Experts In Toxicology Research Articles

Lessons Learned From the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Outbreak Response, Minnesota, 2019-2020.

Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) is a novel noncommunicable disease with an unknown cause. The objective of this analysis was to describe the Minnesota Department of Health's (MDH's) outbreak response to EVALI, including challenges, successes, and lessons learned. MDH began investigating EVALI cases in August 2019 and quickly coordinated an agencywide response. This response included activating the incident command system; organizing multidisciplinary teams to perform the epidemiologic investigation; laboratory testing of e-cigarette, or vaping, products (EVPs) and clinical specimens; and collaborating with partners to gather information and develop recommendations. MDH faced numerous investigational challenges during the outbreak response of EVALI, including the need to gather information on unregulated and illicit substances and their use and collecting information from minors and critically ill people. MDH laboratorians faced methodologic challenges in characterizing EVPs. Despite these challenges, MDH epidemiologists successfully collaborated with the MDH public health laboratory, law enforcement, partners with clinical and toxicology expertise, and local and national public health partners. Lessons learned included ensuring the state public health agency has legal authority to conduct noncommunicable disease outbreak investigations and the necessity of cultivating and using internal and external partnerships, specifically with laboratories that can analyze clinical specimens and unknown substances. The lessons learned may be useful to public health agencies responding to similar public health emergencies. To improve preparedness for the next outbreak of EVALI or other noncommunicable diseases, we recommend building and maintaining partnerships with internal and external partners.

Descriptive Analysis of Inpatient and Outpatient Cohorts Seeking Treatment After Prescription Opioid Misuse and Medical Toxicology Evaluation.

Medical toxicology expertise has expanded into the addiction medicine realm including outpatient medication for opioid use disorder (MOUD) and addiction treatment. Concomitantly, the emergency department (ED) and hospital are increasingly seen as important sites for the screening, prevention, and treatment of patients with substance use disorders and addiction. This analysis seeks to characterize patients seen by medical toxicologists for opioid use and opioid use disorder (OUD) in the ED and inpatient consultation setting (inpatient) versus in the OUD clinic (outpatient) setting. We searched the American College of Medical Toxicology's Toxicology Investigators Consortium Case Registry, a prospective, de-identified, national dataset that includes patients receiving medical toxicology consultation following prescription opioid misuse. The dataset also includes patients seen in outpatient MOUD clinics during the same period between June 2013 and November 2015. Intentional self-harm patients were excluded. We analyzed medical history, drug use patterns, and other factors with odds ratios and confidence intervals. Of 110 patients identified, 60 (54.5%) were inpatients and 50 (45.5%) outpatients. Mean age (39 years), gender (68% male), and race breakdown (60% white/non-Hispanic) were similar. The outpatient group was more likely to have Medicare/Medicaid coverage (p<0.0001). By history, the outpatient group was more likely to have past alcohol misuse, intravenous drug use, prescription drug misuse, and prescription opioid misuse. Most inpatient group members sought a recreational high compared to avoiding withdrawal or treating dependence in the outpatient group. Patients treated in the outpatient compared to inpatient setting were more likely to report adverse sequelae from their drug use including long-term drug use, depression, previous rehabilitation attempts, and seeking to avoid withdrawal.

The Making of Evident Expertise: Transforming Chemical Analytical Methods into Judicial Evidence

This article investigates the question of how forensic toxicologists established the credibility of chemical analytical methods in poisoning lawsuits in the nineteenth century. After encountering the problem of laypersons in court, forensic toxicologists attempted to find strategies to make their evidence compelling to an untrained audience. Three of these strategies are discussed here: redundancy, standard methods, and intuitive comprehensibility. Whereas redundancy was not very practical and legally prescribed standard methods were not very popular with most forensic toxicologists, intuitive comprehensibility proved effective and popular. This strategy relied on employing methods which did not require chemical knowledge to be understandable. The methods aimed to generate a visual aid and to be obvious in their results. Two forms of this strategy are discussed here: the presentation of the actual material and explicit comparison. I argue that this shift towards presenting forensic toxicology expertise as evident represents an important step in the history of forensic expertise.

