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De Baerdemaeker K, Dines AM, Nefau T, Skapurova K, Giraudon I, Alachaher D, Archer JRH, Bentur Y, El Zahran T, Jovic-Stocic J, Omary A, Tahar AM, Thabet H, Thoma E, Vucinic S, Wood DM, Dargan PI. Comparison of recreational drug presentations to the emergency department in Europe, the Middle East and Northern Africa. Eur J Emerg Med 2024; 31:149-151. [PMID: 38416586 DOI: 10.1097/mej.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Affiliation(s)
- Klara De Baerdemaeker
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
| | - Thomas Nefau
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Katerina Skapurova
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Djamel Alachaher
- Emergency Department, University Hospital of Oran, Oran, Algeria
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Yedidia Bentur
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tharwat El Zahran
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Asaad Omary
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ait Mouhab Tahar
- Emergency Department, Mohamed Liamine Debaghine Hospital, Bab El Oued University Hospital Center, Bab El Oued, Algeria
| | - Hafedh Thabet
- Emergency Department, Centre Mahmoud Yacoub d'assistance médicale urgente, Tunis, Tunisia
| | | | - Slavica Vucinic
- The National Poison Control Centre, Military Medical Academy, Belgrade, Serbia
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Sund LJ, Dargan PI, Archer JRH, Blundell MS, Wood DM. The Emerging Cloud: a survey of vapers, their health and utilization of healthcare within the UK. QJM 2023; 116:993-1001. [PMID: 37738584 PMCID: PMC10753409 DOI: 10.1093/qjmed/hcad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/04/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Recent work in the UK estimated the prevalence of current cannabinoid-based vaping to be higher than in the USA, a factor previously associated with e-cigarette or vaping-associated lung injury (EVALI). Research in the USA has demonstrated that attendances to emergency departments relating to e-cigarettes began to rise before the EVALI outbreak, suggesting that vapers also experience milder forms of vaping-related illness. AIM Quantify symptom prevalence and healthcare utilization amongst current UK vapers. DESIGN Voluntary online survey of individuals aged 16 and over within the UK. METHODS Anonymized data were collected on demographics, vaping/smoking status and vaping substances used. Current vapers were asked about the presence of 10 prevalent symptoms from previous US EVALI case series, healthcare attendances and diagnoses given. Risk-ratios were calculated to compare the likelihood of symptoms and attendances between substances. RESULTS A total of 2477 complete responses were analysed. In all, 397 respondents were current vapers. Symptom prevalence within the previous 12 months ranged from 3.8% to 30.5% (bloody sputum, cough). Healthcare attendances per symptomatic respondent ranged from 0.1 to 1.4 (bloody sputum, shortness of breath). Current vapers of cannabinoid-based products (alone/in combination) had the most attendances per symptomatic respondent for 9/10 symptoms and were more likely to report symptoms aside from 'cough' (nicotine-free e-liquids [risk ratio = 1.7]). Clinicians reportedly never diagnosed vaping-related illness. CONCLUSIONS UK vapers experience symptoms previously reported in EVALI cases for which they also seek healthcare. Users of cannabinoid-based products were more likely to report symptoms and accounted for a higher healthcare burden. UK vapers may also experience vaping-related illness that does not meet EVALI case criteria.
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Affiliation(s)
- L J Sund
- St Thomas' Hospital , Department of Emergency Medicine, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
| | - P I Dargan
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
| | - J R H Archer
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
| | - M S Blundell
- St Thomas' Hospital , Department of Emergency Medicine, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
| | - D M Wood
- St Thomas' Hospital , Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, Westminster Bridge Rd, London SE1 7EH, UK
- St Thomas' Hospital campus , Faculty of Life Sciences and Medicine, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
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Sund LJ, Wood DM, Archer JRH, Blundell MS, Dargan PI. The unseen cloud: a survey of vaping practices and the acquisition of vaping products within the UK. QJM 2023; 116:99-106. [PMID: 36066433 DOI: 10.1093/qjmed/hcac220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/25/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited. AIM To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired. DESIGN AND METHODS A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products. RESULTS A total of 2478 responses were included. Median age 45 years (interquartile range 35-57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25-34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16-24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources. CONCLUSION This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK.
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Affiliation(s)
- L J Sund
- From the Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - D M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - J R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - M S Blundell
- From the Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - P I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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De Baerdemaeker KSC, Dines AM, Hudson S, Sund LJ, Waters ML, Hunter LJ, Blundell MS, Archer JRH, Wood DM, Dargan PI. Isotonitazene, a novel psychoactive substance opioid, detected in two cases following a local surge in opioid overdoses. QJM 2023; 116:115-119. [PMID: 35169852 DOI: 10.1093/qjmed/hcac039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity. AIM There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples. METHODS Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database. RESULTS There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml). CONCLUSION We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations.
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Affiliation(s)
- K S C De Baerdemaeker
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - A M Dines
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - S Hudson
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
| | - L J Sund
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - M L Waters
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - L J Hunter
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - M S Blundell
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Emergency Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - J R H Archer
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
- General Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - D M Wood
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
- General Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - P I Dargan
- From the Clinical Toxicology, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Sport and Specialised Analytical Services, LGC Ltd, Fordham, UK
- General Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Sund LJ, Dargan PI, Archer JRH, Wood DM. E-cigarette or vaping-associated lung injury (EVALI): a review of international case reports from outside the United States of America. Clin Toxicol (Phila) 2023; 61:91-97. [PMID: 36636876 DOI: 10.1080/15563650.2022.2160342] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION E-cigarette or vaping-associated lung injury has been reported extensively throughout the United States without a corresponding number of international cases. Cannabinoid-based products have been implicated in the majority of cases. OBJECTIVES To collate published reports of E-cigarette or vaping-associated lung injury outside the United States and to identify the reasons behind the discrepancy in reported cases between the United States and the international community. METHODS PubMed and Healthcare Databases Advanced Search were used to identify published case reports of E-cigarette or vaping-associated lung injury prior to February 2021 using the search terms "e-cigarette", "e-cigarettes", "vaping", "vape" and, "lung injury", "pulmonary", "respiratory". Cases occurring in the United States were excluded. Non-United States case reports were excluded if they did not meet the Centers for Disease Control and Prevention "probable case" criteria. This requires use of a vaping device within 90 days of symptom onset, the presence of pulmonary infiltrates on plain film chest radiography or ground glass opacities on computerised tomography, clinical suspicion that infection was not the underlying cause of lung injury, and the absence of other plausible medical processes to account for the presentation. Patient demographics, nature of exposure, symptomatology and outcome were compared to 125 cases from three regional United States based case series, which were chosen on the basis of having complete data for these comparative factors. RESULTS Seventeen international cases from 13 countries were identified for analysis. There was a male predominance in both non-United States and United States cohorts (76% vs 58-83%), with a marginally higher median patient age in non-United States cases (31 vs 27, 19, 27 years). Reported use of nicotine/flavoured e-liquids was more common in non-United States cases (100% vs 58-67%), and use of cannabinoid-based products was less common (24% vs 78-92%). The most common symptoms across all cohorts were shortness of breath (76% vs 85-91%), cough (59% vs 78-83%) and fever (47% vs 78-83%). The majority of patients were hypoxic (76% vs 69-86%) and required hospital admission (88% vs 90-94%). Fewer of the non-United States patients required intensive care admission (24% vs 55-67%) though their median length of stay was longer (15 days vs 5, 6, 7 days). DISCUSSION Uniformity amongst non-United States cases in regards to nicotine based and/or flavoured e-liquid exposure may underestimate the role of these substances in e-cigarette or vaping-associated lung injury. This is consistent with prior United States based research demonstrating increased presentations to emergency departments prior to the recognised "outbreak" of e-cigarette or vaping-associated lung injury at a time of increased nicotine based e-liquid uptake. A longer length of hospital stay, lower rate of intensive care admission and a higher rate of bronchoscopy in the non-United States cohort could be indicative of clinician inexperience internationally. It is unclear why the non-United States cases also had a lower incidence of gastrointestinal symptoms however this may also be explained by poorer diagnostic awareness. CONCLUSIONS E-cigarette or vaping-associated lung injury is not limited to cannabinoid-based products. Apparent similarities in patient demographics, clinical features, and clinical course between non-United States and United States cases raise concern for underreporting of E-cigarette or vaping- associated lung injury internationally.
