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Brent J, Wax P, Culbreth R, Campleman S, Aldy K. From Patient Registry to Multi-Center Research Consortium: the Toxicology Investigators Consortium (ToxIC) Turns Fifteen. J Med Toxicol 2024; 20:293-298. [PMID: 38935267 PMCID: PMC11288211 DOI: 10.1007/s13181-024-01020-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) was launched as a prospective multi-center registry of cases who receive medical toxicology consultations. Now, with over 100,000 cases, the Core Registry continues to address many medical toxicology research questions and has served as the foundation for multiple sub-registries, including the North American Snakebite Registry and the Medications for Opioid Use Disorder sub-registry. ToxIC also has evolved a portfolio of non-registry-based projects utilizing medical toxicology physician site principal investigators who enroll patients through emergency departments, irrespective of whether they received a medical toxicology consultation. These studies include the FDA-ACMT COVID-19 ToxIC Pharmacovigilance Project, which identifies adverse drug reactions related to the treatment of COVID-19, the Fentalog Study a toxico-surveillance study of suspected opioid overdose cases, the Drug Overdose Toxico-Surveillance Reporting Program which enrolls either suspected stimulant or opioid overdose cases, and the just being launched Real-World Examination of Naloxone for Drug Overdose Reversal project. Given ToxIC's experience in multi-center studies and its well-developed infrastructure, it is well-positioned to provide a nimble response on the part of the medical toxicology community to addressing evolving toxicological threats, drug and chemical toxicosurveillance, and other important medical toxicology priorities.
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Affiliation(s)
- Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA.
- Toxicology Associates, Littleton, CO, USA.
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, USA
| | | | | | - Kim Aldy
- American College of Medical Toxicology, Phoenix, AZ, USA
- Baylor University Medical Center, Dallas, TX, USA
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Amaducci AM, Campleman SL, Li S, Karshenas DL, Spyres MB, Farrugia LA, Kang AM, Culbreth RE, Wax PM, Brent J, Aldy K. The Toxicology Investigators Consortium 2022 Annual Report. J Med Toxicol 2023; 19:313-340. [PMID: 37644342 PMCID: PMC10522558 DOI: 10.1007/s13181-023-00962-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023] Open
Abstract
Since 2010, medical toxicology physicians from the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) have provided reports on their in-hospital and clinic patient consultations to a national case registry, known as the ToxIC Core Registry. De-identified patient data entered into the registry includes patient demographics, reason for medical toxicology evaluation, exposure agents, clinical signs and symptoms, treatments and antidotes administered, and mortality. This thirteenth annual report provides data from 7206 patients entered into the Core Registry in 2022 by 35 participating sites comprising 52 distinct healthcare facilities, bringing the total case count to 94,939. Opioid analgesics were the most commonly reported exposure agent class (15.9%), followed by ethanol (14.9%), non-opioid analgesic (12.8%), and antidepressants (8.0%). Opioids were the leading agent of exposure for the first time in 2022 since the Core Registry started. There were 118 fatalities (case fatality rate of 1.6%). Additional descriptive analyses in this annual report were conducted to describe the location of the patient during hospitalization, telemedicine consultations, and addiction medicine treatments.
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Affiliation(s)
- Alexandra M Amaducci
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, 2545 Schoenersville Rd, Bethlehem, PA, 18017, USA
| | - Sharan L Campleman
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Shao Li
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Dana L Karshenas
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Meghan B Spyres
- Department of Medical Toxicology, Banner - University Medical Center, 1111 E McDowell Rd, Building A, Fl 2, Phoenix, AZ, 85006, USA
| | - Lynn A Farrugia
- Department of Emergency Medicine, UF Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL, 32608, USA
| | - A Min Kang
- Department of Medical Toxicology, Banner - University Medical Center, 1111 E McDowell Rd, Building A, Fl 2, Phoenix, AZ, 85006, USA
- Departments of Internal Medicine and Child Health, University of Arizona College of Medicine - Phoenix, 475 N 5Th St, Phoenix, AZ, 85004, USA
| | - Rachel E Culbreth
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA.
| | - Paul M Wax
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA
| | - Kim Aldy
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
- Department of Emergency Medicine, Baylor University Medical Center, 3500 Gaston Ave, Dallas, TX, 75246, USA
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Basse J, Ruha AM, Baumgartner K, Mullins ME, Greene S, Wax PM, Brent J, Campleman S, Schwarz ES. Clinical Presentations, Treatments, and Outcomes of Non-native Snake Envenomations in the United States Reported in the North American Snakebite Registry. J Med Toxicol 2023; 19:16-25. [PMID: 36175787 DOI: 10.1007/s13181-022-00912-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/31/2022] [Accepted: 09/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Non-native snake envenomations in the United States are uncommon with much unknown about a patient's presenting signs and symptoms. Antivenoms for non-native snake envenomations are not typically available in hospital pharmacies which may limit their administration. What are the clinical presentations, treatments, and outcomes of non-native snake envenomation cases reported to the North American Snakebite Registry (NASBR) of the Toxicology Investigators Consortium (ToxIC)? METHODS This is a descriptive review of all non-native envenomations reported to the NASBR from 2013 to March 2022. Data abstracted included snake species, patient history, clinical signs, diagnostics, treatment (including antivenom usage), follow-up, and final outcome. RESULTS We identified 19 non-native snake envenomations resulting from encounters with eleven different species, eight of which belonged to the Viperidae family. The most common presenting symptoms were edema (18 patients), ecchymosis (seven patients), and necrosis (six patients). Systemic effects and hematologic abnormalities were less common. The most common treatments were extremity elevation and analgesia, with two patients receiving mechanical ventilation. Ten patients received antivenom. No patients died. Three patients had loss of mobility in a digit at the last follow-up visit. One patient had permanent tissue loss of a small area on a finger. CONCLUSIONS The results of this study suggest that non-native snake envenomations in the United States frequently cause local soft tissue effects and less frequently cause systemic or hematologic effects. Most patients received antivenom, although several patients envenomated by snakes for which a specific antivenom exists did not receive any. Sequelae at the last follow-up of such encounters consisted of local mobility deficits.
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Affiliation(s)
- Jack Basse
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Anne-Michelle Ruha
- Banner University Medical Center Phoenix, 1012 E Willetta ST, Phoenix, AZ, Fl285006, USA
| | - Kevin Baumgartner
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Michael E Mullins
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Spencer Greene
- University of Houston College of Medicine, Kingwood, TX, 22999 US Hwy 59N773394, USA
| | - Paul M Wax
- American College of Medical Toxicology, 10645 N. Tatum Blvd, Suite 200-111, Phoenix, AZ, 85028, USA
| | - Jeffrey Brent
- School of Medicine, University of Colorado, 12401 East 17th Avenue, 7th floor, Aurora, CO, 80045, USA
| | - Sharan Campleman
- American College of Medical Toxicology, 10645 N. Tatum Blvd, Suite 200-111, Phoenix, AZ, 85028, USA
| | - Evan S Schwarz
- Washington University School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA.
