Stimulant use in suicides: A systematic review

Suicide remains a global public health concern and the increased supply and use of synthetic stimulants globally may have implications for the burden of suicides attributable to substance use. This systematic review investigated any potential associations of stimulant use detected in post-mortem biological specimens and suicides. We conducted a systematic review and narrative synthesis (CRD42021237966). Medline, EMBASE, TOXLINE, and Scopus databases were searched for terms related to forensic toxicology, post-mortem toxicology, suicide and stimulants. The primary outcome was to estimate the prevalence of stimulant use in suicides. There were 26 studies whichcontributed to prevalence measures; in studies reporting at the individual compound level, suicides involved cocaine (0.1-23%), caffeine (3.2-22%), 3,4-methylenedioxymethamphetamine (0.1-17%), amphetamine (0.2-9.3%), methamphetamine (3.1-7%), and phentermine (0.9-1%). Overall, stimulant use in suicides was over-represented compared to estimates of stimulant use in the general population and has increased over time. Thirteen case reports used to contextualise suicides involving stimulants found no examples of cocaine or methamphetamine mono-intoxication of suicidal intent. This suggests mechanisms other than acute toxicity involved in stimulant-associated suicide. Future research by in-depth psychological autopsies of suicides involving stimulants, in combination with segmental hair analysis to determine the chronicity of stimulant exposure, may contribute to a better understanding of the burden of suicide attributable to stimulant use.

Fluctuations in influenza-like illness epidemics and suicide mortality: A time-series regression of 13-year mortality data in South Korea

AIMS

We explored the association between influenza epidemic and suicide mortality rates in a large population using a time-series regression of 13-year mortality data in South Korea.

METHODS

Weekly suicide mortalities and influenza-like illness (ILI) were analyzed using time series regression. Regression coefficient for suicide mortality based on percentage change of ILI was calculated using a quasi-Poisson regression. Non-linear distributed lag models with quadratic function up to 24 weeks were constructed.

RESULTS

The association between ILI and suicide mortality increased significantly up to 8 weeks post-influenza diagnosis. A significant positive association between ILI and suicide mortality was observed from 2009, when a novel influenza A(H1N1)pdm09 virus provoked a worldwide pandemic. No meaningful association between these factors was observed before 2009.

CONCLUSION

There was a significant positive relationship between ILI and suicide mortality after 2009, when a novel influenza A(H1N1)pdm09 virus provoked a worldwide pandemic.

Sympathomimetic amine compounds and hepatotoxicity: Not all are alike-Key distinctions noted in a short review

Sympathomimetic amine compounds are often pooled together and incorrectly assumed to be interchangeable with respect to potential adverse effects. A brief and specific review of sympathomimetic compounds and one instance (i.e., hepatotoxicity) where these compounds have been improperly grouped together is covered. A review of the proposed mechanisms through which known hepatotoxic sympathomimetic agents (e.g., 3,4-methylenedioxymethamphetamine or MDMA, methamphetamine and amphetamine) cause liver injury, along with a corresponding review of in vitro data, interventional data, animal model studies and observational data allow for a comparison/contrast of different agents and reveals a lack of potential toxicity for some agents (e.g., pseudoephedrine, phenylephrine, ephedrine, 1,3-dimethylamylamine, phentermine) in this broad category. Data show that compounds within the broad group of sympathomimetics display divergent pharmacological and toxicological profiles and can be clearly distinguished with respect to liver injury. These data serve as a reminder to clinicians and others, that even small structural differences between molecules can lead to drastically different pharmacological/toxicological profiles and that one should not assume that all sympathomimetic agents are hepatotoxic. Such assumptions could lead to diagnostic errors and incorrect or insufficient treatment.

