3 gas station drugs that could kill you
Key Takeaways
Kratom, male enhancement drugs, and tianeptine-containing products can all be purchased at gas stations and convenience stores—at the buyer’s own risk.
Physicians should consider overdose or dependence as a differential diagnosis.
Intoxication from these drugs resembles opioid toxicity and is usually treated with naloxone or some other opioid antagonist; ultimately, however, patient education about the risks is key.
As a physician, it may be surprising to see so many dangerous, unregulated drugs available for sale at gas station counters. Some of these drugs are legal, while others are (hopefully) being pulled off the shelf by the FDA. Whether these drugs are legally available or not, doctors should be on the lookout for negative health effects in patients who admit to using these products.
Let’s take a closer look at these dangerous drugs and supplements sold almost exclusively at gas stations and bodegas, along with their potential hazards to your patients’ physical and mental health.
Kratom (Mitragyna speciosa korth)
In Indonesia, Malaysia, and other South Asian countries where Mitragyna speciosa korth grows indigenously, kratom is used to treat a wide range of conditions, including substance use disorder and opioid withdrawal symptoms. It is also used to treat hypertension, stomach ailments, infections, diabetes, and diarrhea. This substance exhibits a bifurcated clinical effect, being a psychostimulant at up to 5 g of ingested material, but with opioid-like effects at between 5 g and 15 g.[]
Kratom is sold at convenience stores, gas stations, and headshops, as well as on the web. In some stores, kratom products are kept under lock and key and only available to customers over 18, while in other stores they are displayed near the cash register, next to cigarette lighters and energy shots.[]
For clinical purposes, it’s important to note that kratom users tend to be White and 30 to 50 years of age.
If you know or suspect a patient is using kratom, be on the lookout for common adverse effects of the drug, including nausea, itching, sweating, tachycardia, drowsiness, and loss of appetite.[]
Longer term effects include anorexia, weight loss, insomnia, hepatotoxicity, seizure, and hallucinations. Several cases of psychosis secondary to addictive kratom use have been reported, including hallucinations, delusions, and confusion.
In the United States, kratom is often advertised by means of colorful imagery, with no mention of ingredients, dosages, type, and alkaloid content.[] In other words, it’s unclear what adulterants are present.
Kratom use can be overlooked, misunderstood, or even unheard of in certain medical environments, note the authors of a case report on kratom overdose published in Cureus.[] Emergency medicine physicians will likely give a single dose of naloxone to the undifferentiated patient.
If urine toxicology test results are negative, the specialist may decide not to give further naloxone for continued symptoms. (There is currently no urine or serum test to detect kratom.) Clinicians should watch for rebound hypoxia, which occurs within 24 hours and must be accounted for during patient management. Currently, there is little specific data guiding the management of kratom toxicity and little is known about the related rebound hypoxia.
Kratom overdose is a diagnosis of exclusion, only made after a thorough toxicology workup ruling out other substances that can cause hypoxia or symptoms.
The case report authors underscored the risk of rebound hypoxia, stating that “it is crucial for ED practitioners to understand this and to ensure patients are admitted for observation in cases of severe toxicity requiring naloxone, even if clinical symptoms appear promising in the first few hours after presentation.”
Should a patient leave emergency care against medical advice, but with full decision-making capacity, they and their companions should be given naloxone before signing out of the department.
Rhino 69
The FDA has long warned of “male enhancement” agents playing on the keyword “Rhino” (eg, Rhino 69) containing active ingredients in the form of PDE5 inhibitors such as sildenafil (Viagra) or tadalafil (Cialis).[]
Typically requiring a prescription, PDE5 inhibitors can dangerously interact with nitrates found in nitroglycerin and other drugs, thus leading to a hypotensive emergencies.[] In the past, the FDA has received reports of people experiencing chest pain, severe headaches, and prolonged erections after taking a Rhino product, resulting in surgery and hospitalization.
Current AHA/ACC advice on treating hypotension induced by PDE5 inhibitor-nitrate interaction dates back to 2010 and includes placing the patient in the Trendelenburg position with aggressive fluid resuscitation.[] Additional ad hoc interventions include the administration of an α-agonist (phenylephrine) or a β-agonist (norepinephrine), and intra aortic balloon counterpulsation.
Tianeptine, aka 'gas station' heroin
In January 2024, the FDA alerted convenience and gas stations to stop selling Neptune’s Fix and any other brand containing tianeptine products.[]
The FDA has fielded accounts of seizure, loss of consciousness, and death among tianeptine users. Consumers were warned that potentially deadly interactions may also result when tianeptine interacts with other drugs.
Tianeptine, which can also be marketed as Coaxil or Stablon in the United States, is used as an antidepressant in Europe, Asia, and Latin America. This atypical tricyclic drug is not approved by the FDA for medical use. Various case studies report that this opioid-receptor agonist can result in severe adverse events and death among recreational users.
The following are some highlights from a recent CDC report that characterized all tianeptine-associated calls reported to poison control centers between 2000 and 2017:[]
Exposure calls for tianeptine increased between 2014 and 2017, thus presenting an emerging public-health risk
Most exposures occurred in adults aged 21-40 years, with moderate clinical outcomes
Tianeptine toxicity usually included neurological, cardiovascular, and gastrointestinal signs and symptoms that resembled opioid toxicity
Coexposure with phenibut, ethanol, benzodiazepines, and opioids was common, with 31% of co-exposures being phenibut
A drastic increase in the number of calls dealing with withdrawal
As with kratom, overdose on tianeptine-containing products can be mistaken for heroin overdose by emergency medicine physicians. Similarly, naloxone or other opioid antagonists have been suggested as treatment. It should be noted that tianeptine urine concentrations are low because the drug is excessively metabolized, thus negating the efficacy of urine tests.[]
What this means for you
Gas stations and convenience stores are contributing to emerging public health threats by selling drugs that exhibit opioid-like toxicities. Physicians should keep toxicities with tianeptine, kratom, or OTC drugs resembling PDE5 inhibitors in mind when treating patients and ask about use of such agents. It’s important to remember that toxicities with these drugs usually occur alongside use of phenibut, ethanol, benzodiazepine, and opioids. Naloxone is a go-to treatment for kratom and tianeptine poisoning, but more research is needed.