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Salomone A, Vincenti M. Detecting novel psychoactive substances around the world. Curr Opin Psychiatry 2024; 37:258-263. [PMID: 38818825 DOI: 10.1097/yco.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
PURPOSE OF REVIEW The worldwide spread of novel psychoactive substances (NPS) in the illicit drug market and their continuous increase in number and type, for the purpose of bypassing controlled substance legislation, represents a continuing challenge for forensic scientists, clinicians and enforcement authorities. We aim to provide information regarding the most urgent harms related to NPS consumption in different world regions and the current state of the art for NPS analysis. RECENT FINDINGS Unfortunately, the identification of NPS in biological samples is controversial, especially when samples are limited, or the drug is promptly and extensively metabolized. This causes a lack of information on their real diffusion in different parts of the world and in different populations. New technologies and instrumental detection of NPS in alternative samples are offering comprehensive information about NPS use. SUMMARY The lack of detection and underreporting of NPS in biological samples makes it difficult to obtain complete qualitative and quantitative information about NPS prevalence. The most innovative strategies that have been proposed in the last 2 years to assist NPS analysis and possibly facilitate the understanding of the NPS diffusion around the world are presented.
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Affiliation(s)
- Alberto Salomone
- Department of Chemistry, University of Turin
- Centro Regionale Antidoping, Orbassano, Turin, Italy
| | - Marco Vincenti
- Department of Chemistry, University of Turin
- Centro Regionale Antidoping, Orbassano, Turin, Italy
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Fitzgerald ND, Cottler LB, Palamar JJ. Public health surveillance of new psychoactive substances: recent developments. Curr Opin Psychiatry 2024; 37:270-276. [PMID: 38587019 PMCID: PMC11142873 DOI: 10.1097/yco.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
PURPOSE OF REVIEW New psychoactive substances (NPS) continue to emerge globally and present a threat to public health. This article summarizes the most recent literature on approaches for monitoring NPS use and adverse events related to use. RECENT FINDINGS A variety of approaches have recently been employed for surveillance of NPS use and associated harms, including the use of toxicology testing of patients in emergency departments, surveys of sentinel populations, drug checking and syringe services programs, wastewater-based epidemiology, and retrospective analyses of clinical samples and toxicology reports. These studies cover a range of time periods and NPS examined across numerous countries. SUMMARY Areas of particular interest for future research include the use of data from drug checking services to inform surveillance efforts of the illicit drug supply and the development of methods for wastewater-based monitoring of NPS. Studies that combine self-report data with toxicology testing in particular are important for capturing unintentional or unknown exposure to NPS including fentanyls and drugs like xylazine. Given the limitations associated with individual indicators of drug use and associated harms, the harmonization of multiple data sources can help present a more complete picture of both trends involving NPS to better inform public health responses.
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Affiliation(s)
- Nicole D. Fitzgerald
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Linda B. Cottler
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Joseph J. Palamar
- NYU Grossman School of Medicine, Department of Population Health, New York, New York, USA
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Smith JL, Greene S, McCutcheon D, Weber C, Kotkis E, Soderstrom J, Douglas B, Lenton S, Grigg J, Dessauer P, Ezard N, Fatovich DM. A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes. Drug Alcohol Rev 2024. [PMID: 38426636 DOI: 10.1111/dar.13830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/26/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.
