TPR Podcast Episode #13: Naloxone in the Age of Carfentanil
In this “Lucky 13” episode of the TPR podcast, Steven and Leon discuss naloxone, and address the following issues:
Does the concept of a “heroin overdose patient” have meaning anymore in this age of U-47700, fentanyl, and carfentanil?
Given the adulteration of both heroin and counterfeit prescription medications with extremely potent synthetic opioids, do we have to reconsider our entire approach to opioid overdose patients?
Can past medical literature guide us in our management of these patients?(Hint: the answer is no.)
What medical toxicology paper do Steve and Leon — in an unusual state of agreement ...
Source: The Poison Review - January 19, 2017 Category: Toxicology Authors: Leon Gussow The Poison Review Tags: Podcast Source Type: news
The 7th Annual Alexander Awards: The Best Tox Reading of 2016
Alexander Gettler
When TPR began giving out the annual Alexander Awards for best long-form writing in the field of toxicology, the eligibility criteria included the requirement that “entries must be fully and freely accessible” on the web. After 2016 — a remarkably truth-impaired year scarred by fake news and unchallenged mendacity — supporting aggressive, unbiased, fearless journalism appears to us to be a civic duty. A number of our selections this year come from sources such as the New York Times and Los Angeles Times that have much of their content behind a paywall. Often they allow access to a cert...
Source: The Poison Review - January 1, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical adder all Alexander awards ayahuasca cannabidiol carfentanil fentanyl Gettler opiates opioids oxycontin Source Type: news
Severe respiratory depression after snorting U-47700
3.5 out of 5 stars
Two cases of intoxication with new synthetic opioid, U-47700. Domanski K et al. Clin Toxicol 2017 Jan;55:46-50.
Abstract
U-47700 was first synthesized by Upjohn in the 1970s — hence the “U”. The company was seeking to develop an analgesic as effective as morphine but not addictive. Work on this compound was abandoned when the addictive properties of the drug became apparent.
U-47700 is a μ-receptor agonist that is approximately 7.5 times as potent as morphine. This paper reports two patients who presented to hospital after insufflating U-47700 (confirmed on laboratory testing.) One pat...
Source: The Poison Review - December 30, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical synthetic opioid U-47700 Source Type: news
Lipid therapy in oral poisoning: a not-so-systematic review
2 out of 5 stars
No support for lipid rescue in oral poisoning: A systematic review and analysis of 160 published cases. Forsberg M et al. Hum Exp Toxicol 2016 Nov 24 [Epub ahead of print]
Abstract
The authors’ goal was “to present a systematic review and case analysis of practically all published reports on humans treated with lipid rescue for LAST [local anesthetic systemic toxicity] or oral poisoning.”
The focus of the paper is on oral poisonings. The authors report that they identified 94 reported cases of oral poisoning with “alleged” positive response to lipid rescue therapy (LRT.) Two a...
Source: The Poison Review - December 27, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical intralipid intravenous lipid emulsion lipid rescue therapy systematic review Source Type: news
Synthetic cannabinoid AMB-FUBINACA responsible for July 2016 “zombie” episode
4 out of 5 stars
“Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York, Adams AJ et al. N Engl J Med 2016 Dec 14 [Epub ahead of print]
Abstract
On July 12, 2016, the New York Times reported that in the course of one day, in the Bushwick and Bedford-Stuyvesant areas of Brooklyn, 33 people had been transported to hospitals after apparently overdosing on a synthetic cannabinoid.
The major manifestations shown by the victims were altered mental status and lethargy. One observer described what he say at the scene:
“’It’s like a scene out of a zombie movie, a horrible scene̵...
Source: The Poison Review - December 18, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical AMB-FUBINACA Brooklyn synthetic cannabinoid zombie Source Type: news
Tox Tunes #107: Lullaby (The Cure)
There is, to be sure, whether the subtext of this song involves child abuse or drug addiction. The director of this video, Tim Pope, has stated that Lullaby is “an allegory of [The Cure frontman] Robert Smith’s druggy past.” Certainly, the lyrics would back back this up:
On candy stripe legs the Spiderman comes
Softly through the shadow of the evening sun
Stealing past the windows of the blissfully dead
Looking for the victim shivering in bed
Searching out fear in the gathering gloom and
Suddenly
A movement in the corner of the room
And there is nothing I can do
When I realize with fright
That the Spider...
Source: The Poison Review - December 12, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical lullaby the cure tox tunes Source Type: news
Great video: tongue fasciculations in organophosphate poisoning
3.5 out of 5 stars
Tongue Fasciculations in Organophosphate Poisoning. Chhabria BA, Bhalla A. . N Engl J Med 2016 Dec 8;375:e47
Full text with video
The New England Journal of Medicine just posted a brief case of dichlorvos poisoning with a great video demonstrating organophosphate-induced tongue fasciculations. The case and video can be seen here.
The NEJM also has video of tongue fasciculations caused by amyotrophic lateral sclerosis (Lou Gehrig’s Disease) that can be seen here.
Here is another video of tongue fasciculations associated with amyotrophic lateral sclerosis:
Other causes of fasciculation and tre...
Source: The Poison Review - December 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical amyotrophic lateral sclerosis lou gehrig's disease organophosphate poisoning tongue fasciculations Source Type: news
Loperamide abuse and cardiac dysrhythmia
3.5 out of 5 stars
Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008-2016. Eggleston W et al. MMWR 2016 Nov 18;65:1276-1277.
Full Text
Last week we reviewed a new paper showing that the number of cases of loperamide abuse reported to the National Poison Data System increased by 91% from the years 2000 to 2015. For reasons detailed in that review and in my recent Emergency Medicine News article on the topic, massive doses of loperamide can alleviate opioid withdrawal symptoms and also produce opioid-like effects.
