Evaluation of naloxone furnishing community pharmacies in San Francisco.

OBJECTIVES: In 2017, the Centers for Disease Control and Prevention reported more than 47,600 deaths as a result of opioid overdose in the United States. In an effort to reduce these deaths, California passed legislation providing pharmacists with the ability to furnish naloxone without a prescription. Our study examined pharmacies in San Francisco that furnished naloxone and provided guidance for pharmacies seeking to develop similar programs. The study aims were to (1) identify the legal, structural, social-environmental, and financial components of a pharmacy model that allows for successful naloxone distribution, (2) evaluate the attitudes and beliefs of pharmacy staff members toward patients receiving or requesting naloxone, and (3) assess relationships between these attitudes and beliefs and naloxone furnishing at the pharmacy. METHODS: This cross-sectional study used a series of semistructured interviews of pharmacy staff in San Francisco conducted April-October 2019. Through a thematic, inductive analysis of collected data, emerging themes were mapped to the primary study aims. RESULTS: We interviewed 14 pharmacists and pharmacy technicians at 4 community pharmacies. We identified 4 factors for success in implementing a naloxone furnishing protocol: administrative-led efforts, pharmacist-led efforts, increasing pharmacist engagement, and increasing patient engagement. The respondents also discussed the approaches they used to overcome previously identified barriers: cost, time, expectations of unwanted clientele, and patients' feelings of stigma. CONCLUSION: Pharmacists' approaches to implementing naloxone furnishing had common features across locations, suggesting many of these strategies could be replicated in other community pharmacies.

An interprofessional clinical toxicology advanced pharmacy practice experience.

BACKGROUND AND PURPOSE: Clinical toxicology is a blend of science, research, and patient management practices involving human poisonings from exposure to natural and synthetic toxins. The objective of this study was to describe the components of an elective advanced pharmacy practice experience (APPE) in clinical toxicology at California Poison Control System (CPCS). EDUCATIONAL ACTIVITY AND SETTING: The APPE requirements included a mix of active participation in case management and supplemental educational exercises, case presentations and consultations, and a structured self-study component consisting of readings and on-line modules. In addition, there were two active learning activities, high acuity poisoning simulation scenarios utilizing a high-fidelity mannequin, and an antidote tasting session. FINDINGS: From April 2012 to October 2017, 82 student pharmacists completed this APPE. Pharmacy students completed 85 pre-simulation surveys and 80 post-simulation surveys. Survey results showed an increase in pharmacy student beliefs that a clinical pharmacist should be involved in the differential diagnosis and management of patients (60% pre-simulation vs. 78.8% post-simulation, p = 0.009). APPE pharmacy students completed an evaluation of the preceptors(s), site, and learning experience. The average score for all areas on the preceptor and site evaluations was >4.5 on a 5-point Likert scale. Qualitative data themes included student satisfaction with opportunities, feedback, and the interprofessional and collaborative environment. SUMMARY: An APPE in the CPCS was successfully designed and implemented. The APPE provides an interprofessional collaborative learning environment that allows student pharmacists to understand the unique role of the pharmacist in this setting.

Comparative Toxicity of Tapentadol and Tramadol Utilizing Data Reported to the National Poison Data System.

