Strychnine as an Emerging Adulterant in the Illicit Fentanyl Drug Supply

<h2>Abstract</h2><h3>Introduction</h3> <b>:</b> Awareness of strychnine as an emerging adulterant is extremely important given its unique clinical findings and morbid clinical sequelae. Strychnine was historically utilized as a tonic, laxative, rodenticide and adulterant in cocaine, heroin and methamphetamine. This report describes a of cluster patients with acute opioid overdose presenting to an inner city medical center with strychnine on serum testing. <h3>Methods</h3> <b>:</b> The data for this case series is from the ToxIC Fentalog Study, a 2020–2025 study of patients aged ≥18 years evaluated in ten regionally distinct emergency departments (ED) after a suspected opioid overdose. Comprehensive toxicology testing was performed on residual serum samples. <h3>Results</h3> <b>:</b> Of the 111 cases submitted by all participating sites in January 2023, four cases from the Denver, Colorado site revealed strychnine on comprehensive toxicology testing. The total cases from all sites in January of 2023 was 921. <h3>Conclusion</h3> <b>:</b> The presence of strychnine in biological samples of patients using opioids in this report, indicates a possible reappearance in its use as an adulterant, warranting further investigation and public preventative health vigilance. Knowledge of local illicit adulterants is crucial for public healthcare providers, as it enables them to consider anticipated clinical course and life-saving interventions.