Cardiovascular toxicities of performance-enhancing substances in sports

Athletes commonly use drugs and dietary supplements to improve athletic performance or to assist with weight loss. Some of these substances are obtainable by prescription or by illegal means; others are marketed as supplements, vitamins, or minerals. Nutritional supplements are protected from Food and Drug Administration regulation by the 1994 US Dietary Supplement Health and Education Act, and manufacturers are not required to demonstrate proof of efficacy or safety. Furthermore, the Food and Drug Administration lacks a regulatory body to evaluate such products for purity. Existing scientific data, which consist of case reports and clinical observations, describe serious cardiovascular adverse effects from use of performance-enhancing substances, including sudden death. Although mounting evidence led to the recent ban of ephedra (ma huang), other performance-enhancing substances continue to be used frequently at all levels, from elementary school children to professional athletes. Thus, although the potential for cardiovascular injury is great, few appropriately designed studies have been conducted to assess the benefits and risks of using performance-enhancing substances. We performed an exhaustive OVID MEDLINE search to Identify all existing scientific data, review articles, case reports, and clinical observations that address this subject. In this review, we examine the current evidence regarding cardiovascular risk for persons using anabolic-androgenic steroids including 2 synthetic substances, tetrahydrogestrinone and androstenedione (andro), stimulants such as ephedra, and nonsteroidal agents such as recombinant human erythropoietin, human growth hormone, creatine, and beta-hydroxy-beta-methylbutyrate.

Fatal blood and tissue concentrations of more than 200 drugs

Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.

Resolution of ephedrine stones with dissolution therapy

A patient with a history of ingesting large quantities of an over-the-counter stimulant developed renal calculi that on further analysis, after stone passage, revealed increased amounts of ephedrine. Over the course of 7 months, all of the patient's ephedrine stones were managed successfully by alkalinization. Similar to previously reported ephedrine calculi, these stones were radiolucent on x-ray imaging, but their course was monitored on serial nonenhanced computed tomography scans. We believe this to be the first reported use of alkaline therapy for the dissolution of renal stones containing ephedrine.

Simultaneous determination of amphetamine and one of its metabolites by HPLC with electrochemical detection

A high-performance liquid chromatographic method coupled with electrochemical detector was developed for the separation and quantitation of amphetamine and one of its metabolites, the 4-hydroxynorephedrine. The pre-column derivatisation of these compounds was carried out with 2,5-dihydroxybenzaldehyde as electroactive labelling reagent, in presence of Borohydride Exchange Resin. The new synthetic method developed was fast, clean and high yielding. The analysis was performed in isocratic mode on a reversed phase column 5 microm Hypersil ODS RP-18, 15 cm, using as a mobile phase methanol-NaH(2)PO(4) buffer (50 mM, pH 5.5)(30:70 v/v) containing trietylamine (0.5% v/v) and the products were detected by a porous graphite electrode set at an oxidation potential of +0.6 V. The linearity of response was examined for each derivatised compound and was analysed using solutions in the range 10-40 nmol/ml. The correlation coefficients of the linear regression of the standard curves were greater than 0.99. The method developed in this study was sensitive and very selective. Because of the specificity for primary phenylethylamines, it could be applicable for the assay of other related substances in toxicology and drugs abuse.

Adverse cardiovascular events temporally associated with ma huang, an herbal source of ephedrine

OBJECTIVE

To evaluate possible cardiovascular toxic effects associated with use of dietary supplements containing ma huang, an herbal source of ephedrine.

METHODS

We reviewed the comprehensive database Adverse Reaction Monitoring System of the Food and Drug Administration, which included clinical records, investigative reports, and autopsy reports related to ma huang use. The main outcome measurements were stroke, myocardial infarction, and sudden death.

RESULTS

From 1995 to 1997, 926 cases of possible ma huang toxicity were reported to the Food and Drug Administration. In 37 patients (23 women and 14 men with a mean +/- SD age of 43 +/- 13 years), use of ma huang was temporally related to stroke (in 16), myocardial infarction (in 10), or sudden death (in 11). Autopsies performed in 7 of the 11 patients who experienced sudden death showed a normal heart in 1, coronary atherosclerosis in 3, and cardiomyopathies in 3. In 36 of the 37 patients, use of ma huang was reported to be within the manufacturers' dosing guidelines.