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Affiliation(s)
- Lachlan J Sund
- Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom of Great Britain and Northern Ireland
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Harnett JT, Dargan PI, Dines AM, Archer JRH, Greene SL, Hunter LJ, Wood DM. Increasing emergency department attendances in central London with methamphetamine toxicity and associated harms. Emerg Med J 2021; 39:463-466. [PMID: 34649939 DOI: 10.1136/emermed-2020-209550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/22/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Methamphetamine is a stimulant drug of abuse with increasing prevalence of use worldwide leading to public health concern. While previous research by our group a decade ago found no evidence of increasing harms associated with methamphetamine use in the UK, there are conflicting data on whether or not this is still the case. This paper aims to identify trends in methamphetamine-related harms and characterise the clinical features of ED presentations involving methamphetamine with gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL). METHODS We retrospectively interrogated a database of all toxicology-related presentations to two central London EDs, extracting data on drugs involved for presentations relating to methamphetamine between 2005 and 2018 to enable analysis of trends. Further clinical data were extracted for presentations between 2014 and 2018 to give a 4-year case series. RESULTS A total of 1244 presentations involving the use of methamphetamine were identified. The number of presentations rose from 4 in 2005 (1.9% of all recreational drug presentations) to 294 (16.2%) in 2018. A total of 850 cases were identified for the 2014-2018 case series, 94.9% were male with a median (range) age of 35.1 (16-67) years. The most common clinical features in the methamphetamine presentations were neuropsychiatric: agitation (41.5%), anxiety (35.2%), hallucinations (16.5%) and psychosis (14.8%). GHB/GBL was co-used in 54.2% of presentations and appeared to attenuate the neuropsychiatric features seen. Use of GHB/GBL was associated with a higher Poisoning Severity Score and requirement for level 2/3 (high dependency unit/intensive care unit (ICU)) care. CONCLUSION ED attendances in central London relating to methamphetamine use have risen over the last decade. Combining methamphetamine with GHB/GBL is common and is associated with a higher Poisoning Severity Score and need for ICU level care. Further work is required to establish whether further resources need to be directed at this clinical and public health problem.
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Affiliation(s)
- James T Harnett
- Emergency Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,'Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,'Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Shaun L Greene
- Victorian Poisons Information Centre, Austin Hospital, Melbourne, Victoria, Australia
| | - Laura J Hunter
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,'Faculty of Life Sciences and Medicine, King's College, London, UK
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Amer H, Archer JRH, Layne K, Dines AM, Wood DM, Greene SL, Dargan PI. Paracetamol toxicity in mild overdose in combination with opioids: A retrospective observational study. Br J Clin Pharmacol 2021; 88:1258-1267. [PMID: 34486149 DOI: 10.1111/bcp.15070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Toxicity in paracetamol overdose with opioid co-ingestion is poorly understood. We compared outcomes in both paracetamol-only and paracetamol-opioid overdoses to determine whether toxicity differed significantly between the groups, and to assess the utility of the ratio of measured plasma paracetamol concentration relative to the 4-hour nomogram-adjusted level (APAPpl /APAPt ). METHODS We conducted a retrospective observational study of all patients (n = 1159) presenting to 2 large UK hospitals between 2005 and 2013 with acute single-dose ingestion paracetamol overdose, with (n = 221) or without (n = 938) opioid co-ingestion. Adverse outcomes included biomarkers of hepatotoxicity and the need for extended treatment. Several outcomes were assessed in relation to the APAPpl /APAPt ratio. RESULTS Median ingested dose of paracetamol was low in both groups (10 g). Statistical comparison of the median APAPpl /APAPt ratios showed a significant difference (0.65 vs. 0.56 for the paracetamol-only and paracetamol-opioid groups respectively, P = .0329). Although there was a trend towards a lower risk of predefined toxic outcomes with opioid co-ingestion, statistical analysis did not show a significant difference, with outcomes for the paracetamol-only and paracetamol-opioid groups including the following: alanine transaminase >2× upper limit of normal, 7.7 vs. 5.7% (P = .6480); alanine transaminase >1000 IU/L, 2.4 vs. 0% (P = .2145); international normalised ratio > 1.3, 8.6 vs. 4.4% (P = .2774); and transfer to tertiary liver unit, 0.2 vs. 0% (P nonsignificant). CONCLUSION Our study does not support a change in current clinical practise beyond standard testing at 4 hours or longer post ingestion for mixed low dose paracetamol-opioid overdose.
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Affiliation(s)
- Halima Amer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Department of Clinical Pharmacology, University College London, London, UK
| | - John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kerry Layne
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Alison M Dines
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shaun L Greene
- Austin Toxicology Service and Victorian Poisons Information Centre, Austin Hospital, Victoria, Australia
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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8
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Layne KA, Dargan PI, Dines AM, Leaper C, Yates C, Hovda KE, Heyerdahl F, Archer JRH, Giraudon I, Wood DM. Acute toxicity related to misuse (nonmedical use) of tramadol: Experience of the European Drug Emergencies Network Plus. Br J Clin Pharmacol 2020; 87:1668-1675. [PMID: 32503085 DOI: 10.1111/bcp.14408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 01/09/2023] Open
Abstract
Following the development of the tramadol crisis currently affecting countries in the Middle East, and Africa, there has been increasing international interest in the regulation of tramadol. This study investigates the misuse of tramadol in patients presenting to emergency departments across Europe. Data from 32 emergency departments in 21 countries were extracted from the Euro-DEN Plus database for the 4-year period from 1 January 2014 to 31 December 2017. Of the reported 24,957 emergency department presentations, tramadol misuse was reported in 105 (0.4% presentations). Tramadol misuse was most common in Bratislava (Slovakia; n = 11, 7.5% of all presentations to this centre), Riga (Latvia; n = 4, 4.9%) and Munich (Germany; n = 17, 2.9%). On arrival, 14 (13.3%) of presentations were in coma/Glasgow coma score ≤ 8 and 9 of these had a respiratory rate <12 breaths/min. These presentations potentially pose a significant burden on emergency departments with a large proportion requiring admission to hospital for ongoing care.
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Affiliation(s)
- Kerry A Layne
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Craig Leaper
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Mallorca, Spain
| | - Knut Erik Hovda
- The Norwegian CBRNe Centre of Medicine, Oslo University Hospital, Oslo, Norway
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
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Archer JRH, Mendes F, Hudson S, Layne K, Dargan PI, Wood DM. Evaluation of long-term detection trends of new psychoactive substances in pooled urine from city street portable urinals (London, UK). Br J Clin Pharmacol 2020; 86:517-527. [PMID: 32050035 DOI: 10.1111/bcp.14239] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/03/2020] [Accepted: 01/12/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS To evaluate the long-term trends of new psychoactive substance (NPS) detection in pooled urine samples collected across a city centre. METHODS Pooled urine samples from portable stand-alone urinals were collected on a monthly basis over 5.5 years (July 2013-December 2018) across a city centre. These were analysed using a high-performance liquid chromatography system, interfaced to a high-resolution accurate mass spectrometer. Data were processed against a database containing over 2000 drugs/metabolites including over 800 NPS. RESULTS In total, 44 NPS were detected with variation over time including cathinones (15, 34.1%), synthetic cannabinoids (8, 18.2%) and 21 (47.7%) other NPS. Since the introduction of the UK Psychoactive Substances Act (May 2016) cathinone detection has decreased with minimal detection over the last 4 months of the study. Synthetic cannabinoids were not detected on a regular basis until July 2016 with a subsequent variable detection frequency. There was a consistent, low level detection frequency of all other NPS throughout the study, but which appears to have increased alongside the decrease in cathinone detection. CONCLUSION Pooled urine analysis of samples taken from portable urinals in a city centre can be used as an effective monitoring tool to determine long-term trends in the use of NPS. The results of this study demonstrate the impact of the Psychoactive Substances Act and reflect the findings of population surveys and clinical studies. Triangulation of these data with other data sources will enable greater insight into the NPS phenomenon.
