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Warrick B.J.,Childrens Hospital of Michigan Regional Poison Center | Hill M.,Childrens Hospital of Michigan Regional Poison Center | Christensen R.,Childrens Hospital of Michigan Regional Poison Center | Goetz R.,Cincinnati Poison Center | And 10 more authors.
Annals of Emergency Medicine | Year: 2013

Study objective: A new generation of designer stimulants marketed as "bath salts" emerged in late 2010. The goal is to describe the epidemiologic emergence of designer stimulants in 9 states in the Midwest. Methods: A retrospective review of the National Poison Data System was performed between November 1, 2010, and November 30, 2011. Inclusion criteria were health care-evaluated bath salts or other synthetic stimulants exposures. Cases were excluded if the exposure was unrelated to a designer stimulant. Demographic and clinical characteristics of cases were calculated and differences in outcome and exposure by generation were examined. Results: One thousand six hundred thirty-three patients met the inclusion criteria. Age ranged from 1 day to 61 years (mean=29.2 years), with 67.9% male patients. The most common clinical features were agitation (62.2%), tachycardia (55.2%), and hallucinations (32.7%). In addition to 15.5% of patients having a major medical effect, 0.6% died. Reason for use was primarily intentional abuse (88.5%). However, 0.7% of patients reported withdrawal. Treatment involved primarily benzodiazepines (58.5%), with 8.7% of patients being intubated. Baby Boomers were more likely to have a major medical outcome (24.2%) and to report injection as the method of administration (8.6%-12.9%). Conclusion: Synthetic stimulants rapidly swept across the Midwest, resulting in more than 1,600 patients seeking medical care. Serious medical effects or death was observed in 16.1% of cases. Older generations were more likely to inject and to have a major medical outcome. © 2013 American College of Emergency Physicians.

Spiller H.A.,Central Ohio Poison Center | Beuhler M.C.,Carolinas Poison Center | Beuhler M.C.,University of North Carolina at Chapel Hill | Ryan M.L.,Louisiana Poison Center | And 5 more authors.
Pediatric Emergency Care | Year: 2013

OBJECTIVE: The nature of pediatric poisonings is dynamic, with changes occurring over time. We evaluated poisoning in children younger than 6 years for trends during an 11-year period regarding the substances involved in the poisoning, medical outcomes, and health care use. METHODS: This was retrospective study of poisoning in children younger than 6 years reported to 12 poison centers in 5 US states for the years 2000 through 2010. Data abstracted included substance category involved in the exposure, age of patient, year of occurrence, location of patient management, and medical outcome. RESULTS: There were 2,577,036 poison exposures in children younger than 6 years, with a 12.4% increase from 210,270 poison exposures in 2000 to 236,425 poison exposures in 2010. There was a 33% increase (P < 0.05) in pharmaceutical related exposures in children younger than 6 years and a 2.8% decline in the number of nonpharmaceutical related exposures. Among those substance categories representing more than 1% of exposures, the only pharmaceutical showing decline was cough/cold preparations. There was a 53% increase in serious medical outcomes, including 119 deaths and a significant increase in health care facility use, primarily owing to pharmaceutical exposures. CONCLUSIONS: Poisoning in young children increasingly involves pharmaceuticals and is associated with an increased number of serious outcomes and children treated in a health care facility. We believe that these changes are related to increased availability of medications in the home and poison prevention education efforts should include a focus on the availability of these products to small children. Copyright © 2013 by Lippincott Williams & Wilkins.

