Drug Checking Findings: April - June 2026

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The Philadelphia Department of Public Health (PDPH), Division of Substance Use Prevention & Harm Reduction (SUPHR), analyzed 505 drug samples collected between April and June 2026. Most samples consisted of drug litter recovered by SUPHR staff from public spaces. 

Testing was conducted by the Center for Forensic Science Research and Education (CFSRE) using advanced toxicological methods. The results reveal a rapidly evolving drug supply, with increasing variability that may increase the risk of overdose, complicate overdose recognition, response, and withdrawal management. 

Overview

PDPH SUPHR staff collected primarily drug litter samples, including glassine bags, centrifuge tubes, and other paraphernalia, found in public spaces between April and June 2026 (Table 1). Samples were also submitted by two collaborating community-based organizations, collected via an amnesty box in Kensington and syringe-disposal boxes throughout the city. While these samples provide valuable insight into drug use patterns, their origin and handling introduce uncertainty. It is often unclear whether the detected substances were sold together, mixed by the person who consumed the drug, or contaminated after disposal.  

These results are based on a limited sample. They should not be considered representative of the broader Philadelphia drug supply. Still, they can be used for harm reduction education, updating response to overdose, adapting clinical management, and informing early warning about adverse effects of the illicit drug supply. 

Most samples were collected in the Kensington area (Table 2). North/Northeast accounted for 18 percent of the samples, while smaller numbers came from Center City (10 percent), South/Southwest (6 percent), and West (3 percent).  

Sample Collection

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Table 1. Drug Sample Collection Volume, April - June 2026

Month n (%)
April 225 (45)
May 168 (33)
June 112 (22)
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Table 2. Drug Sample Collection Volume by City Section, April - June 2026

Section n (%)
Kensington 320 (63)
Northeast/North 90 (18)
Center City 50 (10)
South/Southwest 30 (6)

The CFSRE laboratory utilizes innovative analytical techniques for drug testing, employing comprehensive non-targeted data acquisition through gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF). The testing panel includes more than 1,100 substances, including a wide range of novel psychoactive substances (NPS) and other relevant compounds. This report includes results from both GC-MS and LC-QTOF analysis. 

The quarterly analysis period is defined by the date on which SUPHR staff collected the samples. Initial classification of drug litter samples is determined by the staff submitting the sample, based on the visual characteristics of the drug product, the packaging type, and/or the drug associated with the paraphernalia at the time of collection. Following laboratory analysis, samples are reclassified according to the primary substance identified. 

Laboratory Analysis

Samples with Primary Substance Heroin or Fentanyl (n=227) 

Fentanyl remained the most frequently detected substance in suspected dope samples, detected in 94 percent of samples, a 5 percent decrease since 2026 Q1 (Table 3).1 Carfentanil continues to decline and was present in 7 percent of samples, a 36 percent decrease from the previous quarter. Acetylfentanyl, a fentanyl analog approximately 15–30 percent as potent as fentanyl, was detected in 36 percent of samples.2 Heroin was detected in 28 percent of samples, an 87 percent increase from 2026 Q1. Of the samples that tested positive for heroin, 22 percent (n=14) did not have fentanyl present, an increase from last quarter, where only 1 percent (n=4) of samples with a primary substance of heroin did not have codetection of fentanyl. Biologically inactive fentanyl precursors, including 4-ANPP (88%), phenethyl-4-ANPP (82%), and ethyl-4-ANPP (51%), remained highly prevalent, consistent with continued illicit fentanyl synthesis. There is a wide range in the quantity of fentanyl in the dope supply, with the current average being around 6 percent, consistent with the potency reported in the last quarter.3
Suspected dope samples, or samples in which fentanyl (n=182) or heroin (n=45) were identified as the primary substance, contained an average of 10.5 detected compounds (range: 3-21). Two suspected dope samples were excluded because no active substances were identified.
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Table 3. Most Frequent Co-Occurring Substances in Samples with Fentanyl or Heroin as the Primary Drug and Percentage Change Since 2026 Q1