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Affiliation(s)
- John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fiona Mendes
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Simon Hudson
- Laboratory and Managed Services, LGC, Fordham, UK
| | - Kerry Layne
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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10
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Harnett JT, Dines AM, Wood DM, Archer JRH, Dargan PI. Cold water extraction of codeine/paracetamol combination products: a case series and literature review. Clin Toxicol (Phila) 2019; 58:107-111. [PMID: 31081395 DOI: 10.1080/15563650.2019.1612069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Tampering with opioid containing medications for use other than their prescribed indication is well documented; however, the published literature has concentrated on stronger, prescription opioids. Less potent opioids, such as codeine, are available without prescription in many European countries in the form of combination analgesic products and these can also be altered, with reports in particular of "cold-water extraction" being a tampering method achievable using household kitchen equipment.Methods: We searched a database of patients attending two South London emergency departments for cases of self-reported ingestion of the products of cold-water extraction, with subsequent review of their case notes. We searched the scientific and grey literature to identify current knowledge of this technique.Results: We identified seven presentations in six patients, none of whom developed paracetamol toxicity or had concentrations suggesting ingestion of a significant dose of paracetamol. A review of the scientific literature on the method also demonstrated that the technique reduces recovered paracetamol in experimental laboratory settings. Additionally, the established literature characterizes the use of codeine in a recreational setting and reports one fatality associated with the method. Review of grey literature user-forums further describes recreational codeine use in relation to the method and frequent adverse events including hospital admission for paracetamol toxicity.Discussion: Whilst the method appears capable of providing a recreational dose of codeine with reduction in the recovered paracetamol, it cannot be considered safe. Pharmaceutical production methods have been successfully developed to prevent tampering through other means but none thus far have been directed at the cold water extraction technique.Conclusions: Clinicians should be aware of the potential toxicity from tampered nonprescription analgesics. There is also the need for public health education regarding the potential risks associated with these methods.
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Affiliation(s)
- James T Harnett
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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11
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Layne KA, Dargan PI, Archer JRH, Wood DM. Gadolinium deposition and the potential for toxicological sequelae - A literature review of issues surrounding gadolinium-based contrast agents. Br J Clin Pharmacol 2018; 84:2522-2534. [PMID: 30032482 DOI: 10.1111/bcp.13718] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/10/2018] [Accepted: 07/14/2018] [Indexed: 01/12/2023] Open
Abstract
Every year, approximately 30 million magnetic resonance imaging scans are enhanced with gadolinium-based contrast agents (GBCAs) worldwide. Although the development of nephrogenic systemic fibrosis in patients with renal impairment is well-documented, over recent years it has become apparent that exposure to GBCAs can potentially result in gadolinium deposition within human bone and brain tissue even in the presence of normal renal function. This review will address some of the controversies surrounding the safety of GBCA administration based on evidence from in vivo experiments, animal studies and clinical studies. We additionally evaluate the potential risk of toxicity from exposure to gadolinium in light of new guidance published by the US Food and Drug Administration and the European Medicines Agency, and discuss whether gadolinium deposition disease exists as a new diagnosis.
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Affiliation(s)
- Kerry A Layne
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and Faculty of Life Sciences and Medicine, King's College London, London, UK
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12
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Webb NE, Wood DM, Greene SL, Hunter LJ, Archer JRH, Dines AM, Dargan PI. Change in the new psychoactive substances associated with Emergency Department acute toxicity presentations associated with the introduction of the UK 2016 Psychoactive Substances Act. Clin Toxicol (Phila) 2018; 57:36-41. [PMID: 30067112 DOI: 10.1080/15563650.2018.1494277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES In May 2016, the Psychoactive Substances Act (PSA) came into effect in UK making it an offence to produce or supply new psychoactive substances (NPS). The aim of this study was to determine whether this was associated with a change in Emergency Department (ED) presentations with acute NPS toxicity. METHOD ED presentations to our inner-city hospital in London, UK, with acute NPS toxicity in the 12 months before and after the PSA introduction [June 2015-May 2016 (2015/2016) and June 2016-May 2017 (2016/2017)] were obtained from our database. The following data were extracted: (i) demographics; (ii) NPS(s) self-reported [categorized as synthetic cannabinoids (SC), cathinones, and "other NPS")]; and (iii) month of presentation. RESULTS There were 1884 presentations with recreational drug toxicity, 447 (23.7%) involved NPS. There was no difference in the overall proportion of presentations involving an NPS in 2015/2016 [n = 196 (22.3%)] and 2016/2017 [251 (24.9%); (p = .48)]. There were a mean ± SD of 16.3 ± 3.7 NPS-related presentations per month in 2015/2016 and 20.9 ± 9.2 in 2016/2017; there was no significant change in overall monthly NPS-related presentations between these periods (p = .15). However, mean ± SD monthly SC-related presentations increased from 2015/2016 (5.9 ± 2.5) to 2016/2017 (17 ± 9.8); p = .004. Mean monthly cathinone-related presentations decreased from 2015/2016 (8.8 ± 4.2) to 2016/2017 (3.8 ± 2.7); p = .001. There was no significant change in monthly mean "other NPS" presentations from 2015/2016 (1.8 ± 2.2) to 2016/2017 (0.5 ± 0.8); p = .062. Between 2015/2016 and 2016/2017, SCs as a proportion of NPS-related presentations increased (r = .90) whilst cathinones decreased (r = -0.82). CONCLUSION NPS present front-line health services with unique challenges, and the PSA 2016 represents a major legislative effort in UK to limit their availability and supply. The burden of NPS use on this inner-city ED remains large 12 months after this legislation has come into force, with evolving patterns of NPS use.
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Affiliation(s)
- Nicholas E Webb
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK
| | - David M Wood
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK.,b Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - Shaun L Greene
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK.,c Department of Clinical Toxicology , Austin Health , Melbourne , Australia
| | - Laura J Hunter
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK
| | - John R H Archer
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK.,b Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - Alison M Dines
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK
| | - Paul I Dargan
- a Department of Clinical Toxicology , Guy's and St. Thomas' NHS Foundation Trust , London , UK.,b Faculty of Life Sciences and Medicine , King's College London , London , UK
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13
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Abouchedid R, Gilks T, Dargan PI, Archer JRH, Wood DM. Assessment of the Availability, Cost, and Motivations for Use over Time of the New Psychoactive Substances-Benzodiazepines Diclazepam, Flubromazepam, and Pyrazolam-in the UK. J Med Toxicol 2018; 14:134-143. [PMID: 29671244 DOI: 10.1007/s13181-018-0659-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 03/03/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION There has been increasing interest in the availability of non-prescription benzodiazepines and their sale as new psychoactive substances. We wanted to determine UK availability from Internet suppliers and motivations for use of three benzodiazepines (diclazepam, flubromazepam, and pyrazolam). METHODS In November 2014 and March 2016, using the European Monitoring Centre for Drugs and Drug Addiction Snapshot Methodology, Internet search engines ( google.co.uk , uk. yahoo.com and ask.com.uk ) were searched using the terms 'buy diclazepam', 'buy flubromazepam' and 'buy pyrazolam'. Threads from drug-user forums ( bluelight.org , drugs-forum.com , erowid.org , legalhighsforum.com ) were analysed using a general inductive approach. Data were converted into price per gram/pellet to allow cost comparisons and to determine motivations for use. RESULTS There was an increase in websites selling these benzodiazepines between 2014 and 2016: diclazepam (49 in 2014 to 55 in 2016), pyrazolam (33 to 35), and flubromazepam (39 to 45). Thirty-eight (63.3%) sites were based in the UK/Europe. Drugs were sold as pellets (49 websites, 81.7%), powder (19, 31.7%), and blotters (1, 1.7%). Pill forms were not available, and one (1.7%) website sold diclazepam/flubromazepam in liquid form. The cost reduced with increasing purchase quantities. Main motivations for use included anxiolysis, management of benzodiazepine withdrawal, sedation/sleep aid, and management of stimulant withdrawal. CONCLUSIONS These three benzodiazepines are widely available online, most commonly as pellets, and are (mis)used for a number of reasons. This study could be used to support triangulation of data from other sources to inform harm minimisation strategies.