News Article | August 22, 2016

For some people, fentanyl can be a life-saver, easing profound pain. But outside of a doctor’s office, the powerful opioid drug is also a covert killer. In the last several years, clandestine drugmakers have begun experimenting with this ingredient, baking it into drugs sold on the streets, most notably heroin. Fentanyl and closely related compounds have “literally invaded the entire heroin supply,” says medical toxicologist Lewis Nelson of New York University Langone Medical Center. Fentanyl is showing up in other drugs, too. In San Francisco’s Bay Area in March, high doses of fentanyl were laced into counterfeit versions of the pain pill Norco. In January, fentanyl was found in illegal pills sold as oxycodone in New Jersey. And in late 2015, fentanyl turned up in fake Xanax pills in California. This ubiquitous recipe-tinkering makes it impossible for users to know whether they’re about to take drugs mixed with fentanyl. And that uncertainty has proved deadly. Fentanyl-related deaths are rising sharply in multiple areas. National numbers are hard to come by, but in many regions around the United States, fentanyl-related fatalities have soared in recent years. Maryland is one of the hardest-hit states. From 2007 to 2012, the number of fentanyl-related deaths hovered around 30 per year. By 2015, that number had grown to 340. A similar rise is obvious in Connecticut, where in 2012, there were 14 fentanyl-related deaths. In 2015, that number was 188. In Massachusetts, two-thirds of people who died from opioid overdoses in the first half of 2016 showed signs of fentanyl. This wave of fentanyl-related overdoses is “horrendous,” says Daniel Ciccarone of the University of California, San Francisco. What’s worse, he says, “I think it’s here to stay.” Fentanyl is not a new drug. Available in the 1960s, it is still used in hospitals as an anesthetic and is available by prescription to fight powerful pain. What’s new, Ciccarone says, is that clandestine drug manufacturers have discovered that the euphoria-producing opioid can be made cheaply and easily — no poppy fields necessary. Fentanyl is about 30 to 40 times stronger than heroin and up to 100 times more powerful than morphine, which means that a given effect on the body can be achieved with a much smaller amount of fentanyl. Inadvertently taking a bit of fentanyl can cause big trouble. “It’s a dosing problem,” Nelson says. “Because the drug is so potent, little changes in measurements can have very big implications for toxicity. That’s really the problem.” That problem is made worse by the variability of illegal drugs — users often don’t know what they’re buying. Illegal labs aren’t pumping out products with carefully calibrated doses or uniform chemical makeup. The drugs change from day to day, making it nearly impossible for a user to know what he or she is about to take, Ciccarone says. He has seen this struggle up close. Drug users have told him that the products they buy are unpredictable. Another thing people are telling him: “That they and their friends and compatriots are dropping like flies.” Tellingly, some of the most experienced drug users have recently begun doing “tester shots,” small doses to get a sense of the type and dose of drug they’re about to use, Ciccarone says. Users are right to be wary. Typically, opioids can kill by gradually depressing a person’s ability to breathe. Illicit fentanyl, a recent study suggests, can kill within minutes by paralyzing muscles. Doctors have known that when injected quickly, fentanyl can paralyze chest wall muscles, prevent breathing and kill a person rapidly. That effect, called “wooden chest,” might help explain the rise in fentanyl-related deaths, scientists report in the June Clinical Toxicology. A quick injection of fentanyl “literally freezes the muscles and you can’t move the chest,” says toxicologist Henry Spiller of the Central Ohio Poison Center in Columbus. That’s why doctors who dispense fentanyl in the hospital intentionally proceed very slowly and keep the opioid-counteracting drug naloxone (Narcan) on hand. “If you give it too fast, we know this occurs,” Spiller says. But it wasn’t known whether this same phenomenon might help explain the death rate of people using the drug illegally. Spiller and colleagues tested post-mortem concentrations of fentanyl and its breakdown product norfentanyl in 48 fentanyl-related deaths. The body usually begins breaking down fentanyl into norfentanyl within two minutes, an earlier study found. Yet in 20 of the cases, the researchers found no signs of norfentanyl, indicating death came almost immediately after first receiving fentanyl. Naloxone can counteract the effects of opioids if someone nearby can administer the antidote. But for people whose chests quickly freeze from fentanyl, resuscitation becomes more unlikely. Fentanyl “is just a bad drug,” Spiller says. Fentanyl’s danger is magnified for people not accustomed to taking opioids, such as those addicted to cocaine, a situation illustrated by a recent tragedy in New Haven, Conn. New Haven authorities noticed a string of suspicious overdoses in late June, leaving three people dead. Drug users thought they were buying cocaine, but the drugs contained fentanyl, says analytical toxicologist Kara Lynch of the University of California, San Francisco. As one of the handful of labs capable of testing blood and urine for fentanyl, hers was called on to identify the culprit. Her lab spotted fentanyl in Norco tablets back in March. Lynch’s group uses high-resolution mass spectrometry to detect many drugs’ chemical signatures. But this method reveals only the drugs scientists suspect. “We can look for what we know to look for,” she says. And success depends on getting the samples in the first place. The logistical hurdles of figuring out exactly what a person took, and how much, and when, are large. Ciccarone contrasts the situation with cases of food poisoning. When people start getting sick, public health officials can figure out what lettuce people ate and test it for pathogens. The same kind of tracking system doesn’t exist for drugs. His efforts to develop a system for testing illegal drugs in Baltimore broke down in part because no one had time to do the work. “The coroner is so busy right now with dead bodies,” he says. “They don’t have the time to test the ‘lettuce.’ ” In the quest to curb fentanyl-related deaths, scientists and public health officials are searching for new strategies. Spiller advocates a more targeted public health message to users, one that emphasizes that fentanyl is simply a deadly drug, not just a more potent high. Ciccarone says that facilities where drug users can take illegal drugs under the care of medical personnel might reduce the number of fatalities. For now, the scope of the problem continues to grow, Nelson says. The situation is made worse by the ingenuity of illicit drugmakers, who readily experiment with new compounds. Fentanyl itself can be tweaked to create at least 16 related forms, one of which, acetyl fentanyl, has been linked to overdose deaths. New drugs and new tweaks to old drugs rapidly evolve (SN: 5/16/15, p. 22), Nelson says, creating a game of whack-a-mole in which designer drugs confound public health officials and law enforcement. “There is no single easy solution to this problem,” he says.