Substance n (%) Percent Change
Fentanyl 213 (94) - 5%
4-ANPP 209 (92) - 5%
Phenethyl-4-ANPP 187 (82) - 3%
Lidocaine 185 (81) - 9%
Medetomidine 183 (81) - 10%
Procaine 149 (66) - 5%
Cocaine 131 (58) - 2%
Ethyl-4-ANPP 115 (51) - 15%
Caffeine 81 (36) - 38%
Acetylfentanyl 81 (36) - 8%
Tetracaine 69 (30) - 19%
Methamphetamine 65 (29) + 3%
Heroin 63 (28) + 87%
Quinine 51 (22) + 47%
Xylazine 46 (20) - 28%
Acetaminophen 23 (10) - 67%
BTMPS 22 (10) + 42%
Carfentanil 17 (7) - 36%
Veterinary sedatives continue to be widespread in the dope supply, with 82 percent of all dope samples containing xylazine and/or medetomidine. Nevertheless, dope samples without medetomidine or xylazine increased from 7 percent in the previous quarter to 17 percent, a 142 percent increase. Medetomidine continues to be detected in most suspected dope samples (81 percent) but decreased by 10 percent from last quarter. There is a wide range in the quantity of medetomidine in the dope supply, the current average being around 13 percent.4
Xylazine detection continues to decline and was detected in 20 percent of samples, a 28 percent decrease from last quarter. Codetection of xylazine and medetomidine also continues to decline from 26 percent during Q1 2026 to 18 percent, representing a 31 percent decrease (Figure 1). The presence of these sedatives complicates overdose response, as naloxone does not reverse their effects. Reported symptoms of medetomidine withdrawal include severe vomiting, diaphoresis, hypertensive crisis, fluctuating hypoactive encephalopathy, tremors, and tachycardia.5,6 Clinical observations in Philadelphia have also indicated high acuity among patients with suspected medetomidine-associated withdrawal, including frequent intensive care admission and need for intubation.7

Figure 1. Veterinary Sedatives in Samples with Fentanyl or Heroin as the Primary Substance in 2026 Q2

Tianeptine, an atypical antidepressant that is not FDA-approved for medical use in the U.S., was detected in trace amounts in 9 samples collected during 2026 Q2. Tianeptine is commonly sold at gas stations, smoke shops, and online, and is also known by the product names Tianaa, Zaza, and Neptune’s Fix.8 Although these compounds were detected in only a small number of samples at low concentrations, which are not expected to produce clinically significant effects, tianeptine can produce opioid-like effects, and frequent exposure can lead to adverse events, including respiratory depression, sedation, withdrawal symptoms similar to opioid withdrawal, and death.9
Phenothiazines, a class of first-generation antipsychotics, were detected in six samples this quarter.10 Chlorpromazine, an antipsychotic, and promazine, a metabolite of chlorpromazine and often used as a tranquilizer in veterinary medicine, were identified in four samples. Acepromazine, a veterinary sedative and antiemetic, was detected in two samples.11 Although these compounds were detected in only a small number of samples at low concentrations, which are not expected to produce clinically significant effects, higher concentrations could result in prolonged sedation and signs of toxicity associated with phenothiazine-derived antipsychotics, including sedation, tachycardia, hypotension, QT prolongation, anticholinergic effects, and hyperthermia.12–14
Quinine detection has increased from 15 percent in the last quarter to 22 percent, a 47 percent increase. Quinine, an antimalarial medication, is commonly used as an adulterant in illicit opioids due to its bitter taste, which can mimic heroin. Quinine is pharmacologically active and has been associated with adverse effects, including cinchonism (flushing, tinnitus, sweating), hypoglycemia, and cardiotoxicity. Severe quinine toxicity may result in arrhythmia and hypotension.15,16
Though detections of local anesthetics declined, they remained widely present, including lidocaine (81 percent), procaine (66 percent), and tetracaine (30 percent). At least one local anesthetic was present in 92 percent of dope samples (n=209). There is a wide range in the quantity of local anesthetics in the dope supply, with the current average being around 17 percent.4 The presence of these agents may contribute to atypical overdose presentations, including numbness, bradycardia, hypotension, confusion, anxiety, methemoglobinemia, respiratory depression, and seizures. In some cases, this reflects Local Anesthetic Systemic Toxicity (LAST), a rare but life-threatening condition affecting the central nervous and cardiovascular systems.17,18
Cocaine was detected in 58 percent of suspected dope samples. Notably, 55 percent of dope samples (n = 125) contained fentanyl, cocaine, and at least one sedative. Methamphetamine was detected in 29 percent of samples with fentanyl as the primary substance, a slight increase from the previous quarter. The frequent detection of stimulants highlights continued polysubstance use, which may reflect attempts to counteract the sedative effects of the current dope supply.19 This combination, often referred to as “speedballs” (cocaine and fentanyl) or “goofballs” (methamphetamine and fentanyl), is associated with heightened risk of severe outcomes, including coma, stroke, respiratory failure, myocardial infarction, aneurysm, and death.20 The Philadelphia Department of Public Health issued a health advisory in October 2025, noting a 110 percent increase in drug–use–related emergency department visits where seizures were the chief or primary complaint.21 Elevated seizure risk has been associated with cocaine, methamphetamine, and local anesthetics.17

