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Hughes A, Amaducci A, Campleman SL, Li S, Costantini M, Spyres MB, Spungen H, Kent J, Falise A, Culbreth R, Wax PM, Brent J, Aldy K. The Toxicology Investigators Consortium 2023 Annual Report. J Med Toxicol 2024; 20:350-380. [PMID: 39256327 DOI: 10.1007/s13181-024-01033-w] [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: 07/17/2024] [Revised: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 09/12/2024] Open
Abstract
Since 2010, the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) has maintained the ToxIC Core Registry, a national case registry of in-hospital and clinic patient consultations submitted by medical toxicology physicians. Deidentified 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 fourteenth annual report provides data from 7392 patients entered into the Core Registry in 2023 by 36 participating sites comprising 61 distinct healthcare facilities, bringing the total case count to 102331 between 2010 and 2023. Ethanol was the most commonly reported exposure agent class (24.4%), followed by opioids (22.7%), non-opioid analgesics (16.7%), and antidepressants (11.7%). For the first time since the registry's initiation, in 2023, ethanol was the leading agent of exposure. There were 98 fatalities (case fatality rate of 1.3%). Additional descriptive analyses in this annual report were conducted to describe the reasons for medical toxicology consultation by age in 2023, and yearly trends for opioid and psychoactive exposures, physostigmine and rivastigmine treatments, and acetaminophen exposures treated with fomepizole.
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Affiliation(s)
- Adrienne Hughes
- Department of Emergency Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Alexandra 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
| | - Mari Costantini
- 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, Phoenix, AZ, 85006, USA
| | - Hannah Spungen
- Department of Medical Toxicology, Banner - University Medical Center, 1111 E McDowell Rd. Building A, Phoenix, AZ, 85006, USA
| | - Jessica Kent
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
| | - Alyssa Falise
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Rachel 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
- Southwestern Medical School, University of Texas, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jeffery Brent
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA
- Toxicology Associates, 26 West Dry Creek Circle, Littleton, CO, 80120, 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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Magnusson K, Glidden E, Mustaquim D, Welder LE, Stokes EK, Beauchamp GA, Greenberg MR, Aldy K, Mazzaccaro RJ, Careyva BA, Sabino JN, Fikse DJ, McLain K, Amaducci AM. Differences in Drug Poisonings Among Those Who Identify as Transgender Compared to Cisgender: An Analysis of the Toxicology Investigators Consortium (ToxIC) Core Registry, United States 2017-2021. Clin Ther 2024:S0149-2918(24)00256-X. [PMID: 39299811 DOI: 10.1016/j.clinthera.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 08/15/2024] [Accepted: 08/20/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE In this manuscript, the abbreviation TG is defined as persons who identify as transgender, GNC is defined as persons who identify as gender nonconforming, and CG is defined as persons who identify as cisgender. TG and GNC (e.g., nonbinary), are those whose gender identity and sex assigned at birth do not align, as opposed to CG. This study describes drug poisonings among TG, GNC, and CG captured in the Toxicology Investigators Consortium (ToxIC) Core Registry during 2017-2021. METHODS Authors conducted a secondary data analysis of medical toxicology physician consultations involving intentional exposures (i.e., use with the knowledge of the exposed person) within the ToxIC Core Registry from 2017 through 2021. Demographic characteristics, exposure intent, and reported drug classes are reported by gender identity and sex assigned at birth. FINDINGS From a total of 15,800 medical toxicology consultations, 213 (1.3%) involved both TG (n = 187, 1.2%) and GNC (n = 26, 0.2%), and 15,587 (98.7%) involved CG. Among TG, 128 (68.8%) were transgender men, 58 (31.2%) transgender women. Sixty-two percent of TG/GNC (n = 132) and 34.8% of CG (n = 5,428) were aged ≤18 years. Reported intent for exposure (i.e., self-harm and misuse/harmful use) differed proportionally across both sexes assigned at birth and gender identity among transgender men and cisgender men. IMPLICATIONS In the ToxIC Core Registry, the consultations varied proportionally by age group across TG/GNC and CG, with more than half of TG/GNC aged ≤18 years. The proportion of consultations also varied by intent across TG/GNC and CG. Further research to delineate differences between TG/GNC and CG could increase knowledge in prevention, assessment, and treatment of drug poisonings in this population.
