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PubMed2004

Comparison of patient questionnaires and plasma assays in intentional drug overdoses.

Our aim was to explore the agreement between clinically collected information on purported drug intake and plasma data in intentional drug overdose. We included all subjects with intentional drug overdose above 15 years of age consecutively admitted to the Emergency Department of the University Hospital during 4 months. Information about drugs used and sources of this information was collected and compared to presence of drug in plasma, concerning four drugs with high toxic potential (tricyclic antidepressants, meprobamate, paracetamol and ethanol). Sensitivity, specificity, predictive positive and negative values of all sources of information pooled were assessed for each drug. 413 intentional drug overdoses were included, 66% with more than one drug. According to clinical information, 8% took tricyclic antidepressants, 11% meprobamate, 9% paracetamol and 41% ethanol. Systematic plasma assays confirmed this in 59% of cases for tricyclic antidepressants, 76% for meprobamate and ethanol, and 77% for paracetamol. Plasma concentrations were considered toxic in 28% of cases for tricyclic antidepressants, 65% for meprobamate, 43% for ethanol and never for paracetamol. Tricyclic antidepressants and meprobamate were found unexpectedly in 3%, paracetamol in 7% and ethanol in 6%. Toxic concentrations were found only with meprobamate. The risk of erroneous, clinically collected information was greater by excess (25 to 40% false positives) than by lack (3 to 7% false negatives). Thus, the consequences of erroneous, clinically collected information were probably more excess cost for the institution than medical risk for the patients. However these results found at the population level may not be true at an individual level.

Acetaminophen↗

PubMed2006

Cause and motivation in cases of non-fatal drug overdoses in opiate addicts.

INTRODUCTION: Drug overdose (OD) is a frequent incident among opiate addicts. Survivors of ODs are at risk for additional and eventually fatal ODs. ODs may be classified as accidental (aOD) or deliberate (dOD). Investigations into the connection between OD and suicide attempts have led to insconsistent results. PURPOSE: (1) to determine how many non-fatal ODs were dODs and how many were aODs; (2) to determine how many cases of dODs were motivated by explicit or by ambivalent suicidal intentions; (3) to determine how many cases of aODs had causes that might respond to preventative measures; (4) to compare the addiction histories of dODs and aODs; (5) to compare the drugs causing the ODs; and (6) to compare the severity of the ODs in both groups. METHODS: Prospective study utilizing a standardized questionnaire to evaluate opiate-addicted patients admitted to our treatment unit for OD. All cases underwent standardized drug testing to identify drug use patterns. RESULTS: Seventy-four cases of OD underwent standardized interviews after awakening. Forty-three percent of the cases were dOD. Cases of dOD had significantly more OA in substitution programs, more previous ODs, and more often consumed methadone and cocaine. Among dODs, 22.5% had suicidal intention and 9.6% were ambivalent about committing suicide; background motivations were most often conflicts with spouses. Fifty-seven percent of the cases were aOD. Cases of aODs had significantly more potential lethal intoxications and had heroin detected more frequently. aODs happened with unexpected pure heroin (46%), in combination with alcohol (36%), as relapse after abstinence (40%) or after institutionalized treatment (19%). This group should be accessible for targeted education.

Adult↗

PubMed1988

Implications of discordance between clinical impression and toxicology analysis in drug overdose.

Two hundred nine cases of intentional drug overdose were reviewed to determine the importance of discordance between drugs identified by toxicology analysis and those suspected clinically. The laboratory agreed exactly with the clinical impression in 47% of cases. Clinically unsuspected drugs were identified by the laboratory in 27% of cases; the characteristics of these patients did not differ significantly from those of other patients. Unexpected toxicology findings led to changes in therapy in only three cases, and none of these changes appeared to have a major impact on outcome. Although routine comprehensive toxicology screening frequently may identify unsuspected drugs, it is likely that a policy of more selective use of the laboratory would not compromise the care of patients with drug overdose.

Adult↗

PubMed1976

The reduction of coma time in lipophilic drug overdose using castor oil.