Samples with Primary Substance Cocaine (n=181) 

An average of 3.7 substances were identified in samples with cocaine as a primary substance (range: 1 to 15). One suspected cocaine sample was excluded because no active substances were detected.  

Relative to dope samples, cocaine samples contained fewer adulterants, although several substances increased in frequency compared to the previous reporting period (Table 4). The most common co-occurring substances were lidocaine (28 percent) and phenacetin (17 percent), both typical adulterants associated with cocaine. Phenacetin is a recognized carcinogen, and exposure has been linked to nephrotoxicity, nephropathy, hemolytic anemia, methemoglobinemia, as well as increased risks of kidney and bladder cancer.22
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Table 4. Most Frequent Co-Occurring Substances in Samples with Cocaine as the Primary Drug and Percentage Change Since 2026 Q1

Substance n (%) Percent Change
Lidocaine 50 (28) + 22%
Phenacetin 31 (17) + 13%
Caffeine 18 (10) + 233%
Medetomidine 17 (9) + 50%
Fentanyl 14 (8) + 14%
Levamisole 11 (6) + 20%
Methamphetamine 8 (4) + 300%
Levamisole detection increased to 6 percent in Q2 2026, a 20 percent increase from the previous quarter. Levamisole, an anthelminthic agent primarily used in veterinary medicine, is historically a common cocaine adulterant that has been linked to serious adverse effects, including neutropenia, agranulocytosis, and vasculitis, which is associated with a painful, purple rash that forms a "retiform" (branching) pattern commonly found on the ears, nose, face, or extremities and can become necrotic.23–27
Medetomidine (9 percent) and Fentanyl (8 percent) were present in a small number of samples with a primary substance of cocaine. Given that these samples were drug litter, these results should not be taken to imply that medetomidine or fentanyl are present in the broader cocaine supply, as the end user may have mixed other drugs in the sample before use. Nonetheless, these findings highlight continuing patterns of polysubstance exposure, whether intentional or unintentional.

Samples with Primary Substance Methamphetamine (n=36) 

Similar to cocaine, an average of 3.2 substances were detected in samples with methamphetamine as a primary substance (range: 1 to 15). One suspected methamphetamine sample was excluded because no active substances were detected. A larger number of methamphetamine samples is needed to strengthen future analysis.  

The most frequently co-occurring substances detected in methamphetamine samples were cocaine, lidocaine, fentanyl, and medetomidine. Compared with 2026 Q1, the prevalence of fentanyl and medetomidine increased to 19 percent. Local anesthetics tetracaine (14 percent), lidocaine (22 percent), and procaine (14 percent) also increased in prevalence since the previous quarter. Precursors dimethylamphetamine (active precursor to methamphetamine) and 4-ANPP (inactive precursor to fentanyl) were both present in 19 percent of samples. Cocaine (28 percent) was the only one of the most detected co-occurring substances to decrease. 

These findings should be interpreted with caution, as some samples consisted of drug litter, including smoking paraphernalia. These results should not be taken to imply that medetomidine or fentanyl are present in the broader methamphetamine supply, as the end user may have mixed other drugs in the sample before use. Nonetheless, these findings highlight continuing patterns of polysubstance exposure, whether intentional or unintentional. 