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Affiliation(s)
| | - Emily Glidden
- National Network of Public Health Institutes (NNPHI), New Orleans, Louisiana; National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Desiree Mustaquim
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura E Welder
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin K Stokes
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gillian A Beauchamp
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Marna R Greenberg
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania.
| | - Kim Aldy
- American College of Medical Toxicology (ACMT), Phoenix, Arizona
| | - Richard J Mazzaccaro
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Beth A Careyva
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Judith N Sabino
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Derek J Fikse
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Katelyn McLain
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
| | - Alexandra M Amaducci
- Lehigh Valley Health Network/ USF Morsani College of Medicine, Allentown, Pennsylvania
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Wang RQ, Bonomo YA, Hallinan CM. Overview of global monitoring systems for the side effects and adverse events associated with medicinal cannabis use: a scoping review using a systematic approach. BMJ Open 2024; 14:e085166. [PMID: 39025811 DOI: 10.1136/bmjopen-2024-085166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES The use of cannabis-based medicine (CBM) as a therapeutic has surged in Australia over the past 5 years. Historically, the United Nations Single Convention on Narcotic Drugs (1961) prohibited cannabis use in Europe, the USA, the UK and Australia, leading to legislative resistance and limited preclinical data on CBM. Existing safety monitoring systems for CBM are poorly structured and do not integrate well into the workflows of busy health professionals. As a result, postmarketing surveillance is inconsistent. This review aims to evaluate international systems for monitoring CBM side effects and adverse events. DESIGN To undertake a scoping review with a systematic approach, we used the Population, Intervention, Comparison, Outcome (PICO) framework to develop keyword elements, and two search queries to maximise search sensitivity and specificity. DATA SOURCES Search queries were entered into Embase and Scopus for peer-reviewed literature, and additional searches for grey literature were conducted on 23 June 2023. ELIGIBILITY CRITERIA We included 54 full-text articles in the review: 39 from peer-reviewed searches, 8 from grey literature and 7 from citations of relevant texts. DATA EXTRACTION AND SYNTHESIS Our search yielded two main forms of monitoring systems: databases and registries. Out of the 24 monitoring systems identified, there were 10 databases and 14 registries, with databases often created by regulatory authorities. Systems differed in methods of causality assessment, level of detail collected, terminology and affiliations. RESULTS Within the monitoring systems with enough published data for analysis, all except one remain active at the time of this review. VigiBase is the largest centralised monitoring system, receiving international case reports, however data heterogeneity persists. CONCLUSIONS Our study emphasises the need for a centralised, consistent and accessible system for the postmarketing surveillance of side effects and adverse events associated with medicinal cannabis use.
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Affiliation(s)
- Rebecca Qi Wang
- Department of General Practice and Primary Care, The University of Melbourne, Parkville, Victoria, Australia
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Yvonne Ann Bonomo
- Addiction Medicine, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Parkville, Victoria, Australia
| | - Christine Mary Hallinan
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
- HaBIC R2, Department of General Practice and Primary Care, The University of Melbourne, Parkville, Victoria, Australia
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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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Glidden E, Suen K, Mustaquim D, Vivolo-Kantor A, Brent J, Wax P, Aldy K. Characterization of Nonfatal Opioid, Cocaine, Methamphetamine, and Polydrug Exposure and Clinical Presentations Reported to the Toxicology Investigators Consortium Core Registry, January 2010-December 2021. J Med Toxicol 2023; 19:180-189. [PMID: 36650409 PMCID: PMC10050626 DOI: 10.1007/s13181-022-00924-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/22/2022] [Accepted: 12/08/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION To characterize and compare opioid-only, cocaine-only, methamphetamine-only, opioid-and-cocaine exposure, and opioid-and-methamphetamine exposure and to examine clinical presentations, leading to a better understanding of overdose effects involving these drug exposures. METHODS We examined drug exposures in the Toxicology Investigators Consortium (ToxIC) Core Registry from January 2010 to December 2021, a case registry of patients presenting to participating healthcare sites that receive a medical toxicology consultation. Demographic and clinical presentations of opioid-only, cocaine-only, methamphetamine-only, and opioid-and-cocaine exposure, and opioid-and-methamphetamine exposure consultations were described; differences between single and polydrug exposure subgroups were calculated to determine statistical significance. Clinical presentations associated with exposures were evaluated through calculated adjusted relative risk. RESULTS A total of 3,883 consultations involved opioids, cocaine, methamphetamine, opioid-and-cocaine exposure, or opioid-and-methamphetamine exposure. Opioid-only (n = 2,268, 58.4%) and methamphetamine-only (n = 712, 18.3%) comprised most consultations. There were significant differences in clinical presentations between exposure subgroups. Opioid-and-cocaine exposure consultations were 8.15 times as likely to present with a sympathomimetic toxidrome than opioid-only. Conversely, opioid-and-cocaine exposure and opioid-and-methamphetamine exposure were 0.32 and 0.42 times as likely to present with a sympathomimetic toxidrome compared to cocaine-only and methamphetamine-only consultations, respectively. Opioid-and-cocaine exposure was 0.67 and opioid-and-methamphetamine exposure was 0.74 times as likely to present with respiratory depression compared to opioid-only consultations. Similarly, opioid-and-cocaine exposure was 0.71 and opioid-and-methamphetamine exposure was 0.78 times as likely to present with CNS depression compared to opioid-only consultations. CONCLUSIONS Used in combination, opioids and stimulants may mask typical clinical presentations of one another, misattributing incorrect drugs to overdose in both clinical treatment and public health surveillance.