BACKGROUND: Tapentadol (TAP) and tramadol (TRA) provide pain relief through similar monoaminergic and opioid agonist properties. OBJECTIVE: To compare clinical effects and medical outcomes between TAP and TRA exposures reported to the National Poison Data System of the American Association of Poison Control Centers. METHODS: A retrospective cohort study was conducted analyzing national data for single medication TAP or TRA cases reported from June 2009 through December 2011. Case outcomes, dichotomized as severe versus mild; clinical effects; and use of naloxone were compared. RESULTS: There were 217 TAP and 8566 TRA cases. Significantly more severe outcomes were associated with TAP exposures for an all-age comparison (relative risk [RR] = 1.24; 95% CI = 1.04-1.48), and for the <6-year-old age group (RR = 5.76; 95% CI = 2.20-15.11). Patients with TAP exposures had significantly greater risk of respiratory depression (RR = 5.56; 95% CI = 3.50-8.81), coma (RR = 4.16; 95% CI = 2.33-7.42), drowsiness/lethargy (RR = 1.38; 95% CI = 1.15-1.66), slurred speech (RR = 3.51; 95% CI = 1.98-6.23), hallucination/delusion (RR = 7.25; 95% CI = 3.61-14.57), confusion (RR = 2.54; 95% CI = 1.56-4.13) and use of naloxone (RR = 3.80; 95% CI = 2.96-4.88). TRA exposures had significantly greater risk of seizures (RR = 7.94; 95% CI = 2.99-20.91) and vomiting (RR = 1.96; 95% CI = 1.07-3.60). CONCLUSION: TAP was associated with significantly more toxic clinical effects and severe outcomes consistent with an opioid agonist. TRA was associated with significantly higher rates of seizures and vomiting.

Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California.

BACKGROUND: Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented. OBJECTIVE: The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes. METHODS: We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP). RESULTS: Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs. CONCLUSIONS: Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.

Predictors of Death and Prolonged Renal Insufficiency in Ethylene Glycol Poisoning.

BACKGROUND: We assessed the predictive value of selected factors on the outcomes of death and prolonged renal insufficiency (RI) from ethylene glycol poisoning. METHODS: Retrospective, observational California Poison Control System study, over a 10-year period (1999-2008). We compared 2 groups. The first group (D/RI) included 59 patients who died (9 patients) or had prolonged RI (50 patients). Prolonged RI was defined as kidney injury in which dialysis was required for greater than 3 days after presentation. The second group (RECOV) of 62 patients had an uncomplicated recovery. Secondarily, we evaluated the association of time to antidote (ethanol and/or fomepizole) and time to dialysis with these outcomes. RESULTS: The D/RI group was more likely than the RECOV group to present comatose, have seizures, and require intubation. The D/RI group had a lower mean initial arterial pH of 7.03 (standard deviation [SD] 0.20), compared to 7.27 (SD 0.14) for the RECOV group. The D/RI group had a higher initial creatinine (1.7 mg/dL, SD 0.71) than that of the RECOV group (1.0 mg/dL, SD 0.33). Patients with a time to antidote greater than 6 hours had a higher odds of dying or having prolonged RI (OR 3.34, 95% CI : 1.21-9.26) Patients with a time to dialysis greater than 6 hours had a lower odds of dying or having prolonged RI (OR 0.36, 95% CI : 0.15-0.87). CONCLUSION: Compared to survivors with an uncomplicated recovery, patients poisoned with ethylene glycol who died or had prolonged RI were more likely to exhibit clinical signs such as coma, seizures, and acidosis. Antidote administration within 6 hours is associated with better outcomes, unlike earlier time to dialysis.

Investigating the reliability of substance toxicity information found on the Internet in pediatric poisonings.

OBJECTIVES: The Internet may be the first source of information used by parents during a suspected poisoning of their children. Our primary aim was to assess the reliability of the Internet as a resource for information for parents to initially manage a suspected poisoning involving their child without outside consultation. METHODS: We distributed a self-administered survey to English-speaking parents to evaluate their Internet access behaviors so we could emulate their search strategies for a poisoning. A panel of clinical toxicologists performed an evaluation of Websites to determine the proportion that provided accurate and adequate information on common substances involved in poisonings. RESULTS: Of 21 parents surveyed, 15 (71%) used the Internet daily, with Google and Yahoo being the most commonly used search engines. Seven parents (39%) were somewhat to very likely to utilize the Internet during a poisoning scenario with prescription medications involving their child. Overall, only 27 (38%) of the Websites reviewed advised the user to call the poison center with the proper 800 telephone number, whereas no Website provided adequate information to manage the poisoning without outside consultation. Few Websites provided information on the toxic dose (13%), how to determine whether to manage the poisoning at home or in a hospital (22%), or first aid (28%). CONCLUSIONS: The information provided on the Internet for substances involved in poisonings is variable and often incomplete. Reliance on the Internet for poisonings could create needless delays and inappropriate assessments and actions to manage a pediatric poisoning incident.