This very brief report has some interesting clinical and epidemiological nuggets. The authors l...
Source: The Poison Review - November 25, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cardiotoxicity ecg ekg electrocardiogram imodium loperamide Source Type: news
Treating “heroin” overdose: the past is no guide
1.5 out of 5 stars
Do heroin overdose patients require observation after receiving naloxone? Tillman MW et al. Clin Toxicol 2016 Nov 16:1-7 [Epub ahead of print]
Abstract
The stated goal of this study was to search the medical literature in an attempt to answer 3 main questions:
“What are the medical risks to a heroin user who refuses ambulance transfer after naloxone?
“If the heroin user is treated in the emergency department after naloxone, how long must the be observed prior to discharge?
“How effective in heroin users is naloxone administered by first responders and bystanders?”
The authors...
Source: The Poison Review - November 22, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical antidote emergency department heroin naloxone narcan opiate opioid overdose pre-hospital treat-and-release Source Type: news
How to interpret urine drug tests for marijuana: a review
Linda Parton/shutterstock.com
4 out of 5 stars
Interpretation of Workplace Tests for Cannabinoids. Kulig K. J Med Toxicol 2016 Sep 29 [Epub ahead of print]
Abstract
The interpretation of workplace urine drug tests for marijuana often becomes a point of contention in workman’s compensation cases or proceedings moving towards firing an employee. In may experience, the court or arbitrator not infrequently gets the science of these tests wrong. Such misinterpretation can be devastating for the employee who is at risk of losing his or her job and benefits. This concise review of the subject by Ken Kulig gets the science r...
Source: The Poison Review - November 19, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical marijuana occupational medicine THC THC acid THC-COOH THCa urine drug screen workman's compensation Source Type: news
Missing loperamide (Imodium) abuse can be a fatal mistake
3 out of 5 stars
Epidemiologic Trends in Loperamide Abuse and Misuse. Vakkalanka JP et al. Ann Emerg Med 2016 Nov 4 [Epub ahead of print]
Abstract
This paper reviews loperamide exposures reported to the National Poison Data System over the 6-year period from 2010 through 2015. Because of the well-recognized limitations involved in retrospective analysis of poison center data, there is not much clinically useful information revealed by their study. The authors did find — unsurprisingly — that reported exposures to loperamide went up from 2010 to 2015, increasing by 91%.
As we’ve discussed before, loperamide i...
Source: The Poison Review - November 15, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cardiotoxicity fatality imodium loperamide overdose prolonged QT syndrome Source Type: news
Does exposure to marijuana cause myocardial infarction?
2 out of 5 stars
Prolonged cardiac arrest complicating a massive ST-segment elevation myocardial infarction associated with marijuana consumption. Orsini J et al. J Community Hosp Intern Med Perspect 2016 Sept 7;6(4):31695
Full Text
The medical literature contains scattered, rare case reports and series describing myocardial infarction, acute coronary syndrome, and cardiac arrest associated with exposure to cannabis. (Extreme emphasis on the word “associated.”) This literature is limited by a number of crippling problems, including failure to screen completely for presence of other drugs, failure to collect com...
Source: The Poison Review - November 12, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cannabis cardiotoxicity heart attack cardiac arrest marijuana myocardial infarction Source Type: news
Exposure to edible marijuana products causes lethargy, especially in children
Li’l Ratskull Designs/shutterstock.com
3 out of 5 stars
Characterization of edible marijuana product exposures reported to United States poison centers. Cao D et al. Clin Toxic 2016 Nov;54:840-846.
Abstract
As mentioned here a number of times in the past, I find papers that abstract and collate data from computerized poison center registries frustrating and infuriating. They are invariably beset by multiple intractable limitations: incomplete and unreliable data, poor follow-up, unconfirmed assertions, reporting bias, mis-coding, etc etc. Typically, extensive statistical analysis manipulations are carried out on...
Source: The Poison Review - November 4, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical brownies cannabis edibles marijuana Source Type: news
Alcoholic ketoacidosis: case report and review
3.5 out of 5 stars
A Patient with Alcoholic Ketoacidosis and Profound Lactemia. Gerrity RS et al. J Emerg Med 2016 Oct;51:447-449.
Abstract
This is a very good short case-based review of alcoholic ketoacidosis (AKA), and well-worth the 5 – 10 minutes reading time.
Some key points:
Development of AKA requires increased (binge) alcohol intake along with starvation (decreased food and water intake.)
The characteristic high anion gap metabolic acidosis with elevated lactate and β-hydroxybutyrate levels are the result of dehydration, decreased glycogen stores, increased reducing potential (increased NADH) and release ...
Source: The Poison Review - October 12, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical alcoholic ketoacidosis fluid repletion Review thiamine TUSH ultrasound Source Type: news
TPR Podcast Episode #12: 25 years of weird and wacky toxicology papers
25th Anniversary The Poison Review Podcast: Wild, Wacky and Weird Toxicology Articles From The Last Quarter-Century
“It is universally well known, that in ingesting our common food, there is created or produced in the bowels of human creatures, a great quantity of wind.” Benjamin Franklin
Does Beano prevent gas? A double-blind crossover study of oral alpha-galactosidase to treat dietary oligosaccharide intolerance. Ganiats TG et al. J Fam Pract 1994 Nov;39:441-5.
An air stewardess with puzzling diarrhoea. Greaves RR et al. Lancet 1996 Nov 30;348:1488
Lithium intoxication of unusual origin. Pristach CA. Psych...
Source: The Poison Review - September 26, 2016 Category: Toxicology Authors: Leon Gussow The Poison Review Tags: Medical Podcast Source Type: news