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Affiliation(s)
- Rachelle Abouchedid
- Emergency Department, Austin Hospital, 145 Studley Rd., Heidelberg, VIC, 3056, Australia.
| | - Thea Gilks
- Undergraduate Medical Program, University of British Columbia, Vancouver, BC, Canada
| | - Paul I Dargan
- Clinical Toxicology Department, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology Department, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,King's College London, London, UK
| | - David M Wood
- Clinical Toxicology Department, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,King's College London, London, UK
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14
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Ho JH, Leikin JB, Dargan PI, Archer JRH, Wood DM, Brent J. Metal-on-Metal Hip Joint Prostheses: a Retrospective Case Series Investigating the Association of Systemic Toxicity with Serum Cobalt and Chromium Concentrations. J Med Toxicol 2017; 13:321-328. [PMID: 28900863 DOI: 10.1007/s13181-017-0629-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/09/2017] [Accepted: 08/17/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION There have been concerns about prosthesis failure and the potential for systemic toxicity due to release of cobalt and chromium from metal-on-metal hip joint prostheses (MoM-HP). There is conflicting evidence on whether there is a correlation between higher cobalt and chromium concentrations and systemic toxicity. METHODS We undertook a retrospective review of consecutive patients with MoM-HP referred for outpatient review in toxicology clinics in London, UK, and in the USA recorded in the Toxicology Investigators Consortium (ToxIC) Registry from June 2011 to June 2015. RESULTS Thirty-one cases were identified; the median (IQR) serum cobalt concentration was 10.0 (3.8-32.8) mcg/L, and the median (IQR) serum chromium concentration was 6.9 (3.7-18.7) mcg/L. Twenty-three (74.2%) had symptoms, most commonly lethargy, hearing loss, and tinnitus. The odds ratios of symptomatic/asymptomatic patients for metal ion concentrations above/below 7 mcg/L were 1.87 (95% CI 0.37-9.57, p = 0.45) and 0.60 (95% CI 0.10-3.50, p = 0.57) for cobalt and chromium, respectively. Two (6.5%) patients with systemic cobalt toxicity had median (IQR) serum cobalt concentrations significantly higher than those without systemic features (630.4 [397.6-863.2] mcg/L versus 9.8 [2.9-16.4] mcg/L; p = 0.017). However, overall, there were no differences between cobalt (p = 0.38) or chromium (p = 0.92) concentrations between symptomatic and asymptomatic patients and no clinical features or investigation results correlated with cobalt or chromium concentration. CONCLUSION Two (6.5%) of 31 individuals referred for assessment of MoM-HP were diagnosed with systemic cobalt toxicity. However, despite a high prevalence of reported symptoms, neither symptoms nor investigation results correlated with serum cobalt or chromium concentrations.
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Affiliation(s)
- James H Ho
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jerrold B Leikin
- Medical Toxicology, Glenbrook Hospital, NorthShore University Health System-OMEGA, Glenview, IL, USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK.
- Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, Westminster Bridge Road, London, SE1 7EH, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA
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15
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Thurtle N, Abouchedid R, Archer JRH, Ho J, Yamamoto T, Dargan PI, Wood DM. Prevalence of Use of Electronic Nicotine Delivery Systems (ENDS) to Vape Recreational Drugs by Club Patrons in South London. J Med Toxicol 2017; 13:61-65. [PMID: 27599520 PMCID: PMC5330959 DOI: 10.1007/s13181-016-0583-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 08/05/2016] [Accepted: 08/17/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Electronic nicotine delivery systems (ENDS, often called e-cigarettes) are nicotine delivery devices that heat nicotine into vapour that is inhaled, a process called 'vaping'. Use eclipsed nicotine-replacement therapy (NRT) in 2014 but ENDS role in smoking cessation remains controversial. Safety has not been proven and there have been reports to US poison centres regarding potential ENDS-related nicotine toxicity. A further concern is use of ENDS to vape recreational drugs, but there is limited data to substantiate this. The aim of this study was to report on ENDS use to vape recreational drugs in patrons of a South London nightclub where high prevalence of recreational drug use has previously been shown. METHODS A convenience sample of 101 participants was surveyed in March 2015 as part of a larger survey on drug use. Individuals were asked if they used ENDS to vape nicotine and/or other substances (and if so which substances). RESULTS Ninety (89.1 %) of respondents were male with median age of 28 years (IQR 23-34). Eighty (79.2 %) currently smoked cigarettes; 20 (19.8 %) currently used ENDS for nicotine. Six (5.9 %) reported using ENDS to take other substances: 2 for 'liquid cannabis' and 4 did not elaborate on the substance(s) used. Of these 6, 3 were using ENDS to vape nicotine and 3 had never used them for nicotine. CONCLUSION 5.9 % of individuals in this sample reported using ENDS to vape substances other than nicotine. Further work is required in larger populations to determine how common this is, evaluate which agents are being vaped and to inform appropriate public education.
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Affiliation(s)
- Natalie Thurtle
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.
| | - Rachelle Abouchedid
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - John R H Archer
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - James Ho
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Takahiro Yamamoto
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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16
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Abouchedid R, Hudson S, Thurtle N, Yamamoto T, Ho JH, Bailey G, Wood M, Sadones N, Stove CP, Dines A, Archer JRH, Wood DM, Dargan PI. Analytical confirmation of synthetic cannabinoids in a cohort of 179 presentations with acute recreational drug toxicity to an Emergency Department in London, UK in the first half of 2015. Clin Toxicol (Phila) 2017; 55:338-345. [PMID: 28421836 DOI: 10.1080/15563650.2017.1287373] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
CONTEXT Synthetic cannabinoid receptor agonists are the largest group of new psychoactive substances reported in the last decade; in this study we investigated how commonly these drugs are found in patients presenting to the Emergency Department with acute recreational drug toxicity. METHODS We conducted an observational cohort study enrolling consecutive adult patients presenting to an Emergency Department (ED) in London (UK) January-July 2015 (6 months) with acute recreational drug toxicity. Residual serum obtained from a serum sample taken as part of routine clinical care was analyzed using high-resolution accurate mass-spectrometry with liquid-chromatography (HRAM-LCMSMS). Minimum clinical data were obtained from ED medical records. RESULTS 18 (10%) of the 179 patient samples were positive for synthetic cannabinoid receptor agonists. The most common was 5F AKB-48 (13 samples, concentration 50-7600 pg/ml), followed by 5F PB-22 (7, 30-400 pg/mL), MDMB-CHMICA (7, 80-8000 pg/mL), AB-CHMINACA (3, 50-1800 pg/mL), Cumyl 5F-PINACA (1, 800 pg/mL) and BB-22 (1, 60 pg/mL). Only 9/18 (50%) in whom synthetic cannabinoid receptor agonists were detected self-reported synthetic cannabinoid receptor agonist use. The most common clinical features were seizures and agitation, both recorded in four (22%) individuals. Fourteen patients (78%) were discharged from the ED, one of the four admitted to hospital was admitted to critical care. CONCLUSIONS Synthetic cannabinoid receptor agonists were found in 10% of this cohort with acute recreational drug toxicity but self-reported in only half of these. This suggests that presentations to the ED with acute synthetic cannabinoid receptor agonist toxicity may be more common than reported.
