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Zheng JX, Randall S, Grimsrud K, Bainbridge S, Tran NK. Not Carfentanil-A Case of Unexpected Xylazine Detection. J Appl Lab Med 2024; 9:629-634. [PMID: 38300830 DOI: 10.1093/jalm/jfad119] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/25/2023] [Indexed: 02/03/2024]
Abstract
Historically, xylazine has been utilized in veterinary medicine for decades as an anesthetic and analgesic sedative to facilitate safe handling, diagnostic testing, and surgical procedures in large animals. Currently, xylazine is an emerging threat to human health. It has been detected in the illicit drug supply chain, often as an adulterant. It has been more commonly added to illicit substances, most notably fentanyl, by drugmakers to enhance drug effect. End users are often unaware of its presence. This is alarming given the large number of xylazine-involved overdose deaths while laboratory detections are deficient and reversal agents are absent. Herein, we present the first documented case of xylazine identified via gas chromatography-tandem mass spectrometry at University of California Davis Health despite a peculiarly mild clinical presentation. We hope to increase awareness of this potentially fatal adulterant that is often missed in evaluation and engender further opportunities to study this ongoing issue.
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Affiliation(s)
- Jasper X Zheng
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Shelby Randall
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Kristin Grimsrud
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Scott Bainbridge
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, United States
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Gomila Muñiz I, Socias Crespí L, Puiguriguer Ferrando J, Guiu Marti AM, Elorza Guerrero MÁ, Barceló Martín B. [Retrospective analysis of venlafaxine-induced hypoglycemia in patients with overdose]. Med Clin (Barc) 2024; 162:328-332. [PMID: 38182480 DOI: 10.1016/j.medcli.2023.11.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/28/2023] [Accepted: 11/02/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION Recent publications relate the presence of hypoglycemia in venlafaxine (VLX) poisoning depending on the dose. Our aim was to analyze the clinical characteristics of patients who presented hypoglycemia induced by VLF overdose. PATIENTS AND METHODS Retrospective study carried out in the Balearic Islands (2020-2023). INCLUSION CRITERIA serum concentrations of VLX + O-desmethyl-venlafaxine (O-VLX)>800 ng/mL. The characteristics of patients with and without hypoglycemia were compared. RESULTS Twenty-one patients were included, 8 (38.1%) with hypoglycemia. No differences were found in the doses referred to in both groups. Peak concentrations of VLX + O-VLX (ng/mL) were 9,783 [4,459-17,976] in patients with hypoglycemia and 1,413 [930-1,719] in patients without hypoglycemia (p<0.0001). The presence of hypoglycemia was associated with: lower age and level of consciousness; and higher frequency of suicide attempts, seizures, mydriasis, tachycardia and serotonin syndrome, invasive respiratory support, fluid therapy and ICU admission (p<0.05). CONCLUSIONS The detection of hypoglycemia in a VLX overdose case is a readily available marker to suspect the severity of the patient. In any case, serum concentrations when available allow us to confirm intoxication.
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Affiliation(s)
- Isabel Gomila Muñiz
- Servicio de Análisis Clínicos, Hospital Universitario Son Llàtzer, Palma de Mallorca, España; Grupo de Investigación en Toxicología Clínica, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España
| | - Lorenzo Socias Crespí
- Servicio de Medicina Intensiva, Hospital Universitario Son Llàtzer, Palma de Mallorca, España
| | - Jordi Puiguriguer Ferrando
- Grupo de Investigación en Toxicología Clínica, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España; Servicio de Urgencias, Hospital Universitario Son Espases, Palma de Mallorca, España
| | | | - Miguel Ángel Elorza Guerrero
- Grupo de Investigación en Toxicología Clínica, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España; Servicio de Análisis Clínicos, Unidad de Toxicología Clínica, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Bernardino Barceló Martín
- Grupo de Investigación en Toxicología Clínica, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España; Servicio de Análisis Clínicos, Unidad de Toxicología Clínica, Hospital Universitario Son Espases, Palma de Mallorca, España; Departamento de Medicina, Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca, España.
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Bjornson S, Grindeland CJ, Werremeyer AB. Impact of Implementing Screening and Interventions to Target Prevention of Opioid Misuse and Accidental Overdose in the Inpatient Setting. J Pharm Pract 2024; 37:442-447. [PMID: 36472932 DOI: 10.1177/08971900221144183] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Introduction: There are limited publications supporting the use of screening tools to implement upstream prevention of opioid-related problems. Opioid and Naloxone Education (ONE) is utilized in outpatient pharmacies to screen and identify patients at risk of opioid-related problems and make interventions. Objectives: To implement ONE in the inpatient setting to promote prevention of opioid-related problems and overdose risk mitigation. Methods: For this pilot, ONE screening tool was completed via chart review and patient interview for inpatients prescribed an opioid. Risk scores were calculated and recommendations were provided. Outcomes evaluated included morphine milligram equivalents (MME) prior to hospitalization, inpatient screening pre-, post-, and at discharge; naloxone orders at discharge; and comparison of overdose risk from different sources. Results: The control group (n = 44) had a mean MME decrease of 1.5, and following implementation of pharmacist interventions, the experimental group (n = 45) observed a mean MME decrease of 28.6 (P = .0001). For the threshold of 50 MME, 8.6% of patients in the control group had a change from >50 MME to <50 MME at 24 hour follow up. This change occurred in 29% of patients in the experimental group (P = .03). For non-opioid analgesics, 6.8% of patients in the control group had non-opioid analgesic orders added or increased compared to 26.6% in the experimental group (P = .01). Conclusion: Screening for opioid misuse and accidental overdose risk appears impactful in the inpatient setting. Screening and appropriate risk-based intervention was associated with decreases in total daily MME and increased non-opioid analgesics.
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Affiliation(s)
- Siri Bjornson
- Department of Pharmacy, Sanford Medical Center, Fargo, ND, USA
| | | | - Amy B Werremeyer
- Department of Pharmacy, Sanford Medical Center, Fargo, ND, USA
- School of Pharmacy, North Dakota State University, Fargo, ND, USA
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Vega IL, Griswold MK, Laskey D. Acute Medication Poisoning. Am Fam Physician 2024; 109:143-153. [PMID: 38393798] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Poisoning is the leading cause of injury-related morbidity and mortality in the United States. The highest rates of exposure to poisons occur in children five years and younger, but opioid overdoses in young adults account for most deaths from poisonings in recent years. Intentional or accidental medication poisoning should be considered when evaluating patients with mental status changes, vital sign abnormalities, seizures, and gastrointestinal or cardiovascular problems. For all poisoned patients, a comprehensive history and physical examination are needed. Knowledge of toxidromes may help identify the cause in unknown ingestions; however, their usefulness may be limited when multiple toxins are ingested. Electrocardiography is indicated in patients reporting chest pain and dyspnea and in overdoses of beta blockers, tricyclic antidepressants, and antidysrhythmics. Measurement of electrolyte, serum creatinine, and serum bicarbonate levels and calculation of the anion gap may be helpful based on the clinical presentation. Treatment of a patient with acute poisoning is based on resuscitation and stabilization with a focus on airway, breathing, and circulation. When poisoning is suspected, the Poison Control provides health care workers and the public with access to a specialist 24 hours a day.
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Affiliation(s)
- Irbert L Vega
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Matthew K Griswold
- Hartford Hospital, University of Connecticut School of Medicine, Hartford, Connecticut
| | - Dayne Laskey
- University of Saint Joseph School of Pharmacy, West Hartford, Connecticut
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Graham SS, Shifflet S, Amjad M, Claborn K. An interpretable machine learning framework for opioid overdose surveillance from emergency medical services records. PLoS One 2024; 19:e0292170. [PMID: 38289927 PMCID: PMC10826931 DOI: 10.1371/journal.pone.0292170] [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] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 09/14/2023] [Indexed: 02/01/2024] Open
Abstract
The goal of this study is to develop and validate a lightweight, interpretable machine learning (ML) classifier to identify opioid overdoses in emergency medical services (EMS) records. We conducted a comparative assessment of three feature engineering approaches designed for use with unstructured narrative data. Opioid overdose annotations were provided by two harm reduction paramedics and two supporting annotators trained to reliably match expert annotations. Candidate feature engineering techniques included term frequency-inverse document frequency (TF-IDF), a highly performant approach to concept vectorization, and a custom approach based on the count of empirically-identified keywords. Each feature set was trained using four model architectures: generalized linear model (GLM), Naïve Bayes, neural network, and Extreme Gradient Boost (XGBoost). Ensembles of trained models were also evaluated. The custom feature models were also assessed for variable importance to aid interpretation. Models trained using TF-IDF feature engineering ranged from AUROC = 0.59 (95% CI: 0.53-0.66) for the Naïve Bayes to AUROC = 0.76 (95% CI: 0.71-0.81) for the neural network. Models trained using concept vectorization features ranged from AUROC = 0.83 (95% 0.78-0.88)for the Naïve Bayes to AUROC = 0.89 (95% CI: 0.85-0.94) for the ensemble. Models trained using custom features were the most performant, with benchmarks ranging from AUROC = 0.92 (95% CI: 0.88-0.95) with the GLM to 0.93 (95% CI: 0.90-0.96) for the ensemble. The custom features model achieved positive predictive values (PPV) ranging for 80 to 100%, which represent substantial improvements over previously published EMS encounter opioid overdose classifiers. The application of this approach to county EMS data can productively inform local and targeted harm reduction initiatives.
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Affiliation(s)
- S. Scott Graham
- Department of Rhetoric & Writing, Center for Health Communication, University of Texas at Austin, Austin, TX, United States of Amedrica
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
| | - Savannah Shifflet
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
| | - Maaz Amjad
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
| | - Kasey Claborn
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, United States of Amedrica
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Nagashima K, Yasuno N, Watanabe M. Creating and evaluating the score to assess overdose: the OD score. BMC Emerg Med 2024; 24:5. [PMID: 38185623 PMCID: PMC10773033 DOI: 10.1186/s12873-023-00923-6] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND During disasters (including epidemics such as coronavirus disease 2019), the capacity of emergency departments is exceeded, thereby hindering the administration of appropriate lifesaving measures. Furthermore, the number of overdose patients increases because of the stress overload during emergency situation. The fact that overdose patients are forced to be transported to medical facilities that do not typically treat them is becoming worrisome. Moreover, there is no definitive score for overdose. This study aimed to create a patient-specific scoring system to assess overdose. METHODS This was a retrospective single-center study. The evidence-based OD score was evaluated on a scale of 0-15. Further, logistic analysis and receiver operating characteristic (ROC) curve analysis were performed to evaluate the score. RESULTS Overall, 262 patients (including 118 overdose patients) receiving care at the intensive care unit of Japan's Teikyo University Hospital in 2021 were targeted. Regarding the total OD score, ROC analysis revealed a cutoff of 8 (area under the curve [AUC]: 0.99, 95% confidence interval [CI]: 0.980-0.997, sensitivity: 0.95, specificity: 0.95, p < 0.05), which was considered to indicate an overdose. Of the items evaluated in the OD score, the scenario at the location of the patient's discovery (adjusted odds ratio [AOR]: 16.8, 95% CI: 5.0-255.9, p = 0.002) and recent experience of mental anxiety (AOR: 55.7, 95% CI: 2.8-5399.5, p = 0.03) significantly predicted an overdose in multivariable logistic regression analysis. External validation revealed that the OD score could also identify overdose in patients treated in a cohort from 2022 (average cutoff: 8.6, average AUC: 1.0, p < 0.0001). CONCLUSIONS The OD score could accurately assess overdose patients. Medical facilities that do not frequently address overdose patients will benefit from the use of this score.