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Desai NM, Mistry RD, Brou L, Boehnke ME, Lee JS, Wang GS. Pediatric Exposures Reported to the Toxicology Investigators Consortium, 2010-2015. Pediatr Emerg Care 2021; 37:e1039-e1043. [PMID: 31464880 DOI: 10.1097/pec.0000000000001893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Poisoning is the leading cause of injury death in pediatric patients. Hospital and provider readiness, including pharmacy stocking, depends on reliable surveillance data describing local patterns of age-specific clinically significant exposures and the therapeutic modalities employed in their treatment. We aimed to characterize trends in clinically significant toxic exposures and their management. METHODS We performed a retrospective review of patients 18 years or younger in the American College of Medical Toxicology's Toxicology Investigators Consortium (ToxIC) Registry, a self-reporting database completed by bedside consulting medical toxicologists. We reviewed cases from January 1, 2010, through December 31, 2015. In 2015, ToxIC included 101 health care facilities. Data collected included demographics, geographic region, encounter and exposure details, survival, and therapeutic modalities employed, including antidotes, antivenoms, gastric decontamination, enhanced elimination, hyperbaric oxygen therapy, and extracorporeal membrane oxygenation. RESULTS From 2010 to 2015, 11,616 consults were recorded in ToxIC. Pediatric consultations increased from 934 (23.7%) in 2010 to 2425 (29.9%) in 2015 (P < 0.001). Exposures were most commonly reported in females (57.8%) and adolescents (59.4%). Intentional ingestions (55.5%) comprised the majority of cases. The most frequent agents of exposure were analgesics (21.0%). There were 38 deaths reported (0.9%). The antidote used most commonly was N-acetylcysteine (11.0%). Geographic variation was demonstrated in prevalence of envenomations and heavy metal exposures, their respective treatments, and overall use of decontamination. CONCLUSIONS Toxicology consultations for pediatric exposures increased from 2010 to 2015. Understanding which pediatric exposures require toxicologist management, the therapies most frequently employed, and geographical patterns is paramount to facility-level planning, pharmacy stocking, and provider education.
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Affiliation(s)
- Neil M Desai
- From the Section of Pediatric Emergency Medicine, British Columbia Children's Hospital, Vancouver, BC, Canada
| | | | - Lina Brou
- Department of Family Medicine, University of Colorado, Aurora, CO
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Bachar R, Majewski JR, Shrack C, El-Khoury A. Acute psychosis and serotonin syndrome in the setting of "Triple-C" overdose: a case report. J Med Case Rep 2021; 15:548. [PMID: 34732250 PMCID: PMC8566019 DOI: 10.1186/s13256-021-03163-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/20/2021] [Indexed: 12/17/2022] Open
Abstract
Background Over-the-counter medication overdose is a difficult diagnostic challenge for many physicians as common drug screening assays cannot detect these substances. We present a case of acute psychosis, serotonin syndrome, and anticholinergic overdose-like properties in the setting of Coricidin HBP Cough & Cold tablets, known by their street name Triple-C. This is the first case report we are aware of involving a patient presenting with these symptoms and requiring critical-care-level support. Case presentation A 31-year-old African American female with a past medical history of anxiety, childhood asthma, previous methamphetamine abuse, and coronavirus disease 2019 infection in August 2020 was brought to the emergency department by the local police department with altered mental status. Initial blood work, including extended drug screens, were unremarkable for a definitive diagnosis. This patient required critical-care-level support and high sedation because of her symptoms. Collateral history revealed the patient regularly consumed Triple-C daily for the 6 weeks prior to admission. A trial off sedation was attempted after 24 hours with no complications. The patient admitted to regular Triple-C consumption and auditory hallucinations since adolescence. She was discharged safely after 48 hours back into the community. She was lost to follow-up with psychiatry and internal medicine; however, she was evaluated in the emergency room 1 month later with a similar psychiatric presentation. Conclusion Overdose of Triple-C should be kept in the differential diagnosis of patients presenting with a triad of psychosis, serotonin syndrome, and anticholinergic overdose, in the setting of unknown substance ingestion.
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Affiliation(s)
- Roudi Bachar
- Indiana University School of Medicine, 520 S. St, Vincennes, Indiana, 47591, USA.
| | - John Robert Majewski
- Indiana University School of Medicine, 520 S. St, Vincennes, Indiana, 47591, USA
| | - Christopher Shrack
- Indiana University School of Medicine, 520 S. St, Vincennes, Indiana, 47591, USA
| | - Anthony El-Khoury
- Indiana University School of Medicine, 520 S. St, Vincennes, Indiana, 47591, USA
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Malnourishment-Associated Acetaminophen Toxicity in Pregnancy. Obstet Gynecol 2021; 137:877-880. [PMID: 33831932 DOI: 10.1097/aog.0000000000004351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although acetaminophen is commonly used in pregnancy, it can deplete glutathione concentrations and cause accumulation of 5-oxoproline, with subsequent metabolic acidosis. CASE A malnourished 25-year-old woman, G2P1001, with chronic acetaminophen use presented with abdominal pain and high anion gap metabolic acidosis. After ruling out other potential causes, her urine 5-oxoproline level was found to be elevated. She received N-acetylcysteine, with resolution of the acidosis. CONCLUSION Those who care for pregnant patients should remain alert to 5-oxoprolinemia as a cause of metabolic acidosis during pregnancy. Care must be taken when using acetaminophen in states of malnutrition. N-acetylcysteine seems to be an effective antidote.
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Zwartsen A, Olijhoek ME, Westerink RHS, Hondebrink L. Hazard Characterization of Synthetic Cathinones Using Viability, Monoamine Reuptake, and Neuronal Activity Assays. Front Neurosci 2020; 14:9. [PMID: 32063828 PMCID: PMC7000521 DOI: 10.3389/fnins.2020.00009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/07/2020] [Indexed: 12/20/2022] Open
Abstract
Synthetic cathinones are the second largest class of new psychoactive substances (NPS) on the drug market. Despite the large number of different cathinones and their abundant use, hazard characterization is mainly limited to their potential to inhibit monoamine transporters. To expand the current hazard characterization, we first investigated the acute effects of several synthetic cathinones [4-methylethcathinone (4-MEC), 3-methylmethcathinone (3-MMC), 4-MMC, methylone, pentedrone, α-pyrrolidinovalerophenone (α-PVP), and 3,4-methylenedioxypyrovalerone (MDPV)] on human dopamine, norepinephrine, and serotonin reuptake transporters (hDAT, hNET, and hSERT), which were stably transfected in human embryonic kidney (HEK) 293 cells. Next, we examined effects on spontaneous neuronal activity in rat primary cortical cultures grown on microelectrode arrays (MEAs) as an integrated endpoint for neurotoxicity. Changes in neuronal activity were assessed after acute (30 min) and prolonged (4.5 h) exposure. Moreover, we investigated whether neuronal activity recovered after washout of the exposure (24 h after the start of the 5 h exposure). Low micromolar concentrations of synthetic cathinones inhibited monoamine uptake via hDAT and hNET, while higher cathinone concentrations were needed to inhibit uptake via hSERT. Comparable high concentrations were needed to inhibit spontaneous neuronal activity during acute (30 min) and prolonged (4.5 h) exposure. Notably, while the inhibition of neuronal activity was reversible at low concentrations, only partial recovery was seen following high, but non-cytotoxic, concentrations of synthetic cathinones. Synthetic cathinones with either a pyrrolidine moiety or long alkyl-tail carbon chain more potently inhibit monoamine uptake via hDAT and neuronal activity. Monoamine uptake via hNET was most potently inhibited by synthetic cathinones with a pyrrolidine moiety. The combination of integrated measurements (MEA recordings of neuronal activity) with single target assays (monoamine reuptake transporter inhibition) indicates inhibition of hDAT and hNET as the primary mode of action of these synthetic cathinones. Changes in neuronal activity, indicative for additional mechanisms, were observed at higher concentrations.