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Affiliation(s)
- Rachelle Abouchedid
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Simon Hudson
- b Laboratory and Managed Services , LGC Ltd , Fordham , Cambridgeshire, UK
| | - Natalie Thurtle
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Takahiro Yamamoto
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - James H Ho
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - George Bailey
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Michelle Wood
- c Department of Health Sciences , Waters Corporation , Wilmslow , Cheshire, UK
| | - Nele Sadones
- d Laboratory of Toxicology , Ghent University , Ghent , Belgium
| | | | - Alison Dines
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - John R H Archer
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK.,e Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - David M Wood
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK.,e Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - Paul I Dargan
- a Clinical Toxicology , Guy's and St Thomas' NHS Foundation Trust , London , UK.,e Faculty of Life Sciences and Medicine , King's College London , London , UK
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17
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Abstract
BACKGROUND MDMB-CHMICA (methyl 2-[[1-(cyclohexylmethyl)indole-3-carbonyl]amino]-3,3-dimethylbutanoate) is a synthetic cannabinoid receptor agonist that has been detected in several recreational drug products in Europe since August 2014. OBJECTIVES This article aims to describe the prevalence of use, availability, and desired and adverse effects of MDMB-CHMICA. METHODS Data were collated from published scientific literature, and systematic searches were conducted of publically available Internet sources (the "gray literature"), including websites offering to sell MDMB-CHMICA and Internet discussion forums featuring user reports. RESULTS There are two case reports of fatalities in the published literature and one series of analytically confirmed cases of intoxication with MDMB-CHMICA. Seventy-eight websites offered to sell MDMB-CHMICA and a range of quantities were available with discounts for purchase of larger quantities (from 0.25 g at $27.95/g to 100 kg at $1.28/g). We identified 36 reports from MDMB-CHMICA users on Internet discussion forums dated October 2014 onwards. The most common positive effect reported by users was euphoria (11; 30.6%) and almost all reports (33; 91.7%) described one or more adverse effects, most commonly palpitations (11; 30.6%), vomiting (9; 25.0%), loss of consciousness (6; 16.7%), visual hallucinations (6; 16.7%), chest pain (5; 13.9%), and anxiety (5; 13.9%). CONCLUSIONS This systematic review of qualitative and scientific data relating to MDMB-CHMICA shows that it is widely available from Internet-based suppliers. Users describe a spectrum of effects that are consistent with other synthetic cannabinoids, but there was a high prevalence of adverse effects, and both users and suppliers warn of its high potency.
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Affiliation(s)
- Mark Haden
- a Emergency Department , St Thomas Hospital , London , UK.,b Department of Clinical Toxicology , St. Thomas Hospital , London , UK
| | - John R H Archer
- b Department of Clinical Toxicology , St. Thomas Hospital , London , UK.,c Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - Paul I Dargan
- b Department of Clinical Toxicology , St. Thomas Hospital , London , UK.,c Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - David M Wood
- b Department of Clinical Toxicology , St. Thomas Hospital , London , UK.,c Faculty of Life Sciences and Medicine , King's College London , London , UK
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18
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Marks DJB, Dargan PI, Archer JRH, Davies CL, Dines AM, Wood DM, Greene SL. Outcomes from massive paracetamol overdose: a retrospective observational study. Br J Clin Pharmacol 2017; 83:1263-1272. [PMID: 28002875 DOI: 10.1111/bcp.13214] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/27/2016] [Accepted: 12/18/2016] [Indexed: 02/06/2023] Open
Abstract
LINKED ARTICLE This article is commented on by Bateman DN and Dear JW. Should we treat very large paracetamol overdose differently? Br J Clin Pharmacol 2017; 83: 1163-5. https://doi.org/10.1111/bcp.13279 AIMS: Treatment of paracetamol (acetaminophen) overdose with acetylcysteine is standardized, with dose determined only by patient weight. The validity of this approach for massive overdoses has been questioned. We systematically compared outcomes in massive and non-massive overdoses, to guide whether alternative treatment strategies should be considered, and whether the ratio between measured timed paracetamol concentrations (APAPpl ) and treatment nomogram thresholds at those time points (APAPt ) provides a useful assessment tool. METHODS This is a retrospective observational study of all patients (n = 545) between 2005 and 2013 admitted to a tertiary care toxicology service with acute non-staggered paracetamol overdose. Massive overdoses were defined as extrapolated 4-h plasma paracetamol concentrations >250 mg l-1 , or reported ingestions ≥30 g. Outcomes (liver injury, coagulopathy and kidney injury) were assessed in relation to reported dose and APAPpl :APAPt ratio (based on a treatment line through 100 mg l-1 at 4 h), and time to acetylcysteine. RESULTS Ingestions of ≥30 g paracetamol correlated with higher peak serum aminotransferase (r = 0.212, P < 0.0001) and creatinine (r = 0.138, P = 0.002) concentrations. Acute liver injury, hepatotoxicity and coagulopathy were more frequent with APAPpl :APAPt ≥ 3 with odds ratios (OR) and 95% confidence intervals (CI) of 9.19 (5.04-16.68), 35.95 (8.80-158.1) and 8.34 (4.43-15.84), respectively (P < 0.0001). Heightened risk persisted in patients receiving acetylcysteine within 8 h of overdose. CONCLUSION Patients presenting following massive paracetamol overdose are at higher risk of organ injury, even when acetylcysteine is administered early. Enhanced therapeutic strategies should be considered in those who have an APAPpl :APAPt ≥ 3. Novel biomarkers of incipient liver injury and abbreviated acetylcysteine regimens require validation in this patient cohort.
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Affiliation(s)
- Daniel J B Marks
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Department of Clinical Pharmacology, University College London, London, UK
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Charlotte L Davies
- Department of Clinical Pharmacology, University College London, London, UK
| | - Alison M Dines
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - David M Wood
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shaun L Greene
- Austin Toxicology Service and Victorian Poisons Information Centre, Austin Hospital, Victoria, Australia
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Bailey GP, Wood DM, Archer JRH, Rab E, Flanagan RJ, Dargan PI. An assessment of the variation in the concentration of acetylcysteine in infusions for the treatment of paracetamol overdose. Br J Clin Pharmacol 2016; 83:393-399. [PMID: 27558662 DOI: 10.1111/bcp.13099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/12/2016] [Accepted: 08/18/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intravenous acetylcysteine is the treatment of choice for paracetamol poisoning. A previous UK study in 2001 found that 39% of measured acetylcysteine infusion concentrations differed by >20% from anticipated concentrations. In 2012, the UK Commission on Human Medicines made recommendations for the management of paracetamol overdose, including provision of weight-based acetylcysteine dosing tables. The aim of this study was to assess variation in acetylcysteine concentrations in administered infusions following the introduction of this guidance. METHODS A 6-month single-centre prospective study was undertaken at a UK teaching hospital. After preparation, 5-ml samples were taken from the first, second and third/any subsequent acetylcysteine infusions. Acetylcysteine was measured in diluted (1:50) samples by high-performance liquid chromatography. Comparisons between measured and expected concentrations based on prescribed weight-based dose and volume were made for each infusion. RESULTS Ninety samples were collected. There was a variation of ≤10% in measured compared to expected concentration for 45 (50%) infusions, of 10-20% for 27 (30%) infusions, 20.1-50% for 14 (16%) infusions and >50% for four (4%) infusions. There was a median (interquartile range) variation in measured compared to expected concentration of -3.6 mg ml-1 (-6.7 to -2.3) for the first infusion, +0.2 mg ml-1 (-0.9 to +0.4) for the second infusion and -0.3 mg ml-1 (-0.6 to +0.2) for third and fourth infusions. CONCLUSION There has been a moderate improvement in the variation in acetylcysteine dose administered by infusion. Further work is required to understand the continuing variation and consideration should be given to simplification of acetylcysteine regimes to decrease the risk of administration errors.
