Recreational drug use at a major music festival: trend analysis of anonymised pooled urine

Objective: The spread of new psychoactive substances (NPS) has expanded rapidly in the last decade. The complexity of the pharmacological effects of NPS challenges the traditional treatment guidelines, and information of the emergence of new arrivals is valuable. Our knowledge on the actual range of recreational drugs used and NPS available in Denmark is limited as identification is possible only when consumers become patients in the healthcare system or through drug seizures. We aimed to detect classical recreational drugs and NPS in the urine of music festival attendees and evaluate if the use of NPS could have been predicted by comparing study data with drug seizure data from the previous year published by European and Danish health authorities.

Methods: In a cross-sectional study, 44 urine samples were collected from three urinals at Roskilde Festival 2016—the largest Danish music festival. Two urinals were placed at music stages with late-night concerts, and one urinal was placed at a camp site. Samples were prepared using enzymatic hydrolysis followed by cationic and anionic solid phase extraction, and analysed using ultra performance liquid chromatography-high-resolution time-of-flight mass spectrometry (UPLC-HR-TOF-MS). Data were processed using an in-house library of 467 target substances, including legal and illegal drugs and metabolites. Urine drug-screening immunoassays were also evaluated and results were compared to UPLC-HR-TOF-MS results.

Results: In total, 77 drugs, including metabolites, were qualitatively identified in the 44 urine samples. The recreational drugs identified were amphetamine (n?=?30), cocaine (n?=?44), MDA (n?=?40), MDMA (n?=?44), THC-COOH (n?=?19) and ketamine (n?=?17). No NPS were identified. Sample testing using the urine drug-screening immunoassays showed presence of cocaine (n?=?27), methamphetamine/MDMA (n?=?4), THC (n?=?7), “Spice” (n?=?7) and methylphenidate (n?=?1). These discrepancies might be caused by differences in cut-off values between the analytical methods, limited specificity or cross-reactivity of the urine drug-screening immunoassays compared to UPLC-HR-TOFMS results.

Conclusion: Widespread uses of classical recreational drugs were identified in pooled urine samples. The prevalence of NPS was not as comprehensive as expected based on the European and Danish health authorities reports on illegal drugs. Urine drug-screening immunoassays results are advised to be confirmed by chromatographic bioanalysis.     

Clinical survey assessing the appropriate management of individuals with acute recreational drug toxicity at a large outdoor festival event

Background: The published ambulance referral criteria (ARC) for assessing individuals with acute recreational drug toxicity in the prehospital setting consist of nine domains. The ARC recommend that an ambulance is called to transfer those with a score ≥1 to hospital.

Methods: Individuals presenting to a physician-led medical facility with acute drug and/or ethanol toxicity during an outdoor festival were assessed to determine whether the ARC recommended hospital transfer. Final disposition following management in the facility was compared with ARC assessment to determine if physician-led management reduced the need for hospital transfer.

Results: A total of 28 patients were presented during the study period; 16 (57.1%) had an initial ARC ≥1 (range 1–5). Twelve (75%) of these were discharged after management in the facility. Four were transferred to hospital: two for severe acute recreational drug toxicity and two due to closure of the facility at the end of the event.

Conclusions: Physicians present at this festival event significantly reduced the need for hospital transfer of individuals with acute recreational drug toxicity. Organisers of similar festivals should consider whether it would be appropriate to arrange for appropriate physician-level support to reduce the use of local health-care resources during the event for individuals with acute recreational drug/ethanol toxicity.     

Current European data collection on emergency department presentations with acute recreational drug toxicity: Gaps and national variations

