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To the Editor:—
The California Bureau of Narcotics has recently advised me that nurse addicts are substituting 1 cc ampules of isoproterenol (Isuprel) hydrochloride for 1 cc 50 mg ampules of meperidine (Demerol) hydrochloride.The substitution is made possible by the similarity of size and color coding of the two products. The addict "messes up" the label and slips the Isuprel ampule into the narcotics box, removing the Demerol ampule as she does so. Unless careful attention is taken to read each of these ampules the substitution may slip by with disastrous results. The manufacturer has been notified.
Bloomquist ER. Demerol-Isuprel Switch by Addicted Nurses. JAMA. 1964;190(11):1015. doi:10.1001/jama.1964.03070240061025