Clinical vs. laboratory identification of drugs of abuse in patients admitted for acute poisoning

Clinical effect of ethanol co-use in patients with acute drug toxicity involving the use of central nervous system depressant recreational drugs

BACKGROUND AND IMPORTANCE

Patients who use recreational drugs frequently co-ingest ethanol, which is considered a central nervous system (CNS) depressant. The clinical relevance of this in acute toxicity involving other CNS depressants is not well described.

OBJECTIVE

To assess the clinical impact of ethanol co-use in patients presenting to the emergency department (ED) with acute toxicity involving the use of CNS depressant drugs.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective multicentre study using data from the Euro-DEN Plus database from January 2014 to December 2019.

OUTCOMES MEASURE AND ANALYSIS

Comparison of epidemiologic and clinical characteristics, ED and hospital management of patients with CNS depressant intoxication with or without ethanol co-use.

MAIN RESULTS

Although 7644 (17.5%) of the 43 633 presentations were included, ethanol was co-ingested in 3811 (49.9%). In total 53.3% required medical treatment, 14 patients died. Patients with ethanol co-use more frequently presented with a Glasgow Coma Scale (GCS) ≤8 (34.1% vs. 22.4%; P  < 0.001), vomiting (8.1% vs. 4.6%; P  < 0.001), anxiety (12 % vs. 6.4%; P  < 0.001), agitation/aggression (22% vs. 14.7%; P  < 0.001), seizures (3.8% vs. 2.4%; P  < 0.001) and hypotension (7.5% vs. 4.6%; P  < 0.001). They more often required ambulance transport (85.5% vs. 76.5%; P  < 0.001), medical treatment (57.3% vs. 48.0%; P  < 0.001), hospitalization (27.7% vs. 18.9%; P  < 0.001), and admission to intensive care (12.2% vs. 4.0%; P  < 0.001). Subgroup analysis showed that GCS ≤8 was particularly common in patients who combined ethanol with opioids or gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL).

CONCLUSION

Co-use of ethanol with CNS-depressant drugs appears to increase the risk of adverse effects and is associated with a higher need for medical treatment, especially when ethanol is combined with opioids or GHB/GBL.

Can emergency department clinicians diagnose gamma-hydroxybutyrate (GHB) intoxication based on clinical observations alone?

OBJECTIVES

Gamma-hydroxybutyrate (GHB) is a drug of abuse with central depressing effects, which may cause coma with a GCS score as low as 3. A rapid diagnosis 'GHB intoxication' may prevent unnecessary diagnostic work-up and may lead to guided, less invasive, treatment. The aim of this study was to evaluate if ED physicians' clinical evaluation were sufficient for diagnosis in patients with suspected GHB-intoxication.

METHODS

Patients presenting at the ED with a GCS<15 and a potential intoxication with drugs of abuse for whom urine toxicology screen was performed were included consecutively. After a first assessment, the ED physician registered the most likely initial diagnosis in the hospital information system. Urine of these patients was tested with a validated gas chromatography analytical method for GHB (confirmation test). The initial diagnoses were compared for agreement with the results of the confirmation test.

RESULTS

A total of 506 patients were included, 100 patients tested positive for GHB and 406 patients tested negative for GHB. Sensitivity and specificity of the ED physicians compared with the confirmation test to diagnose GHB intoxications were 63% (95% CI 52 to 73) and 93% (95% CI 90 to 95), respectively. The positive predictive value was 67% (95% CI 60 to 77) and the negative predictive value was 92% (95% CI 88 to 94).

CONCLUSION

Physicians underestimate the presence of GHB intoxication and can fail to diagnose GHB intoxication based on clinical observations alone. In the future, a rapid reliable initial analytical GHB test in addition to clinical judgement could be valuable to reduce false negative diagnosis.

Epidemiological and cost analysis of self-poisoning cases in ankara, Turkey

Background:

Poisoning is a global public health problem. Self-poisoning has potentially serious consequences. Follow-up studies have found that 3-10% of self-harm patients eventually succeed.

Objectives:

This study was designed to investigate the epidemiological, clinical and economical aspects of deliberate self-poisoning patients admitted to Yenimahalle State Hospital Intensive Care Unit.

Patients and Methods:

The study was carried out retrospectively in Ankara Yenimahalle State Hospital. It included Seventy-one patients over 16 years of age who were admitted to the hospital due to poisoning during 2012. Exposed poisons were classified into one of three categories; pharmaceuticals, pesticides, and alcohols. Cost account was based on the medical invoices at patient discharge. Data were compared using Student’s T test and chi-square test. A P value of less than 0.05 was considered significant.

