Advocacy for Equity Around Evidence-Based Treatments: Overview and Proceedings of the AMERSA 2023 Conference

This commentary provides an overview of the 2023 Association of Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) annual conference: Advocacy for Equity Around Evidence-Based Treatments, held from November 1 to 4, 2023, in Washington, DC. The conference featured 9 interactive workshops, 106 oral abstract presentations, and 130 posters. From the preconference workshop to plenary sessions, paper, and poster presentations, there was a focus on addressing imbalanced social systems and structures underlying disparities. In the face of increasing drug overdose deaths, diminished access to prevention, intervention, treatment, and recovery supports for racial and ethnic minorities, there is a pressing need for advocacy for equity around evidence-based treatments.

Trends in reported GHB-related presentations to Sydney emergency departments between 2012 and 2021

OBJECTIVES

In overdose, gamma-hydroxybutyrate (GHB) and its precursors can cause decreased levels of consciousness, coma and death. Here, we aim to describe reported exposure to GHB at four EDs in Sydney, New South Wales (NSW), Australia.

METHODS

We searched the ED databases of four Sydney metropolitan hospitals for presentations relating to GHB exposure between 2012 and 2021. We calculated annual number of presentations stratified by hospital, age, sex, mode of arrival and triage category.

RESULTS

A total of 3510 GHB-related presentations to ED were recorded across the four hospitals. Data for all hospitals were only available from 2015 onwards and between 2015 and 2021; there was a 114% increase in annual presentations (from 228 to 487). Males represented 68.7% of all presentations and the median age was 31 years (range 16-74 years). There was an increase in the proportion of female presentations between 2012 and 2021 (from 27.9% to 37.9%) along with the severity of presentation over the same period, with the proportion of presentations with a triage category 1 increasing from 19.7% to 34.5%.

CONCLUSIONS

Increases in recorded absolute number and severity of GHB-related presentations to Sydney EDs are a major public health concern. There may also be shifts in the demographics of those with GHB-related presentations. Renewed efforts are required to understand the drivers of these increases to optimally target harm reduction approaches.

Utilizing extracorporeal membrane oxygenation and surfactant in the management of severe acute respiratory distress syndrome due to hydrocarbon pneumonitis

Severe cases of hydrocarbon aspiration requiring Extracorporeal Membrane Oxygenation (ECMO) are rarely reported in pediatrics, and 90% of hospitalized patients have a relatively benign clinical course. We describe a 14 month-old female with accidental hydrocarbon ingestion and aspiration due to organic makeup brush cleaner that suffered severe ARDS and multiorgan failure, successfully managed with ECMO and surfactant. She was decannulated after a total of 72 hours on ECMO, extubated on hospital day 15 (HD 15), and discharged home in her normal state of health after one month in the hospital. ECMO and adjunctive therapies such as surfactant may be helpful in the management of severe hydrocarbon pneumonitis and there are limited reports of ECMO as a supportive method for these pediatric patients.

Rapid Identification of Suspected Drug Overdose Deaths by Death Investigators, New Jersey, 2020

OBJECTIVE

While the number of overdoses in the United States continues to increase, lags in data availability have undermined efforts to monitor, respond to, and prevent drug overdose deaths. We examined the performance of a single-item mandatory radio button implemented into a statewide medical examiner database to identify suspected drug overdose deaths in near-real time.

MATERIALS AND METHODS

The New Jersey Office of the Chief State Medical Examiner operates a statewide mandated case management data system to document deaths that fall under the jurisdiction of a medical examiner office. In 2018, the New Jersey Office of the Chief State Medical Examiner implemented a radio button into the case management data system that requires investigators to report whether a death is a suspected drug overdose death. We examined the performance of this tool by comparing confirmed drug overdose deaths in New Jersey during 2020 with suspected drug overdose deaths identified by investigators using the radio button. To measure performance, we calculated sensitivity, specificity, positive predictive value, negative predictive value, and false-positive and false-negative error rates.

RESULTS

During 2020, New Jersey medical examiners investigated 26 527 deaths: 2952 were confirmed by the state medical examiner as a drug overdose death and 3050 were identified by investigators using the radio button as a suspected drug overdose death. Sensitivity was calculated as 96.1% (2837/2952), specificity as 99.1% (23 362/23 575), positive predictive value as 93.0% (2837/3050), negative predictive value as 99.5% (23 362/23 477), false-positive error rate as 7.0% (213/3050), and false-negative error rate as 3.9% (115/2952).

PRACTICE IMPLICATIONS

Implementation of a radio button into death investigation databases provides a simple and accurate method for identifying and tracking drug overdose deaths in near-real time.

Substance Use Overdose Deaths Among Black and Indigenous Women in Wisconsin: A Review of Death Certificate Data From 2018 to 2020

OBJECTIVES

We are in the midst of an overdose epidemic that has grown during the concurrent COVID-19 pandemic. In Wisconsin, overdose deaths increased 11-fold from 2000 to 2020, with over 1200 deaths in 2020. Because of disparities in substance use initiation, relapse, and treatment success among racially minoritized women, this study's purpose was to investigate overdose death rates among Black and Indigenous women in Wisconsin from 2018 to 2020.

METHODS

Overdose death rates were examined under the following parameters: sex, race (Black, Indigenous, White), age, year, and manner of death. Logistic regression analysis was also conducted looking at death count data, with race, age, and year as potential predictor variables.

RESULTS

Death rates (per 100,000) in 2018 were 14.1 (12.6-15.5) for White women, 20.8 (14.7-26.9) for Black women, and 26.5 (10.0-42.9) for Indigenous women; these rates increased in 2020 to 16.4 (14.8-17.9), 32.5 (25.0-40.0), and 59.9 (35.8-84.0) for White, Black, and Indigenous women, respectively. Regression findings illustrated that being Black or Indigenous and aged 15 to 44 or 45 to 64 years were significantly more likely to die from most causes of death (any drug, any opioid, prescription opioid, heroin, synthetic opioids, and cocaine; adjusted odds ratios > 1.25, P s < 0.001).

CONCLUSIONS

This study confirms that deaths in Wisconsin are disproportionately higher in female minoritized populations. Understanding the complex intricacies between the impacts of the COVID-19 pandemic coupled with barriers to treatment access or acceptability in these populations is urgently needed. It will take a multipronged approach to address the overdose epidemic and better serve these marginalized, vulnerable populations.

Accidental substance-related acute toxicity deaths in older adults in 2016 and 2017: a national chart review study

INTRODUCTION

Limited research exists on substance-related acute toxicity deaths (ATDs) in older adults (≥60 years) in Canada. This study aims to examine and describe the sociodemographic characteristics, health histories and circumstances of death for accidental ATDs among older adults.

METHODS

Following a retrospective descriptive analysis of all coroner and medical examiner files on accidental substance-related ATDs in older adults in Canada from 2016 to 2017, proportions and mortality rates for coroner and medical examiner data were compared with general population data on older adults from the 2016 Census. Chisquare tests were conducted for categorical variables where possible.

RESULTS

From 2016 to 2017, there were 705 documented accidental ATDs in older adults. Multiple substances contributed to 61% of these deaths. Fentanyl, cocaine and ethanol (alcohol) were the most common substances contributing to death. Heart disease (33%), chronic pain (27%) and depression (26%) were commonly documented. Approximately 84% of older adults had contact with health care services in the year preceding their death. Only 14% were confirmed as having their deaths witnessed.

CONCLUSIONS

Findings provide insight into the demographic, contextual and medical history factors that may influence substance-related ATDs in older adults and suggest key areas for prevention.

