1
|
Alexander GC, Budnitz D, Hughes C, Maas R, Mair A, McDonald EG, Meid AD, Payne R, Seidling HM, Shakir S, Suissa S, Tannenbaum C, Schneeweiss S, Dreischulte T. Proceedings of the International Ambulatory Drug Safety Symposium: Munich, Germany, June 2023. Drug Saf 2024; 47:103-111. [PMID: 37917316 DOI: 10.1007/s40264-023-01362-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Affiliation(s)
- G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6035, Baltimore, MD, 21205, USA.
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany.
| | - Daniel Budnitz
- Kenvue, Fort Washington, PA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
- United States Public Health Service (Retired), Atlanta, GA, USA
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Renke Maas
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, UK
| | - Emily G McDonald
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, QC, Canada
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rupert Payne
- Exeter Collaboration for Academic Primary Care (APEx), Exeter Medical School, University of Exeter, Exeter, UK
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Saad Shakir
- Drug Safety Research Unit, University of Portsmouth, Southampton, UK
| | - Samy Suissa
- Department of Epidemiology and Biostatistics, and Department of Medicine, McGill University, Montreal, QC, Canada
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | | | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
2
|
Sheng CQ, Wang W, Xue Y, Li YM. Demographics and Clinical Characteristics Assessment of Severe Acute Toxic Ingestions in Pediatric Patients: A Single-Center Study in Jilin Province of China. Pediatr Emerg Care 2023; 39:957-962. [PMID: 38019715 DOI: 10.1097/pec.0000000000003077] [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: 12/01/2023]
Abstract
OBJECTIVE This study aimed to describe the demographic and clinical characteristics of severe acute toxic ingestions in children in Jilin Province and provide a reference for seeking effective measures to prevent poisoning accidents. METHODS The clinical data of patients diagnosed with acute toxic ingestions and who presented with severe life-threatening symptoms or organ dysfunction at the Pediatric Intensive Care Unit of the First Hospital of Jilin University were retrospectively analyzed. Patients with incomplete clinical medical records, unclear toxic substance, and loss to follow-up within 6 months of discharge are excluded. We sorted out these children's demographic characteristics, types of poisoning, clinical manifestations, treatment process, and follow-up, etc. RESULTS This study enrolled 141 cases with no significant differences in sex and region; adolescents accounted for 44.68%. The most common poisons were pesticides and insecticides for rural areas and internal medication for urban areas. With poisoning details as a grouping variable, there was no statistical difference between sex groupings (χ2 = 6.018, P = 0.198) and no difference between region groups (χ2 = 3.775, P = 0.289). However, there were statistical differences between age groups (χ2 = 28.22, P = 0.001). In this research, patients younger than 6 years are mainly unintentionally poisoned, whereas the suicide rate of the urban group (P < 0.05), adolescents (P < 0.01), and girls (P < 0.01) has increased significantly; moreover, the suicide group is more likely to take more overdose medication or pesticides and insecticides (P < 0.01). In addition, there was a statistical difference between suicide and length of intensive care unit stay (r = 0.268, P < 0.01). A total of 90.78% of the patients were successfully discharged after comprehensive treatment. Children aged younger than 12 years had good psychological and intellectual development during the follow-up period, whereas adolescents diagnosed with depression often required long-term psychological and medication intervention. CONCLUSIONS This study identified poisoning details in different ages, regions, and sex of acute severe oral poisoning in children from Jilin Province. The results presentation of different prevention priorities should vary among children of different ages and emphasize adolescent suicide being a reality in Jilin Province. There is an urgent need for further culture-specific research in this area.
Collapse
Affiliation(s)
- Chu-Qiao Sheng
- From the Pediatric Critical Care, Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Wenzhen Wang
- From the Pediatric Critical Care, Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Xue
- Pediatric Rehabilitation, Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yu-Mei Li
- From the Pediatric Critical Care, Department of Pediatric Intensive Care Unit, The First Hospital of Jilin University, Changchun, Jilin, China
| |
Collapse
|
3
|
Deutsch SA, De Jong AR. Xylazine Complicating Opioid Ingestions in Young Children. Pediatrics 2023; 151:190352. [PMID: 36550066 DOI: 10.1542/peds.2022-058684] [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] [Accepted: 10/05/2022] [Indexed: 12/24/2022] Open
Abstract
The authors of this report present 3 cases of synthetic opioid intoxication complicated by the concomitant presence of the additive xylazine, a nonopioid sedative analgesic and muscle relaxant used in veterinary medicine that potentiates respiratory depression associated with the opioid toxidrome. Three exposed children presented with severe signs and symptoms, 2 of whom experienced cardiac arrest, a need for continuous naloxone infusion or multiple naloxone doses, or mechanical ventilation to treat respiratory failure after their exposures. Additives were detected in urine studies only through the performance of specialized toxicology testing. Detection of xylazine among adult overdose deaths has recently increased sharply, particularly across the northeastern United States. Adulteration by xylazine is an emerging public health threat nationally. Our report reveals that pediatricians should be aware of sentinel drug trends among adults, including the emerging types of illicit, synthetic, or counterfeit formulations of recreational substances, because children may be harmed because of accidental or intentional exposure. Children exposed to dangerous substances also need child protection services that may entail safe relocation outside of the home and the referral of affected caregivers to necessary substance use treatment services. Given epidemic drug use among adults, pediatricians should be competent to recognize common toxidromes and be aware that signs and symptoms may be potentiated by synergistic novel additives or polysubstance exposures. Importantly, standard urine drug screens may not detect synthetic opioid derivatives or contributing additives, so that diagnosis will require specialized toxicology testing.
Collapse
|
4
|
Kim I, Goulding M, Tian F, Karami S, Pham T, Cheng C, Biehl A, Muñoz M. Benzonatate Exposure Trends and Adverse Events. Pediatrics 2022; 150:189946. [PMID: 36377394 PMCID: PMC9732921 DOI: 10.1542/peds.2022-057779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adverse events (AE), including death, occur in children with benzonatate use. This study aims to understand recent trends in benzonatate exposure and clinical consequences in pediatric patients. METHODS This retrospective analysis of data from IQVIA pharmacy drug dispensing, National Poison Data System, National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project, FDA Adverse Event Reporting System, and the medical literature evaluated exposure trends and medication-related AEs with benzonatate. Trends for comparator narcotic and nonnarcotic antitussive medications were analyzed where possible for context. RESULTS During the study period, pediatric benzonatate prescription utilization increased but remained low compared with pediatric utilization of dextromethorphan-containing prescription antitussive medications. Among the 4689 pediatric benzonatate exposure cases reported to US poison control centers from 2010 to 2018, 3727 cases (80%) were for single-substance exposures. Of these, 3590 cases (77%) were unintentional exposures and most involved children 0 to 5 years old (2718 cases, 83%). Cases involving intentional benzonatate exposure increased among children 10 to 16 years old with a more pronounced increase for multiple-substance exposures. Most benzonatate cases involving misuse or abuse were for children 10 to 16 years old (59 cases, 61%). The proportion of cases with serious adverse effects was low. There were few cases annually of serious AEs with benzonatate in children. CONCLUSIONS There were rising patterns of unintentional ingestion of benzonatate in children 0 to 5 years old and intentional benzonatate ingestion in children 10 to 16 years old. Rational prescribing and improved provider and caregiver awareness of benzonatate toxic effects may reduce risks associated with benzonatate exposure.
Collapse
|
5
|
Wiener Amram H, Daviko BHA, Dalal Y, Meirson G, Brantz I, Tasher D, Ovadia A, Dalal I. Unintentional Acute Poisoning Related Emergency Department Visits in Children in a Single-Center: A Nine-Year Prospective Survey. Clin Pediatr (Phila) 2022; 61:615-621. [PMID: 35673846 DOI: 10.1177/00099228221094127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pediatric morbidity due to unintentional poison exposure is a significant burden on public health. We prospectively characterize patterns of unintentional poison exposure in a single pediatric emergency department, using a detailed computerized questionnaire for all unintentional injuries admitted during 2009 to 2017. Out of 71,765 visits due to unintentional injuries, 252 children were admitted due to unintentional poison exposure. Most (198/252, 79%) were between 1 and 3 years of age. The majority of events (209/252, 82.9%) occurred at the patient's home and 81% (205/255) were classified as exploratory ingestion. In 41/252 (14%) cases, exposure to more than one substance was reported. Most events 231/293 (79%) involved medications and 21% were due to domestic products. Four medications account for 45% of the events (Paracetamol, Salbutamol, Antihypertensive, and Antidepressants). Opioids were responsible for only 1.7%. By, collaboration between government, public health, educational institutions and commercial companies, can the burden of pediatric unintentional poison exposure be reduced.
Collapse
Affiliation(s)
| | | | - Yotam Dalal
- Pediatric Department, E. Wolfson Medical Center, Holon, Israel
| | - Gila Meirson
- Pediatric Emergency Department, E. Wolfson Medical Center, Holon, Israel
| | - Ilona Brantz
- Pediatric Emergency Department, E. Wolfson Medical Center, Holon, Israel
| | - Diana Tasher
- Pediatric Department, E. Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Ovadia
- Pediatric Department, E. Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Dalal
- Pediatric Department, E. Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
6
|
Renny MH, Thaker RH, Dayan PS. Caregiver Practices and Knowledge Regarding Leftover Prescription Medications in Homes With Children. Pediatr Emerg Care 2022; 38:e1557-e1563. [PMID: 35857916 DOI: 10.1097/pec.0000000000002680] [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: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were to determine the frequency of and factors associated with leftover or expired prescription medication ("leftover medication") presence in homes with children and to assess caregivers' reported behaviors and knowledge regarding disposal of leftover medications in the home. METHODS This study is a planned secondary analysis from a survey of primary caregivers of children aged 1 to 17 years presenting to an emergency department. The survey assessed leftover medications in the home and medication disposal practices, knowledge, and guidance. The survey was developed iteratively and pilot tested. Multivariable logistic regression was used to identify factors associated with leftover medication presence in the home. RESULTS We enrolled 550 primary caregivers; 97 of the 538 analyzed (18.0%; 95% confidence interval [CI], 14.8-21.5) reported having leftover medications in their home, most commonly antibiotics and opioids. Of respondents, 217/536 (40.5%) reported not knowing how to properly dispose of medications and only 88/535 (16.4%) reported receiving guidance regarding medication disposal. Most caregivers reported throwing leftover medications in the trash (55.7%) or flushing them down the toilet (38.5%). Caregivers with private insurance for their child were more likely to have leftover medications (adjusted odds ratio [aOR], 1.99; CI, 1.15-3.44), whereas Hispanic caregivers (aOR, 0.24; CI, 0.14-0.42) and those who received guidance on leftover medications (aOR, 0.30; CI, 0.11-0.81) were less likely to have leftover medications in the home. CONCLUSIONS Leftover medications are commonly stored in homes with children and most caregivers do not receive guidance on medication disposal. Improved education and targeted interventions are needed to ensure proper medication disposal practices.