Three samples with methamphetamine as the primary substance were orange pills with markings resembling Adderall 30 mg (see Pills Tested between June 2025 and June 2026 for more information)

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Table 5. Most Frequent Co-Occurring Substances in Samples with Methamphetamine as the Primary Drug and Percentage Change Since 2026 Q1

Substance n (%) Percent Change
Cocaine 10 (28) - 10%
Lidocaine 8 (22) +16%
Dimethylamphetamine 7 (19) + 217%
Fentanyl 7 (19) + 217%
Medetomidine 7 (19) + 26%
4-ANPP 7 (19) + 217%
Tetracaine 5 (14) + 133%
Procaine 5 (14) + 8%

Samples with Primary Substance Cannabis or Synthetic Cannabinoids (n=36)

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Table 6. Most Frequently Found Substances in Samples with Cannabinoids as the Primary Drug and Percentage Change Since 2026 Q1

Substance n (%) Percent Change
Delta-9 THC 24 (66) - 6%
5F-ADB 7 (20) - 20%
MDMB-4en-PINACA 5 (14) - 7%
MDMB-INACA 5 (14) NA
Medetomidine 4 (11) NA
Procaine 4 (11) NA
Fentanyl 4 (11) NA
Lidocaine 3 (8) NA
Cocaine 3 (8) - 40%
MDMB-5me-INACA 2 (6) NA

An average of 3.3 substances was detected in samples with a primary substance of cannabis (n=23) or a synthetic cannabinoid (n=13), with a range of 1 to 14. Delta-9 THC refers to naturally occurring THC from cannabis. 5F-ADB, AB-MDMSBA, MDMB-INACA, MDMB-5me-INACA, and MDMB-4en-PINACA are synthetic cannabinoids.  

Co-detection of delta-9 THC and synthetic cannabinoids was identified in one sample, a counterfeit cannabis vape. Three synthetic cannabinoid samples tested positive for fentanyl and dope-associated substances (medetomidine, local anesthetics). This included a rolled cigarette and two samples of plant residue in mylar bags. Given the increase in prevalence of smoking fentanyl in the community, these codetections likely reflect polysubstance use or shared smoking equipment rather than adulteration of synthetic cannabinoids. 

5F-ADB and MDMB-4en-PINACA were the more prevalent strains of synthetic cannabinoids, both structurally related and potent indazole-based synthetic cannabinoids, linked to adverse side effects that include sedation and coma.28

  • Seven samples with no active substances were excluded from all analyses. 

  • Seven samples with a primary substance of PCP (n=5) and ketamine (n=2) were excluded from this report due to the limited sample size, which was insufficient for meaningful analysis. 

  • Drug litter samples, while non-invasive and informative, limit conclusions about the illicit drug supply. 

Two synthetic cannabinoid samples were white rectangular pills with markings resembling alprazolam (see Pills Tested between June 2025 and June 2026 for more information).

Additional Notes

Pills Tested between June 2025 and June 2026 (n=23)

Due to the nature of the surveillance program, pills represent a relatively small proportion of all samples analyzed, as drug litter remains the primary source of submissions. Nevertheless, counterfeit pharmaceutical tablets continue to present a significant public health concern because they often closely resemble prescription medications while containing entirely different active ingredients. The visual appearance of counterfeit pills (color, shape, and imprint markings) cannot reliably predict their contents, making laboratory analysis essential for identifying the substances present. Since June 2025, SUPHR received results for 23 pills that were suspected to be benzodiazepines (n=12), amphetamines (n=9), and MDMA (n=2).

Twelve pills were submitted that were suspected to be benzodiazepines based on their appearance, including white rectangular bars, green bars, and blue round tablets. All samples had markings consistent with alprazolam (Xanax), one of the most commonly prescribed benzodiazepines and among the most frequently counterfeited pharmaceutical products in illicit drug markets. Drug checking programs across the U.S. have documented the presence of novel benzodiazepines that may be more potent, longer-acting, and/or lack research on human consumption.24,25 Of those 12 samples, 25 percent (n=3) were confirmed to contain alprazolam. One sample containing alprazolam as the primary substance also contained an unidentified substance. The remaining 75 percent of samples (n=9) did not contain alprazolam as the primary active ingredient and had a variety of novel benzodiazepines and synthetic compounds. Bromazolam was the most frequently encountered substitute, identified in 42 percent of samples (n=5). Bromazolam is a designer drug that is not FDA-approved for medical use. It’s toxicity is similar to other benzodiazepines including sedation and dependence.26,27 One sample with a primary substance of bromazolam also contained methamphetamine. Ethylbromazolam (n=2) and phenazolam (n=1), designer benzodiazepines structurally similar to bromazolam, were also identified in benzodiazepine samples.28,29

Benzodiazepines (n=12) 

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Table 7. Most Frequently Found Substances in Suspected Benzodiazepine Pills between June 2025 and June 2026