Accidental substance-related acute toxicity deaths among youth in Canada: a descriptive analysis of a national chart review study of coroner and medical examiner data

INTRODUCTION

Substance-related acute toxicity deaths (ATDs) are a public health crisis in Canada. Youth are often at higher risk for substance use due to social, environmental and structural factors. The objectives of this study were to understand the characteristics of youth (aged 12-24 years) dying of accidental acute toxicity in Canada and examine the substances contributing to and circumstances surrounding youth ATDs.

METHODS

Data from a national chart review study of coroner and medical examiner data on ATDs that occurred in Canada between 2016 and 2017 were used to conduct descriptive analyses with proportions, mortality rates and proportionate mortality rates. Where possible, youth in the chart review study were compared with youth in the general population and youth who died of all causes, using census data.

RESULTS

Of the 732 youth who died of accidental acute toxicity in 2016-2017, most (94%) were aged 18 to 24 years. Youth aged 20 to 24 who were unemployed, unhoused or living in collective housing were overrepresented among accidental ATDs. Many of the youth aged 12 to 24 who died of accidental acute toxicity had a documented history of substance use. Fentanyl, cocaine and methamphetamine were the most common substances contributing to death, and 38% of the deaths were witnessed or potentially witnessed.

CONCLUSION

The findings of this study point to the need for early prevention and harm reduction strategies and programs that address mental health, exposure to trauma, unemployment and housing instability to reduce the harms of substance use on Canadian youth.

Cardiac Arrest Following Drug Overdose in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival

BACKGROUND

Given increases in drug overdose-associated mortality, there is interest in better understanding of drug overdose out-of-hospital cardiac arrest (OHCA). A comparison between overdose-attributable OHCA and nonoverdose-attributable OHCA will inform public health measures.

METHODS AND RESULTS

We analyzed data from 2017 to 2021 in the Cardiac Arrest Registry to Enhance Survival (CARES), comparing overdose-attributable OHCA (OD-OHCA) with OHCA from other nontraumatic causes (non-OD-OHCA). Arrests involving patients <18 years, health care facility residents, patients with cancer diagnoses, and patients with select missing data were excluded. Our main outcome of interest was survival with good neurological outcome, defined as Cerebral Performance Category score 1 or 2. From a data set with 537 100 entries, 29 500 OD-OHCA cases and 338 073 non-OD-OHCA cases met inclusion criteria. OD-OHCA cases involved younger patients with fewer comorbidities, were less likely to be witnessed, and less likely to present with a shockable rhythm. Unadjusted survival to hospital discharge with Cerebral Performance Category score =1 or 2 was significantly higher in the OD-OHCA cohort (OD: 15.2% versus non-OD: 6.9%). Adjusted results showed comparable survival with Cerebral Performance Category score =1 or 2 when the first monitored arrest rhythm was shockable (OD: 28.9% versus non-OD: 23.5%, P=0.087) but significantly higher survival rates with Cerebral Performance Category score =1 or 2 for OD-OHCA when the first monitored arrest rhythm was nonshockable (OD: 9.6% versus non-OD: 3.1%, P<0.001).

CONCLUSIONS

Among patients presenting with nonshockable rhythms, OD-OHCA is associated with significantly better outcomes. Further research should explore cardiac arrest causes, and public health efforts should attempt to reduce the burden from drug overdoses.

Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study

BACKGROUND

Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined.

OBJECTIVE

To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days.

DESIGN

Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors.

PARTICIPANTS

All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients).

MAIN MEASURES

Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME).

KEY RESULTS

Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk.

CONCLUSIONS

Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

Background

Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.

Methods

This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA).

Results

Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.

Conclusion

Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.

Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention

BACKGROUND

There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes.

AIMS

To describe cases of drug use by inpatients requiring an urgent clinical response.

METHODS

We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021.

RESULTS

Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four.

CONCLUSIONS

Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Visual Analytics for Data-Driven Understanding of the Substance Use Disorder Epidemic

The substance use disorder epidemic has emerged as a serious public health crisis, presenting complex challenges. Visual analytics offers a unique approach to address this complexity and facilitate effective interventions. This paper details the development of an innovative visual analytics dashboard, aimed at enhancing our understanding of the substance use disorder epidemic. By employing record linkage techniques, we integrate diverse data sources to provide a comprehensive view of the epidemic. Adherence to responsive, open, and user-centered design principles ensures the dashboard's usefulness and usability. Our approach to data and design encourages collaboration among various stakeholders, including researchers, politicians, and healthcare practitioners. Through illustrative outputs, we demonstrate how the dashboard can deepen our understanding of the epidemic, support intervention strategies, and evaluate the effectiveness of implemented measures. The paper concludes with a discussion of the dashboard's use cases and limitations.

Deaths From Drug Overdoses What School Nurses Need to Know

Drug overdose deaths in pre-teen and adolescent students have risen over the past several years, causing increasing concerns in our society, along with concerns over the rise in availability of more counterfeit pills and illegally manufactured fentanyl. School nurses interface regularly with pre-teen and adolescent students and therefore are in a position to recognize students at risk for illicit drug use and provide important education to students, staff, parents, and the community. The purpose of this article is to briefly discuss risk factors for opioid misuse and to provide recommendations for interventions school nurses can use, including collaboration with other school and community leaders, to help prevent opioid overdose and death in pre-teen and adolescence.

Acute Lung Injury As Severe Acute Respiratory Distress Syndrome After Fentanyl Overdose

Acute lung injury following fentanyl overdose is an unusual presentation. Pulmonary edema has been associated with opioid and naloxone use. However, to our knowledge, there have been no previous reports of inhaled fentanyl-associated acute lung injury presenting with acute hypoxic respiratory failure secondary to severe acute respiratory distress syndrome. We report a case of inhaled fentanyl-related severe acute respiratory distress syndrome which presented immediately after snorting fentanyl. This patient developed hypoxia requiring 100% oxygen on non-rebreather mask, and acute respiratory distress syndrome was confirmed on chest X-ray and computed tomography on admission. He was successfully treated with steroids with recovery in 48 hours. Naloxone was used in this patient, which has been associated with pulmonary edema in case reports and series, but clinical findings were more consistent with acute respiratory distress syndrome rather than pulmonary edema. The mechanism for this clinical presentation is not well known. Proposed mechanisms include lung injury from inhalation against an obstruction in a manner similar to post-obstructive pulmonary edema. Although our patient rapidly responded to symptomatic treatment and steroid course, our case also highlights the need for further study to elucidate the various clinical presentations associated with fentanyl use-related lung toxicity including acute respiratory distress syndrome.

Apixaban overdose in children: case report and proposed management. A brief communication from the Pediatric and Neonatal Thrombosis and Hemostasis SSC of ISTH

Background

Direct oral anticoagulants are commonly prescribed for adults and increasingly also for children requiring anticoagulation therapy. While household medications should not be accessible to children, accidental, and intentional overdoses occur.

Key Clinical Question

How should apixaban overdose in children be managed?.

Clinical Approach

We present a case of an accidental overdose with the factor Xa antagonist apixaban in a young child and propose an approach to the management of cases of apixaban overdose in children.

Conclusion

Given the increasing use of direct oral anticoagulants, it is important to have an approach to the management of overdose of these medications.