Background. The number of new (novel) psychoactive substances (NPS) available in the illegal market is increasing; however, current monitoring of the drug situation in Europe focuses mainly on classical drugs of abuse, with limited emphasis on clinical presentation in the emergency department (ED). The European Drug Emergencies Network (Euro-DEN) is a European Commission-funded project that aims to improve the knowledge of acute drug toxicity of both classical recreational drugs and NPS. As a baseline for this project, we performed a study to establish which data are currently being collected and reported in Europe on ED presentations with acute toxicity related to NPS and classical drugs of abuse. Methods. We used a three-pronged approach to identify any systematic collection of data on NPS toxicity in Europe by i) performing a literature search, ii) utilising an online survey of the European Monitoring Centre for Drugs and Drug Addiction Re seau Europe en d’Information sur les Drogues et les Toxicomanies national focal points and iii) exploiting the knowledge and resources of the Euro-DEN network members. Results. The literature search revealed 21 papers appropriate for assessment, but only one described a systematic collection of clinical data on NPS. Twenty-seven of thirty countries responded to the online survey. More than half of all the countries (52%) did not perform any registration at all of such data, 37% collected systematic clinical data on NPS at a national level, while 44% collected data on classical drugs. A few examples for good practice of systematic collection of clinical data on ED presentations due to acute toxicity were identified. Conclusion. The systematic collection of data on ED presentation of toxicity related to NPS and classical drugs in Europe is scarce; the existing collection is limited to single centres, single countries, groups of patients or not focused on novel drugs; the collection of data is highly variable between the different countries. Euro-DEN, a European Commission funded project, aims at closing some of these gaps.     

Change in the new psychoactive substances associated with Emergency Department acute toxicity presentations associated with the introduction of the UK 2016 Psychoactive Substances Act

Objectives: In May 2016, the Psychoactive Substances Act (PSA) came into effect in UK making it an offence to produce or supply new psychoactive substances (NPS). The aim of this study was to determine whether this was associated with a change in Emergency Department (ED) presentations with acute NPS toxicity.

Method: ED presentations to our inner-city hospital in London, UK, with acute NPS toxicity in the 12 months before and after the PSA introduction [June 2015–May 2016 (2015/2016) and June 2016–May 2017 (2016/2017)] were obtained from our database. The following data were extracted: (i) demographics; (ii) NPS(s) self-reported [categorized as synthetic cannabinoids (SC), cathinones, and “other NPS”)]; and (iii) month of presentation.

Results: There were 1884 presentations with recreational drug toxicity, 447 (23.7%) involved NPS. There was no difference in the overall proportion of presentations involving an NPS in 2015/2016 [n?=?196 (22.3%)] and 2016/2017 [251 (24.9%); (p?=?.48)]. There were a mean?±?SD of 16.3?±?3.7 NPS-related presentations per month in 2015/2016 and 20.9?±?9.2 in 2016/2017; there was no significant change in overall monthly NPS-related presentations between these periods (p?=?.15). However, mean?±?SD monthly SC-related presentations increased from 2015/2016 (5.9?±?2.5) to 2016/2017 (17?±?9.8); p?=?.004. Mean monthly cathinone-related presentations decreased from 2015/2016 (8.8?±?4.2) to 2016/2017 (3.8?±?2.7); p?=?.001. There was no significant change in monthly mean “other NPS” presentations from 2015/2016 (1.8?±?2.2) to 2016/2017 (0.5?±?0.8); p?=?.062. Between 2015/2016 and 2016/2017, SCs as a proportion of NPS-related presentations increased (r?=?.90) whilst cathinones decreased (r?=??0.82).

Conclusion: NPS present front-line health services with unique challenges, and the PSA 2016 represents a major legislative effort in UK to limit their availability and supply. The burden of NPS use on this inner-city ED remains large 12 months after this legislation has come into force, with evolving patterns of NPS use.     

Intoxications involving acrylfentanyl and other novel designer fentanyls – results from the Swedish STRIDA project

Background: The number of new psychoactive substances (NPS) introduced through the online recreational drugs market increases continuously. This report from the Swedish STRIDA project describes analytically confirmed intoxications involving the novel fentanyl analogs acrylfentanyl, 4-chloroisobutyrfentanyl (4Cl-iBF), 4-fluoroisobutyrfentanyl (4F-iBF), and tetrahydrofuranfentanyl (THF-F), and cyclopentylfentanyl in a drug product.

Methods: Patients with suspected NPS exposure presenting in emergency departments (ED) or intensive care units (ICU) in Sweden and requiring hospital care are invited to the STRIDA project. NPS analysis of serum and urine samples was performed by multi-component liquid chromatography-mass spectrometry. Data on clinical features were retrieved from telephone consultations with the Swedish Poisons Information Centre and from medical records.