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Affiliation(s)
- Jennifer L Smith
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
| | - Shaun Greene
- Emergency Department, Austin Hospital, Melbourne, Australia
- Victorian Poisons Information Centre, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - David McCutcheon
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
- Royal Perth Hospital Research Foundation, Perth, Australia
| | - Courtney Weber
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
| | - Ellie Kotkis
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
| | - Jessamine Soderstrom
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
| | | | - Simon Lenton
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | - Jodie Grigg
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | | | - Nadine Ezard
- The National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia
- The National Centre for Clinical Research on Emerging Drugs, UNSW Sydney, Sydney, Australia
- New South Wales Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Daniel M Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
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Syrjanen R, Schumann JL, Lyons T, McKinnon G, Hodgson SE, Abouchedid R, Gerostamoulos D, Koutsogiannis Z, Fitzgerald J, Greene SL. A risk-based approach to community illicit drug toxicosurveillance: operationalisation of the Emerging Drugs Network of Australia - Victoria (EDNAV) project. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104251. [PMID: 37952318 DOI: 10.1016/j.drugpo.2023.104251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The Emerging Drugs Network of Australia - Victoria (EDNAV) project is a newly established toxicosurveillance network that collates clinical and toxicological data from patients presenting to emergency departments with illicit drug related toxicity in a centralised clinical registry. Data are obtained from a network of sixteen public hospital emergency departments across Victoria, Australia (13 metropolitan and three regional). Comprehensive toxicological analysis of a purposive sample of 22 patients is conducted each week, with reporting of results to key alcohol and other drug stakeholders. This paper describes the overarching framework and risk-based approach developed within Victoria to assess drug intelligence from EDNAV toxicosurveillance. METHODS Risk management principles from other spheres of public health surveillance and healthcare clinical governance have been adapted to the EDNAV framework with the aim of facilitating a consistent and evidence-based approach to assessing weekly drug intelligence. The EDNAV Risk Register was reviewed over the first two years of EDNAV project operation (September 2020 - August 2022), with examples of eight risk assessments detailed to demonstrate the process from signal detection to public health intervention. RESULTS A total of 1112 patient presentations were documented in the EDNAV Clinical Registry, with 95 signals of concern entered into the EDNAV Risk Register over the two-year study period. The eight examples examined in further detail included suspected drug adulteration (novel opioid adulterated heroin, para-methoxymethamphetamine adulterated 3,4-methylenedioxymethamphetamine (MDMA)), drug substitution (25B-NBOH sold as lysergic acid diethylamide, five benzodiazepine-type new psychoactive substances in a single tablet, protonitazene sold as ketamine), new drug detection (N,N-dimethylpentylone), contamination (unreported acetylfentanyl) and a fatality subsequent to MDMA use. A total of four public Drug Alerts were issued over this period. CONCLUSIONS Continued toxicosurveillance efforts are paramount to characterising the changing landscape of illicit drug use. This work demonstrates a functional model for risk assessment of illicit drug toxicosurveillance, underpinned by analytical confirmation and evidence-based decision-making.
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Affiliation(s)
- Rebekka Syrjanen
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jennifer L Schumann
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Victorian Institute of Forensic Medicine, Toxicology Department, Southbank, Victoria, Australia; Monash University, Monash Addiction Research Centre, Frankston, Victoria, Australia
| | - Tom Lyons
- The Department of Health, Alcohol and Other Drugs Strategy Team, Victorian State Government, Melbourne, Victoria, Australia
| | - Ginny McKinnon
- The Department of Health, Alcohol and Other Drugs Strategy Team, Victorian State Government, Melbourne, Victoria, Australia
| | - Sarah E Hodgson
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rachelle Abouchedid
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Bendigo Health, Emergency Department, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Dimitri Gerostamoulos
- Monash University, Department of Forensic Medicine, Southbank, Victoria, Australia; Victorian Institute of Forensic Medicine, Toxicology Department, Southbank, Victoria, Australia
| | - Zeff Koutsogiannis
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia
| | - John Fitzgerald
- The University of Melbourne, Melbourne School of Population and Global Health, Parkville, Victoria, Australia
| | - Shaun L Greene
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia; Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria, Australia.
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Isoardi KZ, Roberts DM, Holford AG, Brown JA, Griffiths A, Soderstrom J, McDonald C, Gerostamoulos D, Sakrajda P, Turner C, Yates H, Gunja N, Greene S. A cluster of acute thebaine poisonings from non-food grade poppy seeds in the Australian food supply. Clin Toxicol (Phila) 2023; 61:639-643. [PMID: 37855308 DOI: 10.1080/15563650.2023.2265053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Poppy seed tea is used for its opioid effects and contains multiple opium alkaloids, including morphine, codeine, papaverine, and thebaine. Animal studies indicate thebaine has strychnine-like properties, but there is limited literature describing human thebaine poisoning. We describe a cluster of acute thebaine poisoning in people ingesting tea made using poppy seeds with high thebaine content that entered the Australian food supply chain. METHODS This is an observational study of patients poisoned after drinking poppy seed tea. Cases were identified by three prospective toxicovigilance systems: the Emerging Drug Network of Australia collaboration, the New South Wales Prescription, Recreational and Illicit Substance Evaluation program, and the Emerging Drugs Network of Australia Victoria study. We report characteristics of clinical toxicity in cases with reported ingestion of poppy seed tea and analytical confirmation of thebaine exposure. RESULTS Forty cases presenting with multi-system toxicity following poppy seed tea ingestion were identified across seven Australian states/territories from November 2022 to January 2023. Blood testing in 23 cases confirmed high thebaine concentrations. All 23 were male (median age 35, range 16-71 years). All patients experienced muscle spasms. Rigidity was described in nine, convulsions in six, while rhabdomyolysis, acute kidney injury, and metabolic acidosis occurred in five patients. There were two cardiac arrests. The thebaine median admission blood concentration was 1.6 mg/L, with a range of 0.1-5.6 mg/L, and was the dominant opium alkaloid in all samples. Convulsions, acute kidney injury, metabolic acidosis, and cardiac arrest were associated with increasing median thebaine concentrations. Four patients were managed in the Intensive Care Unit, with two receiving continuous kidney replacement therapy (one also received intermittent haemodialysis) for kidney injury. There was one death. CONCLUSIONS Thebaine toxicity, like strychnine poisoning, resulted in neuromuscular excitation characterized by muscle spasm, rigidity, and convulsions. Severe toxicity, including acute kidney injury, metabolic acidosis, and cardiac arrest, appears dose-dependent.