Rhabdomyolysis in the Context of Designer Benzodiazepine Misuse

Designer benzodiazepines belong to a class of lab-created psychoactive compounds, with limited federal regulation, no toxicity testing, and reported high potency, leading to substantial overdose risk and harmful clinical syndromes. Benzodiazepine misuse has been previously documented to be associated with rhabdomyolysis, with elevated creatine kinase (CK) during and after acute episodes of intoxication. Here, we present a case of profound rhabdomyolysis and associated acute kidney injury (AKI) after acute designer benzodiazepine intoxication. A 26-year-old male with a history of poly-substance misuse, including alcohol, psychedelics, opiates, kratom, and benzodiazepines, presented to the emergency department with altered mental status and agitation after an accidental overdose on liquid flubromazolam and clonazolam, designer benzodiazepines purchased online. He went on to develop seizure-like activity. Additional labs revealed AKI with creatinine 2.22 mg/dL (reference 0.74-1.35 mg/dL, baseline 0.88 mg/dL). He was discovered to have severe rhabdomyolysis that peaked at 131,920 U/L (reference 55-170 U/L) on the fourth day of admission. This case demonstrates the potential deleterious effects of the designer benzodiazepine class, including prolonged sedation, AKI, and severe rhabdomyolysis. In addition, seizure-like manifestations may occur during the intoxication or withdrawal phase. Designer benzodiazepines may produce rhabdomyolysis; however, the mechanism is unknown. Direct myotoxicity or prolonged immobilization may be contributors to rhabdomyolysis. More research is needed to elucidate the consequences of designer benzodiazepine misuse. Clinicians should be aware of their use given the ease of availability online and rising popularity.

Extensive ischemic gastroduodenal necrosis caused by antihypertensive drug overdose in a young man

To raise the awareness of the rare and life-threatening clinical entity, we report a 23-year-old male presenting with acute abdomen who was finally diagnosed with gastroduodenal necrosis due to gut hypoperfusion after antihypertensive drug overdose.

Excessively High Chronic Propranolol Overdose in Infantile Hemangioma: A Case Report

BACKGROUND Infantile hemangiomas are the most common benign tumors of childhood, occurring in approximately 5% of infants. Oral propranolol at 2 to 3 mg/kg daily is recommended for systemic treatment of high-risk infantile hemangiomas. Multiple propranolol formulations exist, and propranolol overdose can occur due to improper patient counseling. Propranolol acute toxicity in the pediatric population and its management are well described in the literature. However, data are lacking on chronic propranolol overdose and how to manage it, with the awareness that abrupt discontinuation of therapeutic doses of propranolol can lead to rebound sinus tachycardia. CASE REPORT A 7-month-old girl was prescribed a therapeutic dose of propranolol (1 mg/kg/day) to treat infantile hemangioma. However, due to an administration error, the patient received approximately 8 times the recommended dose (7.6 mg/kg/day for 2 months, then increased to 15.5 mg/kg/day for 2 weeks) and, surprisingly, remained asymptomatic. Her electrocardiogram was normal, and all routine laboratory tests were within the reference range. Propranolol was successfully tapered over 3 weeks by reducing the dose by 50% weekly until it reached the therapeutic dose. After tapering, the patient was asymptomatic, with a mild increase in hemangioma size. After 6 weeks of the therapeutic dose, the hemangioma was fading away. CONCLUSIONS This case is one of the few cases reported in the literature of high, chronic propranolol overdose in pediatric patients. The patient remained asymptomatic, and the overdose was successfully managed with gradual tapering over several weeks. This case report can serve as a guide in managing subsequent cases.

Management of an unintentional enoxaparin overdose: A case report and literature review

PURPOSE

The aim of this article is to describe a case in which protamine was used for a low-molecular-weight heparin (LMWH) overdose and present an up-to-date review of the literature on the management of LMWH overdose in adults.

SUMMARY

An unintentional administration of enoxaparin 900 mg occurred in a 73-year-old man with coronavirus disease 2019-related pulmonary embolism. Management of the overdose included a protamine bolus followed by an infusion. Anti-factor Xa levels and activated partial thromboplastin time were monitored. Anti-factor Xa levels declined in a linear fashion irrespective of protamine administration. No bleeding or further thrombotic complications occurred in the patient. A review of the literature revealed that the optimal strategy to treat an LMWH overdose is unknown, with treatment of overdoses ranging from clinical observation to aggressive protamine dosing in reported cases. Although protamine effectively neutralizes unfractionated heparin, it is unable to completely reverse LMWH activity and has variable effects on laboratory measures of LMWH anticoagulant activity.

CONCLUSION

The current case report provides additional data to previous literature suggesting that protamine may have a limited effect in decreasing anti-factor Xa levels in LMWH overdose. Continued reporting on the management of LMWH overdoses is warranted to clarify the optimal treatment strategy.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Bilirubin Elevation Caused by Naproxen Overdose: A Case Report Highlighting Laboratory Interference

BACKGROUND Overdoses on over-the-counter (OTC) drugs are increasing in the United States, which includes widely available non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. Symptoms of NSAID toxicity are well known and nonspecific, including nausea, vomiting, abdominal pain, and headaches. Extreme cases can present with confusion, seizures, and renal failure. CASE REPORT We present the case of 63-year-old man with a history of hyperthyroidism and polysubstance use who had an elevated total bilirubin level after attempting suicide via ingestion of 16 tablets of naproxen. The patient presented with vague abdominal pain and nausea in the setting of 2 weeks of worsening psychiatric symptoms, including suicidal ideation. Vital signs, physical examination, and review of systems revealed no significant findings. Medical workup was notable only for an elevated total bilirubin level; workup for hemolysis, biliary stasis, hepatic dysfunction was all within normal limits. Direct bilirubin was not elevated. The patient received intravenous fluids and antiemetic medications, and indirect hyperbilirubinemia resolved by the following day. After ruling out other causes of hyperbilirubinemia, it was determined that his elevated bilirubin was due a naproxen metabolite, O-desmethylnaproxen (ODMN), that has been shown to interfere with certain bilirubin assays when naproxen is ingested over the therapeutic dose. CONCLUSIONS Supratherapeutic naproxen ingestion can lead to laboratory findings of elevated total bilirubin in some assays due to ODMN interference. With the rise in suicide attempts in the United States with OTCs, clinicians should consider laboratory error in such clinical circumstances where the clinical data does not fit the history and physical examination.

Initiation Patterns and Transitions Among Adults Using Stimulant Drugs: Latent Transition Analysis

BACKGROUND

The fourth wave of the drug overdose epidemic in the United States includes increasing rates of stimulant-involved overdose. Recent studies of transitions leading to stimulant misuse have shown complex patterns that are not universally applicable because they have isolated individual populations or individual behaviors. A comprehensive analysis of transitions between behaviors and the associations with present-day problematic drug use has not been conducted.

OBJECTIVE

This study aims to determine whether adults from the general population who use stimulants initiate use through a heterogeneous combination of behaviors and quantify the association between these typologies with present-day problematic drug use.

METHODS

Individuals who have reported use of any stimulant in their lifetime were recruited from the 2021 Survey of Nonmedical Use of Prescription Drugs Program, a nationally representative web-based survey on drug use, to participate in a rapid follow-up survey about their past stimulant use. Individuals were asked which stimulants they used, the reasons for use, the routes of administration, and the sources of the stimulant. For each stimulant-related behavior, they were asked at what age, between 6 and 30 years, they initiated each behavior in a 6-year time window. A latent transition analysis was used to characterize heterogeneity in initiation typologies. Mutually exclusive pathways of initiation were identified manually by the researchers. The association of these pathways with present-day problematic drug use was calculated using logistic regression adjusted by the current age of the respondent.

RESULTS

From a total of 1329 participants, 740 (55.7%) reported lifetime prescription stimulant use and 1077 (81%) reported lifetime illicit stimulant use. Three typologies were identified. The first typology was characterized by illicit stimulant initiation to get high, usually via oral or snorting routes and acquisition from friends or family or a dealer (illicit experimentation). The second typology was characterized by low, but approximately equal probabilities of initiating 1-2 new behaviors in a time window, but no singular set of behaviors characterized the typology (conservative initiation). The third was characterized by a high probability of initiating many diverse combinations of behaviors (nondiscriminatory experimentation). The choice of drug initiated was not a strong differentiator. Categorization of pathways showed those who were only in an illicit experimentation status (reference) had the lowest odds of having severe present-day problematic drug use. Odds were higher for a conservative initiation-only status (odds ratio [OR] 1.84, 95% CI 1.14-2.94), which is higher still for those moving from illicit experimentation to conservative initiation (OR 3.50, 95% CI 2.13-5.74), and highest for a nondiscriminatory experimentation status (OR 5.45, 95% CI 3.39-8.77).