(PR NewsChannel) / November 29, 2016 / Oakville, OntarioThe International Association of HealthCare Professionals is pleased to welcome Mohamed Enara, PhD, CACII (Certified Addiction Counselor), to their prestigious organization with his upcoming publication in The Leading Physicians of the World. He is a highly trained and qualified addiction counselor with an extensive expertise in all facets of his work. Dr. Mohamed Enara has been in practice for more than 28 years and is currently serving clients as an Addiction Counselor at Neworld Medical Detox Centre, Ontario, Canada. Dr. Mohamed Enara graduated with Bachelor Degree in 1988 from Cairo University in Egypt. He later earned his PhD degree. Alongside his current practice, he also serves as a lecturer at Cairo University Kasr Al Ainy School of Medicine. Additionally, Dr. Enara holds a Master Degree in Occupational Medicine. Dr. Enara is a Canadian certified Addiction Counselor, and maintains  membership with the Alberta Society for Human Toxicology, Canadian Society of Addiction Medicine and the Canadian Addiction Counselor Certification Federation. He attributes his success to the great mentors he’s had along the way, particularly Dr. Marcel Casavant of the Central Ohio Poison Center. When he is not assisting clients, Dr. Enara enjoys reading, as well as judo and soccer. View Dr. Mohamed Enara’s Profile Here: Learn more about Dr. Enara by reading his upcoming publication in The Leading Physicians of the World. About is a hub for all things medicine, featuring detailed descriptions of medical professionals across all areas of expertise, and information on thousands of healthcare topics.  Each month, millions of patients use FindaTopDoc to find a doctor nearby and instantly book an appointment online or create a review. features each doctor’s full professional biography highlighting their achievements, experience, patient reviews and areas of expertise.  A leading provider of valuable health information that helps empower patient and doctor alike, FindaTopDoc enables readers to live a happier and healthier life.  For more information about FindaTopDoc, visit