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Affiliation(s)
- George P Bailey
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Emergency Department, St. Mary's Hospital, Imperial College NHS Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Edmund Rab
- Toxicology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert J Flanagan
- Toxicology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Toxicology Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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20
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Bailey GP, Najafi J, Elamin MEMO, Waring WS, Thomas SHL, Archer JRH, Wood DM, Dargan PI. Delays during the administration of acetylcysteine for the treatment of paracetamol overdose. Br J Clin Pharmacol 2016; 82:1358-1363. [PMID: 27412926 DOI: 10.1111/bcp.13063] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/23/2016] [Accepted: 07/09/2016] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The licensed intravenous acetylcysteine regimen for treating paracetamol overdose in most countries uses three separate infusions over 21 h. This complex regimen, requiring different infusion concentrations and rates, has been associated with administration errors. The aim of the present study was to assess the extent of administration delays occurring during this acetylcysteine regimen. METHOD A 6-month retrospective observational study was conducted at three English teaching hospitals with clinical toxicology services from October 2014. Patients aged 16 years and over, treated with intravenous acetylcysteine for paracetamol overdose, were included. The start times for infusions were recorded and the delays compared with the prescribed infusion times were calculated. Anaphylactoid reactions, intravenous cannula problems, overdose intent and smoking status were recorded to assess their contribution to delays. RESULTS From 263 cases identified, 198 met the study inclusion criteria. The median time between the start of infusions 1 and 3 was delayed from the intended 5 h by a median (interquartile range) of 90 (50-163) min, with 135 (68%) cases delayed by more than 1 h. Significantly longer delays were observed in patients with anaphylactoid reactions [median delay 267 (217-413) min, n = 8] and accidental/supratherapeutic overdose [median delay 170 (95-260) min, n = 29]. There were no significant differences between smokers and nonsmokers, or for patients with intravenous cannula problems. CONCLUSION Long delays were identified during the three-infusion acetylcysteine regimen for the treatment of paracetamol overdose. These were of clinical significance and could lead to periods of subtherapeutic plasma acetylcysteine concentrations and potentially avoidable hepatotoxicity, as well as delaying hospital discharge.
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Affiliation(s)
- George P Bailey
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Emergency Department, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Javad Najafi
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Simon H L Thomas
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK. .,Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Abouchedid R, Ho JH, Hudson S, Dines A, Archer JRH, Wood DM, Dargan PI. Acute Toxicity Associated with Use of 5F-Derivations of Synthetic Cannabinoid Receptor Agonists with Analytical Confirmation. J Med Toxicol 2016; 12:396-401. [PMID: 27456262 DOI: 10.1007/s13181-016-0571-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/25/2016] [Accepted: 07/05/2016] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Synthetic Cannabinoid Receptor Agonists (SCRAs) are the largest group of new psychoactive substances reported to the European Warning System and the United Nations Office on Drugs and Crime to date. The heterogeneous nature and speed of diversification of these compounds make it challenging to accurately characterise and predict harms of these compounds in pre-clinical studies, ahead of their appearance. CASE REPORT We report the case of a 19-year-old female who purchased three products from a headshop: two new psychoactive substances (sachets of "cannabis tea" and "mushroom tea") as well as two LSD blotters. After the "cannabis tea" was smoked and the two LSD blotters and "mushroom tea" were ingested, the patient became tachycardic (HR 128), developed seizures, agitation, visual hallucinations as well as suspected serotonergic toxicity (sustained ankle clonus 20-30 beats) 1-2 hours after use. She was treated with 1 mg of intravenous midazolam. Symptoms/signs resolved within 13 hours. No further supportive care was required. Plasma, blood, and urine samples confirmed the presence of two SCRAs: 5FAKB-48 and 5F-PB-22. The patient also reported therapeutic use of both fluoxetine and citalopram for depression. DISCUSSION To the best of our knowledge, this is the first case report of non-fatal intoxication with 5F-AKB-48 with analytical confirmation and exposure times. It also highlights the difficulties in understanding the pattern of toxicity of certain SCRAs in the context of psychotropic medications/co-morbid mental illness.
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Affiliation(s)
- Rachelle Abouchedid
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.
| | - James H Ho
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | | | - Alison Dines
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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22
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Abstract
Type 2 diabetes mellitus (T2DM) is commonly associated with chronic obstructive pulmonary disease (COPD). Metformin is a valuable treatment for T2DM, and may offer additional benefits in COPD. However, due to its rare association with lactic acidosis, its safety in COPD is uncertain. We retrospectively identified patients with T2DM who had been admitted to hospital for COPD exacerbations. We compared those who were taking metformin with those who were not, with respect to their lactate concentration (primary endpoint) and survival (secondary endpoint). The study cohort (n = 130) had a mean (±standard deviation) age of 73.0 ± 9.8 years and 47 (36%) were female. Arterial blood gases were recorded in 120 cases: 88 (73%) were hypoxemic, 45 (38%) were in respiratory failure and 33 (28%) had respiratory acidosis. The 51 patients (39%) in the metformin group had a median (interquartile range) lactate concentration of 1.45 mmol/L (1.10-2.05) versus 1.10 mmol/L (0.80-1.50) in the non-metformin group (p = 0.012). Median survival was 5.2 years (95% CI 4.5-5.8) versus 1.9 years (1.1-2.6), respectively (hazard ratio 0.57; 95% CI 0.35-0.94). This remained significant in a multivariate model adjusted for measurable confounders. In conclusion, among patients with COPD at high risk for lactate accumulation, metformin therapy was associated with a minor elevation of lactate concentration of doubtful clinical significance. Metformin was associated with a survival benefit, but this must be interpreted cautiously due to possible effects from unmeasured confounders. Viewed collectively, the results suggest that COPD should not present a barrier to the investigational or clinical use of metformin.
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Affiliation(s)
- Andrew W Hitchings
- 1Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London , London , UK
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23
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Owen DR, Wood DM, Archer JRH, Dargan PI. Phenibut (4-amino-3-phenyl-butyric acid): Availability, prevalence of use, desired effects and acute toxicity. Drug Alcohol Rev 2015; 35:591-6. [PMID: 26693960 DOI: 10.1111/dar.12356] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 09/19/2015] [Accepted: 09/22/2015] [Indexed: 02/03/2023]
Abstract
INTRODUCTION AND AIMS There has been a global increase in the availability and use of novel psychoactive substances (NPS) over the last decade. Phenibut (β-phenyl-γ-aminobutyric acid) is a GABAB agonist that is used as an NPS. Here, we bring together published scientific and grey information sources to further understand the prevalence of use, desired effects and acute toxicity of phenibut. DESIGN AND METHODS Using European Monitoring Centre for Drugs and Drug Addiction Internet snapshot methodology, we undertook an English language Internet snapshot survey in May 2015 to gather information on the availability and price of phenibut from Internet NPS retailers. To gather information on prevalence of use, desired effects and/or adverse effects, we searched grey literature (online drug discussion forums) and medical literature (PubMed and abstracts from selected International Toxicology conferences). RESULTS We found 48 unrelated Internet suppliers selling phenibut in amounts ranging from 5 g (US$1.60, £1.01/g) to 1000 kg (US$0.23, £0.14/g). Capsules containing 200-500 mg of phenibut were available in packs of between 6 (US$4.45, £2.80/g) and 360 (US$0.43, £0.27/g). According to the grey literature, phenibut is taken for its anxiolytic and euphoric properties, with tolerance and withdrawal syndromes commonly reported adverse effects. Phenibut is taken orally at an average dose of 2.4 g. Case reports in the medical literature feature users who present to emergency departments heavily sedated or experiencing withdrawal. There have been no reported deaths relating to phenibut use. DISCUSSION AND CONCLUSIONS Phenibut is readily available in the UK from Internet sites selling NPS. Its desired and adverse effects appear similar to other gamma-aminobutyric acid receptor agonists. [Owen DR, Wood DM, Archer JRH, Dargan PI. Phenibut (4-amino-3-phenyl-butyric acid): Availability, prevalence of use, desired effects and acute toxicity. Drug Alcohol Rev 2016;35:591-596].