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Affiliation(s)
- Anne Zwartsen
- Neurotoxicology Research Group, Toxicology Division, Institute for Risk Assessment Sciences (IRAS), Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands.,Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Michiel E Olijhoek
- Neurotoxicology Research Group, Toxicology Division, Institute for Risk Assessment Sciences (IRAS), Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Remco H S Westerink
- Neurotoxicology Research Group, Toxicology Division, Institute for Risk Assessment Sciences (IRAS), Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Laura Hondebrink
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Spyres MB, Farrugia LA, Kang AM, Calello DP, Campleman SL, Pizon A, Wiegand T, Kao L, Riley BD, Li S, Wax PM, Brent J. The Toxicology Investigators Consortium Case Registry-the 2018 Annual Report. J Med Toxicol 2019; 15:228-254. [PMID: 31642014 PMCID: PMC6825068 DOI: 10.1007/s13181-019-00736-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 10/25/2022] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) Registry was established by the American College of Medical Toxicology (ACMT) in 2010. The Registry collects data from participating sites with the agreement that all bedside medical toxicology consultation will be entered. The objective of this ninth annual report is to summarize the Registry's 2018 data and activity with its additional 7043 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from 1 January to 31 December 2018. Detailed data was collected from these cases and aggregated to provide information which included demographics, reason for medical toxicology evaluation, agent and agent class, clinical signs and symptoms, treatments and antidotes administered, mortality, and whether life support was withdrawn. A total of 51.5% of cases were female, 48% were male, and 0.6% transgender. Non-opioid analgesics were the most commonly reported agent class, followed by antidepressants and opioids. Acetaminophen was once again the most common agent reported. There were 106 fatalities, comprising 1.5% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe exposures in elderly patients, addiction consultation practices, and risk factors for bupropion-induced seizures. The launch of the ToxIC Qualified Clinical Data Registry (TQCDR) is also described.
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Affiliation(s)
- Meghan B Spyres
- Department of Emergency Medicine, Division of Medical Toxicology, University of Southern California, 1200 N State St. Rm 1011, Los Angeles, CA, 90033, USA.
| | - Lynn A Farrugia
- Hartford Hospital and University of Connecticut School of Medicine, 80 Seymour Street, Hartford, CT, 06102, USA
| | - A Min Kang
- Departments of Medicine and Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Medical Toxicology, Banner-University Medical Center, 1012 E Willetta Street, Fl 2, Phoenix, AZ, 85006, USA
| | - Diane P Calello
- New Jersey Medical School, Rutgers, The State University of New Jersey, 140 Bergen Street, Suite G1600, Newark, NJ, 07101-1709, USA
| | - Sharan L Campleman
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Anthony Pizon
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Timothy Wiegand
- University of Rochester Medical Center and Strong Memorial Hospital, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Louise Kao
- Indiana university school of medicine, 340 West 10th Street, Suite 6200, Indianapolis, IN, 46202, USA
| | - Brad D Riley
- Michigan State University College of Human Medicine, 100 Michigan NE MC49, Grand Rapids, MI, 49503, USA
| | - Shao Li
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Paul M Wax
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jeffery Brent
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA
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Anderson SAR, Oprescu AM, Calello D, Monte A, Dayan PS, Hurd YL, Manini AF. Neuropsychiatric Sequelae in Adolescents With Acute Synthetic Cannabinoid Toxicity. Pediatrics 2019; 144:e20182690. [PMID: 31285395 PMCID: PMC6697124 DOI: 10.1542/peds.2018-2690] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Adolescents represent the largest age group that presents to emergency departments (ED) for synthetic cannabinoid (SC) toxicity; however, the neurotoxic effects of acute SC exposures in this group are understudied. Our aim was to characterize the neuropsychiatric presentation of adolescents with SC-related exposure in the ED compared with those with traditional cannabis exposure. METHODS A multicenter registry of clinical information prospectively collected by medical toxicologists (Toxicology Investigators Consortium Case Registry) was reviewed for adolescents presenting to the ED after SC or cannabis exposure from 2010 through 2018. Associations were measured between drug exposures and neuropsychiatric symptoms and/or signs. Exposures were classified into 4 groups: SC-only exposure, SC-polydrug exposures, cannabis-only exposure, and cannabis-polydrug exposures. RESULTS Adolescents presenting to the ED with SC-only exposure (n = 107) had higher odds of coma and/or central nervous system depression (odds ratio [OR] 3.42; 95% confidence interval [CI] 1.51-7.75) and seizures (OR 3.89; 95% CI 1.39-10.94) than those with cannabis-only exposure (n = 86). SC-only drug exposure was associated with lower odds of agitation than cannabis-only exposure (OR 0.18; 95% CI 0.10-0.34). In contrast, the group with SC-polydrug exposures (n = 38) had higher odds of agitation (OR 3.11; 95% CI 1.56-7.44) and seizures (OR 4.8; 95% CI 1.80-12.74) than the cannabis-polydrug exposures group (n = 117). CONCLUSIONS In this multisite cohort of US adolescents assessed in the ED, SC exposure was associated with higher odds of neuropsychiatric morbidity than cannabis exposure providing a distinct neurospychiatric profile of acute SC toxicity in adolescents.