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Affiliation(s)
- Emily Glidden
- National Network of Public Health Institutes, New Orleans, LA USA
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Kyle Suen
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
- Department of Emergency Medicine, Division of Medical Toxicology, Emory School of Medicine, Atlanta, GA USA
| | - Desiree Mustaquim
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Alana Vivolo-Kantor
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Jeffery Brent
- University of Colorado School of Medicine, Aurora, CO USA
| | - Paul Wax
- University of Texas Southwestern Medical Center, Dallas, TX USA
- American College of Medical Toxicology, Phoenix, AZ USA
| | - Kim Aldy
- University of Texas Southwestern Medical Center, Dallas, TX USA
- American College of Medical Toxicology, Phoenix, AZ USA
| | - On behalf of the Toxicology Investigators Consortium (ToxIC) Study Group
- National Network of Public Health Institutes, New Orleans, LA USA
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
- Department of Emergency Medicine, Division of Medical Toxicology, Emory School of Medicine, Atlanta, GA USA
- University of Colorado School of Medicine, Aurora, CO USA
- University of Texas Southwestern Medical Center, Dallas, TX USA
- American College of Medical Toxicology, Phoenix, AZ USA
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Chidiac AS, Buckley NA, Noghrehchi F, Cairns R. Paracetamol (acetaminophen) overdose and hepatotoxicity: mechanism, treatment, prevention measures, and estimates of burden of disease. Expert Opin Drug Metab Toxicol 2023; 19:297-317. [PMID: 37436926 DOI: 10.1080/17425255.2023.2223959] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Paracetamol is one of the most used medicines worldwide and is the most common important poisoning in high-income countries. In overdose, paracetamol causes dose-dependent hepatotoxicity. Acetylcysteine is an effective antidote, however despite its use hepatotoxicity and many deaths still occur. AREAS COVERED This review summarizes paracetamol overdose and toxicity (including mechanisms, risk factors, risk assessment, and treatment). In addition, we summarize the epidemiology of paracetamol overdose worldwide. A literature search on PubMed for poisoning epidemiology and mortality from 1 January 2017 to 26 October 2022 was performed to estimate rates of paracetamol overdose, liver injury, and deaths worldwide. EXPERT OPINION Paracetamol is widely available and yet is substantially more toxic than other analgesics available without prescription. Where data were available, we estimate that paracetamol is involved in 6% of poisonings, 56% of severe acute liver injury and acute liver failure, and 7% of drug-induced liver injury. These estimates are limited by lack of available data from many countries, particularly in Asia, South America, and Africa. Harm reduction from paracetamol is possible through better identification of high-risk overdoses, and better treatment regimens. Large overdoses and those involving modified-release paracetamol are high-risk and can be targeted through legislative change.