News Article | February 12, 2017

Parents, beware: accidental poisoning from pet medicines is likely to happen among children when less attention is given to storing these seemingly harmless veterinary medications. The warning in your disinfectant and pesticide packaging to "Keep Out Of Reach Of Children," must be applied to pet medicines, too. Some 74.1 million households in the United States own at least one pet. There were at least 78 million dogs living in the household as pets back in 2012. And half of these households have children below 19. The results of a new study published in the journal Pediatrics revealed that accidental poisoning is high among children 19 years old or younger. Preventable poisonings among children accounted for more than 60,000 emergency cases and almost one million calls to poison centers; 48 percent of annual calls made to poison centers involved children below five years old. From 1999 to 2013, the Central Ohio Poison Center, for instance, recorded 1,431 cases of accidental poisoning among children. Eighty-seven percent of these calls involved children below five years old. Eighty-eight percent of the exposures were related to pet medicines for canine, whether they were through ingestion (94 percent) and ocular (2.1 percent) or skin contact (1.1 percent), with most of these cases happening at home. "It's much more common than we thought," COPC Director Henry Spiller, one of the authors of the study, said. The research indicated that these accidental poisonings had no serious medical effect. Parents are urged, however, to pay attention to storing medicines, including medicines for pets, carefully. At Mattel Children's Hospital UCLA, parents are counselled on medication safety. These pet medicines may appear "yummy candy to kids," Dr. Tanya Altmann, founder of Calabasas Pediatrics, said. It is a must, she said, that these medicines are kept out of children's reach. She reminded parents that children are curious and eager to explore everything. The children might "accidentally get into something that they shouldn't," she added. To prevent accidental poisoning, parents must ensure that medicines are stored in child-resistant containers, and pet medicines must be stored separately from human medications. Dr. Michael Topper of the American Veterinary Medical Association advised pet owners when administering medicines to their pets. "If pet owners are unsure on how to give it, before they leave the vet, ask them to give lessons on how to give pills to your pet," Topper said. © 2017 Tech Times, All rights reserved. Do not reproduce without permission.

Spiller H.A.,Central Ohio Poison Center | Spiller H.A.,Ohio State University | Hays H.L.,Central Ohio Poison Center | Hays H.L.,Ohio State University | Aleguas Jr. A.,Tampa General Hospital
CNS Drugs | Year: 2013

The prevalence of attention-deficit hyperactivity disorder (ADHD) in the USA is estimated at approximately 4-9 % in children and 4 % in adults. It is estimated that prescriptions for ADHD medications are written for more than 2.7 million children per year. In 2010, US poison centers reported 17,000 human exposures to ADHD medications, with 80 % occurring in children <19 years old and 20 % in adults. The drugs used for the treatment of ADHD are diverse but can be roughly separated into two groups: the stimulants such as amphetamine, methylphenidate, and modafinil; and the non-stimulants such as atomoxetine, guanfacine, and clonidine. This review focuses on mechanisms of toxicity after overdose with ADHD medications, clinical effects from overdose, and management. Amphetamine, dextroamphetamine, and methylphenidate act as substrates for the cellular monoamine transporter, especially the dopamine transporter (DAT) and less so the norepinephrine (NET) and serotonin transporter. The mechanism of toxicity is primarily related to excessive extracellular dopamine, norepinephrine, and serotonin. The primary clinical syndrome involves prominent neurological and cardiovascular effects, but secondary complications can involve renal, muscle, pulmonary, and gastrointestinal (GI) effects. In overdose, the patient may present with mydriasis, tremor, agitation, hyperreflexia, combative behavior, confusion, hallucinations, delirium, anxiety, paranoia, movement disorders, and seizures. The management of amphetamine, dextroamphetamine, and methylphenidate overdose is largely supportive, with a focus on interruption of the sympathomimetic syndrome with judicious use of benzodiazepines. In cases where agitation, delirium, and movement disorders are unresponsive to benzodiazepines, second-line therapies include antipsychotics such as ziprasidone or haloperidol, central alpha-adrenoreceptor agonists such as dexmedetomidine, or propofol. Modafinil is not US FDA approved for treatment of ADHD; however, it has been shown to improve ADHD signs and symptoms and has been used as an off-label pharmaceutical for this diagnosis in both adults and children. The mechanism of action of modafinil is complex and not fully understood. It is known to cause an increase in extracellular concentrations of dopamine, norepinephrine, and serotonin in the neocortex. Overdose with modafinil is generally of moderate severity, with reported ingestions of doses up to 8 g. The most common neurological effects include increased anxiety, agitation, headache, dizziness, insomnia, tremors, and dystonia. The management of modafinil overdose is largely supportive, with a focus on sedation, and control of dyskinesias and blood pressure. Atomoxetine is a selective presynaptic norepinephrine transporter inhibitor. The clinical presentation after overdose with atomoxetine has generally been mild. The primary effects have been drowsiness, agitation, hyperactivity, GI upset, tremor, hyperreflexia, tachycardia hypertension, and seizure. The management of atomoxetine overdose is largely supportive, with a focus on sedation, and control of dyskinesias and seizures. Clonidine is a synthetic imidazole derivative with both central and peripheral alpha-adrenergic agonist actions. The primary clinical syndrome involves prominent neurological and cardiovascular effects, with the most commonly reported features of depressed sensorium, bradycardia, and hypotension. While clonidine is an anti-hypertensive medication, a paradoxical hypertension may occur early with overdose. The clinical syndrome after overdose of guanfacine may be mixed depending on central or peripheral alpha-adrenoreceptor effects. Initial clinical effects may be drowsiness, lethargy, dry mouth, and diaphoresis. Cardiovascular effects may depend on time post-ingestion and may present as hypotension or hypertension. The management of guanfacine overdose is largely supportive, with a focus on support of blood pressure. Overdose with ADHD medications can produce major morbidity, with many cases requiring intensive care medicine and prolonged hospital stays. However, fatalities are rare with appropriate care. © 2013 Springer International Publishing Switzerland.

