Common Substances of Abuse

Patterns and Emerging Trends in Acute Poisoning with Substances of Abuse Used for Recreational Purposes in Adolescents: A Six-Year Multicentre Study

This six-year multicentre study investigated acute intentional poisoning with substances of abuse in adolescents to identify changes and patterns in substance use. Data from 562 adolescents were collected from three paediatric poison centres in Romania between January 2017 and December 2022. This study analysed the epidemiological and sociodemographic characteristics of the adolescents, including age, gender, place of residence, history of substance abuse, psychiatric history, and history of institutionalised care. The findings revealed that cannabis and new psychoactive substances (NPSs) are the most commonly implicated substances, each with distinct profiles among adolescents. Cannabis was involved in 46.1% of cases, with a significant association with urban residency. NPSs were identified as the second most prevalent substance, accounting for 39.3% of cases. These were more prevalent in rural areas and among patients with psychiatric disorders. Cannabis and NPSs were also the most commonly implicated substances in acute intentional poisoning cases with substances of abuse. These substances have distinct profiles among adolescents, including age, gender, residency area, history of substance abuse, psychiatric history, and institutional care. These findings underscore the necessity of targeted public health interventions and integrated care approaches to address substance use and related mental health issues in adolescents.

Prevalence and correlates of internalizing and externalizing mental health problems among in-school adolescents in eastern Ethiopia: a cross-sectional study

Adolescent's mental health issues are a major social burden and a significant public health issue, but they have not received enough attention in Ethiopia. Therefore, this study aimed to determine the prevalence and correlates of internalizing and externalizing mental health problems among in-school adolescents in the Harari region, eastern Ethiopia. A cross-sectional study was conducted among 3227 in-school adolescents. Multistage sampling was used to select schools and eligible students to participate in the study. A guided, self-administered strength and difficulty questionnaire measured mental health problems. Data were double-entered, validated, and cleaned using EpiData 3.1 and analyzed using STATA version 17. Ordinal logistic regression analysis was performed to estimate the adjusted odds ratio between mental health problems and their correlates. Statistical significance was set at p-value < 0.05. The magnitudes of mental health problems among in-school adolescents by subscale was 24.17% (95% CI 22.72; 25.67) for internalizing and 11.93% (95% CI 10.85; 13.09) for externalizing problems. A high internalizing problem score was associated with females, rural residents, alcohol users, attending public schools, those bullied at school, and those in the lowest wealth index. Likewise, the likelihood of a high externalizing problem score was high among alcohol users, adolescents whose fathers are uneducated, rural, and bullied at school. The study suggests that mental health problems are prevalent among in-school adolescents in Ethiopia, especially internalizing problems. The study also identifies several risk factors associated with internalizing and externalizing problems, such as wealth index, school types, alcohol use, bullying, and rural residence. These factors may indicate the need for more mental health awareness and support programs for adolescents in Ethiopia. This highlights that schools and communities should prioritize mental health awareness and support programs for adolescents. These programs should be tailored to address the specific needs of the population, such as rural residents, those in the lowest wealth index, and those who have experienced bullying.

Predictors and Correlates of Positive Urine Drug Screening in a Retrospective Cohort Analysis of Child and Adolescent Psychiatry Inpatients Throughout the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Youth substance use is associated with significant psychological, neurological, and medical complications. Risk factors for substance use among children and adolescents in the general population include peer and/or parental substance use, certain psychiatric illnesses (eg, Attention-Deficit/Hyperactivity Disorder, depression), and history of maltreatment. Co-occurring substance use and psychiatric illness have been associated with increased suicidality, but few prior studies have characterized substance use among child/adolescent inpatients. As such, it remains unclear how substance use contributing to acute psychiatric presentations has changed since the start of the COVID-19 pandemic.

METHODS

This is a retrospective cohort study of 816 unique child/adolescent psychiatry inpatients with urine drug screening (UDS) results from a diverse urban setting. Charts of patients hospitalized between June 1, 2018 and November 30, 2021 were reviewed for sociodemographic characteristics, indication for admission, psychiatric history, hospital course, treatment plan, and discharge diagnosis. Differences in sociodemographic and clinical characteristics, such as age, race, and diagnoses, between patients with and without positive UDS were explored throughout various periods of the COVID-19 pandemic. Descriptive and comparative statistics were performed, as well as a logistic regression model to identify the predictors of positive UDS.

