Prevalence and healthcare burden of illegal drug use among emergency department patients

Electronic-Screening, Brief Intervention and Referral to Treatment (e-SBIRT) for Addictive Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Addictive disorders are significant global public health burdens. Treatment uptake with these disorders is low and outcomes can be mixed. Electronic screening, brief intervention, and referral to treatment (e-SBIRT) programs have potential to improve uptake and treatment outcomes. To date, however, no prior review of the literature has been conducted to gauge the effectiveness of e-SBIRT for addictive disorders.

METHODS

We conducted a systematic review and meta-analysis of the literature concerning e-SBIRT for addictive disorders by surveying the MEDLINE, PubMed, Web of Science, Scopus, Embase, and PsycInfo databases on January 17, 2023.

RESULTS

Ten articles were included at analysis reporting evaluation of e-SBIRT interventions for substance use disorders including alcohol use in a variety of settings. No articles were identified regarding treatment for behavioral addictions such as disordered/harmful gambling. Meta-analysis found e-SBIRT to be effective at reducing drinking frequency in the short term only. e-SBIRT was not found to be advantageous over control conditions for abstinence or other treatment outcomes. We identified and described common components of e-SBIRT programs and assessed the quality of available evidence, which was generally poor.

CONCLUSION

The present findings suggest that research regarding e-SBIRT is concentrated exclusively on higher-risk substance use. There is a lack of consensus regarding the effectiveness of e-SBIRT for addictive disorders. Although common features exist, e-SBIRT designs are variable, which complicates identification of the most effective components. Overall, the quality of outcome evidence is low, and furthermore, high-quality experimental treatment evaluation research is needed.

Risk characteristics of alcohol and/or drug misuse in repeat emergency department attendees for seizures: a case-control study

BACKGROUND

There is a bi-directional relationship between seizures and substance misuse, i.e., alcohol and recreational drugs. Seizures and substance misuse are recognised separately to influence increased emergency department (ED) admissions and early death. There is however no understanding of the cumulative influence of these matters on repeat ED attenders for seizures esp. as a third are likely to re-attend within the year. This case-control study compares the characteristics of people with substance misuse to those without substance misuse presenting recurrently with seizures to the ED.

METHODS

From a single ED serving a rural population in the Southwest of England, data of all people presenting more than once with a seizure over a 4-year period were examined. The diagnosis of alcohol or drug misuse, deaths, demographic characteristics, and service use were captured.

RESULTS

Of 450 repeat attenders, 95 had a recorded history of alcohol and/or drug problems. Those with substance misuse had double the mortality when adjusted for age and gender compared to those without. They were also more likely to be male, younger in age, have mental health issues, live in socially deprived neighborhoods, not take anti-seizure medications and not have had a specialist review in epilepsy services in the previous year. Nearly a quarter of those with addiction issues died in the 4-year period.

DISCUSSION

Service provision for this vulnerable group may need to be modelled along different lines to traditional approaches, such as an assertive outreach community-based service as provided for chronic psychiatric and addiction management.

Accuracy of substance exposure history in patients attending emergency departments after substance misuse; a comparison with biological sample analysis

CONTEXT

Acute toxicity caused by illicit substance use is a common reason for emergency department (ED) presentation. Knowledge of the substances involved is helpful for predicting and managing potential toxicity, but limited information is available about the accuracy of patient-reported substance exposure. This study assessed the accuracy of the history of exposure in those reporting use of a single substance by comparison with those identified by detailed toxicological analysis, focusing on synthetic cannabinoid receptor agonists (SCRA).

METHODS

Adults (≥16 years) presenting between March 2015 and July 2021 to participating UK hospitals with toxicity after reporting use of a single illicit substance were included. Exposure details were documented from medical records and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry (HRAM LCMS). Sensitivity, specificity, and positive and negative predictive values of the exposure history were calculated by comparison with biological sample analysis ("gold standard").

