Drug Checking Findings: July - September 2026

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The Philadelphia Department of Public Health (PDPH), Division of Substance Use Prevention & Harm Reduction (SUPHR), analyzed 372 drug samples collected between July and September 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 drug-related paraphernalia, found in public spaces between July and September 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 the adverse effects of the illicit drug supply.  

Most samples were collected in the Kensington area (Table 2). Center City accounted for 15 percent of the samples, while smaller numbers came from North/Northeast (9 percent), South/Southwest (6 percent), and West (4 percent).  Three percent of samples (n=13) were from an unknown section of the city. Seven samples were excluded from analysis because no substances were detected (n=3) or they were pending analysis at the time of this report (n=4).

Sample Collection

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Table 1. Drug Sample Collection Volume, July - September 2026

Month n (%)
July 120 (32)
August 128 (35)
September 124 (33)
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Table 2. Drug Sample Collection Volume by City Section, July - September 2026

Section n (%)
Kensington 229 (62)
Northeast/North 34 (9)
Center City 54 (14)
South/Southwest 23 (6)
West 14 (4)
Unknown 18 (5)

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=230) 

Fentanyl remained the most frequently detected substance in suspected dope samples, detected in 92 percent of samples, a 2 percent decrease since 2026 Q2 (Table 3).1 Carfentanil continues to decline and was present in 3 percent of samples, a 65 percent decrease from the previous quarter. Acetylfentanyl, a fentanyl analog approximately 15–30 percent as potent as fentanyl, was detected in 30 percent of samples.2 Heroin was detected in 25 percent of samples, a slight decrease from 2026 Q2. Of the samples that tested positive for heroin, 33 percent (n=19) did not have fentanyl present, an increase from last quarter, where only 22 percent (N=14) of samples with a primary substance of heroin did not have co-detection of fentanyl. Biologically inactive fentanyl precursors, including 4-ANPP (91 percent), phenethyl-4-ANPP (83 percent), and ethyl-4-ANPP (45 percent), remained highly prevalent, consistent with continued illicit fentanyl synthesis. The concentration of fentanyl in suspected dope samples varies widely, with a reported average of approximately 7 percent by weight, a slight increase from previous reports.3
Suspected dope samples, or samples in which fentanyl (n=190) or heroin (n=40) were identified as the primary substance, contained an average of 10.3 detected compounds (STD: 3.6, range: 3-26). The average number of detected compounds in the dope supply is similar to Q2, which had an average of 10.0 compounds (STD = 3.0, range: 3-20). The interquartile range for both quarters was 8-12, indicating that 50 percent of all samples contained between 8 and 12 substances.
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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 Q2

Substance n (%) Percent Change
Fentanyl211 (92)- 2%
4-ANPP210 (91)- 1%
Medetomidine195 (85)+ 5%
Phenethyl-4-ANPP190 (83)0%
Lidocaine182 (79)- 3%
Procaine159 (69)+ 5%
Cocaine141 (61)+ 6%
Caffeine107 (47)+ 30%
Ethyl-4-ANPP103 (45)- 12%
Tetracaine86 (37)+ 23%
Methamphetamine69 (30)+ 5%
Acetylfentanyl68 (30)- 17%
Heroin58 (25)- 9%
Acetylcodeine43 (19)- 12%
Xylazine30 (13)- 36%
Acetaminophen28 (12)+ 20%
BTMPS26 (11)+ 17%
Quinine20 (9)- 61%
SR-170186 (3)NA
Carfentanil6 (3)- 65%
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
Veterinary sedatives continue to be widespread in the dope supply (Figure 1). Medetomidine continues to be detected in most suspected dope samples (85 percent), which reflects a nonsignificant 5 percent increase (p=0.2390) from last quarter. The concentration of medetomidine in suspected dope samples varies widely, with a reported average of approximately 10 percent by weight, a decrease from previous reports.1 Codetection of xylazine and medetomidine continues to decline. In 2026, Q3 saw 13 percent of samples, Q2 saw 18 percent, and Q1 saw 26 percent. While the decrease from 2026 Q2 to Q3 is insignificant (p=0.1387), this pattern reflects a significant change in Xylazine’s presence in 13 percent of samples reflects a significant 36 percent decrease (p<0.05) from Q3 to Q2. However, 100 percent of samples that tested positive for xylazine also tested positive for medetomidine. The number of dope samples without medetomidine or xylazine remained relatively stable at 15 percent compared to 18 percent in 2026 Q2. 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. 4,5 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.6

Figure 1. Veterinary Sedatives in Samples with Fentanyl or Heroin as the Primary Substance in 2026 Q3