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Affiliation(s)
| | - Anna M Oprescu
- Departments of Psychiatry, Neuroscience, and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diane Calello
- Department of Emergency Medicine, New Jersey Medical School, Rutgers University, Newark, New Jersey; and
| | - Andrew Monte
- Departments of Emergency Medicine and Pharmaceutical Sciences, School of Medicine, University of Colorado, Aurora, Colorado
| | - Peter S Dayan
- Departments of Pediatrics and
- Emergency Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, New York
| | - Yasmin L Hurd
- Departments of Psychiatry, Neuroscience, and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai and Elmhurst Hospital Center, New York, New York
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Zimmerman L, Kilwein TM, Beyer D, Marks C, Looby A. "Not for Human Consumption": A Descriptive Investigation into User Characteristics, Motives, and Consequences Associated with Bath Salt Use. J Psychoactive Drugs 2019; 51:218-224. [PMID: 30724703 DOI: 10.1080/02791072.2019.1571652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Synthetic cathinones, commonly referred to as "bath salts," are recreational designer drugs that recently emerged as a drug of abuse. However, little is known about bath salt users, particularly in the United States (US). This descriptive study aims to better characterize users and user behavior, including common motives for and consequences of use. Individuals with a lifetime history of bath salt use (BSU; n = 110) completed an Internet survey. Participants (50.9% male) were aged 18 to 58 (M = 31.21, SD = 10.25) years and were from 32 US states. Most participants reported past-year BSU, via intranasal use, obtained from a friend or acquaintance. Recreational motives (e.g., to get high, experimentation) were commonly reported, as was use due to drug availability. Participants reported experiencing an average of 5.50 consequences, with both physical (e.g., rapid heartbeat) and psychological (e.g., anxiety) negative outcomes commonly reported. This descriptive information on BSU from a small but diverse sample of users may inform efforts to reduce use and negative consequences, such as eliminating riskier routes of administration (e.g., injection) and targeting specific motives for use (e.g., providing alternative methods for mood expansion).
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Affiliation(s)
- Lauren Zimmerman
- a Department of Psychology, University of Wyoming , Laramie , WY , USA
| | - Tess M Kilwein
- a Department of Psychology, University of Wyoming , Laramie , WY , USA
| | - Danielle Beyer
- b Department of Psychology, University of North Dakota , Grand Forks , ND , USA
| | - Cassidy Marks
- b Department of Psychology, University of North Dakota , Grand Forks , ND , USA
| | - Alison Looby
- a Department of Psychology, University of Wyoming , Laramie , WY , USA
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Farrugia LA, Rhyee SH, Campleman SL, Judge B, Kao L, Pizon A, Porter L, Riederer AM, Wiegand T, Calello D, Wax PM, Brent J. The Toxicology Investigators Consortium Case Registry-the 2017 Annual Report. J Med Toxicol 2018; 14:182-211. [PMID: 30094774 PMCID: PMC6097971 DOI: 10.1007/s13181-018-0679-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) Case Registry was established by the American College of Medical Toxicology in 2010. The Registry collects data from participating sites with the agreement that all bedside medical toxicology consultations will be entered. The objective of this eighth annual report is to summarize the Registry's 2017 data and activity with its additional 7577 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from 1 January to 31 December 2017. Detailed data was collected from these cases and aggregated to provide information which includes demographics (e.g., age, gender, race, ethnicity), reason for medical toxicology evaluation (e.g., intentional pharmaceutical exposure, envenomation, withdrawal from a substance), agent and agent class, clinical signs and symptoms (e.g., vital sign abnormalities, organ system dysfunction), treatments and antidotes administered, fatality, and life support withdrawal data. Females were involved in 50.4% of cases. Transgender demographic information collection was initiated in 2017 to better represent the population and there were 36 cases involving transgender patients. Adults aged 19-65 were the most commonly reported age group. Non-opioid analgesics were the most commonly reported agent class, with acetaminophen again the most common agent reported. There were 93 fatalities reported in 2017. Treatment interventions were frequently reported with 30.6% receiving specific antidotal therapy. Major trends in demographics and exposure characteristics remained similar to past years' reports. While treatment interventions were commonly required, fatalities were rare.
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Affiliation(s)
- Lynn A Farrugia
- Hartford Hospital and University of Connecticut School of Medicine, 80 Seymour Street, Hartford, CT, 06102, USA.
| | - Sean H Rhyee
- University of Massachusetts Medical School, 55 Lake Avenue North, LA-202, Worcester, MA, 01655, USA
| | - Sharan L Campleman
- American College of Medical Toxicolog, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Bryan Judge
- Spectrum Health Blodgett Hospital, 1840 Wealthy Street SE, Grand Rapids, MI, 49506, USA
| | - Louise Kao
- Indiana University School of Medicine, 340 West 10th Street, Suite 6200, Indianapolis, IN, 46202, USA
| | - Anthony Pizon
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Lauren Porter
- Banner-University Medical Center Phoenix, 925 E. McDowell Rd, Phoenix, AZ, 85006, USA
| | - Anne M Riederer
- American College of Medical Toxicolog, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Timothy Wiegand
- University of Rochester Medical Center and Strong Memorial Hospital, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Diane Calello
- New Jersey Medical School, Rutgers, The State University of New Jersey, 140 Bergen Street, Suite G1600, Newark, NJ, 07101-1709, USA
| | - Paul M Wax
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA
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Farrugia LA, Rhyee SH, Calello DP, Campleman SL, Riederer AM, Malashock HR, Pizon A, Wiegand T, Wax PM, Brent J. The Toxicology Investigators Consortium Case Registry-the 2016 Experience. J Med Toxicol 2017; 13:203-226. [PMID: 28766237 PMCID: PMC5570732 DOI: 10.1007/s13181-017-0627-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 02/01/2023] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) Case Registry was established by the American College of Medical Toxicology in 2010. The Registry contains data from participating sites with the agreement that all bedside medical toxicology consultations will be entered. Currently, 83% of accredited medical toxicology fellowship programs in the USA participate. The Registry continues to grow each year, and as of 31 December 2016, a new milestone was reached, with more than 50,000 cases reported since its inception. The objective of this seventh annual report is to summarize the Registry's 2016 data and activity with its additional 8529 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from 1 January to 31 December 2016. Detailed data was collected from these cases and aggregated to provide information which includes the following: demographics (age, gender, race, ethnicity, HIV status), reason for medical toxicology evaluation (intentional pharmaceutical exposure, envenomation, withdrawal from a substance), agent and agent class, clinical signs and symptoms (vital sign abnormalities, organ system dysfunction), treatments and antidotes administered, fatality and life support withdrawal data. Fifty percent of cases involved females, and adults aged 19-65 were the most commonly reported. There were 86 patients (1.0%) with HIV-positive status known. Non-opioid analgesics were the most commonly reported agent class, with acetaminophen the most common agent reported. There were 126 fatalities reported in 2016 (1.5% of cases). Major trends in demographics and exposure characteristics remained similar overall with past years' reports. While treatment interventions were commonly required, fatalities were rare.