Chemical prioritisation strategy in the European Human Biomonitoring Initiative (HBM4EU) - Development and results.

The European Human Biomonitoring Initiative (HBM4EU1) has established a European Union-wide human biomonitoring (HBM) programme to generate knowledge on human internal exposure to chemical pollutants and their potential health impacts in Europe, in order to support policy makers' efforts to ensure chemical safety and improve health in Europe. A prioritisation strategy was necessary to determine and meet the most important needs of both policy makers and risk assessors, as well as common national needs of participating countries and a broad range of stakeholders. This strategy consisted of three mains steps: 1) mapping of knowledge gaps identified by policy makers, 2) prioritisation of substances using a scoring system, and 3) generation of a list of priority substances reflective of the scoring, as well as of public policy priorities and available resources. For the first step, relevant ministries and agencies at EU and national levels, as well as members of the Stakeholder Forum each nominated up to 5 substances/substance groups of concern for policy-makers. These nominations were collated into a preliminary list of 48 substances/substance groups, which was subsequently shortened to a list of 23 after considering the total number of nominations each substance/substance group received and the nature of the nominating entities. For the second step, a panel of 11 experts in epidemiology, toxicology, exposure sciences, and occupational and environmental health scored each of the substances/substance groups using prioritisation criteria including hazardous properties, exposure characteristics, and societal concern. The scores were used to rank the 23 substances/substance groups. In addition, substances were categorised according to the level of current knowledge about their hazards, extent of human exposure (through the availability of HBM data), regulatory status and availability of analytical methods for biomarker measurement. Finally, in addition to the ranking and categorisation of the substances, the resources available for the project and the alignment with the policy priorities at European level were considered to produce a final priority list of 9 substances/substance groups for research activities and surveys within the framework of the HBM4EU project.

Protocol Design and Implementation for Monitoring Parental Substance Use in Child Custody Litigation

In child custody litigation, protecting child safety during access with a parent with substance use disorder (SUD) presents a vexing challenge for the court, parents, and parents’ counsel. Standardization of monitoring protocols for this population is lacking. Monitoring protocols utilized in clinical settings and child welfare agencies are not necessarily applicable to child custody litigation. This article is the first of its kind to initiate standardization of monitoring protocols for parental substance use in child custody litigation. This article also proposes the inclusion of, and rationale for, a neutral evaluator and a separate neutral monitor to oversee the monitoring protocol. Topics that inform the practical aspects of protocol design and implementation, such as relapse risk, monitoring duration, treatment recommendations, mandated treatment, mutual help groups, and confidentiality, are described. Family courts and matrimonial counsel benefit from an understanding of the rationale for the evaluation, treatment, and monitoring of parental substance use disorders by individuals with expertise and/or certification in substance use disorders and forensic toxicology.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January2021.

Identifying the Gaps: Needs Assessment to Guide Development of a Dedicated Toxicology Curriculum for Emergency Medicine Residents

The American Board of Emergency Medicine identifies medical toxicology as an essential curricular element for emergency medicine (EM) residencies; however, access to medicaltoxicology education varies widely by institution. We hypothesized thatEM residents areuncomfortable with core toxicology content and would be interested in a dedicated toxicology curriculum. An electronic needs assessmentsurvey developed by experts in EM and medical toxicology was sent to residents and program leadership at nine EM programs participating in the Emergency Medicine Education Research Alliance (EMERA), a geographically diverse sampling ofacademic EM residency programs. We queried the presence of a current toxicology curriculum, interest in a dedicated toxicology curriculum, and comfort with core toxicology concepts for board examinations and in clinical practice. RESULTS: A total of 148 residents and 8facultyleadership completed the survey. Only 29% ofresidentrespondents felt comfortable with toxicology concepts, and only 66% of respondents reported access to a toxicology curriculum. Of those without a known toxicology curriculum, mostwere interested in a formal curriculum. Faculty respondents reported 6/8 programs offered a toxicology curriculum. Faculty at the two programs without a formal curriculum expressed interest in a dedicated curriculum. Emergency medicineresidents remain uncomfortable with the core toxicology content in clinical practice. The majority of residents without a known toxicology curriculum would be interested in a dedicated toxicology curriculum.