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Affiliation(s)
- Annabelle S Chidiac
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, Australia
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
- Faculty of Medicine and Health, School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Firouzeh Noghrehchi
- Faculty of Medicine and Health, School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Rose Cairns
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, Australia
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
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Kunzler NM, Cole JB, Driver BE, Carlson J, April M, Brown CA. Risk of peri-intubation adverse events during emergency department intubation of overdose patients: a national emergency airway registry (near) analysis. Clin Toxicol (Phila) 2022; 60:1293-1298. [PMID: 36346031 DOI: 10.1080/15563650.2022.2131564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than 20,000 emergency department (ED) patients undergo intubation for overdose each year. While the characteristics of patients intubated for overdose and poisoning are well described, little is known about the intubation outcomes of overdose patients in the ED. OBJECTIVES We quantify the frequency of peri-intubation adverse events for patients intubated in the ED for overdose, and determine whether first attempt success without adverse events differs between patients intubated for overdose and patients intubated for other reasons. METHODS We analyzed data from the National Emergency Airway Registry (NEAR), a prospective multicenter registry of ED intubations collected from an international network of 22 academic and community hospitals. We included patients 14 years and older whose first attempt was oral intubation, with data entered into NEAR between 1 January 2016 and 31 December 2018. The primary outcome was successful intubation on the first attempt. We used multivariable logistic regression to determine whether indication was independently associated with successful intubation on the first attempt after adjusting for age, gender, obesity, initial impression of difficult airway, presence of difficult airway characteristics, and use of video laryngoscopy. Secondary outcomes included successful intubation on the first attempt without adverse events, the occurrence of rescue surgical airways, and the occurrence of adverse events. Adverse events included hypoxemia, hypotension, peri-intubation cardiac arrest, bradycardia, mechanical injury to oral or airway structures, vomiting, tachydysrhythmia, esophageal intubation, laryngospasm, and pneumothorax. RESULTS We analyzed 17,984 patients, including 1,983 (11%) intubated for overdose, and 16,001 (89%) intubated for other indications. Patients intubated for overdose were younger (median age 38 vs 55 years), were less frequently obese (26% vs 34%), and fewer had difficult airway characteristics (38% vs 53%). Overdose patients were more likely to have preoxygenation performed (45% vs 35%), more likely to have apenic oxygenation (39% vs 31%), and more likely to have bougie used (33% vs 17%). First attempt success was 90.5% in patients intubated for overdose and 87.5% in patients intubated for other reasons (absolute difference 3.0%; 95% CI: -1.3 to 7.3). First attempt success without adverse events was higher in overdose patients (85.0%) compared to other patients (78.7%) (absolute difference, 6.3%; 95% CI 1.0 to 11.7%). Overdose patients experienced significantly less hypotension (1.5% vs 4.1%), and tended to have fewer adverse events overall. Multivariable model results were consistent with the unadjusted results including no difference in first pass success (adjusted odd ratio 1.02 [95% CI 0.86-1.23]). There was a higher first pass success without complication in patients intubated for overdose (adjusted odds ratio 1.23; 95% CI 1.07 to1.43). CONCLUSION For patients in whom the primary indication for intubation is overdose there is an increased chance of first attempt success without adverse event.
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Affiliation(s)
- Nathan M Kunzler
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Jestin Carlson
- Department of Emergency Medicine, Allegheny Health Network, Erie, PA, USA
| | - Michael April
- Department of Military and Emergency Medicine, Uniformed Services University of The Health Sciences (USUHS), Bethesda, MD, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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The Toxicology Investigators Consortium Case Registry-the 2021 Annual Report. J Med Toxicol 2022; 18:267-296. [PMID: 36070069 PMCID: PMC9450833 DOI: 10.1007/s13181-022-00910-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 11/29/2022] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) Core Registry was established by the American College of Medical Toxicology in 2010. The Core Registry collects data from participating sites with the agreement that all bedside and telehealth medical toxicology consultations will be entered. This twelfth annual report summarizes the registry’s 2021 data and activity with its additional 8552 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2021. 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. Gender distribution included 50.4% of cases in females, 48.2% of cases in males, and 1.4% of cases in transgender or gender non-conforming individuals. Non-opioid analgesics were the most commonly reported agent class (14.9%), followed by opioids (13.1%). Acetaminophen was the most common agent reported. Fentanyl was the most common opioid reported and was responsible for the greatest number of fatalities. There were 120 fatalities, comprising 1.4% of all cases. Major trends in demographics and exposure characteristics remained similar to past years’ reports. Sub-analyses were conducted to describe new demographic characteristics, including marital status, housing status and military service, the continued COVID-19 pandemic and related toxicologic exposures, and novel substances of exposure.
