Positive Toxicology Research Articles

Limited Utility of Toxicology Testing at Delivery for Perinatal Cannabis Use.

To describe the characteristics of individuals undergoing toxicology testing at delivery for a sole indication of cannabis use and to evaluate the rate of unexpected positive toxicology testing results among this cohort. This retrospective cohort study included dyads with a maternal history of cannabis use who underwent peripartum toxicology testing between 2016 and 2020 at 5 birthing hospitals in Massachusetts. We collected information on maternal demographic characteristics and toxicology test results and reviewed records of dyads with unexpected positive results to identify additional social risk factors and clinical outcomes. Of 60 608 live births reviewed, 1924 dyads underwent toxicology testing, including 614 (31.9%) for a sole indication of cannabis use. Significantly greater percentages of patients in the cannabis cohort were <25 years old (32.4% vs 6.1% of the birthing population, P <.001), non-Hispanic Black (32.4% vs 8.1%, P < .001), Hispanic or Latino (30.5% vs 15.5%), American Indian/Alaskan (0.7% vs 0.1%), and publicly insured (39.9% vs 15.6%, P <.001). Eight of the 614 dyads (1.3%) had an unexpected positive toxicology test result, including 2 (0.3%) unexpectedly positive for opioids. Seven dyads (1.1%) had false positive test results for unexpected substances. Only 1 test result changed clinical management; a urine test positive for opioids prompted monitoring (but not medication) for neonatal opioid withdrawal syndrome. Toxicology testing of patients for a sole indication of cannabis use, without other risk factors, may be of limited utility in elucidating other substance use and may exacerbate existing disparities in perinatal outcomes.

Trauma activation patient preinjury toxicology-positive proportions and associated risk conditions: A retrospective study

BackgroundUnlike prior guidelines for a positive toxicology screen, the 2022 national trauma data bank dictionary requires the exclusion of postinjury drugs. We aimed to (1) investigate the proportion of drugs in the toxicology screen that were given postinjury; (2) determine preinjury toxicology-positive associations with smoking, psychiatric, and drug abuse histories in an activation patient (ACT-Pt) cohort; and (3) explore whether ACT-Pt varied toxicology testing rates would produce similar preinjury toxicology-positive results. MethodsIn this retrospective study, the historic parent database included consecutive trauma center admissions where toxicology testing was discretionary. A supplementary electronic medical record audit of ACT-Pts age 18–60 years assessed smoking, psychiatric, and drug abuse histories. Subsequently, ACT-Pt age 18–100 years testing was encouraged by attending surgeons and, later routine testing was implemented. ResultsOf 2,076 patients in the historic parent database, discretionary toxicology testing occurred in 23.9% (n = 496) and the positive proportion was 58.9% (n = 292). However, 23.6% (n = 69) of the positive screens had the drug given postinjury. The preinjury positive-toxicology proportion was 45.0% (223/496). Preinjury toxicology positivity was greater in ACT-Pts age 18–60 years (52.3%) than in other patients (activations >60 years of age or consultations) (33.7%; p < 0.0001; odds ratio [OR] = 2.2). Smoking, psychiatric, and drug abuse histories were more common in ACT-Pts age 18–60 years preinjury toxicology-positive patients (74.4%, 51.3%, and 98.7%) than in negative patients (36.6%, 25.2%, and 25.2%; p < 0.0001). In ACT-Pts age 18–100 years, when compared to historic discretionary testing (32.7%), testing was increased with encouraged testing (62.1%; p < 0.0001; OR = 3.4) and routine testing (73.1%; p < 0.0001; OR = 5.6). ACT-Pt preinjury toxicology positivity was similar for historic discretionary (47.9%), encouraged (57.6%), and routine (51.3%) (p = 0.3670) testing. The meta-analytic toxicology-positive proportion for the three testing strategies was 49.8%. ConclusionsSubstantial toxicology-positive findings are due to postinjury drug administration. Toxicology positivity is associated with ACT-Pts age 18–60 years and smoking, psychiatric, and drug abuse histories. ACT-Pt age 18–100 years preinjury toxicology positivity is 50% and does not vary with different testing proportions and strategies.

