Dr. Gustin's Blog

Intoxication and ER deaths from Synthetic Cannabinoids

Synthetic cannabinoids are part of a group of drugs called new psychoactive substances (NPS). NPS are unregulated mind-altering substances that have become newly available on the market and are intended to produce the same effects as illegal drugs. Some of these substances may have been around for years but have reentered the market in altered chemical forms, or due to renewed popularity.

Individuals reported acquiring the contaminated synthetic cannabinoid products (i.e., K2, spice, synthetic marijuana, and legal weed) from convenience stores, dealers, and friends, in counties across the state.   

Synthetic cannabinoids are human-made, mind-altering chemicals that are either sprayed on dried, shredded plant material so they can be smoked or sold as liquids to be vaporized and inhaled in e-cigarettes and other devices. They are sold for recreational drug use with claims they will provide the user the effects of cannabis. These products are also known as herbal or liquid incense and have brand names such as K2, Spice, Black Mamba, Bombay Blue, Genie, and Zohai, but may be packaged under other brand names also.

These chemicals are called cannabinoids because they are similar to chemicals found in the marijuana plant. Because of this similarity, synthetic cannabinoids are sometimes misleadingly called "synthetic marijuana" (or "fake weed"), and they are often marketed as safe, legal alternatives to that drug. In fact, they are not safe and may affect the brain much more powerfully than marijuana; their actual effects can be unpredictable and, in some cases, more dangerous or even life-threatening.

Deaths from synthetic cannabinoids have occurred from ingesting too much of the drug.  Also, deaths from synthetic cannabinoid-related motor vehicle accidents are now widely reported in the news.

Sythetic cannabinoid is ofter overlooked in the emergency department.  A recent study highlights this.

Nearly half of patients with suspected synthetic-cannabinoid-receptor agonist (SCRA) intoxication test negative for an SCRA, and many test positive for another substance, researchers report.  Clinicians caring for patients with reported synthetic-cannabinoid exposures must have a high index of suspicion for other drugs of abuse, trauma, or other medical conditions, and should evaluate and treat accordingly,

Additionally, for patients that are exposed to synthetic cannabinoids, it is essential to look out for new or different symptoms and complications, as the chemical composition of these agents is rapidly evolving.

SCRAs, sometimes referred to as "K2" or "Spice," have become popular recreational drugs due to their easy availability, legal ambiguity, inability to be detected by current drug screens, and the potent high associated with their use. Acute SCRA intoxication presents with a wide range of symptoms and poses significant challenges to emergency medicine clinicians seeking to identify and manage these patients.

Dr. Mazer-Amirshahi and colleagues sought to characterize and confirm the constituents of reported or suspected SCRA exposures presenting to two academic emergency departments in Washington, D.C.  Among the 128 unique patients included in the study, only 71 (55.5%) tested positive for an SCRA. Most (40/71) were positive for an SCRA alone, but 31 were positive for an SCRA and another substance.  Among those testing positive, 12 were positive for two SCRAs, four were positive for three SCRAs, and two were positive for four SCRAs, the researchers report in the American Journal of Emergency Medicine, online December 24.

Of the 57 patients who tested negative for an SCRA, 28 (21.9% overall) tested positive for another substance, the most common being tetrahydrocannabinol (THC) and phencyclidine (PCP). The rest (22.7% of patients overall) tested negative for SCRAs and toxicology screens.

The most commonly detected SCRAs were AB-fubinaca (39.4%), ADB-fubinaca (21.1%), AB-chminaca 3-methyl-butanoic acid (21.1%), ADB-chminaca (19.7%) and 5-flouro-PB-22 (11.3%).  There was a significant shift in the chemical constituents from prior studies, which is a known trend to avoid legal regulation.


SOURCE:  https://bit.ly/2RqfTU1

Am J Emerg Med 2018.  Intoxication From Synthetic-Cannabinoid-Receptor Agonists Often Missed.


Update on EMTALA Law


Randy Strickland walked into the ER at North Metro Medical Center burning with fever and trembling. He told the man and the woman who were staffing the triage desk that he was nauseated and felt like he needed to throw up. The emergency room was nearly empty. Randy was a volunteer at the Jacksonville, AR, hospital and hoped he would get home quickly.  But repeated visits by his wife, Mary, and son James to the triage desk didn't bring Randy any closer to getting care. Over the next 2 hours, he lost his ability to speak or respond to questions. His breathing became labored. Finally, on a trip to the bathroom, his legs buckled as he held onto Mary for support.  "I can't hold him up!" Mary yelled as she pounded on the wall that separated the bathroom from the triage desk, trying to summon the ER attendants.  When no help came, James picked up his phone and dialed 911. Could they take his dad to a different ER? he asks the operator, according to a transcript of the call.  "I'm sorry sir, my ambulance will not respond to a hospital," the operator responds. "Have you tried talking to them or anything?"  "It's just — I don't know what they're waiting for," James says.  After a pause, the dispatcher asks if they can get Randy out to his car in the parking lot, where paramedics could pick him up.  James and Mary wheeled Randy outside in a drenching rain and slid him into the back seat of their gray Toyota RAV4.