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Affiliation(s)
- Lynn A Farrugia
- Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
| | - Sean H Rhyee
- Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT, 06105, USA
| | - Diane P Calello
- New Jersey Medical School, Rutgers, the State University of New Jersey, 140 Bergen Street, Suite G1600, Newark, NJ, 07101-1709, USA
| | - Sharan L Campleman
- American College of Medical Toxicology, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Anne M Riederer
- American College of Medical Toxicology, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Hannah R Malashock
- University of Arizona College of Medicine, Banner University Medical Center, 1012 E. Willetta Ave, Phoenix, AZ, 85006, USA
| | - Anthony Pizon
- University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Timothy Wiegand
- University of Rochester Medical Center, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Paul M Wax
- American College of Medical Toxicology, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA
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Valento M, Lebin J. Emerging Drugs of Abuse: Synthetic Cannabinoids, Phenylethylamines (2C Drugs), and Synthetic Cathinones. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
OBJECTIVES Drug misuse is a disturbing, common practice among youth. One in 4 American adolescents reports consuming prescription medications without a clinical indication. We sought to explore current trends of drug misuse in adolescents. METHODS Using the 37 participating sites of the ToxIC (Toxicology Investigators Consortium) Case Registry, a cross-country surveillance tool, we conducted an observational cohort study of all adolescents (aged 13-18 years) who presented to emergency departments with drug misuse and required a bedside medical toxicology consultation between January 2010 and June 2013. RESULTS Of 3043 poisonings, 202 (7%) involved drug misuse (139 [69%] were males). Illicit drugs (primarily synthetic cannabinoids and "bath salts") were encountered in 101 (50%), followed by prescription medications (56 [28%]) and over-the-counter (OTC) drugs (51 [25%]). Dextromethorphan was the most commonly misused legal medication (24 [12%]). Polypharmacy exposure was documented in 74 (37%). One hundred sixty-three adolescents (81%) were symptomatic; of these, 81% had central nervous system impairments: psychosis (38%), agitation (30%), coma (26%), myoclonus (11%), and seizures (10%); and 66 (41%) displayed a specific toxidrome, most commonly sedative-hypnotic. Benzodiazepines were the most frequently administered medications (46%). Antidotes were administered to 28% of adolescents, primarily naloxone, physostigmine, N-acetyl-cysteine, and flumazenil. No deaths were recorded. CONCLUSIONS Adolescents presenting with drug misuse may be exposed to a wide range and combinations of therapeutics or illicit substances and frequently display central nervous system abnormalities, compromising the ability to obtain a reliable history. Frontline clinicians should maintain a high index of suspicion, as routine toxicology screenings fail to detect most contemporary misused legal and designer drugs.
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Romanek K, Stenzel J, Schmoll S, Schrettl V, Geith S, Eyer F, Rabe C. Synthetic cathinones in Southern Germany – characteristics of users, substance-patterns, co-ingestions, and complications. Clin Toxicol (Phila) 2017; 55:573-578. [DOI: 10.1080/15563650.2017.1301463] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Katrin Romanek
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jochen Stenzel
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sabrina Schmoll
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Verena Schrettl
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefanie Geith
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Eyer
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Rabe
- Department of Clinical Toxicology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Wang GS, Levitan R, Wiegand TJ, Lowry J, Schult RF, Yin S. Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC). J Med Toxicol 2016; 12:95-9. [PMID: 26013746 DOI: 10.1007/s13181-015-0486-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although there have been many developments related to specific strategies for treating patients after poisoning exposures, the mainstay of therapy remains symptomatic and supportive care. One of the most aggressive supportive modalities is extracorporeal membrane oxygenation (ECMO). Our goal was to describe the use of ECMO for toxicological exposures reported to the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC). We performed a retrospective review of the ACMT ToxIC Registry from January 1, 2010 to December 31, 2013. Inclusion criteria included patients aged 0 to 89 years, evaluated between January 2010 through December 2013, and received ECMO for toxicological exposure. There were 26,271 exposures (60 % female) reported to the ToxIC Registry, 10 (0.0004 %) received ECMO: 4 pediatric (< 12 years), 2 adolescent (12-18 years), and 4 adults (>18 years). Time of initiation of ECMO ranged from 4 h to 4 days, with duration from 15 h to 12 days. Exposures included carbon monoxide/smoke inhalation (2), bitter almonds, methanol, and several medications including antihistamines (2), antipsychotic/antidepressant (2), cardiovascular drugs (2), analgesics (2), sedative/hypnotics (2), and antidiabetics (2). Four ECMO patients received cardiopulmonary resuscitation (CPR) during their hospital course, and the overall survival rate was 80 %. ECMO was rarely used for poisoning exposures in the ACMT ToxIC Registry. ECMO was utilized for a variety of ages and for pharmaceutical and non-pharmaceutical exposures. In most cases, ECMO was administered prior to cardiovascular failure, and survival rate was high. If available, ECMO may be a valid treatment modality.
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Affiliation(s)
- G S Wang
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, 13123 E 16th Ave B251, Aurora, CO, 80045, USA. .,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO, USA.
| | - R Levitan
- Department of Emergency Medicine and Medical Toxicology, University of Arizona, Banner Good Samarian Medical Center, Phoenix, AZ, USA
| | - T J Wiegand
- Department of Emergency Medicine, University of Rochester Medicine, Rochester, NY, USA
| | - J Lowry
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy, Kansas City, MO, USA
| | - R F Schult
- Department of Emergency Medicine, University of Rochester Medicine, Rochester, NY, USA.,Department of Pharmacy, University of Rochester Medicine, Rochester, NY, USA
| | - S Yin
- Cincinnati Drug and Poison Information Center, Cincinnati, OH, USA
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Rhyee SH, Farrugia L, Campleman SL, Wax PM, Brent J. The Toxicology Investigators Consortium Case Registry--the 2014 Experience. J Med Toxicol 2016; 11:388-409. [PMID: 26602099 DOI: 10.1007/s13181-015-0507-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) Case Registry was established in 2010 by the American College of Medical Toxicology. The Registry includes all medical toxicology consultations performed at participating sites. The Registry was queried for all cases entered between January 1 and December 31, 2014. Specific data reviewed for analysis included demographics (age, gender, ethnicity), source of consultation, reasons for consultation, agents involved in toxicological exposures, signs, symptoms, clinical findings, fatalities, and treatment. In 2014, 9172 cases were entered in the Registry across 47 active member sites. Females accounted for 51.1 % of cases. The majority (65.1 %) of cases were adults between the ages of 19 and 65. Caucasians made up the largest identified ethnic group (48.9 %). Most Registry cases originated from the inpatient setting (93.5 %), with a large majority of these consultations coming from the emergency department or inpatient admission services. Intentional and unintentional pharmaceutical exposures continued to be the most frequent reasons for consultation, accounting for 61.7 % of cases. Among cases of intentional pharmaceutical exposure, 62.4 % were associated with a self-harm attempt. Non-pharmaceutical exposures accounted for 14.1 % of Registry cases. Similar to the past years, non-opioid analgesics, sedative-hypnotics, and opioids were the most commonly encountered agents. Clinical signs or symptoms were noted in 81.9 % of cases. There were 89 recorded fatalities (0.97 %). Medical treatment (e.g., antidotes, antivenom, chelators, supportive care) was rendered in 62.3 % of cases. Patient demographics and exposure characteristics in 2014 Registry cases remain similar to prior years. The majority of consultations arose in the acute care setting (emergency department or inpatient) and involved exposures to pharmaceutical products. Among exposures, non-opioid analgesics, sedative/hypnotics, and opioids were the most frequently encountered. A majority of cases required some form of treatment, but fatalities were rare.