Results:

The female/male ratio was 2.55. The mean age of the 71 poisoned patients was 28.92 ± 11.51 years. Most of the poisoning agents were pharmaceuticals (68 cases). Among the pharmaceuticals, antidepressants were involved most often, followed by analgesics. There was no statistically significant difference between pharmaceutical agents in terms of hospital cost (P > 0.05). The mean length of hospital stay was 6.4 ± 4.3 days. There was a statistically significant difference between the lengths of stay of patients in terms of hospital cost (P < 0.05).

Conclusions:

The patient cost increased as the length of stay increased due to the policy of bundle pricing.

Estimating the prevalence of illicit opioid use in New York City using multiple data sources

BACKGROUND

Despite concerns about its health and social consequences, little is known about the prevalence of illicit opioid use in New York City. Individuals who misuse heroin and prescription opioids are known to bear a disproportionate burden of morbidity and mortality. Service providers and public health authorities are challenged to provide appropriate interventions in the absence of basic knowledge about the size and characteristics of this population. While illicit drug users are underrepresented in population-based surveys, they may be identified in multiple administrative data sources.

METHODS

We analyzed large datasets tracking hospital inpatient and emergency room admissions as well as drug treatment and detoxification services utilization. These were applied in combination with findings from a large general population survey and administrative records tracking prescriptions, drug overdose deaths, and correctional health services, to estimate the prevalence of heroin and non-medical prescription opioid use among New York City residents in 2006. These data were further applied to a descriptive analysis of opioid users entering drug treatment and hospital-based medical care.

RESULTS

These data sources identified 126,681 cases of opioid use among New York City residents in 2006. After applying adjustment scenarios to account for potential overlap between data sources, we estimated over 92,000 individual opioid users. By contrast, just 21,600 opioid users initiated drug treatment in 2006. Opioid users represented 4 % of all individuals hospitalized, and over 44,000 hospitalizations during the calendar year.

CONCLUSIONS

Our findings suggest that innovative approaches are needed to provide adequate services to this sizeable population of opioid users. Given the observed high rates of hospital services utilization, greater integration of drug services into medical settings could be one component of an effective approach to expanding both the scope and reach of health interventions for this population.

Prescription use disorders in older adults

The number of older adults needing substance abuse treatment is projected to rise significantly in the next few decades. This paper will focus on the epidemic of prescription use disorders in older adults. Particular vulnerabilities of older adults to addiction will be considered. Specifically, the prevalence and patterns of use of opioids, stimulants, and benzodiazepines will be explored, including the effects of these substances on morbidity and mortality. Treatment intervention strategies will be briefly discussed, and areas for future research are suggested.

Recent substance intake among patients admitted to acute psychiatric wards: physician's assessment and on-site urine testing compared with comprehensive laboratory analyses

This cross-sectional study of acute psychiatric admissions compared physicians' assessments of recent substance intake and on-site urine testing with comprehensive laboratory drug analyses. The sample comprised 325 consecutive admissions from 2 acute psychiatric wards. Physicians on call were asked to judge if the patient had recently taken benzodiazepines, opiates, alcohol, amphetamines, cannabis, or cocaine. Blood and urine samples were obtained and analyzed with chromatographic laboratory methods for a wide range of substances. A routine on-site urine screening test was performed in 92 of the cases. Physicians' assessments and on-site urine testing were compared with the reference standard of laboratory analyses. The sensitivity of the physician's assessment was highest for amphetamines (76%), followed by benzodiazepines (61%), opiates (57%), cannabis (55%), and cocaine (50%), whereas specificity was greater than 90% for all substances. The sensitivity of the on-site test ranged from 76% for amphetamine to 97% for cannabis, and specificity ranged from 82% for cannabis to 100% for cocaine. The study indicates clinical underdetection of recent substance intake among acute psychiatric admissions. On-site urine testing identified substance use that was not recognized by the physician's initial assessment, although specificity for cannabis and benzodiazepines was low. Chromatographic methods, which offered important supplementary information about substance use, should be considered for the routine screening of acutely admitted psychiatric patients.

Suicidal intention, psychosocial factors and referral to further treatment: a one-year cross-sectional study of self-poisoning

BACKGROUND

Patients treated for self-poisoning have an increased risk of death, both by natural and unnatural causes. The follow-up of these patients is therefore of great importance. The aim of this study was to explore the differences in psychosocial factors and referrals to follow-up among self-poisoning patients according to their evaluated intention.

METHODS

A cross-sectional multicenter study of all 908 admissions to hospital because of self-poisoning in Oslo during one year was completed. Fifty-four percent were females, and the median age was 36 years. The patients were grouped according to evaluated intention: suicide attempts (moderate to high suicide intent), appeals (low suicide intent) and substance-use related poisonings. Multinomial regression analyses compared patients based on their evaluated intention; suicide attempts were used as the reference.