A clinical trial of castor oil in overdoses of lipophilic drugs gave a strong clinical impression that it was effective in speeding up recovery. Therefore, animal experiments were undertaken to confirm that castor oil acts as a ligand in Ethchlorvynol poisoning and that its use reduces coma time. Serial serum levels of Ethchlorvynol were obtained from dogs given Ethchlorvynol 150 mg/kg alone, and the same dose dissolved in castor oil 15 ml/kg in a crossover fashion. The result was a reduction of peak serum levels and of the half-life of the drug when the castor oil solution was used. In order to mimic the clinical situation more closely, a further crossover study was undertaken using Ethchlorvynol 300 mg/kg alone and the same dose followed by castor oil 15 ml/kg repeated q12h. This showed no delay in reaching peak serum concentration and no reduction of peak levels. However, it did show a 31 per cent reduction in the half-life of the drug. This change is statistically significant, and supports the continued use of castor oil in lipophilic drug overdose.

Animals↗

PubMed2003

Comprehensive drug screening in decision making of patients attending the emergency department for suspected drug overdose.

OBJECTIVES: This study aimed to evaluate the usefulness of a comprehensive drug screening method as a first line diagnostic tool on clinical decision making in patients attending an emergency department for suspected drug overdose in terms of agreement between physicians on patients' disposal. METHODS: Five emergency physicians retrospectively evaluated the records of 142 adult patients, admitted to the emergency department of a community hospital for suspected drug overdose. They were asked for an expert opinion on patients' disposal at the end of the observation period, based on paired records, with/without the results of a comprehensive drug screening. RESULTS: In the absence of the drug screening, a very poor agreement (kappa statistics) was observed between physicians. When the drug screening was available, the interobserver agreement for decision on patients' disposal increased to the fair to good range (global agreement: from 0.238 (0.019) to 0.461 (0.020) (mean(SE)); p<0.001). The agreement also increased when admission to an intensive care unit, to a general ward, and discharge from hospital were separately analysed. The availability of drug screening would have saved 21.7% of hospital admissions and 53.3% of high dependency and/or intensive care unit admissions. CONCLUSION: Comprehensive drug screening adds to decision making for patients attending an emergency department for suspected drug overdose, improving agreement among physicians on patients' disposal and potentially saving hospital resources.

Adult↗

PubMed1998

Surveillance of drug overdose deaths using medical examiner data.

This paper describes the epidemiology of drug overdose deaths investigated by the medical examiner in one of the cities participating in the Canadian Community Epidemiology Network on Drug Use and assesses the quality of the information obtained from medical examiner charts with respect to drug overdose deaths, for surveillance purposes. Information was abstracted from medical examiner charts of all deaths involving drugs from 1993 to 1995 in Halifax, Nova Scotia. During these three years, 636 deaths from all causes were investigated by the medical examiner. Of the 42 overdose deaths, 47.6% were suicides. Ethanol was detected in 47.8% of overdose deaths, and 61.9% of all overdose deaths involved psychotropic medications. Two deaths were attributed to an illicit drug (cocaine). An independent review performed by a toxicologist and a medical examiner revealed poor overall agreement concerning overdose as a cause of death (Kappa coefficient: 0.27). In conclusion, the average crude mortality rate due to drug overdose in Halifax from 1993 to 1995 was 4.1 deaths per 100,000 population. Potential threats to the quality of data were the lack of standardization concerning toxicological testing and the definition of drug overdose.

Adult↗

PubMed2003

Income distribution and risk of fatal drug overdose in New York City neighborhoods.

Accidental drug overdose is a substantial cause of mortality for drug users. Neighborhood-level factors, such as income distribution, may be important determinants of overdose death independent of individual-level factors. We used data from the Office of the Chief Medical Examiner to identify all cases of accidental deaths in New York City (NYC) in 1996 and individual-level covariates. We used 1990 US Census data to calculate the neighborhood-level income distribution. This multi-level case-control study included 725 accidental overdose deaths (cases) and 453 accidental deaths due to other causes (controls) in 59 neighborhoods in NYC. Overdose deaths were more likely in neighborhoods with higher levels of drug use and with more unequal income distribution. In multi-level models, income maldistribution was significantly associated with risk of overdose independent of individual-level variables (age, race, and sex) and neighborhood-level variables (income, drug use, and racial composition). The odds of death due to drug overdose were 1.63-1.88 in neighborhoods in the least equitable decile compared with neighborhoods in the most equitable decile. Disinvestment in social and economic resources in unequal neighborhoods may explain this association. Public health interventions related to overdose risk should pay particular attention to highly unequal neighborhoods.