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Affiliation(s)
- David R Owen
- Division of Brain Sciences, Imperial College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK. .,Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Archer JRH, Hudson S, Jackson O, Yamamoto T, Lovett C, Lee HM, Rao S, Hunter L, Dargan PI, Wood DM. Analysis of anonymized pooled urine in nine UK cities: variation in classical recreational drug, novel psychoactive substance and anabolic steroid use. QJM 2015; 108:929-33. [PMID: 25770158 DOI: 10.1093/qjmed/hcv058] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Analysis of anonymous pooled urine samples from street urinals has been used to demonstrate time-trends in the detection of classical recreational drugs and novel psychoactive substances (NPS). AIM This study aimed to expand this to undertake a geographical trend analysis of classical recreational drugs/NPS across UK. METHODS Samples of anonymous pooled urine were collected from street urinals that had been in place for one night in April 2014 in nine cities across the UK. Collected samples were then analysed for the presence of recreational drugs, NPS anabolic steroids using high-performance liquid chromatography coupled to high-resolution accurate mass full-scan mass spectrometry and gas chromatography coupled to electron impact ionization mass spectrometry operating in selected ion monitoring and full-scan modes. RESULTS Ten classical recreational drugs, nine NPS and four anabolic steroids were detected across the nine cities; the range of detection was from 1 in Leeds to 14 in London. The most common classical drugs were cocaine (9 cities) and 3,4-methylenedioxy-methamphetamine (8 cities); the most common NPS was 4-methylmethcathinone (5 cities). In addition there was variation in the detection of NPS, with methylhexaneamine detected only in Bristol and London, piperazines (3-trifluoromethylphenylpiperazine and 1-benzylpiperazine) and pentedrone only detected in Birmingham and the cathinone methylone only detected in London. CONCLUSIONS There is variability in the detection of classical recreational drugs, NPS and anabolic steroids across UK, likely reflecting variation in their use. This technique can be used to supplement drug use surveys to determine geographical and time trends in the use of these substances. This is important to ensure appropriate targeting of drug-related interventions.
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Affiliation(s)
- J R H Archer
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - S Hudson
- Laboratory and Managed Services, LGC, Fordham, UK
| | - O Jackson
- Hull York Medical School, Hull, UK and
| | - T Yamamoto
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - C Lovett
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - H M Lee
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - S Rao
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - L Hunter
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - P I Dargan
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK, King's College London, London, UK
| | - D M Wood
- From the Clinical Toxicology Service Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK, King's College London, London, UK
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Affiliation(s)
- James H Ho
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Lee HMD, Wood DM, Hudson S, Archer JRH, Dargan PI. Acute toxicity associated with analytically confirmed recreational use of methiopropamine (1-(thiophen-2-yl)-2-methylaminopropane). J Med Toxicol 2015; 10:299-302. [PMID: 24706157 DOI: 10.1007/s13181-014-0399-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Methiopropamine use in Europe has been detected since January 2011, but there is limited information on its acute toxicity. Here, we describe a case of analytically confirmed methiopropamine acute toxicity. CASE REPORT A 27-year-old woman with no previous medical history was brought to the emergency department with palpitations, chest tightness, anxiety, nausea, vomiting and visual hallucinations following the use of a 'Quicksilver'. Toxicological analysis of her urine collected at presentation to the ED detected methiopropamine at a concentration of 400 ng/mL. Other drugs were also detected but at a much lower concentration. CONCLUSION This is the first ever case report of analytically confirmed acute toxicity related to methiopropamine use. It confirms the potential for significant acute toxicity with cardiovascular, gastrointestinal and psychotic symptoms thus providing further information to help with managing these patients and allow legislative authorities to consider the need for its control.
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Affiliation(s)
- Hwee Min D Lee
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK,
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27
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Ho JH, Bailey GP, Archer JRH, Dargan PI, Wood DM. Ethylphenidate: availability, patterns of use, and acute effects of this novel psychoactive substance. Eur J Clin Pharmacol 2015. [DOI: 10.1007/s00228-015-1906-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sadones N, Archer JRH, Ingels ASME, Dargan PI, Wood DM, Wood M, Neels H, Lambert WE, Stove CP. Do capillary dried blood spot concentrations of gamma-hydroxybutyric acid mirror those in venous blood? A comparative study. Drug Test Anal 2015; 7:336-40. [DOI: 10.1002/dta.1760] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/05/2014] [Accepted: 11/05/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Nele Sadones
- Laboratory of Toxicology; Ghent University; Ghent Belgium
| | - John R. H. Archer
- Guy's and St Thomas' NHS Foundation Trust; Clinical Toxicology; London UK
| | - Ann-Sofie M. E. Ingels
- Laboratory of Toxicology; Ghent University; Ghent Belgium
- Laboratory of Toxicology; National Institute for Criminalistics and Criminology; Brussels Belgium
| | - Paul I. Dargan
- Guy's and St Thomas' NHS Foundation Trust; Clinical Toxicology; London UK
- King's College London; London UK
| | - David M. Wood
- Guy's and St Thomas' NHS Foundation Trust; Clinical Toxicology; London UK
- King's College London; London UK
| | - Michelle Wood
- Waters Corporation; MS Technologies Centre; Manchester UK
| | - Hugo Neels
- Toxicological Centre; University of Antwerp; Wilrijk Belgium
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Lee HMD, Bonnici K, Archer JRH, Dargan PI, Wood DM. From the internet to the hospital: current experiences of individuals presenting to the Emergency Department with acute recreational drug toxicity. Journal of Substance Use 2014. [DOI: 10.3109/14659891.2014.980863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Potter T, Chan WL, Archer JRH, Barrett J, Dargan PI, Wood DM. Development of a 'patient information leaflet' for use following assessment of patients with reported or suspected paracetamol overdose in the UK. Pharmacol Res Perspect 2014; 2:e00075. [PMID: 25505616 PMCID: PMC4186451 DOI: 10.1002/prp2.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 07/13/2014] [Accepted: 07/15/2014] [Indexed: 12/04/2022] Open
Abstract
The aim of this study was to design an information leaflet for patients with paracetamol overdose based on Medicines and Healthcare products Regulatory Agency guidance and to assess its readability. A two-sided one page information leaflet was designed for patients being discharged from hospital after a paracetamol overdose. Patients presenting with an acute paracetamol overdose, irrespective of whether they were treated or not, were recruited to read the leaflet and then answer a brief structured questionnaire based on the leaflet. The readability of the information leaflet was assessed using the Flesch reading ease score. Thirty patients (15 male, 12 female, 3 not recorded; mean age 38 ± 13.0 years) were recruited, wherein 100% of patients reported the language used was understandable, 96.6% knew which symptoms would require urgent medical review after discharge and 100% of patients knew the liver was affected by paracetamol. The Flesch reading ease score was 67.6 (out of a maximum of 100), equivalent to a UK reading age of 10–11years old. Our information leaflet for all patients being discharged after paracetamol overdose was well received by patients, provided them with the required knowledge and had an appropriate reading age based on UK literacy rates. We would recommend that this leaflet could be used as a template on a national level, localized to individual hospitals, to improve patient knowledge of paracetamol toxicity, and facilitate early medical review in the event of deterioration following discharge from the hospital.
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Affiliation(s)
- Thomas Potter
- Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom
| | - Wui Ling Chan
- Emergency Department, Tan Tock Seng Hospital Singapore, Singapore
| | - John R H Archer
- Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom ; Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom
| | - Jessica Barrett
- Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom
| | - Paul I Dargan
- Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom ; Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom ; King's College London London, United Kingdom
| | - David M Wood
- Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom ; Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners London, United Kingdom ; King's College London London, United Kingdom
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Hitchings AW, Archer JRH, Srivastava SA, Baker EH. Safety of Metformin in Patients with Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus. COPD 2014; 12:126-131. [PMID: 24915551 DOI: 10.3109/15412555.2014.898052] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is commonly associated with chronic obstructive pulmonary disease (COPD). Metformin is a valuable treatment for T2DM, and may offer additional benefits in COPD. However, due to its rare association with lactic acidosis, its safety in COPD is uncertain. We retrospectively identified patients with T2DM who had been admitted to hospital for COPD exacerbations. We compared those who were taking metformin with those who were not, with respect to their lactate concentration (primary endpoint) and survival (secondary endpoint). The study cohort (n = 130) had a mean (±standard deviation) age of 73.0 ± 9.8 years and 47 (36%) were female. Arterial blood gases were recorded in 120 cases: 88 (73%) were hypoxemic, 45 (38%) were in respiratory failure and 33 (28%) had respiratory acidosis. The 51 patients (39%) in the metformin group had a median (interquartile range) lactate concentration of 1.45 mmol/L (1.10-2.05) versus 1.10 mmol/L (0.80-1.50) in the non-metformin group (p = 0.012). Median survival was 5.2 years (95% CI 4.5-5.8) versus 1.9 years (1.1-2.6), respectively (hazard ratio 0.57; 95% CI 0.35-0.94). This remained significant in a multivariate model adjusted for measurable confounders. In conclusion, among patients with COPD at high risk for lactate accumulation, metformin therapy was associated with a minor elevation of lactate concentration of doubtful clinical significance. Metformin was associated with a survival benefit, but this must be interpreted cautiously due to possible effects from unmeasured confounders. Viewed collectively, the results suggest that COPD should not present a barrier to the investigational or clinical use of metformin.