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Affiliation(s)
- Kazuki Nagashima
- Laboratory of Practical Pharmacy, Graduate School and Faculty of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8675, Japan.
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Nobuhiro Yasuno
- Laboratory of Hospital Pharmacy, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Machiko Watanabe
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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Stolbach AI, Mazer-Amirshahi M, Nelson LS, Cole JB. American College of Medical Toxicology and the American Academy of Clinical Toxicology Position Statement: Nalmefene Should Not Replace Naloxone as the Primary Opioid Antidote at This Time. J Med Toxicol 2024; 20:64-67. [PMID: 38032431 PMCID: PMC10774510 DOI: 10.1007/s13181-023-00981-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
| | | | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jon B Cole
- Minnesota Poison Control System, Departments of Emergency Medicine, Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, MN, USA
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Watson DP, Ray B, Phalen P, Duhart Clarke SE, Taylor L, Swartz J, Gastala N. Fentanyl Exposure and Detection Strategies Utilized by Clinical Trial Participants Seeking Linkage to Opioid Use Disorder Treatment at a Syringe Service Program. J Med Toxicol 2024; 20:13-21. [PMID: 38048033 PMCID: PMC10774457 DOI: 10.1007/s13181-023-00979-7] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/30/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023] Open
Abstract
INTRODUCTION The USA continues to face a fentanyl-driven overdose epidemic. Prior research has demonstrated users of illicit opioids are concerned about fentanyl exposure and overdose, but the strategies they report using to detect fentanyl's presence lack empirical support. This study compares self-report and biologically detected fentanyl use and investigates overdose risk and risk reduction behaviors among a sample of high-risk people who use opioids. METHODS Structured enrollment interviews conducted as part of a larger clinical trial assessed self-reported fentanyl exposure as well as strategies used to determine believed fentanyl exposure and prevent overdose among 240 participants enrolled at a Chicago, IL syringe service program. Urinalysis measured actual fentanyl exposure. RESULTS Most participants identified as African American (66.7%) and had considerable overdose experience (76.7% lifetime and 48% in the past year). Most also tested positive for fentanyl (93.75%) despite reporting no past year use of fentanyl or fentanyl-adulterated drugs (64.17%). The most utilized approaches reported for identifying fentanyl exposure were stronger effects of the drug (60.7%), sight or taste (46.9%), and being told by someone using the same drugs (34.2%). Few participants (14%) reported using fentanyl test strips. No significant associations were identified between self-report and urinalysis measures or urinalysis results and risk reduction strategies. CONCLUSION This study adds to prior fentanyl exposure risk research. The disconnect between participants' fentanyl detection methods and reported overdose experiences supports the need for more research to identify and understand factors driving access and use of overdose prevention resources and strategies.
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Affiliation(s)
- Dennis P Watson
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA.
| | - Bradley Ray
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Peter Phalen
- Department of Psychiatry, University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA
| | - Sarah E Duhart Clarke
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Lisa Taylor
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA
| | - James Swartz
- Jane Addams College of Social Work, The University of Illinois at Chicago, 1040 W Harrison Street, Chicago, IL, 60607, USA
| | - Nicole Gastala
- Department of Family Medicine, Mile Square Health Centers, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
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9
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Simon M, Kaplan S, Muschler K, Hoyte C, Brent J. The role of QRS complex prolongation in predicting severe toxicity in single-xenobiotic overdose. Clin Toxicol (Phila) 2024; 62:32-38. [PMID: 38329803 DOI: 10.1080/15563650.2024.2307356] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The QRS complex duration is commonly used to prognosticate severity, predict outcomes, and indicate treatment in overdose. However, literature to support this practice is mixed in tricyclic antidepressant overdoses and absent in non-tricyclic antidepressant overdoses. Our objective was to assess the validity of QRS complex duration as a prognostic marker in overdose. METHODS This was a secondary analysis of cases reported to the Toxicology Investigators Consortium between January 1, 2010, and December 31, 2022. Cases were assessed to determine the six xenobiotics most associated with QRS complex prolongation. All cases involving these six xenobiotics, regardless of QRS complex duration, constituted the study cohort. Inclusion criteria were cases of patients older than 12 years old with single-xenobiotic exposures. Clinical outcomes evaluated were seizure, ventricular dysrhythmia, metabolic acidosis, and death. RESULTS Of 94,939 total cases, diphenhydramine, amitriptyline, bupropion, quetiapine, nortriptyline, and cocaine were most associated with QRS complex prolongation. Inclusion criteria were met by 4,655 cases of exposure to these xenobiotics. QRS complex prolongation was associated with increased odds ratio of seizure in all included xenobiotics, of ventricular dysrhythmia in all included xenobiotics except nortriptyline, and of metabolic acidosis or death in all included xenobiotics except nortriptyline and quetiapine. A normal QRS complex duration had a negative predictive value of greater than or equal to 93.0 percent of developing metabolic acidosis and 98.0 percent of developing a ventricular dysrhythmia or death from the xenobiotics studied. DISCUSSION This study demonstrates that patients with QRS complex prolongation from all six xenobiotics studied had an increased prevalence and odds of developing severe outcomes. Furthermore, patients who did not develop QRS complex prolongation were unlikely to develop a ventricular dysrhythmia, metabolic acidosis, or death. These findings were noted in six xenobiotics that mechanistically can cause QRS complex prolongation through sodium channel or gap junction inhibition. CONCLUSION Identification of patients at risk for severe outcomes after overdose can be aided by measuring the QRS complex duration. If prospectively validated, these outcomes have implications on risk stratification, disposition level of care, and appropriateness of treatments.
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Affiliation(s)
- Mark Simon
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sabrina Kaplan
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Karen Muschler
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
| | - Jeffrey Brent
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
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Brown HM, Riley SB. Quantitative Assay of Fentanyl and Analogs Using LC-MS/MS. Methods Mol Biol 2024; 2737:283-295. [PMID: 38036830 DOI: 10.1007/978-1-0716-3541-4_26] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Drug overdoses and drug-involved deaths continue to increase in the United States, with most drug overdose deaths involving opioids. Among drug overdose deaths, opioids, particularly fentanyl and its analogs, remain the most prevalent substances involved. Despite the increase in the recreational use of fentanyl analogs and their role in drug overdoses, fentanyl and its analogs are not commonly included in clinical drug testing panels due to the need for specialized testing platforms. To address this, a rapid, robust, and accurate LC-MS/MS method for the quantitation of fentanyl and fentanyl analogs was developed. Identification and quantitation of each analyte was made using multiple reaction monitoring (MRM) with two transitions, along with the corresponding deuterated internal standard for each analyte for accurate measurement.
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Affiliation(s)
- Hannah M Brown
- Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Sarah B Riley
- Department of Pathology, St. Louis University School of Medicine, St. Louis, MO, USA.
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Tas B, Walker H, Lawn W, Matcham F, Traykova EV, Evans RAS, Strang J. What impacts the acceptability of wearable devices that detect opioid overdose in people who use opioids? A qualitative study. Drug Alcohol Rev 2024; 43:213-225. [PMID: 37596977 DOI: 10.1111/dar.13737] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/26/2023] [Accepted: 07/29/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Drug-related deaths involving an opioid are at all-time highs across the United Kingdom. Current overdose antidotes (naloxone) require events to be witnessed and recognised for reversal. Wearable technologies have potential for remote overdose detection or response but their acceptability among people who use opioids (PWUO) is not well understood. This study explored facilitators and barriers to wearable technology acceptability to PWUO. METHODS Twenty-four participants (79% male, average age 46 years) with current (n = 15) and past (n = 9) illicit heroin use and 54% (n = 13) who were engaged in opioid substitution therapy participated in semi-structured interviews (n = 7) and three focus groups (n = 17) in London and Nottingham from March to June 2022. Participants evaluated real devices, discussing characteristics, engagement factors, target populations, implementation strategies and preferences. Conversations were recorded, transcribed and thematically analysed. RESULTS Three themes emerged: device-, person- and environment-specific factors impacting acceptability. Facilitators included inconspicuousness under the device theme and targeting subpopulations of PWUO at the individual theme. Barriers included affordability of devices and limited technology access within the environment theme. Trust in device accuracy for high and overdose differentiation was a crucial facilitator, while trust between technology and PWUO was a significant environmental barrier. DISCUSSION AND CONCLUSIONS Determinants of acceptability can be categorised into device, person and environmental factors. PWUO, on the whole, require devices that are inconspicuous, comfortable, accessible, easy to use, controlled by trustworthy organisations and highly accurate. Device developers must consider how the type of end-user and their environment moderate acceptability of the device.
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Affiliation(s)
- Basak Tas
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hollie Walker
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Will Lawn
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Clinical Psychopharmacology Unit, University College London, London, UK
| | - Faith Matcham
- School of Psychology, University of Sussex, Falmer, UK
| | - Elena V Traykova
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rebecca A S Evans
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Denmark Hill, London, UK
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12
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Kang M, Moon S, Kim B, Kim SH, Kim J, Park H, Choi H, Kim S, Park M. Detection of thiocyanate in postmortem blood of a fatal potassium thiocyanate-poisoning patient using gas chromatography-mass spectrometry. J Anal Toxicol 2023; 47:867-870. [PMID: 37756625 DOI: 10.1093/jat/bkad075] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
Thiocyanate is an inorganic compound used in industrial applications. Here, we report a case of suicidal death due to acute thiocyanate overdose. A 44-year-old man who consumed an unknown amount of thiocyanate solution was transferred to the emergency room and died 2 h after admission. An autopsy was performed 2 days after death. General toxicological analysis of blood using gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-tandem mass spectrometry found no drug or alcohol. Quantification using GC-MS post-derivatization with pentafluorobenzyl bromide revealed 2,290 and 1,920 mg/L of thiocyanate in the heart and femoral blood samples, respectively. Thus, the cause of death was attributed to thiocyanate overdose. This study provides useful information for the interpretation of thiocyanate-related fatalities.