Risk factors for relapse among methamphetamine users receiving a joint legal–medical treatment program as a diversion intervention: A one-year follow-up study

BackgroundMethamphetamine (METH) is a Schedule II illicit drug in Taiwan. A 12-month legal–medical joint intervention program has been developed for first-time METH offenders during deferred prosecution. Risk factors associated with METH relapse use among these individuals were unknown. MethodsWe enrolled a total of 449 METH offenders referred by the Taipei District Prosecutor's Office to Taipei City Psychiatric Center. The study defines relapse as having any positive urine toxicology result or self-report of METH use during 12-month treatment. We compared demographic and clinical variables between a relapse group and nonrelapse group and used a Cox proportional hazards model to determine variables associated with time to relapse. ResultsOf all participants, 37.8 % relapsed to use METH and 23.2 % were noncompleters in the one-year follow-up. Compared to the nonrelapse group, the relapse group had lower educational attainment, more severe psychological symptoms, longer duration of METH use, higher odds of polysubstance use, higher craving severity, and higher odds of positive baseline urine. The Cox analysis revealed individuals with positive urine results and higher craving severity at baseline were at higher risks of METH relapse (hazard ratio [95 % CI]: 3.85 [2.61–5.68] and 1.71 [1.19–2.46], respectively, p < 0.001). Baseline positive urine results and high craving could also predict a shorter length of time to relapse than their respective counterparts. ConclusionsPositive urine screening for METH at baseline and high craving severity are two indicators of an increased risk of drug relapse. Tailored treatment plans incorporating these findings to prevent relapse are warranted in our joint intervention program.

Cocaine-Filled Capsule Detected after Firearm Injury: A Case Report

Emergency departments are facing increasing drug-related health problems with difficult medicolegal and social consequences. A 25-year-old male with no past medical history arrived at our emergency department. He was brought to the emergency room of our hospital by the security forces, as he suffered a gunshot wound while traveling to a place. The cocaine-filled capsule was seen on plain abdominal film. The plain abdominal film is the most commonly used radiological tool to detect 2-8 cm drug-filled packages within the gastrointestinal tract of body packers. In a study that analyzed the role of drugs in firearm deaths in New York between 1990 and 1998, more than half of firearm deaths had positive drug toxicology. Physicians working in the emergency unit should be prepared for secondary diagnoses. In addition, different examination and imaging findings should be kept in mind in suspicious cases.

740. Does Natural Language Processing Improve Identification of Hospitalized People Who Use Drugs?

Abstract Background In the absence of substance use disorder treatment and harm reduction tools, people who use drugs (PWUD) are at increased risk for severe injection-related infections (SIRI). Health services research characterizing the scope and trends of hospitalizations for SIRI often requires administrative billing records, urine toxicology, and medications to treat opioid use disorder, often supplemented with manual chart review. The goal of this research was to examine the feasibility of using natural language processing (NLP) to augment traditional systems of PWUD. We explored the practicality of using Natural Language Processing as a tool to accurately identify PWUD in electronic medical records (EMR). Methods We worked with information technology/computer science specialists to create a cohort of all people hospitalized at Tufts Medical Center from January 1, 2020, to April 1, 2022. Patients entered this cohort through the presence of any of these criteria: ICD10 codes for substance use disorder, positive urine toxicology results for drugs (including opiates, cocaine, amphetamine), prescriptions for medications to treat substance use disorder (at admission, during hospitalization or discharge) and the presence of NLP keywords. The NLP keyword list was created through iterative meetings with IT specialists (Table 1). Results There were 3102 patients with 3501 hospitalizations. The Venn Diagram (Figure 1) displays the overlap of the 4 criteria. Only 55 people were identified by NLP terms only. The most frequent criteria filled for cohort entry was the toxicology screen. Only 4.1% of the group had all 4 criteria. Conclusion Identifying PWUD using an NLP algorithm was possible, but there was a small number of people who were added to the cohort only on NLP criteria. Improved methodologies of identifying PWUD with medical needs are necessary to better identify gaps in healthcare, facilitate benchmarking of quality care, and improve the lives of PWUD. Disclosures All Authors: No reported disclosures.