Substance n (%)
Bromazolam 5 (42)
Alprazolam 3 (25)
Ethylbromazolam 2 (17)
AB-MDMSBA 2 (17)
4Br-alpha-PVP 2 (17)
Unknown Substance 2 (17)
Medetomidine 1 (8)
Lidocaine 1 (8)
Methamphetamine 1 (8)
Two suspected alprazolam pills collected in April 2026 contained AB-MDMSBA, a synthetic cannabinoid.36 In February 2026, the National Center for Clinical Research on Emerging Drugs (NCCRED) issued an alert about AB-MDMSBA being found in suspected alprazolam pills in Melbourne, Australia.37 Additionally, both samples also contained 4Br-α-PVP, a synthetic cathinone analog of α-PVP, also known as bath salts or Flakka.38 One sample contained bromazolam, while the other contained several low-abundance unknown compounds that are likely illicit benzodiazepines.
One suspected benzodiazepine pill submitted in April 2026 consisted primarily of medetomidine and only trace amounts of bromazolam and lidocaine. In June 2026, PAGroundhogs, a statewide drug checking program, issued a public health alert about a similar finding of a counterfeit alprazolam pill containing high concentrations of the veterinary sedative medetomidine.35

Amphetamines (n=9) 

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Table 8. Most Frequently Found Substances in Suspected Amphetamine Pills between June 2025 and June 2026

Substance n (%)
Methamphetamine 9 (100)
Cocaine 3 (33)
Nine pills were suspected to be prescription amphetamines based on their appearance, all of them round orange pills with markings consistent with amphetamine-dextroamphetamine (Adderall). All suspected amphetamine-dextroamphetamine pills tested positive for methamphetamine (n=9). Additionally, 33 percent of the pills tested positive for cocaine (n=3).
Two pills were submitted that were suspected to be MDMA based on their appearance. Both pills were quantified and resulted in 26 percent and 24 percent MDMA, respectively.

MDMA (n=2) 

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Table 9. Most Frequently Found Substances in Suspected MDMA Pills between June 2025 and June 2026

Substance n (%)
MDMA 2 (100)
Tadafidil 2 (100)
Dimethyl Sulfone 2 (100)
Cocaine 1 (50)
In addition to MDMA, both samples contained tadalafil, similar to sildenafil, a phosphodiesterase-5 inhibitor approved for the treatment of erectile dysfunction and pulmonary arterial hypertension.39 Both substances can independently affect cardiovascular function. Both tablets also contained dimethyl sulfone (MSM), an organic sulfur compound with low toxicity that is commonly encountered as a cutting agent in illicit drug markets due to its crystalline appearance and relative chemical stability. One tablet additionally contained cocaine.

This report was prepared by Tracy Esteves Camacho, MPH; Rose Laurano, MPH; Allyson Bisgay, MPH(c); Aoife Frankel, MPH; Joseph D’Orazio, MD; and Daniel Teixeira da Silva, MD, MSHP. This work is funded by the Centers for Disease Control and Prevention (CDC) through the Overdose Data to Action (OD2A) grant.  

Corresponding author: Tracy Esteves Camacho, MPH: tracy.camacho@phila.gov 

Acknowledgements

  1. Philadelphia Department of Public Health. Jan-March 2026 drug checking report. Substance Use Philly. May 2026. Accessed July 8, 2026. https://www.substanceusephilly.com/q12026 

  2. Higashikawa Y, Suzuki S. Studies on 1-(2-phenethyl)-4-(N-propionylanilino)piperidine (fentanyl) and its related compounds. VI. Structure-analgesic activity relationship for fentanyl, methyl-substituted fentanyls and other analogues. Forensic Toxicol. 2008;26:1-5. doi:10.1007/s11419-007-0039-1 

  3. Center for Forensic Science Research and Education. Drug Checking Quarterly Report (Q4 2025): Mid-Atlantic, USA. April 9, 2026. Accessed April 30, 2026. https://www.cfsre.org/images/content/reports/drug_checking/2025_Q4_Drug_Checking_Quarterly_Report_CFSRE_NPS_Discovery.pdf 

  4. Center for Forensic Science Research and Education. Drug Checking-Quarterly Report, Mid-Atlantic Q1 2026. 2026. www.cfsre.org/images/content/reports/drug_checking/2026_Q1_Drug_Checking_Quarterly_Report_CFSRE_NPS_Discovery.pdf 

  5. Philadelphia Department of Public Health. Health Alert: Hospitals and Behavioral Health Providers Are Reporting Severe and Worsening Presentations of Withdrawal among People Who Use Drugs (PWUD) in Philadelphia. 2024. 