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Affiliation(s)
- Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia
- Queensland Poisons Information Centre, Queensland Children's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Darren M Roberts
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Sydney, Australia
- Edith Collins Centre, Drug Health Services, Royal Prince Alfred Hospital, Sydney, Australia
| | - Amanda G Holford
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia
- Queensland Poisons Information Centre, Queensland Children's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Sydney, Australia
- Centre for Alcohol and Other Drugs, NSW Ministry of Health, Sydney, Australia
| | - Andrew Griffiths
- Forensic Toxicology, Forensic and Scientific Services, Brisbane, Australia
| | - Jessamine Soderstrom
- Centre of Clinical Research in Emergency Medicine, Emergency Department, Royal Perth Hospital, Perth, Australia
| | - Catherine McDonald
- Forensic Toxicology, Forensic & Analytical Science Service, NSW Health Pathology, Sydney, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, Victorian Institute of Forensic Medicine, Southbank, Victoria, Australia
| | - Paul Sakrajda
- Forensic Science Laboratory, ChemCentre, Perth, Australia
| | - Claire Turner
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Sydney, Australia
- Centre for Alcohol and Other Drugs, NSW Ministry of Health, Sydney, Australia
| | - Hans Yates
- Organic Chemistry, Forensic and Scientific Services, Brisbane, Australia
| | - Naren Gunja
- NSW Poisons Information Centre, Sydney Children's Hospitals Network, Sydney, Australia
- Dept of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia
| | - Shaun Greene
- Victorian Poisons Information Centre, Austin Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
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Weber C, Smith JL, Soderstrom J, Burrows S, McCutcheon D, Oosthuizen F, Fatovich DM. Analytically confirmed illicit and novel psychoactive drug use in Western Australian emergency departments: initial results from the Emerging Drugs Network of Australia (EDNA). Clin Toxicol (Phila) 2023:1-9. [PMID: 37449677 DOI: 10.1080/15563650.2023.2229951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION The burden of acute illicit drug use in Australia is largely unknown. Establishing a prospective drug surveillance system in emergency departments using analytical confirmation may facilitate the early identification of emerging drugs. We describe demographic data and acute toxicity patterns, stratified by analytical confirmation of illicit drugs and novel psychoactive substances, to emergency departments in Western Australia. METHODS Patients presenting with severe and/or unusual clinical features consistent with recreational drug toxicity were identified across five Western Australian emergency departments participating in the Emerging Drugs Network of Australia between April 2020 and December 2021. Demographic and toxicology patterns in patients with and without analytically confirmed illicit drugs/novel psychoactive substances from blood samples were collected during the emergency department presentation. RESULTS The cohort included 434 severe and/or unusual toxicology presentations; median age 33 years (first and third quartiles 25-40 years), 268 (61.8%) males. Any substance (illicit, novel psychoactive substance, pharmaceutical) was detected in 405 (93.3%) presentations. Illicit drugs/novel psychoactive substances were detected in 257 (59.2%) presentations, including 73 (28.3%) with more than one confirmed illicit drug/novel psychoactive substance. Frequent illicit drugs identified were metamfetamine (n = 201, 77.9%) and gamma-hydroxybutyrate (n = 30, 11.6%). Forty-eight novel psychoactive substances were detected within 43 (16.7%) presentations. Novel benzodiazepines were most frequently detected (n = 29, 60.4%). Frequent pharmaceuticals detected included diazepam (n = 100, 26.1%) and clonazepam (n = 40, 10.4%). One hundred and fifty-five (35.7%) presentations were discharged home and 56 (12.9%) were admitted to intensive care. Presentations with detected illicit drugs/novel psychoactive substances had a lower median intensive care length of stay compared to presentations without detected illicit drugs/novel psychoactive substances (32.6 h versus 50.8 h respectively, P < 0.001). CONCLUSIONS Integration of clinical and analytic data in patients with severe and/or unusual toxicology presentations via the Emerging Drugs Network of Australia provides insight into illicit drug/novel psychoactive substance use responsible for acute harm across Western Australian emergency departments.