Results: Between April and October 2016, eleven intoxications involving acrylfentanyl (8 cases), acrylfentanyl together with 4Cl-iBF (1), 4F-iBF (1), and THF-F (1) were analytically confirmed. Patients were aged 19–51 (median 28) years and 91% were men. Six (55%) were monitored at the ED, and five admitted to the ICU. Typical clinical features were decreased consciousness, respiratory depression, and miosis. In 8 cases, the antidote naloxone was administered to counter the opioid effects. The 4F-iBF positive patient eventually died of brain edema. The serum acrylfentanyl concentration (n?=?8) ranged 0.5–2.1 (median 0.9) ng/mL, and in urine (n?=?9) 0.2–10.5 (mean 4.6, median 5.2) μg/mmol creatinine. For 4Cl-iBF, 4F-iBF, and THF-F (n?=?1 each), higher serum (5–45?ng/mL) and urine (11–136?μg/mmol creatinine) concentrations were found. Other NPS (e.g., flunitrazolam) and/or classical drugs were detected in five cases. In early 2016, nasal sprays with a claimed content of acrylfentanyl brought to hospital by patients or obtained by test purchase were demonstrated to instead contain fentanyl.

Conclusions: Potentially life-threatening opioid toxicity was seen in 11 acute intoxications involving the fentanyl analogs acrylfentanyl, 4Cl-iBF, 4F-iBF, and THF-F, which are available through open Internet trading. All patients were supported with acute and intensive hospital care, and naloxone was effective to reverse the opioid symptoms. One patient died of brain edema.     

Underestimated impact of novel psychoactive substances: laboratory confirmation of recreational drug toxicity in Oslo,Norway

Context: Recreational drug toxicity is frequent. Availability of new psychoactive substances is steadily increasing. However, data with verified analyses from clinical settings are limited. To evaluate the impact of novel psychoactive substances (NPS) on recreational drug toxicity in Oslo, Norway, we analysed samples from a selection of patients.

Methods: All the patients presenting with recreational drug toxicity at the Oslo Accident and Emergency Outpatient Clinic (OAEOC) and at the Oslo University Hospital (OUH) were registered from April through September 2014. Oral fluid samples were collected at the OAEOC. Blood samples were collected at the OUH. The samples were screened using ultra-high performance liquid chromatography – tandem mass spectrometry (UHPLC-MS/MS).

Results: Nine hundred and sixty-four cases were included, 841 (87.2%) at the OAEOC and 123 (12.8%) at the OUH. A total of 55 oral fluid samples (OAEOC) and 103 blood samples (OUH) could be analysed. NPS were not clinically suspected in any of the screened cases. At the outpatient clinic, the most commonly found substances were clonazepam in 42/55 (76.4%) cases, amfetamines in 40/55 (72.7%) and heroin in 39/55 (70.9%). In seven (12.7%) cases NPS were detected: 4-methylamfetamine in three cases, dimethyltryptamine in two, methylone in one, and N,N-dimethyl-3,4-methylenedioxyamfetamine in one. Among the hospital patients, the most commonly found substances were clonazepam in 51/103 (49.5%) cases, amfetamines in 48/103 (46.6%), heroin in 31/103 (30.1%), and diazepam in 30/103 (29.1%). In five (4.9%) cases NPS were detected: JWH-210 in two cases, AM-2201 in two, and 5-EAPB in one.

Conclusion: NPS were clinically not suspected, though found in eight percent of cases. Still, the vast majority of patients treated for recreational drug toxicity in Oslo have taken classical drugs. Management of these patients should be based on their clinical condition. However, it is highly important to be alert to atypical presentations possibly resulting from unsuspected drugs.     

Perceived risk of using novel psychoactive substances in school students: lower in users compared to non-users

Background: There has been an increase in the availability of novel psychoactive substances (NPS) over the last decade. The 2013 US Monitoring the Future study suggested that the perceived risk of NPS use in US students was greater than for classical recreational drugs. This survey was undertaken to determine the perceived risk of NPS in adolescents in UK education.