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Affiliation(s)
- Minji Kang
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Sungmin Moon
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Byungjoo Kim
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - So-Hyun Kim
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Junghyun Kim
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Heejin Park
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Hyeyoung Choi
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Seongho Kim
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
| | - Meejung Park
- Forensic Toxicology and Chemistry Division, Seoul Institute of National Forensic Service, 139, Jiyang-ro, Yangcheon-gu, Seoul 08036, Republic of Korea
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Bateman DN, Dart RC, Dear JW, Prescott LF, Rumack BH. Fifty years of paracetamol (acetaminophen) poisoning: the development of risk assessment and treatment 1973-2023 with particular focus on contributions published from Edinburgh and Denver. Clin Toxicol (Phila) 2023; 61:1020-1031. [PMID: 38197864 DOI: 10.1080/15563650.2023.2293452] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Fifty years ago, basic scientific studies and the availability of assay methods made the assessment of risk in paracetamol (acetaminophen) poisoning possible. The use of the antidote acetylcysteine linked to new methods of risk assessment transformed the treatment of this poisoning. This review will describe the way in which risk assessment and treatments have developed over the last 50 years and highlight the remaining areas of uncertainty. METHODS A search of PubMed and its subsidiary databases revealed 1,166 references published in the period 1963-2023 using the combined terms "paracetamol", "poisoning", and "acetylcysteine". Focused searches then identified 170 papers dealing with risk assessment of paracetamol poisoning, 141 with adverse reactions to acetylcysteine and 114 describing different acetylcysteine regimens. To manage the extensive literature, we focused mainly on contributions made by the authors during their time in Edinburgh and Denver. DOSE AND CONCENTRATION RESPONSE The key relationship between paracetamol dose and toxicity risk was established in 1971 and led to the development of the Rumack-Matthew nomogram from data collected in Edinburgh. MECHANISMS OF TOXICITY A series of papers on the mechanisms of toxicity were published in 1973, and these showed that paracetamol hepatotoxicity was caused by the formation of a toxic intermediate epoxide metabolite normally detoxified by glutathione but which, in excess, was bound covalently to hepatic enzymes and proteins. An understanding of the relationship between the rate of paracetamol metabolism, paracetamol concentration, and toxic hazard in humans soon followed. ANTIDOTE DEVELOPMENT AND EFFICACY IN PATIENTS These discoveries were followed by the testing of a range of sulfhydryl-donors in animals and "at risk" patients. Acetylcysteine was developed as the lead intravenous antidote in the United Kingdom. The license holder in the United States refused to make an intravenous formulation. Thus, oral acetylcysteine became the antidote trialed in the United States National Multicenter Study. Intravenous acetylcysteine regimens used initially in the United Kingdom and subsequently in the United States used loading doses of 150 mg/kg over 15 minutes or one hour, 50 mg/kg over four hours, and 100 mg/kg over 16 hours. These regimens were associated with adverse drug reactions (nausea, vomiting and anaphylactoid reactions) and hence, treatment interruption. Newer dosing regimens now give loading doses more slowly. One, the Scottish and Newcastle Anti-emetic Pretreatment protocol, using an acetylcysteine regimen of 100 mg/kg over two hours followed by 200 mg/kg over 10 hours, has been widely adopted in the United Kingdom. A cohort comparison study suggests this regimen has comparable efficacy to standard regimens and offers opportunities for selective higher acetylcysteine dosing. RISK ASSESSMENT AT PRESENTATION No dose-ranging studies with acetylcysteine were done, and no placebo-controlled studies were performed. Thus, there is uncertainty regarding the optimal dose of acetylcysteine, particularly in patients ingesting very large overdoses of paracetamol. The choice of intervention concentration on the Rumack-Matthew nomogram has important consequences for the proportion of patients treated. The United States National Multicenter Study used a "treatment" line starting at 150 mg/L (992 µmol/L) at 4 hours post overdose, extending to 24 hours with a half-life of 4 hours, now standard there, and subsequently adopted in Australia and New Zealand. In the United Kingdom, the treatment line was initially 200 mg/L (1,323 µmol/L) at 4 hours (the Rumack-Matthew "risk" line). In 2012, the United Kingdom Medicines and Healthcare products Regulatory Agency lowered the treatment line to 100 mg/L (662 µmol/L) at 4 hours for all patients, increasing the number of patients admitted and treated at a high cost. Risk assessment is a key issue for ongoing study, particularly following the development of potential new antidotes that may act in those at greatest risk. The development of biomarkers to assess risk is ongoing but has yet to reach clinical trials. CONCLUSION Even after 50 years, there are still areas of uncertainty. These include appropriate acetylcysteine doses in patients who ingest different paracetamol doses or multiple (staggered) ingestions, early identification of at-risk patients, and optimal treatment of late presenters.
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Affiliation(s)
- D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Medical Toxicology, University of CO School of Medicine, Aurora, CO, USA
| | - James W Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Laurie F Prescott
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Barry H Rumack
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Vohra V, Stroh-Steiner GK, Jones P. Qualitative and quantitative characteristics of xylazine-associated deaths detected using a post-mortem toxicology testing program. Clin Toxicol (Phila) 2023; 61:1040-1046. [PMID: 38088581 DOI: 10.1080/15563650.2023.2288540] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/22/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION The United States drug overdose crisis continues to evolve. Xylazine has been increasingly identified as an adulterant in illicit opioid supplies. The incorporation of novel adulterants, like xylazine, into the illicit drug supply adds complexity to post-mortem toxicology testing, public health messaging, substance use mitigation, and the treatment of people who use drugs. METHODS We assessed trends, decedent characteristics, drug co-detection, and blood concentrations of xylazine-positive post-mortem cases in Michigan. We utilized a toxicology testing program capable of detecting several opioids and non-opioids in post-mortem blood samples within 72 hours. RESULTS A total of 279 deaths were xylazine-positive between October 2019 and June 2023, with 100 percent positive for fentanyl. Only 30 percent of xylazine-involved samples were positive for naloxone, while 21.2 percent of xylazine-negative and opioid-positive samples were positive for naloxone. The percentage of xylazine-positive deaths increased from 3.2 percent in 2021 to 4.7 percent in January-June 2023. A median of five total drug groups were present among xylazine-positive deaths. Post-mortem xylazine concentrations for 55 decedent blood samples ranged from 5.2 to 200 µg/L. DISCUSSION Our study demonstrated increases in xylazine detection among post-mortem cases. Our findings are consistent with national trends of increasing xylazine presence among drug-involved deaths. Our range of detected post-mortem xylazine blood concentrations was consistent with what has been reported in previous literature. Fentanyl was detected in 100 percent of xylazine-positive overdose deaths. Naloxone detection was relatively low, highlighting the continued importance of increasing naloxone access and distribution. Deaths associated with xylazine often involved multiple other drugs. Limited human clinical xylazine research precludes accurate interpretation and attribution of causality from these data. CONCLUSIONS Overdose-related deaths with xylazine detection are increasing in Michigan and across the United States. Further clinical and toxicological research can help contextualize the clinical significance of xylazine in opioid overdose, clarify epidemiologic and clinical research, and inform appropriate public health messaging.
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Affiliation(s)
- Varun Vohra
- Department of Emergency Medicine, Michigan Poison & Drug Information Center, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Prentiss Jones
- Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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Linton E, Pak T, Halhouli O, Field MG, Gunderson C, Chung SM. Posterior Reversible Encephalopathy Syndrome With Visual Disturbances in an Adolescent After Overdose With Adderall XR: A Case Report. J Neuroophthalmol 2023; 43:e278-e279. [PMID: 36190919 DOI: 10.1097/wno.0000000000001615] [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: 11/25/2022]
Affiliation(s)
- Edward Linton
- Department of Ophthalmology and Visual Sciences (EL, MGF, SMC), University of Iowa Hospitals and Clinics, Iowa City, Iowa; University of Iowa Carver College of Medicine (TP), Iowa City, Iowa; Department of Neurology (OH, SMC), University of Iowa Hospitals and Clinics, Iowa City, Iowa; and Department of Psychiatry (CG), University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Matsuoka M, Arai R, Ihara S, Murata N, Yamaguchi J, Okumura Y, Kinoshita K. Diphenhydramine overdose detected early by integration of toxidrome and electrocardiography and treated with venoarterial extracorporeal membrane oxygenation: a case report. J Int Med Res 2023; 51:3000605231205449. [PMID: 37843498 PMCID: PMC10683571 DOI: 10.1177/03000605231205449] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
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.
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Affiliation(s)
- Masaru Matsuoka
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Riku Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shingo Ihara
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Nobuhiro Murata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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Rivoal Y, Quintyn JC. [Case report of intraocular toxicity of an intravitreal overdose of amphotericin B]. J Fr Ophtalmol 2023; 46:e257-e258. [PMID: 37105840 DOI: 10.1016/j.jfo.2022.12.038] [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] [Received: 12/05/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 04/29/2023]
Affiliation(s)
- Y Rivoal
- Centre hospitalier universitaire de Caen Normandie, avenue de la Côte-de-Nacre, 14000 Caen, France.
| | - J-C Quintyn
- Centre hospitalier universitaire de Caen Normandie, avenue de la Côte-de-Nacre, 14000 Caen, France
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Argenyi MS, Evans JK, Gay Y, Epstein DH, Weiss ST. The Opioid Overdose Resuscitation Education for Addiction Counselors and Trainees (Opioid Overdose REACT) naloxone response education pilot project improved confidence and knowledge among addiction counselors and trainees. Clin Toxicol (Phila) 2023; 61:509-517. [PMID: 37427894 PMCID: PMC10528373 DOI: 10.1080/15563650.2023.2229508] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Community programs to teach nonmedical laypeople how to recognize an opioid overdose and effectively resuscitate the victim using naloxone have proliferated recently as a significant component of harm-reduction efforts. Although many such programs target laypeople like first responders or friends and family members of people who use drugs, there are currently no programs that specifically target addiction counselors, despite their work with a client population at high risk of an opioid overdose. METHODS The four-hour curriculum designed by the authors covered opioid agonist and antagonist pharmacology; opioid toxidrome signs; legal implications and indications for using the naloxone kits; and hands-on training. Participants were two cohorts of addiction counselors and addiction counseling trainees at our institution and an affiliated Opioid Treatment Program methadone clinic. Surveys testing participant knowledge and confidence were conducted at baseline, immediately post-training, six months post-training, and 12 months post-training. RESULTS Overall, opioid and naloxone pharmacology knowledge, as well as the confidence to intervene in an overdose emergency, improved among participants in both cohorts. Knowledge scores at baseline (n = 36, median 5/10) improved significantly immediately post-training (n = 31, median 7/10, P < 0.0001, Wilcoxon signed-rank test) and were sustained six (n = 19) and 12 months (n = 11) later. Two participants reported using their naloxone kits to successfully reverse a client overdose in the 12 months after taking the course. DISCUSSION These results from our knowledge translation pilot project suggest that our educational program to train addiction counselors in opioid pharmacology and toxicology, allowing them to recognize and respond to an opioid overdose, is feasible and could be effective. Specific barriers to implementing such educational programs include cost, stigma, and unclear best practice for designing and conducting these programs. CONCLUSIONS Further study of providing opioid pharmacology education and overdose and naloxone training to addiction counselors and counseling trainees appears to be warranted.