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Mohr ALA, Logan BK, Fogarty MF, Krotulski AJ, Papsun DM, Kacinko SL, Huestis MA, Ropero-Miller JD. Reports of Adverse Events Associated with Use of Novel Psychoactive Substances, 2017-2020: A Review. J Anal Toxicol 2022; 46:e116-e185. [PMID: 35445267 PMCID: PMC9282356 DOI: 10.1093/jat/bkac023] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022] Open
Abstract
An important role of modern forensic and clinical toxicologists is to monitor the adverse events of novel psychoactive substances (NPS). Following a prior review from 2013 to 2016, this critical literature review analyzes and evaluates published case reports for NPS from January 2017 through December 2020. The primary objective of this study is to assist in the assessment and interpretation of these cases as well as provide references for confirmation methods. Chemistry, pharmacology, adverse events and user profiles (e.g., polypharmacy) for NPS are provided including case history, clinical symptoms, autopsy findings and analytical results. Literature reviews were performed in PubMed and Google Scholar for publications using search terms such as NPS specific names, general terms (e.g., 'designer drugs' and 'novel psychoactive substances'), drug classes (e.g., 'designer stimulants') and outcome-based terms (e.g., 'overdose' and 'death'). Government and website drug surveillance databases and abstracts published by professional forensic science organizations were also searched. Toxicological data and detailed case information were extracted, tabulated, analyzed and organized by drug category. Case reports included overdose fatalities (378 cases), clinical treatment and hospitalization (771 cases) and driving under the influence of drugs (170 cases) for a total of 1,319 cases providing details of adverse events associated with NPS. Confirmed adverse events with associated toxidromes of more than 60 NPS were reported including synthetic cannabinoid, NPS stimulant, NPS hallucinogen, NPS benzodiazepine and NPS opioid cases. Fifty of these NPS were reported for the first time in January 2017 through December 2020 as compared to the previous 4 years surveyed. This study provides insight and context of case findings described in the literature and in digital government surveillance databases and websites during a recent 4-year period. This review will increase the awareness of adverse events associated with NPS use to better characterize international emerging drug threats.
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Affiliation(s)
- Amanda L A Mohr
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
| | - Barry K Logan
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
- NMS Labs, 200 Welsh Rd, Horsham, PA 19044, USA
| | - Melissa F Fogarty
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
| | | | | | - Marilyn A Huestis
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, 2300 Stratford Ave, Willow Grove, PA 19090, USA
- Institute of Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Jeri D Ropero-Miller
- RTI International, Center for Forensic Sciences, 3040 East Cornwallis Rd, Research Triangle Park, NC 27709, USA
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12
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Spyres MB, Aldy K, Farrugia LA, Kang AM, Love JS, Campleman SL, Li S, Amaducci A, Schwarz E, Wax PM, Brent J. The Toxicology Investigators Consortium 2020 Annual Report. J Med Toxicol 2021; 17:333-362. [PMID: 34535889 PMCID: PMC8447896 DOI: 10.1007/s13181-021-00854-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022] Open
Abstract
The Toxicology Investigators Consortium (ToxIC) 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 and telehealth medical toxicology consultation will be entered. This eleventh annual report summarizes the Registry's 2020 data and activity with its additional 6668 cases. Cases were identified for inclusion in this report by a query of the ToxIC database for any case entered from January 1 to December 31, 2020. 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. Gender distribution included 50.6% cases in females, 48.4% in males, and 1.0% identifying as transgender. Non-opioid analgesics were the most commonly reported agent class, followed by opioid and antidepressant classes. Acetaminophen was once again the most common agent reported. There were 80 fatalities, comprising 1.2% of all registry cases. Major trends in demographics and exposure characteristics remained similar to past years' reports. Sub-analyses were conducted to describe race and ethnicity demographics and exposures in the registry, telemedicine encounters, and cases related to the COVID-19 pandemic.
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Affiliation(s)
- Meghan B Spyres
- Department of Emergency Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA.
- Department of Medical Toxicology, Banner-University Medicial Center Phoenix, 1012 E Willetta Street, Fl 2, Phoenix, AZ, 85006, USA.