When the paramedics pulled up, Mary says, they knew immediately that Randy was too sick to be taken to another hospital. They took him back into the ER through an entrance used by ambulance crews, and the hospital's medical teams finally jumped into action. But by that time, Randy was critically ill.

 A team of doctors and nurses struggled for about an hour to save him.  Finally, a doctor came to speak with Mary.  "Is he gone?" Mary asked.  "He is, but we're going to do CPR until you tell us to stop," he told her.

Randy Strickland died after North Metro failed to follow standards of care established by the federal Emergency Medical Treatment and Labor Act, or EMTALA, records show. Investigators cited the hospital for failing to keep adequate records on Randy and for failing to do an appropriate medical screening exam.  North Metro Medical Center and its parent company, Allegiance Health Management, based in Shreveport, LA, were found guilty of EMTALA citations.

Though EMTALA has been on the books for more than 30 years, hospitals are still violating it hundreds of times a year, sometimes with devastating results for patients.

An analysis of EMTALA violations by hospitals around the United States from March 2008 to March 2018 was performed using hospital records obtained under a Freedom of Information Act request that involved cases where complaints were substantiated by investigators for the federal Centers for Medicare and Medicaid Services, meaning the hospital was found to be at fault. Investigation found:

  • More than 4,300 violations from 1,682 hospitals in total over 10 years
  • Violators represent about a third of the nation's approximately 5,500 hospitals, according to statistics from the American Hospital Association.
  • Hospitals in the Southeast accounted for 1,175 violations over 10 years, more than any other region.
  • Florida was the worst state in the nation for the number of violations, followed by Texas, Pennsylvania, New York, California, and Georgia.
  • Smaller hospitals — those with fewer than 100 beds — accounted for the largest number of violations — 1,488, or 34% of the total.
  • Failure to do a thorough medical screening exam was the most common violation committed by hospitals, accounting for more than 1,300 citations, nearly twice as many as the second most common violation: transferring patients inappropriately.
  • In a deeper analysis of investigation reports from January 2016 to March 2018, at least 34 patients died during that period after emergency departments violated the law.
  • A medical condition often cited in these violations was pregnancy. About 1 in 12 involved women who were pregnant or in labor. About 1 in 7 involved patients who were having a mental health crisis, including having suicidal thoughts.

 While violators over the 10 years represent about a third of hospitals across the United States, the chances of any individual trip to the ER resulting in a documented violation are very low. In 2016, for example, there were just 459 EMTALA violations across the country out of 142.6 million emergency room visits, according to the American Hospital Association.  Yet experts say the raw numbers don't accurately reflect both the scope and severity of the problems they see. That's because enforcement of the law depends on someone filing a complaint. Although anyone can file a complaint, it's most often a doctor, nurse, or hospital administrator.

When someone from a hospital makes a complaint about what happened at another hospital, both hospitals are investigated. While complaints are anonymous, investigations can be rigorous, and they often catch smaller violations — like failing to post signs about patient rights in an emergency room — along with larger ones that directly affect patient care.  That system of going after both sides really discourages people from complaining.  Given that fact, when you do see an EMTALA violation recorded in the system, it's usually because something really serious happened.

EMTALA, signed into law by President Ronald Reagan in 1986, was designed to prevent the practice of so-called wallet biopsies — where hospitals would turn away patients who couldn't prove they had financial resources like health insurance to pay for their care.  Those patients ended up at public hospitals, often in unstable conditions.  They died about three times more often than patients who were not transferred this way, according to an influential 1986 study on the practice.

While this kind of patient dumping still happens, it appears to be far less common than it used to be.  It appears that hospitals violate EMTALA most often because they lack the resources to provide the level of care the law requires, not because of financial considerations.

Hospitals that violate EMTALA are most likely to be smaller hospitals, or those with fewer than 100 beds. They accounted for 1,488 violations over the decade, more than any other group. According to statistics from the American Hospital Association, hospitals with fewer than 100 beds accounted for about half of all hospitals in the U.S. in 2016.