CONCLUSIONS

Initiation of stimulant-related use behaviors occurred across many time windows, indicating that multiple intervention opportunities are presented. Screening should be continued throughout adulthood to address unhealthy drug use before developing into full substance use disorders.

Diphenhydramine overdose detected early by integration of toxidrome and electrocardiography and treated with venoarterial extracorporeal membrane oxygenation: a case report

Drug overdose can lead to a range of symptoms, including potentially life-threatening cardiac arrhythmias. However, identifying the specific causative drug upon admission can be challenging in many cases. The toxidrome approach is a method that utilizes toxidromes, which are collections of findings obtained from physical examination and ancillary tests, that may be caused by a specific toxin. In this particular case, a man presented with an unknown drug overdose that caused symptoms indicative of anticholinergic effects and abnormal electrocardiogram (ECG) findings. The ECG revealed an R wave in lead aVR, S waves in leads I and aVL, and wide QRS tachycardia with a Brugada pattern. Shortly after arrival, the patient developed cardiac arrest due to a lethal arrhythmia. Prompt initiation of venoarterial extracorporeal cardiopulmonary membrane oxygenation (VA-ECMO) was performed. Fortunately, the patient achieved full neurological recovery, and the overdosed drug was identified as diphenhydramine. When diagnosing and treating drug overdose caused by an unidentified substance, diphenhydramine toxicity should be considered when an anticholinergic toxidrome is present and a Brugada pattern is observed on the ECG. VA-ECMO demonstrates potential as a viable treatment option when initial interventions prove ineffective.

Treatment burden for people experiencing homelessness with a recent non-fatal overdose: a questionnaire study

BACKGROUND

People experiencing homelessness (PEH) who have problem drug use have complex medical and social needs, with barriers to accessing services and treatments. Their treatment burden (workload of self-management and impact on wellbeing) remains unexplored.

AIM

To investigate treatment burden in PEH with a recent non-fatal overdose using a validated questionnaire, the Patient Experience with Treatment and Self-management (PETS).

DESIGN AND SETTING

The PETS questionnaire was collected as part of a pilot randomised control trial (RCT) undertaken in Glasgow, Scotland; the main outcome is whether this pilot RCT should progress to a definitive RCT.

METHOD

An adapted 52-item, 12-domain PETS questionnaire was used to measure treatment burden. Greater treatment burden was indicated by higher PETS scores.

RESULTS

Of 128 participants, 123 completed PETS; mean age was 42.1 (standard deviation [SD] 8.4) years, 71.5% were male, and 99.2% were of White ethnicity. Most (91.2%) had >5 chronic conditions, with an average of 8.5 conditions. Mean PETS scores were highest in domains focusing on the impact of self-management on wellbeing: physical and mental exhaustion (mean 79.5, SD 3.3) and role and social activity limitations (mean 64.0, SD 3.5) Scores were higher than those observed in studies of patients who are not homeless.

CONCLUSION

In a socially marginalised patient group at high risk of drug overdose, the PETS showed a very high level of treatment burden and highlights the profound impact of self-management work on wellbeing and daily activities. Treatment burden is an important person-centred outcome to help compare the effectiveness of interventions in PEH and merits inclusion in future trials as an outcome measure.

Differing Behaviors Around Adult Nonmedical Use of Prescription Stimulants and Opioids: Latent Class Analysis

BACKGROUND

The availability of central nervous system stimulants has risen in recent years, along with increased dispensing of stimulants for treatment of, for example, parent-reported attention-deficit/hyperactivity disorder in children and new diagnoses during adulthood. Typologies of drug use, as has been done with opioids, fail to include a sufficient range of behavioral factors to contextualize person-centric circumstances surrounding drug use. Understanding these patterns across drug classes would bring public health and regulatory practices toward precision public health.

OBJECTIVE

The objective of this study was to quantitatively delineate the unique behavioral profiles of adults who currently nonmedically use stimulants and opioids using a latent class analysis and to contrast the differences in findings by class. We further evaluated whether the subgroups identified were associated with an increased Drug Abuse Screening Test-10 (DAST-10) score, which is an indicator of average problematic drug use.

METHODS

This study used a national cross-sectional web-based survey, using 3 survey launches from 2019 to 2020 (before the COVID-19 pandemic). Data from adults who reported nonmedical use of prescription stimulants (n=2083) or prescription opioids (n=6127) in the last 12 months were analyzed. A weighted latent class analysis was used to identify the patterns of use. Drug types, motivations, and behaviors were factors in the model, which characterized unique classes of behavior.

RESULTS

Five stimulant nonmedical use classes were identified: amphetamine self-medication, network-sourced stimulant for alertness, nonamphetamine performance use, recreational use, and nondiscriminatory behaviors. The drug used nonmedically, acquisition through a friend or family member, and use to get high were strong differentiators among the stimulant classes. The latter 4 classes had significantly higher DAST-10 scores than amphetamine self-medication (P<.001). In addition, 4 opioid nonmedical use classes were identified: moderate pain with low mental health burden, high pain with higher mental health burden, risky behaviors with diverse motivations, and nondiscriminatory behaviors. There was a progressive and significant increase in DAST-10 scores across classes (P<.001). The potency of the opioid, pain history, the routes of administration, and psychoactive effect behaviors were strong differentiators among the opioid classes.

CONCLUSIONS

A more precise understanding of how behaviors tend to co-occur would improve efficacy and efficiency in developing interventions and supporting the overall health of those who use drugs, and it would improve communication with, and connection to, those at risk for severe drug outcomes.

Nutmeg Intoxication: A Case Report

Nutmeg intoxication is an uncommon precipitant of hyperactive delirium with severe agitation (HDSA) with anticholinergic properties that require a high index of suspicion for diagnosis. We present a case of a young adult who presented to the emergency department (ED) with HDSA. The patient was intubated and transferred to the medical intensive care unit (MICU) due to increasing safety threats unresponsive to multimodal de-escalation. He ultimately self-extubated, reported excessive nutmeg ingestion, and was discharged home after a short period of observation. Improved detection and streamlined management pathways for nutmeg intoxication will minimize unnecessary invasive procedures and costs to the healthcare system.

Amlodipine Overdose in a Transgender Woman: A Case Study

Calcium channel blockers are a major cause of cardiovascular toxicity. The clinical spectrum of these patients is very variable and there is no consensus on the dose required for toxicity. We present a case of a 43-year-old transgender woman who presented with hypotension and tachycardia owing to drug overdose that was later confirmed to be amlodipine. Given the catastrophic cascade of events involved with such toxicities, it is important to highlight amlodipine as one of the causes of drug overdose that can be overlooked.

Correlation Between Opioid Drug Prescription and Opioid-Related Mortality in Spain as a Surveillance Tool: Ecological Study

BACKGROUND

Opioid drug prescription (ODP) and opioid-related mortality (ORM) have increased in Spain. However, their relationship is complex, as ORM is registered without considering the type of opioid (legal or illegal).

OBJECTIVE

This ecological study aimed to examine the correlation between ODP and ORM in Spain and discuss their usefulness as a surveillance tool.

