Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States

Recently, there has been a worldwide rise in the popularity and abuse of synthetic cathinones. In 2009 and 2010, a significant rise in the abuse of a new group of synthetic cathinones was reported in Western Europe. In 2010, the rapid emergence of a new drug of abuse, referred to as bath salts or “legal high,” occurred in the USA. The growing number of cases along with the alarming severity of the effects caused by the abuse of these substances prompted significant concern from both healthcare providers and legal authorities. We report the experience of the first 8 months of two regional poison centers after the emergence of a new group of substances of abuse. Method. This was a retrospective case series of patients reported to two poison centers with exposures to bath salts. Additionally, 15 “product samples” were obtained and analyzed for drug content using GC/MS. Results. There were 236 patients of which 184 (78%) were male. Age range was 16–64 years (mean 29 years, SD 9.4). All cases were intentional abuse. There were 37 separate “brand” names identified. Clinical effects were primarily neurological and cardiovascular and included: agitation (n = 194), combative behavior (n = 134), tachycardia (n = 132), hallucinations (n = 94), paranoia (n = 86), confusion (n = 83), chest pain (n = 40), myoclonus (n = 45), hypertension (n = 41), mydriasis (n = 31), CPK elevations (n = 22), hypokalemia (n = 10), and blurred vision (n = 7). Severe medical outcomes included death (n = 1), major (n = 8), and moderate (n = 130). Therapies included benzodiazepines (n = 125), antipsychotics (n = 47), and propofol (n = 10). Primary dispositions of patients were: 116 (49%) treated and released from ED, 50 (21%) admitted to critical care, 29 (12%) admitted to psych, and 28 (12%) lost to follow up. Nineteen patients had blood and/or urine analyzed using GC/MS. MDPV was detected in 13 of 17 live patients (range 24–241 ng/mL, mean 58 ng/mL). The four samples with no drug detected, reported last use of bath salts >20 h prior to presentation. Three of five patients had MDPV detected in urine (range 34–1386 ng/mL, mean 856 ng/mL). No mephedrone or methylone was detected in any sample. Quantitative analysis performed on postmortem samples detected MDPV in blood at 170 ng/mL and in urine at 1400 ng/mL. No other synthetic cathinones were detected. Discussion. This is the first report of MDPV exposures with quantitative blood level confirmation. Clinical effects displayed a sympathomimetic syndrome, including psychotic episodes often requiring sedation, movement disorders, and tachycardia. Within 8 months of their appearance, 16 states had added synthetic cathinones to the controlled substances list as a Schedule I drug. Conclusion. We report the emergence of a new group of substances of abuse in the USA, known as bath salts, with quantitative results in 18 patients. State and federal authorities used timely information from poison centers on the bath salt outbreak during investigations to help track the extent of use and the effects occurring from these new drugs. Close collaboration between state authorities and poison centers enhanced a rapid response, including legislation.     

‘Our favourite drug’: prevalence of use and preference for mephedrone in the London night-time economy 1 year after control

There is a significant body of literature in the field of screening and brief alcohol intervention. This paper reviews that literature in order to provide a comprehensive overview of this important field of study. The format of the paper is not intended to be one of a systematic review with meta‐analysis, but rather a gathering of data to give readers a concise summary of the vast quantity of literature relating to screening and brief alcohol intervention. The review will provide a working definition of screening and brief intervention and explain why it is considered to be an important element of preventive care. Data will also be presented relating to the effectiveness, attitudes, involvement, cost and accuracy of a variety of health professionals involved in screening and brief intervention along with the patient's perspective on these health professionals' roles. The review will also examine the settings in which screening and brief intervention can and does take place.     

