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Introduction The epidemic of prescription opioid overdose and mortality parallels the dispensing rates of prescription opioids, and the availability of increasingly potent opioid analgesics. Objective The common assumption that more potent opioid analgesics are associated with higher rates of adverse outcomes has not been adequately substantiated. We compared the rate of serious adverse events among commonly prescribed opioid analgesics of varying potency. Methods Serious adverse events (SAEs; defined as death, major medical effect, or hospitalization) resulting from exposure to tablets containing seven opioid analgesics (oxycodone, hydrocodone, morphine, hydromorphone, oxymorphone, tapentadol, and tramadol) captured by the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS ® ) System Poison Center Program were evaluated from 2010 through 2016. Rates of SAEs were adjusted for availability through outpatient dispensing data and regressed on morphine milligram equivalents (MME). Results There were 19,480 cases of SAE during the 7-year study period. Hydrocodone and oxycodone contributed to 77% of SAE cases. Comparing rates of outcome by relative potency, a hierarchy was observed with hydromorphone (8.02 SAEs/100 kg) and tapentadol (0.27 SAE/100 kg) as the highest and lowest rates, reflecting a 30-fold difference among individual opioid products. SAE rate and potency were related linearly—SAEs increased 2.04 per 100 kg drug dispensed for each 1-unit rise in MME ( p  = 0.004). Linear regression of SAE/100 kg drug dispensed and drug potency identified that MME comprised 96% of the variation observed. In contrast, potency did not explain variation seen using other study denominators (prescriptions dispensed, dosage units dispensed, and the number of individuals filling a prescription). Conclusions and Relevance Potency of a prescription opioid analgesic demonstrates a significant, highly positive linear relationship with exposures resulting in SAEs per 100 kg drug dispensed reported to poison centers. Potency should be carefully considered from both individual provider and public health perspectives.

Since the beginning of the coronavirus pandemic, there has been a concurrent global rise in misinformation about the prevention and treatment of coronavirus disease (COVID-19). [...]both the World Health Organization and the National Institute on Alcohol Abuse and Alcoholism have since released statements refuting these claims, but cite evidence only highlighting the adverse effects of chronic alcohol consumption [1,2]. [...]we sought to evaluate the association between COVID-19 infection and chronic alcohol use by comparing the incidence of COVID-19 infection in patients with chronic alcohol use versus the general population who presented to the emergency department. Variable Frequency, N (%) Age (years, mean ± SD) 51.7 ± 12.2 Male Gender 135 (83.8) Race Caucasian Hispanic African American Asian Not Specified/Other 67 (41.6) 48 (29.8) 34 (21.1) 5 (3.1) 7 (4.3) Diagnosis Alcohol Use Disorder Alcohol Withdrawal Alcoholic Cirrhosis > 3 Alcohol-Related ED Visits in Prior Year 103 (63.9) 141 (87.5) 31 (19.3) 73 (45.3) Blood Alcohol Level (mg/dL, mean ± SD) 262 ± 140 Number of alcohol related ED visits in the past year (mean ± SD) 5.44 ± 8.5 Table 1 Summary of demographics and clinical characteristics of patients with chronic alcohol use (N = 161), May to July 2020.

As of April 21, 2020, more than 2.5 million cases of coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, have been reported in 210 countries and territories, with the death toll at 171,810. Both chloroquine and hydroxychloroquine have gained considerable media attention as possible therapies, resulting in a significant surge in demand. In overdose, both medications can cause severe, potentially life-threatening effects. Here, we present a brief overview of the pharmacology of chloroquine and hydroxychloroquine, manifestations of toxicity, and treatment considerations.

[...]naloxone distribution programs have been increasingly integrated into the emergency department (ED) in an effort to better reach high-risk patients. [...]future ED naloxone programs should focus on directly dispensing naloxone at the point of care and overcoming administrative barriers to ensure patient access.Funding source This project was supported by a grant from the National Institute on Drug Abuse K23DA039974. Variable Cohorta Total No prescription Prescription N = 438 N = 343 N = 95 Age in years (SD) 37.4 (12.0) 38.0 (12.1) 35.1 (11.7) Female 107 (24.4) 86 (25.1) 21 (22.1) Insurance CAID 299 (68.3) 242 (70.6) 57 (60) Other 88 (20.1) 66 (19.2) 22 (23.2) Self 51 (11.6) 35 (10.2) 16 (16.8) Race Black/African American 62 (14.2) 53 (15.5) 9 (9.5) White/Caucasian 331 (75.6) 255 (74.3) 76 (80) Other 45 (10.3) 35 (10.2) 10 (10.5) Medical history Opioid poisoning 143 (32.6) 126 (36.7) 17 (17.9) Opioid use 174 (39.7 156 (45.5) 18 (18.9) Other substance use# 127 (29) 107 (31.2) 20 (21.1) Mental Illness% 121 (27.6) 104 (30.3) 17 (17.9) Prior naloxone prescription 3 (0.7) 2 (0.6) 1 (1.1) Chief complaint Opioid overdose 414 (94.5) 321 (93.6) 93 (97.9) Heroin overdose 337 (76.9) 255 (74.3) 82 (86.3) Heroin use 21 (4.8) 20 (5.8) 1 (1.1) Polysubstance use 3 (0.7) 2 (0.6) 1 (1.1) Social work evaluation 89 (20.3) 65 (19) 24 (25.3) Psychiatric evaluation 10 (2.3) 10 (2.9) 0 (0) ED Naloxone administered 129 (29.5) 104 (30.3) 25 (26.3) Table 1 Comparison of demographics and visit characteristics between no prescription and prescription cohorts Variable aOR (95% CI) Age 0.98 (0.96–1.00) Female 0.79 (0.44–1.42) Insurance vs CAID Other 1.15 (0.63–2.09) Self 1.24 (0.61–2.54) Social work evaluation 1.29 (0.73–2.29) Chief complaint Opioid overdose 7.46 (0.96–58.01) Polysubstance use 14.87 (0.54–407.96) Any opioid use in 5 Years prior 0.31 (0.17–0.56) Table 2 Multivariate Logistic Regression Model for Receiving Naloxone Prescription

