Controlling the Spread of Counterfeit Norco

Counterfeit opioids have become a major problem in the US and led to high numbers of deaths. The issue means it's all the more important that physicians educate their patients on the proper use and disposal of prescription opioids.

Synthetic opioids are responsible for the highest increase in opioid related deaths in recent years. Opioid effects on the Central Nervous System lead to respiratory depression that may ultimately result in death even when appropriately managed.

Over the past several months increased cases of counterfeit Norco intoxication have been reported. The counterfeit tablets were found to be comprised of fentanyl and promethazine, instead of the usual composition of acetaminophen and hydrocodone.

As stated in a CDC report, analysis of a tablet obtained from a patient indicated that it contained 3.5 mg of fentanyl, 2.3 mg of promethazine, 39.2 mg of acetaminophen, and trace amounts of cocaine.

Promethazine is known to potentiate the effects of opioids. It is important for healthcare systems to be vigilant in working to control the use of non-prescribed medications. This collaborative effort includes increased awareness and the notification of suspected cases to local poison centers.

Fentanyl has a higher likelihood of abuse as it has approximately 100 times the potency of morphine and the fact that it is highly lipophilic allows for its quick entry into the central nervous system.

If a patient requires larger doses of naloxone for reversal of symptoms then the possibility of intoxication with a counterfeit substance should be considered. Additionally the gravity of the dangers should be emphasized to patients to only consume prescribed medications, acquired from a reputable source through the appropriate channels.

Signs of acute opioid intoxication:

• Depressed mental status

• Decreased respiratory rate

• Decreased tidal volume

• Decreased bowel sounds

• Pin-point pupils

Proper Disposal of Opioids and Other Medications

Medication can be safely disposed of by using a medicine take-back program or through US Drug Enforcement Agency-authorized collectors. If unsure of how to dispose of medications, reach out and consult with your local pharmacy, hospital, or law enforcement agency.

In 2015, approximately 309 tons (or more than 617,000 pounds) of prescription medications where collected by the DEA through such efforts.

To find an authorized collector in your area follow this link.

There are some medications that can be safely disposed of in the trash. Regulators recommend the following process:

• First, mix the medication with an unpalatable substance (but don’t crush the medications in the process).

• Place the mixture in a sealed container such as a plastic bag.

• De-identify any labels on the medication bottles so that they are illegible.

However, it is not advised that medications containing controlled substances such as fentanyl and other opioids be thrown in the trash. These medications may be disposed of by flushing. A list of the recommended medications for disposal by flushing can be seen at this link.

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