CONCLUSIONS

Analysis of the 37 patients indicates the following findings: (1) ma huang use is temporally related to stroke, myocardial infarction, and sudden death; (2) underlying heart or vascular disease is not a prerequisite for ma huang-related adverse events; and (3) the cardiovascular toxic effects associated with ma huang were not limited to massive doses. Although the pathogenesis of the cardiac toxic effects of ma huang remains incompletely defined, available observational and circumstantial evidence indicates that use of the substance may be associated with serious medical complications.

Sympathomimetic drug use in adolescents presenting to a pediatric emergency department with chest pain

BACKGROUND

Drug use has been associated with chest pain in adults presenting for emergency care. The association of drug use and chest pain in adolescents presenting to a pediatric emergency department has not been evaluated.

METHODS

Urine drug testing was conducted in a convenience sample of healthy adolescents with chest pain (cases) and compared to a control group of adolescents presenting with other complaints to a pediatric emergency department. Exclusion criteria were known diagnoses associated with chest pain (e.g., cardiac disease, sickle cell disease) and major trauma (due to its association with drug use). Urine drug testing consisted of 2 screening tests and gas chromatography-mass spectrometry confirmation of all positive or indeterminate results. All patients completed a questionnaire regarding recently prescribed, over-the-counter, and illicit drug use.

RESULTS

Twenty-eight cases and 26 controls completed the study over an 11-month study period. No cases or controls were positive for cocaine whereas marijuana was detected in 7 (25.0%) cases and in 7 (26.7%) controls. Five (17.8%) of the cases but none of the controls were positive for ephedrine (p = 0.05).

CONCLUSIONS

Ephedrine exposure appeared to be associated with chest pain in adolescents presenting for emergency care and marijuana was the most common drug of abuse, regardless of presenting complaint.

Hair analysis for drugs of abuse. XIX. Determination of ephedrine and its homologs in rat hair and human hair

A sensitive GC-MS method was developed for the quantitative analysis of ephedrine (EP), phenylpropanolamine (PPA) and methylephedrine (ME) in animal and human hair. After washing with 0.1% sodium dodecyl sulfate, hair samples (10 mg) were added with deuterated internal standards, extracted by 1-h sonication and over night soaking in 2 ml of 5 M HCl-methanol (1:20) at room temperature. Following evaporation of the liquid phase, the residue was dissolved in phosphate buffer solution (pH 6.0) and purified using a solid-phase extraction procedure with Bond Elut Certify columns. Two types of derivatization were compared - using trifluoroacetic anhydride (TFAA) and pentafluoropropionic anhydride (PFPA) - for discrimination of EP and methamphetamine (MA). Derivatized extracts were analyzed by GC-MS in the EI mode using a capillary column (OV-1 equivalent). From the results comparing three GC-MS conditions, PFP-derivatives separated with a temperature gradient of 20 degrees C/min from 60 degrees C to 280 degrees C gave the best resolution between EP and MA. ME was analyzed as a trimethylsilyl derivative using N,O-bis-trimethylsilyl acetamide at the above GC condition. The assay was linear from 0.5 to 50 ng/mg (r=0.998) and capable of detecting less than 50 pg of derivatized EP, PPA and ME on-column. Intra-assay precision was characterized by C.V. values from 5 to 16% in the concentration range of 1-10 ng/mg hair. The method was used for the quantitative determination of EP, PPA and ME in the hair obtained from three rats with dark brown hair after ten intraperitoneal injections (5 mg/kg/day) of the three drugs and from three male and one female volunteers with black hair after an oral dose of 50 mg/day of EP-HCl for three days. Hair samples were collected by shaving from the back of rats and cutting from the scalp of humans 28 days after the first dose. The incorporation rates of EP, PPA and ME into hair (the ratios of [hair concentration] to [AUC]) obtained from the animal experiment were 0.10, 0.07 and 0.03, respectively, which are a little lower than those (0.14, 0.10 and 0.04) of their desoxy-compounds, MA, amphetamine and dimethylamphetamine. EP was detected at an average of 2.25 ng/mg (n=4) in human scalp hair and at a range of 1-29 ng/mg (n=3) in human beard hair until day 14, but its metabolite (PPA) was at a trace level in the hair of the four subjects. The method was successfully used for detection of ME and EP in the hair of a neonate and its mother who was abusing Bron syrup containing ME during the pregnancy.