Biosurveillance of Drug Overdoses and Substance Misuse Treated in Selected Emergency Departments in Minnesota, 2017-2020.

OBJECTIVES: Increasing knowledge about the toxicology of drug overdose and substance misuse (DOSM) is important in improving our understanding of the epidemic. We describe the Minnesota Drug Overdose and Substance Use Pilot Surveillance Activity, which started collecting data on emergency department (ED) visits attributable to DOSM in 2017, with a focus on the toxicology results of a subset of clinical encounters. METHODS: From November 1, 2017, through January 30, 2020, we collected near-real-time data on DOSM-related ED encounters. The Minnesota Department of Health Public Health Laboratory tested leftover clinical specimens (blood and/or urine) for the presence of various substances for patients who died, were hospitalized, had an atypical clinical presentation, or were part of a local drug overdose cluster. Testing looked for >250 drugs or their metabolites, including those commonly misused (eg, methamphetamine, cocaine), prescription medications, synthetic cannabinoids and cathinones, and opioids. We describe characteristics of the overall group and a subgroup of clinical encounters with toxicology results. RESULTS: Specimens submitted from 6 EDs during the study period represented 239 clinical encounters. Methamphetamine was the most frequently detected substance (67.4%) but was suspected in only 45.6% of encounters. At least 1 opioid was detected in 42.5% of encounters but suspected in only 29.7%. Testing also detected potential adulterants and additives (eg, fentanyl, fentanyl analogues, levamisole) and showed frequent patient exposure to substances not reported by patients or suspected by clinicians. Nearly half (44.4%) of clinical encounters had >1 substance detected. CONCLUSIONS: ED surveillance for DOSM encounters, enhanced by toxicology testing, can provide local situational awareness on overdoses, prevent potential mischaracterization of the true drug overdose epidemic, and inform harm reduction and drug overdose prevention efforts.

Vaping, lung injury, and mental health Minnesota 2018-2019.

This report describes and contextualizes the high prevalence of mental health conditions (MHC) among Minnesota 2019 EVALI patients by examining the prevalence of MHC and associations between MHC and e-cigarette or vaping product (EVP) use in Minnesota population surveys. Investigators reviewed medical records for 140 EVALI patients to determine history of MHC. History of MHC and EVP use in the general population was estimated using self-reported measures and screening tools from two population-based surveys, the 2019 Minnesota Student Survey (MSS) and the 2018 Minnesota Behavioral Risk Factor Surveillance Survey (MN-BRFSS). Some 64.3% of EVALI patients had an MHC. In both Minnesota population surveys, MHCs were common among people who used EVP. The odds of MHC among youth aged <18 were higher among those who reported current EVP use compared with those did not report EVP use. Similarly, the odds of depression were higher among adults who reported current EVP use compared with those who did not. Clinicians treating patients with EVALI should consider evaluating the need for, and providing indicated referrals to, post-discharge mental health services for their patients.

Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement - Minnesota, 2018 and 2019.

During August 9-October 31, 2019, 96 patients were classified as having e-cigarette, or vaping, product use-associated lung injury (EVALI) by the Minnesota Department of Health (MDH); other patients are being investigated for case classification and exposures. Among 58 patients interviewed, 53 (91%) reported obtaining tetrahydrocannabinol (THC)-containing products from informal sources such as friends, family members, or in-person or online dealers. Using gas chromatography-mass spectrometry (GCMS), the MDH Public Health Laboratory (PHL) analyzed 46 THC-containing e-cigarette, or vaping, products obtained from 12 EVALI patients for various potential toxicants, including vitamin E acetate, which has recently been detected in some THC-containing products and in samples of lung fluid from EVALI patients (1-4). To explore whether vitamin E acetate is a recently added component in THC-containing products, MDH tested ten products seized by law enforcement in 2018, before the EVALI outbreak, and 20 products seized in 2019, during the outbreak. Twenty-four products obtained from 11 EVALI patients from 2019 contained vitamin E acetate. Among the seized products tested by MDH, none seized in 2018 contained vitamin E acetate, although all tested THC-containing products seized in 2019 tested positive for vitamin E acetate. These chemical analyses of products obtained from EVALI patients and of products intended for the illicit market both before and during the outbreak support a potential role for vitamin E acetate in the EVALI outbreak; however, the number of products tested was small, and further research is needed to establish a causal link between exposure to inhaled vitamin E acetate and EVALI. Collaboration between public health jurisdictions and law enforcement to characterize THC-containing products circulating before the recognition of the EVALI outbreak and during the outbreak might provide valuable information about a dynamic market. These Minnesota findings highlight concerns about e-cigarette, or vaping, products that contain THC acquired from informal sources. Because local supply chains and policy environments vary, CDC continues to recommend not using e-cigarette, or vaping, products that contain THC or any e-cigarette, or vaping, products obtained from informal sources. E-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.* Until the relationship between inhaled vitamin E acetate and lung health is better characterized, vitamin E acetate should not be added to e-cigarette, or vaping, products.