RESULTS

Of the study sample, 18% had a positive UDS. Older age, diagnosis of impulsive or behavioral disorder, and a history of violence were found to be predictors of positive UDS. Asian/South Asian or Hispanic/LatinX race and history of a developmental or intellectual disability were found to be negative predictors. The frequency of positive UDS in this population did not change based on COVID-19.

DISCUSSION AND CONCLUSIONS

Multiple factors may predispose children and adolescents to substance use. Though no impact of COVID-19 was found in this sample, longer-term studies are needed.

SCIENTIFIC SIGNIFICANCE

This study identifies independent predictors of active substance use in the child and adolescent psychiatric inpatient population.

Health status outcome among cannabis addicts after treatment of addiction

The abuse of Cannabis is a widespread issue in the Asir region. It has a lot of legal and occupational repercussions. The purpose of this study was to evaluate the health status of cannabis addicts at admission and after treatment using body mass index, glycemic status, liver function, renal function, and oxidative stress. A cross-sectional study was conducted with 120 participants. The study was conducted at Al Amal Hospital for Mental Health in Asir region of Saudi Arabia, with 100 hospitalized patients receiving addiction treatment and 20 healthy volunteers. The participants were divided into two groups: group I, the control group, and group II, the cannabis addicts. The socio-demographic data were gathered. The level of cannabis in the urine and the CWAS [Cannabis Withdrawal Assessment Scale] were determined. In addition, the Body Mass Index [BMI], vital signs [temperature, heart rate, systolic blood pressure, diastolic blood pressure, and respiratory rate], serum levels of albumin, total bilirubin, direct bilirubin, AST, ALT, and ALP, urea, creatinine, Thiobarbituric acid-reactive substances [TBARS], superoxide dismutase [SOD], reduced glutathione [GSH], and catalase [CAT] were analyzed on the first day of admission and after treatment. According to the results, there was no significant change in the body mass index. The vital signs in the cannabis user group were significantly lower than the corresponding admission values. Regarding renal function tests such as urea and creatinine, we found that after treatment, the mean urea and creatinine values in the cannabis user group did not differ significantly from the corresponding admission values. However, after treatment, the mean values of fasting blood glucose levels in the cannabis user group were significantly lower than at admission. Also, the mean values of liver function tests such as albumin, total bilirubin, direct bilirubin, AST, ALT, and ALP in the cannabis user group were significantly lower than the corresponding admission values after treatment. In assessing the antioxidant system, we found that the mean values of TBARS, SOD, GSH, and CAT in the cannabis user group did not differ significantly from the corresponding admission values after treatment. The current findings have revealed that cannabis addiction harms the various body systems and has significant implications for the addict's state of health. The values of oxidative stress biomarkers did not change in this study, but other measured parameters improved after treatment.

Consensus paper of the WFSBP task force on cannabis, cannabinoids and psychosis

OBJECTIVES

The liberalisation of cannabis laws, the increasing availability and potency of cannabis has renewed concern about the risk of psychosis with cannabis.

METHODS

The objective of the WFSBP task force was to review the literature about this relationship.

RESULTS

Converging lines of evidence suggest that exposure to cannabis increases the risk for psychoses ranging from transient psychotic states to chronic recurrent psychosis. The greater the dose, and the earlier the age of exposure, the greater the risk. For some psychosis outcomes, the evidence supports some of the criteria of causality. However, alternate explanations including reverse causality and confounders cannot be conclusively excluded. Furthermore, cannabis is neither necessary nor sufficient to cause psychosis. More likely it is one of the multiple causal components. In those with established psychosis, cannabis has a negative impact on the course and expression of the illness. Emerging evidence also suggests alterations in the endocannabinoid system in psychotic disorders.

CONCLUSIONS

Given that exposure to cannabis and cannabinoids is modifiable, delaying or eliminating exposure to cannabis or cannabinoids, could potentially impact the rates of psychosis related to cannabis, especially in those who are at high risk for developing the disorder.