BTMPS (Tinuvin 770) was present in 11 percent of samples, a 17 percent increase since 2026 Q2. While BTMPS’ presence decreased from 2025 Q3 to 2026 Q1, its presence across all dope samples has increased each quarter since 2026 Q2. BTMPS is an industrial chemical not approved for human consumption that functions as a light stabilizer in plastic materials to help protect them from light-induced degradation and is also used in product manufacturing and packaging.7 BTMPS emerged as an adulterant in the drug supply in 2024 in Philadelphia, PA, and other U.S. cities. At present, there is insufficient evidence to define a characteristic human toxidrome associated with BTMPS exposure or determine whether the quantities detected in the illicit drug supply produce clinically significant toxicity.8,9 Suspected dope samples that had BTMPS present were more likely to also have heroin present, but the proportion of samples with both has decreased since 2026 Q2: more than half of the samples that had BTMPS present (n=26) also had heroin present (N=14, 54 percent) during 2026 Q3. This reflects a decrease from 2026 Q2, when 73 percent of samples with BTMPS present (n=22) also had heroin present (N=16).
5,6-dichloro desmethylchlorphine (SR-17018) is a novel synthetic opioid found in six samples during this quarter. SR-17018 is structurally similar to other benzimidazolones like brophine and chlorphine, and its potency is comparable to morphine.10 SR-17018 is a research chemical with limited information available, but some have reported using SR-17018 to self-treat opioid and 7-hydroxymitragynine (7-OH) withdrawal symptoms.11,12 The DEA scheduled it as a temporary Schedule I substance in August 2026.13
Though detections of local anesthetics declined, they remained widely present, including lidocaine (79 percent), procaine (69 percent), and tetracaine (37 percent). At least one local anesthetic was present in 89 percent of dope samples (n=204). The concentration of local anesthetics in suspected dope samples varies widely, with a reported average of approximately 7 percent by weight, a large decrease from previous reports.3 Although frequently detected as adulterants, the clinical significance of these findings depends on the specific agent, amount present, and route of administration. At sufficiently high systemic exposures, local anesthetics can cause central nervous system toxicity, including seizures, as well as cardiac conduction abnormalities, dysrhythmia, and cardiovascular collapse, collectively referred to as Local Anesthetic Systemic Toxicity (LAST). However, detection alone does not establish that concentrations are sufficient to cause toxicity.14,15
Most samples (N=151, 66 percent) with a primary substance of fentanyl or heroin also had a stimulant present. Cocaine was detected in 61 percent of dope samples, and methamphetamine was detected in 30 percent of samples. A quarter of samples (26 percent) with fentanyl or heroin as the primary substance had both methamphetamine and cocaine present. The frequent detection of stimulants highlights continued polysubstance use, which may reflect attempts to counteract the sedative effects of the current dope supply.16 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.17 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.18 Elevated seizure risk has been associated with cocaine, methamphetamine, and local anesthetics.14

Samples with Primary Substance Cocaine (n=77) 

An average of 3.3 substances were identified in samples with cocaine as a primary substance (STD: 2.1, range: 1-13). This is similar to the findings from Q2, during which an average of 3.8 substances were identified per cocaine sample (STD: 1.9, range: 1-14). While the middle 50 percent of samples in Q2 contained 3-4 substances, the interquartile range reflecting the middle 50 percent of samples in Q3 contained 2-4 substances. 

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 occurring substances were phenacetin (25 percent) and lidocaine (13 percent), both typical adulterants associated with cocaine.
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Table 4. Most Frequent Co-Occurring Substances in Samples with Cocaine as the Primary Drug and Percentage Change Since 2026 Q2

Substance n (%) Percent Change
Phenacetin19 (25)+ 44%
Lidocaine10 (13)- 53%
Fentanyl7 (9)+ 18%
Procaine7 (9)+ 311%
Levamisole5 (6)+ 7%
Medetomidine5 (6)- 31%
Tetracaine3 (4)+ 135%
Caffeine2 (3)- 74%
Methamphetamine1 (1)- 71%
Phenacetin increased from 17 percent to 25 percent, reflecting a nonsignificant increase of 44% (p=0.16). 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.19
Levamisole detected stayed relatively stable and was present in 6 percent of samples. Levamisole is primarily used in veterinary medicine as an anthelmintic agent. It is a historically common cocaine adulterant that has been linked to serious adverse effects, such as 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. 20–24

Local anesthetics, including lidocaine, procaine, and tetracaine, can be commonly seen in cocaine samples. While lidocaine was still one of the most common substances seen in the cocaine supply, the presence of lidocaine decreased from 27.62 percent to 12.99 percent, a significant 53 percent decrease (p<0.05). Of all cocaine samples that contained any local anesthetic in Q2, 74 percent contained lidocaine alone. In Q3, among all samples containing a local anesthetic, lidocaine alone was observed only 38 percent of the time. Procaine (9 percent) and tetracaine (4 percent) each saw an increase in their presence from Q2, with increases of 311 percent and 135 percent, respectively. However, the presence of any local anesthetic decreased from 31 percent in Q2 to 17 percent in Q3, a significant 46 percent reduction (p<0.05). 

