Faculty Bibliography

IMPORTANCE:The US and Canada currently have no formal published nationwide guidelines for specialists in poison information or emergency departments for the management of acetaminophen poisoning, resulting in significant variability in management. OBJECTIVE:To develop consensus guidelines for the management of acetaminophen poisoning in the US and Canada. EVIDENCE REVIEW:Four clinical toxicology societies (America's Poison Centers, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association of Poison Control Centers) selected participants (n = 21). Led by a nonvoting chairperson using a modified Delphi method, the panel created a decision framework and determined the appropriate clinical management of a patient with acetaminophen poisoning. Unique to this effort was the collection of guidelines from most poison centers in addition to systematic collection and review of the medical literature. Comments from review by external organizations were incorporated before the guideline was finalized. The project began in March 2021 and ended in March 2023. FINDINGS:The search retrieved 84 guidelines and 278 publications. The panel developed guidelines for emergency department management of single or repeated ingestion of acetaminophen. In addition, the panel addressed extended-release formulation, high-risk ingestion, coingestion of anticholinergics or opioids, age younger than 6 years, pregnancy, weight greater than 100 kg, and intravenous acetaminophen use. Differences from current US practice include defining acute ingestion as an ingestion presentation from 4 to 24 hours after overdose was initiated. A revised form of the Rumack-Matthew nomogram was developed. The term massive ingestion was replaced with the term high-risk ingestion and denoted by a specific nomogram line. Other recommendations include specific criteria for emergency department triage, laboratory evaluation and monitoring parameters, defining the role of gastrointestinal decontamination, detailed management of acetylcysteine treatment, associated adverse effects, and stopping criteria for acetylcysteine treatment, as well as criteria for consultation with a clinical toxicologist. Finally, specific treatment considerations, including acetylcysteine dosing, fomepizole administration, and considerations for extracorporeal elimination and transplant evaluation, were addressed. CONCLUSIONS AND RELEVANCE:This qualitative study provides a consensus statement on consistent evidence-based recommendations for medical, pharmacy, and nursing education and practice to optimize care of patients with acetaminophen poisoning.

BACKGROUND AND AIMS:Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. DESIGN:This is a retrospective cross-sectional study. SETTING:This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. PARTICIPANTS:This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. MEASUREMENTS:The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. FINDINGS:For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations. CONCLUSIONS:Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.

BACKGROUND AND AIMS/OBJECTIVE:Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. DESIGN/METHODS:This is a retrospective cross-sectional study. SETTING/METHODS:This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. PARTICIPANTS/METHODS:This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. MEASUREMENTS/METHODS:The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. FINDINGS/RESULTS:For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations. CONCLUSIONS:Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.

OBJECTIVE:Oxycodone/acetaminophen is one of the most commonly prescribed medications for pain management in the emergency department (ED) despite its high abuse liability. Our objective was to determine whether oral immediate-release morphine is as effective and well tolerated as oral oxycodone/acetaminophen for pain relief in stable ED patients. DESIGN/METHODS:This is a prospective comparative study in which stable adult patients with acute painful conditions who had either oral morphine (15 or 30 mg) or oxycodone/acetaminophen (5/325 mg or 10/650 mg) ordered for them at the discretion of a triage physician were recruited. SETTING/METHODS:This study took place in an urban, academic ED from 2016 to 2019. PARTICIPANTS/METHODS:Seventy-three percent of the subjects were between the ages of 18 and 59, 57 percent were female, and 85 percent were African American. Most presented with abdominal, extremity, or back pain. Patient characteristics were similar between treatment groups. INTERVENTIONS/METHODS:Of the 364 enrolled patients, 182 were given oral morphine and 182 were given oxycodone/acetaminophen at the discretion of the triage provider. They were asked to rate their pain score prior to receiving analgesia and at 60 and 90 minutes after administration. MAIN OUTCOME MEASURES/METHODS:We examined pain scores, adverse effects, overall satisfaction, willingness to accept the same treatment again, and the need for additional analgesia. RESULTS:There was no difference in satisfaction reported by patients who received morphine versus oxycodone/acetaminophen: 15.9 percent vs 16.5 percent were very satisfied, 31.9 percent vs 26.4 percent were somewhat satisfied, and 23.6 percent vs 22.5 percent were not satisfied, p = 0.56. Secondary outcomes also showed no significant difference: net change in pain score -2 vs -2 at 60 and 90 minutes, p = 0.91 and p = 0.72, respectively; adverse effects 20.9 percent vs 19.2 percent, p = 0.69; need for further analgesia 9.3 percent vs 7.1 percent, p = 0.44; willingness to accept analgesic again 73.1 percent vs 78.6 percent, p = 0.22. CONCLUSIONS:Oral morphine is a feasible alternative to oxycodone/acetaminophen for analgesia in the ED.