Risk factors for complications of drug-induced seizures.

The purpose of this study is to determine clinical factors associated with complications of drug-induced seizures. This prospective observational study was conducted at an American Association of Poison Control Centers-certified regional poison control center (PCC) over a 1-year period. All consecutive cases reported to a PCC involving seizures were forwarded to investigators, who obtained standardized information including the specific drug or medication exposure, dose, reason for exposure, vital signs, laboratory data, treatment, and outcome. Patients were monitored by daily telephone follow-up until death or discharge. Subjects were excluded if the seizure was deemed to be unrelated to exposure. Odds ratios were used to analyze variables for associations with admission to the hospital for >72 h, endotracheal intubation, status epilepticus, anoxic brain injury, or death. One hundred twenty-one cases met inclusion criteria. Sixty-three (52%) were male, and the mean age was 30 (SD14) years. Common exposures included: antidepressants (33%), stimulants (15%), and anticholinergics (10%). One hundred and three (85%) of the exposures were intentional, of which 74 were suicide attempts and 16 were drug abuse or misuse. Forty-nine (40%) patients required endotracheal intubation, 12(10%) had status epilepticus, 50(41%) were hospitalized for more than 72 h, and one patient died. Median hospital stay was 3 days. Variables significantly associated with complications included stimulant exposure (odds ratios, OR=11 [95% confidence intervals (CI) 1.9-52]), suicide attempt (OR=2.2 [95% CI 1.02-4.7]), initial hypotension (OR=11.2 [95% CI 1.4-89.3]), admission glucose >130 mg/dL (OR=5.4 [95% CI 1.6-18.1]), and admission HCO(3) <20 mEq/L (OR=4.0 [95% CI 1.4-11.3]). Significant clinical factors associated with complications of drug-related seizures include stimulant exposure, suicide attempt, initial hypotension, and admission acidosis or hyperglycemia.

Topical antacid therapy for capsaicin-induced dermal pain: a poison center telephone-directed study.

PURPOSE: The study aimed to assess the effects of topical antacids for treatment of capsaicin-induced dermal pain after exposure to capsaicin containing hot peppers, personal protection sprays, or topical creams. PROCEDURES: Participants of the study were California Poison Control System (CPCS) hotline callers 12 years or older with dermal pain from exposure to capsaicin-containing products or plants. Participants were instructed to apply a topical antacid and assessed for perceived pain (using a 0-10 scale) pre- and posttreatment. A positive response was defined as a sustained reduction of pain 33% or more within 30 minutes or achieving a pain score of 0 to 1. MAIN FINDINGS: Of 93 eligible patients, 64 applied antacids and had outcome data available. Patients contacted the CPCS a median of 1 hour postexposure with a median initial pain score of 7.5/10. Thirty-six (56%) were exposed to unrefined (natural) peppers and 28 (44%) to refined capsaicin (eg, capsaicin-containing cream). Before calling the CPCS, 57 (89%) attempted at least one treatment. Forty-five (70%) reported positive response to antacid treatment as a 33% reduction in pain in 30 minutes (n = 17), a reduction in pain to a score of 0 to 1 (n = 3), or both (n = 25). A 33% reduction in pain within 30 minutes was associated with exposure to refined capsaicin (odds ratio, 3.37; 95% confidence interval, 0.98-11.66). Concomitant refined capsaicin exposure and early treatment (<1 hour of symptoms) was associated with even greater odds of response (odds ratio, 5.4; 95% confidence interval, 1.4-21.2). CONCLUSION: Topical application of antacids for capsaicin-induced pain is effective, particularly in early treatment of exposure to refined capsaicin.

Comparing acute toxicity of first- and second-generation antipsychotic drugs: a 10-year, retrospective cohort study.