Collapse
Affiliation(s)
| | - Riddhi H Thaker
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons
| | - Peter S Dayan
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons
| |
Collapse
|
7
|
Odegard M, Kelley-Quon LI. Postoperative Opioid Prescribing, Use, and Disposal in Children. Adv Pediatr 2022; 69:259-271. [PMID: 35985715 DOI: 10.1016/j.yapd.2022.03.003] [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: 11/26/2022]
Abstract
This article provides an overview of postoperative opioid prescribing, use, and disposal patterns in children and also identifies gaps in knowledge and areas for improvement. We present evidence that there is a need to tailor prescriptions to specific procedures to reduce the number of excess, unused prescription opioid pills in the home. We also explain the need to provide culturally competent care when managing a child's pain after surgery. Finally, we discuss the need for widespread provider and caregiver education about safe prescription opioid use, storage, and disposal.
Collapse
Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA.
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA 90033, USA
| |
Collapse
|
8
|
DePhillips M, Watts J, Sample J, Dowd MD. Use of Outpatient Opioids Prescribed From a Pediatric Acute Care Setting. Pediatr Emerg Care 2022; 38:e1298-e1303. [PMID: 35470302 DOI: 10.1097/pec.0000000000002731] [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: 11/26/2022]
Abstract
OBJECTIVES Deaths due to prescription opioid overdoses are at record high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy, but little is known about how much is needed to adequately treat acutely painful conditions for outpatients. The purpose of this study was to quantify the usage of opioids prescribed from the pediatric emergency departments of a Midwestern tertiary care children's hospital system. METHODS This was a prospective descriptive study in which patients aged 0 to 17 years seen in 2 pediatric emergency departments who received a prescription for an outpatient opioid were enrolled. The main outcome was opioid doses used at home, which was obtained via phone follow-up. Additional information, including patient demographics, location, prescriber specialty, diagnosis, and opioid name and amount prescribed, was obtained via chart review. RESULTS A total of 295 patients were enrolled, with 281 completing the study (95%). The median numbers of opioid doses prescribed and used were 12 and 2 doses, respectively, with 9 doses in excess. Patients with lower extremity fractures used more opioids than other diagnoses, with a median of 8 doses. The majority of families reported keeping extra doses at home. CONCLUSIONS Prescribed opioid doses exceeded used doses by a factor of 6. Lower extremity fractures required more doses than other acutely painful conditions. We should consider limiting doses prescribed to decrease excess opioids available for misuse and abuse.
Collapse
Affiliation(s)
| | | | - Jennifer Sample
- Pharmacology, Toxicology, and Therapeutic Innovations, Children's Mercy Hospital, Kansas City, MO
| | | |
Collapse
|
9
|
Howard-Azzeh M, Pearl DL, Berke O, O’Sullivan TL. Spatial, temporal, and space-time clusters associated with opioid and cannabis poisoning events in U.S. dogs (2005–2014). PLoS One 2022; 17:e0266883. [PMID: 35482776 PMCID: PMC9049357 DOI: 10.1371/journal.pone.0266883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
While a substantial amount of research has focused on the abuse of opioids and cannabinoids in human populations, few studies have investigated accidental poisoning events in pet populations. The objective of this study was to identify whether poisoning events involving opioids and cannabinoids clustered in space, time, and space-time, and compare the locations of clusters between the two toxicants. Data were obtained concerning reports of dog poisoning events from the American Society for the Prevention of Cruelty to Animals’ (ASPCA) Animal Poisoning Control Center (APCC), from 2005–2014. The spatial scan statistic was used to identify clusters with a high proportion of these poisoning events. Our analyses show that opioid and cannabinoid poisoning events clustered in space, time, and space-time. The cluster patterns identified for each toxicant were distinct, but both shared some similarities with human use data. This study may help increase awareness to the public, public health, and veterinary communities about where and when dogs were most affected by opioid and cannabinoid poisonings. This study highlights the need to educate dog owners about safeguarding opioid and cannabinoid products from vulnerable populations.
Collapse
Affiliation(s)
- Mohammad Howard-Azzeh
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
- * E-mail:
| | - David L. Pearl
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
| | - Olaf Berke
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
| | - Terri L. O’Sullivan
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
| |
Collapse
|
10
|
Farkas A, Kostic M, Huang CC, Gummin D. Poison center consultation reduces hospital length of stay. Clin Toxicol (Phila) 2022; 60:863-868. [PMID: 35261300 DOI: 10.1080/15563650.2022.2039686] [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: 11/03/2022]
Abstract
CONTEXT Prior studies have observed shorter lengths of stay when practitioners consult a US poison control center (PCC) regarding hospitalized toxicology patients, but the most recent study used data from 2010. Since then, the implementation of the Affordable Care Act, a trend toward shorter hospitalizations and substantial adjustments in hospital charges have occurred. METHODS This is a retrospective study of administrative hospital data and poison center data obtained from the Wisconsin Hospital Association and Wisconsin Poison Center for patients treated from 2010 to 2017. Stratified analysis was used to investigate the potential effects of PCC consultation on hospitalization. Univariate and multivariable regression analysis was used to characterize which factors were associated with an increased rate of PCC consultation. DISCUSSION 127,224 hospitalized cases were found, of which 44,628 were entered into a stratified hospital charge and length of stay analysis. PCC consultation was associated with an 11.6 h (95% CI 10.4-13.0 h) shorter mean length of stay overall, with children aged 0-6 having a larger reduction of 1.18 days. While total charges were higher by $600 in PCC consultation cases in the overall analysis (95% CI $390-$777), mean charges in patients aged 0-6 were $6695 lower when the PCC was consulted. PCC consultation was more likely to occur in cases involving children and adolescents, intentional overdoses (versus accidental or unknown intent), and women. CONCLUSIONS Our findings suggest that PCC consultation should be encouraged to potentially shorten hospitalizations of poisoned patients, and for pediatric patients in particular. Intentionality and demographic factors affect the rate of PCC consultation for overdose, but the nature of these relationships is unclear.
Collapse
Affiliation(s)
- Andrew Farkas
- Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI, USA.,Wisconsin Poison Center, Children's Wisconsin, Milwaukee, WI, USA
| | - Mark Kostic
- Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI, USA.,Wisconsin Poison Center, Children's Wisconsin, Milwaukee, WI, USA
| | - Chiang-Chin Huang
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - David Gummin
- Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI, USA.,Wisconsin Poison Center, Children's Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
11
|
Smola C, Wu CL, Narayanan S, Nichols MH, Pruitt C. Utilization of Monitored Beds for Children Admitted With Unintentional Poisonings. Pediatr Emerg Care 2022; 38:121-125. [PMID: 35226620 DOI: 10.1097/pec.0000000000002542] [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: 11/26/2022]
Abstract
OBJECTIVES Children with unintentional poisonings (UPs) are frequently admitted to monitored beds (MBs), though most require minimal interventions. We aimed to (1) describe clinical factors and outcomes for children admitted for UPs and (2) identify clinical factors associated with MB placement. METHODS In this single-center retrospective cohort study, we studied patients younger than 6 years admitted from the emergency department (ED) for UPs over a 5-year period to a quaternary-care children's hospital. Primary outcome was disposition (MB vs non-MB). Secondary outcomes included length of stay, escalation of inpatient care, 7-day readmission, and death. Covariates included age, certainty of ingestion, altered mental status, and ED provider training level. Subanalysis of drug class effect on disposition was also studied. Associations of clinical factors with MB placement were tested with multivariable logistic regression. RESULTS Of 401 patients screened, 345 subjects met inclusion criteria. Most subjects (308 of 345 [89%]) were admitted to MBs. Children with high certainty of ingestion (adjusted odds ratio [aOR], 4.2; 95% confidence interval [CI], 1.52-11.58), altered mental status (aOR, 5.82; 95% CI, 2.45-13.79), and a fellow (vs faculty) ED provider (aOR, 2.34; 95% CI, 1.04-5.24) were more likely to be admitted to MBs. No escalations of care, readmissions, or deaths occurred. Exposures to cardiac drugs had increased MB placement (aOR, 6.74; 95% CI, 1.93-23.59). CONCLUSIONS The majority of children admitted for UPs were placed in MBs. Regardless of inpatient placement, no adverse events were observed, suggesting opportunities for optimized resource utilization. Future research may focus on direct costs, inpatient interventions, or prospective outcomes to validate these findings.