Adolescent↗

PubMed1990

Quantitative serum toxic screening in the management of suspected drug overdose.

Data were collected on 176 consecutive cases of drug overdose evaluated in an emergency department. Quantitative serum toxic screening (TS) was performed for 164 (93%) of these patients; positive results were noted for 133 patients (81%). Six classes of drugs (ethanol, benzodiazepines, salicylates, acetaminophen, barbiturates, and tricyclic antidepressants) were responsible for nearly 70% of all drug detections and were associated with 80% of all admissions in this patient sample. Only two patients (1%) had drug-specific treatment initiated because of TS results. In 12 patients (7%), TS confirmed substances for which specific treatments had been initiated on clinical grounds. Four patients (2%) had drug-specific treatment discontinued because of TS results. Thirty-two patients (19%) were admitted to a medical service; however, only seven patients (4%) were admitted primarily because of TS results. All other patients were admitted because of clinical abnormalities that required inpatient care. It is concluded that only a few drugs are responsible for most drug overdoses. Moreover, TS results rarely change the treatment or disposition of overdose patients; these decisions are typically based on clinical parameters.

Acetaminophen↗

PubMed1982

Effect of ethanol ingestion on outcome of drug overdose.

It was traditionally assumed that ethanol, as part of an intentional drug overdose, will increase morbidity and mortality. The authors prospectively studied the effect of ethanol on the outcome of intentional drug overdose in 468 adults, 196 of whom required hospital admission. Ethanol was detected in significantly fewer patients who required admission. Ethanol ingestion was not related to coma, impaired vital signs or mortality. Indeed, the duration of coma was significantly shorter in patients in whom ethanol was detected, but this group had a lesser incidence of multiple drug and nonbarbiturate hypnotic ingestion and a greater incidence of chronic ethanol use. Thus, it seems that ethanol is not associated with a worse clinical course if the drug overdose patient reaches medical care before an irreversible event.

Adolescent↗

PubMed2003

The limited utility of electrocardiography variables used to predict arrhythmia in psychotropic drug overdose.

OBJECTIVE: The aim of the present study was to examine the relationship between serious arrhythmias in patients with psychotropic drug overdose and electrocardiography (ECG) findings that have been suggested previously to predict this complication. METHODS: Thirty-nine patients with serious arrhythmias (ventricular tachycardia, supraventricular tachycardia or cardiac arrest) after tricyclic antidepressant overdose or thioridazine overdose were compared with 117 controls with clinically significant overdose matched to each case for the drug ingested. These patients with psychotropic drug overdose had presented for treatment to the Department of Clinical Toxicology, Newcastle and to the Princess Alexandra Hospital, Brisbane. The heart rate, the QRS width, the QTc and QT intervals, the QT dispersion, and the R wave and R/S ratios in aVR on the initial ECGs were compared in cases and controls. RESULTS: The cases had taken dothiepin (16 patients), doxepin (six patients), thioridazine (five patients), amitriptyline (five patients), nortriptyline (three patients), imipramine (one patient) and a combination of dothiepin and thioridazine (three patients). In 20 of the 39 patients with arrhythmias, the arrhythmia had been a presumed ventricular tachycardia. Of the other 19 patients, 15 patients had a supraventricular tachycardia, two patients had cardiac arrests (one asystole, one without ECG monitoring) and two patients had insufficient data recorded to make classification of the arrhythmias possible. The QRS was >/= 100 ms in 82% of cases but also in 76% of controls. QRS >/= 160 ms had a sensitivity of only 13% and occurred in 2% of controls. QRS > 120 ms, QTc > 500 and the R/S ratio in aVR appeared to have a stronger association with the occurrence of arrhythmia: QRS > 120 ms (odds ratio [OR], 3.56; 95% confidence interval [CI], 1.46-8.68), QTc > 500 (OR, 3.07; 95% CI, 1.33-7.07), and R/S ratio in aVR > 0.7 (OR, 16; 95% CI, 3.47-74). Excluding thioridazine overdoses and performing the analysis for tricyclic antidepressant overdoses alone gave increased odds ratios for QRS > 120 ms (OR, 4.83; 95% CI, 1.73-13.5) and QTc > 500 (OR, 4.5; 95% CI, 1.56-13) but had little effect on that for the R/S ratio in aVR > 0.7 (OR, 14.5; 95% CI, 3.10-68). CONCLUSION: ECG measurements were generally weakly related to the occurrence of arrhythmia and should not be used as the sole criteria for risk assessment in tricyclic antidepressant overdose. The frequently recommended practice of using either QRS >/= 100 ms or QRS >/= 160 ms to predict arrhythmias is not supported by our study. R/S ratio in aVR > 0.7 was most strongly related to arrhythmia but had estimated positive and negative predictive values of only 41% and 95%, respectively. The use of these specific predictors in other drug overdoses is not recommended without specific studies.

