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Million dollar ride: Crime committed during involuntary scopolamine intoxication

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Million dollar ride: Crime committed during involuntary scopolamine intoxication

VOL 63: MAY MAI 2017 | Canadian Family Physician Le Médecin de famille canadien 369
Case Report
Scopolamine, also known as burundanga, is a trop-
ical alkaloid produced by species of plants such as
Hyoscyamus albus and Datura stramonium.1 Uses of these
plants around the world range from food to ornaments to
medicinal preparations that take advantage of their strong
anticholinergic, antiemetic, and hallucinogenic proper-
ties.2-4 Criminal administration of extracts of Datura has
been reported in South America since the 1950s.2 The
most intriguing phenomenon seen in burundanga intoxi-
cation is not the anticholinergic side effects (ie, mydriasis,
confusion, and palpitations), but the submissive and obe-
dient behaviour of the victim.2 This phenomenon is caused
by a reduction in declarative memory.5 Criminals typically
use burundanga to take their victims on the “million dollar
ride,” during which victims submissively withdraw money
from a bank machine. The drug is commonly blown in the
faces of the victims or placed in their beverages. Victims
often surrender their valuables to the criminals without
resistance. Neither the victim nor the surrounding people
are aware that a crime is being committed and, as a result,
there are usually no witnesses. Although it is well known
in South America, criminal use of scopolamine has rarely
been described in the Canadian primary care literature.
This report serves to educate FPs regarding the impor-
tance of considering scopolamine intoxication in the set-
ting of amnesia and anticholinergic toxidrome.
Case
A healthy 47-year-old man presented to his Canadian FP
worried that he had been robbed at a bus terminal after
vacationing in Bogotá, Colombia, 6 days previously. The
patient was amnestic for approximately 12 hours during
and after the event. He was able to successfully board
a bus despite his state and after returning home and
becoming aware of his surroundings, he noted he was
missing an estimated $250 in cash and his cell phone.
He had no signs of physical or sexual assault; however,
he felt disoriented and confused, was unable to concen-
trate, and suffered from marked xerostomia.
Upon his return to Canada he discussed the event
with his family, who believed he might have been
exposed to burundanga (scopolamine). As he still felt
unwell he presented to his physician with questions
about scopolamine toxicity and long-term effects. Urine
toxicology screening and drug screening for scopol-
amine and flunitrazepam were performed. Test results
were negative, and the patient returned for follow-up 2
days later to monitor his symptoms, according to advice
from poison control. Poison control indicated that there
would be no benefit from dialysis but that there might
be a role for activated charcoal and lavage within hours
Million dollar ride
Crime committed during involuntary scopolamine intoxication
Sonja Reichert MD MSc CCFP Cassandra Lin MD CCFP William Ong Claudia Chon Him MD Saadia Hameed MD MClSc CCFP
Editor’s kEy points
• Scopolamine intoxication should be considered as part
of the differential diagnosis for patients who present with
anticholinergic toxidrome and who have recently traveled
to South America. The 2 most notorious clinical signs of
scopolamine intoxication are severe anterograde amnesia
and submissiveness.
• Scopolamine does not have a very long half-life; even
high doses leave the body in 3 to 4 days. Scopolamine is
excreted unchanged in the urine within the first 12 hours
after oral ingestion, which makes obtaining a positive
urine toxicologic test result challenging.
• Patients should be educated on safety precautions when
traveling to countries that commonly use scopolamine as
a predatory drug. Patients taking commercial preparations
of scopolamine should be warned of the possibility of
accidental intoxication.
points dE rEpèrE du rédactEur
• On devrait envisager une intoxication à la scopolamine parmi
les diagnostics différentiels chez les patients qui présentent un
toxidrome anticholinergique et qui ont récemment voyagé en
Amérique du Sud. Les 2 signes cliniques les plus remarquables
d’une intoxication à la scopolamine sont une amnésie
antérograde sévère et la docilité.
• La scopolamine n’a pas une très longue demi-vie; même
à fortes doses, elle disparaît du corps en 3 ou 4 jours. La
scopolamine est excrétée sans changement dans l’urine
durant les 12 premières heures après une ingestion par la
bouche, ce qui complique l’obtention de résultats de tests
toxicologiques positifs dans l’urine.
• Il faudrait informer les patients des précautions à
prendre pour leur sécurité lorsqu’ils voyagent dans des
pays où la scopolamine est couramment utilisée comme
drogue par des escrocs. Il faut avertir les patients qui
prennent des préparations commerciales de scopolamine
de la possibilité d’une intoxication accidentelle.
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
Can Fam Physician 2017;63:369-70
370 Canadian Family Physician Le Médecin de famille canadien | VOL 63: MAY MAI 2017
Case Report
of scopolamine ingestion.6 Given that he presented days
after exposure, no additional intervention was offered.
At follow-up, the patient’s neurologic examination
findings were normal. He was alert and oriented, with
a blood pressure of 110/68 mm Hg. He experienced
palpitations and lethargy for 3 days and shakiness
that lasted for a week after exposure, and he contin-
ued to have permanent anterograde amnesia for the
12-hour period around the exposure, but fully recov-
ered to his previous level of functioning.
