Opium poisoning in modern times. An overview

A cluster of acute thebaine poisonings from non-food grade poppy seeds in the Australian food supply

INTRODUCTION

Poppy seed tea is used for its opioid effects and contains multiple opium alkaloids, including morphine, codeine, papaverine, and thebaine. Animal studies indicate thebaine has strychnine-like properties, but there is limited literature describing human thebaine poisoning. We describe a cluster of acute thebaine poisoning in people ingesting tea made using poppy seeds with high thebaine content that entered the Australian food supply chain.

METHODS

This is an observational study of patients poisoned after drinking poppy seed tea. Cases were identified by three prospective toxicovigilance systems: the Emerging Drug Network of Australia collaboration, the New South Wales Prescription, Recreational and Illicit Substance Evaluation program, and the Emerging Drugs Network of Australia Victoria study. We report characteristics of clinical toxicity in cases with reported ingestion of poppy seed tea and analytical confirmation of thebaine exposure.

RESULTS

Forty cases presenting with multi-system toxicity following poppy seed tea ingestion were identified across seven Australian states/territories from November 2022 to January 2023. Blood testing in 23 cases confirmed high thebaine concentrations. All 23 were male (median age 35, range 16-71 years). All patients experienced muscle spasms. Rigidity was described in nine, convulsions in six, while rhabdomyolysis, acute kidney injury, and metabolic acidosis occurred in five patients. There were two cardiac arrests. The thebaine median admission blood concentration was 1.6 mg/L, with a range of 0.1-5.6 mg/L, and was the dominant opium alkaloid in all samples. Convulsions, acute kidney injury, metabolic acidosis, and cardiac arrest were associated with increasing median thebaine concentrations. Four patients were managed in the Intensive Care Unit, with two receiving continuous kidney replacement therapy (one also received intermittent haemodialysis) for kidney injury. There was one death.

CONCLUSIONS

Thebaine toxicity, like strychnine poisoning, resulted in neuromuscular excitation characterized by muscle spasm, rigidity, and convulsions. Severe toxicity, including acute kidney injury, metabolic acidosis, and cardiac arrest, appears dose-dependent.

The history, current state and perspectives of aerosol therapy

Nebulization is a very effective method of drug administration. This technique has been popular since ancient times when inhalation of plants rich in tropane alkaloids with spasmolytic and analgesic effects was widely used. Undoubtedly, the invention of anasthesia in the 19th century had an influence on the development of this technique. It resulted in the search for devices that facilitated anasthesia such as pulveriser or hydronium. From the second half of the 21st century, when the first DPI and MDI inhalers were launched, the constant development of aerosol therapy has been noticed. This is due to the fact that nebulization, compared with other means of medicinal substance application (such as oral and intravenous routes of administration), is safer and it exhibits a positive dose/efficacy ratio connected to the reduction of the dose. It enables drugs administration through the lung and possesses very fast onset action. Therefore, various drugs prescribed in respiratory diseases (such as corticosteroids, β-agonists, anticholinergics) are present on the market in a form of an aerosol.

Fate of Food-Relevant Toxic Plant Alkaloids during Food Processing or Storing and Analytical Strategies to Unveil Potential Transformation Products

Toxic plant alkaloids (TPAs) may contaminate food and pose a threat to consumer health; as a consequence, they are undesired in foodstuff or food commodities. Similar to other ingredients, TPA may be affected by storing or processing of food, often associated with decreased levels of the parent alkaloids. Up to now, little is known about potential transformation products or if they still may exhibit toxic potential to consumers. This perspective briefly summarizes the current knowledge regarding the behavior of opium, pyrrolizidine, and tropane alkaloids toward processing or storing and highlights analytical strategies to identify and elucidate potential transformation products.

Is Cannabis Legalization Eliciting Abusive Behaviors in Parents? A Case Report

The interest in cannabis, cannabis-based compounds, and treatments is rapidly growing along with the legalization of marijuana in many countries and widespread use of cannabis derivatives in medical products. A growing body of literature is warning about possible unintentional intoxication in children because of unregulated and unsupervised use of cannabinoids by parents; to our knowledge, very rarely have parental self-prescription and self-administration to their children (affected by neurologic or other disorders or no disorders at all) been reported. We report a 4-year-old child, suffering from an anti-N-methyl-D-aspartate receptor encephalitis, who was found unpredictably positive for cannabis and other illicit substances after drug testing was performed in order to investigate the child's treatment-resistant behavioral disturbances. Toxicologic analyses were also extended to the child's parents, who finally disclosed that they had deliberately administered a cannabis-derived product (cannabidiol extract) as a home remedy for managing their child's behavior. Careless with regard to the possible adverse effects and certain that the product was legal, they presumed there was no need for them to inform the physicians in charge of treating the child of this practice.

Fatal Outcome in Acutely Poisoned Children With Hospitalization: A 10-Year Retrospective Study From Tehran, Iran

BACKGROUND

Acute poisoning is a significant and preventable cause of mortality among children internationally. The aims of this study were to assess the case fatality rate of children admitted to an inner-city hospital for acute poisoning and to compare the demographics and source of poisoning of fatal cases.

