Background: Globally, an alarming number of pharmaceutically active compounds are now routinely
added to the street drugs of abuse, cocaine and heroin. In some cases, seventeen (17) or more potentially
toxic compounds are found in a single street purchased bag or block of cocaine or heroin. Pharmacologically
active compounds, impurities, or breakdown products from drug manufacturing and industrial
chemicals (collectively referred to as toxic adulterants) are now found in street drugs. They include, but are
not limited to: antipsychotics, antidepressants, anxiolytics, antihistamines, anthelmintics, anesthetics, antiinflammatorys,
antipyretics, analgesics, antispasmodics, antiarrhythmics, antimalarials, veterinary medications,
bronchodilators, expectorants, sedatives, muscle relaxers, natural/synthetic hallucinogens, decongestants,
new psychoactive substances (NPS), industrial compounds, fungicides, and impurities in the manufacturing
process. All can be found within a single street purchase of heroin or cocaine. Routine clinical or
workplace drug testing will not detect all these toxic adulterants. Only specialty forensic tests, specifically
ordered, will detect them. The synergistic effect on the human body of such an unprecedented combination
of pharmacologically active compounds is unknown and potentially deadly. This is especially seen in daily
substance users who are exposed to these combinations multiple times a day over an extended period of
time. Individuals with substance use disorders (SUDs) have several co-occurring health problems that make
them more susceptible to COVID-19, including compromised immune, pulmonary, cardiovascular, and respiratory
systems. These problems are high-risk factors for the acquisition of COVID-19 infection and more
serious complications from the virus, including hospitalization and death.
Objective: The study aims to bring to the attention of public health officials, addiction medicine specialists,
treatment officials, therapists, and the general public the alarming increase of dangerous toxic
adulterants being added to street drugs and their potentially lethal synergistic effects. Also, it aims to
provide insights into how these new formulations can have serious pathophysiological effects on individuals
with Substance Abuse Disorders (SUDs) during the COVID-19 pandemic.
Methods: The literature on street drug cutting agents, toxic adulterants, NPS, manufacturing byproducts,
and other industrial compounds will be reviewed. Also, a review of the literature of pathophysiological
effects, especially on SUD patients, in light of the COVID-19 pandemic will be presented. This
is combined with international and USA studies that were carried out by the Colombo Plan that identified
these new combinations of toxic adulterants in street drugs, using state-of-the-art field and forensic
laboratory detection technologies.
Results: The majority of street drugs, in some cases more than ninety-five percent, now have multiple
toxic adulterants. It is rare that a street purchase of cocaine or heroin does not contain multiple toxic
adulterants, cutting agents, NPS, manufacturing byproducts, or industrial chemicals.
Conclusion: This dangerous new composition in world street drug supply is unprecedented and may
be the undetected cause of many psychostimulant and opioid overdose deaths, as many toxic adulterants
are not routinely tested in post-mortem or street drug seizure cases. In addition, several of these
toxic adulterants create a catastrophic drop in white blood cells, causing neutropenia and making the
substance users susceptible to a wide range of opportunistic infections, including COVID-19. This
profound change in the world street drug supply has catastrophic implications for individuals with
SUDs and our health care system, especially in the era of the COVID-19 pandemic.