Fentanyl in the labor epidural impacts the results of intrapartum and postpartum maternal and neonatal toxicology tests

A positive urine fentanyl toxicology test may have considerable consequences for peripartum individuals, yet the extent to which fentanyl administration in a labor epidural may lead to such a positive test is poorly characterized. This study aimed to quantify the extent to which neuraxial fentanyl in labor neuraxial analgesia can lead to a positive peripartum maternal or neonatal urine toxicology test. We performed a prospective cohort study of pregnant participants planning a vaginal delivery with neuraxial analgesia. Participants with a history of substance use disorder, hypertension, or renal or liver disease were excluded. A urine sample was collected before initiation of neuraxial analgesia, each time the bladder was emptied during labor, and up to 4 times postpartum. Neonatal urine was collected once. Urine fentanyl testing was performed using 2 common toxicology testing methods, namely immunoassay and liquid chromatography with tandem mass spectrometric detection. A total of 33 maternal-infant dyads yielded a total of 178 urine specimens. All maternal specimens were negative for fentanyl using liquid chromatography with tandem mass spectrometric analysis and immunoassay before initiation of neuraxial analgesia. Intrapartum, 26 of 30 (76.7%) participants had positive liquid chromatography with tandem mass spectrometry results for fentanyl or its metabolites, and 12 of 30 (40%) participants had positive immunoassay results. Postpartum, 19 of 21 (90.5%) participants had positive liquid chromatograph with tandem mass spectrometric results, and 13 of 21 (61.9%) had a positive immunoassay result. Of the 13 neonatal specimens collected, 10 (76.9%) were positive on liquid chromatography with tandem mass spectrometry analysis, the last of which remained positive 29 hours and 50 minutes after delivery. Neuraxial fentanyl for labor analgesia may lead to positive maternal and neonatal toxicology tests at various times after epidural initiation and cessation and at different rates depending on the testing method used. Caution should be used in interpreting toxicology test results of individuals who received neuraxial analgesia to avoid false assumptions about nonprescribed use.

Prevalence of illicit drug use in young sudden cardiac death patients; an Australian prospective cohort study

Abstract Background Illicit drug use may accelerate coronary disease and cardiac hypertrophy or stimulate arrhythmias. Rates of illicit drug use in young sudden cardiac death (SCD) patients are uncertain. Purpose To identify rates of illicit drug use in young SCD patients in Australia. Methods A prospective multi-centre registry identified out of hospital cardiac arrest (OHCA) patients aged 1–50 years between April 2019 and April 2020. Clinical characteristics were compared between patients with and without illicit drug use (defined by toxicological results or reported regular use). Illicit drugs included stimulants such as amphetamine-type substances and cocaine, or non-stimulants such as heroin, cannabis and novel psychoactive substances (cathinones and synthetic cannabinoids). Results 770 OHCAs occurred, with 555 patients undergoing forensic assessment. 287 patients had confirmed cardiac cause of OHCA, with 274 undergoing toxicological assessment and 79 (28.8%) having positive toxicology for illicit drugs (n=60) or reported regular drug use (n=19). An additional 121 patients experienced non-cardiac SCD due to illicit drug toxicity, resulting in a total of 200 patients (36.0% of OHCAs) with illicit drug use. Patients with SCD and illicit drug use were more commonly male (86.1% vs 72.3%, p=0.015), regular smokers (36.7% vs 21.5%, p=0.009), had cardiomegaly (76.5% vs 57.5%, p=0.007), and higher rates of coronary disease and cardiomyopathy (coronary disease 44.3% vs 33.3%, cardiomyopathy 30.4% vs 18.5%, p=0.003). Methamphetamines (n=42, 53.1%) were the most common illicit drug identified and polysubstance abuse occurred frequently (n=15, 19.0%). Conclusion Approximately one-third of young SCD patients use illicit drugs, with high rates of polysubstance abuse. Illicit drug use in SCD patients is associated with coronary disease and cardiomyopathy. Funding Acknowledgement Type of funding sources: None.