Collapse
Affiliation(s)
- Cassi Smola
- From the Division of Pediatric Hospital Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Chang L Wu
- From the Division of Pediatric Hospital Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sridaran Narayanan
- Division of Pediatric Hospital Medicine, Children's National, Washington, DC
| | - Michele H Nichols
- Division of Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Chris Pruitt
- Division of Pediatric Emergency Medicine, Medical University of Sou\th Carolina, Charleston, SC
| |
Collapse
|
12
|
O'Reilly D, McCartan F, Rizvi S. An unusual case of buprenorphine overdose secondary to sibling play: Examining how medication delivery devices appear to children. Br J Clin Pharmacol 2022; 88:2996-2997. [PMID: 34989014 DOI: 10.1111/bcp.15196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/03/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Daniel O'Reilly
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Ireland
| | - Frances McCartan
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Ireland
| | - Syed Rizvi
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Ireland
| |
Collapse
|
13
|
Renny MH, Yin HS, Jent V, Hadland SE, Cerdá M. Temporal Trends in Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US From 2006 to 2018. JAMA Pediatr 2021; 175:1043-1052. [PMID: 34180978 PMCID: PMC8240008 DOI: 10.1001/jamapediatrics.2021.1832] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Prescription opioids are involved in more than half of opioid overdoses among younger persons. Understanding opioid prescribing practices is essential for developing appropriate interventions for this population. OBJECTIVE To examine temporal trends in opioid prescribing practices in children, adolescents, and younger adults in the US from 2006 to 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional analysis of opioid prescription data was conducted from January 1, 2006, to December 31, 2018. Longitudinal data on retail pharmacy-dispensed opioids for patients younger than 25 years were used in the analysis. Data analysis was performed from December 26, 2019, to July 8, 2020. MAIN OUTCOMES AND MEASURES Opioid dispensing rate, mean amount of opioid dispensed in morphine milligram equivalents (MME) per day (individuals aged 15-24 years) or MME per kilogram per day (age <15 years), duration of prescription (mean, short [≤3 days], and long [≥30 days] duration), high-dosage prescriptions, and extended-release or long-acting (ER/LA) formulation prescriptions. Outcomes were calculated for age groups: 0 to 5, 6 to 9, 10 to 14, 15 to 19, and 20 to 24 years. Joinpoint regression was used to examine opioid prescribing trends. RESULTS From 2006 to 2018, the opioid dispensing rate for patients younger than 25 years decreased from 14.28 to 6.45, with an annual decrease of 15.15% (95% CI, -17.26% to -12.99%) from 2013 to 2018. The mean amount of opioids dispensed and rates of short-duration and high-dosage prescriptions decreased for all age groups older than 5 years, with the largest decreases in individuals aged 15 to 24 years. Mean duration per prescription increased initially for all ages, but then decreased for individuals aged 10 years or older. The duration remained longer than 5 days across all ages. The rate of long-duration prescriptions increased for all age groups younger than 15 years and initially increased, but then decreased after 2014 for individuals aged 15 to 24 years. For children aged 0 to 5 years dispensed an opioid, annual increases from 2011 to 2014 were noted for the mean amount of opioids dispensed (annual percent change [APC], 10.58%; 95% CI, 1.77% to 20.16%) and rates of long-duration (APC, 30.42%; 95% CI, 14.13% to 49.03%), high-dosage (APC, 31.27%; 95% CI, 16.81% to 47.53%), and ER/LA formulation (APC, 27.86%; 95% CI, 12.04% to 45.91%) prescriptions, although the mean amount dispensed and rate of high-dosage prescriptions decreased from 2014 to 2018. CONCLUSIONS AND RELEVANCE These findings suggest that opioid dispensing rates decreased for patients younger than 25 years, with decreasing rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, opioids remain readily dispensed, and possible high-risk prescribing practices appear to be common, especially in younger children.
Collapse
Affiliation(s)
- Madeline H. Renny
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, New York,Department of Population Health, New York University Grossman School of Medicine, New York,Department of Emergency Medicine, New York University Grossman School of Medicine, New York,Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - H. Shonna Yin
- Department of Population Health, New York University Grossman School of Medicine, New York,Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Victoria Jent
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, New York
| | - Scott E. Hadland
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, New York
| |
Collapse
|
14
|
Ghosh P, Pruitt C, Shah N, Kulkarni A, Slattery A, Nichols M. Unintentional Opioid Ingestions Presenting to a Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:498-501. [PMID: 30601353 DOI: 10.1097/pec.0000000000001709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to describe unintentional opioid exposures in young children, including demographics, medical interventions, and clinical outcomes. METHODS This was a retrospective, cross-sectional study of children 0 to 6 years of age with possible opioid exposure over a 3-year period (July 2010 to June 2013). Data collected included sex, age, specific drug, whether they were referred to the emergency department (ED) by the Regional Poison Control Center, presence of symptoms, therapeutic interventions, ED disposition, and clinical outcomes for admitted patients. RESULTS Median age of patients included in the study was 2 years, and 64% of these children were male. The most common drug of exposure was buprenorphine/naloxone. Of the 429 charts screened, 140 patients were reported to be symptomatic and referred to the ED, of which 113 patients actually presented to the ED. An additional 122 patients presented to the ED without Regional Poison Control Center referral. Of the total 235 patients presenting to ED, 76 (32%) received a therapeutic intervention. Of 231 total opioid exposures, 31 exposures were administered naloxone. Three children underwent endotracheal intubation. Sixty-five patients were hospitalized, with a median length of stay of 1 day. Although there were no fatalities, 1 child suffered severe morbidity (anoxic brain injury). CONCLUSIONS While opioid exposures in young children are a common and potentially life-threatening problem, most children remain asymptomatic. The majority of patients are able to be discharged from the ED after observation, and of those who are admitted, most have favorable outcomes and brief hospital stays. A small number of these patients require considerable medical interventions.
Collapse
Affiliation(s)
- Pallavi Ghosh
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Christopher Pruitt
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Nipam Shah
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | | | - Ann Slattery
- Regional Poison Control Center, Children's of Alabama, Birmingham, AL.Disclosure: The authors declare no conflict of interest
| | - Michele Nichols
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| |
Collapse
|
15
|
Day E, Tach L, Fuzzell L, Mathios E, Kallaher A. The Consequences of Postnatal Parental Opioid Misuse on Child Well-Being: a Scoping Review. JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 2021. [DOI: 10.1080/1067828x.2021.1971130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
16
|
Austin AE, Berkoff MC, Shanahan ME. Incidence of Injury, Maltreatment, and Developmental Disorders Among Substance Exposed Infants. CHILD MALTREATMENT 2021; 26:282-290. [PMID: 32519558 DOI: 10.1177/1077559520930818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Recent changes to federal legislation created a requirement for states to address the needs of infants with prenatal substance exposure. Understanding clinical outcomes among substance exposed infants prior to these changes is important for establishing a baseline of risk and informing systems-level responses. Using North Carolina, Georgia, and Texas Medicaid data, we examined the incidence of inpatient and outpatient diagnoses for injury, maltreatment, and developmental disorders prior to age 12 months and compared types of diagnoses among substance exposed and unexposed infants. The cumulative incidence of maltreatment (1.2% vs. 0.2%) and developmental disorder (10.7% vs. 1.5%) diagnoses prior to age 12 months was significantly higher among substance exposed compared to unexposed infants. The incidence of injury diagnoses was similar (3.7% vs. 3.4%). We observed differences in types of maltreatment and injury diagnoses. For example, diagnoses for neglect were more common among substance exposed infants while diagnoses for physical abuse were more common among unexposed infants. Results provide insight for informing monitoring and intervention by medical and public health professionals.
Collapse
Affiliation(s)
- Anna E Austin
- Department of Maternal and Child Health, 2331University of North Carolina at Chapel Hill, NC, USA
- Injury Prevention Research Center, 2331University of North Carolina at Chapel Hill, NC, USA
| | - Molly Curtin Berkoff
- Department of Pediatrics, 2331University of North Carolina at Chapel Hill, NC, USA
| | - Meghan E Shanahan
- Department of Maternal and Child Health, 2331University of North Carolina at Chapel Hill, NC, USA
- Injury Prevention Research Center, 2331University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
17
|
Hunter K, Poel K, Pennington S, Bindseil I, Banerji S, Leonard J, Wang GS. Trends of prescription psychotropic medication exposures in pediatric patients, 2009-2018. Clin Toxicol (Phila) 2021; 60:243-251. [PMID: 34196239 DOI: 10.1080/15563650.2021.1946556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mental health disorders and related suicide attempts are increasing in both the adult and pediatric patient populations. Because of the increasing prevalence of mental health disorders, there is increased use of psychotropic medications in adult and pediatric patients, which can pose a risk for potentially adverse pediatric ingestions. The objective was to determine trends and outcomes for pediatric psychotropic medication ingestions reported to the American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS). METHODS This was a retrospective review of pediatric (≤18 years of age) exposures reported to AAPCC NPDS between January 1, 2009 and December 31, 2018. Single psychotropic medication ingestions of atypical antipsychotics, bupropion, buspirone, clonidine, lithium, methylphenidate, mirtazapine, monoamine oxidase inhibitors (MAOIs), selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), trazodone, and tricyclic antidepressants (TCAs) were examined. RESULTS Over the 10-year study period, 356,548 pediatric psychotropic medication ingestions were reported to NPDS. SSRI ingestions were the most frequently reported (34%), followed by atypical antipsychotics (17%), and methylphenidate (15%). Unintentional ingestions were most prominent in patients 0-12 years of age (79%), whereas, in patients age 13-18 years, 76% were intentional. SSRI ingestions were asymptomatic in 68% of cases. Clonidine and bupropion ingestions had the highest proportion of moderate and major clinical effects (29 and 25%, respectively). There were 29 deaths: atypical antipsychotics (n = 4), bupropion (n = 10), lithium (n = 1), SNRI (n = 1), SSRIs (n = 7), and TCAs (n = 6); 19 (65%) were in adolescent patients. CONCLUSIONS SSRIs were the most frequently reported ingestion, while bupropion and clonidine were associated with a high percentage of moderate and major clinical effects. This study demonstrates opportunities for targeted prevention strategies to prevent potentially adverse pediatric ingestions to psychotropic medications.
Collapse
Affiliation(s)
- Kiley Hunter
- Department of Pharmacy, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Kevin Poel
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Stephanie Pennington
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Isabelle Bindseil
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Safety, Denver Health Hospitals, Denver, CO, USA
| | - Jan Leonard
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - George Sam Wang
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
18
|
Farrell NM, Hamilton S, Gendron BJ, Corio JL, Lookabill SK. Presence of "One Pill Can Kill" Medications in Medication Organizers: Implications for Child Safety. J Pharm Pract 2021; 35:898-902. [PMID: 34000923 DOI: 10.1177/08971900211017491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medication organizers increased compliance, but they do not contain child protective packaging. Medications organizers have been involved in some pediatric exposures; however, previous reports do not describe if "one pill can kill" (1PCK) medications were involved in the exposures. 1PCK medications may cause toxicity even with a single tablet. OBJECTIVE The purpose of this study is to describe the type and presence of 1PCK medications dispensed in medication organizers at a single center. METHODS Adult patients who received blister packed medications from September 1, 2017 to September 30, 2017 were included in this retrospective review. Medications were excluded if dispensed traditionally during this time. The primary outcome described included 1PCK medications (quantity and type). Secondary outcomes included total number of tablets dispensed, delayed- (DR) and extended-release (ER) formulations, average age of those dispensed 1PCK medications versus those without. RESULTS A total of 450 patients received 486 blister packs and 75.5% of which found to include 1PCK medications. Most commonly included 1PCK medications were beta-blockers and calcium channel blockers (42.4 and 49.4%, respectively). Patients receiving 1PCK medications were older (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p < 0.0001) and included more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications, p < 0.0001). DR and ER formulations were in 150 packs. CONCLUSION The majority of dispensed medication organizers included 1PCK medications. Upon dispensing, patients should be questioned for possible proximity exposures. Additionally, they should receive education on medication safety for children that may be in proximity of the medications during home, work, or social activities.