Substance Use among Adolescents: A Retrospective Study (2017-2018) in the Toxicology Unit, University Hospital of Lille, France

Research on adolescent substance use is of utmost importance. Using local toxicological data, both prevalence and pattern of substance use (SU) and substance-related death (SRD) can be assessed to design effective prevention programs. A retrospective study of toxicology investigations of all adolescents referred to the medico-legal section of the Toxicology Unit of the University Hospital of Lille, France, for a 2-year period from 2017 to 2018. In the total sample of 1961 cases, adolescents accounted for 3.3% of the cases (n = 65). Among the adolescents, 16.9% were aged 10−14 years and 83.1% were aged >14−19 years. About 69.2% were males. Less than 70% of all presented adolescents used substances. More than two-thirds (74%) of positive detections were male. Illicit substances (43%) were the most detected substance followed by alcohol (20%) and prescription substances (20%). Tetrahydrocannabinol (THC) was extremely common as it was found in 29% of all adolescents. Cocaine and amphetamines were detected in 13.8% of total tested adolescents. Polysubstance use was common between alcohol and THC and among males. About one-third of deaths were due to substance use. About 54% of SRD was associated with polysubstance detection. It is recommended that illicit substances, ethanol, and prescription substances are targeted for testing among adolescents in order to provide appropriate prevention.

Cannabis smoking increases the risk of suicide ideation and suicide attempt in young individuals of 11-21 years: A systematic review and meta-analysis

BACKGROUND

Cannabis is the most frequently consumed drug around the world. Its use has been associated with increased suicide behaviors; nonetheless, the association of cannabis smoking and suicide behaviors in adolescents has not yet been established. The aim of this systematic review and meta-analysis was to evaluate the risk of suicide attempt, suicidal ideation or suicide planning in individuals of 11-21 years of age who smoke cannabis.

METHODS

We performed an online searched using PubMed, EBSCO and Science Direct databases, up to July 2021. We calculated odds ratio with 95% confidence intervals to evaluate the association between suicide attempt, suicidal ideation or suicide planning and cannabis smoking in individuals of 11-21 years of age.

RESULTS

Twenty studies reported suicide attempts in 34,859 young individuals, suicidal ideation in 26, 937 individuals, and suicide planning in 9054 young individuals. We found an increased risk of suicide attempt in cannabis smokers than in non-cannabis users (OR: 2.33; 95% CI: 1.78-3.05; Z p value; <0.0001; I² = 97.12%), as well as a significant association between cannabis smoking and suicidal ideation (OR: 2.04; 95%CI: 1.64-2.53; Z p value: <0.001; I²: 94.88) and suicide planning (OR: 1.674; 95% CI: 1.554-1.804; Z p value: 0.000; I²: 92.609). Subgroup analyses showed that American teens have an increased risk of suicidal ideation; the meta-regression analysis revealed that age was negatively associated with the risk of suicide attempt.

CONCLUSIONS

This meta-analysis shows that cannabis smoking increased the risk of suicide attempt, suicidal ideation and suicide planning in young individuals of 11-21 years of age. The high risk of suicide behaviors could vary depending on the population studied; therefore, more studies are necessary to corroborate the risk of presenting suicide behaviors in individuals of 11-21 years of age who smoke cannabis.

Varied Presentations of Pediatric Patients With Positive Cannabinoid Tests

Background: Cannabis (marijuana) is one of the most abused drugs worldwide. The increasing availability of cannabis has been associated with increased emergency department (ED) visits. There is a wide range of presentations documented in the recent literature, and the full scope of symptoms in young children is not fully known.

Objective: The primary objectives were to gather information regarding the characteristics in the presentation of the children with positive cannabinoid urine drug screen (UDS) results in the ED and to determine if there are certain common presentations with cannabinoid ingestion or inhalation.

Design/methods: This study was a descriptive retrospective chart review from March 2013 to June 2020 of pediatric patients <18 years old with positive UDS for cannabinoids. Data collected included age, gender, chief complaint, history, review of systems, vital signs, physical exam findings, laboratory studies, imaging findings, and disposition. Four hundred and twenty-two charts were included in the study. Analysis was done using Stata 13 (College Station, TX).