Methods: Questionnaire survey of 917 students (15–18 years) collected the details of whether: (i) they had heard of NPS; (ii) they had taken an NPS; and (iii) their perceived risk of NPS use.

Results: Five-hundred and fifty-four (57.9%) had heard of NPS and 75 (8.2%) had previously used an NPS. The mean?±?standard deviation perceived risk of using an NPS was 7.32?±?2.07 (95% CI 7.18–7.46), where 1 is “completely safe” and 10 is “not safe at all”; those who had previously used an NPS had a lower perceived risk [6.11?±?2.17 (95% CI 5.60–6.62)] compared to those who had not previously used an NPS [7.46?±?2.00 (95% CI 7.31–7.61) (p?<?0.0001)].

Discussion: Further work is needed to determine whether the lower perceived risk relates to having previously used NPS or whether those who perceive them as low risk are more likely to use NPS. It is important to determine whether this perceived risk is same across all NPS to inform the development of harm minimisation educational strategies.     

Flibanserin toxicity in a toddler following ingestion

Introduction: Flibanserin is a medication recently approved by the FDA for treatment of generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. Its mechanism of action is not fully understood but is thought to modulate serotonin receptors and increase levels of norepinephrine and dopamine. While much is known about toxicity of other drugs which affect these systems, there is little information about toxicity of flibanserin at this time.

Case: We present a case of a 2-year-old boy who ingested an estimated 600?mg of his mother’s flibanserin. Following ingestion, the child developed facial twitching and unresponsiveness to pain, concerning for seizure-like activity. In the emergency department (ED) he was found to have hypertension, mydriasis, slurred speech, and normal labs. He responded well to supportive care including administration of benzodiazepines. Shortly after admission to the hospital, his temperature increased to 38.4?°C. Toxicology testing revealed the presence of 1-(3-trifluoromethylphenyl)-piperazine (TFMPP), a flibanserin metabolite. TFMPP is a recreational drug used as an alternative to 3,4-methylenedioxymethamphetamine (more commonly known as “MDMA” or “ecstasy”).

Discussion: This case highlights potential toxicity associated with ingestion of flibanserin.     

Intoxications in the STRIDA project involving a panorama of psychostimulant pyrovalerone derivatives,MDPV copycats

Context: An increasing number of new psychoactive substances (NPS) of different chemical classes have become available through marketing and sale over the Internet. This report from the Swedish STRIDA project presents the prevalence, laboratory results, and clinical features in intoxications involving 11 stimulant pyrovalerone NPS derivatives over a 5-year period.

Study design: Case series of consecutive patients with admitted or suspected intake of NPS presenting to Swedish hospitals for emergency treatment from January 2011 to March 2016.

Patients and method: Blood and urine samples were collected from intoxicated patients presenting to hospitals all over Sweden. Analyses of NPS and other drugs of abuse were performed by immunochemical and liquid chromatography–mass spectrometry multi-component methods. Clinical data were collected during consultation with the Swedish Poisons Information Centre (PIC), and retrieved from medical records. The study involved analytically confirmed cases with 11 pyrovalerone drugs.

Results: During the study period, 114 intoxications were detected that involved any of 11 new pyrovalerone drugs. In addition to these new pyrovalerone derivatives, 3,4-methylenedioxypyrovalerone (MDPV) was detected in 17 of the cases and α-pyrrolidinovalerophenone (α-PVP) in 45 cases. Identification was made according to forensic standards and comprised the following substances: 4F-α-PVP, α-PHP, PV8, 4Me-PPP, α-PBP, 4F-PV8, α-PPP, MDPHP, α-PVT, 4Cl-α-PVP, and 4F-α-PHP. The three most frequently detected drugs were α-PBP, MDPHP, and 4F-α-PVP. The age range of patients was 16–66 (median 30) years and 84% were males. The substance concentrations in urine and serum were highly variable, ranging from 1?ng/mL to 300 µg/mL. Poly-drug use was common with only 8 of 114 cases (7%) involving one pyrovalerone drug. The additional substances comprised other NPS and classical psychoactive drugs. The patients showed a variety of clinical signs; agitation, delirium, hallucinations, excessive motor activity, seizures, tachycardia, hypertension, and/or hyperthermia.