METHODS

This was an ecological descriptive study using retrospective annual data (2000-2019) from the Spanish general population. Data were collected from people of all ages. Information on ODP was obtained from the Spanish Medicines Agency in daily doses per 1000 inhabitants per day (DHD) for total ODP, total ODP excluding those with better safety protocols (codeine and tramadol), and each opioid drug separately. Rates of ORM (per 1,000,000 inhabitants) were calculated based on deaths registered (International Classification of Diseases, 10th Revision codes) as opioid poisoning by the National Statistics Institute, derived from the drug data recorded by medical examiners in death certificates. Opioid-related deaths were considered to be those that indicated opioid consumption (accidental, infringed, or self-inflicted) as the main cause of death: death due to accidental poisoning (X40-X44), intentional self-inflicted poisoning (X60-X64), drug-induced aggression (X85), and poisoning of undetermined intention (Y10-Y14). A descriptive analysis was carried out, and correlations between the annual rates of ORM and DHD of the prescribed opioid drugs globally, excluding medications of the least potential risk of overdose and lowest treatment tier, were analyzed using Pearson linear correlation coefficient. Their temporal evolution was analyzed using cross-correlations with 24 lags and the cross-correlation function. The analyses were carried out using Stata and StatGraphics Centurion 19.

RESULTS

The rate of ORM (2000-2019) ranged between 14 and 23 deaths per 1,000,000 inhabitants, with a minimum in 2006 and an increasing trend starting in 2010. The ODP ranged between 1.51 to 19.94 DHD. The rates of ORM were directly correlated with the DHD of total ODP (r=0.597; P=.006), total ODP without codeine and tramadol (r=0.934; P<.001), and every prescribed opioid except buprenorphine (P=.47). In the time analysis, correlations between DHD and ORM were observed in the same year, although not statistically significant (all P≥.05).

CONCLUSIONS

There is a correlation between greater availability of prescribed opioid drugs and an increase in opioid-related deaths. The correlation between ODP and ORM may be a useful tool in monitoring legal opiates and possible disturbances in the illegal market. The role of tramadol (an easily prescribed opioid) is important in this correlation, as is that of fentanyl (the strongest opioid). Measures stronger than recommendations need to be taken to reduce off-label prescribing. This study shows that not only is opioid use directly related to the prescribing of opioid drugs above what is desirable but also an increase in deaths.

Risk of Adverse Outcomes Among Veterans Who Screen Positive for Traumatic Brain Injury in the Veterans Health Administration But Do Not Complete a Comprehensive Evaluation: A LIMBIC-CENC Study

OBJECTIVE

To examine whether post-9/11 veterans who screened positive for mild traumatic brain injury (mTBI) but did not complete a Comprehensive TBI Evaluation (CTBIE) were at higher risk of subsequent adverse events compared with veterans who screened positive and completed a CTBIE. Upon CTBIE completion, information assessed by a trained TBI clinician indicates whether there is mTBI history (mTBI+) or not (mTBI-).

SETTING

Veterans Health Administration (VHA) outpatient services.

PARTICIPANTS

A total of 52 700 post-9/11 veterans who screened positive for TBI were included. The follow-up review period was between fiscal years 2008 and 2019. The 3 groups studied based on CTBIE completion and mTBI status were: (1) mTBI+ (48.6%), (2) mTBI- (17.8%), and (3) no CTBIE (33.7%).

DESIGN

This was a retrospective cohort study. Log binomial and Poisson regression models adjusting for demographic, military, pre-TBI screening health, and VHA covariates examined risk ratios of incident outcomes based on CTBIE completion and mTBI status.

MAIN MEASURES

Incident substance use disorders (SUDs), alcohol use disorder (AUD), opioid use disorder (OUD), overdose, and homelessness documented in VHA administrative records, and mortality as documented in the National Death Index, 3 years post-TBI screen. VHA outpatient utilization was also examined.

RESULTS

Compared with the no CTBIE group, the mTBI+ group had 1.28 to 1.31 times the risk of incident SUD, AUD, and overdose, but 0.73 times the risk of death 3 years following TBI screening. The mTBI- group had 0.70 times the risk of OUD compared with the no CTBIE group within the same period. The no CTBIE group also had the lowest VHA utilization.

CONCLUSIONS

There were mixed findings on risk of adverse events for the no CTBIE group relative to the mTBI+ and mTBI- groups. Future research is needed to explore the observed differences, including health conditions and healthcare utilization, documented outside VHA among veterans who screen positive for TBI.

Disability-Adjusted Life-Years for Drug Overdose Crisis and COVID-19 Are Comparable During the Two Years of Pandemic in the United States

OBJECTIVES

The drug overdose crisis with shifting patterns from primarily opioid to polysubstance uses and COVID-19 infections are 2 concurrent public health crises in the United States, affecting the population of sizes in different magnitudes (approximately < 10 million for substance use disorder [SUD] and drug overdoses vs 80 million for COVID-19 within 2 years of the pandemic). Our objective is to compare the relative scale of disease burden for the 2 crises within a common framework, which could help inform policy makers with resource allocation and prioritization strategies.

METHODS

We calculated disability-adjusted life-years (DALYs) for SUD (including opioids and stimulants) and COVID-19 infections, respectively. We collected estimates for SUD prevalence, overdose deaths, COVID-19 cases and deaths, disability weights, and life expectancy from multiple publicly available sources. We then compared age distributions of estimated DALYs.

RESULTS

We estimated a total burden of 13.83 million DALYs for SUD and drug overdoses and 15.03 million DALYs for COVID-19 in 2 years since March 2020. COVID-19 burden was dominated by the fatal burden (> 95% of total DALYs), whereas SUD burden was attributed to both fatal (53%) and nonfatal burdens (47%). The highest disease burden was among individuals aged 30 to 39 years for SUD (27%) and 50 to 64 years for COVID-19 (31%).

CONCLUSIONS

Despite the smaller size of the affected population, SUD and drug overdoses resulted in comparable disease burden with the COVID-19 pandemic. Additional resources supporting evidence-based interventions in prevention and treatment may be warranted to ameliorate SUD and drug overdoses during both the pandemic and postpandemic recovery.

2021 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System

Introduction

This is the 2021 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists.

Methods

Encounters reported to the KSPCC from January 1, 2021 through December 31, 2021 were analyzed. Data recorded includes caller demographics, exposure substance, nature and route of exposure, interventions, medical outcome, disposition, and location of care.

Results

The KSPCC logged 18,253 total encounters in 2021, including calls from every county in Kansas. A majority of human exposure cases (53.6%) were female. Approximately 59.8% were pediatric exposures (defined as 19 years of age or less). Most encounters occurred at a residence (91.7%) and most were managed there (70.5%). Unintentional exposures were the most common reason for exposures (70.5%). The most common reported substance in pediatric encounters was household cleaning products (n = 815) and cosmetics/personal care products (n = 735). For adult encounters, analgesics (n = 1,241) and sedative/ hypnotics/antipsychotics (n = 1,013) were the most frequently reported. Medical outcomes were 26.0% no effect, 22.4% minor effect, 10.7% moderate effect, and 2.7% major effects. There were 22 deaths.

Conclusions

The 2021 KSPCC annual report demonstrated that cases were received from the entire state of Kansas. Pediatric exposures remained most common but cases with serious outcomes continued to increase. This report supported the continued value of the KSPCC to both public and health care providers in the state of Kansas.

Clinical characteristics and outcomes of patients with mental illnesses who attempted suicide by drug overdose: A retrospective analysis of 109 cases

OBJECTIVE

Individuals with mental illnesses are exposed to an increased risk of suicide. In this study, we aimed to investigate the clinical characteristics and outcome of psychiatric patients who attempted suicide by drug overdose and required emergency care.