Results: The data showed that there was a significant increase in the number of pediatric patients with a positive UDS after cannabis legalization. Using cases from November 2013 to November 2019 showed 71% of cases presented after legalization on November 8, 2016 (Z=7.72, p<.01). The majority of cases were patients between the ages of 15 and 17 (78%). 43% (n=182) of patients presented with chief complaints of suicidal ideation. The other most common chief complaints were vomiting (8%, n=33), nausea (5%, n=22), trauma (5%, n=21), and altered mental status (AMS) (5%, n=20). The most common vital sign abnormalities included tachycardia (27%, n=115) and hypertension (18%, n=74). Forty-two percent of patients had tests ordered during their visit with 7% undergoing head computerized tomography. On the UDS, 28% of patients were positive for at least one other drug with amphetamine being the most common (13%, n=55).

Conclusion: Our data showed a significant increase in the number of cases since the legalization of cannabis in 2016, supporting the need for ED physicians to become more familiar with cannabis intoxication and its complications. The presentations of these patients can vary greatly. Common presentations include suicidal ideation, nausea/vomiting, AMS, and trauma with vital sign abnormalities including tachycardia and hypertension. Physicians should continue to consider cannabis use when evaluating these pediatric complaints. It may decrease the number of tests ordered in this patient population.

High Social Capital is Associated with Decreased Mental Health Problem Among In-School Adolescents in Eastern Ethiopia: A Cross-Sectional Study

Purpose

The importance of social capital for adolescent mental health has not been explored in low resource settings like Ethiopia. In this study, we examined the association between social capital and mental health problems among in-school adolescents in Harari Regional State, eastern Ethiopia.

Methods

A cross-sectional study was conducted among 3227 in-school adolescents of 13-19 years. A multistage sampling was used to select participants. Guided self-administered questionnaire was used to collect data. Mental health problem was measured using a self-administered version of the strength and difficulty questionnaire (SDQ), while social capital questionnaire for adolescent students (SCQ-AS) was used to collect data about the condition of social capital. The data were double entered, validated, and cleaned using EpiData 3.1 and analyzed using STATA 14.1. The association between the outcome variable and predictors was analyzed using an ordinal logistic regression model. The result was reported using an odds ratio along with 95% confidence interval (CI) and a p-value <0.05 was considered statistically significant association.

Results

A total of 740 (22.93%) students had mental health problem, of which 9.7% (95% CI, 8.7-10.8) and 13.20% (95% CI, 12-14) were classified as "abnormal" and "borderline", respectively. Factors associated with decreased mental health problem were increased network of friends at school (AOR = 0.75, 95% CI: 0.58-0.99), increased trust in school or neighborhood (AOR = 0.52, 95% CI: 0.44-0.63), and high social cohesion in the community (AOR = 0.75, 95% CI: 0.62-0.89).

Conclusion

Higher social capital is associated with a decreased mental health problem among in-school adolescents. Prevention and treatment of mental health problems require strengthening social capital at school, household, and in the neighborhood.

Pediatric cannabis intoxication trends in the pre and post-legalization era

INTRODUCTION

On April 13, 2017, a bill to legalize cannabis was introduced to the Canadian Parliament and presented to the public. On October 17, 2018, Canada legalized recreational cannabis use. We assessed intoxication severity, reflected by ICU admission rates, risk factors and other characteristics in children who presented to the emergency department (ED) with cannabis intoxication, before and after legalization.

METHODS

A retrospective cohort study of children 0-18 years who presented to a pediatric ED between January 1, 2008 and December 31, 2019 with cannabis intoxication. The pre-legalization period was defined from January 1, 2008 to April 12, 2017 and the peri-post legalization period from April 13, 2017 to December 31, 2019.

