Drugs of Abuse

Is caval index a sufficient parameter for determining and monitoring dehydration in intoxication patients?

BACKGROUND

Cases of intoxication are increasing day by day and these patients are presenting to emergency departments. These patients are usually individuals with poor self-care, inadequate oral intake, and unable to meet their own needs, and may have significant dehydration due to the agents they have taken. The caval index (CI) is a recently used index to determine fluid requirement and response.

AIMS

We aimed to evaluate the success of CI in determining and monitoring dehydration in intoxication patients.

METHODS

Our study was conducted prospectively in the emergency department of a single tertiary care center. A total of ninety patients were included in the study. Caval index was calculated by measuring inspiratory and expiratory inferior vena cava diameters. Caval index measurements were repeated after 2 and 4 h.

RESULTS

Patients who were hospitalized, took multiple drugs, or needed inotropic agents had significantly higher caval index levels. A further increase in caval index levels was observed on second and third caval index evaluations in patients who received inotropic agents along with fluid resuscitation. Levels of systolic blood pressure recorded at admission (0. hour) showed a significant correlation with caval index and shock index. Caval index and the shock index were highly sensitive and specific at predicting mortality.

CONCLUSION

In our study, we found that CI can be used as an index to assist emergency clinicians in determining and monitoring fluid requirement in cases of intoxication presenting to the emergency department.

Increasing prevalence of illicit drug use among employees at Swedish workplaces over a 25-year period

Background

Reports indicate that the proportion of adults using drugs of abuse has been increasing in recent years in Europe. Although there are various indicators of increased drug use in Sweden over time, few studies could demonstrate an increase in the proportion of adults using drugs. To investigate changes in drug use prevalence over time, drug testing at the workplace has been used for a 25-year period.

Methods

The urine samples of employees sent by occupational health services from all over Sweden during a 25-year period were analyzed. The analyzing capacity increased over time (from 3411 in 1994 to 60 315 samples analyzed in 2019), and the majority of the samples was analyzed for the following drugs: cannabis (tetrahydrocannabinol), amphetamine, opiates, cocaine, and benzodiazepines.

Results

There was an overall increase in the proportion of samples that tested positive for illicit drugs over a 25-year period. This increase seemed to take place step-wise, with phases of linear increases and plateaus that over time became shorter. About 1.3% of samples tested positive for drugs in 1994, whereas 5.6% tested positive in 2019. Since 2007, the rate of positive samples has increased for cannabis and decreased for benzodiazepines. Although the rate of samples tested positive for opiates had remained relatively stable over the last 20 years, this rate had increased for amphetamine and cocaine between 2013 and 2019.

Conclusion

The results indicate that the use of illicit drugs among employees at Swedish workplaces has increased during a 25-year period.

Prescription drug diversion, misuse, and abuse among people living with HIV: a scoping review protocol

BACKGROUND

Prescription drugs are controlled medicines due to their potential risks of being diverted, misused, and abused. Since the introduction of antiretroviral (ARVs) drugs, HIV is currently regarded as a chronic condition. However, prescription drug diversion, misuse, and abuse might serve as one of the critical barriers for achieving optimal medication adherence among people living with HIV, thereby negatively impacting the HIV care mandate. The primary aim of this scoping review is to gather evidence on the prevalence, practices, risk factors, and motives associated with prescription drug diversion, misuse, and abuse, as well as the evidence on the association between prescription drug diversion, misuse, and abuse with antiretroviral treatment (ART) adherence.

METHODS

This review will be guided by Arksey and O'Malley's framework as well as recommendations by Levac et al. (Implement Sci 5:69, 2010). We will search the following databases for relevant literature meeting our eligibility criteria: PubMed, Google Scholar, EBSCOhost (Academic Search Complete, MEDLINE, and Newspaper Source), World Health Organization, Science Direct, and Open Access Theses and Dissertations. Studies published within the period of January 1996 to June 2019 are eligible. The included studies should report evidence on the prevalence, practices, risk factors, motives, or association between ART adherence and prescription drug diversion, misuse, and abuse. Thematic analysis will be applied to summarize the review findings.

DISCUSSION

We anticipate finding a considerable number of research studies on prescription drug diversion, misuse, and abuse among people living with HIV. Our synthesis of this evidence base is intended to serve as guidance for future research studies. The study findings will be disseminated through the traditional academic platforms, such as peer-reviewed publications and presentations at relevant local and international conferences, symposiums, and seminars.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074076.