RESULTS

Of all self-poisoning incidents, 37% were suicide attempts, 26% were appeals and 38% were related to substance use. Fifty-five percent of the patients reported previous suicide attempts, 58% reported previous or current psychiatric treatment and 32% reported daily substance use. Overall, patients treated for self-poisoning showed a lack of social integration. Only 33% were employed, 34% were married or cohabiting and 53% were living alone. Those in the suicide attempt and appeal groups had more previous suicide attempts and reported more psychiatric treatment than those with poisoning related to substance use. One third of all patients with substance use-related poisoning reported previous suicide attempts, and one third of suicide attempt patients reported daily substance use. Gender distribution was the only statistically significant difference between the appeal patients and suicide attempt patients. Almost one in every five patients was discharged without any plans for follow-up: 36% of patients with substance use-related poisoning and 5% of suicide attempt patients. Thirty-eight percent of all suicide attempt patients were admitted to a psychiatric ward. Only 10% of patients with substance use-related poisoning were referred to substance abuse treatment.

CONCLUSIONS

All patients had several risk factors for suicidal behavior. There were only minor differences between suicide attempt patients and appeal patients. If the self-poisoning was evaluated as related to substance use, the patient was often discharged without plans for follow-up.

Accuracy of current clinical diagnosis in recreational drug-related attendance to the emergency department

OBJECTIVE

To determine the accuracy of current clinical diagnosis in recreational drug-related attendances to emergency by blood analysis.

METHODS

A prospective convenience sample of 103 patients who attended hospital with suspected recreational drug-related presentations was collected. Doctors' clinical impression of drugs responsible for presentation was compared with a detailed forensic blood analysis for recreational drugs.

RESULTS

Among 103 samples, 80 (78%, 95% confidence intervals [CI] 70-86%) were found to have correct clinical suspicion of the recreational drug responsible for clinical presentation confirmed by laboratory analysis. Clinical diagnosis was most accurate for gamma-hydroxy butyrate (GHB) (sensitivity 97%, specificity 91%) and less accurate for amphetamines (sensitivity 61%, specificity 79%), alcohol (sensitivity 42%, specificity 84%) and opiates (sensitivity 46%, specificity 100%). Multiple drug ingestion was found in 70% (95% CI 61-79%) of samples. Sensitivity and specificity of clinical impression for prediction of multiple drug ingestion presence is 75% (95% CI 66-83%) and 85% (95% CI 78-92%), respectively.

CONCLUSION

Clinical diagnosis in recreational drug-related attendances to the ED was correct in most cases. Drugs, such as GHB, were the most accurately diagnosed. Inaccuracy in recognizing other drugs, like amphetamines, opiates and alcohol, occurs where a coingestant produces a more profound clinical picture. Multiple drug ingestion is a common scenario in recreational drug presentations to emergency.

Drugs of abuse among acute psychiatric and medical admissions: laboratory based identification of prevalence and drug influence

OBJECTIVE

To use laboratory based analyses of blood and urine to determine the prevalence and influence of drugs of abuse among acute psychiatric and medical admissions.

METHOD

In a cross sectional study, urine and blood samples were collected from 100 psychiatric and 106 medical admissions and extensively analysed for legal drugs with abuse potential, alcohol and illegal drugs. Drug influence at the time of admission was estimated on the basis of blood drug concentrations.

RESULTS

Legal drugs were found in 47% of the psychiatric and 42% of the medical admissions. Alcohol was detected in 8% of the psychiatric and 4% of medical admissions, and illegal drugs were detected in 36% of the psychiatric and 13% of the medical admissions. Drug influence was estimated in 26% of the psychiatric and 14% of the medical patients.

CONCLUSION

This study shows widespread use of substances among psychiatric and medical inpatients and that many are under the influence of drugs on admission.

Clinical assessment compared to laboratory screening in acutely poisoned patients

Acute poisonings may require identification of the toxic agents. It is impossible for routine laboratories to provide a full spectrum of toxicological analyses, and clinicians should know the reliability of the clinical diagnoses of toxic agents. We performed a 1-year study of hospitalized acute poisonings to determine the agreement between the clinical assessment on admission and serum laboratory tests for eight common toxic agents. Blood samples were drawn in 665 (70%) of the 947 admissions. The total number of laboratory found agents (967) exceeded the clinically suspected (871) by 11%. The agreement between the clinical assessment and laboratory analyses was good for ethanol and paracetamol ( κ = 0.70 for both), whereas only moderate or fair for other agents ( κ 0.22–0.51). Sensitivities of the clinical assessments compared to the laboratory results were better for common than rare agents, and better for higher than lower serum concentrations. The four most common agents (ethanol, benzodiazepines, paracetamol, and opiates) had overall sensitivity of 82% for higher-than-median serum concentrations, whereas the other agents had sensitivities ranging from 14% to 71% for higher-than-median concentrations. The reliability of the clinical diagnoses varied to such an extent that agents, which are important to recognize for specific treatment, should be tested for.