Lead poisoning outbreak among opium users in the Islamic Republic of Iran, 2016–2017

Abstract

ObjectiveTo describe an outbreak of lead poisoning among opium users in the Islamic Republic of Iran and estimate the number of affected people in the country.MethodsWe used data from the country’s largest poison treatment centre to illustrate the epidemiology of an outbreak of lead poisoning in oral opium users. We describe the government’s referral and treatment guidelines in response to the outbreak. Based on the number of individuals treated and previous studies on the prevalence of oral opium use we estimated the total number of people at risk of lead-contaminated opium nationwide.FindingsIn February 2016, we noticed a steep increase in the numbers of oral opium users referred to our poison treatment centre with abdominal pain, anaemia and constipation. Numbers peaked in June 2016 but the outbreak was ongoing in August 2017. The mean blood lead level in a sample of 80 patients was 140.3 µg/dL (standard deviation: 122.6). Analysis of an illegal opium sample showed 3.55 mg lead in 1 g opium. Treatment was exposure reduction with opioid substitutes and laxatives, or chelation therapy if indicated. Over 7 months, 4294 poison cases were seen at main referral hospitals in Tehran out of an estimated 31 914 oral opium users in the city. We estimate more than 260 000 out of 773 800 users nationwide remain untreated and at risk of poisoning.ConclusionLead-contaminated opium and heroin that has transited through the Iranian markets is a global risk and highlights a need for better monitoring of illegal drug supplies.

Two cases of lead poisoning from inhaled opium in Victoria

“…3,5 Severe lead toxicity may mimic an acute surgical abdomen, with no pathology found on operative intervention. 3,6 Absorption of lead is most commonly reported by inhalation, ingestion or dermal contact. 2 Lead is excreted primarily through the renal and biliary systems, with chronic absorption into cortical bone, teeth, liver, brain and kidneys.…”

“…3 The mainstay of treatment is the removal of the exposure source and chelation therapy. 5,6 Toxicity in the developing world is common with the higher concentrations of lead in fuel, batteries, paint, rubber, printing material, food packaging and soil. 2,3,5 Lead contamination has been reported in opium originating from the Middle East, with impurities being intentionally added to increase the sale weight or arising from a contaminated source.…”

“…2,3,5 Lead contamination has been reported in opium originating from the Middle East, with impurities being intentionally added to increase the sale weight or arising from a contaminated source. 5,6 A national outbreak of lead poisoning in opium users was declared in Iran in 2016 with more than 19 000 cases requiring chelation. 6 Subsequent investigations by the Victorian Department of Health have noted that illegally imported opium from the Middle East was the likely cause of the lead toxicity in our two patients.…”

“…5,6 A national outbreak of lead poisoning in opium users was declared in Iran in 2016 with more than 19 000 cases requiring chelation. 6 Subsequent investigations by the Victorian Department of Health have noted that illegally imported opium from the Middle East was the likely cause of the lead toxicity in our two patients. 7 To our knowledge, these are the first cases of lead poisoning from opioid ingestion originating outside of the Middle East to be reported in the literature.…”

“…Failure to identify toxicity may result in significant morbidity or mortality, with repeat presentations, and exploratory laparotomies having occurred in some cases in Iran. 6 Identification of the source of lead is vital so that knowledge can be disseminated among medical and public health agencies, potentially averting or limiting a public health crisis. Lead toxicity should be considered as a potential, though uncommon, cause of abdominal pain with no localising symptoms.…”