Swedish Poisons Information Center

Stockholm, Sweden

Swedish Poisons Information Center

Stockholm, Sweden
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Backberg M.,Swedish Poisons Information Center | Beck O.,University of Stockholm | Hulten P.,Swedish Poisons Information Center | Rosengren-Holmberg J.,Swedish National Laboratory of Forensic Science | Helander A.,University of Stockholm
Clinical Toxicology | Year: 2014

Context. 5-(2-aminopropyl)indole (5-IT) is a new psychoactive substance (NPS; "legal high" or "research chemical") structurally related to indoleamines and substituted phenethylamines and implicated in several fatalities. We describe the clinical characteristics and results of laboratory investigations of 14 analytically confirmed nonfatal cases of 5-IT intoxication within the Swedish STRIDA project. Study design. Observational case series of consecutive patients with admitted or suspected intake of NPS presenting to hospitals in Sweden in 2012. Patients and methods. Blood and/or urine samples were collected from intoxicated patients presenting to emergency departments and intensive care units over the country. Analysis of NPS was performed using an LC-MS/MS multi-component method. Clinical data were collected when caregivers consulted the Poisons Information Centre and also retrieved from medical records. The severity of poisoning was graded retrospectively using the Poisoning Severity Score (PSS). Results. Eleven male and three female patients (age: 21-53 years, median: 27) tested positive for 5-IT in 2012, all cases appearing in April-July. The 5-IT concentration in serum ranged between 0.015 and 0.59 μg/mL (median: 0.22; n = 8) and in urine between 0.005 and 24.7 μg/mL (median: 5.95; n = 12). Five intoxications were indicated to be caused by 5-IT alone, whereas additional psychoactive substances were detected in the other nine cases. Six (43%) of fourteen cases were graded as severe (PSS 3), five (36%) as moderate (PSS 2), and three (21%) as minor (PSS 1) poisonings. In the severe cases, agitation, hallucinations, dilated pupils without light reaction, tachycardia, hypertension, hyperthermia, myoclonus, muscle rigidity, arrhythmias, seizures, rhabdomyolysis, and/or renal failure were noted. Conclusions. The results demonstrated that severe clinical toxicity was commonly present in patients with analytically confirmed 5-IT exposure. The clinical features are consistent with a sympathomimetic toxidrome, and some patients also displayed symptoms associated with serotonin toxicity. © 2014 Informa Healthcare USA, Inc.


Helander A.,Karolinska Institutet | Helander A.,University of Stockholm | Backberg M.,Swedish Poisons Information Center | Signell P.,University of Stockholm | And 2 more authors.
Clinical Toxicology | Year: 2017

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. © 2017 Informa UK Limited, trading as Taylor & Francis Group.


Helander A.,Karolinska Institutet | Helander A.,University of Stockholm | Backberg M.,Swedish Poisons Information Center | Beck O.,Karolinska Institutet | Beck O.,University of Stockholm
Clinical Toxicology | Year: 2016

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. © 2016 Taylor & Francis.


Beck O.,Karolinska Institutet | Beck O.,University of Stockholm | Franzen L.,Swedish Poisons Information Center | Backberg M.,Swedish Poisons Information Center | And 3 more authors.
Clinical Toxicology | Year: 2016

Abstract: 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 a series of intoxications involving the stimulant NPS α-pyrrolidinovalerophenone (α-PVP), a potent dopamine re-uptake inhibitor, over a 4-year period. Study design: Observational case series of consecutive patients with admitted or suspected intake of NPS presenting to hospitals in Sweden from 2012 to 2015. Patients and methods: In the STRIDA project, blood and urine samples are collected from intoxicated patients with admitted or suspected intake of NPS or unknown drugs presenting to hospitals over the country. Analysis of NPS is performed by mass spectrometry multicomponent methods. Clinical data are collected when caregivers consult the Swedish Poisons Information Centre (PIC), and retrieved from medical records. The severity of poisoning is graded retrospectively using the Poisoning Severity Score (PSS). The inclusion criteria for this study included absence of other stimulants than α-PVP. Results: During the 4-year study period, 23 intoxications were originally coded as “α-PVP related” out of a total 3743 NPS-related inquiries (0.6%) at the PIC. The present study covered 42 analytically confirmed cases in which α-PVP was the only stimulant detected. The age range of patients was 20–58 (median 32) years, of which 79% were males. The α-PVP concentration in serum was 4.0–606 (median 64; n = 42) ng/mL and 2.0–41,294 (median 1782; n = 25) ng/mL in urine. There was no statistically significant association between the serum α-PVP concentration and urinary α-PVP/creatinine ratio in 25 cases, where both sets of data were available. In 14/42 (33%) cases, α-PVP was the only psychoactive substance identified. In the remaining cases, additional substances comprised opioids, benzodiazepines, and ethanol. The main clinical manifestations were tachycardia (80%), agitation (70%), hypertension (33%), hallucinations (20%), and delirium (18%). Classification of poisoning severity yielded 25 (60%) moderate (PSS 2), 7 (17%) severe (PSS 3), and 2 fatal cases (PSS 4). Conclusions: In analytically confirmed α-PVP intoxication cases involving no other stimulant drugs, the urine and serum concentrations showed high variability. The clinical features were consistent with a severe sympathomimetic toxidrome. The results further demonstrated that α-PVP prevailed as a drug of abuse after being classified as a narcotic substance, and despite a high incidence of severe poisonings and fatalities. However, the low prevalence of α-PVP cases registered at the PIC suggested that many were unaware of the actual substance they had taken. © 2016 Informa UK Limited, trading as Taylor & Francis Group.