BACKGROUND/UNASSIGNED:Poison Centers are uniquely positioned to respond to an unprecedented public health threat such as the COVID-19 pandemic, as fully operational 24-h hotlines already staffed with healthcare professionals. METHODS/UNASSIGNED:On January 27, 2020 the New Jersey Poison Information and Education System (NJPIES) agreed to operate the New Jersey Coronavirus Hotline. Call patterns, subject matter, and staffing and infrastructure strategies that were implemented to meet the demand are described. In addition, a sample of 1500 individual calls were collected and analyzed in an endeavor to describe call times, call days, area from which the call originated, callers to the hotline, primary language of the caller, and why a call was placed to the hotline. Binomial regression analysis was utilized in an attempt to identify significant patterns. RESULTS/UNASSIGNED:Since the inception of the hotline through October 31, NJPIES responded to 57,579 calls for COVID-19 information. Most calls (68.7%) were regarding testing for COVID-19 and for general questions/symptoms. Call types varied when they were analyzed by time of day with calls for general questions/symptoms and where to get tested for COVID-19 showing a significant association for the early morning hours, how to obtain test results being significantly associated with the afternoon hours, and how to renew or obtain a medical license showing a significant association to the evening hours. We additionally noted that specific call types became significant when analyzed on a week-to-week basis and as specific events, like the enactment of the CARES Act of 2020, occurred. CONCLUSION/UNASSIGNED:Although not the traditional role of a regional Poison Control Center, pandemic response synergizes with the workflow of this hotline because the infrastructure, staffing, and healthcare expertise are already present. Poison centers can rapidly adapt through scaling and process change to meet the needs of the public during times of public health threats.

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."

Patients experiencing the consequences of opioid use often present to the emergency department (ED) at times of crisis, such as following overdose or when in withdrawal. This highlights the important role of the ED in recognizing opioid use disorder and engaging these patients into ongoing treatment. Given the limited ability of the healthcare system to provide timely addiction treatment, initiation of therapy in the ED, with referral to long-term care, is associated with improved outcomes. The primary evidence-based treatment used in EDs for this indication is buprenorphine. Although clinicians may find the initiation of buprenorphine therapy daunting, it is straightforward and well-tolerated, and many of the barriers are surmountable. This article addresses these barriers, which include stigma, complicated pharmacology, and confusing regulations, and provides a basis for the use of buprenorphine in acute care clinical practice.

BACKGROUND:Drug use is prevalent among electronic dance music (EDM) party attendees, but research is needed to determine the extent of adverse drug-related outcomes in this population in order to better inform prevention and harm reduction efforts. METHOD/METHODS:1029 adults were surveyed entering EDM parties in New York City in 2018. Those reporting past-year use of a drug were asked if they experienced a harmful or very unpleasant effect after use in which they were concerned about their immediate safety. They were also asked about co-use of other drugs and whether they sought help. RESULTS:We estimate that a third (33.5%) of EDM party attendees have experienced a drug-related adverse effect in the past year. Two-thirds (67.8%) of adverse effects involved use of alcohol. Relative to use, adverse effects most commonly resulted from use of opioids (e.g., prescription opioid misuse, 41.2%) or alcohol (33.9%). Among those reporting an adverse effect, concomitant use of other drugs was common, particularly among users of LSD (56.5%), ketamine (56.3%), cocaine (55.7%), and ecstasy/MDMA/Molly (47.7%). Adverse effects resulting from synthetic cathinone ("bath salt") use were most likely to result in a hospital visit (57.1%). CONCLUSION/CONCLUSIONS:Adverse effects from drug use are common among those in the EDM party scene and polydrug use appears to be a common risk factor. More research is needed, however, to determine the extent of event-specific adverse outcomes. Results can inform prevention and harm reduction efforts in this population.