Counterfeit Xanax Contained Toxic Amounts of Opioid Fentanyl Interview with:
Ann M. Arens, MD
California Poison Control Center
San Francisco, CA 94110 What is the background for this study? What are the main findings?

Response: Prescription opioid abuse is a significant public health threat that has garnered the attention of health care providers throughout medicine. With efforts to curb the number of prescriptions for opioid pain medications, users may begin to purchase prescription medications from illegal sources.

Our study reports a series of patients in the San Francisco Bay Area who were exposed to counterfeit alprazolam (Xanax®) tablets found to contain large amounts of fentanyl, an opioid 100 times more potent than morphine, and in some cases etizolam, a benzodiazepine. The California Poison Control System – San Francisco division identified eight patients with unexpected serious health effects after exposure to the tablets including respiratory depression requiring mechanical ventilation, pulmonary edema, cardiac arrest, and one fatality. Patients reportedly purchased the tablets from drug dealers, and were unaware of their true contents. In one case, a 7 month-old infant accidentally ingested a counterfeit tablet dropped on the floor by a family member. What should readers take away from your report?

Response: While adulteration of heroin with large amounts of fentanyl has been previously reported, the manufacture and distribution of counterfeit pills containing potentially lethal medications is novel in the United States. This case series highlights the potential for a variety of different pharmaceuticals including non-FDA approved pharmaceuticals to be compounded into counterfeit tablets. Following the identification of this series of patients, counterfeit pharmaceuticals were implicated in several deaths of users in other parts of the United Sates.

Readers should be aware of the dangerous and potentially fatal consequences of exposures involving counterfeit medications. In this series, it is suspected that the perpetrators obtained a pill press by illicit means, and the pills created were nearly identical to real prescription alprazolam tablets. Health care providers should be aware of the potential for unexpected serious toxicity related to counterfeit prescription medications, and work closely with poison control centers, the public health infrastructure, and law enforcement to identify and respond to future outbreaks. What recommendations do you have for future research as a result of this study?

Response: Future research should focus on our ability to optimize appropriate surveillance of suspected exposures and our ability to respond in a coordinated fashion. In addition, little is known about the pharmacokinetics of oral fentanyl exposures or optimal naloxone, dosing and administration routes. Thank you for your contribution to the community.


Arens AM, van Wijk XR, Vo KT, Lynch KL, Wu AB, Smollin CG. Adverse Effects From Counterfeit Alprazolam Tablets. JAMA Intern Med. Published online August 08, 2016. doi:10.1001/jamainternmed.2016.4306.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on August 10, 2016 by Marie Benz MD FAAD