Brophy T.J.,Ohio State University | Brophy T.J.,Research Institute of Nationwide Childrens Hospital | Spiller H.A.,Ohio State University | Spiller H.A.,Central Ohio Poison Center | And 6 more authors.
Clinical Toxicology | Year: 2014

Context. Previous studies of medication errors have largely focused on healthcare facilities and have not reported generalizable national trends among out-of-hospital medication errors. Objective. We sought to understand U.S. trends in medication errors, including the age-related risks, the involved medications, and the medical outcomes. Materials and methods. We performed a retrospective analysis of National Poison Data System (NPDS) data from the American Association of Poison Control Centers for years 2000-2012. Medication error cases were analyzed by age, gender, pharmaceutical involved, substance rank, dosing error type, management site, level of healthcare received, and medical outcome. Trends in medication error rates were analyzed using Poisson regression. Results. From 2000 to 2012, the NPDS recorded 2,913,924 calls reporting unintentional pharmaceutical-related errors that met inclusion criteria. Non-healthcare facility calls comprised 99.2% calls related to unintentional therapeutic errors. Eighty-seven percent of medication errors were managed on site. The annual medication error rate for all callers per 10,000 U.S. population increased significantly (p < 0.0001) by 69.8% from 2000 (4.98 calls per 10,000 population) to 2012 (8.46 calls per 10,000 population). Among adults aged 20 years and older, age was positively correlating (r = 0.96) with the rate of medication error. Analgesics were the most frequent pharmaceutical class involved in medication errors for ages 6-49 (N = 221,061). Among ages 20-49 years, opioid-related medication errors decreased by 7.9% from 2010 to 2012. Cardiovascular drugs were the leading source of injury among all ages (N = 14,440) and also the leading pharmaceutical class involved in medication errors among adults 50 years and older (N = 187,760). Conclusion. Medication errors continue to be a source of preventable injury with increasing incidence across the out-of-hospital population. © 2014 Informa Healthcare USA, Inc.