Adolescent↗

PubMed1983

Convulsive attacks due to antidepressant drug overdoses: case reports and discussion.

Antidepressant drug overdoses have been reported to induce seizures, but the etiology of this phenomenon is still unclear. Recently we treated three patients who suffered from epileptic seizures after acute overdoses of three antidepressant drugs: (a) Dibenzepin HCl (Noveril), (b) Maprotiline HCl (Ludiomil), and (c) Clorimipramine (Anafranil). After a review of the pertinent literature, the possible role of antidepressant drugs in the genesis of epileptic seizures is discussed.

Adult↗

PubMedDate not supplied

Experimental and clinical studies on corneal grafts from donors dying of drug overdose: a review.

In order to determine whether or not corneal tissues from donors dying of drug overdose are safe to be used as grafts, animal experiments and a small retrospective clinical study (in which the patients received corneal grafts from donors dying of drug overdose) were done. In rabbits, the drug (ethanol, phenobarbital, pentobarbital, methyprylon, salicylate, or morphine) was injected intravenously in one lethal or sublethal dose. The quantity of the agent was determined in various eye tissues using appropriate techniques. Rabbits were also grafted interlamellarly with full-thickness corneas from animals dying from drug overdose. Concentrations of the agent that reduced cellular proliferation and protein synthesis to 50% were determined using corneal cell culture. Chemical analysis of some eyes of Coroner's cases was done. In animals, all grafts carried the drug to the recipient eye, but none of them (except a few from donors killed with phenobarbital) became opaque or produced any abnormal eye reaction. Only salicylate was found in the cornea and aqueous humor of the drugged animals in a cytotoxic concentration, but only for a short time. Ethanol was found in human eyes for up to 4 days. Clinical investigation revealed no obvious relationship between graft failure and drug content of the donor's blood.

Animals↗

PubMedDate not supplied

Chlorprothixene and chlorprothixene-sulfoxide in body fluids from a case of drug overdose.

A case of fatal drug overdose involving chlorprothixene is presented. Chlorprothixene and chlorprothixene sulfoxide (CPT-SO) metabolite concentrations (mg/L) in body fluids as determined by spectrophotofluorometry were: blood, 0.10 and 0.60; bile, 3.9 and 7.0; urine, 0.4 and 3.4; and stomach contents, 340 mg and 25 mg total, respectively. Qualitative identification of chlorprothixene and CPT-SO was by thin layer and gas liquid chromatography and spectrophotofluorometry following alkaline permanganate oxidation.

Adult↗

PubMed1976

Drug overdose emergency room admissions.

The incidence and patterns of drug overdose admissions to the University of Michigan Medical Center Emergency Suite were studied for the first 3 months of each year from 1956 to 1970. Among variables investigated with regard to age, sex, and time comparisons were types of drugs used, purpose of ingestions, medical condition on arrival, disposition after emergency care, and history of treatment for emotional problems. The continuing escalation in drug overdose emergencies, primarily related to intentional self-poisoning, reflects the growing social health problems of drug use proliferation and rise in suicide attempts over the past two decades. Emergency room resources are being increasingly taxed by the psychological and medical care needs of these cases. Renewed effort toward primary prevention is essential.

Age Factors↗

PubMed1970

Late brain recovery processes after drug overdose.