The prevalence of use,dependency and harms of legal ‘party pills’ containing benzylpiperazine (BZP) and trifluorophenylmethylpiperazine (TFMPP) in New Zealand

Piperazine‐based ‘party pills’ containing 1‐benzylpiperazine (BZP) and 1‐(m‐trifluorophenylmethylphenyl)piperazine (TFMPP) have become increasingly popular in New Zealand and many other countries. The aim of this study was to collect data on the population prevalence and related harm from legal party pill use in New Zealand. A national household sample of 2010 people aged 13–45 years old was collected using a computer‐assisted telephone interviewing (CATI) facility. Twenty per cent of the sample had tried legal party pills and 15% had used them in the previous year. Approximately 40% of males aged 18–24 years old had used legal party pills in the past year. While most users reported fairly minor problems from use, such as insomnia (50% of last year users), some users reported potentially more serious physical problems, such as ‘vomiting’ (12%), ‘inability to urinate’ (10%), ‘chest pains’ (4%) and ‘seizures’ (0.8%). Users also reported a range of psychological problems from use such as visual hallucinations (9%), paranoia (8%) and depression (8%). Two per cent of last year users were classified as dependent on legal party pills using a short dependency scale. The extent of harms and incidences of more serious problems, suggest that stricter regulation of the sale and use of legal party pills in New Zealand may be appropriate.     

The use of opioids in the treatment of osteoarthritis: When,why, and how?

As life expectancy increases every decade, the incidence and prevalence of osteoarthritis (OA) also will increase. Despite progress in our knowledge of the pathophysiology of OA, the management of OA-mediated pain continues to challenge physicians. Concern regarding the cardiovascular effects of cyclooxygenase-2 inhibitors and the gastrointestinal and renal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) in general has limited the use of these medications in the management of chronic non-cancer pain. Appropriately dosed and monitored use of opioids for OA pain, when more conservative methods have failed, has potentially fewer life-threatening complications associated with it than the more commonly and often less successfully employed pharmacotherapeutic approaches to care. When used as part of a multimodal approach to pain control, opioids are a safe and effective treatment for joint pain, including that of OA. Patients for whom NSAIDs are contraindicated, or for whom combined acetaminophen, tramadol, and NSAID therapy is ineffective, may be started on low-dose opioids and titrated as needed and tolerated. Patient education and informed consent, exercise, complementary medicine, and the use of a controlled substance agreement increases the likelihood of patient compliance with treatment guidelines, improving functional capacity and quality of life.     

The use of seclusion in the year 2000: what has changed?

This study was undertaken to examine the perceptions of nurses working in three psychiatric settings regarding the effect and use of seclusion. It also aimed to identify current practices at these sites in the metropolitan area of Western Australia. A total of 78 nurses specialising in mental health care participated in the study by completing the 'Attitude towards seclusion survey'. The findings of this study indicate that nurses perceive seclusion as an accepted patient management strategy. The results also showed that the decision to seclude the patient was made by a senior mental health practitioner and that one hour was the average time a patient spent in seclusion. It is important to ensure that punishment, paternalistic attitudes or punitive actions are not part of clinical judgment regarding the use of seclusion. The study has provided evidence of nurses' perceptions concerning seclusion and the results highlight the need for staff to continue to explore and evaluate issues that lead to seclusion in order to facilitate the use of other management strategies that encourage a less restrictive environment.     

A Review of: “The Past in the Present”

Older women report more loneliness than male peers. Loneliness is an area of concern related to the well being of older women because it is a cause of emotional distress and is linked to a variety of health problems in older individuals. Life changes, including widowhood and relocation, are associated with increased vulnerability to loneliness. Gender, social, and cultural factors influence the experience of loneliness in older women. Cognitive and interactionist theoretical approaches to loneliness have utility for nursing practice and research with older women who experience loneliness.     

The “MESACA” study: Methylsulfonylmethane and boswellic acids in the treatment of gonarthrosis

Introduction  

Osteoarthritis is a chronic rheumatoid disease mediated by metalloproteinases and inflammatory cytokines. Methylsulfonylmethane (MSM) and boswellic acids (BA) each show promise in the treatment of inflammatory processes, but the efficacy of combined treatment with these substances in the treatment of arthritis has not yet been studied.     

