Correspondence

Acute Dystonic Reactions to “Street Xanax”

N Engl J Med 2002; 346:1753May 30, 2002

Article

To the Editor:

Acute dystonic reactions have been reported after the ingestion of numerous medications that alter dopaminergic tone in the basal ganglia or antagonize dopamine D2 receptors. At the emergency department of an urban community hospital, we have recently treated six patients presenting with acute dystonia. All patients reported the ingestion of what street sellers had assured them was Xanax (alprazolam). In five of these patients, the ingested drug was actually proved to be haloperidol.

Three teenage boys presented to the emergency department with symptoms consistent with torticollis, oculogyric crisis, and opisthotonos. Each reported the ingestion of “one or two” tablets of “Xanax” 12 to 16 hours before admission. Two of these patients specifically described blue tablets bearing the inscription “GG126,” and the third supplied an unused pill with the same markings. The drugs were identified as 10-mg tablets of the Geneva brand of generic haloperidol. All three patients had rapid resolution of their symptoms after the administration of intravenous diphenhydramine.

We also treated three additional patients with more subtle clinical presentations. A child presented with intermittent mouth puckering and sedation, followed by torticollis and involuntary tongue movements. A 32-year-old woman presented with mild, intermittent bruxism. And a teenage boy presented with a feeling of weakness and spasm in his back and a sensation of swelling in his tongue, followed by dysarthria, buccolingual spasm, and diaphoresis. In all three of these patients, the symptoms resolved rapidly after the administration of intravenous diphenhydramine. In the first patient, a serum assay that used gas chromatography–mass spectroscopy identified haloperidol and detected no alprazolam. The second patient's unused pills were identified as haloperidol. The third patient reported that he had ingested a pill that was identical in appearance to the Geneva brand of generic haloperidol, although the person who supplied the drug to him insisted that the pill in question was generic alprazolam.

The substitution of haloperidol for the benzodiazepine diazepam (“street Valium”) was common on the street in the 1970s and 1980s. Both these pills were blue and had a central hole.1,2 Physicians today should be aware that haloperidol is being substituted for alprazolam (“street Xanax”), even though the pills have different shapes and colors.

Robert G. Hendrickson, M.D.
Anthony P. Morocco, M.D.
Michael I. Greenberg, M.D., Ph.D.
Medical College of Pennsylvania–Hahnemann University, Philadelphia, PA 19129
rob.hendrickson@drexel.edu

2 References

1. 1

   Demetropoulos S, Schauben JL. Acute dystonic reactions from “street Valium.“ J Emerg Med 1987;5:293-297
   CrossRef | Medline

2. 2

   Bryant SG. Street drug misrepresentation. JAMA 1980;244:2160-2160
   CrossRef | Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Derrick D. Lung, Roy R. Gerona, Alan H.B. Wu, Craig G. Smollin. (2011) Confirmed Glyburide Poisoning from Ingestion of “Street Valium”. The Journal of Emergency Medicine
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2. 2

   Joseph L. D'Orazio, John A. Curtis. (2011) Overdose of Propafenone Surreptitiously Sold as “Percocet”. The Journal of Emergency Medicine 41:2, 172-175
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3. 3

   John C.M. Brust. 2007. Barbituriques et autres hypnotiques et sédatifs. , 245-272.
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4. 4

   Robert L Rodnitzky. (2005) Drug-induced movement disorders in children and adolescents. Expert Opinion on Drug Safety 4:1, 91-102
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