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Affiliation(s)
- Courtney Weber
- Harry Perkins Institute of Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
| | - Jennifer L Smith
- Harry Perkins Institute of Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
| | - Jessamine Soderstrom
- Harry Perkins Institute of Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
| | - Sally Burrows
- School of Medicine, The University of Western Australia, Perth, Australia
- Royal Perth Hospital Research Foundation, Perth, Australia
| | - David McCutcheon
- Harry Perkins Institute of Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
| | | | - Daniel M Fatovich
- Harry Perkins Institute of Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Australia
- East Metropolitan Health Service, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
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Caldicott D. The long road to introduce drug checking as a harm reduction strategy in Australia. Emerg Med Australas 2023; 35:341-343. [PMID: 36864636 DOI: 10.1111/1742-6723.14193] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/04/2023]
Affiliation(s)
- David Caldicott
- Emergency Department, Calvary Public Hospital Bruce, Canberra, Australian Capital Territory, Australia
- ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
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Stockham P, Partridge E, Alfred S, Boyle L, Camilleri A, Green H, Haustead D, Humphries M, Kostakis C, Mallon J. Characteristics of analytically confirmed gamma-hydroxybutyrate (GHB) positive patients in the emergency department: presentation, poly-drug use, disposition and impact on intensive care resource utilisation. Clin Toxicol (Phila) 2023; 61:241-247. [PMID: 37129222 DOI: 10.1080/15563650.2023.2178933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Gamma-hydroxybutyrate is a potent central nervous system depressant with a narrow recreational dose window and analytical detection time. We describe data relating to intoxicated patients presenting to emergency departments across metropolitan Adelaide who tested positive for gamma-hydroxybutyrate. This work was part of the Emergency Department Admission Blood Psychoactive Testing study. METHODS Over a 15-month period, patients presenting to four metropolitan emergency departments with symptoms of drug intoxication were enrolled in the study. The methodology involved the collection of demographic and clinical data and a de-identified blood sample which underwent comprehensive toxicological analysis. Gamma-hydroxybutyrate was determined using an acid-catalysed cyclisation followed by liquid-liquid extraction and gas chromatography-mass spectrometry. Data relating to samples positive for gamma-hydroxybutyrate were examined. RESULTS AND DISCUSSION A total of 1120 patients were enrolled between March 2019 and May 2020, 309 of whom were positive for gamma-hydroxybutyrate (27.6%). Of these, 256 (83%) were also positive for metamfetamine (methamphetamine). The most common clinical observation in gamma-hydroxybutyrate-positive patients was central nervous system depression (89%). There was a significant relationship between gamma-hydroxybutyrate status and sex; although males outnumbered females in absolute terms, a higher proportion of females (32%) tested positive for gamma-hydroxybutyrate than males (25%, P = 0.0155). Blood gamma-hydroxybutyrate concentrations ranged from 10 to 651 mg/L (0.096-6.2 mmol/L) and increasing gamma-hydroxybutyrate concentration correlated with severe toxicity. The presence of gamma-hydroxybutyrate had a significant impact on the patient discharge destination: the majority (69.2%) of gamma-hydroxybutyrate-positive patients were managed and discharged from the emergency department or their attached short stay wards. A significantly higher proportion of gamma-hydroxybutyrate-positive patients were admitted to the intensive care unit (28.2%) compared with gamma-hydroxybutyrate-negative patients (12.7%, chi-squared = 36.85, P <0 .001). Gamma-hydroxybutyrate positive cases accounted for 45.8% of all study-related intensive care unit admissions. CONCLUSIONS Gamma-hydroxybutyrate is commonly detected in illicit drug-related emergency department presentations and is detected disproportionately in the patient cohort who require intensive care unit level care.