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Affiliation(s)
- Michael S. Argenyi
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Joni K. Evans
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Yasmin Gay
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - David H. Epstein
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD
| | - Stephanie T. Weiss
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD
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Dong X, Zhang Z, Wan W, Jing B, Deng J, Jin W, Shen D, Gao Z, Liu Y. Integrated Imaging and Proteomic Sensors Resolve Proteome Aggregation in Liver Caused by Non-steroidal Anti-inflammatory Drug Overdose. ACS Sens 2023; 8:2247-2254. [PMID: 37248847 DOI: 10.1021/acssensors.3c00216] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Given the extreme heterogeneity and the loss of defined protein structures, misfolded and aggregated proteins are technically challenging to visualize and analyze. Herein, we assembled an integrated sensor system to resolve aggregated proteome in live cells and animal liver tissues that are overdosed by non-steroidal anti-inflammatory drugs (NSAIDs). A fluorogenic protein aggregation sensor (AggStain) first discovered the presence of aggregated proteome upon overdosing liver cells with NSAIDs. A solvatochromic protein aggregation sensor (AggRetina) further quantified the compactness (polarity) inside these cellular aggregates. Importantly, we exploited a proteomic sensor (AggLink) to selectively capture aggregated proteins upon NSAID overdose and profile their composition, revealing global collapse of cellular protein homeostasis. Finally, we detected subtle proteome aggregation in mouse liver tissue without obvious acute injury at a low NSAID dosage. Overall, we demonstrated an integrated sensor toolset for proteome aggregation studies and unveiled for the first time that NSAID overdose can cause proteome aggregation in liver cells and tissues.
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Affiliation(s)
- Xuepeng Dong
- The Second Hospital of Dalian Medical University, Dalian, Liaoning 116023, China
| | - Zhenduo Zhang
- The Second Hospital of Dalian Medical University, Dalian, Liaoning 116023, China
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
| | - Wang Wan
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
| | - Biao Jing
- The Second Hospital of Dalian Medical University, Dalian, Liaoning 116023, China
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
| | - Jintai Deng
- The Second Hospital of Dalian Medical University, Dalian, Liaoning 116023, China
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
| | - Wenhan Jin
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
| | - Di Shen
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
| | - Zhenming Gao
- The Second Hospital of Dalian Medical University, Dalian, Liaoning 116023, China
| | - Yu Liu
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, Liaoning 116023, China
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Glidden E, Suen K, Mustaquim D, Vivolo-Kantor A, Brent J, Wax P, Aldy K. Characterization of Nonfatal Opioid, Cocaine, Methamphetamine, and Polydrug Exposure and Clinical Presentations Reported to the Toxicology Investigators Consortium Core Registry, January 2010-December 2021. J Med Toxicol 2023; 19:180-189. [PMID: 36650409 PMCID: PMC10050626 DOI: 10.1007/s13181-022-00924-0] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/22/2022] [Accepted: 12/08/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION To characterize and compare opioid-only, cocaine-only, methamphetamine-only, opioid-and-cocaine exposure, and opioid-and-methamphetamine exposure and to examine clinical presentations, leading to a better understanding of overdose effects involving these drug exposures. METHODS We examined drug exposures in the Toxicology Investigators Consortium (ToxIC) Core Registry from January 2010 to December 2021, a case registry of patients presenting to participating healthcare sites that receive a medical toxicology consultation. Demographic and clinical presentations of opioid-only, cocaine-only, methamphetamine-only, and opioid-and-cocaine exposure, and opioid-and-methamphetamine exposure consultations were described; differences between single and polydrug exposure subgroups were calculated to determine statistical significance. Clinical presentations associated with exposures were evaluated through calculated adjusted relative risk. RESULTS A total of 3,883 consultations involved opioids, cocaine, methamphetamine, opioid-and-cocaine exposure, or opioid-and-methamphetamine exposure. Opioid-only (n = 2,268, 58.4%) and methamphetamine-only (n = 712, 18.3%) comprised most consultations. There were significant differences in clinical presentations between exposure subgroups. Opioid-and-cocaine exposure consultations were 8.15 times as likely to present with a sympathomimetic toxidrome than opioid-only. Conversely, opioid-and-cocaine exposure and opioid-and-methamphetamine exposure were 0.32 and 0.42 times as likely to present with a sympathomimetic toxidrome compared to cocaine-only and methamphetamine-only consultations, respectively. Opioid-and-cocaine exposure was 0.67 and opioid-and-methamphetamine exposure was 0.74 times as likely to present with respiratory depression compared to opioid-only consultations. Similarly, opioid-and-cocaine exposure was 0.71 and opioid-and-methamphetamine exposure was 0.78 times as likely to present with CNS depression compared to opioid-only consultations. CONCLUSIONS Used in combination, opioids and stimulants may mask typical clinical presentations of one another, misattributing incorrect drugs to overdose in both clinical treatment and public health surveillance.
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Affiliation(s)
- Emily Glidden
- National Network of Public Health Institutes, New Orleans, LA USA
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Kyle Suen
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
- Department of Emergency Medicine, Division of Medical Toxicology, Emory School of Medicine, Atlanta, GA USA
| | - Desiree Mustaquim
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Alana Vivolo-Kantor
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Jeffery Brent
- University of Colorado School of Medicine, Aurora, CO USA
| | - Paul Wax
- University of Texas Southwestern Medical Center, Dallas, TX USA
- American College of Medical Toxicology, Phoenix, AZ USA
| | - Kim Aldy
- University of Texas Southwestern Medical Center, Dallas, TX USA
- American College of Medical Toxicology, Phoenix, AZ USA
| | - On behalf of the Toxicology Investigators Consortium (ToxIC) Study Group
- National Network of Public Health Institutes, New Orleans, LA USA
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA USA
- Department of Emergency Medicine, Division of Medical Toxicology, Emory School of Medicine, Atlanta, GA USA
- University of Colorado School of Medicine, Aurora, CO USA
- University of Texas Southwestern Medical Center, Dallas, TX USA
- American College of Medical Toxicology, Phoenix, AZ USA
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Love JS, Levine M, Aldy K, Brent J, Krotulski AJ, Logan BK, Vargas-Torres C, Walton SE, Amaducci A, Calello D, Hendrickson R, Hughes A, Kurt A, Judge B, Pizon A, Schwarz E, Shulman J, Wiegan T, Wax P, Manini AF. Opioid overdoses involving xylazine in emergency department patients: a multicenter study. Clin Toxicol (Phila) 2023; 61:173-180. [PMID: 37014353 PMCID: PMC10074294 DOI: 10.1080/15563650.2022.2159427] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Illicit opioids, consisting largely of fentanyl, novel synthetic opioids, and adulterants, are the primary cause of drug overdose fatality in the United States. Xylazine, an alpha-2 adrenergic agonist and veterinary tranquilizer, is being increasingly detected among decedents following illicit opioid overdose. Clinical outcomes in non-fatal overdose involving xylazine are unexplored. Therefore, among emergency department patients with illicit opioid overdose, we evaluated clinical outcome differences for patients with and without xylazine exposures. METHODS This multicenter, prospective cohort study enrolled adult patients with opioid overdose who presented to one of nine United States emergency departments between 21 September 2020, and 17 August 2021. Patients with opioid overdose were screened and included if they tested positive for an illicit opioid (heroin, fentanyl, fentanyl analog, or novel synthetic opioid) or xylazine. Patient serum was analyzed via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect current illicit opioids, novel synthetic opioids, xylazine and adulterants. Overdose severity surrogate outcomes were: (a) cardiac arrest requiring cardiopulmonary resuscitation (primary); and (b) coma within 4 h of arrival (secondary). RESULTS Three hundred and twenty-one patients met inclusion criteria: 90 tested positive for xylazine and 231 were negative. The primary outcome occurred in 37 patients, and the secondary outcome occurred in 111 patients. Using multivariable regression analysis, patients positive for xylazine had significantly lower adjusted odds of cardiac arrest (adjusted OR 0.30, 95% CI 0.10-0.92) and coma (adjusted OR 0.52, 95% CI 0.29-0.94). CONCLUSIONS In this large multicenter cohort, cardiac arrest and coma in emergency department patients with illicit opioid overdose were significantly less severe in those testing positive for xylazine.
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Affiliation(s)
- Jennifer S Love
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Levine
- Department of Emergency Medicine, University of California, Los Angeles, CA, USA
| | - Kim Aldy
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation Willow Grove, Willow Grove, PA, USA
| | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation Willow Grove, Willow Grove, PA, USA
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara E Walton
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation Willow Grove, Willow Grove, PA, USA
| | | | - Diane Calello
- Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | | | | | - Anita Kurt
- Lehigh Valley Health Network, Bethlehem, PA, USA
| | | | - Anthony Pizon
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evan Schwarz
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Joshua Shulman
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy Wiegan
- University of Rochester Medical Center, Rochester, NY, USA
| | - Paul Wax
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Alex F Manini
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Shimozato A, Ohashi K, Saitoh S. Two case reports of extended-release guanfacine overdose in children. Pediatr Int 2023; 65:e15424. [PMID: 36412228 DOI: 10.1111/ped.15424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 10/21/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Asuka Shimozato
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Kei Ohashi
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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Ing Lorenzini K, Wainstein L, Spechbach H, Sarasin F, Ramlawi M, Desmeules J, Piguet V. Opioid-related adverse drug reactions in patients visiting the emergency division of a tertiary hospital. Pharmacol Res Perspect 2022; 10:e01033. [PMID: 36404650 PMCID: PMC9676686 DOI: 10.1002/prp2.1033] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/05/2022] [Indexed: 11/22/2022] Open
Abstract
Opioid use and associated morbidity and mortality have increased in several countries during the past 20 years. We performed a study whose objective was to assess the frequency and causes of opioid-related emergency division (ED) visits in an adult tertiary Swiss University Hospital over 9 weeks in 2018. We primarily assessed opioid-related adverse drug reactions (ADR), secondary overdose, misuse, abuse, and insufficient pain relief. Current opioid use was identified in 1037 (8.3%) of the 12 470 included ED visits. In 64 opioid users, an ADR was identified as a contributing cause of the ED visit, representing 6.2% of opioid users, and 0.5% of the total ED visits. Moreover, we identified an overdose in 16 opioid users, misuse or abuse in 19 opioid users, and compatible withdrawal symptoms in 7 opioid users. After pooling all these events, we conclude that the ED visits could be related to opioid use in 10.2% of opioid users. Finally, in 201 opioid users, insufficient pain relief (pain not responding to the current pharmacological treatment) was identified as a contributing cause of ED visits. In these cases, other factors than simply pharmacological nonresponse may have been involved. In the context of an ever-increasing opioid use to better control chronic pain situations, these results should reinforce emergency network epidemiological surveillance studies at a national level.