Helander A.,Karolinska Institutet | Helander A.,University of Stockholm | Beck O.,Karolinska Institutet | Beck O.,University of Stockholm | Backberg M.,Swedish Poisons Information Center
Clinical Toxicology | Year: 2015

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. © 2015 Informa Healthcare USA, Inc.


Backberg M.,Swedish Poisons Information Center | Beck O.,Karolinska Institutet | Beck O.,University of Stockholm | Jonsson K.-H.,Medical Products Agency | And 2 more authors.
Clinical Toxicology | Year: 2015

Background. The supply of unregulated "new psychoactive substances" (NPS) has shown a steady increase over the past six years. This report from the Swedish STRIDA project describes analytically confirmed non-fatal intoxications involving butyrfentanyl (butyrylfentanyl) or 4-fluorobutyrfentanyl (para-fluorobutyrfentanyl), two fentanyl analogues recently introduced as NPS opioids. Study design. Observational case series of consecutive patients with suspected acute NPS exposure and requiring hospital care from all over Sweden. Patients and methods. From May 2014 to January 2015, blood and urine samples were obtained from four intoxication cases involving butyrfentanyl and one case involving 4-fluorobutyrfentanyl (men, 19-30 years) presenting in emergency departments (ED) or intensive care units (ICU). Laboratory analysis of serum and/or urine samples was performed by multi-component liquid chromatography-mass spectrometry methods. Data on clinical features were collected during consultations with the Poisons Information Centre and retrieved from medical records. Case details. Of the five patients, two were discharged home from the ED and three were admitted to the ICU, of whom two required intubation and mechanical ventilation. Clinical features included typical opioid symptoms such as unconsciousness, respiratory depression, and apnea. In one case, naloxone successfully countered the effects. All patients were discharged the same or the following day. Butyrfentanyl was detected in two serum (0.6 and 0.9 ng/mL) and three urine (2.0-65.6 ng/mL) samples from three of four cases; three cases also contained fentanyl. In the 4-fluorobutyrfentanyl case, the substance was detected in serum (∼15 ng/mL) and urine (∼10 ng/mL). In four cases, other NPS and/or classical drugs were also detected. Analysis of two "butyrfentanyl" NPS products (nasal spray and powder) brought to hospital by patients showed that the 10-fold more potent fentanyl was the main active ingredient (∼7.5-10-fold higher amount) in both. Conclusion. Typical and potentially life-threatening opioid toxicity was seen in acute intoxications involving butyrfentanyl, 4F-butyrfentanyl, and fentanyl. The incorrect labelling of butyrfentanyl NPS products which instead mainly contained fentanyl is alarming, given the narrow range between a safe and a lethal dose for opioids. © 2015 Informa Healthcare USA, Inc.


Backberg M.,Swedish Poisons Information Center | Lindeman E.,Swedish Poisons Information Center | Beck O.,Karolinska Institutet | Beck O.,University of Stockholm | And 2 more authors.
Clinical Toxicology | Year: 2015

Background. 3-Methylmethcathinone (3-MMC) is a synthetic cathinone stimulant structurally related to the new psychoactive substance (NPS) mephedrone (4-methylmethcathinone, 4-MMC). We describe a case series of analytically confirmed intoxications involving 3-MMC presented to emergency departments in Sweden and included in the STRIDA project. Study design. Observational case series of consecutive patients with self-reported or suspected use of NPS presenting to hospitals in Sweden between August 2012 and March 2014. Methods. NPS analysis was performed by a liquid chromatography-mass spectrometry (MS)/MS method that is updated with new substances as they appear. Data on clinical features were collected during Poisons Information Centre consultations and retrieved from medical records. Results. 3-MMC was detected in 50 (6.4%) of the 786 cases included in the STRIDA project during the 20-month study period, with the peak occurring in August 2013. The age range of patients testing positive for 3-MMC was 17-49 years (median 24) and 76% of them were men. The 3-MMC concentration in serum ranged between 0.002 and 1.49 μg/mL (median, 0.091) and between 0.007 and 290 μg/mL (median, 3.05) in urine. Co-exposure to other NPS and/or traditional drugs was very common, and 3-MMC mono-intoxication was found in only 4 (8%) cases. The most frequent clinical features were tachycardia (48% of cases) and agitation (42%). Other features included a reduced level of consciousness (32%), dilated pupils (24%), hallucinations (20%), diaphoresis (12%), seizures (8%), and hyperthermia (6%). Most patients (60%) needed hospital care for only 1 day but in 8% for 3 days or longer. Conclusion. The majority of patients with analytically confirmed 3-MMC exposure had sympathomimetic features similar to those associated with mephedrone intoxication. However, the high incidence of co-exposure to other drugs makes the clinical interpretation difficult. Nevertheless, 3-MMC was associated with a high admittance rate to intensive care (30%), and detected in two cases with a fatal outcome, suggesting that 3-MMC is a harmful drug. © 2014 Informa Healthcare USA, Inc.