  6. Philadelphia Department of Public Health. Health Update: Responding to Overdose and Withdrawal Involving Medetomidine. 2025. https://hip.phila.gov/document/5444/PDPH-HAN-SUPHR-Medetomidine-06.10.2025_1Zu1OZ4.pdf/ 

  7. London KS, Huo S, Murphy L, et al. Severe Fentanyl Withdrawal Associated With Medetomidine Adulteration: A Multicenter Study From Philadelphia, PA. J Addict Med. Published online August 1, 2025. doi:10.1097/ADM.0000000000001560 

  8. Food and Drug Administration. New “Gas Station Heroin” Tianeptine Product Trend. FDA; 2025. Accessed August 3, 2026. https://www.fda.gov/consumers/health-fraud-scams/new-gas-station-heroin-tianeptine-product-trend 

  9. Drug Enforcement Administration. Tianeptine. 2026. https://www.deadiversion.usdoj.gov/drug_chem_info/tianeptine.pdf 

  10. Kidron A, Nguyen H. Phenothiazine. In: StatPearls. StatPearls Publishing; 2026. Accessed July 9, 2026. http://www.ncbi.nlm.nih.gov/books/NBK556113/ 

  11. National Center for Biotechnology Information. Acepromazine. Accessed July 9, 2026. https://pubchem.ncbi.nlm.nih.gov/compound/6077 

  12. James LP, James L, Abel K, Wilkinson J, Simpson PM, Nichols M. Phenothiazine, Butyrophenone, and Other Psychotropic Medication Poisonings in Children and Adolescents. J Toxicol Clin Toxicol. 2000;38(6). doi:10.1081/CLT-100102010 

  13. Long N. Phenothiazines and butyrophenones. November 3, 2020. Accessed January 28, 2026. https://litfl.com/phenothiazines-and-butyrophenones/ 

  14. Barry D, Meyskens FL, Becker CE. Phenothiazine poisoning. A review of 48 cases. Calif Med. 1973;118(1):1-5. 

  15. Liles NW, Page EE, Liles AL, Vesely SK, Raskob GE, George JN. Diversity and severity of adverse reactions to quinine: A systematic review. Am J Hematol. 2016;91(5):461-466. doi:10.1002/ajh.24314 

  16. Bykowski A, Logan TD. Cinchonism. In: StatPearls [Internet]. StatPearls Publishing; 2023. Accessed April 30, 2026. https://www.ncbi.nlm.nih.gov/sites/books/NBK559319/ 

  17. Palamar JJ, DeBord JS, Krotulski AJ, Goldberger BA. Local Anesthetics Adulterating the Illicit Fentanyl Supply. JAMA Psychiatry. Published online May 21, 2025. doi:10.1001/jamapsychiatry.2025.0952 

  18. Song K, Blankenship RB, Derian A. Local Anesthetic Toxicity. In: StatPearls. StatPearls Publishing; 2025. Accessed January 28, 2026. http://www.ncbi.nlm.nih.gov/books/NBK499964/ 

  19. Ivsins A, Fleming T, Barker A, et al. The practice and embodiment of “goofballs”: A qualitative study exploring the co-injection of methamphetamines and opioids. Int J Drug Policy. 2022;107:103791. doi:10.1016/j.drugpo.2022.103791 

  20. Lee-Easton M, Magura S, Abu-Obaid R, et al. Polysubstance use patterns among individuals applying for opioid-use disorder treatment in the U.S. J Subst Use. 2024;0(0):1-8. doi:10.1080/14659891.2024.2372093 

  21. Philadelphia Department of Public Health. Health Advisory: Increasing Incidence of Seizures among People Who Use Drugs (PWUD) in Philadelphia. 2025. https://hip.phila.gov/document/5756/PDPH-HAN_SUPHR_Seizures-10.7.2025.pdf 

  22. Mohr A, Brown T, Nelson L, Logan B. Phenacetin: A Toxic Adulterant Found in Illicit Street Drugs. Fredric Rieders Family Foundation; 2021. https://www.cfsre.org/images/content/reports/public_alerts/2021.04.20.Public-Alert_Phenacetin_Final.pdf 

  23. Solomon N, Hayes J. Levamisole: A High Performance Cutting Agent. Acad Forensic Pathol. 2017;7(3):469-476. doi:10.23907/2017.039 

