Alcohol use trends in Dallas County during the COVID-19 pandemic

Alcohol (ethanol) is the most widely detected drug in forensic toxicology casework and an increase in consumption of alcohol was reported during the COVID-19 pandemic. The increase in consumption could be attributed to rising stress levels and social isolation. To determine whether the pandemic had an impact on ethanol positivity and concentrations in cases analyzed by the Dallas County Southwestern Institute of Forensic Sciences, blood ethanol results were evaluated from January 1, 2019, through December 31, 2021. This time frame captured ethanol prevalence and concentrations before, during, and immediately following the pandemic for comparison. The average ethanol concentration in postmortem casework over the three years for each quarter ranged from 0.116 g/100 mL to 0.142 g/100 mL while the average concentration in driving while intoxicated (DWI) was higher, ranging from 0.173 g/100 mL to 0.188 g/100 mL. The ethanol positivity rate for postmortem casework remained relatively the same at approximately 20% during the time frame, while there was a decrease in ethanol positivity rate for DWI casework during the pandemic in April - June (Q2) 2020. However, the positivity rate returned to pre-pandemic levels by the end of 2020. Despite the self-reported surveys of increased alcohol consumption during the pandemic, a corresponding increase in average ethanol concentrations was not observed in Dallas County and the surrounding area.Copyright © 2023

Effect of Alcohol Intoxication in the Emergency Department on Suicide Mortality

Introduction: Suicide represents a significant worldwide disease burden disproportionately affecting younger patients in their prime working years. Mortality by suicide remains within the five leading causes of death up to the age of 60. Compounding this, alcohol use disorder (AUD) is known to be a risk factor for death by suicide and has been on the rise over the last 20 years, particularly during the COVID-19 pandemic. The emergency department (ED) is often the first point of health care contact for those patients that have suicidal thoughts or behaviours and understanding their acute risk of death by suicide when presenting intoxicated with alcohol remains a challenge for ED physicians. While the chronic disease of AUD elevates their lifetime risk for death by suicide, it has not been established how a presentation for suicidality accompanied by acute alcohol intoxication affects this risk. Method(s): This was a retrospective cohort study using population-based linked health administrative data for adult patients aged 18 or above who presented to Alberta (ED) between 2011 and 2021 for suicidal attempt or self-harm behavior. Patients who were acutely intoxicated with alcohol were identified and analyses compared patients with and without alcohol intoxication. The primary outcome was six-month death by suicide. Categorical variables were summarized using proportions, whereas continuous variables were summarized using means and standard deviations (SD) or medians and interquartile ranges (IQR), as appropriate. Competing risk analysis was performed to explore the cumulative incidence of death by suicide within 180 days after their index ED visit and examine the association between death by suicide and alcohol intoxication. Result(s): Patients presenting to the ED for suicide attempt or self-harm behaviour were intoxicated with alcohol in 30% of cases as determined by diagnostic coding and blood alcohol measurements. Intoxicated patients were more likely to be placed under involuntary mental health hold (26% vs 16%) and had on average a longer length of stay in the ED (411 min vs 277 min) but were less frequently admitted (10.8% vs 15.4%). As a departure from previous literature, those intoxicated with alcohol were more likely to be consulted to psychiatry (15.8% vs 12.6%). Mortality due to suicide in the 6 months following the patient' index ED visit were similar between the intoxicated and non-intoxicated groups (0.3% vs 0.3%) however there was a significant increase in all-cause mortality at 6 months in the nonintoxicated group (1.5% vs 2.1%). Discussion(s): This study examined the patient and ED treatment characteristics of patients presenting to the ED with suicide attempt or self-harm behaviour. It found that the 6-month risk of death by suicide was no different in those who presented with acute alcohol intoxication vs those without. While these results differ from other studies discussing how alcohol use disorder confers a chronically increased risk of death by suicide, they provide new evidence for the emergency department providers to consider when assessing the patient who presents with suicidal behaviours while intoxicated.

