Case Report 43

FATAL 4x100; HOME-MADE KRATOM JUICE COCKTAIL

Wichian Tungtananuwat1,* and Somsong Lawanprasert2
1Institute of Forensic Medicine, The Royal Thai Police Headquarter, Bangkok 10330,Thailand.
2Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok 10330,Thailand.

Abstract: A corpse of 21-years-old man (Muslim) was investigated for the cause of death. His
family declined consent for full autopsy. Thus, only blood and urine were used for toxicological
analysis by liquid chromatography-electrosray ionization-time of flight mass spectrometry.
These following substances were found in the blood and urine samples: mitragynine (an
alkaloid found in Kratom; Mitragyna speciosa leaves), caffeine, diphenhydramine, alprazolam,
nortriptyline, methadone, tramadol, methamphetamine and some of their metabolites. The
findings of this case suggested the possibility of polydrugs abuse calls “4x100”, a Kratom juice
cocktail that has been popular in Southernmost provinces of Thailand. It is made from four
major ingredients, boiled Kratom leaves, Cola soft drink, cough syrup and tranquilizers or
mosquito coils. In this case, the cause of death might be due to multidrugs intoxication of the
additive adverse effects especially CNS and respiratory depression.
Keywords: Kratom juice cocktail, Mitragyna speciosa, intoxication

INTRODUCTION: Kratom (Mitragyna speciosa by the report that 290 Litres of 4x100 were seized
Korth.) juice cocktail called “4x100” formulae is in 2007, but 1,700 Litres were seized in 20083).
becoming abused by youth addicts and causes a Cola soft drink in 4x100 formulae is added for
terrible social problem in Thailand, especially in taste, but the others are added for euphoric effects.
young Muslim in Bangkok and people in three The active ingredients in boiled Kratom leaves are
southernmost provinces of Thailand. The origin of group of Mitragynine alkaloids. More than 25
the name “4x100” is unclear, but it likely came alkaloids had been isolated from Kratom leaves by
from its four ingredients. Boiled Kratom leaves, various researchers regulation4). It is interesting to
Cola soft drink and codeine- or diphenhydramine- note that the “low dose” effects by chewing Kratom
containing cough syrup are three major ingredients leaves are described to be stimulating effect (coca-
while the forth ingredient depends on the like action), while “high dose” usually produces
producer’s satisfaction or is whatever that makes sedative and euphoric effects (opium-like action).
them drunk i.e. mosquito coils, anxiolytic drugs or Jansen and Prast (1988) described mitragynine
antidepressants (alprazolam, diazepam, amitriptyline, alkaloids as substances with highly unusual but
nortriptyline, etc.), analgesic (paracetamol, tramadol), well-documented history as both a depressant and
some of drug abuse (methadone, marijuana, a stimulant while possessing the chemical structure
methamphetamine), herbicide, or even the powder of a suspected psychedelic5). Kratom leaves contain
peeled from the inside of fluorescent light bulbs1,2). approximately 0.2% mitragynine alkaloids by
After War on Drug Campaign in 2003, some weight. Approximately twenty leaves of Kratom
addicts switch to other inebriate substances such (normally used in one pot of boiled Kratom leaves
as alcohol, tranquilizers and Kratom. In this and used to make 4x100 formulae for one serve)
regard, “4x100” has become popular as a cocktail contain approximately 17 mg of mitragynine6).
drug abuse formulae in youthful Muslim because However, the content of mitragynine alkaloids in
consuming this cocktail formulae causes a feeling Kratom leaves is variable and depends on
like drinking alcohol which is prohibited in their geographic origin as well as the different season7).
religious regulation2). Furthermore, most of the Dose-dependent neuropsychiatric effects are shown
ingredients in these formulae are not restricted within five to ten minutes after consumption, and
controlled, except for Kratom and some of drug last for up to one hour6). In the mouse model,
abuse which is an illegal substance. However, this mitragynine alkaloids doses as high as 920 mg/kg
plant can be found naturally in many places. An were given without apparent clinical effect8).
increasing of using the cocktail formulae is shown Since codeine-containing cough syrup was

∗
To whom correspondence should be addressed.
E-mail: [email protected]
Tel. +66 2207 6108