Characteristics and correlates of fentanyl preferences among people with opioid use disorder

ObjectivesFentanyl has come to dominate the U.S. illicit opioid supply. We aimed to characterize and examine correlates of preferences for fentanyl vs. other opioids among individuals starting OUD treatment. MethodsWe interviewed 250 adults initiating buprenorphine treatment with positive fentanyl toxicology at intake. We characterized opioid preferences and examined bivariate associations between opioid preference (preference for heroin, fentanyl, heroin-fentanyl mix, or other opioid) and sociodemographic characteristics, psychosocial factors, and substance use behaviors. We then used multinomial logistic regression to examine factors independently associated with fentanyl preferences. ResultsOver half (52.0 %) of participants preferred fentanyl (21.2 % fentanyl alone, 30.8 % heroin-fentanyl mix). In bivariate comparisons, participants who preferred fentanyl were a higher acuity group with respect to risks and problems in general. In the multinomial logistic regression, people who preferred fentanyl, either alone or mixed with heroin, used non-prescribed buprenorphine less in the 30 days preceding treatment entry compared to people who preferred heroin or other opioids (RRRalone= 0.88 [0.78, 0.99]; P = 0.037 and RRRmixed= 0.91 [0.84, 0.99]; P = 0.046). People who preferred fentanyl alone were also younger (RRR= 0.93 [0.90, 0.97]; P < 0.001) and more likely to have severe mental illness (RRR= 2.5 [1.1, 5.6]; P = 0.027) than people who prefer heroin or other opioids. ConclusionsMany people with OUD report preferring fentanyl. People who express preference for fentanyl differ substantively from those with other opioid preferences, and may be at elevated risk for poor health outcomes. Understanding preferences surrounding fentanyl could inform treatment and harm reduction interventions.

Diamorphine assisted treatment in Middlesbrough: a UK drug treatment case study

ABSTRACT Introduction Diamorphine Assisted Treatment (DAT) is a treatment offer for individuals with Opioid Dependency (OD), who have failed to benefit from standard treatment model (Opioid Substitution Therapy [OST]). In the Middlesbrough DAT service, self-administered injectable synthetic heroin (diacetylmorphine) is offered to participants, twice daily under the supervision of medical staff in a controlled and safe environment. This case report evidences outcomes from the first operational DAT service in England outside of a research trial. Method Descriptive quantitative data from participants who engaged within the first year of operation of DAT (n=14) is presented detailing engagement, harm reduction, and psychosocial outcomes, and criminality of the cohort. Results The DAT service was associated with high engagement, a large reduction in positive toxicology screens for street heroin, reduced homelessness, increased engagement with psychosocial interventions and a substantial reduction of criminal offences. Poly-drug use (specifically the consumption of street tablets) impacted treatment engagement for a proportion of the sample. Conclusions We present this work as an example of bottom-up policy making within the context of UK drug treatment and implications for practice discussed.

The Accuracy of In-State Prescription Monitoring Program Database and Electronic Medical Records Compared to Urine Toxicology Screening in Total Joint Arthroplasty Preoperative Evaluation.

Preoperative narcotic use is associated with poor postoperative pain management and worse outcomes after total joint arthroplasty (TJA). Therefore, identifying controlled substance use preoperatively is necessary. Electronic medical records (EMRs), prescription monitoring programs (PMP), or urine toxicology screening (UTS) are most commonly used. This study aims to compare the accuracy of EMR and PMP versus UTS to determine whether UTS should be implemented as standard of care in TJA preoperative assessment. Preoperative UTS was performed for primary or revision TJA from November 1, 2018, to March 31, 2019. Patient demographics, medical history, prescription history, and UTS results were retrospectively recorded. Prescription monitoring program and EMR were queried for prescription history in the past 2 years. The accuracy of EMR and PMP compared with UTS was calculated. Multivariable logistic regression analysis was performed to identify patient predictors associated with UTS+. Thirty of 148 patients had UTS+. Positive urine toxicology screening was more common in patients younger than 58 years, White race, and undergoing revision surgery. Electronic medical record and PMP documentation had the highest sensitivity (73.3%), specificity (92.4%), positive predictive value (71.0%), and negative predictive value (93.2%). Patients with higher odds of UTS+ include current/former smokers, those with a history of alcohol abuse, drug abuse, hepatitis C diagnosis, and mental illness. For patients without any risk factors for having a UTS+, the use of EMR and PMP may be sufficient to evaluate for controlled substance use; however, UTS should be considered in patients who present with one of the risk factors for UTS+.

Temporal Variability in Inflammatory Gene Methylation and Delirium in Critically Ill Patients.