Kratom-induced Liver Failure and Death: A Case Report

Introduction: Kratom (mitragynine speciosa) is a tree native to Southeast Asia that has both opioid, stimulant, and other unknown properties. It is currently legal in the United States and used for therapeutic and recreational purposes. There is a dearth of literature on kratom’s effects on the body. At least half of reported kratom exposures resulted in a serious medical outcome, including death (1). In contrast, there are no controlled clinical trials on safety and efficacy of kratom as a treatment (2). Case: A 32-year-old Caucasian, currently unemployed, unmarried, mother of two children presented intubated to the MICU from an outside hospital with acute fulminant hepatic failure in the setting of significant kratom use. The patient also presented febrile with intracranial hemorrhage, cerebral edema, GI bleeding, acute renal failure, and diffuse intravascular coagulation. Psychiatry was consulted for potential liver transplant candidacy. Her previous history included six years of opioid use and transition to kratom 1-2 years prior to admission, with recent ingestion up to twenty-five times the patient’s usual amount (up to 125mg). Pertinent positive labs included elevated troponin (0.4), transaminitis ( >11,000), elevated PT/PTT (99/52), D-dimer ( >20), hematuria, pyuria, serum ferritin, prolonged QTc (514), and hypoglycemia. Pertinent negatives included unrevealing serum ethanol, phosphatidylethanol, viral hepatitis, HIV, COVID-19, EBV, CMV, other viral panels, acetaminophen level, toxicology screen, and EEG. Imaging revealed interstitial pulmonary edema and diffuse cerebral edema. Given lack of published information on kratom, the team emergently listed the patient for liver transplant despite significant concern for kratom use disorder. Over the course of three days, the patient’s mental status and labs continued to worsen, ultimately resulting in death. Interventions pursued included dialysis, mechanical ventilation, intracranial pressure monitoring with pressure optimization, anticonvulsant therapy, antibiotic therapy, N-acetylcysteine, and other routine MICU care. Due to relatively unremarkable health before ingestion, lack of other significant events, and severe rapid decline, multidisciplinary team consensus cause of death was due to kratom ingestion causing “acute liver failure with hepatic coma”. Discussion: This case report will go into further detail on kratom by analyzing kratom’s mechanism of action, therapeutic use, known side effects including addictive potential, effects on the liver including acute fulminant injury, and current laws and regulations surrounding kratom in the United States with relevance to public health. This is relevant to psychiatrists in the general consult, transplant, and addictions services. References: 1. Post S, Spiller HA, Chounthirath T, Smith GA. Kratom exposures reported to United States poison control centers: 2011–2017. Clinical Toxicology. 2019 57:10,847-854. DOI:10.1080/15563650.2019.1569236 2. Prozialeck W. Update on the Pharmacology and Legal Status of Kratom. J of the AOA. 2016, 116, 802-809. DOI: https://doi.org/10.7556/jaoa.2016.156

ALCOHOL CONSUMPTION AND MISUSE AMONG PATIENTS WITH RESPIRATORY FAILURE BEFORE AND DURING THE COVID-19 PANDEMIC

Alcohol misuse is associated with the development of respiratory failure, including the acute respiratory distress syndrome (ARDS), with attendant poorer outcomes. Epidemiologic data suggest that alcohol consumption increased during the COVID-19 pandemic;however, consumption habits among critically ill patients are not well-described. We hypothesized that the prevalence of alcohol consumption and misuse among patients with respiratory failure would be greater during the pandemic relative to years prior. Patients with respiratory failure requiring mechanical ventilation in a single academic hospital were enrolled from 2015-19 (pre-pandemic) and 2020-21 (pandemic). Data regarding demographics and alcohol use were obtained from the medical record. Phosphatidylethanol (PEth) was measured in a subset of patients in red blood cells collected within 48 hours of intubation. Patients were characterized as follows: (1) likely drinking: patient or proxy endorsed any drinking on the Alcohol Use Disorders Identification Test (AUDIT) or in social history;or patient was admitted for an alcohol-related diagnosis;or patient had detectable blood alcohol or PEth;(2) likely alcohol misuse: PEth ≥ 250;or AUDIT-C ≥3 (women) or ≥4 (men);or AUDIT ≥5 (women) or ≥ 8 (men);or patient was admitted for an alcohol-related diagnosis;(3) likely severe alcohol misuse: PEth ≥400. Univariable statistics were utilized as appropriate (Fisher's Exact Test, Kruskal- Wallis Test). The prevalence of likely drinking in the study population (n = 195) varied over time (p <0.0001). When pandemic (n = 67) and pre-pandemic patients (n = 128) were compared, the prevalence of likely drinking (93% vs 58%, p <0.0001), likely alcohol misuse (49% vs 33%, p <0.03) and likely severe alcohol misuse (32% vs 10%, p <0.003) were all greater during the pandemic. Among likely drinking patients with available PEth data (n = 97), median PEth was significantly higher during the pandemic compared to pre-pandemic years (251 [135-702] versus 87 [16-374], p = 0.002). Among the subset of patients enrolled during the pandemic, the prevalence of likely current drinking was 100% in those with COVID-19 compared to 76% among non-COVID patients (p = 0.002), but alcohol misuse did not differ. We conclude that alcohol consumption, and alcohol misuse, have increased during the pandemic in this patient cohort. These changes in drinking patterns are concerning and warrant additional research regarding their impact on susceptibility and outcomes for respiratory failure.