“The Future of Nursing: Accelerating gains made to address the continuum of substance use”

PurposeGuided by four key messages from the decade-old Institute of Medicine (IOM) report, “The Future of Nursing,” this paper highlights the progress made by the nursing profession in addressing substance use and its related disorders and offers recommendations to sustain and advance efforts to enhance care for persons who use substances, one of the most stigmatized and vulnerable populations.ResultsPatterns of substance use have shifted over the past 10 years, but the associated harms remain consequential. As awareness of the continuum of substance use has expanded, the care of persons with substance use has also expanded, from the domains of psychiatric-mental health and addictions nursing specialties to the mainstream of nursing. Now, greater efforts are being undertaken to identify and intervene with persons at risk for and experiencing substance use disorders. Nurses have advanced the knowledge and skills necessary for substance-related nursing care including education and training, leadership, care innovations, and workforce expansion and can drive efforts to increase public knowledge about the health risks associated with substance use. Recommendations aligned with each of the four IOM key messages are offered.ConclusionsAs a profession, nursing has a responsibility to expand the progress made in addressing substance use – from prevention and early intervention to tertiary care. Nurses at all levels of education and practice are in key positions to carry out the recommendations herein to accelerate the changes needed to provide high quality care for persons impacted by substance use.     

The use of imaging and biomarkers in diagnosing Barrett’s esophagus and predicting the risk of neoplastic progression

Long-standing gastroesophageal reflux disease can result in transformation of the normal squamous lining of the esophagus into columnar epithelium (with goblet cells). This condition, Barrett’s esophagus (BE), is considered a risk factor for esophageal cancer (EAC) and may be the cause of the increased incidence of EAC over the last few decades. Currently, endoscopy with biopsies revealing dysplasia is the best predictor for neoplastic progression in patients with BE. However, the use of more sophisticated imaging techniques and biomarkers with or without histological assessment may be helpful in more accurate prediction of malignant transformation in these patients. New approaches to the evaluation of BE such as epigenetics, miRNA analysis, detection of DNA content abnormalities and loss of heterozygosity have great potential to shed light on the complex gastroesophageal reflux disease –BE–EAC sequence.     

The use of unofficial “problem patient” files and interinstitutional information transfer in emergency medicine in Iowa

The study objectives were to determine the use of “problem patient” files in full-time Emergency Departments (EDs) in the state of Iowa and the frequency of telephone calls made between these departments about drug-seeking patients. The design and setting were a mail survey of 42 EDs in the state of Iowa determined to be staffed full-time by an in-house physician. The participants were the directors of the full time EDs in the state of Iowa. There were no interventions. The measurements and main results are as follows: 38 of 42 sites responded for a response rate of 90%. Of these, 58% keep problem patient lists and consult them an average of 2.6 times per week (range, 0.2 to 7.5). Only 5% have a policy limiting access to the information in these files, and only 14% have any controls over the adding of information. Thirty-seven of the 38 sites reported making and receiving calls to and from other institutions about drug-seeking patients. The mean number of calls made is 23 a year, and the mean number received is 20 per year. Problem patient files are common in EDs in Iowa, as are calls between institutions about drug-seeking patients. These practices compromise patient confidentiality but may be potentially justified in some instances. The lack of controls on access to patient information files and lack of scrutiny of information entered is of concern.     

The use of rpoB sequence analysis in the differentiation of Mycobacterium abscessus and Mycobacterium chelonae: a critical judgement in cystic fibrosis?

Individuals suffering from fibrocystic disease may acquire non-tuberculous mycobacteria as colonizing or infecting organisms. Mycobacterium abscessus is of particular concern because it may be very difficult to eradicate and may mitigate against lung transplantation. However, this species may be difficult to reliably differentiate from the closely related M. chelonae. We have developed a rapid, low-cost, short sequence-based technique to confirm species identity by analysis of a segment of the RNA Polymerase B (rpoB) gene.     