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Affiliation(s)
- Sean H Rhyee
- University of Massachusetts Medical School, 55 Lake Avenue North, LA-202, Worcester, MA, 01655, USA.
| | - Lynn Farrugia
- Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Sharan L Campleman
- American College of Medical Toxicology, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Paul M Wax
- American College of Medical Toxicology, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA.,UT Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- Toxicology Associates, 2555 South Downing Street, Denver, CO, 80210, USA
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Farrugia LA, Rhyee SH, Campleman SL, Ruha AM, Weigand T, Wax PM, Brent J. The Toxicology Investigators Consortium Case Registry-the 2015 Experience. J Med Toxicol 2016; 12:224-47. [PMID: 27517280 DOI: 10.1007/s13181-016-0580-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022] Open
Abstract
The American College of Medical Toxicology established the Toxicology Investigators Consortium (ToxIC) Case Registry in 2010. The Registry contains all medical toxicology consultations performed at participating sites. The Registry has continued to grow since its inception, and as of December 31, 2015, contains 43,099 cases. This is the sixth annual report of the ToxIC Registry, summarizing the additional 8115 cases entered in 2015. Cases were identified by a query of the Registry for all cases entered between January 1 and December 31, 2015. Specific data reviewed for analysis included demographics (age, race, gender), source of consultation, reason for consultation, agents and agent classes involved in exposures, signs, symptoms, clinical findings, fatalities, and treatment. By the end of 2015, there were 50 active sites, consisting of 101 separate health-care facilities; 51.2 % of cases involved females. Adults between the ages of 19 and 65 made up the majority (64.2 %) of Registry cases. Caucasian race was the most commonly reported (55.6 %); 9.6 % of cases were identified as Hispanic ethnicity. Inpatient and emergency department referrals were by far the most common referral sources (92.9 %). Intentional pharmaceutical exposures remained the most frequent reason for consultation, making up 52.3 % of cases. Of these intentional pharmaceutical exposures, 69 % represented an attempt at self-harm, and 85.6 % of these were a suicide attempt. Nonopioid analgesics, sedative-hypnotics, and antidepressant agents were the most commonly reported agent classes in 2015. Almost one-third of Registry cases involved a diagnosed toxidrome (32.8 %), with a sedative-hypnotic toxidrome being the most frequently described. Significant vital sign abnormalities were recorded in 25.3 % of cases. There were 98 fatalities reported in the Registry (1.2 %). Adverse drug reactions were reported in 4.3 % of cases. Toxicological treatment was given in 65.3 % of cases, with 33.0 % receiving specific antidotal therapy. Exposure characteristics and trends overall were similar to prior years. While treatment interventions were required in the majority of cases, fatalities were rare.
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Affiliation(s)
- Lynn A Farrugia
- Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
| | - Sean H Rhyee
- Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT, 06105, USA
| | - Sharan L Campleman
- American College of Medical Toxicology, 10645 N. Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Anne-Michelle Ruha
- Banner-University Medical Center Phoenix, 925 E. McDowell Rd, Phoenix, AZ, 85006, USA
| | - Timothy Weigand
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Paul M Wax
- UT Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA
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dos Santos MF, Yamada A, Seulin SC, Leyton V, Pasqualucci CAG, Muñoz DR, Yonamine M. Liquid-Phase Microextraction and Gas Chromatographic-Mass Spectrometric Analysis of Antidepressants in Vitreous Humor: Study of Matrix Effect of Human and Bovine Vitreous and Saline Solution. J Anal Toxicol 2016; 40:187-93. [PMID: 26755541 DOI: 10.1093/jat/bkv141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In forensic bioanalytical methods, there is a general agreement that calibrators should be prepared by fortifying analytes in matrix-based blank samples (matrix-based). However, in the case of vitreous humor (VH), the collection of blank samples for the validation and for routine analysis would require the availability of many cadavers. Besides the difficulty of obtaining enough blank VH, this procedure could also represent an ethical issue. Here, a study of matrix effect was performed taking into consideration human and bovine vitreous and saline solution (SS) (NaCl 0.9%). Tricyclic antidepressants [amitriptyline (AMI), nortriptyline (NTR), imipramine (IMI) and desipramine (DES)] were used as model analytes and were extracted from samples by means of liquid-phase microextraction and detected by gas chromatography-mass spectrometry. Samples of human and bovine VH and SS were prepared in six different concentrations of antidepressants (5, 40, 80, 120, 160 and 200 ng/mL) and were analyzed. Relative matrix effect was evaluated by applying a two-tailed homoscedastic Student's t-test, comparing the results obtained with the set of data obtained with human VH and bovine VH and SS. No significant matrix effect was found for AMI and NTR in the three evaluated matrices. However, a great variability was observed for IMI and DES for all matrices. Once compatibilities among the matrices were demonstrated, the method was fully validated for AMI and NTR in SS. The method was applied to six VH samples deriving from real cases whose femoral whole blood (FWB) was analyzed by a previously published method. An average ratio (VH/FWB) of ∼ 0.1 was found for both compounds.
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Affiliation(s)
- Marcelo Filonzi dos Santos
- Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580 13B CEP: 05508-000, São Paulo, SP, Brazil
| | - Adrian Yamada
- Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580 13B CEP: 05508-000, São Paulo, SP, Brazil
| | | | - Vilma Leyton
- Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Mauricio Yonamine
- Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580 13B CEP: 05508-000, São Paulo, SP, Brazil
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Rhyee SH, Farrugia L, Wiegand T, Smith EA, Wax PM, Brent J. The toxicology investigators consortium case registry-the 2013 experience. J Med Toxicol 2015; 10:342-59. [PMID: 25119250 DOI: 10.1007/s13181-014-0417-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) Case Registry was established in 2010 by the American College of Medical Toxicology. The Registry includes all medical toxicology consultations performed at participating sites. This report summarizes the Registry data for 2013. A query of the ToxIC Registry was carried out for the dates of January 1 through December 31, 2013. Specific data reviewed for analysis included demographics (age, gender), source of consultation, reasons for consultation, agents involved in toxicological exposures, signs, symptoms and clinical findings, and treatment. A total of 8,598 cases were entered into the Registry in 2013. Females accounted for 49.2 % of cases, males for 47.7 %, and gender was not reported in 3.1 %. The majority of patients (63.4 %) were adults between the ages of 19 and 65 years. There were 93 fatalities (1.1 %). Most referrals for medical toxicology consultation originated from the emergency department (59.7 %) or inpatient services (16.7 %). Exposures to pharmaceutical products (intentional and unintentional) made up 50.0 % of cases. Illicit drug abuse (8.0 %) and adverse drug reactions (ADRs) (4.8 %) were the next most frequent reasons for consultation. Similar to past years, nonopioid analgesics, sedative-hypnotics, and opioids were the most commonly encountered agents. Symptoms or clinical findings were documented in 71.1 % of patients. Of all cases, 54.6 % required some form of medical treatment (antidotes, antivenom, chelation, specific types of supportive care). This report serves as a comprehensive survey of medical toxicology practice within participating institutions. Prior trends continued to apply this year and indicate analgesic (opioid and nonopioid), sedative-hypnotic/muscle relaxant agents, illicit drug use, and ADRs continue to be major toxicological problems. Cases requiring medical toxicology consultation in 2013 predominantly involved pharmaceuticals and illicit drugs. Reasons for these drug exposures were diverse and included intentional overdose, unintentional exposure, withdrawal syndromes, and ADRs. Nonopioid analgesics, sedative-hypnotic agents, and opioids remained the most frequently encountered agent classes. While over half of cases required some form of medical treatment, fatalities were uncommon.