Collapse
Affiliation(s)
- Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Bryan J Gendron
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jessica L Corio
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Sara K Lookabill
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
19
|
Basco WT, Ward RC, Taber DJ, Simpson KN, Gebregziabher M, Cina RA, McCauley JL, Lockett MA, Moran WP, Mauldin PD, Ball SJ. Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017. Int J Pediatr Otorhinolaryngol 2021; 143:110636. [PMID: 33548590 DOI: 10.1016/j.ijporl.2021.110636] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.
Collapse
Affiliation(s)
- William T Basco
- Pediatrics, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA.
| | - Ralph C Ward
- Public Health Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - David J Taber
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Kit N Simpson
- Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Mulugeta Gebregziabher
- Public Health Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Robert A Cina
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Jenna L McCauley
- Psychiatry and Behavioral Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Mark A Lockett
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - William P Moran
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Sarah J Ball
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| |
Collapse
|
20
|
Kline JN, Badolato GM, Goyal MK. Trends in Pediatric Poisoning-Related Emergency Department Visits: 2001-2011. Pediatr Emerg Care 2021; 37:e7-e12. [PMID: 30973499 DOI: 10.1097/pec.0000000000001817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES We sought to understand the burden of pediatric poisonings on the health care system by characterizing poisoning-related emergency department (ED) visits among children on a national level. METHODS This was a repeated cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey from 2001 to 2011 of children 21 years or younger who presented to an ED. We measured annual rates of visits, trends over time, and patient and visit characteristics associated with poisoning-related ED visits using multivariable logistic regression. We also compared accidental to intentional poisonings. RESULTS There were an estimated 713,345 ED visits per year for poisoning in children, and intentional poisoning-related visits increased over the study period (P trend < 0.001). Compared with all other ED visits, poisoning-related ED visits were more common among males (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.26-1.64) and uninsured patients (aOR, 1.26; 95% CI, 1.05-1.51). Poisoned children were more likely to arrive by ambulance (aOR, 3.38; 95% CI, 2.85-4.01) and be admitted (aOR, 1.35; 95% CI, 1.12-1.61). Compared with accidental poisonings, intentional poisonings were more common as age increased (aOR, 1.16; 95% CI, 1.13-1.92) and in children of non-Hispanic black race/ethnicity (aOR, 1.81; 95% CI, 1.12-2.93) and more likely to be associated with ambulance arrival (aOR, 1.49; 95% CI, 1.07-2.08) and hospital admission (aOR, 1.76; 95% CI, 1.25-2.48). CONCLUSIONS Poisoning-related ED visits among children have remained stable, with significant increase in intentional ingestions from 2001 to 2011. Poisoned children, and particularly those with intentional poisonings, require more health care resources than children with other health concerns. More study is needed on circumstances leading to pediatric poisonings, so that preventive efforts can be targeted appropriately.
Collapse
Affiliation(s)
- Jaclyn N Kline
- From the Division of Emergency Medicine, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | |
Collapse
|
21
|
The impact of the prescription opioid epidemic on young children: Trends and mortality. Drug Alcohol Depend 2020; 211:107924. [PMID: 32178937 DOI: 10.1016/j.drugalcdep.2020.107924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Our objective was to describe trends and deaths in young children associated with opioid analgesics. METHODS Analysis of pediatric exposures using the RADARS System Poison Center Program from July 1, 2010 through December 31, 2018. Cases involving a child < 6 years, with an exposure to one or more opioids: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tramadol. Poisson regression was used to model the shape of the time response curve. RESULTS 48,560 cases were identified, median age 2 years (IQR 1.4, 2.0), 52.4 % male. The most commonly involved opioid was hydrocodone (32.5 %); buprenorphine and methadone had the highest exposure rates when adjusted for dispensed prescriptions (0.84 and 0.73 per 10,000 prescriptions). There were 28 deaths, methadone being the most commonly involved opioid (16). Exposures decreased significantly accounting for population (from 8.39 to 4.19 exposures per 100,000 children) and per prescription (from 0.33 to 0.25 exposures per 10,000 prescriptions). After adjustment for prescriptions, the exposure rate for hydromorphone and fentanyl increased over the study period, while buprenorphine had the greatest decrease in exposure rate. Among 28 deaths, 11 (39 %) were known or suspected to have been exposed, but medical care was not sought or was delayed. CONCLUSION Pediatric opioid exposure rates by prescription and population decreased from July 2010 through December 2018. However, with over 48,000 exposures and 28 deaths, the opioid epidemic continues to impact young children. Many exposures including deaths were preventable. Continued improvements in prevention require a multifaceted approach.
Collapse
|
22
|
Hampp C, Lovegrove MC, Budnitz DS, Mathew J, Ho A, McAninch J. The Role of Unit-Dose Child-Resistant Packaging in Unintentional Childhood Exposures to Buprenorphine-Naloxone Tablets. Drug Saf 2020; 43:189-191. [PMID: 31745829 PMCID: PMC10869110 DOI: 10.1007/s40264-019-00883-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Christian Hampp
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA.
| | - Maribeth C Lovegrove
- Medication Safety Program, Division of Healthcare Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Daniel S Budnitz
- Medication Safety Program, Division of Healthcare Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Justin Mathew
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Amy Ho
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Jana McAninch
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| |
Collapse
|
23
|
Howard-Azzeh M, Pearl DL, O’Sullivan TL, Berke O. The identification of risk factors contributing to accidental opioid poisonings in companion dogs using data from a North American poison control center (2006-2014). PLoS One 2020; 15:e0227701. [PMID: 31995582 PMCID: PMC6988905 DOI: 10.1371/journal.pone.0227701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/26/2019] [Indexed: 01/04/2023] Open
Abstract
In the last decade, there has been a marked increase in opioid-related human deaths in the U.S. However, the effects of the growth in opioid use on vulnerable populations, such as pet dogs, are largely unknown. The objective of this study was to investigate potential risk factors at the dog, county, and state-levels that contributed to accidental dog opioid poisonings. Dog demographic information was collected during calls to the Animal Poison Control Center (APCC), operated by the American Society for the Prevention of Cruelty to Animals, about pet dog exposures to poisons from 2006–2014. Data concerning state-level opioid-related human death rates and county-level human opioid prescription rates were collected from databases accessed from the Centers for Disease Control and Prevention. A multilevel logistic regression model with random intercepts for county and state was fitted to explore associations between the odds of a call to the APCC being related to dog opioid poisonings with the following independent variables: sex, weight, age, reproductive status, breed class, year, source of calls, county-level human opioid prescription rate, and state-level opioid human death rate. There was a significant non-linear positive association between accidental opioid dog poisoning calls and county-level human opioid prescription rates. Similarly, the odds of a call being related to an opioid poisoning significantly declined over the study period. Depending on the breed class, the odds of a call being related to an opioid poisoning event were generally lower for older and heavier dogs. The odds of a call being related to an opioid poisoning were significantly higher for intact compared to neutered dogs, and if the call was made by a veterinarian compared to a member of the public. Veterinarians responding to poisonings may benefit from knowledge of trends in the use and abuse of both legal and illegal drugs in human populations.
Collapse
Affiliation(s)
- Mohammad Howard-Azzeh
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
- * E-mail:
| | - David L. Pearl
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Terri L. O’Sullivan
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Olaf Berke
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| |
Collapse
|
24
|
|
25
|
Dorney K, Dodington JM, Rees CA, Farrell CA, Hanson HR, Lyons TW, Lee LK. Preventing injuries must be a priority to prevent disease in the twenty-first century. Pediatr Res 2020; 87:282-292. [PMID: 31466080 DOI: 10.1038/s41390-019-0549-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/03/2019] [Accepted: 08/13/2019] [Indexed: 02/08/2023]
Abstract
Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.
Collapse
Affiliation(s)
- Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - James M Dodington
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, CT, USA
| | - Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Caitlin A Farrell
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Holly R Hanson
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
| | | |
Collapse
|
26
|
Nadeau N, Samuels-Kalow M, Wittels K, Wilcox SR. A Common Antidote for an Uncommon Indication. J Emerg Med 2019; 57:723-725. [PMID: 31629578 DOI: 10.1016/j.jemermed.2019.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/26/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Nicole Nadeau
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Margaret Samuels-Kalow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
27
|
A Standardized Cardiac Protocol for Pediatric Drug Ingestion Hospital Admissions. Pediatr Qual Saf 2019; 4:e223. [PMID: 32010850 PMCID: PMC6946223 DOI: 10.1097/pq9.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 09/03/2019] [Indexed: 11/21/2022] Open
Abstract
To optimize patient resource utilization and safety, we created a standard-of-care guideline for pediatric drug ingestion hospital admissions.
Collapse
|
28
|
Christensen ML, Davis RL. Identifying the "Blip on the Radar Screen": Leveraging Big Data in Defining Drug Safety and Efficacy in Pediatric Practice. J Clin Pharmacol 2019; 58 Suppl 10:S86-S93. [PMID: 30248191 DOI: 10.1002/jcph.1141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/23/2018] [Indexed: 11/10/2022]
Abstract
The immense amount of electronic health data (pharmacy and administrative claims, electronic health records, and clinical registries) that is being generated every day in the care of patients has the potential to be leveraged for improving clinical decisions at the point of care, uncovering or validating drug efficacy and drug safety. The potential use of big data for improving safe and effective use of medications is especially important in children because of their low drug exposure relative to adults. Electronic health data is collected primarily for clinical or billing purposes and not for research purposes. The major steps involved in data acquisition, extraction, aggregation, analysis, modeling, and interpretation are discussed. It is important to understand the limitation of big data and utilize appropriate study design and statistical methods. Possible applications are presented along with specific examples of how big data has been used in drug research to find that blip on the radar screen that may give an efficacy or safety signal that can lead to further investigation.