The truth about marijuana is all rolled up in a blunt: prevalence and predictors of blunt use among young African–American adults

Several studies suggest that African–American young adults are more likely than other racial groups to smoke marijuana in blunts (i.e., hollowed-out cigars filled with marijuana). Given that tobacco content is found in the wrapper leaf of cigars that are used to make blunts, more studies are needed to assess the co-occurring use of marijuana and tobacco among African–American young adults. The present study was designed to address this gap by examining the prevalence rates and predictors of blunt usage among young African–American men and women (ages 18–25) participating in the 2012 National Survey on Drug Use and Health. Among participants who reported using marijuana in the past month, 74.4% of African–American women (N?=?246) and 82.7% of men (N?=?312) smoked marijuana in a blunt in the past 30 days (current blunt smokers). Logistic regression analyses revealed that current blunt smokers, both men and women, were approximately five times more likely to drive under the influence of illegal drugs in the past year than former and non-blunt smokers. Future marijuana research should examine the dual use of marijuana and tobacco rather than focusing solely on marijuana use, especially among young African–American men and women.     

Alcohol use and misuse in older people: a local prevalence study comparing English and Irish inner‐city residents living in the UK

Background: Alcohol consumption was assessed in English and Irish men and women aged 65 and over, living in an inner‐city area of London, UK.

Method: Participants were assessed using Quantity/Frequency measures of alcohol use and validated questionnaires (SMAST‐G, 10‐item AUDIT, SF‐36).

Results: Sixty subjects with a mean (SD) age of 77.5 (1.2) years were recruited. English subjects showed greater changes between lifetime and last year drinking patterns (chi‐square = 18.9, d.f. = 4, p = 0.001). Irish subjects had a significantly higher mean AUDIT score (2.8 vs. 1.0; Mann–Whitney U = 225, Z = ?3.5, p<0.0001) and were significantly more likely (14/30 vs. 3/30) to have a family psychiatric history (chi‐square = 10.6, d.f. = 1, p = 0.001). Irish subjects were more likely to drink at least once a week, showed a higher mean alcohol intake (6.4 vs. 2.4 g) over the previous year and were more likely to show binge drinking (8/30 vs. 1/30) and drinking above sensible limits (8/30 vs. 1/30). None of these latter observations retained their significance after statistical correction.

Conclusions: The main implication of the study is that closer attention is required in screening for alcohol use in older Irish men in the UK.     

The use of steroids in the management of inoperable intestinal obstruction in terminal cancer patients: do they remove the obstruction?

This multicentre, randomized double-blind study was undertaken to assess the efficacy of corticosteroids as a palliative treatment of intestinal obstruction due to advanced and incurable cancer. Thirty-one French palliative care units agreed to participate in the study and 12 actually recruited at least one patient. To be included, patients had to have an advanced cancer with a surgically inoperable bowel obstruction and to have received no specific anticancer therapy within the preceding 28 days. They had to fulfil at least three of the following criteria: vomiting at least twice a day; colicky abdominal pain; no flatus for 12 h or more; no stool for at least 4 days, faecal impaction being excluded; intestinal distension; air-fluid levels or absence of gas in the colon on an abdominal radiograph. Patients were randomized in three groups to receive either a placebo for 3 days (group A), or methylprednisolone 240 mg daily for 3 days (group B) or methylprednisolone 40 mg daily for 3 days (group C). Symptoms were assessed daily but success or failure of the treatment was assessed on day 4, according to the disappearance or persistence of symptoms. Fifty-eight patients were randomized, of whom 52 were able to be evaluated. Details of symptoms and associated treatments are described below. Of 40 patients without a nasogastric tube, symptoms were relieved in 68% of cases versus 33% among placebo-treated patients (P = 0.047). In 12 patients who had a nasogastric tube already in place, the results are less significant (60% versus 33% with P = 0.080). Because of the small sample size, no conclusions can be reached about the relative efficacy of low versus high-dose treatment regimes.