Intensive care unit (ICU) delirium is associated with a proinflammatory state and poor outcomes. An epigenetic mechanism may modify inflammation. To identify inflammatory gene methylation trajectory groups and explore their clinical and demographic variability. Patients were at least 18 years old; received mechanical ventilation for at least 24 hours; had no brain disorder/injury, preexisting dementia, or positive toxicology screen; and were admitted to a medical or surgical/trauma ICU. Delirium was assessed (Confusion Assessment Method for the ICU) and blood samples were collected daily for up to 10 days. Methylation of 3 genes in the inflammatory pathway was quantified. Latent class analysis identified gene methylation trajectories, and variables (including delirium) were compared between trajectory groups. Of 68 patients (53% female, 88% White), 65% developed delirium. Of 3 methylation trajectories for IL6ST, the group with low initial methylation increasing over time included younger male patients who were less likely to have delirium, and the group with high initial methylation decreasing over time included older (P = .01) female (P = .05) patients who more often had delirium (P = .05). IL17C had 2 methylation trajectories without significant differences in delirium, age, or sex. IL13RA1 had 2 methylation trajectories without differences in delirium or age; the group with sustained high methylation had more female patients (P = .003). Temporal variability in inflammatory gene methylation occurs after ICU admission. Delirium, female sex, and older age were more common with higher IL6ST methylation that decreased over time. Larger studies are needed to further elucidate these relationships.

Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients.

IntroductionThis study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors associated with opioid and benzodiazepine misuse in the older adult population.SignificanceThis study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription.ResultsOf older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription (P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill (P = .0002) and younger (65-74) men were more likely to have a past positive toxicology (P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled.ConclusionsDocumented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.

Delivery timing for the opioid–exposed infant

The prevalence of opioid use disorder and medication-assisted treatment in pregnancy is increasing. Compared with term infants, preterm infants have a lower incidence of neonatal opioid withdrawal syndrome. It is unknown whether early term delivery compared with full or late-term delivery decreases the risk of neonatal opioid withdrawal syndrome. This study aimed to compare the neonatal outcomes among opioid-exposed infants born in the early, full, and late-term periods. This was a retrospective cohort study of opioid-exposed pregnancies delivering at a single center from 2010 to 2017 at ≥37 weeks gestation. Participants with multiple gestations or fetal anomalies were excluded. Maternal opioid exposurewas defined as prescription (including medication-assisted treatment) or nonprescription opioid use or a positive urine drug screen in pregnancy for opiates. The primary outcome was a neonatal composite of respiratory distress syndrome, neonatal sepsis, neonatal seizures, hypoxic ischemic encephalopathy, jaundice requiring treatment, 5-minute Apgar <5, neonatal intensive care unit admission, neonatal opioid withdrawal syndrome, or neonatal death. The secondary outcomes included individual components of the primary outcome, birthweight, need for and length of neonatal opioid withdrawal syndrome treatment, length of hospital admission, and maximum Finnegan scores. Early (37-<39), full (39-<41), and late (41-<42 weeks) term groups were defined by the American College of Obstetricians and Gynecologists. Of 399 infants, 136 (34.1%), 229 (57.4%), and 34 (8.5%) were born in the early, full, and late-term periods, respectively. Two hundred and seventy patients (67.7%) received medication-assisted treatment for opioid use disorder, and the baseline characteristics were similar in all the groups except for history of intranasal heroin use, positive urine toxicology screen for heroin or any opiates, and delivery indication (P<.05). The primary composite outcome occurred in 313 (78.4%) neonates, and 296 (74.2%) neonates had neonatal opioid withdrawal syndrome. More than half (219 [54.9%]) of opioid-exposed neonates were admitted to the neonatal intensive care unit, and 160 (40.1%) required pharmacologic neonatal opioid withdrawal syndrome treatment for a mean duration of almost 3 weeks (19.0±16.1 days). There were no significant differences in the primary composite outcome, incidence of neonatal opioid withdrawal syndrome, or other secondary outcomes (except birthweight) between neonates born in the early, full, or late-term periods. Although neonatal morbidity was frequent among opioid-exposed neonates, the incidence and severity of neonatal opioid withdrawal syndrome or other neonatal outcomes were not different between neonates delivered in the early, full, and late-term periods, suggesting that opioid-exposed infants may not benefit from early term delivery.