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Affiliation(s)
- Peter Stockham
- Forensic Science SA (Toxicology), Adelaide, Australia
- College of Science and Engineering, Flinders University, Bedford Park, Australia
| | - Emma Partridge
- Forensic Science SA (Toxicology), Adelaide, Australia
- College of Science and Engineering, Flinders University, Bedford Park, Australia
| | - Sam Alfred
- Emergency Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Laura Boyle
- Mathematical Sciences Research Centre, Queen's University Belfast, Belfast, UK
- School of Mathematical Sciences, The University of Adelaide, Adelaide, Australia
| | | | - Hannah Green
- Emergency Department, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Daniel Haustead
- Emergency Department, Royal Adelaide Hospital, Adelaide, Australia
- Emergency Department, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Melissa Humphries
- School of Mathematical Sciences, The University of Adelaide, Adelaide, Australia
| | | | - Jake Mallon
- Emergency Department, Flinders Medical Centre, Bedford Park, Australia
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Gerostamoulos D, Glowacki L, Pricone M, Crump K, Di Rago M, Joubert S, Lynch MJ, Woodford NW, Drummer OH. Fatal Intoxications from a Combination of 4-Fluoroamphetamine and 25C-NBOMe. J Anal Toxicol 2023; 47:191-196. [PMID: 35975553 DOI: 10.1093/jat/bkac059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 11/12/2022] Open
Abstract
Six fatalities have occurred from the ingestion of a combination of new psychoactive substances (NPSs), 4-fluoroamphetamine (4FA) and 2-(4-chloro-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine (25C-NBOMe) over a 9-month period. Four of these fatalities (one older female and three young males) were from direct adverse effects of drugs, and one each from a fall while being intoxicated and during restraint. All cases were subject to full postmortem examinations that included collection of femoral blood. The four drug-caused fatalities had postmortem blood concentrations for 4FA and 25C-NBOMe of 330-682 ng/L (median 417) and 1.4-12 ng/mL (median 4.3), respectively. The other two cases (both young males) where death was considered to have been caused indirectly by drug intoxication had 4FA and 25C-NBOMe postmortem concentrations of 21 and 123 ng/mL, and 1.8 and 4.5 ng/mL, respectively. None of these cases showed concentrations of drugs that suggested use of high recreational doses. In one drug-caused death, capsules and a brown powder obtained from the scene were found to contain a mixture of these two NPSs. With the exception of one drug-caused death, other drugs were detected; however, the effects of the two NPSs together were regarded as the primary triggers for the deaths. There were no consistent symptoms or pathology in these cases; however, agitation/aggression was observed in two cases prior to their collapse, with seizures in possibly three cases. Pulmonary and/or cerebral edema was noted in three cases. Potentially significant natural disease (a mildly enlarged heart) was only observed in one drug-caused case. These cases illustrate a possible increased risk of sudden death with this combination of drugs, both of which can elevate serotonin concentrations as well as act as strong stimulants. These cases also illustrate the difficulty in detecting NPS in cases where no prior information is available that might suggest their use.
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Affiliation(s)
- Dimitri Gerostamoulos
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
- Department of Forensic Medicine, Monash University, School of Public Health and Preventive Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Linda Glowacki
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Maria Pricone
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Kerryn Crump
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Matthew Di Rago
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
- Department of Forensic Medicine, Monash University, School of Public Health and Preventive Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Samantha Joubert
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Matthew J Lynch
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
- Department of Forensic Medicine, Monash University, School of Public Health and Preventive Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Noel W Woodford
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
- Department of Forensic Medicine, Monash University, School of Public Health and Preventive Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
| | - Olaf H Drummer
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
- Department of Forensic Medicine, Monash University, School of Public Health and Preventive Medicine, 65 Kavanagh Street, Southbank, Victoria 3006, Australia