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44 Case Report

restricted after War on Drug Campaign, another The eluted sample was transferred to autosampler
cough syrup regimen containing diphenhydramine vial and 10 µl was injected into the liquid
was brought to abuse instead. A study of Tanda et chromatography-electrospray-ionization-time of flight
al.9) demonstrated that diphenhydramine exhibited mass spectrometry (LC-ESI-TOF-MS).
cocaine-like activities and increased dopamine Apparatus
neurotransmission in mesolimbic areas of reward The HPLC system was an Agilent Technologies
system like various drugs of abuse. Presently, most (Waldbronn, Germany) 1200 Series. Chromatographic
cough syrups used to make 4x100 formulae separation was performed with Bruker Inst. ODS-
usually are antihistamine preparations containing AQ (50×4.6 mm i.d.) reversed-phase column at 40
diphenhydramine that are available in drug stores. °C. The mobile phase, delivered at a flow rate of
Reports of toxicity from mitragynine are rare6). 0.5 ml/min, was a gradient of acetonitrile and
In animal models, mitragynine was shown to cause mixture of 0.1% formic acid in 5 mM NH4OAc,
less respiratory depression than other narcotics5). (70% : 30%), transfer acceleration ramps 20 bar/sec,
There is no cases of death due to Kratom were flow 100 ml/min. The mass analyzer was a Bruker
reported in the United States10). Thus, toxicity from Daltonics (Bremen, Germany) micrOTOF™. The
abuse of Kratom leaves seem not to be serious. instrument was operated in electrospray positive
However a corpse autopsied at the Institute of ionization mode (ESI+) using a m/z range of 50-
Forensic Medicine, Police Hospital, The Royal Thai 1,500. Data acquisition, peak integration and
Police Headquarter, on April 2009 was reported calculation were assigned to a computer workstation
with the suspected cause of death from “4x100” running HyStar 3.2 and Hyphenation Star PP
formulae intoxication. V.3.2.37.0 software.
CASE REPORT: RESULTS AND DISCUSSION: Interpretation of
Case History the cause of death in this case was limited and
A corpse of 21-years-old man was taken by could be performed only the toxicological data
police to the Institute of Forensic Medicine, Police from blood and urine samples. However, an
Hospital for investigating the cause of death. His advantage of apparatus for toxicological work, LC-
body showed fixed livor mortis appeared on his ESI-TOF-MS appeared to be an efficient and very
back indicating that he had died for more than 8 sensitive technique for identification of drugs and
hours. His religious is Islamism. His sister gave metabolites in poisoning cases. In this case, mitra-
information that last night he went home and told gynine alkaloid, caffeine, diphenhydramine, alprazolam,
her that he felt sick and wanted to sleep. Next day, nortriptyline, methadone, tramadol, methamphetamine
at noon she found him laid down on the floor and and some of their metabolites were found after blood
not breathing. There were bloody exudates from his and urine analysis. Blood concentrations of alpra-
nose and foamy blood from his mouth. Due to his zolam, tramadol, nortriptyline, methadone, meth-
religion, full autopsy could not be performed. Thus amphetamine and caffeine were 0.2, 0.27, 1.78, 0.3,
only blood and urine samples were collected for 0.4 and 0.39 µg/ml, respectively (Table 1.and
toxicological analysis. Figure 1). Regarding to the analytical results, it
Sample preparation could conclude that this case was abused of
Blood or urine sample volume 1 ml was mixed polydrugs called 4x100 formulae.
with 300 µl of 200 mM KOH and pH value was 4x100 formulae is a home-made Kratom juice
adjusted to 10, after that 3 ml of methanol and 2 cocktail consists of none accurate ingredients.
ml of mixture of water and 200 mM KOH was Types and amounts of ingredients depend on the
added respectively. Then the mixture was applied availability and the sastisfaction of the abusers.
onto the SPE cartridges and clean-up was They always use this substance as well as
accomplished with successive 2 ml of water. The smoking. Thus from results, nicotine and
cartridge was dried for 5 min before elution with 2 cotinine, an active ingredients and metabolite in
ml of a mixture of methanol: ammonia (95:5 v/v). cigarette, were found.