Collapse
Affiliation(s)
- Michael L Christensen
- Department of Clinical Pharmacy and Translational Sciences and the Center for Pediatric Pharmacokinetics and Therapeutics, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert L Davis
- Department of Pediatric and UTHSC and Oakridge National Laboratory Center in Biomedical Informatics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
29
|
Lo Re M, Chaplin M, Aronow B, Modesto-Lowe V. Buprenorphine Overdose in Young Children: An Underappreciated Risk. Clin Pediatr (Phila) 2019; 58:613-617. [PMID: 30740990 DOI: 10.1177/0009922819829038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The escalation of the opioid crisis has led to an increase in the treatment of opioid use disorder. In particular, recent legislation has allowed for office-based treatment with buprenorphine, a partial µ-opioid agonist that is believed to be safer than methadone due to a ceiling effect on respiratory depression in adults. An increasing number of children are being exposed to buprenorphine as more adults in US households receive take-home prescriptions. The ceiling effect seen in adults does not seem to apply to young children, and intoxication with severe symptoms including fatalities can occur. This article outlines the pharmacology of buprenorphine and reviews the current literature on overdose in children. We conclude with practical recommendations for limiting potential exposure and damage to children from accidental buprenorphine overdose.
Collapse
Affiliation(s)
| | - Margaret Chaplin
- 2 Farrell Treatment Center, New Britain, CT, USA.,3 University of Connecticut, Farmington, CT, USA
| | | | - Vania Modesto-Lowe
- 3 University of Connecticut, Farmington, CT, USA.,4 Quinnipiac University, Hamden, CT, USA.,5 Connecticut Valley Hospital, Middletown, CT, USA
| |
Collapse
|
30
|
Hageman JR. Unintentional, Unsupervised Opioid Ingestions in Young Children. Pediatr Ann 2019; 48:e186. [PMID: 31067331 DOI: 10.3928/19382359-20190422-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
31
|
Patel AM, Wheeler DC, Rose SR, Nadpara PA, Pakyz AL, Carroll NV. Prevalence and Characteristics of Pediatric Opioid Exposures and Poisonings in the United States. J Pediatr 2019; 206:148-155.e4. [PMID: 30612813 DOI: 10.1016/j.jpeds.2018.10.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/06/2018] [Accepted: 10/24/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the prevalence and characteristics of pediatric opioid exposures and poisonings in the US. STUDY DESIGN This was a retrospective, cross-sectional analysis using the National Poison Data System from January 1, 2010 to December 31, 2014. Records of children aged <18 years with exposure to opioid-containing medications were identified. Standardized prevalence rates were calculated, and the annual trend was examined. Pediatric opioid exposures were characterized descriptively, and logistic regression was performed to estimate the association between various clinical and sociodemographic characteristics and exposures with serious (ie, moderate, major, or death) outcomes. The association of pediatric opioid exposures and area-level socioeconomic status factors at 5-digit ZIP code level was examined descriptively. RESULTS The prevalence of opioid exposures was 22.6 per 100 000 children and was particularly high among ≤5-year-olds. Prevalence declined from 25.5 to 20 per 100 000 children from 2010 to 2014. There were 83 418 pediatric opioid exposures over the 5-year period and nearly one-half resulted in poisoning. Over 60% of exposures were among children ≤5 years of age, 73.4% were unintentional, and over 90% occurred at home. One in every 2 pediatric opioid exposures was evaluated in a healthcare facility. Annually 4912 children aged ≤5 years were treated in the emergency department or admitted for care. Older age, nonaccidental intent, and single-substance opioid, especially buprenorphine and methadone, were associated with serious outcomes (P < .05). Positive correlations were observed for area-level socioeconomic status factors including proportion of adults and pediatric opioid exposures. CONCLUSIONS Pediatric opioid exposures and poisonings decreased from 2010 to 2014 but morbidity remains high. The epidemiology of opioid exposures differed considerably by age.
Collapse
Affiliation(s)
| | | | | | | | - Amy L Pakyz
- Virginia Commonwealth University, Richmond, VA
| | | |
Collapse
|
32
|
Salzman M, Cruz L, Nairn S, Bechmann S, Karmakar R, Baumann BM. The Prevalence of Modifiable Parental Behaviors Associated with Inadvertent Pediatric Medication Ingestions. West J Emerg Med 2019; 20:269-277. [PMID: 30881547 PMCID: PMC6404704 DOI: 10.5811/westjem.2018.12.40952] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Our aim was to examine potential risk factors and modifiable behaviors that could lead to pediatric poisonings. Our secondary objectives were to explore socioeconomic factors associated with caregiver (parent/guardian) safe medication storage and knowledge of poison control contact information. Methods We conducted a prospective, cross-sectional survey of caregivers of patients 2–10 years old presenting to an inner city pediatric emergency department. Caregiver and patient demographic data, prescription and nonprescription medication type, storage and when and where taken, were recorded. We used multivariable regression to explore factors associated with secure prescription medication storage and knowledge of poison control center contact information. Results Of 1457 caregivers, 29% took daily prescription and 17% took daily non-prescription medications. Only 25% of caregivers stored their prescription medications in a secure place, and <3% stored medications in a locked drawer or safe. Of demographic and socioeconomic factors, only income ≥$80,000 was associated with storage of prescription medication in a secure place (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.27–4.81). When asked how they would access poison control in case of an ingestion, the majority, 86%, had an appropriate plan. In multivariable regression, the only factor associated with knowledge of poison control center contact information was college education in the caregiver (OR 1.6; 95% CI, 1.10–2.32). Conclusion A minority of caregivers store medications in a safe place and even fewer keep prescription medications under lock and key. The majority, however, were aware of how to contact a poison control center in case of ingestion.
Collapse
Affiliation(s)
- Matthew Salzman
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Lia Cruz
- Cooper Medical School of Rowan University, Department of Pediatrics, Camden, New Jersey
| | - Sandra Nairn
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Samuel Bechmann
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Rupa Karmakar
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Brigitte M Baumann
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| |
Collapse
|
33
|
Gaither JR, Shabanova V, Leventhal JM. US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016. JAMA Netw Open 2018; 1:e186558. [PMID: 30646334 PMCID: PMC6324338 DOI: 10.1001/jamanetworkopen.2018.6558] [Citation(s) in RCA: 212] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE It is not yet known how many children and adolescents die each year from opioid poisonings and how mortality rates have changed over time. OBJECTIVE To examine national trends in pediatric deaths from prescription and illicit opioids. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional in which serial mortality data from the Centers for Disease Control and Prevention were analyzed. The population included 8986 children and adolescents (age, <20 years) who died in all US settings from opioid poisonings between 1999 and 2016. Data were collected and analyzed between June 1 and October 31, 2018. EXPOSURES All opioids. MAIN OUTCOMES AND MEASURES Age-specific mortality rates per 100 000 were estimated with smoothing spline Poisson regression. RESULTS Of the 8986 children and adolescents who died between 1999 and 2016 from prescription and illicit opioid poisonings, 6567 (73.1%) were male, 7921 (88.1%) were among adolescents aged 15 to 19 years, and 605 (6.7%) were among children aged 0 to 4 years. The overall pediatric mortality rate increased from 0.22 (95% CI, 0.19-0.25) to 0.81 (95% CI, 0.76-0.88) per 100 000, an increase of 268.2% (P for time effect <.001). The highest annual rates were among adolescents aged 15 to 19 years, but time trends revealed a steady linear increase among children aged 0 to 4 years and those aged 5 to 9 years as well as a steady linear increase until 2008 among the cohorts aged 10 to 14 years and 15 to 19 years, when rates briefly declined before rising again. Among adolescents aged 15 to 19 years, heroin was implicated in 1872 deaths: rates increased from 0.21 (95% CI, 0.17-0.25) to 1.06 (95% CI, 0.97-1.17), an increase of 404.8%, whereas rates for prescription opioids increased by 94.7% from 0.57 (95% CI, 0.49-0.66) to 1.11 (95% CI, 0.99-1.25) (all P for time effect <.001). Between 2014 and 2016, there were 1508 opioid deaths among adolescents aged 15 to 19 years; of these, 468 (31.0%) were attributed to synthetic opioids. Across time, 7263 (80.8%) of all pediatric deaths were unintentional, 5537 (61.6%) occurred outside of a medical facility, and 3419 (38.0%) children died at home or another residential setting. Among children younger than 5 years, 148 (24.5%) deaths were attributed to homicide. CONCLUSIONS AND RELEVANCE Over 18 years, nearly 9000 children and adolescents died from opioid poisonings, and the mortality rate increased nearly 3-fold. These findings suggest that the opioid epidemic is likely to remain a growing public health problem in the young unless legislators, public health officials, clinicians, and parents take a wider view of the opioid crisis and implement protective measures that are pediatric specific and family centered.
Collapse
Affiliation(s)
- Julie R. Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Veronika Shabanova
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - John M. Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
34
|
Toce MS, Chai PR, Burns MM, Boyer EW. Pharmacologic Treatment of Opioid Use Disorder: a Review of Pharmacotherapy, Adjuncts, and Toxicity. J Med Toxicol 2018; 14:306-322. [PMID: 30377951 PMCID: PMC6242798 DOI: 10.1007/s13181-018-0685-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 12/27/2022] Open
Abstract
Opioid use disorder continues to be a significant source of morbidity and mortality in the USA and the world. Pharmacologic treatment with methadone and buprenorphine has been shown to be effective at retaining people in treatment programs, decreasing illicit opioid use, decreasing rates of hepatitis B, and reducing all cause and overdose mortality. Unfortunately, barriers exist in accessing these lifesaving medications: users wishing to start buprenorphine therapy require a waivered provider to prescribe the medication, while some states have no methadone clinics. As such, users looking to wean themselves from opioids or treat their opioid dependence will turn to alternative agents. These agents include using prescription medications, like clonidine or gabapentin, off-label, or over the counter drugs, like loperamide, in supratherapeutic doses. This review provides information on the pharmacology and the toxic effects of pharmacologic agents that are used to treat opioid use disorder. The xenobiotics reviewed in depth include buprenorphine, clonidine, kratom, loperamide, and methadone, with additional information provided on lofexidine, akuamma seeds, kava, and gabapentin.