Conclusions: In analytically confirmed NPS-related intoxications, 11 new pyrovalerone derivatives in addition to MDPV and α-PVP were found. The clinical features were consistent with a sympathomimetic toxidrome, but the urine and serum concentrations were highly variable. The results demonstrated that many novel pyrovalerone stimulants were introduced on the recreational NPS drugs market. Analytical investigations were necessary to obtain this information.     

Readiness to change alcohol and illicit drug use among a sample of emergency department patients

Objective: This study sought to (1) provide estimates of alcohol and illicit drug use, alone and in combination, among a sample of adult emergency department patients and (2) examine readiness to change.

Methods: Consecutive emergency department patients ≥18 years of age from a large regional hospital in Camden, NJ, were enrolled from May to December 2005. Patients provided information on alcohol and illicit drug use, as well as on interest in quitting each of these substance classes.

Results: Of the 1549 subjects surveyed, 98 (6%) indicated weekly use of both alcohol and illicit drugs, and 58 (4%) indicated problems associated with use of both substance classes. Problem users of illicit drugs felt that quitting drugs was more important, that they were more ready and that they were more confident in quitting than problem users of alcohol.

Conclusion: Problem use of multiple substances was relatively common in this emergency department sample. A substantial proportion of problem users of both substance classes were highly motivated to quit the use of one, but not the other, substance class. Further longitudinal and clinical trial research is needed to study the implications of multiple substance use, motivation to change and cessation.     

Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances

Context. There is increasing interest in the analysis of waste water at sewage treatment plants to monitor recreational drug use. This technique is limited for novel psychoactive substances (NPS) due to limited knowledge on their human and bacterial metabolism and stability in waste water. Small studies have reported the detection of NPS using pooled anonymous urine samples, which eliminates some of these potential confounders. Objective. To determine patterns of recreational drug, including NPS, use by confirming their presence in analysis of pooled urine from portable street urinals across a wide geographical area in central London over a 6-month period. Materials and methods. Pooled anonymous urine samples were collected from 12 four-bay stand-alone portable urinals distributed once a month across central London for six consecutive months. Samples were analysed using high-performance liquid chromatography coupled to high-resolution accurate mass spectrometry (LC-HRAM-MS); acquired data were processed against target compound databases. Results. With regards to Classical Recreational Drugs, there was consistency of detection of cathine, cocaine, morphine, MDMA over the 6 months, with variability of detection of amphetamine, ketamine and cannabis. With regards to NPS, a total of 13 NPS were detected during the six months. Mephedrone and methylhexaneamine were detected consistently each month. Other commonly detected NPS included methiopropamine (5 months), pipradrol (4 months), cathinone (4 months), 5-(2-aminopropyl)benzofuran (3 months) and 4-methyethcathinone (3 months). Of note, methoxetamine and the synthetic cannabinoid receptor agonists were not detected in any samples. Discussion. Previous studies using the same method detected three and five NPS in a nightclub and pissoir setting, respectively, on a single night. The longer sampling time of 6 months has allowed detection of 13 NPS. Of note, mephedrone showed the least month-to-month variation in detection over the 6-month sampling period. With regards to classical recreational drugs, those detected were consistent with use-data from UK population surveys. The only exception is amphetamine which these surveys have shown a steady decline in use since 1996 but our study showed some variation in the frequency of its detection. However, the sampling period was too short and a longer study is needed to detect the trend in decreasing use. Conclusion. This study demonstrates that analysis of anonymous pooled urine samples from stand-alone urinals can be used to detect and monitor trends in the use of classical recreational drugs and NPS in a large city centre over time. This technique has the potential to be a novel key indicator alongside other existing indicators to provide a more robust picture of the use of recreational drugs including NPS.     