METHODS

A retrospective study was carried out in the Department of Emergency, the First Affiliated Hospital, Zhejiang University School of Medicine. Electronic medical records of psychiatric patients who were hospitalized due to suicide attempts from March 2019 to February 2022, with a discharge diagnosis of drug overdose were reviewed. Suicide-related data of patients were collected, including suicide month, time from suicide to admission, type of drugs, the number of tablets taken, as well as demographic and clinical profiles (e.g., gender, age, marital status, profession, physical comorbidities, and diagnosis of mental illness).

RESULTS

In the results, half of the patients were young people, female patients accounted for a higher proportion (72.5%), and the incidence of suicide was higher in winter than other seasons. Among the 109 psychiatric patients, 60 patients (55.0%) had a history of major depressive disorder, and 86 patients (78.9%) committed suicide with various psychotropic drugs, among which anxiolytics were the most commonly used drugs. Thirty-seven patients (33.9%) experienced severe physical complications caused by drug overdose, with lung infections being the most common. The clinical outcome of most patients was favorable following emergent treatment, while 2 patients (1.8%) older than 80 failed to survive.

CONCLUSION

A better understanding of psychiatric patients referred to emergency care due to suicide by drug overdose helps to improve the clinical management and prognosis of patients.

A Review on Preventing Tragedy: Strategies to Combat the Devastating Effects of Adolescent Drug Overdoses

Adolescent drug overdose deaths are a growing public health crisis, with significant consequences for individuals, families, and communities. This review article provides a comprehensive overview of prevention strategies to combat the devastating effects of adolescent drug overdose. Drawing on a comprehensive literature search of electronic databases, the article evaluates the effectiveness of prevention strategies and identifies risk factors associated with overdose deaths. The review outlines three key prevention strategies, including education and awareness programs, access to treatment and support services, and policy changes and regulations. The article also discusses the limitations and challenges of prevention efforts, including limited access to treatment and support services, the need for more research on effective prevention strategies, and the ongoing challenges posed by the opioid epidemic and the emergence of new synthetic drugs. Overall, this review highlights the urgent need for continued research, innovative prevention strategies, and effective policies to prevent adolescent drug use and overdose deaths and promote healthier communities for all.

Profile of Childhood Poisoning and Its Outcomes in the United States: A One-Year Nationwide Study of Emergency and Inpatient Admissions

Childhood poisoning is a prevalent and significant public health issue, with a higher incidence among children under the age of five due to their natural inquisitiveness and impulsive behavior. In order to gain a better understanding of the burden and outcomes of acute poisoning in children, this study utilized data from two comprehensive databases: the 2018 Nationwide Emergency Department Sample and the National (Nationwide) Inpatient Sample. A total of 257,312 hospital visits were analyzed, with 85.5% being emergency department visits and 14.5% being inpatient admissions. Drug overdose emerged as the most commonly known cause of poisoning in both emergency and inpatient settings. While alcohol poisoning was the predominantly known cause of non-pharmaceutical poisoning in the inpatient setting, household soaps and detergents were more common in the emergency setting. Among the identified pharmaceutical agents, non-opioid analgesics and antibiotics were the most frequently implicated. However, a significant proportion of the poisoning cases were caused by unidentified substances (26.8% in the pharmaceutical group and 72.2% in the non-pharmaceutical group). There were 211 deaths in total and further analysis revealed that patients with higher Charlson indices and hospital stays exceeding seven days were associated with increased likelihood of mortality. Additionally, admission to teaching hospitals or hospitals located in the western region of the country was linked to an increased likelihood of an extended hospital stay.

Risk Factors in Japanese Drug Overdose Patients: Identifying Their Associations With Suicide Risk

Several suicide attempts presented at the emergency department are due to drug overdose associated with psychiatric disorders. We examined and identified the major risk factors among Japanese drug overdose patients and several close associations of suicide risk. We enrolled 101 patients who attempted suicide by drug overdose between January 2015 and April 2018, assessed their background using the SAD PERSONS scale, and performed association rule analysis to characterize the major risk factors and their associations. We identified three main nodes-depressive state, social support lacking, and no spouse-as considerable risk factors. Furthermore, we identified several close associations of suicide risk and their intensity; in cases with previous suicide attempts and ethanol abuse or substance use, a simultaneous social support lacking is likely. These findings align with previous studies that used conventional statistical analysis on suicide and suicide attempt risk and highlight its importance.

Respiratory aspiration during treatment with clozapine and other antipsychotics: a literature search and a pharmacovigilance study in VigiBase

INTRODUCTION

Antipsychotics (APs), during treatment or overdose, may be associated with respiratory aspiration.

AREAS COVERED

A PubMed search on September 30, 2022, provided 3 cases of respiratory aspiration during clozapine therapy and 1 case during an AP overdose. VigiBase records of respiratory aspiration associated with APs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC).

EXPERT OPINION

The ICs (and IC₀₂₅) were 2.1 (and 2.0) for APs, 3.2 (and 3.0) for clozapine, 2.6 (and 2.4) for quetiapine, and 2.5 (and 2.2) for olanzapine. Cases of respiratory aspiration associated with APs included: 137 overdose/suicide cases (64 fatal) and 609 cases during treatment (385 fatal) including 333 taking clozapine (238 fatal). In logistic regression models of fatal outcomes, the odds ratios, OR, and (95% confidence intervals, CI) of significant independent variables were: a) 2.3 - 2.6 for clozapine in 3 samples of AP treatment of varying size, b) 1.9 (CI 1.0 to 3.5) for geriatric age in 284 patients on clozapine treatment, and c) 1.8 (CI 1.1 - 3.2) for antidepressant co-medication in 276 patients on non-clozapine APs. Multiple AP pharmacological mechanisms may explain respiratory aspiration.

Implementation of a pharmacist toxicology service on treatment of paracetamol (acetaminophen) overdose

INTRODUCTION

Paracetamol is a leading cause of fatality following a toxic ingestion. Individualized treatment is imperative in improving outcomes. Acetylcysteine is the standard of care for paracetamol overdose. Laboratory values and other clinical criteria can be used to guide treatment duration. Our hospital's protocol allows paracetamol overdose to be managed by the emergency department pharmacists. The purpose of this study was to evaluate the effect of a pharmacist toxicology service on the management of paracetamol overdose.

METHODS

This was a single center, retrospective, cohort evaluation. All patients receiving acetylcysteine were divided into pre- and post-implementation groups with data obtained from August 1, 2013 to January 14, 2018 and January 15, 2018 to September 30, 2021, respectively. The primary outcome was the frequency of individualized acetylcysteine therapy.

RESULTS

A total of 238 patients were screened for inclusion in the study with 120 patients included in the final analysis. There were 60 patients included in each cohort. The frequency of individualized acetylcysteine therapy was significantly higher in the post-implementation group versus the pre-implementation group (85% vs. 60% [95% CI 9.1-39.4; P = 0.002]).

CONCLUSIONS

The implementation of a pharmacist toxicology service correlated with increased poison center consultation as well as increased frequency of individualized acetylcysteine therapy and decreased number of missed acetylcysteine doses.

BUPROPION MISUSE BY NASAL INSUFFLATION WITH A FATAL OUTCOME: CASE REPORT AND REVIEW

Bupropion is the only FDA - approved synthetic cathinone, with increasing popularity in clinical practice due to its wide range of action, and lack of sexual side effects. However, its stimulant effect similar to amphetamines has growing the concern regarding its recreational use.

Outcomes following heart or bilateral-lung transplantation from donors who died of drug toxicity in British Columbia, Canada

INTRODUCTION

The illicit drug toxicity (overdose) crisis has worsened across Canada; between 2016 and 2021, more than 28,000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death (DTD) has increased in recent years. This study examines whether survival after heart or bilateral-lung transplantation differed by donor cause of death.