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Affiliation(s)
- Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Center, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency MedicineUniversity Hospitals of GenevaGenevaSwitzerland
- Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Laura Wainstein
- Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Center, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - Hervé Spechbach
- Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Division of Primary Care, Department of Primary Care MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - François Sarasin
- Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Division of Emergency Medicine, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - Majd Ramlawi
- Division of Emergency MedicineLa Tour Medical GroupMeyrinSwitzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Center, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency MedicineUniversity Hospitals of GenevaGenevaSwitzerland
- Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Valérie Piguet
- Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Center, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency MedicineUniversity Hospitals of GenevaGenevaSwitzerland
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Pickens CM, Scholl L, Liu S, Smith H, Snodgrass S. Development and Validation of a Syndrome Definition for Suspected Nonfatal Unintentional/Undetermined Intent Stimulant-Involved Overdoses. Public Health Rep 2022; 137:1079-1090. [PMID: 34727510 PMCID: PMC9574309 DOI: 10.1177/00333549211054489] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To monitor stimulant-involved overdose (SOD) trends, the Centers for Disease Control and Prevention (CDC) developed and evaluated the validity of a syndromic surveillance definition for suspected nonfatal, unintentional/undetermined intent stimulant-involved overdose (UUSOD). METHODS We analyzed all emergency department (ED) visits in CDC's surveillance system that met the UUSOD syndrome definition (January 2018-December 2019). We classified visits as true positive, possible, or not UUSODs after reviewing diagnosis codes and chief complaints. We first assessed whether visits were acute SODs, subsequently classifying acute SODs by intent. The percentage of true-positive UUSODs did not include intentional or possibly intentional visits. We considered all visits with UUSOD diagnosis codes to be acute SODs and reviewed them for intent. We manually reviewed and double-coded a 10% random sample of visits without UUSOD diagnosis codes using decision rules based on signs and symptoms. The overall percentage of true-positive UUSODs was a weighted average of the percentage of true-positive UUSODs based on diagnosis codes and the percentage of true-positive UUSODs determined by manually reviewing visits without codes. RESULTS During 2018-2019, 40 045 ED visits met the syndrome definition for UUSOD. Approximately half (n = 18 793; 46.9%) of 40 045 visits had UUSOD diagnosis codes, indicating acute SOD; of these, 98.6% (n = 18 534) were true-positive UUSODs. Of 2125 manually reviewed visits without UUSOD diagnosis codes, 32.6% (n = 693) were true-positive UUSODs, 54.2% (n = 1151) were possible UUSODs, and 13.2% (n = 281) were not UUSODs. Overall, 63.6% of visits were true-positive UUSODs, 29.3% were possible UUSODs, and 7.1% were not UUSODs. PRACTICE IMPLICATIONS CDC's UUSOD definition may assist in surveillance efforts with further refinement to capture data on SOD clusters and trends.
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Affiliation(s)
- Cassandra M. Pickens
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Scholl
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stephen Liu
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Herschel Smith
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Stephanie Snodgrass
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
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25
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Swartz JA, Lin Q, Kim Y. A measurement invariance analysis of selected Opioid Overdose Knowledge Scale (OOKS) items among bystanders and first responders. PLoS One 2022; 17:e0271418. [PMID: 36240201 PMCID: PMC9565426 DOI: 10.1371/journal.pone.0271418] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/27/2022] [Indexed: 11/18/2022] Open
Abstract
The Opioid Overdose Knowledge Scale (OOKS) is widely used as an adjunct to opioid education and naloxone distribution (OEND) for assessing pre- and post-training knowledge. However, the extent to which the OOKS performs comparably for bystander and first responder groups has not been well determined. We used exploratory structural equation modeling (ESEM) to assess the measurement invariance of an OOKS item subset when used as an OEND training pre-test. We used secondary analysis of pre-test data collected from 446 first responders and 1,349 bystanders (N = 1,795) attending OEND trainings conducted by two county public health departments. Twenty-four items were selected by practitioner/trainer consensus from the original 45-item OOKS instrument with an additional 2 removed owing to low response variation. We used exploratory factor analysis (EFA) followed by ESEM to identify a factor structure, which we assessed for configural, metric, and scalar measurement invariance by participant group using the 22 dichotomous items (correct/incorrect) as factor indicators. EFA identified a 3-factor model consisting of items assessing: basic overdose risk information, signs of an overdose, and rescue procedures/advanced overdose risk information. Model fit by ESEM estimation versus confirmatory factor analysis showed the ESEM model afforded a better fit. Measurement invariance analyses indicated the 3-factor model fit the data across all levels of invariance per standard fit statistic metrics. The reduced set of 22 OOKS items appears to offer comparable measurement of pre-training knowledge on opioid overdose risks, signs of an overdose, and rescue procedures for both bystanders and first responders.
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Affiliation(s)
- James A. Swartz
- Jane Addams College of Social Work, University of Illinois Chicago, Chicago, Illinois, United States of America
- * E-mail:
| | - Qiao Lin
- College of Education, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Yerim Kim
- Jane Addams College of Social Work, University of Illinois Chicago, Chicago, Illinois, United States of America
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26
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Riley ED, Hsue PY, Coffin PO. A Chronic Condition Disguised as an Acute Event: the Case for Re-thinking Stimulant Overdose Death. J Gen Intern Med 2022; 37:3462-3464. [PMID: 35713806 PMCID: PMC9550944 DOI: 10.1007/s11606-022-07692-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/16/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
Recent reports indicate that stimulant-related deaths are increasing dramatically. People who die from acute stimulant toxicity have high rates of pre-existing cardiovascular disease (CVD), much of which is undiagnosed. Moreover, people who use stimulants with CVD often remain asymptomatic until presenting to an emergency department with an acute event. Prior research shows that symptoms of stimulant toxicity may occur on a regular basis, and that people who die from stimulant toxicity are older than those who die of opioid toxicity. Taken collectively, the existing evidence suggests that death from acute stimulant toxicity is often an outcome of long-term, cumulative exposure leading to cardiovascular dysfunction rather than acute intoxication. Strategies tailored to the distinct etiology of stimulant overdose are needed. We propose a three-part approach including (1) implementing stimulant use interventions that promote not only abstinence, but also use reduction, (2) treating ongoing stimulant use as a chronic cardiovascular condition, and (3) making stimulant toxicity interventions relevant to the populations most affected, which includes people outside of the traditional health-care system. In short, to reduce stimulant-related fatality, we need to transform our approach in ways that are tailored to address its natural history.
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Affiliation(s)
- Elise D Riley
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, 1001 Potrero Ave., UCSF Mailbox 0874, San Francisco, CA, 94143-0874, USA.
| | - Priscilla Y Hsue
- Division of Cardiology, Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Phillip O Coffin
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, 1001 Potrero Ave., UCSF Mailbox 0874, San Francisco, CA, 94143-0874, USA
- San Francisco Department of Public Health, San Francisco, CA, USA
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Stephens RJ, Filip AB, Baumgartner KT, Schwarz ES, Liss DB. Benzonatate Overdose Presenting as Cardiac Arrest with Rapidly Narrowing QRS Interval. J Med Toxicol 2022; 18:344-349. [PMID: 35790679 PMCID: PMC9492832 DOI: 10.1007/s13181-022-00904-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/19/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Benzonatate is a local anesthetic-like sodium channel antagonist that is widely prescribed as an antitussive. While it may be reasonable to assume that patients would present with a prolonged QRS interval following benzonatate overdose, the published literature does not support this. We report a case of a patient presenting following a benzonatate overdose with a prolonged QRS on her initial electrocardiograph (ECG) rhythm strip with rapid normalization of QRS duration. CASE REPORT A 14-year-old girl presented in cardiac arrest following a benzonatate overdose. The patient was found in cardiac arrest within minutes of last being known well. Bystanders immediately provided cardiopulmonary resuscitation (CPR), and she was in asystole on emergency medical services (EMS) arrival. Return of spontaneous circulation (ROSC) was obtained following administration of intraosseous epinephrine and naloxone. EMS obtained an ECG rhythm strip following ROSC demonstrating a sinus rhythm with a QRS duration of 160 ms. Over the ensuing 30 minutes, there was progressive narrowing of the QRS. A 12-lead ECG obtained on arrival in the emergency department (ED) 44 minutes later demonstrated a QRS duration of 94 ms. Initially, EMS ECG rhythm strips were unavailable and an isolated benzonatate ingestion was considered less likely as ECG intervals were normal. Benzonatate exposure was later confirmed with a urine benzonatate concentration, which was 8.5 mcg/mL. The patient made a full recovery. DISCUSSION Cases of pediatric benzonatate overdose with rapid development of cardiac arrest and full recovery have been previously reported. In this case, evidence of cardiac sodium channel blockade was demonstrated with a prolonged QRS interval on initial ECG rhythm strip analysis. However, unlike previous cases, rapid resolution of QRS prolongation occurred in this case. While transient QRS prolongation may be observed, finding a normal QRS interval should not discount the possibility of benzonatate overdose.
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Affiliation(s)
- Robert J Stephens
- Department of Emergency Medicine, Barnes-Jewish Hospital, Washington University School of Medicine in Saint Louis, 660 Euclid Avenue, Saint Louis, MO, 63110 CB #8072, USA.
| | - Ari B Filip
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine in Saint Louis, 660 Euclid Avenue, Saint Louis, MO, 63110 CB #8072, USA
| | - Kevin T Baumgartner
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine in Saint Louis, 660 Euclid Avenue, Saint Louis, MO, 63110 CB #8072, USA
| | - Evan S Schwarz
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine in Saint Louis, 660 Euclid Avenue, Saint Louis, MO, 63110 CB #8072, USA
| | - David B Liss
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine in Saint Louis, 660 Euclid Avenue, Saint Louis, MO, 63110 CB #8072, USA
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28
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Nelson SD, McCoy AB, Rector H, Teare AJ, Barrett TW, Sigworth EA, Chen Q, Edwards DA, Marcovitz DE, Wright A. Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project. Anesth Analg 2022; 135:26-34. [PMID: 35343932 PMCID: PMC10823563 DOI: 10.1213/ane.0000000000005976] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing. METHODS We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing. RESULTS The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52). CONCLUSIONS A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.
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Affiliation(s)
- Scott D. Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison B. McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hayley Rector
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew J. Teare
- Department of HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Qingxia Chen
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - David A. Edwards
- Department of Anesthesiology, Division of Pain Medicine, Anesthesiology, and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David E. Marcovitz
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
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29
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Affiliation(s)
- Dominick Shelton
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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30
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Kobylianskii J, Austin E, Kumachev A, Wu PE. A 53-year-old woman with a suspected drug overdose. CMAJ 2022; 194:E163-E166. [PMID: 35131754 PMCID: PMC8900766 DOI: 10.1503/cmaj.211620] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jane Kobylianskii
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont.