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Affiliation(s)
- Sean H Rhyee
- University of Massachusetts Medical School, 55 Lake Avenue North; LA-202, Worcester, MA, 01655, USA,
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Weaver MF, Hopper JA, Gunderson EW. Designer drugs 2015: assessment and management. Addict Sci Clin Pract 2015; 10:8. [PMID: 25928069 PMCID: PMC4422150 DOI: 10.1186/s13722-015-0024-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/06/2015] [Indexed: 12/30/2022] Open
Abstract
Recent designer drugs, also known as “legal highs,” include substituted cathinones (e.g., mephedrone, methylone, and methylenedioxypyrovalerone, often referred to as “bath salts”); synthetic cannabinoids (SCs; e.g., Spice); and synthetic hallucinogens (25I-NBOMe, or N-bomb). Compound availability has evolved rapidly to evade legal regulation and detection by routine drug testing. Young adults are the primary users, but trends are changing rapidly; use has become popular among members of the military. Acute toxicity is common and often manifests with a constellation of psychiatric and medical effects, which may be severe (e.g., anxiety, agitation, psychosis, and tachycardia), and multiple deaths have been reported with each of these types of designer drugs. Clinicians should keep designer drugs in mind when evaluating substance use in young adults or in anyone presenting with acute neuropsychiatric complaints. Treatment of acute intoxication involves supportive care targeting manifesting signs and symptoms. Long-term treatment of designer drug use disorder can be challenging and is complicated by a lack of evidence to guide treatment.
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Affiliation(s)
- Michael F Weaver
- The University of Texas Health Science Center at Houston, 1941 East Road, BBSB 1222, 77054, Houston, TX, USA.
| | - John A Hopper
- St. Joseph Mercy Hospital, 5333 McAuley Drive, Suite R-3009, 48197-1014, Ypsilanti, MI, USA.
| | - Erik W Gunderson
- The University of Virginia, Center for Wellness and Change, 1007 East High Street, 22902, Charlottesville, VA, USA.
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Heyerdahl F, Hovda KE, Giraudon I, Yates C, Dines AM, Sedefov R, Wood DM, Dargan PI. Current European data collection on emergency department presentations with acute recreational drug toxicity: Gaps and national variations. Clin Toxicol (Phila) 2014; 52:1005-12. [DOI: 10.3109/15563650.2014.976792] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The National Center for Health Statistics estimates that more than 100,000 Americans receive chelation each year, although far fewer than 1 % of these cases are managed by medical toxicologists. Unfortunately, fatalities have been reported after inappropriate chelation use. There are currently 11 FDA-approved chelators available by prescription although chelation products may also be obtained through compounding pharmacies and directly over the internet. Promotion of chelation training is prominent on some alternative and complementary medicine websites.
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Affiliation(s)
- Paul M Wax
- Southwestern School of Medicine, University of Texas, Dallas, TX, USA,
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Wiegand T, Wax P, Smith E, Hart K, Brent J. The Toxicology Investigators Consortium Case Registry--the 2012 experience. J Med Toxicol 2014; 9:380-404. [PMID: 24178902 DOI: 10.1007/s13181-013-0352-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In 2010, the American College of Medical Toxicology (ACMT) established its Case Registry, the Toxicology Investigators Consortium (ToxIC). All cases are entered prospectively and include only suspected and confirmed toxic exposures cared for at the bedside by board-certified or board-eligible medical toxicologists at its participating sites. The primary aims of establishing this Registry include the development of a realtime toxico-surveillance system in order to identify and describe current or evolving trends in poisoning and to develop a research tool in toxicology. ToxIC allows for extraction of data from medical records from multiple sites across a national and international network. All cases seen by medical toxicologists at participating institutions were entered into the database. Information characterizing patients entered in 2012 was tabulated and data from the previous years including 2010 and 2011 were included so that cumulative numbers and trends could be described as well. The current report includes data through December 31st, 2012. During 2012, 38 sites with 68 specific institutions contributed a total of 7,269 cases to the Registry. The total number of cases entered into the Registry at the end of 2012 was 17,681. Emergency departments remained the most common source of consultation in 2012, accounting for 61 % of cases. The most common reason for consultation was for pharmaceutical overdose, which occurred in 52 % of patients including intentional (41 %) and unintentional (11 %) exposures. The most common classes of agents were sedative-hypnotics (1,422 entries in 13 % of cases) non-opioid analgesics (1,295 entries in 12 % of cases), opioids (1,086 entries in 10 % of cases) and antidepressants (1,039 entries in 10 % of cases). N-acetylcysteine (NAC) was the most common antidote administered in 2012, as it was in previous years, followed by the opioid antagonist naloxone, sodium bicarbonate, physostigmine and flumazenil. Anti-crotalid Fab fragments were administered in 109 cases or 82 % of cases in which a snake envenomation occurred. There were 57 deaths reported in the Registry in 2012. The most common associated agent alone or in combination was the non-opioid analgesic acetaminophen, being reported in 10 different cases. Other common agents and agent classes involved in death cases included ethanol, opioids, the anti-diabetic agent metformin, sedatives-hypnotics and cardiovascular agents, in particular amlodipine. There were significant trends identified during 2012. Abuse of over-the-counter medications such as dextromethorphan remains prevalent. Cases involving dextromethorphan continued to be reported at frequencies higher than other commonly abused drugs including many stimulants, phencyclidine, synthetic cannabinoids and designer amphetamines such as bath salts. And, while cases involving synthetic cannabinoids and psychoactive bath salts remained relatively constant from 2011 to 2012 several designer amphetamines and novel psychoactive substances were first reported in the Registry in 2012 including the NBOME compounds or "N-bomb" agents. LSD cases also spiked dramatically in 2012 with an 18-fold increase from 2011 although many of these cases are thought to be ultra-potent designer amphetamines misrepresented as "synthetic" LSD. The 2012 Registry included over 400 Adverse Drug Reactions (ADRs) involving 4 % of all Registry cases with 106 agents causing at least 2 ADRs. Additional data including supportive cares, decontamination, and chelating agent use are also included in the 2012 annual report. The Registry remains a valuable toxico-surveillance and research tool. The ToxIC Registry is a unique tool for identifying and characterizing confirmed cases of significant or potential toxicity or complexity to require bedside care by a medical toxicologist.