Though recovery of consciousness after drug overdose may occur within a day or two, the drug itself may not finally leave the brain for another one to three weeks, and at this late time a withdrawal syndrome can occur, with insomnia, restlessness, raised paradoxical (R.E.M.) sleep, epileptic phenomena, and even delirium. It is proposed that a high degree of drug-tolerance and dependence can be rapidly acquired after overdose.Abnormal sleep features of 10 patients resolved only slowly over a period of up to two months after overdose. The data support the view that R.E.M. sleep is concerned with processes of brain repair.

Adult↗

PubMed2003

Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98.

AIMS: Accidental drug overdose contributes substantially to mortality among drug users. Multi-drug use has been documented as a key risk factor in overdose and overdose mortality in several studies. This study investigated the contribution of multiple drug combinations to overdose mortality trends. DESIGN: We collected data on all overdose deaths in New York City between 1990 and 1998 using records from the Office of the Chief Medical Examiner (OCME). We standardized yearly overdose death rates by age, sex and race to the 1990 census population for NYC to enable comparability between years relevant to this analysis. FINDINGS: Opiates, cocaine and alcohol were the three drugs most commonly attributed as the cause of accidental overdose death by the OCME, accounting for 97.6% of all deaths; 57.8% of those deaths were attributed to two or more of these three drugs in combination. Accidental overdose deaths increased in 1990-93 and subsequently declined slightly in 1993-98. Changes in the rate of multi-drug combination deaths accounted for most of the change in overdose death rates, whereas single drug overdose death rates remained relatively stable. Trends in accidental overdose death rates within gender and racial/ethnic strata varied by drug combination suggesting different patterns of multi-drug use among different subpopulations. CONCLUSIONS: These data suggest that interventions to prevent accidental overdose mortality should address the use of drugs such as heroin, cocaine and alcohol in combination.

Adult↗

PubMed2001

Measuring plasma paracetamol concentrations in all patients with drug overdose or altered consciousness: does it change outcome?

OBJECTIVE: To assess whether measuring plasma paracetamol concentrations in all patients with drug overdose or collapse (altered consciousness) changes outcome. METHOD: A retrospective survey was performed of all patients attending the Accident and Emergency Department at Guy's Hospital, London over a 12 month period who had plasma paracetamol concentrations measured (it is hospital policy that patients presenting after any drug overdose, or with a collapse/altered consciousness have a plasma paracetamol concentration). RESULTS: A total of 440 patients were identified who had plasma paracetamol concentrations measured, of whom 411 were eligible for the study. Altogether 115 patients presented after a collapse and paracetamol was detected in four of these. A total of 296 patients presented after a drug overdose-136 denied overdose with a paracetamol containing product and paracetamol was not detected in any of these 136 cases. Of the remaining 160 patients who gave a positive history for overdose with paracetamol, 122 presented within 24 hours and 94 had detectable paracetamol values with 16 cases above the treatment line, 12 presented more than 24 hours after ingestion, and 26 presented with a staggered overdose. One patient died as a result of paracetamol overdose. CONCLUSIONS: This is the first study in the United Kingdom to evaluate the clinical value of routine paracetamol levels in patients presenting to the emergency department after any overdose or a collapse. Taking blood samples for plasma paracetamol estimation in patients who deny taking paracetamol is of little clinical value. However, there is the potential for missing significant paracetamol poisoning in patients presenting with collapse and so screening with a plasma paracetamol concentration is clinically justified in these patients. Such an approach can only be justified in a country in which paracetamol poisoning is prevalent, such as the United Kingdom.

Acetaminophen↗

PubMed1997

Poverty and fatal accidental drug overdoses of cocaine and opiates in New York City: an ecological study.

This ecological study examines the association of the poverty status of urban communities in New York City with their mortality rates of accidental drug overdoses. Mean annual age-adjusted rates of drug overdoses involving cocaine, opiates, or both (n = 1,684) were calculated for each of 59 residential community districts in New York City for 1990-1992. A linear regression analysis was performed to test the association of the mortality rate with the poverty status of the district as measured by the proportion of the district living below the 1989 U.S. poverty line. Poverty status accounted for 69% of the variance in the drug overdose mortality rates of communities (p < .001). This study suggests that mortality rates of overdoses involving cocaine and optiates are significantly associated with the poverty status of communities in New York City.

Adolescent↗