Collapse
Affiliation(s)
- Michael S Toce
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Peter R Chai
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Edward W Boyer
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
35
|
Soichot M, Julliand S, Filatriau J, Hurbain A, Bourgogne E, Mihoubi A, Gourlain H, Delhotal-Landes B. Diagnosis of Heroin Overdose in an 8-Year-Old Boy: Reliable Contribution of Toxicological Investigations. J Anal Toxicol 2018; 42:255-264. [PMID: 29301012 DOI: 10.1093/jat/bkx111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Indexed: 11/12/2022] Open
Abstract
Toxicological investigations are often required by clinicians in comatose patients with suspected poisoning. However, the usefulness of toxicological analyses to support a diagnosis of acute poisoning is debated among clinicians and the interpretation of laboratory tests is challenging given the wide diversity of analytical techniques available. We report the case of an 8-year-old boy who was admitted to an intensive care unit with severe respiratory depression and neurological impairment. In order to formulate appropriate hypothesizes about the diagnosis and circumstances of intoxication, clinicians consulted toxicologists for a comprehensive toxicological screening. Routine blood immunoassays were negative for common toxicants but urine tests were positive for opiates. A general unknown screening using liquid and gas chromatography combined with mass spectrometry detection confirmed the presence of morphine, codeine and related glucuronides metabolites in plasma and urine. Subsequently, morphine and codeine were quantified in plasma samples by online-SPE-LC-MS-MS. In addition, analyses performed with GC-MS and LC-MSn identified compounds used as markers when profiling illicit heroin, namely noscapine, dextromethorphan and codeine. In conjunction with the patient's history, clinical picture and circumstances of intoxication, toxicological findings strongly suggested an acute pediatric opioid overdose as a collateral damage of parental heroin abuse in the home. This case highlights the significant contribution of toxicological investigations in sensitive legal cases and the critical role of communications between clinicians and toxicologists.
Collapse
Affiliation(s)
- M Soichot
- Service de Toxicologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, Paris 75010, France
| | - S Julliand
- Service Mobile d'Urgence et de Réanimation (SMUR), Hôpital Robert Debré, AP-HP, 48 Boulevard Sérurier, Paris 75019, France
| | - J Filatriau
- Service de Réanimation Pédiatrique, Hôpital Robert Debré, AP-HP, 48 Boulevard Sérurier, Paris 75019, France
| | - A Hurbain
- Bruker Daltonics, 34 Rue de l'Industrie, Wissembourg 67160, France
| | - E Bourgogne
- Service de Toxicologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, Paris 75010, France.,UMR 8638, Université Paris Descartes, 4 Avenue de l'Observatoire, Paris 75006, France
| | - A Mihoubi
- Service de Toxicologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, Paris 75010, France
| | - H Gourlain
- Service de Toxicologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, Paris 75010, France
| | - B Delhotal-Landes
- Service de Toxicologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, Paris 75010, France
| |
Collapse
|
36
|
|
37
|
Chung CP, Callahan ST, Cooper WO, Dupont WD, Murray KT, Franklin AD, Hall K, Dudley JA, Stein CM, Ray WA. Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events. Pediatrics 2018; 142:peds.2017-2156. [PMID: 30012559 PMCID: PMC6072590 DOI: 10.1542/peds.2017-2156] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about opioid prescribing for children without severe conditions. We studied the prevalence of and indications for outpatient opioid prescriptions and the incidence of opioid-related adverse events in this population. METHODS This retrospective cohort study between 1999 and 2014 included Tennessee Medicaid children and adolescents aged 2 to 17 without major chronic diseases, prolonged hospitalization, institutional residence, or evidence of a substance use disorder. We estimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid-related adverse events, defined as an emergency department visit, hospitalization, or death related to an opioid adverse effect. RESULTS There were 1 362 503 outpatient opioid prescriptions; the annual mean prevalence of opioid prescriptions was 15.0%. The most common opioid indications were dental procedures (31.1% prescriptions), outpatient procedure and/or surgery (25.1%), trauma (18.1%), and infections (16.5%). There were 437 cases of opioid-related adverse events confirmed by medical record review; 88.6% were related to the child's prescription and 71.2% had no recorded evidence of deviation from the prescribed regimen. The cumulative incidence of opioid-related adverse events was 38.3 of 100 000 prescriptions. Adverse events increased with age (incidence rate ratio = 2.22; 95% confidence interval, 1.67-2.96; 12-17 vs 2-5 years of age) and higher opioid doses (incidence rate ratio = 1.86 [1.45-2.39]; upper versus lower dose tertiles). CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute, self-limited conditions. One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (71.2% of which were related to therapeutic use of the prescribed opioid).
Collapse
Affiliation(s)
| | | | | | | | | | - Andrew D. Franklin
- Anesthesia, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | | | | | | |
Collapse
|
38
|
Bell JC, Bentley JP, Downie C, Cairns R, Buckley NA, Katelaris A, Pearson SA, Nassar N. Accidental pharmacological poisonings in young children: population-based study in three settings. Clin Toxicol (Phila) 2018; 56:782-789. [DOI: 10.1080/15563650.2017.1422509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Jane C. Bell
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - Jason P. Bentley
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | | | - Rose Cairns
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | | | | | - Sallie-Anne Pearson
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| |
Collapse
|
39
|
Khan U, Bloom RA, Nicell JA, Laurenson JP. Risks associated with the environmental release of pharmaceuticals on the U.S. Food and Drug Administration "flush list". THE SCIENCE OF THE TOTAL ENVIRONMENT 2017; 609:1023-1040. [PMID: 28787777 DOI: 10.1016/j.scitotenv.2017.05.269] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 05/06/2023]
Abstract
A select few prescription drugs can be especially harmful and, in some cases, fatal with just one dose when not used as prescribed. Therefore, the U. S. Food and Drug Administration (FDA) recommends that expired, unwanted, or otherwise unused portions of most of these drugs be disposed of quickly through a take-back program. If such an option is not readily available, FDA recommends that they be flushed down the sink or toilet. The goal of the current investigation was to evaluate the ecological and human-health risks associated with the environmental release of the 15 active pharmaceutical ingredients (APIs) currently on the FDA "flush list". The evaluation suggests that even when highly conservative assumptions are used-including that the entire API mass supplied for clinical use is flushed, all relevant sources in addition to clinical use of the API are considered, and no metabolic loss, environmental degradation, or dilution of wastewater effluents are used in estimating environmental concentrations-most of these APIs present a negligible eco-toxicological risk, both as individual compounds and as a mixture. For a few of these APIs, additional eco-toxicological data will need to be developed. Using similar conservative assumptions for human-health risks, all 15 APIs present negligible risk through ingestion of water and fish.
Collapse
Affiliation(s)
- Usman Khan
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
| | - Raanan A Bloom
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
| | - James A Nicell
- Department of Civil Engineering & Applied Mechanics, McGill University, 817 Sherbrooke Street West, Montreal, Quebec, Canada, H3A 0C3
| | - James P Laurenson
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA.
| |
Collapse
|
40
|
Schwartz L, Mercurio-Zappala M, Howland MA, Hoffman RS, Su MK. Unintentional methadone and buprenorphine exposures in children: Developing prevention messages. J Am Pharm Assoc (2003) 2017; 57:S83-S86. [PMID: 28292505 DOI: 10.1016/j.japh.2017.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To develop key messages for methadone and buprenorphine safety education material based on an analysis of calls to the NYC Poison Control Center (NYC PCC) and designed for distribution to caregivers of young children. METHODS Retrospective review of all calls for children 5 years of age and younger involving methadone or buprenorphine from January 1, 2000, to June 15, 2014. A data abstraction form was completed for each case to capture patient demographics, exposure and caller sites, caller relation to patient, qualitative information regarding the exposure scenario, the product information, if naloxone was given, and the medical outcome of the case. RESULTS A total of 123 cases were identified. The ages of the children ranged from 4 days to 5 years; 55% were boys. All exposures occurred in a home environment. The majority of the calls were made to the NYC PCC by the doctor (74%) or nurse (2%) at a health care facility. Approximately one-fourth of the calls came from the home and were made by the parent (22%) or grandparent (2%). More than one-half of the exposures involved methadone (64%). Naloxone was administered in 28% of cases. Approximately one-fourth of the children did not experience any effect after the reported exposure, one-half (51%) experienced some effect (minor, moderate, or major), and there was 1 death (1%). More than one-half of the children were admitted to the hospital, with 40% admitted to critical care and 13% to noncritical care. Approximately 23% were treated and released from the hospital, and 20% were lost to follow-up or never arrived to the hospital. The remaining 4% were managed on site without a visit to the hospital. CONCLUSION Exposures to methadone and buprenorphine are dangerous with some leading to serious health effects. Safe storage and disposal instructions are needed for homes where children may be present.