RESULTS

Single substance exposure was reported for 474 (median age 33 years, IQR: 18 range 16-75, 80% males) patients. Analysis commonly identified multiple substances (Median 3, IQR 2-5). A history of exposure was documented for 121 of 151 patients where a SCRA or metabolite was detected on analysis (sensitivity 80.1%, 95% CI 72.9, 86.2%). Corresponding proportions were lower for 3,4-methylenedioxymethamphetamine (MDMA, 44/70, 62.9%., 95% CI 50.5%, 74.1%), heroin 41/108 (38.0% 95% CI 28.8-47.8%) and cocaine (22/56, 31.3%, 95% CI 20.9, 43.6%).

CONCLUSIONS

Multiple undeclared substances were detected analytically in most patients reporting single substance use. Clinicians should be alert to the potential presence and toxicity of unreported substances when managing patients presenting after substance misuse.

Emergency department presentations of alcohol and other substance misuse: first cross-sectional national study in Qatar

OBJECTIVES

This study attempts the first in a series of investigations into the misuse of alcohol and substances in Qatar. This study explores the emergency presentations of alcohol and substance abuse to all the state funded emergency departments (EDs) in the country which serve around 90% of the population over a 22-month period. Due to legal penalties for alcohol and substance use, and lack of subsidised community-based facilities, ED presentations are a good starting point to explore this burden.

DESIGN AND PARTICIPANTS

A retrospective population-based, cross-sectional study, analysing electronic patient records of all state funded EDs spanning a period of 22 months, from 1 January 2019 to 31 October 2020 was carried out. The study included all eligible individuals aged 18 or over. Primary reason/diagnosis for presentation containing any of the alcohol or substance use key words were included in the study using composite data capture forms by trained clinicians.

RESULTS

An overwhelming majority (95.5%) of the total 1495 cases presenting to the EDs with substance abuse were using alcohol. Only 2.1% of the cases were females. Those of Asian (non-Arab) constituted 70% of this group. Qatari citizens presented with highest proportion of substance abuse other than alcohol (23%). Overall, 2.26% of all presentations to the EDs were related to alcohol and substance abuse and this amounted to 3 ED visits per 10 000 of population per year. 56.6% of the cases presented over the weekend. Less than 1% were referred to psychiatry and no other meaningful rehabilitative interventions were offered to others.

CONCLUSION

As Qatar moves towards establishing community-based rehabilitative resources for alcohol and substances abuse, the findings from this study will help in shaping these developments. These can include ED-based routine screening for alcohol abuse and referral to rehabilitation services without fear of legal penalties.

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis

AIMS

To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

DESIGN

Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

SETTING AND PARTICIPANTS

People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

MEASUREMENTS

Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

FINDINGS

Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

CONCLUSIONS

People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.

The need for further oral health research surrounding the provision of dental treatment for people with drug dependency

The aim of this article is to highlight the need for further research in providing dental care for people with drug dependency. The association between people who misuse substances and dental disease is widely known occurrence, yet there have been few studies conducted in the UK surrounding this issue due to the nature of the cohort. Further to this, there are a multitude of barriers to accessing/seeking dental care that exist for those with drug dependency. Going forward, there is a need for the development of a new service model where dental care is part of a multidisciplinary team working towards treating people with drug dependency in a holistic way.

Monitoring trends in recreational drug use from the analysis of the contents of amnesty bins in gay dance clubs

BACKGROUND

In 2011/12, 8.9% of the UK population reported use of recreational drugs. Problems related to drug use is a major financial burden to society and a common reason for attendance to hospital.

AIM

The aim of this study was to establish current trends in recreational drug use amongst individuals attending gay-friendly nightclubs in South London.

METHOD

Contents of drug amnesty bins located at two night clubs were documented and categorized into powders, herbal products, liquids, tablets and capsules. These were then sent to a Home Office licensed laboratory for identification through a pre-existing database of almost 25 000 substances. If required, further qualitative analysis was performed.