In recent years, EMTALA has largely been forgotten because patients are not in a position to enforce these laws themselves.  Before 2015, fines levied under EMTALA had been authorized under the Social Security Act and were exempt from adjustment for inflation. That means in 30 years, they'd never gone up, says April Washington, a spokeswoman for CMS. Each violation could cost a doctor or hospital up to $50,000. The penalty for hospitals with fewer than 25 beds was $25,000 per violation.  In 2015, Congress passed the Federal Civil Penalties Inflation Adjustment Act, which effectively doubled EMTALA fines and those levied by other federal agencies "to maintain their deterrent effect." according to the legislation.  Now, hospitals face up to $104,826 for each violation.

The adjustment recently resulted in the largest fine ever levied against a hospital for an EMTALA violation — nearly $1.3 million. The nonprofit AnMed hospital system, which serves South Carolina, settled with the Justice Department after investigators found the three hospitals were "boarding" dozens of mental health patients in their emergency room for as long as 38 days when they had open psychiatric beds at the same facilities. The patients had been involuntarily committed. The hospital had a longstanding policy of transferring involuntarily committed patients to the state psychiatric hospital, rather than accepting them to their in-house psychiatric unit, according to news reports. The state mental hospital was short of space, prompting long waits for transfer.


Drug Overdose Deaths vs. ER Management

Deaths from drug overdose in the United States increased by 54% from 2011 to 2016 — with opioids, benzodiazepines (benzos), and stimulants the most commonly used drug classes involved, a new report released today by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS), shows.

 The report notes that there were 41,340 drug overdose deaths in 2011 vs 63,632 such deaths in 2016.

 Although the opioid oxycodone was the most cited drug in overdose death records in 2011, heroin took the top spot from 2012 to 2015.

The story around fentanyl may be even more troubling. The rate of overdose deaths involving it or one of its analogs doubled each year from 2013 through 2016, when it finally took the lead in becoming the most mentioned drug. In 2016, 29% of all overdose deaths involved fentanyl (n = 18,335).

In addition, cocaine was the second or third most cited drug in the overdose death records throughout the entire study period.

The CDC's list of the 10 most frequently mentioned drugs also included the opioids, methadone, morphine, and hydrocodone;  the benzos, alprazolam and diazepam; and the stimulant methamphetamine.

Of all 10 drugs, only methadone was associated with a decreasing overdose death rate from 2011 to 2016.

"While the ranking changed from year to year, the top 10 drugs involved in overdose deaths remained consistent throughout the 6-year period," note the investigators, led by Holly Hedegaard, MD, NCHS.

"This report identifies patterns in the specific drugs most frequently involved in drug overdose deaths…and highlights the importance of complete and accurate reporting in the literal text on death certificates," they write.

The data were published online in the December 12 issue of the National Vital Statistics Reports.


Rise in Overdose Death Toll

An NCHS report released last year showed the age-adjusted rate of US drug overdose deaths increased dramatically from 1999 (6.1 per 100,000 population) to 2016 (19.8 per 100,000).

Although several previous studies on drug overdoses have used National Vital Statistics System-Mortality (NVSS-M) information, this data is coded using the International Classification of Diseases, Tenth Revision (ICD-10); and these ICD-10 codes focus on broad drug categories rather than on individual drugs, note the investigators.

In answer to this, the NCHS and the US Food and Drug Administration "collaboratively developed methods to search the literal text from death certificates to identify mentions of specific drugs and other substances, and to search contextual terms to identify involvement of the drug(s) or substance(s) in the death," the researchers write.

They defined "literal text" as written information from the medical certifier on cause or circumstances related to a death.

For the current report, they examined NVSS-M data from 2011 through 2016. These data were linked to electronic files containing death certificate information.

In addition to the top 10 drugs involved in overdose deaths, drugs that held the number 11 through number 15 ranking throughout the 6-year study period included diphenhydramine, acetaminophen, citalopram, carisoprodol, oxymorphone, tramadol, amitryptyline, clonazepam, gabapentin, and amphetamine. 

Threefold Increase in Heroin Deaths

The involvement of heroin in overdose deaths rose threefold from 4571 deaths in 2011 to 15,961 deaths in 2016. This made it the second-most mentioned drug in 2016, behind fentanyl.

Mentions of cocaine increased from 5892 overdose deaths in 2014 to 11,316 deaths in 2016, giving it that year's number 3 ranking.

