Clinical Update

Unpredictability of Counterfeit Drugs

Novel Psychoactive Substances (NPS) are developed to bypass controlled drug legislation and evade detection by traditional drug testing methods. In many cases they are labelled as “research chemicals” and/or “not for human use.” A new trend is to package NPS as counterfeit versions of common prescription drugs in an effort to make the unauthorized possession of these substances seem less suspicious. The most observed counterfeit exhibits seized by law enforcement are mimics of common prescription opiates, benzodiazepines, and stimulants. These pose a particular danger for pain management or behavioral health patients if ingested, as the tablets rarely, if ever, contain the drug they are intended to mimic. In addition to these patient groups, other individuals who are not under active medical care may purchase counterfeit drugs over the internet for non-medical use. The information provided below is a limited sampling of counterfeit drugs which have been seized by law enforcement.

Counterfeit Opioids
In most cases, counterfeit opioids are made to resemble oxycodone, hydrocodone/acetaminophen, or oxycodone/acetaminophen dosage forms and rarely, if ever, contain the mimicked drug. Currently, the most commonly observed counterfeits are counterfeit oxycodone 30mg tablets.

Counterfeit oxycodone containing fentanyl1

Counterfeit hydrocodone/acetaminophen containing fentanyl and promethazine2

These counterfeit opioids play a role in overdose deaths, with the most commonly observed drug identified in these tablets being illicitly manufactured fentanyl (IMF). IMF is analytically similar to prescription fentanyl, but is typically created utilizing different methods, which introduces opportunities for contamination or adulteration. Additionally, fentanyl analogs (fentalogs) have been introduced into the illicit drug supply over the last decade, which may be more or less potent than IMF. While IMF and fentalogs have been most prevalent, newer classes of designer opioids are emerging in the global illicit drug supply. One such class is the nitazenes, of which isotonitazene is the most detected.

Counterfeit Benzodiazepines
The most commonly encountered counterfeit benzodiazepine is alprazolam, with the contents of the tablet varying significantly. In most cases they contain a designer benzodiazepine(s), such as flualprazolam1,3 but, in select cases, they have been found to contain opioids such as IMF.4 For the opioid-naïve individual, this poses a significant risk for overdose.