| | - Kim Aldy
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Lynn A Farrugia
- Hartford Hospital and University of Connecticut School of Medicine, 80 Seymour Street, Hartford, CT, 06102, USA
| | - A Min Kang
- Department of Medical Toxicology, Banner-University Medicial Center Phoenix, 1012 E Willetta Street, Fl 2, Phoenix, AZ, 85006, USA
- Departments of Medicine and Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jennifer S Love
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, 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
| | - Alexandra Amaducci
- Lehigh Valley Health Network, 2545 Schoenersville Rd, Bethlehem, PA, 18017, USA
| | - Evan Schwarz
- Department of Emergency Medicine, Washington University School of Medicine, 660 South Euclid, St Louis, MO, 63110, USA
| | - Paul M Wax
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
- American College of Medical Toxicology, 10645 N Tatum Blvd., Suite 200-111, Phoenix, AZ, 85028, USA
| | - Jeffery Brent
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA
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Varney SM, Wiegand TJ, Wax PM, Brent J. Descriptive Analysis of Inpatient and Outpatient Cohorts Seeking Treatment After Prescription Opioid Misuse and Medical Toxicology Evaluation. J Med Toxicol 2021; 17:378-385. [PMID: 34402039 DOI: 10.1007/s13181-021-00850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Medical toxicology expertise has expanded into the addiction medicine realm including outpatient medication for opioid use disorder (MOUD) and addiction treatment. Concomitantly, the emergency department (ED) and hospital are increasingly seen as important sites for the screening, prevention, and treatment of patients with substance use disorders and addiction. This analysis seeks to characterize patients seen by medical toxicologists for opioid use and opioid use disorder (OUD) in the ED and inpatient consultation setting (inpatient) versus in the OUD clinic (outpatient) setting. METHODS We searched the American College of Medical Toxicology's Toxicology Investigators Consortium Case Registry, a prospective, de-identified, national dataset that includes patients receiving medical toxicology consultation following prescription opioid misuse. The dataset also includes patients seen in outpatient MOUD clinics during the same period between June 2013 and November 2015. Intentional self-harm patients were excluded. We analyzed medical history, drug use patterns, and other factors with odds ratios and confidence intervals. RESULTS Of 110 patients identified, 60 (54.5%) were inpatients and 50 (45.5%) outpatients. Mean age (39 years), gender (68% male), and race breakdown (60% white/non-Hispanic) were similar. The outpatient group was more likely to have Medicare/Medicaid coverage (p<0.0001). By history, the outpatient group was more likely to have past alcohol misuse, intravenous drug use, prescription drug misuse, and prescription opioid misuse. Most inpatient group members sought a recreational high compared to avoiding withdrawal or treating dependence in the outpatient group. CONCLUSION Patients treated in the outpatient compared to inpatient setting were more likely to report adverse sequelae from their drug use including long-term drug use, depression, previous rehabilitation attempts, and seeking to avoid withdrawal.
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Affiliation(s)
- Shawn M Varney
- Department of Emergency Medicine, University of Texas Health - San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.
| | - Timothy J Wiegand
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Paul M Wax
- Division of Toxicology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine and Colorado School of Public Health, 13001 E 17th Pl, Aurora, CO, 80045, USA
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Weiss ST, Campleman S, Wax P, McGill W, Brent J. Failure of chelator-provoked urine testing results to predict heavy metal toxicity in a prospective cohort of patients referred for medical toxicology evaluation. Clin Toxicol (Phila) 2021; 60:191-196. [PMID: 34184587 DOI: 10.1080/15563650.2021.1941626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Provoked urine testing (PUT), involving chelating agent administration prior to measuring urine metal excretion levels, is used by some alternative health care practitioners to diagnose patients with heavy metal poisoning. Multiple medical societies have advised against this practice due to its presumed unreliability, expense, and lack of validation. However, no prospective study of the predictive value of PUT for heavy metal poisoning has been undertaken. METHODS This study utilized the Toxicology Consortium's prospective case registry to evaluate the reliability of PUT for diagnosing heavy metal poisoning. Inclusion criteria were toxicology clinic patients with PUT results who were subsequently evaluated by a board-certified medical toxicologist and had a determination made regarding whether their signs and symptoms were likely related or unrelated to toxicologic exposures. The primary outcome was the positive predictive value of PUT for heavy metal toxicity as diagnosed by the evaluating medical toxicologist. Patients presenting to participating toxicology clinics without PUT served as a comparison group. RESULTS 74 of 106 cases presenting with PUT results met inclusion criteria and were analyzed. 15 cases were determined by the examining toxicologist to be likely related to a toxicologic exposure. Only three cases were found to be related to heavy metal exposure, giving a positive predictive value of 4.3%. 20.2% of patients with PUT were found to have signs or symptoms related to any toxicologic exposure, compared to 14.3% of clinic patients without PUT. Demographics of toxicology clinic patients with and without PUT results were not significantly different except for age. DISCUSSION Our results provide empiric support that PUT is an inaccurate predictor of a diagnosis of heavy metal poisoning by a board-certified medical toxicologist. Given the inability to properly interpret PUT results along with the increased cost burden and risk of false positives, PUT should not be performed.
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Affiliation(s)
- Stephanie T Weiss
- Addiction Medicine Research Program, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, USA
| | | | - Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA
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