METHODS

We studied transplant recipients in British Columbia who received heart (N = 110) or bilateral-lung (N = 223) transplantation from deceased donors aged 12-70 years between 2013 and 2019. Transplant recipient survival was compared by donor cause of death from drug toxicity or other. Five-year Kaplan-Meier estimates of survival and 3-year inverse probability treatment weighted Cox proportional hazards models were conducted.

RESULTS

DTD donors made up 36% (40/110) of heart and 24% (54/223) of bilateral-lung transplantations. DTD donors were more likely to be young, white, and male. Unadjusted 5-year recipient survival was similar by donor cause of death (heart: 87% for DTD and 86% for non-DTD, p = .75; bilateral- lung: 80% for DTD and 76% for non-DTD, p = .65). Adjusted risk of mortality at 3-years post-transplant was similar between recipients of DTD and non-DTD donor heart (hazard ratio [HR]: .94, 95% confidence interval (CI): .22-4.07, p = .938) and bilateral-lung (HR: 1.06, 95% CI: .41-2.70, p = .908).

CONCLUSION

Recipient survival after heart or bilateral-lung transplantation from DTD donors and non-DTD donors was similar. Donation from DTD donors is safe and should be considered more broadly to increase organ donation.

Overdose Alert and Response Technologies: State-of-the-art Review

BACKGROUND

Drug overdose deaths, particularly from opioids, are a major global burden, with 128,000 deaths estimated in 2019. Opioid overdoses can be reversed through the timely administration of naloxone but only if responders are able to administer it. There is an emerging body of research and development in technologies that can detect the early signs of an overdose and facilitate timely responses.

OBJECTIVE

Our aim was to identify and classify overdose-specific digital technologies being developed, implemented, and evaluated.

METHODS

We conducted a "state-of-the-art review." A systematic search was conducted in MEDLINE, Embase, Web of Science, Scopus, ACM, IEEE Xplore, and SciELO. We also searched references from articles and scanned the gray literature. The search included terms related to telehealth and digital technologies, drugs, and overdose and papers published since 2010. We classified our findings by type of technology and its function, year of publication, country of study, study design, and theme. We performed a thematic analysis to classify the papers according to the main subject.

RESULTS

Included in the selection were 17 original research papers, 2 proof-of-concept studies, 4 reviews, 3 US government grant registries, and 6 commercial devices that had not been named in peer-reviewed literature. All articles were published between 2017 and 2022, with a marked increase since 2019. All were based in or referred to the United States or Canada and concerned opioid overdose. In total, 39% (9/23) of the papers either evaluated or described devices designed to monitor vital signs and prompt an alert once a certain threshold indicating a potential overdose has been reached. A total of 43% (10/23) of the papers focused on technologies to alert potential responders to overdoses and facilitate response. In total, 48% (11/23) of the papers and 67% (4/6) of the commercial devices described combined alert and response devices. Sensors monitor a range of vital signs, such as oxygen saturation level, respiratory rate, or movement. Response devices are mostly smartphone apps enabling responders to arrive earlier to an overdose site. Closed-loop devices that can detect an overdose through a sensor and automatically administer naloxone without any external intervention are still in the experimental or proof-of-concept phase. The studies were grouped into 4 themes: acceptability (7/23, 30%), efficacy or effectiveness (5/23, 22%), device use and decision-making (3/23, 13%), and description of devices (6/23, 26%).

CONCLUSIONS

There has been increasing interest in the research and application of these technologies in recent years. Literature suggests willingness to use these devices by people who use drugs and affected communities. More real-life studies are needed to test the effectiveness of these technologies to adapt them to the different settings and populations that might benefit from them.

Exploring the contextual risk factors and characteristics of individuals who died from the acute toxic effects of opioids and other illegal substances: listening to the coroner and medical examiner voice

INTRODUCTION

Substance-related acute toxicity deaths continue to be a serious public health concern in Canada. This study explored coroner and medical examiner (C/ME)perspectives of contextual risk factors and characteristics associated with deaths from acute toxic effects of opioids and other illegal substances in Canada.

METHODS

In-depth interviews were conducted with 36 C/MEs in eight provinces and territories between December 2017 and February 2018. Interview audio recordings were transcribed and coded for key themes using thematic analysis.

RESULTS

Four themes described the perspectives of C/MEs: (1) Who is experiencing a substance-related acute toxicity death?; (2) Who is present at the time of death?; (3) Why are people experiencing an acute toxicity death?; (4) What are the social contextual factors contributing to deaths? Deaths crossed demographic and socioeconomic groups and included people who used substances on occasion, chronically, or for the first time. Using alone presents risk, while using in the presence of others can also contribute to risk if others are unable or unprepared to respond. People who died from a substance-related acute toxicity often had one or more contextual risk factors: contaminated substances, history of substance use, history of chronic pain and decreased tolerance. Social contextual factors contributing to deaths included diagnosed or undiagnosed mental illness, stigma, lack of support and lack of follow-up from health care.

CONCLUSION

Findings revealed contextual factors and characteristics associated with substance-related acute toxicity deaths that contribute to a better understanding of the circumstances surrounding these deaths across Canada and that can inform targeted prevention and intervention efforts.

Deep Neural Networks for Fine-Grained Surveillance of Overdose Mortality

Surveillance of drug overdose deaths relies on death certificates for identification of the substances that caused death. Drugs and drug classes can be identified through the International Classification of Diseases, Tenth Revision (ICD-10), codes present on death certificates. However, ICD-10 codes do not always provide high levels of specificity in drug identification. To achieve more fine-grained identification of substances on death certificate, the free-text cause-of-death section, completed by the medical certifier, must be analyzed. Current methods for analyzing free-text death certificates rely solely on lookup tables for identifying specific substances, which must be frequently updated and maintained. To improve identification of drugs on death certificates, a deep-learning named-entity recognition model was developed, utilizing data from the Kentucky Drug Overdose Fatality Surveillance System (2014-2019), which achieved an F1-score of 99.13%. This model can identify new drug misspellings and novel substances that are not present on current surveillance lookup tables, enhancing the surveillance of drug overdose deaths.

Estimated Number of People Who Inject Drugs in the United States

BACKGROUND

Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use.

METHODS

We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of nonfatal overdose events among PWID from 2 of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of nonfatal to fatal overdose. The number of nonfatal overdose events was divided by prevalence of nonfatal overdose among current PWID for a population size estimate.

RESULTS

There were an estimated 3 694 500 (95% confidence interval [CI], 1 872 700-7 273 300) PWID in the United States in 2018, representing 1.46% (95% CI, .74-2.87) of the adult population. The estimated prevalence of injection drug use was highest among males (2.1%; 95% CI, 1.1-4.2), non-Hispanic Whites (1.8%; 95% CI, .9-3.6), and adults aged 18-39 years (1.8%; 95% CI, .9-3.6).

CONCLUSIONS

Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the United States in nearly 10 years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased.

Intoxication with massive doses of amlodipine and candesartan requiring venoarterial extracorporeal membrane oxygenation

Background

Calcium channel blockers and angiotensin II receptor blockers are commonly prescribed to treat hypertension. Massive overdoses can cause both distributive and cardiogenic shock because of their effects on vascular smooth muscles and severe myocardial depression.

Case Presentation

We present the case of a 46-year-old man who was brought to our emergency department after ingesting 1210 mg amlodipine and 936 mg candesartan. The patient's hemodynamic status deteriorated despite treatment with vasopressors, calcium gluconate, and hyperinsulinemia-euglycemia therapy with mechanical ventilation. Venoarterial extracorporeal membrane oxygenation was initiated for refractory shock. The patient was weaned off extracorporeal membrane oxygenation on day 5 and discharged on day 18 of hospitalization.

Conclusion

When medical therapies are ineffective, aggressive venoarterial extracorporeal membrane oxygenation should be considered for the management of refractory shock in the setting of calcium channel blocker with angiotensin II receptor blocker overdose.