Telephonic Medical Toxicology Service in a Low-Resource Setting: Setup, Challenges, and Opportunities.

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.

The establishment of a medical toxicology consulting service for advancing care of poisoning and overdose in Qatar.

Objectives: The State of Qatar, in recent decades, underwent rapid, and substantial population growth. The country's emergency medicine (EM) needs are met by government-operated facilities of the Hamad Medical Corporation (HMC), which see virtually all acute-care cases in adults and children. In 2017, emergency departments (ED) established the Medical Toxicology Consulting Service (MTCS). This report aims to outline the MTCS's initial 100 cases’ experience and report salient findings that can help ongoing national strategies in meeting Qatar's medical toxicology needs. Methods: The study setting is Qatar, and the clinical base for the MTCS was the country's sole level I center, Hamad General Hospital. The MTCS group is composed of six physicians, all with advanced training in medical toxicology. The study group is composed of the first 100 consecutive cases of the MTCS registry. Registry entry was triggered by in-person consultation, telephone consultation, or identification of cases by daily MTCS rounder surveillance of the ED's electronic tracking board. Results: The MTCS institution identified a significant number of medical toxicology cases within the national hospital system. The trends of poisoning in this study showed a median age of 30 years (range 1–81 years, IQR 22–36 years). Fourteen patients were < 18 years old. The median interval between exposure and ED presentation was 2 hours, with a range of 15 minutes to 24 hours (IQR 1–3 hours). Most patients (71%, 95% CI, 51%–80%) were symptomatic because they were exposed. The MTCS recommended therapeutic intervention in over a third of cases (36%, 95% CI, 27%–46%). Decontamination procedures were ordered in 8% of cases (95% CI, 4%–15%) and specific therapies recommended in 13 cases (13%, 95% CI, 7%–21%). Conclusions: The study highlighted that the availability of experts in medical toxicology, such as with a poison center or toxicology consultation service, results in significant resource conservation in the management of poisoned patients.

Implementation of a Medication for Addiction Treatment (MAT) and Linkage Program by Leveraging Community Partnerships and Medical Toxicology Expertise.

Implementing a hospital medication for addiction treatment (MAT) and a linkage program can improve care for patients with substance use disorder (SUD); however, lack of hospital funding and brick and mortar SUD resources are potential barriers to feasibility. This study assesses the feasibility of implementation of a SUD linkage program. Components of the program include a county-funded hospital opioid support team (HOST), a hospital-employed addiction recovery specialist (ARS), and a medical toxicology MAT induction service and maintenance program. Data for linkage by HOST, ARS, and MAT program were tracked from July 2018 to December 2019. From July 2018 through December 2019, 1834 patients were linked to treatment: 1536 by HOST and 298 by the ARS. The most common disposition categories for patients linked by HOST were 16.73% to medically monitored detoxification, 9.38% to intensive outpatient, and 8.59% to short-term residential treatment. Among patients linked by the ARS, 65.66% were linked to outpatient treatment and 9.43% were linked directly to inpatient treatment. A total of 223 patients managed by the ARS were started on MAT by medical toxicology and linked to outpatient MAT clinic: 72.68% on buprenorphine/naloxone, 24.59% on naltrexone, 1.09% buprenorphine, and 0.55% acamprosate. Implementing a MAT and linkage program in the ED and hospital setting was feasible. Leveraging medical toxicology expertise as well as community and funding partnerships was crucial to successful implementation.

Application of Environmental Epidemiology in Risk Assessment and Public Health Decision-making: A HESI Initiative

