Dr Paul DarganDr Paul Dargan & Dr David Wood & Dr David WoodConsultant Clinical ToxicologistsConsultant Clinical Toxicologists
Guy’s and St Thomas’ NHS Foundation TrustGuy’s and St Thomas’ NHS Foundation Trust
London, UKLondon, UK
Monitoring Drug Monitoring Drug Emergencies Emergencies
How and Why Should We Do How and Why Should We Do It?It?
Recreational DrugsRecreational Drugs
EMCDDA Annual Report 2008
Recreational Drug use is common
Numerous National, European and International networks collect data on recreational drug use:
i Population surveys of drug use
Life-time prevalence of drug use in Europe:
– 22% cannabis
– 3.6% cocaine
– 2.8% ecstasy
– Variations in pattern of use across EU
Recreational DrugsRecreational Drugs Recreational Drug use is common
Numerous National, European and International networks collect data on recreational drug use:
i Population surveys of drug use
ii Drug seizures, crime reports / surveys
iii Use of treatment agencies for problem drug use
iv Drug-related fatalities
Less co-ordinated data on recreational drug toxicity
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
There is the potential for significant morbidity and mortality
This is dependent on the class of drug
Stimulants
Hallucinogenics
Depressants
MDMA (ecstasy)Amphetamine
Cocaine1-benzylpiperazine
GHB / GBL1,4-butanediol
HeroinOpium
LSDKetamineGlaucineTFMPP
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
What data is available?What data is available? No currently published National Datasets
Not routinely collected by EMCDDA Reitox National Focal Points
Hospital coding of admissions (discharges):
Often only capture admitted patients
– up to 50-75% managed in Emergency Departments or pre-hospital
Based on ICD-10
Acute Recreational Drug Acute Recreational Drug ToxicityToxicityICD-10ICD-10
ICD-10 codes:
– Dependent on cases being coded appropriately
– Not specific for all recreational drug presentations e.g. MDMA, amphetamines, ketamine, GHB not captured
T40.0 Opium
T40.1 Heroin
T40.2 Other opioids (codeine, morphine)
T40.3 Methadone
T40.4 Other synthetic narcotics (pethidine)
T40.5 Cocaine
T40.6 Other and unspecified narcotics
T40.7 Cannabis (derivatives)
T40.8 Lysergide [LSD]
T40.9 Other & unspecified psychodysleptics [hallucinogens] Mescaline, psilocin, psilocybine
ICD-10 recreational drug codes ICD-10 recreational drug codes T40: Poisoning by narcotics and T40: Poisoning by narcotics and
psychodyslepticspsychodysleptics
Poisons Information Services
– Only capture cases that clinicians call about
Ambulance / Pre-Hospital data sets
– UK: >90% cases brought to hospital by ambulance
– Ambulance datasets not widely available / published
– No standard EU / International coding system
– Pilot studies in UK: coding not sufficient to provide reliable / robust data on recreational drug toxicity
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
Other Potential DatasetsOther Potential Datasets
Link in to other established, validated national clinical datasets– National Disease Registers
– Stroke Registers
– Cardiovascular Disease Registers
Would require novel data capture for recreational drug coding
Could potentially allow prospective follow up of a cohort of patients
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
Other Potential DatasetsOther Potential Datasets
Single centre datasets
– Collected within a hospital / city / region
– Requires local interest, finance and logistics
– Provide valuable information, with clinical detail, particularly in a high incidence area
– e.g. London UK, Palma Mallorca, Oslo Norway
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
Other Potential DatasetsOther Potential Datasets
Single centre datasets
– Collected within a hospital / city / region
Potential to link these single centre datasets
– Current EMCDDA funded pilot study led by us
– Looking at data collection in London and Mallorca
– Using a limited dataset
- Demographics and exposure data
- Basic clinical parameters and outcome
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
Other Potential DatasetsOther Potential Datasets
Single centre datasets
– Collected within a hospital / city / region
Potential to link these single centre datasets
– Current EMCDDA funded pilot study led by us
– Looking at data collection in London and Mallorca
– Will allow comparison of epidemiology between specialist centres
– Potential to expand to other centres
Acute Recreational Drug Acute Recreational Drug ToxicityToxicity
Other Potential DatasetsOther Potential Datasets
London Acute Recreational Drug London Acute Recreational Drug Toxicity DataToxicity Data
Guy’s and St Thomas’ NHS Foundation Trust
– Central London Teaching Hospital
– Specialist Clinical Toxicology Service Purpose designed database:
– Detailed data on all poisoned patients
– Full-time database scientist
– 1600 acute poisoning presentations per year
– 39% relate to recreational drug toxicity
Greene SL Postgrad Med J 2008
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Recreational Drug Presentations Recreational Drug Presentations (2008)(2008)
Recent Trends and Other Recent Trends and Other ResultsResults
2005-2008: Increase in cocaine-related toxicity Increase in GHB/GBL presentations Increase in GBL:GHB ratio
Differences in pre-hospital and Emergency Department datasets
Methamphetamine toxicity is not an issue in London or elsewhere in the UK
Wood DM QJM 2008, Wood DM Subst Use Misuse 2009
Users Self-Report Users Self-Report vs vs
Toxicological ScreeningToxicological Screening This and other similar datasets rely on users
self-report Studies suggest users self-report variable in
determining the primary drug(s) responsible for toxicity West E Emerg Med Australas 2008, Brojnaas MA Clin Tox 2006
Users self-report not useful in the context of:– Novel / emerging drugs– Mis-appropriated drugs
Novel Recreational DrugsNovel Recreational Drugs In the last 3 years we’ve detected 9 novel recreational
drugs e.g. piperazines, glaucine, DOC, D2PM, cathinones
On an ad hoc basis using clinical suspicion in patients with an atypical history / clinical features
Increasing availability/use of novel recreational drugs
Incidence of novel recreational drug toxicity is unknown
This could only be determined using comprehensive toxicological screening in a busy specialist centre
Wood DM Lancet 2007, Staack R Lancet 2007, Dargan PI EJCP 2008, Ovaska H EJEM 2008, Lidder S J Med Toxicol 2008, Wood DM J Med Toxicol 2008
ConclusionsConclusions Acute recreational drug toxicity: significant
morbidity ICD-10 not suitable for data collection:
– Poor availability of national / EU data Potential datasets
– Links to established disease registers
– Pooling of single centre, specialist datasets Screening of recreational drug presentations in
a large centre to determine
– the drugs responsible for toxicity
– incidence of novel recreational drug toxicity