Intracerebellar Hemorrhage in a Young Adult

A 28-year-old male was admitted with a history of sudden onset headache, multiple episodes of vomiting, gait disturbance with swaying toward right side, and blurring of vision for 2 days. The patient was conscious, cooperative, and oriented, and his vitals were normal. Bilateral gaze-evoked nystagmus was present. Motor and sensory examinations were within normal limit, and deep tendon reflexes were 2+ in all four limbs. Cerebellar examination reveals positive finger–nose test and dysdiadochokinesia on right side. A computed tomography of head showed acute intraparenchymal hemorrhage in right cerebellar hemisphere with effacement of fourth ventricle and mild hydrocephalus. Computed tomography angiography of cerebral vessels was normal. The coagulation profile (international normalized ratio: 1.02), renal function test, and liver function tests were within normal limit. Urine toxicology screen was positive for tetrahydrocannabinoid. The patient was diagnosed with right cerebellar bleed and cannabis abuse. The patient managed conservatively with intravenous mannitol and was discharged in hemodynamic stable condition.

Acute toxic kidney injury

Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.

Oral healthcare management in heroin and methadone users

Heroin addiction is associated with poor oral health. Oral and dental care in heroin addiction might be complicated by altered mental status, negative attitude towards oral health, dental anxiety and fear, drug interaction, and associated medical co-morbidity. We present the oral findings and discuss the dental, behavioural, and anaesthetic management considerations in a 46-year-old man who had dental anxiety and had been an intravenous heroin user for the past 23 years.

A Difficult Challenge for the Clinical Laboratory: Accessing and Interpreting Manufacturer Cross-Reactivity Data for Immunoassays Used in Urine Drug Testing

Urine drug testing by immunoassay is widely used to detect nonmedical drug use and to monitor patients prescribed controlled substances. A key attribute of urine drug testing immunoassays is cross-reactivity, namely the response of various compounds compared to the target of the assay. In this report, we analyzed the variability in how manufacturer cross-reactivity data are summarized in package inserts for commercially available amphetamines, benzodiazepines, and opiates immunoassays, 3 broad drug classes commonly included in routine drug testing panels. Specifically, we determined the number of compounds tested for cross-reactivity, manner in which cross-reactivity is measured, concentration units used, how often compounds known to be cross-reactive with marketed urine drug testing immunoassays prior to 2010 were tested, availability of the package insert online, and how often cross-reactivity on "designer drugs" was found in the package inserts. There was wide variability in the number of compounds tested (both positive and negative), with the highest number of tested compounds generally found in point-of-care urine drug testing applications. Most package inserts used ng/mL as the concentration units and expressed cross-reactivity in terms of equivalent concentrations to the assay calibrator. Approximately 50% of package inserts were directly available online. Cross-reactivity data were sparse with respect to "off-target" drugs known to be cross-reactive prior to 2010 (an example being quinolone antibiotics and opiates immunoassays) and designer drugs. The present study indicates lack of consistency in cross-reactivity information in package inserts, complicating the interpretation of urine drug testing results. We use 3 example clinical cases to illustrate practical challenges accessing and interpreting cross-reactivity data.

Novel psychoactive substances: overdose of 3-fluorophenmetrazine (3-FPM) and etizolam in a 33-year-old man

Though illegal in the UK, in many countries novel psychoactive substances are quasi-legal synthetic compounds that are widely available online under the guise of research chemicals. These substances are relatively cheap and are often undetectable in standard drug screens. Nearly 200 such compounds are introduced yearly, and little is usually known about their metabolism or physiological effects. Consequently, managing patients in overdose situations on largely unknown substances usually involves supportive care, however anticipating and managing atypical side effects are challenging in the absence of knowledge of these compounds. In this report, we discuss our encounter with a 33-year-old unconscious man presenting with coingestion of a novel stimulant 3-fluorophenmetrazine with a rarely used benzodiazepine etizolam. This patient developed seizure-like activity and delayed widespread T-wave inversions, both of which ultimately resolved without sequelae.

TAAR1 in Addiction: Looking Beyond the Tip of the Iceberg

Trace-amine associated receptor 1 (TAAR1) is the best-characterized member of the family of TAARs. TAAR1 is broadly expressed in the brain, especially within the monoaminergic systems. Evidence from electrophysiological and neurochemical studies evaluating the effects of genetic and pharmacological interventions on TAAR1 revealed that TAAR1 modulates transmission of monoamines, especially dopamine. TAAR1 agonists dampened drugs of abuse-induced dopamine accumulation. In general, TAAR1 agonists specifically inhibited the rewarding and reinforcing effects of drugs of abuse and drug-abuse related behaviors. Details of the mechanism of TAAR1 remain elusive; however, it is thought to be regulated by its interactions with D2 receptors. In addition, the alternative cellular mechanism such as an interaction between TAAR1 and D3 may also participate in the action of TAAR1 agonists. Further studies are required to investigate the role of TAAR1 in other drugs of abuse-related behaviors and the underlying neural mechanisms. Collectively, TAAR1 negatively modulates dopaminergic systems and dopamine-related behaviors and TAAR1 agonists are promising pharmacotherapy to treat drug addiction and relapse.