RESULTS

We identified 298 patients; 232 (77.8%) presented in the pre legalization period and 66 (22.1%) in the peri-post legalization period; median age: 15.9 years (range: 11 months-17.99 years). A higher proportion of children were admitted to the ICU in the peri-post legalization period (13.6% vs. 4.7%, respectively; p = .02). While the median monthly number of cannabis-related presentations did not differ between the time periods (2.1 [IQR:1.9-2.5] in the pre legalization period vs. 1.7 [IQR:1.0-3.0] in the peri-post legalization period; p = .69), the clinical severity did. The proportions of children with respiratory involvement (65.9% vs. 50.9%; p = .05) and altered mental status (28.8% vs. 14.2%; p < .01) were higher in the peri-post legalization period. The peri-post legalization period was characterized by more children younger than 12 years (12.1% vs. 3.0%; p = .04), unintentional exposures (14.4% vs, 2.8%; p = .002) and edibles ingestion (19.7% vs. 7.8%; p = .01). Edible ingestion was an independent predictor of ICU admission (adjusted OR: 4.1, 95%CI: 1.2-13.7, p = .02).

CONCLUSIONS

The recreational cannabis legalization in Canada is associated with increased rates of severe intoxications in children. Edible ingestion is a strong predictor of ICU admission in the pediatric population.

1,1-Difluoroethane Forensic Aspects for the Toxicologist and Pathologist

1,1-Difluoroethane (DFE) is a halogenated hydrocarbon that is commonly used as a propellant in air duster products. Herein, the pharmacology of DFE was reviewed, and questions relevant to medicolegal investigations were addressed. Particular emphasis was given to detection time in biological specimens and the range, onset and duration of effects. DFE may be abused as an inhalant and is rapidly absorbed through the lungs. Onset of central nervous system (CNS) depressant effects is within seconds and the duration may only last minutes. The effects may lead to impairment of human performance, including confusion, lethargy, impaired judgment, loss of motor coordination and loss of consciousness. Death may result even after the first use. With heavy use or in combination with other CNS depressants, extended periods of drowsiness or loss of consciousness may be observed with an increased risk of a fatal event. A majority of impaired driving investigations where DFE was identified included a collision demonstrating the significant impact its use may have on traffic safety. When DFE is identified alone, without other drugs that cause CNS impairment, the effects may not be observable minutes after the crash, making identification of its use difficult. Although concentrations dissipate rapidly, DFE has been detected in blood specimens collected up to 3 hours after the driving incident. Two studies on passive exposure presented herein demonstrated that it is unlikely to detect DFE above concentrations of ∼2.6 µg/mL in blood or urine due to even extreme unintentional exposure. Alternative specimens such as brain, lung and tracheal air should be considered in some postmortem investigations. DFE has been identified in blood specimens from postmortem cases at concentrations from 0.14 to 460 µg/mL and in impaired driving cases from 0.16 to 140 µg/mL.

Suspected Nonfatal Drug-Related Overdoses Among Youth in the US: 2016-2019

BACKGROUND AND OBJECTIVES

During the current drug overdose crisis, the United States is experiencing a significant number of overdose deaths, hospitalizations, and emergency department visits. Given the vulnerability of young persons to substance use, it is important to assess how this crisis affects the nation's youth. In this study, we investigate trends in suspected nonfatal drug-related overdoses (all-drugs, opioids, heroin, and stimulants) among youth using syndromic surveillance data from 2016 to 2019.

METHODS

A retrospective analysis of emergency department syndromic surveillance data were used to detect quarterly trends in suspected drug overdoses from April 2016 through September 2019 among youth aged 0 to 10, 11 to 14, and 15 to 24 years. Syndrome definitions were developed using chief complaint free-text and discharge diagnosis codes to identify overdoses involving all-drugs, opioids, heroin, and stimulants. Pearson χ² tests detected quarter-to-quarter changes, and joinpoint regression analysis assessed trends over time.

RESULTS

On average, there was a 2.0% increase for youth aged 0 to 10 years and a 2.3% increase for youth aged 11 to 14 years for suspected all-drug overdoses. Suspected heroin overdoses decreased by an average of 3.3% per quarter for youth aged 15 to 24 years. Among all age groups, suspected stimulant overdoses increased across the study period, 3.3% for 0 to 10-year-olds, 4.0% for 11- to 14-year-olds, and 2.3% for 15- to 24-year-olds.