IntroductionPhenobarbital has been successfully used in the emergency department (ED) to manage symptoms of alcohol withdrawal, but few studies have reported outcomes for ED patients who receive phenobarbital and are discharged. We compared return encounter rates in discharged ED patients with alcohol withdrawal who were treated with benzodiazepines and phenobarbital.MethodsThis is a retrospective cohort study conducted at a single academic medical center utilizing chart review of discharged ED patients with alcohol withdrawal from July 1, 2016, to June 30, 2019. Patients were stratified according to ED management with benzodiazepines, phenobarbital, or a combination of both agents. The primary outcome was return ED encounter within three days of the index ED encounter. Multivariate logistic regression identified significant covariates of an ED return encounter.ResultsOf 470 patients who were discharged with the diagnosis of alcohol withdrawal, 235 were treated with benzodiazepines, 133 with phenobarbital, and 102 with a combination of both. Baseline characteristics were similar among the groups. However, patients who received phenobarbital were provided significantly more lorazepam equivalents compared to patients who received benzodiazepines alone. Treatment with phenobarbital, alone or in combination with benzodiazepines, was associated with significantly lower odds of a return ED visit within three days compared with benzodiazepines alone [AOR 0.45 (95% CI 0.23, 0.88) p = 0.02 and AOR 0.33 (95% CI 0.15, 0.74) p = 0.007].ConclusionsPatients who received phenobarbital for alcohol withdrawal were less likely to return to the ED within three days of the index encounter. Despite similar baseline characteristics, patients who received phenobarbital, with or without benzodiazepines, were provided greater lorazepam equivalents the ED.

Ingesting sodium nitrite as a suicide method appears to be gaining popularity, spurred by online suicide blogs and an easily obtainable product. However, the exact nature of this trend has not been studied. We conducted an 11-year retrospective review of intentional sodium nitrite ingestions reported to the National Poison Data System from January 1, 2009-December 31, 2019. We included all cases coded as \"nitrite or nitrate\" in the initial request. We requested full case records for the initial cohort to confirm details. NPDS recorded 390 individual \"nitrite or nitrate\" exposures during the study period, and 42 met inclusion criteria. We received full case records for 35/42 patients, and 17 were included in the final cohort (N = 17). The mean age was 23.2 years old. Visible cyanosis was present in 13/17 patients with a mean oxygen saturation of 85%. Methylene blue was administered in 14/17 cases with 8/17 requiring advanced cardiac life support. The overall mortality rate was 41% (7/17). All patients presented in the final two years of the study period. Intentionally ingesting sodium nitrite represents a novel, growing trend and carries a high mortality rate among young adults. Abbreviations: AAPCC, American Association of Poison Control Center; ACLS, Advanced Cardiac Life Support; CPCS, California Poison Control System; NPDS, National Poison Data System; PCC, Poison Control Center; SPI, Specialist in Poison Information.

BackgroundTake-home naloxone, an opioid antagonist, has become part of a multimodal approach to curbing opioid-related mortality. However, there is little information about the utility of take-home naloxone in pediatric patients. We report a case of opioid toxicity after exposure to methadone in a pediatric patient, which was successfully reversed with take-home naloxone.CaseA previously healthy 22-month-old girl ingested an unknown amount of liquid methadone. The child became progressively somnolent. The mother administered intranasal naloxone at home with reversal of somnolence. The patient presented to the emergency department and had recurrence of symptoms. The patient was placed on a naloxone infusion and discharged from a tertiary care facility, uneventfully, 2 days after ingestion.ResultsTo our knowledge, we report the first case of pediatric opioid toxicity reversed by take-home naloxone. In the setting of rising opioid-related mortality, providers and public health officials should consider expanding access of take-home naloxone for children at high risk for opioid overdose.

IntroductionA species of hawthorn, Crataegus mexicana (tejocote), has been marketed as a weight-loss supplement that is readily available for purchase online. While several hawthorn species have shown clinical benefit in the treatment of heart failure owing to their positive inotropic effects, little is known about hawthorn, and tejocote in particular, when consumed in excess. We describe a case of tejocote exposure from a weight-loss supplement resulting in severe cardiotoxicity.Case ReportA healthy 16-year-old girl presented to an emergency department after ingesting eight pieces of her mother’s tejocote root weight-loss supplement. At arrival, she was drowsy, had active vomiting and diarrhea, and had a heart rate of 57 with normal respirations. Her initial blood chemistries were unremarkable, except for an elevated digoxin assay of 0.7 ng/mL (therapeutic range 0.5–2.0 ng/mL). All other drug screens were negative. She later developed severe bradycardia and multiple episodes of hypopnea that prompted a transfer to our institution, a tertiary pediatric hospital. Her ECG demonstrated a heart rate of 38 and Mobitz type 1 second-degree heart block. She was subsequently given two vials of Digoxin Immune Fab due to severe bradycardia in the setting of suspected digoxin-like cardiotoxicity after discussion with the regional poison control center. No clinical improvement was observed. Approximately 29 hours after ingestion, subsequent ECGs demonstrated a return to normal sinus rhythm, and her symptoms resolved.DiscussionTejocote root toxicity may cause dysrhythmias and respiratory depression. Similar to other species of hawthorn, tejocote root may cross-react with some commercial digoxin assays, resulting in a falsely elevated level.