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Affiliation(s)
- Timothy Wiegand
- The University of Rochester Medical Center and Strong Memorial Hospital, Rochester, USA,
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dos Santos MF, Ferri CC, Seulin SC, Leyton V, Pasqualucci CAG, Muñoz DR, Yonamine M. Determination of antidepressants in whole blood using hollow-fiber liquid-phase microextraction and gas chromatography–mass spectrometry. Forensic Toxicol 2014. [DOI: 10.1007/s11419-014-0226-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Over the past decade, emerging drugs of abuse and synthetic derivatives of more traditional agents have flooded the market. While Europe was the first to experience a surge in the use of drugs such as synthetic cathinones and cannabinoids, poison centers throughout the United States have seen a dramatic rise in calls related to these new designer drugs of abuse. In the majority of cases, care is largely supportive but significant medical and traumatic complications may occur. Providers must be aware of the ever-changing trends in abuse, so that they may optimally care for poisoned patients.
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Affiliation(s)
- A Pourmand
- Department of Emergency Medicine, Medical Center, George Washington University, Washington, DC, USA
| | - P Armstrong
- Department of Emergency Medicine, Medical Center, George Washington University, Washington, DC, USA
| | - M Mazer-Amirshahi
- Department of Emergency Medicine, Medical Center, George Washington University, Washington, DC, USA
| | - H Shokoohi
- Department of Emergency Medicine, Medical Center, George Washington University, Washington, DC, USA
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Raeder J. Opioids in the treatment of postoperative pain: old drugs with new options? Expert Opin Pharmacother 2014; 15:449-52. [DOI: 10.1517/14656566.2014.879292] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
This paper is the thirty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2012 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Liss DB, Paden MS, Schwarz ES, Mullins ME. What is the clinical significance of 5-oxoproline (pyroglutamic acid) in high anion gap metabolic acidosis following paracetamol (acetaminophen) exposure? Clin Toxicol (Phila) 2013; 51:817-27. [DOI: 10.3109/15563650.2013.844822] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Substituted cathinone products: a new trend in "bath salts" and other designer stimulant drug use. J Addict Med 2013; 7:153-62. [PMID: 23732954 DOI: 10.1097/adm.0b013e31829084b7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is a growing concern about the availability of a new generation of "designer drug" stimulants that are marketed as "bath salts" and other household products. The products are not true bath salts and contain substituted cathinone stimulant substances, such as methylenedioxypyrovalerone (MDPV) and mephedrone. Calls to the American Association of Poison Control Centers regarding "bath salts" consumption began in 2010 and have continued since that time. Few reports of systematic epidemiologic surveillance or definitive clinical effects of toxicity specifically associated with "bath salts" consumption have been reported in the medical literature. The current narrative review describes the growing trend of designer substituted cathinone use, pharmacology, clinical effects, and recent regulatory changes. It is hoped that a greater understanding of the clinical effects and use patterns will help inform policy and practice.
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German CL, Fleckenstein AE, Hanson GR. Bath salts and synthetic cathinones: an emerging designer drug phenomenon. Life Sci 2013; 97:2-8. [PMID: 23911668 DOI: 10.1016/j.lfs.2013.07.023] [Citation(s) in RCA: 203] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/17/2013] [Accepted: 07/19/2013] [Indexed: 11/18/2022]
Abstract
Synthetic cathinones are an emerging class of designer drugs abused for psychostimulant and hallucinogenic effects similar to cocaine, methylenedioxymethamphetamine (MDMA), or other amphetamines. Abuse of synthetic cathinones, frequently included in products sold as 'bath salts', became prevalent in early 2009, leading to legislative classification throughout Europe in 2010 and schedule I classification within the United States in 2011. Recent pre-clinical and clinical studies indicate that dysregulation of central monoamine systems is a principal mechanism of synthetic cathinone action and presumably underlie the behavioral effects and abuse liability associated with these drugs. This review provides insight into the development of synthetic cathinones as substances of abuse, current patterns of their abuse, known mechanisms of their action and toxicology, and the benefits and drawbacks of their classification.
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Affiliation(s)
- Christopher L German
- Department of Pharmacology & Toxicology, University of Utah, Salt Lake City, UT 84112, USA.
| | - Annette E Fleckenstein
- Department of Pharmacology & Toxicology, University of Utah, Salt Lake City, UT 84112, USA
| | - Glen R Hanson
- Department of Pharmacology & Toxicology, University of Utah, Salt Lake City, UT 84112, USA
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Wood KE. Exposure to bath salts and synthetic tetrahydrocannabinol from 2009 to 2012 in the United States. J Pediatr 2013; 163:213-6. [PMID: 23391041 DOI: 10.1016/j.jpeds.2012.12.056] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/04/2012] [Accepted: 12/19/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe bath salts and synthetic tetrahydrocannabinol (THC) exposures in the US from 2009 to 2012, hypothesizing a yearly increase. STUDY DESIGN All exposures reported to American Association of Poison Control Centers between January 1, 2009, and April 30, 2012, were extracted from the National Poison Data System using generic and product codes. RESULTS Bath salts and synthetic THC exposures totaled 7467 and 11,561, respectively. Bath salts exposures were 0 in 2009, 298 in 2010, and 6062 in 2011. Synthetic THC exposures were 14 in 2009, 2821 in 2010, and 6255 in 2011. First-tertile bath salts exposures were lower in 2012 (n = 1007) than in 2011 (n = 2027), and synthetic THC exposures were higher in 2012 (n = 2389) than in 2011 (n = 1888). Most exposures occurred in the midwest and southeast regions (64.8% of bath salts and 58% of synthetic THC exposures). Male subjects comprised 69% (n = 5153) of bath salts users and 74% (n = 8505) of synthetic THC users. Exposure to bath salts were highest in subjects 20-29 years of age (n = 2943), and exposure to synthetic THC was highest for subjects 13-19 years of age (n = 5349). Intentional abuse and inhalation were most common reason for and mode of exposure, respectively. CONCLUSIONS Bath salts and synthetic THC abuse increased from 2009 to 2011. Synthetic THC emerged first and has more reported exposures than bath salts. In 2012, bath salts abuse declined and synthetic marijuana abuse increased. Young men intentionally abusing the drug via inhalation make up the majority of users.
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Affiliation(s)
- Kelly E Wood
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.
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