  24. Olash B. Levamisole-Adulterated Cocaine: A Case of Vasculitis and Severe Neutropenia. Cureus. 2025;17(12):e100358. doi:10.7759/cureus.100358 

  25. Lee KC, Ladizinski B, Federman DG. Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc. 2012;87(6):581-586. doi:10.1016/j.mayocp.2012.03.010 

  26. Donkers J, Feijen R, Rutgers A. (Levamisole Adulterated) Cocaine-Induced Vasculitis: What Is Known/Current Evidence | Current Treatment Options in Rheumatology | Springer Nature Link. Curr Treat Options Rheumatol. 2024;10:35-42. doi:10.1007/s40674-024-00215-5 

  27. Gillis JA, Green P, Williams J. Levamisole-induced vasculopathy: staging and management. J Plast Reconstr Aesthetic Surg JPRAS. 2014;67(1):e29-31. doi:10.1016/j.bjps.2013.08.015 

  28. Philadelphia Department of Public Health. Synthetic cannabinoids (K2). Substance Use Philly. Accessed April 30, 2026. https://www.substanceusephilly.com/synthetic 

  29. Center for Forensic Science Research and Education. Bromazolam Prevalence Surging Across the United States Driven In Part by Increasing Detections Alongside Fentanyl. 2022. https://www.cfsre.org/images/content/reports/public_alerts/Public-Alert_Bromazolam_NPS-Discovery_061522.pdf 

  30. Kaye AD, Tassin JP, Upshaw WC, et al. Fake Xanax: Designer Emerging Benzodiazepine Epidemic Linked to Morbidity and Mortality a Narrative Review. Neurol Ther. 2024;13(4):965-973. doi:10.1007/s40120-024-00628-3 

  31. Ehlers PF. Notes from the Field: Seizures, Hyperthermia, and Myocardial Injury in Three Young Adults Who Consumed Bromazolam Disguised as Alprazolam — Chicago, Illinois, February 2023. MMWR Morb Mortal Wkly Rep. 2024;72. doi:10.15585/mmwr.mm725253a5 

  32. Drug Enforcement Administration. DEA Emergency Schedules Bromazolam. March 18, 2026. Accessed July 8, 2026. https://www.dea.gov/press-releases/2026/03/18/dea-emergency-schedules-bromazolam 

  33. Center for Forensic Science Research and Education. Novel Benzodiazepine Phenazolam Increasing In Detections and Prevalence Among U.S. Recreational Drug Markets. December 19, 2025. Accessed July 8, 2026. https://www.cfsre.org/nps-discovery/public-alerts/novel-benzodiazepine-phenazolam-increasing-in-detections-and-prevalence-among-u-s-recreational-drug-markets 

  34. Center for Forensic Science Research and Education. Ethylbromazolam. October 10, 2025. Accessed July 8, 2026. https://www.cfsre.org/nps-discovery/monographs/ethylbromazolam 

  35. PAGroundhogs. High levels of Medetomidine Found in Dark Web Xanax. PAGroundhogs. June 9, 2025. Accessed July 8, 2026. https://pagroundhogs.org/alerts 

  36. Center for Forensic Science Research and Education. AB-MDMSBA. Accessed July 8, 2026. https://www.cfsre.org/nps-discovery/monographs/ab-mdmsba 

  37. AB-MDMSBA (a synthetic cannabinoid) found in alprazolam (Xanax®) - The Know. February 12, 2026. Accessed July 8, 2026. https://theknow.org.au/alerts_warnings/ab-mdmsba-a-synthetic-cannabinoid-found-in-alprazolam-xanax/ 

  38. Błażewicz A, Bednarek E, Sitkowski J, et al. Identification and structural characterization of four novel synthetic cathinones: α-methylaminohexanophenone (hexedrone, HEX), 4-bromoethcathinone (4-BEC), 4-chloro-α-pyrrolidinopropiophenone (4-Cl-PPP), and 4-bromo-α-pyrrolidinopentiophenone (4-Br-PVP) after their seizures. Forensic Toxicol. 2017;35(2):317-332. doi:10.1007/s11419-017-0360-2 

  39. Fahmy G, Hess J. Tadalafil. In: StatPearls. StatPearls Publishing; 2026. Accessed July 21, 2026. http://www.ncbi.nlm.nih.gov/books/NBK603743/ 

References