Helander A.,Karolinska Institutet | Helander A.,University of Stockholm | Backberg M.,Swedish Poisons Information Center | Beck O.,Karolinska Institutet | Beck O.,University of Stockholm
Clinical Toxicology | Year: 2014

Background. MT-45 (1-cyclohexyl-4-(1,2-diphenylethyl)piperazine) is an opioid analgesic drug candidate developed in the 1970s that has recently been introduced as a new psychoactive substance (NPS) on the "recreational" drug market. We describe a case series of non-fatal intoxications associated with MT-45 within the Swedish STRIDA project. Study design. Observational case series of consecutive patients with admitted or suspected intake of NPS presenting to hospitals in Sweden from November 2013 to February 2014. Patients and methods. Blood and urine samples were collected from intoxicated patients presenting to emergency departments and intensive care units over the country. NPS analysis was performed by an LC-MS/MS multi-component method. Clinical data were collected when caregivers consulted the Poisons Information Centre and also retrieved from medical records. Case series. Among nine intoxications where MT-45 was detected in the biological samples, four cases were indicated to only involve MT-45, while one or several psychoactive substances were found along with MT-45 in the others. All patients were men aged 17-32 years and they commonly presented with opioid-like adverse symptoms, such as unconsciousness and respiratory depression. Naloxone appeared to have utility in the treatment of MT-45 intoxication in several cases. Three patients complained of bilateral hearing loss that in one case persisted after two weeks. Conclusion. MT-45 should be added to the growing list of harmful NPS causing life-threatening poisonings, and rapid actions taken to make it a controlled substance. © 2014 Informa Healthcare USA, Inc.


Helander A.,Karolinska Institutet | Beck O.,Karolinska Institutet | Hagerkvist R.,Swedish Poisons Information Center | Hulten P.,Swedish Poisons Information Center
Scandinavian Journal of Clinical and Laboratory Investigation | Year: 2013

Aim. The study aimed to collect information concerning the increasing use of new psychoactive substances, commonly sold through online shops as 'Internet drugs' or 'legal highs', or in terms of masked products such as 'bath salts' and 'plant food'. Methods. The Karolinska Institutet and Karolinska University Laboratory and the Swedish Poisons Information Centre have initiated a project called 'STRIDA' aiming to monitor the occurrence and trends of new psychoactive substances in Sweden, and collect information about their clinical symptoms, toxicity and associated health risks. A liquid chromatographic-tandem mass spectrometric (LC-MS/MS) multi-component method has been developed, currently allowing for the determination of > 80 novel psychoactive compounds or metabolites thereof. This study focused mainly on the particular drug substances identified and the population demographics of the initial STRIDA cases. Results. In urine and/or blood samples obtained from 103 consecutive cases of admitted or suspected recreational drug intoxications in mostly young subjects (78% were ≤ 25 years, and 81% were males) presenting at emergency departments all over the country, psychoactive substances were detected in 82%. The substances comprised synthetic cannabinoids ('Spice'; JWH analogues), substituted cathinones ('bath salts'; e.g. butylone, MDPV and methylone) and tryptamines (4-HO-MET), plant-based substances (mitragynine and psilocin), as well as conventional drugs-of-abuse. In 44% of the cases, more than one new psychoactive substance, or a mixture of new and/or conventional drugs were detected. Conclusion. The initial results of the STRIDA project have documented use of a broad variety of new psychoactive substances among mainly young people all over Sweden. © 2013 Informa Healthcare.


Persson H.,Swedish Poisons Information Center
Medicine | Year: 2012

The incidence of fungal poisoning varies a lot in a global perspective and is related to local habits, economic factors and lifestyle. Among thousands of mushroom species fewer than a hundred are toxic. Most fungal toxins cause mild or moderate poisoning. However, it is the ingestion of a few species of extremely poisonous fungi that define the medical dimension of the problem. Mushroom poisoning is mostly accidental and the result of a mix-up between edible and toxic fungi, but intentional ingestion of psychotropic ('magic') mushrooms is also a problem. The most dreaded poisonings are those caused by cytotoxic agents, e.g. amatoxins in death cap and destroying angel (severe gastroenteritis and liver damage) or orellanine in Cortinarius spp. (kidney damage). Dramatic, but rarely lethal, effects are caused by fungi holding neurotoxins like muscarine (Clitocybe and Inocybe spp.), psilocybin (Psilocybe and Panaeolus spp. - 'magic' mushrooms), isoxazoles (fly agaric and panther cap) and gyromitrin (false morels). Most poisonous species cause gastroenteritis only. Treatment includes gastrointestinal decontamination and general symptomatic and supportive care. Specific antidotes exist for fungi containing muscarine, gyromitrin and amatoxins. © 2011 Published by Elsevier Ltd.

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