RESULTS

A total of 544 samples were obtained. Of them, 240 (44.1%) were liquids, 220 (40.4%) powders, 42 (7.7%) herbal and 41 (7.5%) tablets or capsules. Gamma-butyrolactone (GBL) was the most common liquid drug (n = 160, 66.7%) followed by poppers (n = 72, 30.0%). Powders provided the widest range of drugs with mephedrone being the most common (n = 105, 47.7%) followed by ketamine (n = 28, 12.7%), 3,4-methylenedioxy-N-methylamphetamine (MDMA) (n = 26, 11.8%), and cocaine (n = 21, 9.5%). Tablets and capsules included medicinal drugs, recreational drugs and plaster of Paris tablets that mimicked the appearance of 'ecstasy' tablets.

CONCLUSION

This study has provided a snapshot of the pattern of drug use in the gay community which compliments findings of the self-reported surveys and other studies from the same population. The information obtained will be helpful in guiding in designing harm reduction interventions in this community and for monitoring the impact of changes in legislation.

Acute hand ischemia after intra-arterial injection of meprobamate powder

BACKGROUND

Meprobamate tablets contain microcrystalline cellulose, a potent embolic agent that has been shown to cause gangrene in animal studies. Microvascular embolization caused by microcrystalline cellulose can contribute to the ischemic process.

OBJECTIVE

We report a case of acute hand ischemia after accidental intra-arterial injection of crushed meprobamate powder in a 23-year-old male drug abuser.

CASE REPORT

The distal tips of the patient's right thumb, index finger, ring finger, and little finger continued to develop gangrene despite medical therapy with heparinization, low molecular-weight dextran infusion, corticosteroid administration, and hyperbaric oxygen therapy.

CONCLUSION

We believe this is the first case of acute limb ischemia caused by intra-arterial injection of meprobamate powder documented in humans. Emergency physicians should be aware that accidental intra-arterial injection of crushed oral drug formulations is potentially limb threatening and prompt recognition of similar clinical scenarios is of vital importance.

Radiology of Recreational Drug Abuse

Recreational drug abuse is increasing throughout the world. Use of these drugs may result in a diverse array of acute and chronic complications involving almost any body organ, and imaging frequently plays a vital role in detection and characterization of such complications. The nature of the complications depends to a large extent on the drug used, the method of administration, and the impurities associated with the drug. Radiologically demonstrable sequelae may be seen after use of opiates, cocaine, amphetamines and their derivatives such as 3,4-methylenedioxymethamphetamine ("ecstasy"), marijuana, and inhaled volatile agents including amyl nitrite ("poppers") and industrial solvents such as toluene. Cardiovascular complications include myocardial infarction, cardiomyopathy, arterial dissection, false and mycotic aneurysms, venous thromboembolic disease, and septic thrombophlebitis. Respiratory complications may involve the upper airways, lung parenchyma, pulmonary vasculature, and pleural space. Neurologic complications are most commonly due to the cerebrovascular effects of illicit drugs. Musculoskeletal complications are dominated by soft-tissue, bone, and joint infections caused by intravenous drug use. Awareness of the imaging features of recreational drug abuse is important for the radiologist because the underlying cause may not be known at presentation and because complications affecting different body systems may coexist. Intravenous drug abuse in particular should be regarded as a multisystem disease with vascular and infective complications affecting many parts of the body, often synchronously. Discovery of one complication should prompt the radiologist to search for coexisting pathologic conditions, which may alter management.

Drug consumption rooms: an overdue extension to harm reduction policy in the UK?

This commentary examines the drug policy context of drug consumption rooms (DCRs) in the UK and describe the conclusions of an Independent Working Group (IWG) that was set up to evaluate the evidence of need in the UK, the international evaluation literature and legal, political and ethical concerns. Having considered this evidence, the IWG produced its report in May 2006, recommending a trial of DCRs in the UK, on the basis that DCRs offer a unique and promising way to work with problematic drug users in order to reduce the risk of overdose, improve their health and lessen the damage and costs to society. However, despite support for the idea from a number of quarters, the UK Government has rejected this recommendation, citing previously deployed arguments that do not appear to be carry much weight in 2007.