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Affiliation(s)
- Andrew W Hitchings
- a 1 Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London , London , UK
| | - John R H Archer
- a 1 Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London , London , UK.,b 2 Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Shelley A Srivastava
- a 1 Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London , London , UK.,c 3 Charing Cross Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Emma H Baker
- a 1 Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London , London , UK
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Archer JRH, Dargan PI, Hudson S, Wood DM. Analysis of anonymous pooled urine from portable urinals in central London confirms the significant use of novel psychoactive substances. QJM 2013. [PMID: 23178933 DOI: 10.1093/qjmed/hcs219] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIM Analysis of urine samples collected across a city centre, for the detection of novel psychoactive substances (NPS). DESIGN Cross-sectional study of anonymized urine samples used for the analysis of classical recreational drugs, NPS and metabolites. METHODS Pooled urine samples collected from portable stand-alone four-person urinals across a city centre were analysed using full-scan accurate-mass high-resolution liquid chromatography coupled to tandem mass spectrometry. Data were processed against compound databases containing >1700 drug compounds and metabolites. RESULTS Seven established recreational drugs (3,4-methylenedioxyamphetamine, cocaine, cannabis, ketamine, 3,4-methylenedioxy-N-methylamphetamine, methamphetamine and amphetamine) and six potential NPS [hordenine (all 12 urinals), cathine (11), methylhexaneamine (9), 4-methylmethcathinone (6), methiopropamine and metabolites (2) and methoxetamine and metabolites (1)] were detected. Methylhexaneamine, methiopropamine and hordenine are currently uncontrolled in the UK, whereas methoxetamine is currently subject to a Temporary Class Drug Order. Metabolites of the anabolic steroid nandrolone were found in two urinals and trenbolone metabolites and clenbuterol in one urinal. CONCLUSION Analysis of pooled urine samples collected anonymously from stand-alone urinals in a large inner city can detect the use of recreational drugs, NPS and anabolic steroids. Metabolite detection indicates actual drug use, metabolism and elimination rather than simply discarded drugs in the urinals. This technique by confirming the actual drug(s) used has the potential to be additive to currently used datasets/key indicators providing more robust information for healthcare authorities, legislative and law enforcement on the drugs actually being used.
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Affiliation(s)
- J R H Archer
- Medical Toxicology Office, 3rd Floor, Block C, South Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
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Affiliation(s)
- John R H Archer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Archer JRH, Beaumont PO, May D, Dargan PI, Wood DM. Clinical survey assessing the appropriate management of individuals with acute recreational drug toxicity at a large outdoor festival event. Journal of Substance Use 2011. [DOI: 10.3109/14659891.2011.592899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
BACKGROUND Hyperglycaemia is associated with poor outcomes from exacerbations of chronic obstructive pulmonary disease (COPD). Glycaemic control could improve outcomes by reducing infection, inflammation and myopathy. Most patients with COPD are managed on the acute medical unit (AMU) outside intensive care (ICU). OBJECTIVE To determine the feasibility, safety and efficacy of tight glycaemic control in patients on an AMU. DESIGN Prospective, non-randomised, phase II, single-arm study of tight glycaemic control in COPD patients with acute exacerbations and hyperglycaemia admitted to the AMU. Participants received intravenous, then subcutaneous, insulin to control blood glucose to 4.4-6.5 mmol/l. Tight glycaemic control was evaluated: feasibility, protocol adherence; acceptability, patient questionnaire; safety, frequency of hypoglycaemia (capillary blood glucose (CBG) <2.2 mmol/l and 2.2-3.3 mmol/l); efficacy, median CBG, fasting CBG, proportion of measurements/time in target range, glycaemic variability. RESULTS were compared with 25 published ICU studies. Results 20 patients (10 females, age 71 ± 9 years; forced expiratory volume in 1 s: 41 ± 16% predicted) were recruited. Tight glycaemic control was feasible (78% CBG measurements and 89% of insulin-dose adjustments were adherent to protocol) and acceptable to patients. 0.2% CBG measurements were <2.2 mmol/l and 4.1% measurements 2.2-3.3 mmol/l. The study CBG and proportion of measurements/time in target range were similar to that of ICU studies, whereas the fasting CBG was lower, and the glycaemic variability was greater. CONCLUSIONS Tight glycaemic control is feasible and has similar safety and efficacy on AMU to ICU. However, as more recent ICU studies have shown no benefit and possible harm from tight glycaemic control, alternative strategies for blood glucose control in COPD exacerbations should now be explored. Trial registration number ISRCTN: 42412334. http://Clinical.Trials.gov NCT00764556.
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Affiliation(s)
- John R H Archer
- Division of Biomedical Science, St. George's, University of London, London, UK
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Lidder S, Ovaska H, Archer JRH, Greene SL, Jones AL, Dargan PI, Wood DM. Doctors' knowledge of the appropriate use and route of administration of antidotes in the management of recreational drug toxicity. Emerg Med J 2009; 25:820-3. [PMID: 19033500 DOI: 10.1136/emj.2007.054890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Specific antidotes (eg, naloxone, flumazenil, cyproheptadine and benzodiazepines) are available for the management of certain recreational drug-induced toxicities. Some controversies surround the use of some of these antidotes, especially flumazenil in benzodiazepine toxicity. There are no previously published data on doctors' knowledge of the use of these specific antidotes. METHODS A questionnaire survey was designed to determine internal/emergency medicine doctors' knowledge of the appropriate use of antidotes in the management of clinical scenarios of acutely poisoned patients. For nine simulated clinical scenarios of acute toxicity from recreational drugs (benzodiazepines, cocaine, N-methyl-L-(3,4-methylene-dioxyphenyl)-2-aminopropane (MDMA)-induced serotonin toxicity and opioids), they were asked to indicate whether the suggested antidote and route of administration were correct. RESULTS 42 physicians of all grades completed the questionnaire. The mean correct score was 5.4 (SD 1.1) (median 6, interquartile range 5-7). The percentages correct for the various clinical scenarios were 68.3% for opioid toxicity, 81% for benzodiazepine toxicity, 28.6% for MDMA-induced serotonin toxicity and 70.2% for cocaine toxicity. Doctors were more likely to record an answer of "unsure" for the use of cyproheptadine in ST serotonin toxicity (28.6%) compared with the use of the other antidotes (1.4%; p<0.001). CONCLUSION Knowledge of the appropriate use of antidotes in recreational drug toxicity is not consistent, with poorer knowledge on the use of newer antidotes such as cyproheptadine in serotonin toxicity. Education is required both to increase overall knowledge on the use of specific antidotes in the management of recreational drug-induced toxicity, as well as focusing on newer antidotes such as cyproheptadine.
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Affiliation(s)
- S Lidder
- Guy's and St Thomas Poisons Unit, Guy's and St Thomas' NHS Foundation Trust, London SE14 5ER, UK
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Affiliation(s)
- John R H Archer
- Guy's and St Thomas' Poisons Unit, Guy's and St Thomas' NHS Foundation Trust, London SE14 5ER.
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