabilities and resources of the emergency department and intensive care units.


A serious outbreak of exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on the street as hydrocodone/acetaminophen is underway in California. These patients required higher dosing and prolonged infusions of naloxone. Additionally, observation periods off naloxone were extended due to delayed, recurrent toxicity. The outbreak has serious ramifications for public health and safety, law enforcement, and health-care facilities and resources. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27322591 [PubMed – as supplied by publisher]

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