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Case Report 45

Figure1 LC-ESI-TOF-MS chromatogram of urine sample

Table 1 Drugs concentrations

Concentration (µg/ml)
Drugs
Blood Urine
Alprazolam 0.2 0.65
Tramadol 0.27 26.73
Nortriptyline 1.78 4.60
Methadone 0.30 5.20
Methamphetamine 0.4 2.5
Caffeine 0.39 2.32
Mitragynine not quantitative not quantitative
Diphenhydramine not quantitative not quantitative
Nicotine not quantitative not quantitative

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46 Case Report

Considering the probability of each drug found with other medicine may cause more increased
in this case that which one seemed to be the interaction risk. For example, co-administration
cause of death. Methadone tramadol and nortriptyline with diphenhydramine may increase anticholi-
are likely to be capable of causing death from nergic side effects, while, co-administration with
several previous reports, while very few data is methadone may cause dose-related prolongation of
available for mitragynine as a cause of death. QT interval, elevated cardiac risk and fatal.
Blood methamphetamine level in this case (0.4 Methadone, an opiate withdrawal medication, is
µg/ ml) was much lower than the lethal range (over restrictly available only in the special hospital.
4.5 µg/ml) that was demonstated by Takayasu et al11). Manifestation of toxic overdose of methadone
Tramadol, an opioid analgesic, in therapeutic includes stupor, muscle flaccidity, respiratory
dose, CNS side effects such as nausea, vomiting, depression, coma and circulatory collapse. Several
drowsiness, vertigo, constipation, headache and fatal methadone concentrations had been reported
somnolence had been reported. In case of poisoning, in previous studies. For example, Milroy et al.21)
severe complications may occur including seizures 16). studied in 50 adult victims and reported the
The risk of tramadol induce seizures may be postmortem range of methadone between 0.08 –
increased during co-administration with any 2.7 µg/ml. The methadone blood concentration
substances that can reduce the seizure threshold found in this present study was 0.3 µg/ml, which
such as methamphetamine, methadone and nor- is consistent with the report earlier.
triptyline, Decker et al.17) reported one case of fatal Alprazolam, a short acting benzodiazepine, that
intoxication due to tramadol alone. Blood tramadol is most commonly found in 4x100 formulae. Street
levels was 8 µg/ml was found, while therapeutic name in Thai is “Mano” or “Zolam”. In general,
blood levels in adults range from 0.1 to 0.3 µg/ml. benzodiazepines have a flatter dose-response curve
18)
Goeringer et al. reported that tramadol concentration than other sedative-hypnotics, and exhibit a low
in the case of drug-combined fatalities is range from incidence of toxicity in humans. Although alprazolam
0.03 to 22.59 µg/ml, which is consistent with the has generally been considered to be safe, more
finding in this study (Tramadol concentration in central nervous system depressant effects were
blood was 0.27 µg/ml). shown at high doses. Schulz et al.12) reported that
Nortriptyline is one of the classical tricyclic therapeutic and toxic plasma levels of alprazolam
antidepressants (TCA) widely used in Thailand. ranged between 0.005-0.05 and 0.1-0.4 µg/ml,
Plasma concentration of the parent drug and its respectively. In contrast, McCormick et al.13)
metabolites over 1 µg/ml are prognostic factors of presented two patients who attempted to commit
serious intoxication19). The clinical manifestations of suicide by ingest a handful of alprazolam. These
a TCA overdose are directly linked to its pharmaco- patients had markedly elevated serum alprazolam
logy. There are four major classes of effects, concentrations, ten times greater than the
including anticholinergic, direct adrenergic blockade, therapeutic levels. Surprisingly, they did not show
inhibition of norepinephrine and serotonin reuptake, any significant alterations in vital signs or CNS
and blockade of fast sodium channels. Manifestations depression. A study of Barbara et al.14) on 178
of these effects include decreased consciousness, cases with alprazolam-related death indicated that
confusion, delirium, seizures, hypotension, and alprazolam alone was rarely a cause of death, but
ECG changes. Hypotension is a major cause of death was always due to combined drug toxicity. In
mortality, and is related to reduce myocardial this study, blood alprazolam concentration was 0.2
contractility and systemic vascular resistance. µg/ml which was consistent to the concentration
Cardiac manifestations include PR and QT found by Michaud et al.15) that had been reported
prolongation, QRS widening to resemble a right the fatal case of alprazolam and tramadol
bundle branch block, atrioventricular block, and overdose. Thus, combined toxicity of alprazolam
persistent sinus tachycardia.20) Overdoses of only with other depressants seemed likely to be a
nortriptyline could be fatal, but co-administration cause of death of this case.

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