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Brien R, Volpe I, Grigg J, Lyons T, Hughes C, McKinnon G, Tzanetis S, Crawford S, Eade A, Lee N, Barratt MJ. Co-designing drug alerts for health and community workers for an emerging early warning system in Victoria, Australia. Harm Reduct J 2023; 20:30. [PMID: 36894933 PMCID: PMC9995746 DOI: 10.1186/s12954-023-00761-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Alerts about changes in unregulated drug markets may be useful for supporting health and community workers to anticipate, prevent, and respond to unexpected adverse drug events. This study aimed to establish factors influencing the successful design and implementation of drug alerts for use in clinical and community service settings in Victoria, Australia. METHODS An iterative mixed methods design was used to co-produce drug alert prototypes with practitioners and managers working across various alcohol and other drug services and emergency medicine settings. A quantitative needs-analysis survey (n = 184) informed five qualitative co-design workshops (n = 31). Alert prototypes were drafted based on findings and tested for utility and acceptability. Applicable constructs from the Consolidated Framework for Implementation Research helped to conceptualise factors that impact successful alert system design. RESULTS Timely and reliable alerts about unexpected drug market changes were important to nearly all workers (98%) yet many reported insufficient access to this kind of information (64%). Workers considered themselves 'conduits' for information-sharing and valued alerts for increasing exposure to drug market intelligence; facilitating communication about potential threats and trends; and improving capacity for effective responding to drug-related harm. Alerts should be 'shareable' across a range of clinical and community settings and audiences. To maximise engagement and impact, alerts must command attention, be easily recognisable, be available on multiple platforms (electronic and printable formats) in varying levels of detail, and be disseminated via appropriate notification mechanisms to meet the needs of diverse stakeholder groups. Three drug alert prototypes (SMS prompt, summary flyer, and a detailed poster) were endorsed by workers as useful for supporting their work responding to unexpected drug-related harms. DISCUSSION Alerts informed by coordinated early warning networks that offer close to real-time detection of unexpected substances can provide rapid, evidence-based drug market intelligence to inform preventive and responsive action to drug-related harm. The success of alert systems requires adequate planning and resourcing to support design, implementation, and evaluation, which includes consultation with all relevant audiences to understand how to maximise engagement with information, recommendations, and advice. Our findings about factors impacting successful alert design have utility to inform the development of local early warning systems.
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Affiliation(s)
- Rita Brien
- Turning Point, Eastern Health Statewide Services, Richmond, Australia.,Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Isabelle Volpe
- Social and Global Studies Centre, RMIT University, Melbourne, Australia.,Drug Policy Modelling Program, Social Policy Research Centre, UNSW Sydney, Sydney, Australia
| | - Jasmin Grigg
- Turning Point, Eastern Health Statewide Services, Richmond, Australia.,Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Tom Lyons
- Department of Health, State Government of Victoria, Melbourne, Australia
| | - Caitlin Hughes
- Law and Commerce, Flinders University, Adelaide, Australia.,National Drug and Alcohol Research Centre, UNSW, Sydney, Australia
| | - Ginny McKinnon
- Department of Health, State Government of Victoria, Melbourne, Australia
| | - Stephanie Tzanetis
- Harm Reduction Victoria (DanceWize), Melbourne, Australia.,CanTEST - Directions Health Services, Canberra, Australia
| | - Sione Crawford
- Harm Reduction Victoria (DanceWize), Melbourne, Australia
| | - Alan Eade
- Safer Care Victoria, Melbourne, Australia.,Department of Paramedicine, Monash University, Melbourne, Australia
| | - Nicole Lee
- 360Edge, Melbourne, Australia.,National Drug Research Institute, Curtin University, Perth, Australia
| | - Monica J Barratt
- Social and Global Studies Centre, RMIT University, Melbourne, Australia. .,National Drug and Alcohol Research Centre, UNSW, Sydney, Australia. .,Digital Ethnography Research Centre, RMIT University, Melbourne, Australia.
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11
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New Psychoactive Substances: Major Groups, Laboratory Testing Challenges, Public Health Concerns, and Community-Based Solutions. J CHEM-NY 2023. [DOI: 10.1155/2023/5852315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Across communities worldwide, various new psychoactive substances (NPSs) continue to emerge, which worsens the challenges to global mental health, drug rules, and public health risks, as well as combats their usage. Specifically, the vast number of NPSs that are currently available, coupled with the rate at which new ones emerge worldwide, increasingly challenges both forensic and clinical testing strategies. The well-established NPS detection techniques include immunoassays, colorimetric tests, mass spectrometric techniques, chromatographic techniques, and hyphenated types. Nonetheless, mitigating drug abuse and NPS usage is achievable through extensive community-based initiatives, with increased focus on harm reduction. Clinically validated and reliable testing of NPS from human samples, along with community-driven solution, such as harm reduction, will be of great importance, especially in combating their prevalence and the use of other illicit synthetic substances. There is a need for continued literature synthesis to reiterate the importance of NPS, given the continuous emergence of illicit substances in the recent years. All these are discussed in this overview, as we performed another look into NPS, from differentiating the major groups and identifying with laboratory testing challenges to community-based initiatives.