Intentional ingestion of cyanoacrylate

Abstract

Background. Diphenidine (1-(1,2-diphenylethyl)piperidine) and its 2-methoxylated derivative methoxphenidine (MXP, 2-MeO-diphenidine) are substances with dissociative effects that were recently introduced for “recreational” purpose through the online-based sale of new psychoactive substances (NPS). A number of analytically confirmed non-fatal intoxications associated with diphenidine or MXP have occurred in Sweden and were included in the STRIDA project. Study design. Observational case series of consecutive patients with admitted or suspected intake of NPS and requiring intensive treatment in an emergency room and hospitalization in Sweden. Patients and methods. Blood and urine samples were collected from intoxicated patients presenting at emergency departments all over the country. NPS analysis was performed by multi-component liquid chromatography–mass spectrometry methods. Data on clinical features were collected during telephone consultations with the Poisons Information Centre and retrieved from medical records. Information was also obtained from online drug discussion forums. Case series. Over a 12-month period from January to December 2014, 750 cases of suspected NPS intoxication originating from emergency departments were enrolled in the STRIDA project of which 14 (1.9%) tested positive for diphenidine and 3 (0.4%) tested positive for MXP. Co-exposure to several other NPS (e.g., 5-/6-(2-aminopropyl)benzofuran, 2-4-bromomethcathinone, butylone, 3,4-dichloromethylphenidate, 5-methoxy-N-isopropyltryptamine, methiopropamine, and α-pyrrolidinopentiothiophenone), also including other dissociative substances (3-/4-methoxyphencyclidine), and classical drugs of abuse (e.g., cannabis and ethanol) was documented in 87% of these cases. The 17 patients were aged 20–48 (median: 32) years, and 13 (76%) were men. They commonly presented with hypertension (76%), tachycardia (47%), anxiety (65%), and altered mental status (65%) including confusion, disorientation, dissociation, and/or hallucinations. Eight patients (47%) displayed severe intoxication (Poisoning Severity Score 3). The diphenidine- or MXP-positive patients required hospitalization for 1–3 (median: 2) days. In addition to standard supportive therapy, half of the cases were treated with benzodiazepines and/or propofol. Conclusion. The adverse effects noted in analytically confirmed cases of NPS intoxication involving diphenidine or MXP were similar to those reported for other dissociative substances such as ketamine and methoxetamine. However, the high proportion of polysubstance use might have played a role in the intoxication and clinical features in some cases.     

Drug misuse among patients admitted to a general hospital

Aims In this paper we report the prevalence of prescribed drugs of misuse and illicit drugs used by patients admitted to a general hospital and the level of detection of drug problems by general medical staff.

Design This is a prospective questionnaire survey, interview and case note review.

Setting This study is a snapshot of one week's admission to a general hospital.

Findings Of the 408 people approached, 285 (70%) participated in the study. One hundred and sixty‐six people (62%) reported misuse of drugs at some time in their lives. Of these, 46 (17%) reported use of illegal drugs at some time in their lives, 22 (8%) in the past year, and 7 (2.6%) in the previous month. The most frequently reported drug type used ever, in the past year, and in the previous month, was over‐the‐counter medication and sedatives. All nine dependent patients identified by the interview were polydrug users and were significantly younger. Two of these patients were assessed for substance misuse by the medical staff.

Conclusion This study suggests that younger patients should be asked about their drug use, especially their use of more readily available drugs. At present, few questions are being asked by health professionals, leaving drug misuse to continue to drain both healthcare and society's resources.     

Analytical confirmation of synthetic cannabinoids in a cohort of 179 presentations with acute recreational drug toxicity to an Emergency Department in London,UK in the first half of 2015

Context: Synthetic cannabinoid receptor agonists are the largest group of new psychoactive substances reported in the last decade; in this study we investigated how commonly these drugs are found in patients presenting to the Emergency Department with acute recreational drug toxicity.

Methods: We conducted an observational cohort study enrolling consecutive adult patients presenting to an Emergency Department (ED) in London (UK) January–July 2015 (6 months) with acute recreational drug toxicity. Residual serum obtained from a serum sample taken as part of routine clinical care was analyzed using high-resolution accurate mass-spectrometry with liquid-chromatography (HRAM-LCMSMS). Minimum clinical data were obtained from ED medical records.