Collapse
|
41
|
Walsh SL, Comer SD, Lofwall MR, Vince B, Levy-Cooperman N, Kelsh D, Coe MA, Jones JD, Nuzzo PA, Tiberg F, Sheldon B, Kim S. Effect of Buprenorphine Weekly Depot (CAM2038) and Hydromorphone Blockade in Individuals With Opioid Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2017; 74:894-902. [PMID: 28655025 PMCID: PMC5710238 DOI: 10.1001/jamapsychiatry.2017.1874] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Buprenorphine is an efficacious, widely used treatment for opioid use disorder (OUD). Daily oral transmucosal formulations can be associated with misuse, diversion, and nonadherence; these limitations may be obviated by a sustained release formulation. OBJECTIVE To evaluate the ability of a novel, weekly, subcutaneous buprenorphine depot formulation, CAM2038, to block euphorigenic opioid effects and suppress opioid withdrawal in non-treatment-seeking individuals with OUD. DESIGN, SETTING, AND PARTICIPANTS This multisite, double-blind, randomized within-patient study was conducted at 3 controlled inpatient research facilities. It involved 47 adults with DSM-V moderate-to-severe OUD. The study was conducted from October 12, 2015 (first patient enrolled), to April 21, 2016 (last patient visit). INTERVENTIONS A total of five 3-day test sessions evaluated the response to hydromorphone (0, 6, and 18 mg intramuscular in random order; 1 dose/session/day). After the first 3-day session (ie, qualification phase), participants were randomized to either CAM2038 weekly at 24 mg (n = 22) or 32 mg (n = 25); the assigned CAM2038 dose was given twice, 1 week apart (day 0 and 7). Four sets of sessions were conducted after randomization (days 1-3, 4-6, 8-10, and 11-13). MAIN OUTCOMES AND MEASURES The primary end point was maximum rating on the visual analog scale for drug liking. Secondary end points included other visual analog scale (eg, high and desire to use), opioid withdrawal scales, and physiological and pharmacokinetic outcomes. RESULTS A total of 46 of 47 randomized participants (mean [SD] age, 35.5 [9] years; 76% male [n = 35]) completed the study. Both weekly CAM2038 doses produced immediate and sustained blockade of hydromorphone effects (liking maximum effect, CAM2038, 24 mg: effect size, 0.813; P < .001, and CAM2038, 32 mg: effect size, 0.753; P < .001) and suppression of withdrawal (Clinical Opiate Withdrawal Scale, CAM2038, 24 mg: effect size, 0.617; P < .001, and CAM2038, 32 mg: effect size, 0.751; P < .001). CAM2038 produces a rapid initial rise of buprenorphine in plasma with maximum concentration around 24 hours, with an apparent half-life of 4 to 5 days and approximately 50% accumulation of trough concentration from first to second dose (trough concentration = 0.822 and 1.23 ng/mL for weeks 1 and 2, respectively, with 24 mg; trough concentration = 0.993 and 1.47 ng/mL for weeks 1 and 2, respectively, with 32 mg). CONCLUSIONS AND RELEVANCE CAM2038 weekly, 24 and 32 mg, was safely tolerated and produced immediate and sustained opioid blockade and withdrawal suppression. The results support the use of this depot formulation for treatment initiation and stabilization of patients with OUD, with the further benefit of obviating the risk for misuse and diversion of daily buprenorphine while retaining its therapeutic benefits. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02611752.
Collapse
Affiliation(s)
- Sharon L. Walsh
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | - Sandra D. Comer
- Department of Psychiatry, Columbia University, New York, New York
| | | | - Bradley Vince
- Vince and Associates Clinical Research, Overland Park, Kansas
| | | | - Debra Kelsh
- Vince and Associates Clinical Research, Overland Park, Kansas
| | - Marion A. Coe
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | | | - Paul A. Nuzzo
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | | | | | - Sonnie Kim
- Braeburn Pharmaceuticals, Princeton, New Jersey
| |
Collapse
|
42
|
Affiliation(s)
| | - Michele M Burns
- Harvard Medical Toxicology Program and.,Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA
| |
Collapse
|
43
|
Tomasi S, Roberts KJ, Stull J, Spiller HA, McKenzie LB. Pediatric Exposures to Veterinary Pharmaceuticals. Pediatrics 2017; 139:peds.2016-1496. [PMID: 28167514 DOI: 10.1542/peds.2016-1496] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the epidemiology of veterinary pharmaceutical-related exposures to children based on calls to a regional poison control center. METHODS A retrospective analysis of pediatric (≤19 years of age) exposures to pharmaceutical products intended for animal use, managed by a regional poison control center from 1999 through 2013, was conducted. Case narratives were reviewed and coded for exposure-related circumstances and intended species. Descriptive statistics were generated. RESULTS From 1999 through 2013, the Central Ohio Poison Center received 1431 calls that related to a veterinary pharmaceutical exposure for children ≤19 years of age. Most of the pediatric calls (87.6%) involved children ≤5 years of age. Exploratory behavior was the most common exposure-related circumstance (61.4%) and ingestion accounted for the exposure route in 93% of cases. Substances commonly associated with exposures included: veterinary drugs without human equivalent (17.3%), antimicrobial agents (14.8%), and antiparasitics (14.6%). Based on substance and quantity, the majority of exposures (96.9%) were not expected to result in long-term or lasting health effects and were managed at home (94.1%). A total of 80 cases (5.6%) were referred to a health care facility, and 2 cases resulted in a moderate health effect. CONCLUSIONS Children ≤5 years of age are most at risk for veterinary pharmaceutical-related exposures. Although most exposures do not result in a serious medical outcome, efforts to increase public awareness, appropriate product dispensing procedures, and attention to home storage practices may reduce the risk of veterinary pharmaceutical exposures to young children.
Collapse
Affiliation(s)
- Suzanne Tomasi
- Center for Injury Research and Policy, The Research Institute, and.,Department of Veterinary Preventive Medicine, College of Veterinary Medicine
| | | | - Jason Stull
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine
| | - Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Lara B McKenzie
- Center for Injury Research and Policy, The Research Institute, and.,Department of Pediatrics, College of Medicine, and.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| |
Collapse
|
44
|
McDonald EM, Kennedy-Hendricks A, McGinty EE, Shields WC, Barry CL, Gielen AC. Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics 2017; 139:peds.2016-2161. [PMID: 28219969 DOI: 10.1542/peds.2016-2161] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To describe safe storage practices and beliefs among adults who have used a prescription opioid pain reliever (OPR) in the past year; to compare practices and beliefs among those living with younger (<7 years) versus older children (7-17 years). METHODS A survey was administered to a nationally representative sample of adults reporting OPR use in the previous 12 months and who had children <18 years old living with them. We used Health Belief Model-derived items to measure beliefs. Safe storage was defined as locked or latched for younger children and as locked for older children. Regression models examined the association between beliefs and safe storage practices. RESULTS Among 681 adults who completed our survey and reported having children in their home, safe storage was reported by 32.6% (95% confidence interval [CI], 21.4-43.8) of those with only young children, 11.7% (95% CI, 7.2-16.2) among those with only older children, and 29.0% (95% CI, 18.3-39.8) among those with children in both age groups. Among those asked to answer survey questions thinking about only their oldest child, the odds of reporting safe storage decreased by half as perceived barriers increased (0.505; 95% CI, 0.369-0.692), increased twofold as efficacy increased (2.112; 95% CI, 1.390-3.210), and increased (1.728; 95% CI, 1.374-2.174) as worry increased. CONCLUSIONS OPRs are stored unsafely in many households with children. Educational messages should address perceived barriers related to safe storage while emphasizing how it may reduce OPR access among children.
Collapse
Affiliation(s)
- Eileen M McDonald
- Johns Hopkins Center for Injury Research and Policy, .,Department of Health, Behavior and Society
| | - Alene Kennedy-Hendricks
- Center for Mental Health and Addiction Policy Research.,Department of Health Policy and Management, and
| | - Emma E McGinty
- Johns Hopkins Center for Injury Research and Policy.,Center for Mental Health and Addiction Policy Research.,Department of Health Policy and Management, and.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Wendy C Shields
- Johns Hopkins Center for Injury Research and Policy.,Department of Health Policy and Management, and
| | - Colleen L Barry
- Center for Mental Health and Addiction Policy Research.,Department of Health Policy and Management, and.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrea C Gielen
- Johns Hopkins Center for Injury Research and Policy.,Department of Health, Behavior and Society
| |
Collapse
|
45
|
The New Kid on the Block--Incorporating Buprenorphine into a Medical Toxicology Practice. J Med Toxicol 2016; 12:64-70. [PMID: 26574020 DOI: 10.1007/s13181-015-0518-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Buprenorphine represents a safe and effective therapy for treating opioid dependence, alleviating craving and withdrawal symptoms in opioid-dependent patients. Buprenorphine has a "blocking" effect against the action of other opioids at the mu-receptor, preventing not only opioid-induced euphoria, but CNS and respiratory depressant effects as well. Buprenorphine was approved for the treatment of opioid dependence in 2002 after the passage of Drug Abuse Treatment Act 2000 (DATA 2000) which allowed clinicians to treat opioid-dependent patients with specifically named opioid agonist therapies in an office setting. Buprenorphine programs reduce the prevalence of HIV and hepatitis C and reduce criminal behaviors associated with illicit drug use. Patients stabilized on buprenorphine have increased employment, enhanced engagement with social services, and better overall health and well-being.
Collapse
|
46
|
Gaither JR, Leventhal JM, Ryan SA, Camenga DR. National Trends in Hospitalizations for Opioid Poisonings Among Children and Adolescents, 1997 to 2012. JAMA Pediatr 2016; 170:1195-1201. [PMID: 27802492 PMCID: PMC7245935 DOI: 10.1001/jamapediatrics.2016.2154] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE National data show a parallel relationship between recent trends in opioid prescribing practices and hospitalizations for opioid poisonings in adults. No similar estimates exist describing hospitalizations for opioid poisonings in children and adolescents. OBJECTIVE To describe the incidence and characteristics of hospitalizations attributed to opioid poisonings in children and adolescents. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of serial cross-sectional data from a nationally representative sample of US pediatric hospital discharge records collected every 3 years from January 1, 1997, through December 31, 2012. The Kids' Inpatient Database was used to identify 13 052 discharge records for patients aged 1 to 19 years who were hospitalized for opioid poisonings. Data were analyzed within the collection time frame. MAIN OUTCOMES AND MEASURES Poisonings attributed to prescription opioids were identified by codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. In adolescents aged 15 to 19 years, poisonings attributed to heroin were also identified. Census estimates were used to calculate incidence per 100 000 population. The Cochran-Armitage test for trend was used to assess for changes in incidence over time. RESULTS From 1997 to 2012, a total of 13 052 (95% CI, 12 500-13 604) hospitalizations for prescription opioid poisonings were identified. The annual incidence of hospitalizations for opioid poisonings per 100 000 children aged 1 to 19 years rose from 1.40 (95% CI, 1.24-1.56) to 3.71 (95% CI, 3.44-3.98), an increase of 165% (P for trend, <.001). Among children 1 to 4 years of age, the incidence increased from 0.86 (95% CI, 0.60-1.12) to 2.62 (95% CI, 2.17-3.08), an increase of 205% (P for trend, <.001). For adolescents aged 15 to 19 years, the incidence increased from 3.69 (95% CI, 3.20-4.17) to 10.17 (95% CI, 9.48-10.85), an increase of 176% (P for trend, <.001). In this age group, poisonings from heroin increased from 0.96 (95% CI, 0.75-1.18) to 2.51 (95% CI, 2.21-2.80), an increase of 161% (P for trend, <.001); poisonings involving methadone increased from 0.10 (95% CI, 0.03-0.16) to 1.05 (95% CI, 0.87-1.23), an increase of 950% (P for trend, <.001). CONCLUSIONS AND RELEVANCE During the course of 16 years, hospitalizations attributed to opioid poisonings rose nearly 2-fold in the pediatric population. Hospitalizations increased across all age groups, yet young children and older adolescents were most vulnerable to the risks of opioid exposure. Mitigating these risks will require comprehensive strategies that target opioid storage, packaging, and misuse.