Associations between Circumstances Surrounding Overdose and Underlying Classes of Polysubstance Overdose Deaths

BACKGROUND

The overdose crisis is worsening, with polysubstance overdose deaths involving psychostimulants increasing in the U.S. Substance-specific prevention and intervention activities may not be as effective for polysubstance use, so we sought to classify substances used among overdose decedents to identify unique factors related to these classes.

METHODS

We used data from the Nevada State Unintentional Drug Overdose Reporting System, Jan 2019-Jun 2021, which comes from death certificates, coroner/medical examiner reports, and postmortem toxicology. Latent class analysis, multinomial logistic regression, and Chi-squared tests determined underlying drug use classes, differences in characteristics and circumstances surrounding overdose, and assessed relationships between circumstances and drug use classes.

RESULTS

We identified four latent classes: (1) prescription drugs (19.1%), (2) predominately methamphetamine (31.4%), (3) multi-drug (28.9%), and (4) opioid and stimulant (20.6%). Compared to other classes, the prescription drug class had a higher percentage of female decedents, from rural counties, with mental health diagnoses, who died at home. The predominately methamphetamine class had a higher percentage of decedents experiencing homelessness. The multi-drug use class had higher percentage of younger and Hispanic decedents. Those in the opioid and stimulant class had higher odds of being recently released from an institutional setting, compared to the multi drug class.

CONCLUSIONS

These underlying classes were associated with several characteristics and circumstances that can prove useful for prevention, treatment, and harm reduction agencies when designing programs and interventions to target specific groups of people at-risk for drug overdose.

Drug Overdose Patterns Among Emergency Department Patients at an Academic Hospital in Jeddah

Background Drug overdose is a significant healthcare issue and remains a common phenomenon in the emergency department (ED). The incidents have increased over the last few years worldwide. There are a few studies about drug overdose in Saudi Arabia in general and Jeddah city specifically. We aimed to describe the pattern of drug overdoses in the emergency department at an academic hospital in Jeddah between 2015-2022. Methodology A retrospective record review study was done in 2022 at an academic hospital in Jeddah between 2015-2021, where charts were reviewed for all reported patients presenting to the ED with drug overdose, including all ages and both genders. A careful review of their medical records, data collection, and processing was done using Google Forms (Google, Mountain View, California) and Microsoft Excel (Microsoft, Redmond, Washington), respectively. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 26 software (IBM Inc. Armonk, New York). Results Seventy-eight patients were identified, meeting the criteria from the medical records. Most of the patients were children under 12 years of age. Most patients were clinically stable when they arrived at the emergency department. Gastrointestinal symptoms were the most common clinical presentations, followed by drowsiness, while some patients were non-symptomatic. Analgesics and nonsteroidal were the most common causes of drug overdose. Conclusion We concluded from this limited study that the most commonly used causative agent in drug overdoses was nonsteroidal and analgesics. Moreover, children younger than 12 years of age constituted the majority of drug overdose patients, and accidental overdose represented the majority of cases. Therefore, it is important to increase public awareness of proper child supervision and keep drugs out of children's reach. More research using larger and more representative data is needed to identify patterns of drug overdose in the community.

Expanding the accessibility of harm reduction services in the United States: Measuring the impact of an automated harm reduction dispensing machine

BACKGROUND

In 2021, approximately 107,622 Americans died from drug overdose in the United States. With overdose deaths rising rapidly, it is imperative that prevention efforts focus on expanding proven, evidence-based strategies to curb overdose death rates such as targeted naloxone distribution and syringe service programs (SSPs). The COVID-19 pandemic placed additional strain on SSPs, increasing the need for programs that minimize direct contact and potential COVID-19 exposure. The purpose of this study is to evaluate the impact of an automated harm reduction dispensing machine on the local accessibility of harm reduction services.

OBJECTIVES

The primary outcome of the study is the number of harm reduction supplies distributed to the community by the dispensing machine in its first year compared to the number of supplies distributed by the same organization in the previous year. Secondary outcomes include the countywide incidence of fatal drug overdose and human immunodeficiency virus (HIV) compared to previous years.

METHODS

The machine is located outside, in the same location as a once weekly, in-person SSP. Clients register with the program over the phone with a harm reduction coordinator. Each client is connected to products and services such as naloxone, sharps containers, safer injection/smoking kits, pregnancy tests, HIV tests, substance use disorder treatment, and more.

RESULTS

Since installation, 637 individuals registered with the program, 12% of whom had never reportedly used harm reduction services before. Within its first year of use, the machine dispensed 3360 naloxone doses and 10,155 fentanyl test strips, more than any other SSP in the county.

CONCLUSION

The implementation of an automated harm reduction dispensing machine led to an increased accessibility of harm reduction products and services and was associated with a lower countywide incidence of unintentional overdose death and HIV. The association with decreased overdose death and HIV incidence should be further investigated to assess causality.

Description of Opioid-involved Hospital Deaths that Do Not Have a Subsequent Autopsy

BACKGROUND

Surveillance systems rely on death records to monitor the most severe outcome of the opioid epidemic. However, few studies have linked data from hospital systems with death records to determine potential undercount of opioid-involved deaths occurring in hospitals. This study describes characteristics of decedents less likely to have an autopsy following an opioid-involved death in hospitals and estimates the resulting undercount.

METHODS

A probabilistic data linkage of hospital and medical examiner data involving 4,936 opioid-involved deaths among residents of Cook County, Illinois, US from 2016 to 2019. We included only hospital deaths that met a national case definition and presented with clinical signs of opioid overdose.

RESULTS

Decedents had higher odds of not having an autopsy if they were 50+ years, admitted to the hospital (aOR = 3.7: 2.1, 6.5), hospitalized for 4+ days (aOR = 2.2: 1.5, 3.1), and had a comorbid diagnosis of malignant cancer (aOR = 4.3: 1.8, 10.1). However, decedents exposed to heroin and synthetic opioids (aOR = 0.39: 0.28, 0.55), and concurrent exposure to stimulants (aOR = 0.44: 0.31, 0.64) were more likely to have an autopsy). Compared to estimates from the US Centers for Disease Control and Prevention (CDC), we observed undercounts of opioid overdose deaths ranging from 6% to 15%.

CONCLUSIONS

Surveillance systems may undercount decedents that do not meet the typical profile of those more likely to have an autopsy, particularly older patients with chronic health conditions. Our undercount estimate likely exists in addition to the estimated 20%-40% undercount reported elsewhere. See video abstract at, http://links.lww.com/EDE/B990 .

Management of Massive Rivaroxaban Overdose With Acetaminophen and Isosorbide Mononitrate Overdose

Direct oral anticoagulants (DOACs) have been used more frequently for the prevention and management of thromboembolic disease in comparison to their predecessors. DOACs provide greater ease of administration, shorter half-lives, less monitoring, and fewer drug-drug interactions. With the rise of DOACs such as rivaroxaban, the opportunity for abuse also increases. Therefore, standardization of care based on rivaroxaban misuse must also be explored, an area in which there is not ample information. We present a case where a patient consumed a stockpile of her home medications in hopes to commit suicide. A 64-year-old female presented to the emergency department due to the ingestion of rivaroxaban 5,000 mg along with ingestion of acetaminophen 30,000 mg and isosorbide mononitrate 1000 mg in the setting of intentional self-harm with multiple declarations of being classified as Do Not Resuscitate. There have been documented cases of rivaroxaban overdose, however, there are no documented cases with levels of ingestion reaching 5,000 mg along with signs of severe bleeding. Our case study reviews the previously documented management of rivaroxaban abuse and the treatment that was given to our patient in the setting of extreme anticoagulant ingestion.