Application of Environmental Epidemiology in Risk Assessment and Public Health Decision-making: A HESI InitiativeIn Fall 2017, the Health and Environmental Sciences Institute (HESI) launched a project designed to start a dialogue around the issues that limit the full utilization of environmental epidemiology in risk assessment and regulatory decision-making. The purpose of this project is to identify factors limiting the use of epidemiological data in public health policy and regulatory decision-making, and to design solutions to facilitate that incorporation in risk assessment. The project engages representatives from government, academia, and industry with a wide range of expertise in epidemiology, toxicology, risk assessment, and exposure science. This project aims to improve practices for the collection of human data to meet the standards of the practice of epidemiology and to further contribute to the rigorous characteristics required to provide confidence in science-based assessments for regulatory decision-making.To fulfill this mission, this HESI committee started with an exploratory phase, based on the organization of four focus groups whose goals were to 1) foster dialogue among epidemiologists, risk assessors, exposure scientists, statisticians, and other experts; 2) identify barriers to the optimal integration of epidemiological data into quantitative risk assessment; and 3) propose consensus solutions for a positive impact in this space.Thanks to the active engagement of participants, these interactive meetings identified specific areas of focus, such as funding attribution, data access, insufficient cross-training, and lack of cross-disciplinary communication, where improvements could be made to ultimately increase the use of environmental epidemiology in risk assessment. Salient issues and the lessons learned from these focus groups will be presented, as well as the concrete steps taken by the HESI committee, and their recommendations to increase the relevance of epidemiological data to quantitative risk assessment.

Podcasting in Medicine: The Current Content by Emergency Medicine Subspecialty.

BackgroundPodcasts and their use in medical education, particularly emergency medicine (EM), are growing and becoming more popular. Many podcasts focus on EM, but the number of podcasts on each EM subspecialty remains unknown. Therefore, the goal of this study was to ascertain the number of podcasts available by EM subspecialty and collect the basic characteristics of each podcast.MethodsWe conducted a Google-based, investigational study of EM podcasts by subspecialty from July 2019 to January 2020. Search terms included “podcasts in ____”, where the EM subspecialties of Toxicology, Ultrasound, Wilderness Medicine, Emergency Medicine Services, Medical Education, and Simulation were inserted to identify podcasts.Results Emergency Medical Services (EMS) and Medical Education subspecialties have the most active podcasts. Toxicology and EMS have the most inactive podcasts, while Medical Education and Simulation were the only subspecialties found to not have any identified inactive podcasts.ConclusionsThe use of podcasts in EM has been increasing overall, but physicians in specific subspecialties, such as EMS and Medical Education, have access to a larger number of podcasts specific to their subspecialty than others. There is an opportunity for experts in Toxicology, Simulation, and Ultrasound to create podcast content.

Measuring Intracellular Concentrations of Calcineurin Inhibitors: Expert Consensus from the International Association of Therapeutic Drug Monitoring and Clinical Toxicology Expert Panel.

Therapeutic drug monitoring (TDM) of the 2 calcineurin inhibitors (CNIs), tacrolimus (TAC) and cyclosporin A, has resulted in improvements in the management of patients who have undergone solid organ transplantation. As a result of TDM, acute rejection (AR) rates and treatment-related toxicities have been reduced. Irrespective, AR and toxicity still occur in patients who have undergone transplantation, showing blood CNI concentrations within the therapeutic range. Moreover, the AR rate is no longer decreasing. Hence, smarter TDM approaches are necessary. Because CNIs exert their action inside T lymphocytes, intracellular CNIs may be a promising candidate for improving therapeutic outcomes. The intracellular CNI concentration may be more directly related to the drug effect and has been favorably compared with the standard, whole-blood TDM for TAC in liver transplant recipients. However, measuring intracellular CNIs concentrations is not without pitfalls at both the preanalytical and analytical stages, and standardization seems essential in this area. To date, there are no guidelines for the TDM of intracellular CNI concentrations. Under the auspices of the International Association of TDM and Clinical Toxicology and its Immunosuppressive Drug committees, a group of leading investigators in this field have shared experiences and have presented preanalytical and analytical recommendations for measuring intracellular CNI concentrations.

The Role of a Regional Poison Center in Assessing and Managing Disaster Risk.