Collapse
Affiliation(s)
- Julie R. Gaither
- Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Connecticut2Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut3Biomedical Informatics/Research Service, Veterans Affairs Connecticut Healthcare System, Department of Veterans Affairs, West Haven, Connecticut
| | - John M. Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Sheryl A. Ryan
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Deepa R. Camenga
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut5Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
47
|
Acute Ataxia in Children: A Review of the Differential Diagnosis and Evaluation in the Emergency Department. Pediatr Neurol 2016; 65:14-30. [PMID: 27789117 DOI: 10.1016/j.pediatrneurol.2016.08.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 08/26/2016] [Indexed: 11/21/2022]
Abstract
Acute ataxia in a pediatric patient poses a diagnostic dilemma for any physician. While the most common etiologies are benign, occasional individuals require urgent intervention. Children with stroke, toxic ingestion, infection, and neuro-inflammatory disorders frequently exhibit ataxia as an essential-if not the only-presenting feature. The available retrospective research utilize inconsistent definitions of acute ataxia, precluding the ability to pool data from these studies. No prospective data exist that report on patients presenting to the emergency department with ataxia. This review examines the reported causes of ataxia and attempts to group them into distinct categories: post-infectious and inflammatory central and peripheral phenomena, toxic ingestion, neurovascular, infectious and miscellaneous. From there, we synthesize the existing literature to understand which aspects of the history, physical exam, and ancillary testing might aid in narrowing the differential diagnosis. MRI is superior to CT in detecting inflammatory or vascular insults in the posterior fossa, though CT may be necessary in emergent situations. Lumbar puncture may be deferred until after admission in most instances, with suspicion for meningitis being the major exception. There is insufficient evidence to guide laboratory evaluation of serum, testing should be ordered based on clinical judgement-recommended studies include metabolic profiles and screening labs for metabolic disorders (lactate and ammonia). All patients should be reflexively screened for toxic ingestions.
Collapse
|
48
|
Basco WT, Garner SS, Ebeling M, Hulsey TC, Simpson K. Potential Acetaminophen and Opioid Overdoses in Young Children Prescribed Combination Acetaminophen/Opioid Preparations. Pediatr Qual Saf 2016; 1:e007. [PMID: 29862380 PMCID: PMC5965365 DOI: 10.1097/pq9.0000000000000007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 10/20/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Combination preparations of acetaminophen/opioid are the most common opioid form prescribed to children. We tested the hypothesis that dispensed prescriptions of acetaminophen/opioid preparations more appropriately match acetaminophen dosing parameters than opioid dosing parameters. We also hypothesized that the frequency of potential overdose was inversely related to subject age. METHODS Using 2011 to 2012 South Carolina outpatient Medicaid data, the authors identified acetaminophen/opioid preparations dispensed to children 0 to 36 months. Utilizing Centers for Disease Control and Prevention (CDC) data to impute subject weights as the 97th percentile for age and gender, the authors used imputed weights to calculate the maximum recommended daily dose (expected dose) of each component. We calculated the dose delivered per day (observed dose) based on drug concentration, volume dispensed, and days' supply and then calculated the frequency of overdose (observed dose/expected dose, >1.10) by each component, comparing overdose frequency of acetaminophen to the overdose frequency of opioid using a risk ratio. Logistic regression evaluated differences in potential overdose by age, controlling for race/ethnicity and gender. RESULTS Among 2,653 dispensed prescriptions of study drugs to 2,308 children 0 to 36 months old, the frequency of potential overdose was 0.7% for acetaminophen and 1.6% for opioid (risk ratio, 2.28). Age less than 3 months was associated with a greater frequency of potential overdose of either acetaminophen or opioid, even after controlling for gender and race/ethnicity. CONCLUSIONS Prescriptions of acetaminophen-opioid drugs dispensed to children 0 to 36 months old contained potential overdoses of opioid at greater than twice the frequency of acetaminophen and were more likely to occur in infants less than 3 months old.
Collapse
Affiliation(s)
- William T. Basco
- From the Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, S.C.; Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Charleston, S.C.; Department of Epidemiology, West Virginia University, Morgantown, W.Va.; and Department of Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, Charleston, S.C
| | - Sandra S. Garner
- From the Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, S.C.; Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Charleston, S.C.; Department of Epidemiology, West Virginia University, Morgantown, W.Va.; and Department of Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, Charleston, S.C
| | - Myla Ebeling
- From the Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, S.C.; Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Charleston, S.C.; Department of Epidemiology, West Virginia University, Morgantown, W.Va.; and Department of Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, Charleston, S.C
| | - Thomas C. Hulsey
- From the Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, S.C.; Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Charleston, S.C.; Department of Epidemiology, West Virginia University, Morgantown, W.Va.; and Department of Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, Charleston, S.C
| | - Kit Simpson
- From the Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, S.C.; Department of Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Charleston, S.C.; Department of Epidemiology, West Virginia University, Morgantown, W.Va.; and Department of Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, Charleston, S.C
| |
Collapse
|
49
|
Toce MS, Burns MM, O'Donnell KA. Clinical effects of unintentional pediatric buprenorphine exposures: experience at a single tertiary care center. Clin Toxicol (Phila) 2016; 55:12-17. [PMID: 27756148 DOI: 10.1080/15563650.2016.1244337] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Exploratory buprenorphine ingestions in young children have been associated with clinically significant toxicity. However, detailed data on the clinical presentation and management of these patients are lacking. In an attempt to obtain more comprehensive data, we sought to examine a single center cohort of patients with report of buprenorphine exposure and provide descriptive analysis of rates of respiratory depression, time to respiratory depression, interventions, disposition, and outcomes. STUDY DESIGN We performed a retrospective cohort study at a single pediatric tertiary care center of children between the age of 6 months and 7 years of age hospitalized between 1 January 2006 and 1 September 2014 with report of buprenorphine or buprenorphine/naloxone exposure. Patients with possible exposure to more than one agent were excluded. We extracted clinical findings, including time to respiratory depression, interventions, and disposition from the medical record. RESULTS Eighty-eight patients met the inclusion criteria. Seven patients were excluded. The median age was 24 months [IQR 18-30]. 20 patients (23%) received activated charcoal while 48 (55%) were treated with naloxone. 36 (41%) patients were admitted to the ICU. Observed clinical effects included respiratory depression (83%), oxygen saturation by pulse oximetry (SpO2) < 93% (28%), depressed mental status (80%), miosis (77%), and emesis (45%). Median time from exposure to respiratory depression was 263 min [IQR 105-486]. The median hospital length of stay was 22 h [IQR 20-26] and was positively associated with estimated exposure dose (p = 0.002). CONCLUSION Pediatric patients exposed to buprenorphine are likely to exhibit signs and symptoms of opioid toxicity, including respiratory depression, altered mental status and miosis. Although the majority of patients developed signs of clinical toxicity within 8 h of reported exposure, the optimum duration of monitoring remains unclear.
Collapse
Affiliation(s)
- Michael S Toce
- a Harvard Medical Toxicology Program , Boston Children's Hospital , Boston , MA , USA
| | - Michele M Burns
- a Harvard Medical Toxicology Program , Boston Children's Hospital , Boston , MA , USA.,b Division of Emergency Medicine, Department of Medicine , Boston Children's Hospital , Boston , MA , USA
| | - Katherine A O'Donnell
- a Harvard Medical Toxicology Program , Boston Children's Hospital , Boston , MA , USA.,c Division of General Pediatrics, Department of Medicine , Boston Children's Hospital , Boston , MA , USA
| |
Collapse
|
50
|
Daughton CG. Pharmaceuticals and the Environment (PiE): Evolution and impact of the published literature revealed by bibliometric analysis. THE SCIENCE OF THE TOTAL ENVIRONMENT 2016; 562:391-426. [PMID: 27104492 DOI: 10.1016/j.scitotenv.2016.03.109] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/15/2016] [Accepted: 03/15/2016] [Indexed: 05/28/2023]
Abstract
The evolution and impact of the published literature surrounding the transdisciplinary, multifaceted topic of pharmaceuticals as contaminants in the environment is examined for the first time in an historical context. The preponderance of literature cited in this examination represents the earlier works. As an historical chronology, the focus is on the emergence of key, specific aspects of the overall topic (often termed PiE) in the published literature and on the most highly cited works. This examination is not a conventional, technical review of the literature; as such, little attention was devoted to the more recent literature. The many dimensions involved with PiE span over 70years of published literature. Some articles began to appear in published works in the 1940s and earlier, while others only began to receive attention in the 1990s and later. Decades of early research on what at the time seemed to be disconnected topics eventually coalesced in the mid-to-late 1990s around a number of interconnected concerns and issues that now comprise PiE. Major objectives are to provide a new perspective to the topic, to facilitate more efficient and effective review of the literature by others, and to recognize the more significant, seminal contributions to the advancement of PiE as a field of research. Some of the most highly cited articles in all of environmental science now involve PiE. As of April 2015, a core group of 385 PiE articles had each received at least 200 citations; one had received 5424 citations. But hundreds of additional articles also played important roles in the evolution and advancement of the field.
Collapse
Affiliation(s)
- Christian G Daughton
- Environmental Futures Analysis Branch, Systems Exposure Division, National Exposure Research Laboratory, Office of Research and Development, U.S. Environmental Protection Agency, 944 East Harmon Avenue, Las Vegas, NV 89119, USA.
| |
Collapse
|