METHODS

This was a retrospective review of patient data recorded in the Hospital Information System for Loghman Hakim Hospital, that is, the central referral hospital for poisoning in Tehran, Iran. We searched Hospital Information System for all admissions for poisoning in children (age, 0-12 years) over the 10-year period from March 2010 to March 2020, and all cases were included in the analysis. We determined the case fatality rate by dividing the number of fatal cases by the number of included cases.

RESULTS

Of 8158 children admitted for poisoning, 28 cases (0.3%) died, among whom 19 (67.9%) were boys and 9 (32.1%) girls. The median age was 42 months, ranging from 2 to 144 months. Twenty-two cases (78.6%) were 0 to 5 years old. The most common cause of mortality in acute poisoning was methadone (n = 13, 46.4%), followed by raw opium (n = 5, 17.9%), aluminum phosphide, carbon monoxide, and wild mushrooms (n = 2 deaths each, 7.1%). Tramadol, colchicine, and petroleum accounted for 1 death each (3.6%).

CONCLUSIONS

Mortality from unintentional poisoning disproportionately affects children younger than 5 years. Opioids (ie, methadone, opium, tramadol) accounted for two thirds of deaths in our sample. Our findings highlight the importance of educating parents that any toxic materials (licit or illicit) must be stored out of reach for children.

Determination of morphine, codeine, and thebaine concentrations from poppy seed tea using magnetic carbon nanotubes facilitated dispersive micro-solid phase extraction and GC-MS analysis

With tightening enforcement and restrictions amid the opioid epidemic, poppy seed tea is consumed as an alternative to mitigate the withdrawal symptoms or as a home remedy to relieve pain and stress. Previously published studies suggested the potential danger of consuming tea brewed with a moderate to a large amount of poppy seed. In this study, the effects of small quantity and repeat brewing on opiate concentrations were evaluated. A dispersive-micro solid phase extraction facilitated by magnetic carbon nanotubes (Mag-CNTs/d-µSPE) was developed, optimized, successfully validated, and applied to ten poppy seed tea samples using gas chromatography-mass spectrometry (GC-MS) analysis. A total of ten poppy seed samples were evaluated in this work. Two grams of bulk poppy seeds were brewed with 6 mL of heated and acidified DI water three times. The brewed tea samples were subjected to the validated Mag-CNTs/d-µSPE/GC-MS analysis. The total mean opiate concentrations obtained from three brews were 1.1-1926, 20.2-311, and 9.0-100 mg/kg for morphine, codeine, and thebaine, respectively. The total opiate yields obtained from the small quantity brewing, i.e., 6 g seed in 18 mL tea, in this study may provide minimal analgesic and euphoric effects. Over 80% of the total opiate yield was extracted in the first brew with acidified deionized water from the 10 min brewing period, and opiate yields from the second and third brew were minimal. However, potential overdose could occur for some tea samples when scaled up to the starter quantity of seed suggested for new users.

Opioid exposure associated with poppy consumption reported to poison control centers and the U.S. Food and Drug Administration

OBJECTIVE

To assess characteristics of exposures to contaminated poppy and identify trends in exposure and poppy-related deaths.

METHODS

Cross-sectional analysis of adverse events associated with exposure to poppy products (primarily poppy seeds) from the American Association of Poison Control Centers' National Poison Data System (NPDS), 2000-2018, supplemented with analysis of overdoses and deaths related to poppy from the U.S. Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition's Adverse Event Reporting System (CAERS) (2004-2018), and the FDA Adverse Event Reporting System (FAERS) (1968-2018).

RESULTS

There were 591 NPDS exposure cases involving poppy between 2000 and 2018 including 392 in persons aged 13+. Rates of intentional exposures in NPDS increased among the age 13+ group over the study period. Most intentional exposures occurred in males in their teens and twenties. NPDS included 18 overdoses and three deaths likely attributable to poppy, most involving poppy seed tea. CAERS and FAERS included five additional deaths likely attributable to opioids in poppy.

CONCLUSIONS

Including previously reported cases, there are now at least 19 U.S. deaths associated with poppy seeds in the literature. We recommend that practitioners working in opioid treatment and recovery be alert to use of poppy to treat pain and symptoms of withdrawal.

Death from Poppy Tea Consumption

The historical practice of brewing poppy tea for its opioid-like effects is reoccurring with modern-day substance users. We present four postmortem cases with toxicology results that serve as case studies for the potential hazards of poppy tea ingestion. There is limited information regarding the risks of this practice due to the variability of the morphine content of the opium exuded from the plant. While internet tea recipes offer guidance, differences in poppy cultivation, washing, and infusing time are some of the reasons why the beverage may contain inconsistent and clinically significant alkaloid concentrations for each preparation. Variability in opioid tolerance along with additional drugs taken will impact the overall degree of toxicity experienced from the opiates in the tea. Advancements in the genetic modification of the poppy plant could greatly alter the ratio of alkaloids seen in biological fluids and will be highly dependent on the source of the poppy product. The blood concentrations of free morphine and free codeine in cases 1-3 where the toxicity from the tea was considered the primary cause of death were 0.94 and 0.11 mg/L, 0.62 and 0.034 mg/L, and 0.16 and 0.010 mg/L, respectively. The urine concentrations of morphine and codeine were 13 and 0.94 mg/L in case 1 and 16 and 1.6 mg/L in case 2, respectively. The opium alkaloids thebaine and laudanosine were identified qualitatively by our routine organic base/neutral drug detection procedure.