The United States constantly faces the threat of large-scale disasters caused by natural and human factors. Emergency medical services, other first responders, and emergency department professionals are responsible for triaging and caring for victims of mass casualty incidents that include biological, chemical, and radiological agents. These providers need immediate access to individuals with expertise in infectious disease, medical toxicology, and biological, chemical, and radiological exposure who are readily available or easily accessible in the event of an emergency. Poison centers play a key public health role during disasters, in part because of the specialized training staff-including medical toxicologists-receive in all facets of toxic exposure risk identification, assessment, and management, which are foundational areas critical to disaster health response. Integrating poison centers into the public health infrastructure and public health surveillance is crucial for disaster response. Through enhanced partnerships with public health agencies, poison centers have leveraged their readily accessible expertise and surveillance capabilities to expand their roles in disaster planning and response. This paper highlights the pivotal role the Nebraska Regional Poison Center plays in preparing for and responding to disasters and other public health emergencies at local, state, and regional levels. With an emphasis on its role in risk assessment and management in partnership with healthcare coalitions and public health departments, we recommend the Nebraska Regional Poison Center as a model to inform other poison centers across the United States.

Achieving a High Level of Protection from Pesticides in Europe: Problems with the Current Risk Assessment Procedure and Solutions

The regulation of pesticides in the European Union (EU) relies on a network of hard law (legislation and implementing acts) and soft law (non-legally binding guidance documents and administrative and scientific practices). Both hard and soft laws govern how risk assessments are conducted, but a significant role is left to the latter. Europe’s pesticide regulation is one of the most stringent in the world. Its stated objectives are to ensure an independent, objective and transparent assessment of pesticides and achieve a high level of protection for health and environment. However, a growing body of evidence shows that pesticides that have passed through this process and are authorised for use may harm humans, animals and the environment. The authors of the current paper – experts in toxicology, law and policy – identified shortcomings in the authorisation process, focusing on the EU assessment of the pesticide active substance glyphosate. The shortcomings mostly consist of failures to implement the hard or soft laws. But in some instances the law itself is responsible, as some provisions can only fail to achieve its objectives. Ways to improve the system are proposed, requiring changes in hard and soft laws as well as in administrative and scientific practices.

Outcome of the pesticides peer review meeting on general recurring issues in mammalian toxicology

The technical report reflects the outcome of the discussion during the mammalian toxicology experts’ meeting on general recurring issues,which took place in Parma in October 2019. The issues discussed and identified during the EFSA peer review of pesticide active substances under Regulation (EC) No 1107/2009 were mainly related to: the assessment of substances with endocrine disrupting properties, the assessment of impurities, isomers and metabolites, the genotoxicity of mixtures,the use of in silico methods for the assessment of genotoxicity and the use of the benchmark dose instead of the NOAEL. In addition, EFSA provided an update of the ongoing activities such as the in vitro metabolism, dermal absorption and developmental neurotoxicity.

Toxicologie médico-légale et agonistes des récepteurs GABA

The role of GABA agonists in forensic toxicology in France depends on its different areas of investigation. If the prevalence of GHB / GBL, baclofen and pregabalin is very low in toxic deaths, it is necessary to remain vigilant and to screen it systematically within the context of toxicological expertise because new uses can be individually dramatic as shown by the few annual fatal cases. However, the prevalence of conventional GABA agonists like alcohol and benzodiazepines remains high in toxic deaths, but is most often associated with other psychoactive substances. All GABA agonists can modify behavior. In driving, alcohol is always analyzed since it remains involved in 30 % of fatal accidents. In contrast, the involvement of benzodiazepines and Z-drugs is not well described, despite significant consumption, due to a lack of systematic analysis. In other forensic situations such as workplace accidents or acts of violence, toxicologists are also solicited to analyze ethanol and psychoactive drugs. Finally, in the field of Drug-facilitated crime GABA agonists are mainly involved because benzodiazepines or Z-drugs have for many years been in the top trio of substances listed in the annual national surveys.