Supplement-Induced Thyrotoxicosis Presenting as New Onset Tachycardia

INTRODUCTION: Dietary and herbal supplements can contain clinically significant amounts of exogenous thyroid stimulants and hormones, including T3 and T4, thus placing consumers at increased risk of thyrotoxicosis and other metabolic-related adverse effects. We present a case of thyrotoxicosis in a young man with no history of thyroid disease, who was found to be consuming an extensive variety of supplements. DESCRIPTION: A 31 year old man with hypertension presented with 1 week of intermittent palpitations. He was in his usual state of health until 1 week prior to admission, when he noticed intermittent, self-resolving episodes of tachycardia as high as the 160s on his smart watch, associated with palpitations, dyspnea, low grade fevers, and intermittent dry cough. He came to the ED for persistence of symptoms. In the ED: T 98.8 F, HR 129, BP 152/77, RR 18, SpO2 98% on RA. CBC, BMP, UA, UTox, blood alcohol content, troponin and COVID tests were unremarkable. TSH was < .007 [0.358-3.740 ulU/mL], with a free thyroxine of 0.54 [0.70-1.48 ng/dL];other thyroid studies later returned with TSI < 0.10 [0.00-0.55 IU/L], free T3 32.50 [1.80-4.60 pg/mL], and an unremarkable thyroid ultrasound. CXR showed no acute infiltrates. EKG revealed sinus tachycardia, no Wolff-Parkinson-White syndrome, and no Brugada waveforms. He was given 2L NS, ceftriaxone 1g IV, aspirin 81mg PO, and tylenol 650mg PO, and admitted to the telemetry unit. Exam revealed an anxious appearing man with tachycardia. On ROS, patient admitted to drinking 6-8 cups of coffee daily, and to taking at least a dozen different supplements. He was started on propranolol 30 mg every 6 hours with improvement in his heart rate, and was counseled to stop the supplements and wean his caffeine intake. He was discharged the following day with plan for endocrinology and primary care follow-up. DISCUSSION: Thyrotoxicosis in this young patient with no history of thyroid disease posed a diagnostic quandary. This prompted further investigation into a more detailed social history, which revealed the extensive variety of supplements he was taking, consistent with thyrotoxicosis factitia. In patients presenting with newonset tachycardia, our case highlights the importance of collecting a thorough social history and maintaining early suspicion for thyroid disease and thyrotoxicosis.

Increased proportion of alcohol-related trauma in a South London major trauma centre during lockdown, a cohort study

Background: Alcohol has been associated with 10-35% trauma admissions and 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of 'lockdown' on 23rd March 2020. Restrictions were most significantly eased on 1st June 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions. Method: All adult patients admitted as 'trauma calls' to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown;N=316), and 1st April - 31st May 2020 (lockdown;N=191) had electronic patient records analysed. Patients' blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre- and post-lockdown cohorts were compared using multiple regression analyses. Results: Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%);(Odds Ratio (OR) 0.83, 95% CI 0.38 to 1.28, p<0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%);OR -0.40, 95% CI -0.79 to -0.02, p=0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p>0.05). Conclusions: UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of subsequent global 'waves' of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.