Russell J.L.,Ohio State University | Russell J.L.,Nationwide Childrens Hospital | Wiles D.A.,Ohio State University | Wiles D.A.,Nationwide Childrens Hospital | And 4 more authors.
Journal of Medical Toxicology | Year: 2014

Concentrated laundry pods have been reported to cause significant clinical effects including oropharyngeal burns and respiratory distress requiring intubation. Dermal burns have been reported, but no incidents of serious isolated dermal injury have been published. We report a case of significant, isolated dermal injury as a result of dermal exposure to a concentrated laundry detergent pod. Total body surface area partial thickness burns in this case were estimated at approximately 2 % with an additional 4-5 % of total body surface area (TBSA) displaying superficial burns/chemical dermatitis. Health-care providers should be aware of this complication and should perform thorough dermal decontamination in the event of an exposure. Parents should be educated regarding the dangers associated with dermal exposure to laundry pod compounds and the need to secure these items away from children as well as proper decontamination techniques should an exposure occur. © 2014 American College of Medical Toxicology.

Valdez A.L.,Nationwide Childrens Hospital | Valdez A.L.,University of Washington | Casavant M.J.,Central Ohio Poison Center | Casavant M.J.,Ohio State University | And 7 more authors.
Pediatrics | Year: 2014

OBJECTIVE: Laundry detergent pods are a new product in the US marketplace. This study investigates the epidemiologic characteristics and outcomes of laundry detergent pod exposures among young children in the United States. METHODS: Using data from the National Poison Data System, exposures to laundry detergent pods among children younger than 6 years of age during 2012-2013 were investigated. RESULTS: There were 17 230 children younger than 6 years exposed to laundry detergent pods in 2012-2013. From March 2012 to April 2013, the monthly number of exposures increased by 645.3%, followed by a 25.1% decrease from April to December 2013. Children younger than 3 years accounted for 73.5% of cases. The major route of exposure was ingestion, accounting for 79.7% of cases. Among exposed children, 4.4% were hospitalized and 7.5% experienced a moderate or major medical outcome. A spectrum of clinical effects from minor to serious was seen with ingestion and ocular exposures. There were 102 patients (0.6%) exposed to a detergent pod via ingestion, aspiration, or a combination of routes, including ingestion, who required tracheal intubation. There was 1 confirmed death. CONCLUSIONS: Laundry detergent pods pose a serious poisoning risk to young children. This nationwide study underscores the need for increased efforts to prevent exposure of young children to these products, which may include improvements in product packaging and labeling, development of a voluntary product safety standard, and public education. Product constituent reformulation is another potential strategy to mitigate the severity of clinical effects of laundry detergent pod exposure. Copyright © 2014 by the American Academy of Pediatrics.

Smith M.D.,Nationwide Childrens Hospital | Spiller H.A.,Central Ohio Poison Center | Spiller H.A.,Ohio State University | Casavant M.J.,Central Ohio Poison Center | And 6 more authors.
Pediatrics | Year: 2014

OBJECTIVE: To investigate out-of-hospital medication errors among young children in the United States. METHODS: Using data from the National Poison Database System, a retrospective analysis of out-of-hospital medication errors among children <6 years old from 2002 through 2012 was conducted. RESULTS: During 2002-2012, 696 937 children <6 years experienced out-of-hospital medication errors, averaging 63 358 episodes per year, or 1 child every 8 minutes. The average annual rate of medication errors was 26.42 per 10 000 population. Cough and cold medication errors decreased significantly, whereas the number (42.9% increase) and rate (37.2% increase) of all other medication errors rose significantly during the 11-year study period. The number and rate of medication error events decreased with increasing child age, with children <1 year accounting for 25.2% of episodes. Analgesics (25.2%) were most commonly involved in medication errors, followed by cough and cold preparations (24.6%). Ingestion accounted for 96.2% of events, and 27.0% of medication errors were attributed to inadvertently taking or being given medication twice. Most (93.5%) cases were managed outside of a health care facility; 4.4% were treated and released from a health care facility; 0.4% were admitted to a non-critical care unit; 0.3% were admitted to a critical care unit; and 25 children died. CONCLUSIONS: This is the first comprehensive study to evaluate the epidemiologic characteristics of out-of-hospital medication errors among children,6 years of age on a national level. Increased efforts are needed to prevent medication errors, especially those involving non-cough and cold preparations, among young children. Copyright © 2014 by the American Academy of Pediatrics.

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