CONCLUSIONS

Suspected stimulant-involved drug overdoses appear to be rising among youth. These findings could inform targeted interventions, such as stimulant-focused prevention, and comprehensive approaches, including school-based prevention and other strategies to lower morbidity and mortality.

Substance abuse among children

Substance abuse (SA) among children is a recognized challenge for policymakers and law enforcement and has life-threatening consequences owing to the impact on the children's development and the consequent increase in vulnerability. This work outlines several important issues related to SA among children: (1) SA prevalence including onset, common examples, extent, and spectrum of SA; (2) the presence of new psychoactive substances, which are rapidly spreading worldwide with limitations regarding their prevalence, detection, and interventions; (3) street children and their recruitment in drug supply; (4) SA and substance use disorder pathways, risk and protective factors for the development of SA; (5) SA consequences in the case of early initiation, including deaths; and (6) current preventive interventions for the pediatric population. In conclusion, this challenge requires consistent and unremitting attention in order to execute effective prevention programs with continuous re-evaluation of the situation.

Illicit Drug Exposures in Young Pediatric Patients Reported to the National Poison Data System, 2006-2016

This retrospective review of poison center calls found that there were 9122 illicit drug exposures reported in children <10 years of age between 2006 and 2016. Marijuana and methamphetamine were reported most frequently, with significant increases over the study period; methamphetamine was associated with the most deaths.

Adolescent exposures to traditional and novel psychoactive drugs, reported to National Poison Data System (NPDS), 2007-2017

BACKGROUND

Survey data on adolescent drug use trends have limitations evaluating the impact of drug use on health and may lag current trends. The objective was to describe National Poison Data System (NPDS) trends, medical outcomes, and healthcare encounters from adolescent exposures of traditional and novel psychoactive drugs.

METHODS

Retrospective review of adolescent (10-18 years of age) exposure calls to all U.S. poison centers, from January 1, 2007 through December 31, 2017, using generic codes for traditional and novel psychoactive drugs. Descriptive statistics and univariate Poisson regression modeling were used for analysis.

RESULTS

There were 49,757 exposure calls for the included psychoactive drugs. The median age was 16 years (IQR 15,17), 64% were male, and the majority were evaluated in a healthcare facility (92%). Marijuana had the most exposure calls (36.6%), followed by synthetic cannabinoids (e.g., spice; 21.3%). There were 181 (<1%) deaths; the highest fatality rates were from fentanyl, 2C drugs (phenylethylamine derivatives), and heroin. LSD exposure calls have had the most significant increase over the past 10 years.

CONCLUSION

U.S. Poison Centers reported almost 50,000 exposure calls and 181 deaths over 10 years for adolescent exposures of both traditional and novel psychoactive drugs, demonstrating the significant health impact on this vulnerable population. Opioids and 2C drugs contributed to the highest mortality rates, moderate/major symptoms and healthcare utilization, and LSD had the most significant increase in calls. Multi-source surveillance methodology is critical in understanding the public health impact on drug abuse in the adolescent population.

Cannabis-related emergencies in children and teens

PURPOSE OF REVIEW

To examine the spectrum of emergency department presentations associated with cannabis use or misuse that are currently seen in the pediatric population.

RECENT FINDINGS

There is a growing concern that pediatric emergency department visits related to cannabis are on the rise, especially given rapidly changing legislation on cannabis and its broad availability in certain areas. These concerns are substantiated in the current literature, as the evidence mounts for an array of emergency department presentations of intentional or accidental cannabis use. The range of presentations documented in the recent literature spans gastrointestinal, psychiatric and cardiorespiratory effects, in addition to traumatic injuries and accidental ingestions by younger children. Complications of chronic cannabis use, such as 'cannabis hyperemesis syndrome', depression, psychosis or cognitive impairment, are now recognized outcomes and even more are likely to emerge.

SUMMARY

An array of cannabis-related symptoms is possible from acute use or exposure. Common presentations include acute intoxication, hyperemesis, depression and acute physical injuries from impaired psychomotor function. Uncommon presentations include cardiorespiratory effects, and a range of symptoms in young children that include hyperkinesis and coma. Clinical vigilance is needed to suspect and clinically diagnose cannabis exposure in the emergency department.