guy’s and st thomas’ nhs foundation trust and king’s .... p. da… · guy’s and st...
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Professor Paul I Dargan
Guy’s and St Thomas’ NHS Foundation Trust
and King’s College London, London, UK
Member, Scientific Committee EMCDDA
Sources of Data on Acute Drug Toxicity
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� Systematic data is available & reported on
– Prevalence of drug use
– Drug seizures
– Problematic drug use
– Drug-related deaths
� There is no systematic data collated on
acute drug (and NPS) toxicity
– Despite this being a key public
health indicator on the impact of drug
use on the population
Acute Drug Toxicity Data
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Why is systematic data on
acute drug toxicity not
available?
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� Hospital admissions (discharges) coded using ICD-10
� ICD-10 codes: not available for most drugs
� No: amphetamine, methamphetamine, MDMA, ketamine,
GHB … and definitely not NPS
� Yes: heroin, cocaine, LSD
– But cases often coded by presenting feature
e.g. chest pain, coma, convulsion, psychosis
– In most countries only admitted patients are coded
Hospital Coding of Acute Drug Toxicity
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13.2% appropriate ICD-10 code to be able to identify
as acute drug toxicity
Hospital Coding of Acute Drug Toxicity
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Hospital Coding of Acute Drug Toxicity
Therefore not possible to automate
data collection on acute drug toxicity
to facilitate national data collection
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Potential sources of information on acute drug toxicity
� Data triangulation from a variety of imperfect
sources to minimise the limitations and ↑strength of
the combination
� In vitro pharmacological studies, animal studies
� Internet discussion forums
� User and sub-population surveys
� Poisons Information Services
� Clinical reports from ED presentations
– Linked sentinel centres
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� All European countries (and 54% countries worldwide)
have at least one poisons centre
– Some public & health care professional (HCP) access,
some HCP access only
� Provide information to clinicians on management of
drug toxicity AND collect data on these case
– Generally this data is only reported within local or
national poisons centre reports
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� Can collate data on
– Geographical/time patterns, clinical patterns of toxicity
BUT
� Data collection is second-hand, self-reported drugs
� Requires clinicians to contact poisons service (maybe less
likely to call about familiar drugs) AND report all used drugs
� May get multiple calls about one case
� Often don’t have outcome data
� For NPS needs awareness of NPS by poisons centre/clinicians
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Enquiries regarding 61 drugs/NPS
- 1561 telephone enquiries
- 58,649 TOXBASE (online database) accesses
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STRIDA Project� Collaboration between Swedish Poisons Information
Centre (PIC) and Karolinska Institute
– calls to Swedish PIC relating to potential NPS
toxicity, blood/urine samples sent for analysis
– clinical data combined with analytical results
� Powerful dataset of analytically confirmed acute NPS
toxicity: 9 case series published to date
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Emergency Department Data
� Collection of data recorded in the medical notes
� Gold standard = analytically confirmed
– Need access / funding for specialist analyses,
– Generally requires patient consent
� Labour intensive
– Requires interest, time and finance
– Will generally only happen in centres with a specialist
clinical toxicology interest: “SENTINEL” centres
– Sentinel centres can be linked to allow intra and trans
national comparisons
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Drug Abuse Warning Network (DAWN)
� US data collection 1972-2011
– Using weighted cluster sampling
– From metropolitan areas in 37 States (complete
coverage of 13 States)
– Data on acute drug toxicity, deaths and other
indicators of drug-related harm
� May continue from 201617 through the US National
Hospital Care Survey
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0
50
100
150
200
250
300
2006 2007 2008 2009 2010
Year of presentation
Num
ber
of p
rese
ntat
ions
Cocaine
GHB/GBL
MDMA
Ketamine
Cannabis
Amphetamine
Methamphetamine
Volatile Nitrites
LSD
Magic Mushrooms
Novel Pyschoactive Drugs
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The Euro-DEN project has financial support from the DPIP/ISEC
Programme of the European Union
Network of 16
specialist ED,
clilnical toxicology
centres
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� Data collection on alll acute drug toxicity
presentations to the centre
– Enable analysis of geographical and seasonal trends
– Data on clinical patterns / severity of toxicity,
treatment and outcome
� First year of data collection Oct 2013 – Sept 2014
– 5,529 cases involving 8,709 substances
� Continuing as Euro-DEN Plus with 19 sentinel centres
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Clinical Features
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Disposition from ER
Length of hospital stay
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440 NPS cases reported to Euro-DEN in Year 1
484 different NPS reported
� Cathinones were most common (378)
– 245 mephedrone, 92 methedrone, 22 MDPV
� Non-cathinone cases (106)
– Branded NPS 48, SCRA 26
0
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Den
mar
k
Esto
nia
Fran
ceGer
man
y
Irelan
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Nor
way
Poland
Spain
Switze
rlan
d UK
cou
nt
of
pre
sen
tati
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s
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Conclusions� Significant potential for acute harm associated drug use
� Limited European data collection systems and no
systematic reporting
� Poisons information services can provide useful
information: need to be co-ordinated; STRIDA provides
powerful analytically confirmed NPS case series
� Euro-DEN project is novel pan-European co-ordinated
approach to collecting Emergency Department data
– Snapshot sampling currently being explored
The ideal would be an acute harm indicator for reporting to
ECMDDA: hospital and poisons centre data
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