| | - Emily Austin
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont
| | - Alexander Kumachev
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont
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31
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Shekhar AC, Campbell T, Mann NC, Blumen I. Overdose-Attributable Out-of-Hospital Cardiac Arrest in the United States (2017 to 2019). Am J Cardiol 2022; 162:200-201. [PMID: 34702556 DOI: 10.1016/j.amjcard.2021.09.008] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Aditya C Shekhar
- University of Minnesota, Minneapolis, Minnesota; The University of Chicago, Chicago, Illinois
| | | | - N Clay Mann
- The University of Utah, Salt Lake City, Utah
| | - Ira Blumen
- The University of Chicago, Chicago, Illinois
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Abstract
We herein report a 46-year-old man who suffered an intentional acetaminophen overdose. Laboratory results revealed leukocytosis and an elevated procalcitonin level (8.48 ng/mL). Computed tomography showed findings suggesting possible colitis. Due to concerns about sepsis in addition to acetaminophen overdose, oral N-acetyl cysteine and piperacillin/tazobactam were started. His procalcitonin levels further increased; however, the patient remained afebrile, and the C-reactive protein levels were normal. Piperacillin/tazobactam was discontinued, and he remained stable without antibiotics. The present case shows that the toxicokinetics of acetaminophen overdose can cause an elevated procalcitonin level. Furthermore, procalcitonin levels alone should not guide the need for antibiotics in such cases.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai 'i, USA
| | - Jakrin Kewcharoen
- Department of Medicine, John A. Burns School of Medicine, University of Hawai 'i, USA
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33
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Chapman BP, Lai JT, Krotulski AJ, Fogarty MF, Griswold MK, Logan BK, Babu KM. A Case of Unintentional Opioid (U-47700) Overdose in a Young Adult After Counterfeit Xanax Use. Pediatr Emerg Care 2021; 37:e579-e580. [PMID: 30789871 DOI: 10.1097/pec.0000000000001775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Indexed: 11/26/2022]
Abstract
ABSTRACT We report the case of a young adult who became unresponsive after insufflating what he believed to be "crushed Xanax." Naloxone was administered, reversing his altered mental status and respiratory depression. Clinicians suspected opioid toxicity; however, the patient adamantly denied opioid use. Because of unclear etiology of his symptoms, blood and urine specimens were obtained. A urine specimen was split and then submitted for a clinical comprehensive drug screen using gas chromatography-mass spectrometry. The blood specimen and the remaining urine specimen were sent to a reference laboratory for analysis using liquid chromatography quadrupole time-of-flight mass spectrometry and liquid chromatography tandem mass spectrometry. The standard, clinical gas chromatography-mass spectrometry urine drug testing procedure only detected caffeine; however, analysis by liquid chromatography quadrupole time-of-flight mass spectrometry and liquid chromatography tandem mass spectrometry confirmed the presence of U-47700 (a high-potency clandestine opioid) and its metabolites in the urine and blood. These findings implicate U-47700 as the agent responsible for the patient's signs of opioid toxicity. In this case, a young adult intending to use alprazolam encountered U-47700 with life-threatening effect. Clinicians must remain vigilant for symptoms consistent with opioid overdose, especially with increasing prevalence of counterfeit drugs containing clandestine opioids. Clinicians must also consider obtaining specimens for appropriate analytical testing to improve surveillance and facilitate public health interventions.
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Affiliation(s)
- Brittany P Chapman
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Jeffrey T Lai
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | - Melissa F Fogarty
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | | | - Barry K Logan
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | - Kavita M Babu
- From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
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34
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Scholl L, Liu S, Vivolo-Kantor A, Board A, Stein Z, Roehler DR, McGlone L, Hoots BE, Mustaquim D, Smith H. Development and Validation of a Syndrome Definition to Identify Suspected Nonfatal Heroin-Involved Overdoses Treated in Emergency Departments. J Public Health Manag Pract 2021; 27:369-378. [PMID: 33346583 DOI: 10.1097/phh.0000000000001271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT The Centers for Disease Control and Prevention (CDC) works closely with states and local jurisdictions that are leveraging data from syndromic surveillance systems to identify meaningful changes in overdose trends. CDC developed a suspected nonfatal heroin overdose syndrome definition for use with emergency department (ED) data to help monitor trends at the national, state, and local levels. OBJECTIVE This study assesses the percentage of true-positive unintentional and undetermined intent heroin-involved overdose (UUHOD) captured by this definition. DESIGN/SETTING CDC applied the UUHOD definition to ED data available in CDC's National Syndromic Surveillance Program (NSSP). Data were analyzed from 18 states that shared access to their syndromic data in NSSP with the CDC overdose morbidity team. Data were analyzed using queries and manual reviews to identify heroin overdose diagnosis codes and text describing chief complaint reasons for ED visits. MEASURES The percentage of true-positive UUHOD was calculated as the number of true-positives divided by the number of total visits captured by the syndrome definition. RESULTS In total, 99 617 heroin overdose visits were identified by the syndrome definition. Among 95 323 visits identified as acute heroin-involved overdoses, based on reviews of chief complaint text and diagnosis codes, 967 (1.0%) were classified as possible intentional drug overdoses. Among all 99 617 visits, 94 356 (94.7%) were classified as true-positive UUHOD; 2226 (2.2%) and 3035 (3.0%) were classified as "no" and "maybe" UUHOD, respectively. CONCLUSION Analysis of the CDC heroin overdose syndrome definition determined that nearly all visits were captured accurately for patients presenting to the ED for a suspected acute UUHOD. This definition will continue to be valuable for ongoing heroin overdose surveillance and epidemiologic analysis of heroin overdose patterns. CDC will evaluate possible definition refinements as new products and terms for heroin overdose emerge.
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Affiliation(s)
- Lawrence Scholl
- Division of Overdose Prevention, National Center for Injury Prevention and Control (Drs Scholl, Liu, Vivolo-Kantor, Board, Roehler, and Hoots, Messrs McGlone and Smith, and Ms Mustaquim), Epidemic Intelligence Service (Dr Board), and Division of Health Informatics and Surveillance, Center for Surveillance, Epidemiology, and Laboratory Services (Mr Stein), Centers for Disease Control and Prevention, Atlanta, Georgia; ICF, Atlanta, Georgia (Mr Stein); 2M Research, Dallas/Fort Worth, Texas (Mr McGlone); and Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee (Mr Smith)
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35
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Mian P, Meussen E, Piersma D, Lankheet NAG. Relatively mild symptoms after chronic overdose with a double-dose encorafenib: a case report. Anticancer Drugs 2021; 32:589-591. [PMID: 33587356 DOI: 10.1097/cad.0000000000001052] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Encorafenib (Braftovi) is indicated for the treatment of adult patients with unresectable or metastatic melanoma with a BRAF V600 mutation, in combination with binimetinib (Mektovi). According to the product label of encorafenib, there are no specific treatment recommendations in case of an overdose. We report on a 63-year-old man who ingested a double dose (900 mg) of encorafenib for 16 days. He developed overall minor chronic overdose symptoms such as nausea and vomiting grade 1 and muscle pain. Based on the most occurring adverse events of encorafenib, liver values, kidney function parameters and QTc interval were measured. Kidney function parameters were normal, whereas liver values were slightly increased (grade 1) and QTc slightly prolonged. The plasma concentration 3 h after the last dose was 2110 ng/mL. We describe the course of a case with a chronic overdose during 16 days of the double dose of encorafenib as well as the followed approach, which could be taken into account when observing an encorafenib overdose. Providing information in times of Covid-19 is challenging, but remains necessary for good clinical care.
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Affiliation(s)
| | - Elvera Meussen
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
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Minissale MG, Giannitrapani L, Capitano A, Morreale I, Licata A. A questionable diagnosis in a woman with drowsiness. Intern Emerg Med 2021; 16:1017-1021. [PMID: 31848993 DOI: 10.1007/s11739-019-02256-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Giovanna Minissale
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy.
| | - Lidya Giannitrapani
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy
| | - Adele Capitano
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy
| | - Ilaria Morreale
- Unità di Farmacologia Clinica, Centro di Riferimento Siciliano per la Farmacovigilanza, AOUP P. Giaccone, Università di Palermo, Palermo, Italy
| | - Anna Licata
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy
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Tielli A, Jullien V, Pull L, Bouchaud O, Siriez JY. Unintentional artenimol/piperaquine overdose in two children occurring without evidence of subsequent cardiotoxicity. Int J Antimicrob Agents 2021; 57:106347. [PMID: 33892107 DOI: 10.1016/j.ijantimicag.2021.106347] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/20/2021] [Accepted: 04/02/2021] [Indexed: 11/19/2022]
Abstract
At the emergency department of the Robert-Debré children's hospital in Paris, France, artenimol/piperaquine (AP) has been the first-line antimalarial treatment since September 2012. Most children receive the first dose at the hospital and return home if, after 1 hour's observation, there have been no episodes of vomiting. Here we report the case of two children, aged 11 years and 5 years, respectively, in whom the entire cumulative 3 days' treatment course combined was accidentally administered instead of just the first-day treatment dose. Serum piperaquine levels were measured between Hour 40 (H40) and Day 29 (D29) post-ingestion for the first patient, and between H17 and D7 for the second patient. Corrected QT (QTc) values were measured between H12 and D20 for the first patient and between H17 and H64 for the second patient. Despite reports of adverse electrophysiological events, AP overdose occurred without consequence on the QTc interval or clinical cardiac state in these two children.
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Affiliation(s)
- Alexandra Tielli
- Hôpital Robert-Debré, Service d'Accueil des Urgences pédiatriques, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France.
| | - Vincent Jullien
- Groupe hospitalier Paris Seine Saint-Denis, UF de Pharmacologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lauren Pull
- Hôpital Robert-Debré, Service d'Accueil des Urgences pédiatriques, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
| | - Olivier Bouchaud
- Hôpital Avicenne, Service des Maladies Infectieuses et Tropicales, Assistance Publique-Hôpitaux de Paris, 93000 Bobigny, France
| | - Jean-Yves Siriez
- Hôpital Robert-Debré, Service d'Accueil des Urgences pédiatriques, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
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Hall OE, Trent Hall O, Eadie JL, Teater J, Gay J, Kim M, Cauchon D, Noonan RK. Street-drug lethality index: A novel methodology for predicting unintentional drug overdose fatalities in population research. Drug Alcohol Depend 2021; 221:108637. [PMID: 33657469 PMCID: PMC11032745 DOI: 10.1016/j.drugalcdep.2021.108637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emerging evidence suggests the composition of local illicit drug markets varies over time and the availability and relative lethality of illicit drugs may contribute to temporal trends in overdose mortality. Law enforcement drug seizures represent a unique opportunity to sample the makeup of local drug markets. Prior research has associated shifts in the types of drugs seized and trends in unintentional drug overdose mortality. The present report builds on this work by demonstrating a novel methodology, the Street-Drug Lethality Index, which may serve as a low-lag predictor of unintentional overdose deaths. METHODS Data included administrative records of law enforcement drug seizures and unintentional drug overdose deaths in Ohio from 2009 -to- 2018. Death records and lab results from drug seizures occurring during the calendar year 2017 were transformed via the described procedure to create lethality indices for individual drugs. These indices were then summed annually to create the independent variable for a linear regression model predicting unintentional overdose deaths for all years during the study period. RESULTS The regression model explained 93 % of the year-to-year variance in unintentional overdose fatalities (slope = 0.009480; CI = 0.007369 to 0.011590; t10 = 10.355942; P = 0.000007; Y = 11.808982 + 0.009480X, r2 = 0.931). CONCLUSION These findings contribute to a growing body of evidence that changes in the composition of the drug supply may predict trends in unintentional overdose mortality. The proposed methodology might inform future overdose prevention and response efforts as well as research.