Results: 18 (10%) of the 179 patient samples were positive for synthetic cannabinoid receptor agonists. The most common was 5F AKB-48 (13 samples, concentration 50–7600?pg/ml), followed by 5F PB-22 (7, 30–400?pg/mL), MDMB-CHMICA (7, 80–8000?pg/mL), AB-CHMINACA (3, 50–1800?pg/mL), Cumyl 5F-PINACA (1, 800?pg/mL) and BB-22 (1, 60?pg/mL). Only 9/18 (50%) in whom synthetic cannabinoid receptor agonists were detected self-reported synthetic cannabinoid receptor agonist use. The most common clinical features were seizures and agitation, both recorded in four (22%) individuals. Fourteen patients (78%) were discharged from the ED, one of the four admitted to hospital was admitted to critical care.

Conclusions: Synthetic cannabinoid receptor agonists were found in 10% of this cohort with acute recreational drug toxicity but self-reported in only half of these. This suggests that presentations to the ED with acute synthetic cannabinoid receptor agonist toxicity may be more common than reported.     

Intoxications involving the fentanyl analogs acetylfentanyl, 4-methoxybutyrfentanyl and furanylfentanyl: results from the Swedish STRIDA project

Background: Potent and potentially harmful new psychoactive substances (NPS) are continuously introduced on the recreational drugs market. This report from the Swedish STRIDA project describes analytically confirmed cases of intoxication involving the fentanyl analogs acetylfentanyl, 4-methoxybutyrfentanyl, and furanylfentanyl. Methods: Patients with suspected NPS exposure presenting in emergency departments and intensive care units in Sweden and requiring hospital care are invited to the STRIDA project. Toxicological analysis of serum and urine samples was performed by multi-component liquid chromatographic–mass spectrometric methods. Data on clinical features were retrieved from telephone consultations with the Swedish Poisons Information Centre and from medical records. Results: Between April and November 2015, 14 analytically confirmed intoxications involving acetylfentanyl (nine cases), 4-methoxybutyrfentanyl (3), furanylfentanyl (1), and 4-methoxybutyrfentanyl together with furanylfentanyl (1) were identified. The patients were aged 20–40 (mean 28.5) years and 86% were men. Twelve patients (86%) were admitted to intensive care, where two required intubation and mechanical ventilation. Typical clinical features were decreased consciousness, respiratory depression, and miosis. In eight cases, the antidote naloxone was administered to counter the effects. The serum acetylfentanyl concentration (N?=?7) was 0.6–51.6 (mean 18.3 and median 14.8) ng/mL, and in urine (N?=?8) 0.1–686 (mean 155 and median 66.6) ng/mmol creatinine. The serum 4-methoxybutyrfentanyl concentration (N?=?2) was 1.3 and 3.1?ng/mL, and 5.1–51.3?ng/mmol creatinine in urine (N?=?3). For furanylfentanyl, the serum concentrations were 4.4 and 148?ng/mL and in urine 9.2 and 85?ng/mmol creatinine, respectively. In 13 cases (93%), other NPS and/or classical drugs were also detected. Drug products brought to hospital by patients contained acetylfentanyl (nasal spray and pink tablet), 4-methoxybutyrfentanyl (green tablet), furanylfentanyl/traces of 4-methoxybutyrfentanyl (nasal spray), and 4-fluorobutyrfentanyl (purple tablet). Conclusion: Potentially life-threatening opioid toxicity was seen in acute intoxications involving acetylfentanyl, 4-methoxybutyrfentanyl, and furanylfentanyl. Intensive care treatment for one month was necessary in one acetylfentanyl case and one acetylfentanyl patient died from cerebral hemorrhage.     

Supraventricular tachycardia and acute confusion following ingestion of e-cigarette fluid containing AB-FUBINACA and ADB-FUBINACA: a case report with quantitative analysis of serum drug concentrations

Background: AB-FUBINACA and ADB-FUBINACA are structurally similar synthetic cannabinoids with potent CB₁ receptor agonistic effects. Very little is known about their pharmacology and toxicology.

