Public health alert: Life-Threatening Risk -- Cocaine Laced with Levamisole

Alcohol and other drug programs across California should be on the look out for a dangerous substance-levamisole-that is showing up with increasing frequency in illicit cocaine powder and crack cocaine, most recently in San Francisco and Los Angeles.

Levamisole-a veterinary anti-parasitic drug-severely reduces the number of white blood cells in humans leading to an acute condition called agranulocytosis that should be treated at a hospital. Ingesting cocaine mixed with levamisole suppresses immune function and the body's ability to fight off even minor infections. People who snort, smoke, or inject crack or powder cocaine contaminated by levamisole can experience overwhelming, rapidly-developing, life threatening infections. Agranulocytosis manifests the following symptoms:

- high fever, chills, or weakness
- swollen glands
- painful sores (mouth and anal)
- infections that won't go away or get worse very fast, including sore throat or mouth sores; skin infections; abscesses; thrush (white coating of the mouth, tongue or throat); pneumonia (fever, cough, shortness of breath)

The Substance Abuse and Mental Health Services Administration (SAMHSA) began alerting medical professionals, substance abuse treatment centers, and other public health authorities in September about the risks.

Used in veterinary medicine, levamisole is currently approved for use in cattle, sheep and swine as an anti-parasitic agent. Formerly used in human medicine for treating autoimmune diseases and cancer, it is no longer approved for human use.

SAMHSA is working with the U.S. Centers for Disease Control and Prevention (CDC), the Drug Enforcement Administration (DEA), the Food and Drug Administration, the Office of National Drug Control Policy, and other federal and international organizations, as well as state agencies to monitor the levamisole issue. CDC will publish a case report analysis in the Morbidity and Mortality Weekly Report and will work with state health departments to systematically collect information on cocaine-associated agranulocytosis cases. Information from this effort will be used to guide treatment and prevention initiatives to address the public health concern.

According to the DEA and state testing laboratories, the percentage of cocaine specimens containing levamisole has increased steadily since 2002, with levamisole now found in more than 70 percent of the illicit cocaine analyzed last July. In addition, a recent analysis in Seattle, Washington, found that almost 80 percent of individuals who test positive for cocaine also test positive for levamisole.

ADP is asking all providers to report suspected and confirmed cases of agranulocytosis associated with cocaine abuse to their local health departments. Cases can also be reported to local Poison Control Centers (1-800-222-1222), which may assist in clinical management and additional reporting. For further medical/technical information, contact Nicholas Reuter, SAMHSA Nicholas.reuter@samhsa.hhs.gov.

**We at Cliffside Malibu, a drug rehab facility in Malibu, California, just received this notice from the ADP director and we felt that it posed such an extraordinary risk that we wanted to disseminate it immediately to the general public. We have published this notice in its entirety.

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