Outcomes in Subsequent Pregnancies of Individuals With Opioid Use Disorder Treated in Multidisciplinary Clinic in Prior Pregnancy

Untreated opioid misuse in pregnancy is associated with adverse outcomes. Limited information is available on maternal and perinatal outcomes in subsequent pregnancies for individuals initiated on medication for opioid use disorder (MOUD) in a prior pregnancy. Evaluate maternal and neonatal outcomes in subsequent pregnancies for individuals initiated on MOUD in prior pregnancy. Historical cohort study including individuals with opioid use disorder with ≥2 pregnancies between 2013 and 2020, received care in our colocated multidisciplinary clinic for >1 pregnancy, and delivered at our institution. Primary outcome was rate of preconception MOUD. Secondary outcomes included rate of neonatal opioid withdrawal syndrome requiring pharmacologic treatment and length of hospital stay. Forty-two individuals with opioid use disorder in their index pregnancies (n = 42) and 46 subsequent pregnancies were identified. Individuals were more likely to receive long-acting reversible contraception in subsequent pregnancies (35% vs 14%, P = 0.04). No differences in tobacco use, gestational age at initiation of prenatal care or delivery was noted. Individuals in their subsequent pregnancies were 6 times more likely to be on MOUD preconception (78% vs 36%; OR, 6.48; [95% CI, 2.52-16.64]) and 67% less likely to have positive illicit urine drug screen upon initiation of care (36% vs 64%; OR, 0.33; 95% [CI, 0.14-0.78]). Neonates had similar rates of neonatal abstinence withdrawal syndrome requiring pharmacological treatment, positive illicit toxicology results, and neonatal length of stay. Participation in multidisciplinary obstetric and opioid use disorder program increases rate of MOUD in subsequent pregnancy with decrease in illicit drug use.

Thromboembolic Outcomes in Tetrahydrocannabinol-Positive Trauma PatientsWith Traumatic Brain Injury.

Traumatic brain injury (TBI) is a significant source of morbidity and mortality in the United States. Recent shifts in state legislation have increased the use of recreational and medical marijuana. While cannabinoids and tetrahydrocannabinol (THC) have known anti-inflammatory effects, the impact of preinjury THC use on clinical outcomes in the setting of severe TBI is unknown. We hypothesized that preinjury THC use in trauma patients suffering TBI would be associated with decreased thromboembolic events and adverse outcomes. The American College of Surgeons Trauma Quality Improvement Program was used to identify patients aged ≥18y with TBI and severe injury (Injury Severity Score≥16) in admit year 2017. Patients with smoking or tobacco history or missing or positive toxicology tests for drug and/or alcohol use other than THC were excluded. Propensity score matching was used to compare THC+ patients to similar THC- patients. A total of 13,266 patients met inclusion criteria, of which 1669 were THC+. A total of 1377 THC+ patients were matched to 1377 THC- patients. No significant differences were found in in-hospital outcomes, including mortality, length of stay, cardiac arrest, pulmonary embolism, deep vein thrombosis, or acute respiratory distress syndrome. No patients had ischemic stroke, and THC+ patients had significantly decreased rates of hemorrhagic stroke (0.5% versus 1.5%, P=0.02, odds ratio 0.41 [95% confidence interval 0.18-0.86]). Preinjury THC use may be associated with decreased hemorrhagic stroke in severely injured patients with TBI, but there was no difference in thromboembolic outcomes. Further research into pathophysiological mechanisms related to THC are needed.

Donor Utilization in the Recent Era: Effect of Sex, Drugs, and Increased Risk.