Objective: To report a case of supraventricular tachycardia and acute confusion after ingestion of e-cigarette fluid containing AB-FUBINACA and ADB-FUBINACA, with quantitative analysis of the serum drug concentrations.

Case report: A healthy 24-year-old man ingested two drops of e-cigarette fluid which were later found to contain AB-FUBINACA and ADB-FUBINACA. Within 30?min of ingestion, he became somnolent, confused, and agitated, with palpitation and vomiting. On arrival to the emergency department, a short run of supraventricular tachycardia was noted, which resolved spontaneously. Bedside urine immunoassay failed to detect recreational drugs. Laboratory blood tests showed mild hypokalemia. Exposure to AB-FUBINACA and ADB-FUBINACA was confirmed analytically, with serum concentrations of 5.6?ng/mL and 15.6?ng/mL, respectively, in the blood sample collected on presentation. The patient recovered uneventfully with supportive treatment and was discharged 22?h after admission.

Discussion: AB-FUBINACA and ADB-FUBINACA are orally bioavailable with rapid onset of toxicity after ingestion. In this case, supraventricular tachycardia was likely the result of exposure to AB-FUBINACA and ADB-FUBINACA. The serum concentrations of AB-FUBINACA and ADB-FUBINACA were higher than those previously reported in fatal cases.

Conclusion: In the context of acute poisoning, the presence of unexplained tachyarrhythmias, confusion, and a negative recreational drug screen should prompt clinicians to consider synthetic cannabinoid toxicity as a differential diagnosis.     

Demographic and clinical features of patients with substance-induced mental disorders admitted to the psychiatric hospital in Kermanshah,Iran

Background: Evaluating the prevalence and clinical features of substance induced mental disorders leading hospitalization is important in programming for better management of these disorders. There is a lack of studies investigated the pattern of drugs leading admission in mental hospitals.

Objectives: To evaluate demographic and clinical features of patients with substance induced mental disorders admitted to Farabi psychiatric hospital in Kermanshah, Iran.

Methods: This is a cross-sectional study conducted in 2013. 359 patients whom admitted with substance related psychiatric disorders were evaluated using demographic questionnaire, clinical and paraclinical exams. patients diagnosed with primary mental disorders, and mental disorders due to other medical condition were excluded.

Results: The participant's mean age was 31.44 years. The most of the patients were unemployed males with low education living in urban areas. Amphetamines in 289 (80.5%), opioids in 57 (15.8%), cannabis in 11(3.1%), and benzodiazepines in 2 (0.6%) patients were the main drugs leading admission. Amphetamine induced psychotic disorder with hallucination (40.4%) were the most common diagnosis among the study subjects.

Discussion: Amphetamines was the most problematic drug in our setting and amphetamine induced mental disorders were the most prevalent causes of hospitalization. Opioids induced psychiatric disorders were in the second rank.     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Acute toxicity following analytically confirmed use of the novel psychoactive substance (NPS) methiopropamine. A report from the Identification of Novel psychoActive substances (IONA) study

Objective: Use of the New Psychoactive Substance (NPS) methiopropamine was first reported in 2011, but there are limited data on its acute toxicity. We report 11 patients presenting with analytically confirmed methiopropamine use.

Methods: Adults presenting to 26 hospitals in the UK with severe acute toxicity after suspected NPS use were recruited from March 2015 to April 2018. Clinical features were recorded and biological samples analysed using tandem mass spectrometry.

Results: Methiopropamine was detected in 11 of 414 patients, with the last detection in August 2016. It was the only substance detected in one patient; other substances detected included other NPS in nine and conventional drugs of misuse in five. Common features included tachycardia (10/11), agitation (7/11), confusion (7/11), reduced level of consciousness (5/11), hallucinations (5/11) and a raised creatine kinase (7/11). The median length of hospital stay was 17?hours; ten were discharged without sequelae and one was transferred for in-patient psychiatric treatment.

Conclusions: Methiopropamine was only detected during 2015 and 2016; most patients had other drugs detected, particularly other NPS. Raised CK was common but it is not possible to determine the degree to which this and other features could be contributed to by co-use of other substances.