The fourth most mentioned drug in overdose deaths in 2016 was methamphetamine. Its 6762 related deaths signified a sharp increase from the 1887 related deaths in 2011.

"An analysis of trends…showed that, for several drugs, the age-adjusted rate of drug overdose deaths increased considerably within a relatively short period," the investigators write.

Heroin, cocaine, and methamphetamine all showed significant increasing trends for age-adjusted rates of drug overdose deaths between 2011 and 2016 (1.5 vs 5.1 per 100,000 population; 1.6 vs 3.6 per 100,000; and 0.6 vs 2.1 per 100,000, respectively; all, P < .05).

Fentanyl showed a significant increasing trend between 2013 and 2016 (0.6 vs 5.9 per 100,000; P < .05).

The only decrease for a specific drug came from methadone, which was mentioned in 4545 overdose deaths in 2011 vs 3493 deaths in 2016 (1.4 vs 1.1 per 100,000). Still, it was the eighth most mentioned drug in 2016.

 For the 2016 top 10 drugs, "the proportion of deaths involving both the referent drug and at least one other concomitant drug ranged from 50% for methamphetamine to 96% for alprazolam or diazepam," the researchers report.


Finally, drugs most frequently recorded in unintentional overdose deaths in 2016 were fentanyl, heroin, and cocaine. The most frequently cited drugs in suicide by overdose were oxycodone, diphenhydramine, hydrocodone, and alprazolam.


NCHS National Vital Statistics Reports. Published December 12, 2018. Full text

Narcan Effectiveness in ED Treatment of Heroin Overdoses

Recently published in the Acad. Emerg. Med. December 28, 2018

Most patients who overdose on opioids can be safely discharged from the emergency department (ED) as early as an hour after prehospital administration of the opioid antagonist naloxone, the study has found.

Opioid-related ED visits nearly doubled in the United States from 2005 to 2014. 

The researchers conducted a prospective study to validate the early discharge rule practiced at St. Paul's Hospital, Vancouver, Canada, which allows for discharge after 1 hour for those in whom the following six criteria are within normal limits: ambulation, oxygen saturation (> 95%), respiratory rate (>10 and <20 breaths/min), temperature (>35.0° C and <37.5° C), heart rate (>50 and <100 beats/min), and Glasgow Coma Scale score (15).

The study included 538 adult patients who presented by ambulance to the ED from 2016 to 2017, who had been administered at least one dose of naloxone before entering the hospital, and who underwent evaluation by an emergency medicine provider 1 hour after naloxone administration. (The typical observation period at the hospital is 4 hours.) The mean age of the patients was 33.4 years, and 69.5% were male.

The researchers examined whether clinical judgment, the St. Paul's Early Discharge Rule, or both, when utilized 1 hour after prehospital administration of naloxone, could predict who would have an adverse event (AE) within 24 hours.

AEs occurred in 82 patients (15.4%), but none died within 48 hours. The most common AEs were need for supplemental oxygen (11.3%), repeat naloxone for hypoventilation (3%), and assisted ventilation (2.6%).

Overall, the rule had a sensitivity of 84.1% (95% confidence interval [CI], 76.2 - 92.1), a specificity of 62.1% (95% CI, 57.6 - 66.5), and a negative predictive value of 95.6% (95% CI, 93.3 - 97.9). The inability to mobilize normally had the greatest sensitivity (58.0%) for predicting AEs; an abnormal temperature had the greatest specificity (99.1%). The rule failed to predict AEs in just 13 of 538 cases (2.4%).

These results are in line with the derivation study by the rule's originators, which found that the AE rate was 16% and the negative predictive value was 99%.

Only one patient in the study whose 1-hour evaluation results were normal subsequently needed additional naloxone following another presumed heroin overdose.

When used in tandem with healthcare provider judgment, the rule had a sensitivity of 87.8% (95% CI, 80.7% - 94.9%), a specificity of 53.0% (95% CI, 48.4% - 57.7%), and a negative predictive value of 96.0% (95% CI, 93.5 - 98.4%). Used together, provider judgment and the St. Paul's Early Discharge Rule predicted AEs in all but 10 of 529 patients (1.9%) .

 "Applying the prediction rule for patients for whom providers have a low clinical suspicion for AEs is a reasonable approach for risk stratifying patients for early discharge following naloxone administration for suspected opioid overdose," the authors write. They add, however, that the rule should be used with caution in cases of known oral or mixed overdose. They also call for further study to determine the rule's effectiveness in the context of overdoses of different drugs, drug combinations, and routes of administration.

Acad Emerg Med. Published online December 28, 2018. Full text

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