Background:Heart transplantation volumes have increased in recent years, yet less than a third of donors are typically accepted for transplantation. Whether donor sex, donor drug use, or perception of increased risk affects utilization for transplantation is unclear.Methods:The United Network for Organ Sharing database was queried for donors from January 1, 2007, to December 31, 2017. Donor toxicology was collected when available. Multivariate analysis was conducted to examine correlations with donor utilization.Results:Between January 1, 2007, and December 31, 2017, there were 87 816 heart donors aged ≥15 years. The mean age was 42.7±15.8 years, and 24 831 donors (28.3%) were utilized for heart transplantation. Subsequent analyses focused on donors between 15 and 39 years old.The strongest associations with donor acceptance were for male donor sex, blood type, hepatitis C antibody, donor age, left ventricular hypertrophy, and history of donor drug use. After removing hepatitis C, Public Health Service Increased Risk was identified as a strong negative predictor. Most positive drug toxicology results were associated with donor nonuse except for donors between 15 and 19 years of age. Exceptions included alcohol, marijuana, and cocaine. Opiates were associated with less utilization at all donor ages. The Public Health Service Increased Risk status was associated with significantly less utilization in all age groups except 15- to 19-year-old donors.Conclusions:While male donors were preferentially utilized, donors with drug use or those deemed Public Health Service Increased Risk were significantly less utilized for heart transplantation. Further consideration of such donors would be appropriate particularly as the demand for transplantation continues to increase.

Suicidal Behavior and Its Relationship with Postmortem Forensic Toxicological Findings.

Suicide affects all sociodemographic levels, age groups, and populations worldwide. The factors that can increase the risk of suicidal tendencies are widely studied. The aim of this study was to analyze the types and combinations of toxics found in fatal suicide victims with different suicide mechanisms. A total of 355 autopsies were retrospectively studied, and 26 toxics were determined and related to mechanisms of suicide. Hanging (55%), drug overdose (22.7%), and jumping from a height (17.8%) were most represented suicide mechanisms with positive toxicology. Hanging was the most represented in men (50.3%; p = 0.019), while jumping from a height was more represented in women (29.7%, p = 0.028). Drugs of abuse were the most frequent toxics found in men (55.5%; p < 0.001), while medicines were the most frequent type found in women (70.3%, p < 0.001). Alcohol, nordiazepam, cocaine, and venlafaxine were the most consumed toxics. Benzodiazepines and venlafaxine were found in suicides involving drug overdose, hanging, and jumping from a height. In conclusion, most suicides were associated with drug abuse in men. Hanging was more represented in men and jumping from a height in women. Alcohol was present in combination with other toxics and medicines. The toxicological analysis is fundamental to understanding consumption patterns and establishing strategies and protocols for detecting and preventing suicide.

A positive toxicology screen is a rare finding in sports-related sudden cardiac deaths

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): University of Copenhagen Introduction Sports-related sudden cardiac deaths (SrSCD) are rare events often occurring in healthy individuals. An underlying cardiac disease may, in combination with strenuous exercise, trigger lethal arrhythmias. Intake of drugs (legal and illicit) increases the risk of sudden cardiac death (SCD), but knowledge on toxicological findings in SrSCD remains sparse. Purpose This study aimed to characterize the SrSCD population in an international consortium by investigating the epidemiology and autopsy findings in SrSCD. Methods Participating centers of the consortium (Denmark, Australia, England, Spain) provided data on all forensically autopsied SCDs aged 12—49 years in their respective cohorts, spanning from 2000—2019. Demographics, autopsy findings, and toxicology screen were assessed. A toxicology screen was considered positive if any drug was detected, except drugs related to resuscitation. Results Of all 5,029 SCDs, we identified 435 (9%) SrSCD. The majority (88%) died during sports while the remaining 12% died within one hour from exercise. SrSCD occurred more often in males (91% vs 71%, p&amp;lt;0.001) who were younger (32 vs 36 years). In SrSCD, the autopsy more frequently revealed an underlying structural cardiac cause of death (64% vs 54%, p&amp;lt;0.001); the most frequent causes of death among SrSCDs were sudden unexpected death (SUD), ischemic heart disease (IHD), and arrhythmogenic cardiomyopathy (ACM). Toxicological screens were performed in approx. 90% of cases, regardless of relation to sport. Among SrSCD cases, the rate of a positive toxicology was less than half compared to other SCDs (18% vs 44%, p&amp;lt;0.001). The most frequent toxicological findings among SrSCDs were ethanol, central stimulants, cannabinoids, and non-opioid analgesics. Conclusions Sports-related SCD accounted for 9% of all SCDs in our population aged 12—49 years. The majority of sports-related deaths (88%) occurred during exercise activity. SrSCDs more often had an underlying structural cardiac disease, mainly IHD and ACM. Positive toxicology screens were half as frequent in SrSCDs compared with non-SrSCDs.