The number of samples with medetomidine present decreased from 9 to 6 percent. Fentanyl in samples with a primary substance of cocaine had a nonsignificant increase from 8 to 9 percent. Of all cocaine samples that contained medetomidine (N=5), 100 percent also contained fentanyl. Two additional cocaine samples contained fentanyl without medetomidine. Methamphetamine presence had a nonsignificant decrease from 4 to 1 percent. 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 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=27) 

Similar to cocaine, an average of 3.7 substances were identified in samples with methamphetamine as a primary substance (STD: 4.4, range: 1-20). This is in line with results from Q2, which identified an average of 3.3 substances per methamphetamine sample (STD: 4.0, range: 1:15). The interquartile range increased from 1 to 2.5 substances in Q2 to 1 to 5 substances in Q3. None of the changes were statistically significant, as a larger number of methamphetamine samples is needed to power future analysis. 

The most frequently occurring substances detected in samples with a primary substance of methamphetamine were dimethylamphetamine, lidocaine, and medetomidine (Table 5). Compared to 2026 Q1, the prevalence of dimethylamphetamine, an active precursor of methamphetamine, increased 33 percent.25 The presence of fentanyl (22 percent) and inactive related precursor phenethyl-4-ANPP (15 percent) increased in presence while 4-ANPP (19 percent) slightly decreased. Veterinary sedatives medetomidine and xylazine were also found in primary methamphetamine samples. Local anesthetics lidocaine (26 percent) and procaine (22 percent) increased in presence while tetracaine decreased by 47 percent. 

As with cocaine samples, 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. 

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Table 5. Most Frequent Co-Occurring Substances in Samples with Methamphetamine as the Primary Drug and Percentage Change Since 2026 Q2

Substance n (%) Percent Change
Dimethylamphetamine7 (26)+ 33%
Lidocaine7 (26)+ 17%
Medetomidine7 (26)+ 33%
Cocaine6 (22)- 20%
Fentanyl6 (22)+ 14%
Procaine6 (22)+ 60%
4-ANPP5 (19)- 5%
Phenethyl-4-ANPP4 (15)+ 167%
Tetracaine2 (7)- 47%
Xylazine2 (7)+ 167%
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Table 6. Most Frequent Co-Occurring Substances in Samples with Cannabis as the Primary Drug and Percentage Change Compared to 2026 Q2*

Substance n (%) Percent Change
Delta-9 THC (N) 12 (100%) 0%
Cannabinol (CBN) (N) 9 (75%) +44%
Tetrahydrocannabinolic Acid (THCA) (N) 6 (50%) -36%
Cannabigerol (CBG)(N) 6 (50%) +130%
THC-O Acetate (SS) 4 (33%) +156%
Cannabidiol (CBD) (N) 4 (33%) +527%
Delta-9 THC-O (SS) 3 (27%) +527%
Methamphetamine 2 (17%) +283%
Cocaine 1 (8%) -4%
Lidocaine 1 (8%) NA

Samples with Primary Substance Cannabis or Synthetic Cannabinoid (N=24) 

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Table 7. Most Frequently Found Substances in Samples with Semi- and Synthetic Cannabinoids as the Primary Drug and Percentage Change Compared to 2026 Q2*