Discussion
Scopolamine and other plant derivatives are potential
drugs of abuse for both recreational and criminal pur-
poses. In our case, the patient suspected scopolamine was
the causative agent, as it is commonly used in Colombia
and his symptoms matched what would be expected from
such intoxication. We cannot discern whether he was
given a mixture of psychoactive drugs and their specific
doses; however, his symptoms were mostly anticholiner-
gic and were not severe enough to require intervention.
Extensive review of the MEDLINE and EMBASE data-
bases, with search terms criminal, poisoning, intoxica-
tion, and scopolamine, revealed 40 documented cases of
intentional and unintentional poisoning with scopolamine,
although accurate information on this intoxication is dif-
ficult to ascertain.2 In one case, a 28-year-old woman was
poisoned by an elegantly dressed man. She subsequently
cashed her pay cheque and gave the money to him.2 In a
meditation session, 30 people were intentionally poisoned
and many required supportive therapy.7 In another case, a
19-year-old man intentionally ingested an unknown quan-
tity of D stramonium seeds to experience their hallucino-
genic effects and was found dead.8 Increasing misuse has
led to prohibition by law in certain regions of planting cer-
tain species of plants that produce potentially lethal toxins.9
Scopolamine is tasteless and odourless and can be
administered through oral, dermal, intravenous, or inhala-
tion routes.10 Intoxication presents clinically as tachycardia,
palpitations, dry mouth, flushed skin, blurred vision, uri-
nary retention, disorientation, confusion, insomnia, and
severe anterograde amnesia.2,11,12 After scopolamine is
orally ingested, most of it is excreted unchanged in the
urine within 12 hours, which explains the challenge in
obtaining a positive urine toxicologic result, as laboratory
tests are usually done more than 12 hours after inges-
tion.2 Toxic doses vary greatly among individuals and chil-
dren are very susceptible, with less than 10 mg leading to
death.7 In addition, a combination of tropane alkaloids can
have a synergistic action and might lead to death.
In Canada, scopolamine can be purchased without a
prescription and comes in 2 commercial preparations:
the Transderm-V patch and Buscopan. One case report
revealed a substitution error by a pharmacist that led to
hyoscine hydrobromide overdose. The patient involved
experienced long-lasting effects including decreased abil-
ity to concentrate and memory disturbances.13 Further,
there has been an increase in poisoning caused by sco-
polamine disguised and sold as flunitrazepam tablets.14
This increase has been explained by the lower availabil-
ity and higher production costs of flunitrazepam.14
We recognized that our patient described the anticholin-
ergic toxidrome expected in scopolamine intoxication; he
was reassured that scopolamine does not have a long half-
life and that even high doses leave the body in 3 to 4 days.
This patient fully recovered from his symptoms and was
educated on safety precautions when traveling to countries
that commonly use scopolamine as a predatory drug.
Conclusion
As clinicians, we encourage that when patients present to
their FPs with unknown drug intoxication, the common
standard of care be applied. However, if screening results
are negative and there is no identifiable cause of the symp-
toms, the patient should be educated on possible scopol-
amine intoxication, particularly if that patient presents
with an anticholinergic toxidrome and traveled to a coun-
try that uses scopolamine for recreational and predatory
purposes. This case describes suspected toxic alkaloid poi-
soning managed in primary care. It is important to become
educated about the toxicities and potential risks associ-
ated with criminal and recreational use of scopolamine.
Dr Reichert is Assistant Professor in the Department of Family Medicine at Western
University in London, Ont. Dr Lin is a third-year enhanced skills resident in academic family
medicine in the Department of Family Medicine at Western University. Mr Ong is a clinical
pharmacist at the St Joseph’s Family Medical and Dental Centre in London. Dr Chon Him is
an internationally trained physician with a special interest in internal medicine. Dr Hameed
is Assistant Professor in the Department of Family Medicine at Western University.
Competing interests
None declared
Correspondence
Dr Cassandra Lin; e-mail clin55@uwo.ca
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... Its anticholinergic hallucinogenic behavior, due to its antagonist actions toward the acetylcholine receptors, makes the tropane alkaloid ideal as a poison, while its hallucinogenic effects make it appealing as a recreational drug. 5 Atropine is considered one of the most important tropane alkaloids used for medical purposes, where it is employed for the treatment of Parkinson's disease 6,7 to slow down the progression of myopia 8 and as a treatment for organophosphate poisoning. 9 In contrast to other popular naturally occurring recreational drugs, such as cannabis, atropine and scopolamine producing species remain largely unregulated in many countries; indeed, pharmaceutics containing the tropane alkaloid can often be obtained without a medical prescription. ...
... 9 In contrast to other popular naturally occurring recreational drugs, such as cannabis, atropine and scopolamine producing species remain largely unregulated in many countries; indeed, pharmaceutics containing the tropane alkaloid can often be obtained without a medical prescription. 5 The use of atropine as a poison is not a novel concept, as is highlighted by the 1994 case of Dr. Paul Agutter. Dr Agutter, a biology professor at Edinburgh Napier University, attempted to murder his wife by spiking her gin and tonic with the deadly tropane alkaloid. ...
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