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Affiliation(s)
- Orman E Hall
- Ohio High Intensity Drug Trafficking Area, Cleveland, OH, USA; College of Health Sciences and Professions, Ohio University, Athens, OH, USA.
| | - O Trent Hall
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center Talbot Hall, Columbus, OH, USA
| | - John L Eadie
- National Emerging Threats Initiative (NETI), National High Intensity Drug Trafficking Areas (HIDTA), Norcross, GA, USA
| | - Julie Teater
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center Talbot Hall, Columbus, OH, USA
| | - Joe Gay
- College of Health Sciences and Professions, Ohio University, Athens, OH, USA
| | - Meelee Kim
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | | | - Rita K Noonan
- National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Lattey K, Quinn S, O'Brien K. Over-the-counter antacids linked to severe hypokalaemia in the context of threatened preterm labour. BMJ Case Rep 2021; 14:e236083. [PMID: 33431440 PMCID: PMC7802640 DOI: 10.1136/bcr-2020-236083] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 01/13/2023] Open
Abstract
A healthy multiparous woman presented at 35 weeks and 4 days' gestation with threatened preterm labour on multiple occasions. An incidental finding of severe hypokalaemia (2.4 mmol/L) was detected on routine blood tests. The cause of this hypokalaemia was not initially obvious. It was eventually linked to overuse of over-the-counter antacids for pregnancy-associated heartburn. The patient was managed with parenteral and then oral electrolyte replacement which corrected a pH of 7.55, bicarbonate of 36.7 mEq/L and a base excess 13.1. In this case report we consider whether hypokalaemia could be linked to uterine irritability and threatened preterm labour, whether antacids were being abused in the context of an eating disorder and the importance of taking a full drug history.
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Affiliation(s)
- Katherine Lattey
- Department of Obstetrics and Gynaecology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Quinn
- Department of Obstetrics and Gynaecology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Katherine O'Brien
- Department of Obstetrics and Gynaecology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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Burket GA, Horowitz BZ, Hendrickson RG, Beauchamp GA. Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature. J Med Toxicol 2021; 17:61-69. [PMID: 32394224 PMCID: PMC7785763 DOI: 10.1007/s13181-020-00779-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/04/2020] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. DISCUSSION A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. CONCLUSIONS ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.
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Affiliation(s)
- Glenn A Burket
- SCL Health St Mary's Medical Center, 2635 North 7th Street, Grand Junction, CO, 81501, USA
- Mesa County EMS, 215 Rice St, Grand Junction, CO, 81501, USA
| | - B Zane Horowitz
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Robert G Hendrickson
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Gillian A Beauchamp
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine, Division of Medical Toxicology, USF Morsani College of Medicine, Lehigh Valley Campus, Cedar Crest Boulevard & I-78, Allentown, PA, 18101, USA.
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Shastry S, Ellis J, Loo G, Vedanthan R, Richardson LD, Manini AF. Antidotal Sodium Bicarbonate Therapy: Delayed QTc Prolongation and Cardiovascular Events. J Med Toxicol 2021; 17:27-36. [PMID: 32737857 PMCID: PMC7785762 DOI: 10.1007/s13181-020-00799-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sodium bicarbonate therapy (SBT) is currently indicated for the management of a variety of acute drug poisonings. However, SBT effects on serum potassium concentrations may lead to delayed QTc prolongation (DQTP), and subsequent risk of adverse cardiovascular events (ACVE), including death. Emergency department (ED)-based studies evaluating associations between SBT and ACVE are limited; thus, we aimed to investigate the association between antidotal SBT, ECG changes, and ACVE. METHODS This was a secondary data analysis of a consecutive cohort of ED patients with acute drug overdose over 3 years. Demographic and clinical data as well as SBT bolus dosage and infusion duration were collected, and outcomes were compared with an unmatched consecutive cohort of patients with potential indications for SBT but who did not receive SBT. The primary outcome was the occurrence of ACVE, and secondary outcomes were delayed QTc (Bazett) prolongation (DQTP), and death. Propensity score and multivariable adjusted analyses were conducted to evaluate associations between adverse outcomes and SBT administration. Planned subgroup analysis was performed for salicylates, wide QRS (> 100 ms), and acidosis (pH < 7.2). RESULTS Out of 2365 patients screened, 369 patients had potential indications for SBT, of whom 31 (8.4%) actually received SBT. In adjusted analyses, SBT was found to be a significant predictor of ACVE (aOR 9.35, CI 3.6-24.1), DQTP (aOR 126.7, CI 9.8-1646.2), and death (aOR 11.9, CI 2.4-58.9). Using a propensity score model, SBT administration was associated with ACVE (OR 5.07, CI 1.8-14.0). Associations between SBT and ACVE were maintained in subgroup analyses of specific indications for sodium channel blockade (OR 21.03, CI 7.16-61.77) and metabolic acidosis (OR: 6.42, 95% CI: 1.20, 34.19). CONCLUSION In ED patients with acute drug overdose and potential indications for SBT, administration of SBT as part of routine clinical care was an independent, dose-dependent, predictor of ACVE, DQTP, and death. This study was not designed to determine whether the SBT or acute overdose itself was causative of ACVE; however, these data suggest that poisoned patients receiving antidotal SBT require close cardiovascular monitoring.
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Affiliation(s)
- Siri Shastry
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 3 East 101st Street, 2nd Floor, New York, NY, 10029, USA.
| | | | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 3 East 101st Street, 2nd Floor, New York, NY, 10029, USA
| | - Rajesh Vedanthan
- Department of Population Health, New York University, New York, NY, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 3 East 101st Street, 2nd Floor, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine, Elmhurst Hospital Center, New York, NY, USA
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Fernández Alonso C, Lázaro Del Nogal M, Quintela Jorge Ó, Santiago-Sáez AE. [Suspicion of chemical submission in older subjects attending a hospital emergency department]. Rev Esp Geriatr Gerontol 2020; 55:354-357. [PMID: 32718580 DOI: 10.1016/j.regg.2020.03.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/30/2020] [Indexed: 06/11/2023]
Abstract
Chemical Submission (CS) is considered a danger to health and a form of violence. There are different forms of proactive CS (involuntary consumption of psychoactive substances) and opportunistic CS (voluntary consumption), with criminal intent, usually theft, submission, or sexual assault. The objective of this work is to describe the characteristics of cases of suspected CS in adults older than 65 years treated in the Emergency Department of the San Carlos Clinical Hospital and the results of the toxicological analysis performed by the INTCF in Madrid (April 1, 2015-2019). There were 12 (8%) cases of suspected CS, with a mean age of 75 (SD 8) years, of which 8 (66.7%) men, with two different profiles, all associated with theft, and in 3 (25%) possible sexual assault. In 9 (75%) cases, benzodiazepines and / or usual drugs were identified. CS is a problem to consider in Emergency Departments and is not exclusive to the young population.
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Affiliation(s)
- Cesáreo Fernández Alonso
- Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, España; Comisión Contra la Violencia, Hospital Clínico San Carlos, Madrid, España.
| | - Montserrat Lázaro Del Nogal
- Servicio de Geriatría, Hospital Clínico San Carlos, Madrid, España; Comisión Contra la Violencia, Hospital Clínico San Carlos, Madrid, España
| | - Óscar Quintela Jorge
- Servicio de Química, Instituto Nacional de Toxicología y Ciencias Forenses (INTCF)
| | - Andres E Santiago-Sáez
- Servicio de Medicina Legal, Hospital Clínico San Carlos, Madrid, España; Comisión Contra la Violencia, Hospital Clínico San Carlos, Madrid, España
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Speed KA, Gehring ND, Launier K, O'Brien D, Campbell S, Hyshka E. To what extent do supervised drug consumption services incorporate non-injection routes of administration? A systematic scoping review documenting existing facilities. Harm Reduct J 2020; 17:72. [PMID: 33028363 PMCID: PMC7539556 DOI: 10.1186/s12954-020-00414-y] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Most of the existing research on supervised consumption services (SCS) is focused on injection drug use. Less is known about the applicability of SCS for people who consume drugs orally, intranasally, or through inhalation. This is problematic because people who use drugs through modes other than injection are also at risk of overdose death and other harm, and experience barriers accessing health and social services. We aimed to describe existing SCS models that accommodate these alternate routes of drug consumption, and synthesize available information on characteristics of program participants. METHODS We conducted a systematic scoping review of 9 peer-reviewed and 13 grey literature databases on SCS that incorporate non-injection routes of consumption. We screened 22,882 titles, and excluded 22,843 (99.8%) articles. We ultimately included 39 (0.2%) full-text articles; 28 (72%) of these articles explicitly identified SCS that permit alternate routes of consumption and 21 (54%) discussed characteristics of participants who consume drugs through non-injection routes. Data on study characteristics, terms and definitions, and site and program participant characteristics were extracted and double-coded. Extracted data were analyzed using descriptive statistics and narrative synthesis. RESULTS Included articles describe 48 SCS that permit non-injection routes of consumption, most of which were located in Germany. The majority of these SCS were legally sanctioned and had models of care that were largely comparable to supervised injection services. Notable differences included physical infrastructure such as ventilated rooms or outdoor areas to accommodate inhalation, and shorter time limits on non-injection drug consumption episodes. Program participants engaging in non-injection forms of consumption were typically men over the age of 30 and structurally vulnerable (e.g., experiencing homelessness or unstable housing). CONCLUSIONS Extant academic and grey literature indicates that site characteristics and demographics of program participants of SCS that permit non-injection routes of consumption largely reflect those of supervised injection services. Further research on the range of existing SCS that incorporate non-injection routes of consumption is needed to ensure high quality service provision, and improved health outcomes for people who consume drugs via oral, intranasal, and inhalation routes.
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Affiliation(s)
- Kelsey A Speed
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Nicole D Gehring
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Katherine Launier
- Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Daniel O'Brien
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Sandy Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
- Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, AB, Canada.
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Palatnick W, Jelic T. Calcium channel blocker and beta blocker overdose, and digoxin toxicity management. Emerg Med Pract 2020; 22:1-42. [PMID: 33136356] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
While relatively uncommon, an overdose of calcium channel blockers, beta blockers, or digoxin can result in significant morbidity and mortality, and management can be complex. An acute overdose will require different management strategies than chronic toxicity while on therapeutic dosing. Toxicity from these agents must be considered in bradycardic and hypotensive patients. This supplement provides an evidence-based overview of emergency department management of calcium channel blocker overdose, beta blocker overdose, and digoxin toxicity, and focuses on the caveats of treatment for each.
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Affiliation(s)
- Wesley Palatnick
- Department of Emergency Medicine, University of Manitoba; Department of Emergency Medicine, Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba; Department of Emergency Medicine, Health Sciences Centre, Winnipeg, Manitoba, Canada
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Krock K, Nickley J, Tran K, Greg Ackerman RT, Pesce A. Correlation of Fentanyl Positive Drug Screens with Other Medications in Patients from Pain, Rehabilitation and Behavioral Programs. Ann Clin Lab Sci 2020; 50:260-265. [PMID: 32366566] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Fentanyl has been associated with many drug overdose deaths; its presence in many street drugs has been postulated to be increasing. We examined 1.3 million urine drug tests from April 2016 to April 2019 for fentanyl and other drugs. The highest relationship was observed with heroin. Approximately 30%-40% of the drug tests positive for the heroin metabolite 6-monacetylmorphine (6-MAM) were also positive for fentanyl. There was a large variance over time, but the percent positive in 2016 and 2019 were similar. In contrast, there was a definite increase in the presence of fentanyl with cocaine and methamphetamine. There was not a large increase over time associated with methadone, buprenorphine, and marijuana.