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12
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Syrjanen R, Schumann J, Fitzgerald J, Gerostamoulos D, Abouchedid R, Rotella JA, Knott J, Maplesden J, Hollerer H, Hannon L, Bourke E, Hodgson SE, Greene SL. The Emerging Drugs Network of Australia - Victoria Clinical Registry: A state-wide illicit substance surveillance and alert network. Emerg Med Australas 2023; 35:82-88. [PMID: 36053993 DOI: 10.1111/1742-6723.14059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/11/2022] [Accepted: 07/26/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES With an increasingly dynamic global illicit drug market, including the emergence of novel psychoactive substances, many jurisdictions have moved to establish toxicosurveillance systems to enable timely detection of harmful substances in the community. This paper describes the methodology for the Emerging Drugs Network of Australia - Victoria (EDNAV) project, a clinical registry focused on the collection of high-quality clinical and analytical data from ED presentations involving illicit drug intoxications. Drug intelligence collected from the project is utilised by local health authorities with the aim to identify patterns of drug use and emerging drugs of concern. METHODS The project involves 10 public hospital EDs in Victoria, Australia. Patients 16 years and over, presenting to a network ED with a suspected illicit drug-related toxicity and a requirement for venepuncture are eligible for inclusion in the study under a waiver of consent. Clinical and demographic parameters are documented by site-based clinicians and comprehensive toxicological analysis is conducted on patient blood samples via specialised forensic services. All data are then deidentified and compiled in a project specific database. RESULTS Cases are discussed in weekly multidisciplinary team meetings, with a view to identify potentially harmful substances circulating in the community. High-risk signals are escalated to key stakeholders to produce timely and proportionate public health alerts with a focus on harm minimisation. CONCLUSIONS The EDNAV project represents the first centralised system providing near real-time monitoring of community drug use in Victoria and is fundamental in facilitating evidence-based public health intervention.
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Affiliation(s)
- Rebekka Syrjanen
- Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennifer Schumann
- Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia
| | - John Fitzgerald
- Department of Criminology, School of Social and Political Sciences, Faculty of Arts, The University of Melbourne, Melbourne, Victoria, Australia
| | - Dimitri Gerostamoulos
- Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rachelle Abouchedid
- Emergency Department, Bendigo Hospital, Bendigo Health, Bendigo, Victoria, Australia.,Victorian Poisons Information Centre, Austin Hospital, Austin Health, Melbourne, Victoria, Australia
| | - Joe-Anthony Rotella
- Victorian Poisons Information Centre, Austin Hospital, Austin Health, Melbourne, Victoria, Australia.,Emergency Department, The Northern Hospital, Northern Health, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Knott
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Victoria, Australia
| | - Jacqueline Maplesden
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Hans Hollerer
- Emergency Department, Footscray Hospital, Western Health, Melbourne, Victoria, Australia
| | - Liam Hannon
- Emergency Department, Bendigo Hospital, Bendigo Health, Bendigo, Victoria, Australia
| | - Elyssia Bourke
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Ballarat Base Hospital, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Sarah E Hodgson
- Victorian Poisons Information Centre, Austin Hospital, Austin Health, Melbourne, Victoria, Australia.,Emergency Department, Austin Hospital, Austin Health, Melbourne, Victoria, Australia
| | - Shaun L Greene
- Victorian Poisons Information Centre, Austin Hospital, Austin Health, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Austin Hospital, Austin Health, Melbourne, Victoria, Australia
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13
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Solmi M, Chen C, Daure C, Buot A, Ljuslin M, Verroust V, Mallet L, Khazaal Y, Rothen S, Thorens G, Zullino D, Gobbi G, Rosenblat J, Husain MI, De Gregorio D, Castle D, Sabé M. A century of research on psychedelics: A scientometric analysis on trends and knowledge maps of hallucinogens, entactogens, entheogens and dissociative drugs. Eur Neuropsychopharmacol 2022; 64:44-60. [PMID: 36191546 DOI: 10.1016/j.euroneuro.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 11/22/2022]
Abstract
A scientometric analysis was realized to outline clinical research on psychedelics over the last century. Web of Science Core Collection was searched up to March 18, 2022, for publications on psychedelics. Network analyses and bibliometrics were combined, to identify research themes and trends with Bibliometrix and CiteSpace. The primary aim was to measure research trends evolution over time, and the secondary aims were to identify bibliometric performance and influence networks of publications, authors, institutions, and countries. Sensitivity analyses were conducted for 2016-2022, and 2021 time periods. We included 31,687 documents (591,329 references), which aggregated into a well-structured network with credible clustering. Research productivity was split into an early less productive period mainly focusing on safety issues, and a "psychedelic renaissance" after the 1990s. Major trends were identified for hallucinogens/entheogens, entactogens, novel psychoactive substances (NPS), and on dissociative substances. There was a translational evolution from the bench to the bedside, with phase 2 and 3 trials and/or evidence synthesis in particular. The most recent trends concerned NPS, ketamine-associated brain changes, and ayahuasca-assisted psychotherapy. The USA and Canada were the most productive settings for the research overall, and more recently this geographical distribution became more prominent, reflecting legislative context/policy making. A translational evolution of psychedelics has been occurring, that has brought approval of esketamine for depression and will likely lead to approval of additional psychedelics across mental and physical conditions. Toxicology screening tools for NPS are urgently needed, which in turn might follow the same translational evolution of psychedelics in the future.