Substance n (%) Percent Change
5F-ADB (S) 10 (83%) +55%
MDMB-INACA (S) 4 (33%) -13%
Cocaine 3 (25%) +225%
Lidocaine 3 (25%) +8%
Diphenhydramine 2 (17%) NA
Cannabidiol (CBD) (N) 1 (8%) +8%
Cannabigerol (CBG)(N) 1 (8%) NA
Cannabinol (CBN) (N) 1 (8%) +8%
Delta-8 THC (SS) 1 (8%) +8%
Delta-9 THC (N) 1 (8%) +8%
Hexahydrocannabinol (HHC) (SS) 1 (8%) NA
Hydroxy-Hexahydrocannabinol (SS) 1 (8%) +8%
Delta-9 THC-O (SS) 1 (8%) NA
MDMB-4en-PINACA (S) 1 (8%) -78%
MDMB-5me-INACA (S) 1 (8%) -46%
Medetomidine 1 (8%) -73%
During the third quarter, 24 samples were identified as having cannabis (n=12) or synthetic cannabinoids (n=12) as the primary substance. Cannabis samples contained an average of 4.3 detected compounds, while synthetic cannabinoid samples contained an average of 2.8 compounds (Tables 6 and 7). Naturally occurring cannabis constituents, including delta-9 THC, cannabinol (CBN), cannabigerol (CBG), and cannabidiol (CBD), were frequently detected. Among samples classified as synthetic cannabinoids, 5F-ADB was the most frequently identified substance, detected in 83 percent (n=10), followed by MDMB-INACA in 33 percent (n=4). Unlike naturally occurring cannabinoids, these potent synthetic cannabinoid receptor agonists can produce unpredictable and potentially severe toxicity, including profound sedation, agitation, seizures, and coma.26
Of particular concern was the co-detection of naturally occurring cannabis compounds with semisynthetic or synthetic cannabinoids in five samples, including four vape cartridges and one rolled joint. Semisynthetic cannabinoids, such as THC-O acetate, are chemically modified derivatives of naturally occurring cannabinoids, whereas substances such as 5F-ADB and MDMB-4en-PINACA are fully synthetic cannabinoid receptor agonists. These findings highlight the potential for cannabis products to contain additional psychoactive compounds with different pharmacologic properties and toxicities. Individuals consuming these products may be unaware of the presence of these substances and their associated risks.
Fentanyl was not detected in any samples classified as cannabis or synthetic cannabinoids during this reporting period. Medetomidine was identified in one synthetic cannabinoid sample consisting of brown plant material collected in a plastic baggie.

  • 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. 

Additional Notes

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. April - June 2026 drug checking report. Substance Use Philly. August 2026. Accessed October 22, 2026. https://www.substanceusephilly.com/q22026 

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 Toxicology. 2008;26:1-5. doi:10.1007/s11419-007-0039-1 

3. Center for Forensic Science Research and Education. Drug Checking Quarterly Report (Q2 2026): Mid-Atlantic, USA. 2026. Accessed October 21, 2026. https://www.cfsre.org/nps-discovery/drug-checking/drug-checking-quarterly-report-q2-2026-mid-atlantic-usa 

4. 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. 

5. 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/ 

6. 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 

7. Center for Forensic Science Research and Education. BTMPS. August 2024. Accessed October 23, 2026. https://www.cfsre.org/nps-discovery/monographs/bis2266-tetramethyl-4-piperidyl-sebacate 

8. Philadelphia Department of Public Health. Hazardous Industrial Chemical Detected in Philadelphia’s Drug Supply. September 25, 2024. Accessed October 23, 2026. https://hip.phila.gov/document/4717/PDPH-HAN-0442A-09-25-24.pdf/ 

9. U.S. Department of Homeland Security. BTMPS: An Industrial Additive in the Illicit Drug Supply. July 2025. Accessed October 23, 2026. https://www.dhs.gov/sites/default/files/2025-08/25_0814_st_btmps_an_industrial_additive_in_the_illicit_drug_supply_fact_sheet.pdf 

10. Center for Forensic Science Research and Education. 5,6-Dichloro Desmethylchlorphine. August 2024. Accessed October 23, 2026. https://www.cfsre.org/nps-discovery/monographs/56-dichloro-desmethylchlorphine 

11. Fritzwanker S, Schulz S, Kliewer A. SR-17018 Stimulates Atypical µ-Opioid Receptor Phosphorylation and Dephosphorylation. Molecules. 2021;26(15):4509. doi:10.3390/molecules26154509 

12. Picard MP. Observational characterization of self-reported SR-17018 exposure and outcomes in individuals with prior opioid use histories. Front Pharmacol. 2026;17. doi:10.3389/fphar.2026.1899247 

13. Drug Enforcement Administration. Schedules of Controlled Substances: Temporary Placement of 5,6-Dichloro Brorphine, 5,6-Dichloro Desmethylchlorphine, N-Propionitrile Chlorphine, and Spirochlorphine in Schedule I of the Controlled Substances Act. Federal Register. August 27, 2026. Accessed October 23, 2026. https://www.federalregister.gov/documents/2026/08/27/2026-17531/schedules-of-controlled-substances-temporary-placement-of-56-dichloro-brorphine-56-dichloro 

14. 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 

15. 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/ 

16. 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. International Journal of Drug Policy. 2022;107:103791. doi:10.1016/j.drugpo.2022.103791 

17. 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. Journal of Substance Use. 2024;0(0):1-8. doi:10.1080/14659891.2024.2372093 

18. 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 

19. 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 

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

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

22. 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 

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

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

25. Cody JD. Metabolic Precursors to Amphetamine and Methamphetamine. Forensic Sci Rev. 1993;5(2):109-127. 

26. Philadelphia Department of Public Health. Synthetic cannabinoids (K2) in Philadelphia. Substance Use Philly. Accessed October 26, 2026. https://www.substanceusephilly.com/synthetic 

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