E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach

Since June, 2019, more than 1000 new cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported in the USA. Patients presented with dyspnoea, cough, and were found to be hypoxaemic with bilateral airspace opacities on chest imaging. Most patients required management in the intensive care unit and steroid therapy. All patients recovered with cessation of vaping, supportive care, and steroid therapy and remained symptom free at follow up. E-cigarette use continues to rapidly escalate in the USA, particularly among youth. Cases were defined as patients admitted to the University of Rochester Medical Center (Rochester, NY, USA) who had used e-cigarettes or another vaping device in the 30 days before presentation, and who had bilateral airspace opacification on chest imaging (CT or x-ray). Case details were obtained via medical record review and patient interviews over the past 3 months including symptomatology, physical exam data, imaging studies, laboratory data, vaping history, and subsequent outpatient follow-up data. In collaboration with the New York State Department of Health, our hospital developed a novel clinical practice algorithm based on statewide physician feedback along with input from experts in environmental health, medical toxicology, infectious disease, epidemiology, and chronic disease prevention. We report 12 cases treated for suspected EVALI at our medical centre between June 6, 2019, and Sept 15, 2019. Ten (83%) patients had dyspnoea, fever, and emesis and nine (75%) had cough. 11 (92%) patients reported the use of e-cigarette cartridges containing tetrahydrocannabinol oil. Although eight (67%) patients required admission to the intensive care unit for hypoxaemic respiratory failure, no deaths occurred. The median hospitalisation duration was 7 days (IQR 7-8). All patients completing follow up (6 [50%]) had resolution of previous chest CT findings and normal spirometry. The clinical algorithm focuses on the key signs and symptoms of EVALI and the importance of ruling out infection and other cardiopulmonary conditions before making a presumptive diagnosis of EVALI. Patients with suspected EVALI in our cohort had life-threatening hypoxaemia, with 67% requiring management in the intensive care unit. Despite the severity of presentation, similar to previous reports of patients with EVALI, most patients improved within 1-2 weeks of initial presentation after vaping cessation and administration of systemic corticosteroids when needed. Almost all (92%) patients with suspected EVALI reported vaping a THC product, making THC containing e-liquids or oils a key focus on the ongoing nationwide investigations into the cause of EVALI. Additional research is required to understand the potential toxins, underlying pathophysiological mechanisms, and identification of susceptible individuals at higher risk for hospitalisation due to EVALI. To our knowledge we present the first clinical practice algorithm for the evaluation and management of EVALI, which will be useful for both acute management and improved accurate reporting of this life-threatening respiratory illness. None.

Considerations for refining the risk assessment process for formaldehyde: Results from an interdisciplinary workshop

Anticipating the need to evaluate and integrate scientific evidence to inform new risk assessments or to update existing risk assessments, the Formaldehyde Panel of the American Chemistry Council (ACC), in collaboration with the University of North Carolina, convened a workshop: “Understanding Potential Human Health Cancer Risk - From Data Integration to Risk Evaluation” in October 2017. Twenty-four (24) invited-experts participated with expertise in epidemiology, toxicology, science integration and risk evaluation. Including members of the organizing committee, there were 29 participants. The meeting included eleven presentations encompassing an introduction and three sessions: (1) “integrating the formaldehyde science on nasal/nasopharyngeal carcinogenicity and potential for causality”; (2) “integrating the formaldehyde science on lymphohematopoietic cancer and potential for causality; and, (3) “formaldehyde research-data suitable for risk assessment”. Here we describe key points from the presentations on epidemiology, toxicology and mechanistic studies that should inform decisions about the potential carcinogenicity of formaldehyde in humans and the discussions about approaches for structuring an integrated, comprehensive risk assessment for formaldehyde. We also note challenges expected when attempting to reconcile divergent results observed from research conducted within and across different scientific disciplines - especially toxicology and epidemiology - and in integrating diverse, multi-disciplinary mechanistic evidence.

Adolescents and Drug Abuse: 21st Century Synthetic Substances

Illicit drug use by adolescents is an old problem with new clinical challenges, as teens access synthetic drugs in schools, on the street, and through internet purchase. Detection of synthetic drugs and unknown adulterants is often impossible using standard drug screens, but may be identified with the assistance of regional poison centers and the forensic laboratories of local universities and law enforcement, including the Drug Enforcement Agency. While clinical care for most intoxication and overdose cases is still largely supportive, critical interventions may be necessary for some. Toxicology experts at poison centers not only provide management advice contemporaneous to care, but compile data to identify local dangerous drug activity. This article reviews current knowledge of synthetic cannabinoids, amphetamines, and opioids, as well as the increasing teen use of “vaping” devices for delivery of tobacco and other substances.