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Affiliation(s)
| | | | - Keith Tran
- Precision Diagnostics, San Diego, CA, USA
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Krauskopf J, Gosink MM, Schomaker S, Caiment F, Warner R, Johnson K, Kleinjans J, Aubrecht J. The MicroRNA-based Liquid Biopsy Improves Early Assessment of Lethal Acetaminophen Poisoning: A Case Report. Am J Case Rep 2020; 21:e919289. [PMID: 32086430 PMCID: PMC7049075 DOI: 10.12659/ajcr.919289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/24/2020] [Accepted: 11/04/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acetaminophen overdose is the most common cause of acute liver failure. Nevertheless, new biomarker approaches enabling early prediction of the outcome of the acetaminophen overdose are needed. Recently, using next-generation sequencing analysis of serum from human study participants we uncovered injury-specific signatures of circulating microRNAs (miRNAs) that represented underlying molecular mechanisms of toxicity. This case study is first to show the application of miRNA profiling to assess prognosis of acetaminophen poisoning. CASE REPORT The patient was admitted to the hospital following supra therapeutic acetaminophen ingestion. The patient showed elevated levels of biomarkers of hepatocellular injury alanine aminotransferase, aspartate transaminase, and glutamate dehydrogenase. Even though treatment with N-acetyl cysteine was initiated 24 hours post-ingestion, levels of alanine-aminotransferase and aspartate transaminase peaked at about 40 hours post ingestion of acetaminophen. We analyzed global circulating miRNA levels from 24 consecutive serum samples from this study participant covering the period from admission to time of death. CONCLUSIONS The resulting global miRNA profiles were compared with profiles from study participants with non-lethal acetaminophen poisoning and healthy controls. At the admission, the miRNA profiles of both lethal and non-lethal acetaminophen poisoning showed induction of cellular stress and oxidative damage. Later, the miRNA profiles of the lethal poisoning featured fibrosis and coagulation pathways while profiles of non-lethal cases resembled those of healthy study participants. Although additional confirmatory studies are needed, our case study is first to indicate that global miRNA profiles to be used as liquid biopsies have potential to facilitate the assessment of acetaminophen poisoning.
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Affiliation(s)
- Julian Krauskopf
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Mark M. Gosink
- Department of Pathology, University of Michigan, Ann Arbor, MI, U.S.A
| | - Shelli Schomaker
- Drug Safety Research and Development, Pfizer, Inc., Groton, CT, U.S.A
| | - Florian Caiment
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Roscoe Warner
- Department of Pathology, University of Michigan, Ann Arbor, MI, U.S.A
| | - Kent Johnson
- Department of Pathology, University of Michigan, Ann Arbor, MI, U.S.A
| | - Jos Kleinjans
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Jiri Aubrecht
- Drug Safety Research and Development, Pfizer, Inc., Groton, CT, U.S.A
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Abstract
RATIONALE Procalcitonin (PCT) is used as a biomarker for identifying the occurrence of sepsis. Previous studies have reported high levels of PCT with acetaminophen intoxication without evidence of infection. Here, we report two patients with acetaminophen intoxication with high levels of PCT without showing any symptoms of bacterial infection. PATIENT CONCERNS This case study examined two unrelated patients with acetaminophen intoxication admitted to emergency at different times. The first patient was admitted to the emergency department after ingesting approximately 8000 mg (153.8 mg/kg) of acetaminophen. On admission, C-reactive protein (CRP), glutamic oxaloacetic transaminase (GOT), and glutamic pyruvic transaminase (GPT) were normal. PCT and acetaminophen levels were 31.89 ng/mL and below 0.5 μg/mL, respectively. The second patient was admitted to the emergency department 8 h after ingesting ∼23,600 mg (280.6 mg/kg) of acetaminophen. By the second day of admission, GOT and GPT increased to 2508 and 1473 IU/L, respectively. PCT was 45.66 ng/mL with acetaminophen level at 116.9 μg/mL. Both patients were clear of symptoms associated with bacterial infection. DIAGNOSIS Acetaminophen intoxication. INTERVENTIONS N-acetylcysteine was given intravenously to both patients for 20 h per protocol. OUTCOMES Both patients were discharged without complications. LESSONS Observations suggests that elevated levels of PCT in patients intoxicated with acetaminophen may be associated with involvement of other organs impacted by cytokine stimuli from sterile inflammation resulting from hepatic damage rather than PCT secretion directly caused by hepatic cell damage.
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Affiliation(s)
- Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon
| | - Young Suk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea
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48
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Haden M, Woods B. LSD Overdoses: Three Case Reports. J Stud Alcohol Drugs 2020; 81:115-118. [PMID: 32048609] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE In academic settings around the world, there is a resurgence of interest in using psychedelic substances for the treatment of addictions, posttraumatic stress disorder, depression, anxiety, and other diagnoses. This case series describes the medical consequences of accidental overdoses in three individuals. METHOD Case series of information were gathered from interviews, health records, case notes, and collateral reports. RESULTS The first case report documents significant improvements in mood symptoms, including reductions in mania with psychotic features, following an accidental lysergic acid diethylamide (LSD) overdose, changes that have been sustained for almost 20 years. The second case documents how an accidental overdose of LSD early in the first trimester of pregnancy did not negatively affect the course of the pregnancy or have any obvious teratogenic or other negative developmental effects on the child. The third report indicates that intranasal ingestion of 550 times the normal recreational dosage of LSD was not fatal and had positive effects on pain levels and subsequent morphine withdrawal. CONCLUSIONS There appear to be unpredictable, positive sequelae that ranged from improvements in mental illness symptoms to reduction in physical pain and morphine withdrawal symptoms. Also, an LSD overdose while in early pregnancy did not appear to cause harm to the fetus.
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Affiliation(s)
- Mark Haden
- Executive Director, MAPS Canada (Multidisciplinary Association for Psychedelic Studies), Vancouver, British Columbia, Canada
- Adjunct Professor, University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | - Birgitta Woods
- Adult Psychiatrist, Vancouver Coastal Health, Vancouver, British Columbia, Canada
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Carpenter J, Murray BP, Atti S, Moran TP, Yancey A, Morgan B. Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl. J Med Toxicol 2020; 16:41-48. [PMID: 31471760 PMCID: PMC6942078 DOI: 10.1007/s13181-019-00735-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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] [Received: 05/19/2019] [Revised: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Illicitly manufactured fentanyl (IMF) is responsible for a growing number of deaths. Some case series have suggested that IMF overdoses require significantly higher naloxone doses than heroin overdoses. Our objective was to determine if the naloxone dose required to treat an opioid overdose is associated with the finding of fentanyl, opiates, or both on urine drug screen (UDS). METHODS A retrospective chart review was conducted at a single emergency department and its affiliated emergency medical services (EMS) agency. The charts of all patients who received naloxone through this EMS from 1/1/2017 to 6/15/2018 were reviewed. The study included patients diagnosed with a non-suicidal opioid overdose whose UDS was positive for opiates, fentanyl, or both. Data collected included demographics, vital signs, initial GCS, EMS and ED naloxone administrations, response to treatment, laboratory findings, and ED disposition. The fentanyl-only and fentanyl + opiate groups were compared to the opiate-only group using the stratified (by ED provider) variant of the Mann-Whitney U test. RESULTS Eight hundred and thirty-seven charts were reviewed, and 121 subjects were included in the final analysis. The median age of included subjects was 38 years and 75% were male. In the naloxone dose analysis, neither the fentanyl-only (median 0.8 mg, IQR 0.4-1.6; p = 0.68) nor the fentanyl + opiate (median 0.8 mg, IQR 0.4-1.2; p = 0.56) groups differed from the opiate-only group (median 0.58 mg, IQR 0.4-1.6). CONCLUSION Our findings refute the notion that high potency synthetic opioids like illicitly manufactured fentanyl require increased doses of naloxone to successfully treat an overdose. There were no significant differences in the dose of naloxone required to treat opioid overdose patients with UDS evidence of exposure to fentanyl, opiates, or both. Further evaluation of naloxone stocking and dosing protocols is needed.
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Affiliation(s)
- Joseph Carpenter
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA.
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | | | - Sukhshant Atti
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Arthur Yancey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Brent Morgan
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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50
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Puiguriguer-Ferrando J, Yates-Bailo C, Gervilla-García E, Ortega-Pérez J, Alfaro García-Belenguer E, Jiménez-López R. Medication overdoses: changes over time. Emergencias 2019; 31:107-110. [PMID: 30963738] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To review changes occurring over time in cases of medication overdose attended by an emergency department. MATERIAL AND METHODS Retrospective review of epidemiologic and care variables related to drug poisonings in a university teaching hospital in 2007 and 2017. We used multivariate analysis to compare the 2 years. RESULTS A total of 750 cases were included; 438 (58.4%) were from 2007. Fewer cases were seen in 2017 even though the total numbers of emergencies and poisonings had risen (P<.001). Fewer cases were suicides or suicide attempts in 2017 (P<.001), and digestive tract decontamination and antidotes were used less often (P<.001 and P=.007, respectively). Admissions (P=.004) and voluntary self-discharges or patient losses were also down in 2017 (P=.03). However, multidrug poisonings increased (P=.001), especially in the context of recreational drug use by men. Benzodiazepine overdoses accounted for most of such cases (65.1%). CONCLUSION Medication overdoses seem to be decreasing, although the proportion of men overdosing is rising. Suicide attempts, the abuse of specific medications, and admissions also seem to be decreasing.
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Affiliation(s)
- Jordi Puiguriguer-Ferrando
- Unidad de Toxicología, Servicio de Urgencias. Hospital Universitario Son Espases. Grupo de Trabajo en Toxicología Clínica del Área de Neurociencias del Institut d'Investigació Sanitària de Baleares (IdiSBA), España
| | - Christopher Yates-Bailo
- Unidad de Toxicología, Servicio de Urgencias. Hospital Universitario Son Espases. Grupo de Trabajo en Toxicología Clínica del Área de Neurociencias del Institut d'Investigació Sanitària de Baleares (IdiSBA), España
| | - Elena Gervilla-García
- Área de Metodología de las Ciencias del Comportamiento, Departamento de Psicología de la Universitat de les Illes Balears. Grupo de Trabajo en Procedimientos Estadísticos y Psicométricos Aplicados en Ciencias de la Salud del Institut d'Investigació Sanitària de Baleares (IdiSBA), España
| | - Juan Ortega-Pérez
- Unidad de Toxicología, Servicio de Urgencias. Hospital Universitario Son Espases. Grupo de Trabajo en Toxicología Clínica del Área de Neurociencias del Institut d'Investigació Sanitària de Baleares (IdiSBA), España
| | - Elena Alfaro García-Belenguer
- Unidad de Toxicología, Servicio de Urgencias. Hospital Universitario Son Espases. Grupo de Trabajo en Toxicología Clínica del Área de Neurociencias del Institut d'Investigació Sanitària de Baleares (IdiSBA), España
| | - Rafael Jiménez-López
- Área de Metodología de las Ciencias del Comportamiento, Departamento de Psicología de la Universitat de les Illes Balears. Grupo de Trabajo en Procedimientos Estadísticos y Psicométricos Aplicados en Ciencias de la Salud del Institut d'Investigació Sanitària de Baleares (IdiSBA), España
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