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Affiliation(s)
- Marco Solmi
- Department of Psychiatry, University of Ottawa, Ontario, Canada; Department of Mental Health, The Ottawa Hospital, Ontario, Canada; Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Chaomei Chen
- College of Computing & Informatics, Drexel University, Philadelphia, PA, USA
| | - Charles Daure
- Université de Paris, INSERM UMRS1144, 4 avenue de l'Observatoire, 75006 Paris, France
| | - Anne Buot
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, France; Hôpital de la Pitié Salpêtrière, Paris, France
| | - Michael Ljuslin
- Palliative Medicine Division, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
| | - Vincent Verroust
- Centre d'histoire des sciences, des sociétés et des conflits, Université Picardie Jules-Vernes, Amiens, France; UR PsyComAdd, hôpital Paul Brousse, Villejuif, France
| | - Luc Mallet
- Univ Paris-Est Créteil, DMU IMPACT, Département Médical-Universitaire de Psychiatrie et d'Addictologie, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France; Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France; Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Yasser Khazaal
- Addiction Medicine, Lausanne University Hospital and Lausanne University, Switzerland Bugnon 23 a, 1011, Lausanne, Switzerland
| | - Stephane Rothen
- Division of Addiction Psychiatry, Department of Psychiatry, University Hospitals of Geneva, 70, Grand-Pré, CH-1202 Geneva, Switzerland
| | - Gabriel Thorens
- Division of Addiction Psychiatry, Department of Psychiatry, University Hospitals of Geneva, 70, Grand-Pré, CH-1202 Geneva, Switzerland
| | - Daniele Zullino
- Division of Addiction Psychiatry, Department of Psychiatry, University Hospitals of Geneva, 70, Grand-Pré, CH-1202 Geneva, Switzerland
| | - Gabriella Gobbi
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Joshua Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Alberta, Edmonton, Canada; Institute of Medical Science, University of Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Muhammad Ishrat Husain
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Danilo De Gregorio
- Division of Neuroscience, Vita-Salute San Raffaele University, 20132, Milan, Italy
| | - David Castle
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Michel Sabé
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Thonex, Switzerland.
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14
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Smith JL, McCutcheon D, Weber C, Soderstrom J, Burcham J, Fatovich DM. ‘Trial by fire’: An online survey exploring confidence of junior doctors in managing toxicology presentations to the emergency department. Drug Alcohol Rev 2022; 41:1554-1564. [DOI: 10.1111/dar.13526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/22/2022] [Accepted: 07/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jennifer L. Smith
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
- East Metropolitan Health Service Department of Health Perth Australia
| | - David McCutcheon
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
- Emergency Department Royal Perth Hospital Perth Australia
- Emergency Medicine The University of Western Australia Perth Australia
- Royal Perth Hospital Research Foundation Royal Perth Hospital Perth Australia
| | - Courtney Weber
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
- East Metropolitan Health Service Department of Health Perth Australia
| | - Jessamine Soderstrom
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
- Emergency Department Royal Perth Hospital Perth Australia
- Emergency Medicine The University of Western Australia Perth Australia
| | - Jonathon Burcham
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
- East Metropolitan Health Service Department of Health Perth Australia
- Emergency Department Royal Perth Hospital Perth Australia
| | - Daniel M. Fatovich
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Australia
- East Metropolitan Health Service Department of Health Perth Australia
- Emergency Department Royal Perth Hospital Perth Australia
- Emergency Medicine The University of Western Australia Perth Australia
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