Untargeted toxicology in sudden cardiac arrest victims

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme to J.T.-H under acronym ESCAPE-NET Background Sudden cardiac arrest (SCA) is a major public health challenge and is associated with poor outcomes. Many drugs are known to increase risk of arrythmias and ultimately sudden cardiac death. To our knowledge an untargeted toxicological analysis has not previously been performed in an initially resuscitated SCA cohort. Purpose We aimed to determine the qualitative and quantitative drug composition present in SCA patients by using forensic toxicological analytical chemistry of all illicit, non-prescription and prescribed drugs, and further investigate whether these drugs are in therapeutic levels or overdosed and to correlate the clinical findings with the toxicology results. Methods We performed a prospective single-tertiary-center study and included all SCA victims (aged 18-90 years) admitted to our cardiac intensive care unit, between February 2019 to November 2019 (Figure 1). Traumatic and overt overdose related SCA were not included in the study. Drugs used during resuscitation and administered prior to sample collection were identified in each patient and excluded. Results We prospectively identified 85 all-cause SCA patients with a median age of 60 years (IQR: 53-71) and male predominance (80%). The majority had a shockable rhythm as first rhythm (95%). The major cause of cardiac arrest was acute and chronic ischemia (56/77, 66%), followed by cardiomyopathy (9/77, 12%), idiopathic ventricular fibrillation (8/77, 10%), bradycardia (2/77, 2.6%), primary arrhythmia (1/77, 1.3%), other (1/77, 1.3%). The remaining 8 patients (9.4%) died prior to diagnosis. A positive toxicology was identified in 67 patients (79%) with a total of 218 detected drugs. The most frequent drugs were mild analgesics (32/85, 38%), beta-blockers (21/85, 25%) and ACE-inhibitors/ARB (20/85, 24%). A total of 9 (11%) patients had one or more potentially abusable drugs detected, with the most common being opioid agonists in 5 patients (Figure 2). Importantly, all drugs were found at sub-therapeutic or therapeutic concentrations. None had overdose concentrations. Moreover, polypharmacy was common and a median of 2 drugs (IQR: 1-4) were detected (excluding caffeine that was detected in 83 patients). Conclusion We found that the majority had drugs detected, and polypharmacy is displayed in a considerable proportion. Potentially abusive drugs were encountered in 11%. However, we did not identify any occult overdose related cardiac arrests among all resuscitated SCA patients. In our setting, toxicological screening in cardiac arrest patients who is not obviously overdosed is excessive.

Methamphetamine/amphetamine use over time among persons with opioid use disorders treated with buprenorphine/naloxone versus extended-release naltrexone

BackgroundMethamphetamine use is increasing among persons with opioid use disorder (OUD). The study aims were to describe methamphetamine/amphetamine (MA/A) use among patients treated for OUD with buprenorphine/naloxone (BUP-NX) or extended-release naltrexone (XR-NTX), and to explore associations between treatment arm and MA/A use. MethodsSecondary analysis of data from a multi-site, open-label, randomized controlled trial of XR-NTX versus BUP-NX for 24 weeks. The outcome variable was MA/A use defined by either positive urine drug toxicology or self-report. The main predictor was treatment assignment (BUP-NX v. XR-NTX). Longitudinal mixed-effects logistic regression models were fit to model the odds of MA/A use during the study. Additional predictors included study visit and baseline MA/A use. ResultsAmong the sample of 570 participants with OUD, baseline use of MA/A was observed in 105 (18.4%). There was no significant treatment effect over the study period, though BUP-NX subjects, on average, had about half the odds of MA/A use compared to XR-NTX subjects (OR=0.50; p = 0.051). In the same model, baseline MA/A use and study visit were both significantly associated with MA/A use over time. ConclusionIn this sample of treated OUD patients, nearly a fifth of participants had MA/A use at baseline and the frequency of use did not decline over time: in fact, the odds of use slightly increased for each later visit. These secondary analyses found no significant difference in MA/A use between BUP-NX and XR-NTX treatment arms, however, the observation of less MA/A in the buprenorphine arm merits further investigation. Clinical trial registrationClinicalTrials.gov (NCT02032433)