OBJECTIVE: Second-generation antipsychotics (SGAs) are far more commonly used in the United States compared to first-generation antipsychotics (FGAs), but the relative safety of SGAs compared to FGAs following acute toxic ingestions has not been studied. METHOD: A retrospective cohort study was performed by chart review of the California Poison Control System electronic database of 1975 cases from the 10-year period 1997 to 2006 involving patients aged 18 to 65 years who ingested a single SGA or FGA. Cases were coded for overall severity of adverse outcome as defined by the American Association of Poison Control Centers criteria and for presence of specific symptoms and treatments. Odds ratios were calculated between SGAs and FGAs for various symptoms, treatments, and outcome severity. RESULTS: Odds of a major adverse outcome or death were significantly higher for SGAs than FGAs (OR = 1.71, 95% CI = 1.09 to 2.71). Patients taking SGAs had higher odds of respiratory depression (OR = 2.39, 95% CI = 1.09 to 5.26), coma (OR = 2.18, 95% CI = 1.30 to 3.65), and hypotension (OR = 1.80, 95% CI = 1.23 to 2.63) compared to those taking FGAs but lower odds of dystonia (OR = 0.12, 95% CI = 0.08 to 0.19) or rigidity (OR = 0.30, 95% CI = 0.10 to 0.90). CONCLUSION: SGAs appear no safer than FGAs in acute overdose. While neuromuscular symptoms appear less frequently with SGAs compared to FGAs, the relatively greater rates of central nervous system depression associated with SGA overdose may be more dangerous.

Evolving epidemiology of drug-induced seizures reported to a Poison Control Center System.

INTRODUCTION: We sought to determine whether or not the causes and consequences of drug-induced seizures have changed in the last decade. METHODS: We conducted a retrospective review of all calls to the California Poison Control System in 2003 in which seizures occurred in association with poisoning or drug intoxication. We reviewed the poison center chart of each case to determine the drug(s) involved, the type of seizures, and the medical outcome. We compared the cause of reported seizures to that found in previous investigations. RESULTS: 386 cases were evaluated and related to poisoning or drug intoxication. The leading causes of seizures were bupropion (89 cases, 23%), diphenhydramine (32 cases, 8.3%), tricyclic antidepressants (30 cases, 7.7%), tramadol (29 cases, 7.5%), amphetamines (27 cases, 6.9%), isoniazid (23 cases, 5.9%), and venlafaxine (23 cases, 5.9%). Since 1993, there was a statistically significant increase in antidepressant related seizures but a decrease in TCA and cocaine related seizures. In 265 patients (68.6%) only a single seizure was reported, while 3.6% (14 cases) reported status epilepticus. Two-thirds (65.5%) of the cases involved suicide attempts and 14.8% the direct result of drug abuse. There were 7 deaths. Of the 7 deaths, 4 people had significant hyperthermia. There was a statistically significant increased risk of death associated with stimulant exposure. CONCLUSION: While tricyclic antidepressants, antihistamines, stimulants, and isoniazid remain common causes of drug induced seizures, bupropion, tramadol, and venlafaxine have emerged as common causes of drug-induced seizures for which poison center consultation is requested.

Protocols for pediatric poisonings from nontoxic substances: are they valid?

OBJECTIVES: Most pediatric poisonings have favorable outcomes and are managed in the home by poison control centers utilizing protocols that deem products or substances as nontoxic. We sought to evaluate the validity of protocols for nontoxics. METHODS: This is retrospective study in which poison control center case records within a statewide poison control center system during calendar year 2001 were searched for products or substances involved in a pediatric poisoning ingestion and identified in the poison control center nontoxic substance or product list. This was coupled with systematic literature search to ascertain if any significant medical outcomes were associated with ingestion of a nontoxic substance or product. RESULTS: During the 1-year study period, 20,900 pediatric ingestions involving 46 different nontoxic substances or products were analyzed for significant outcomes. Only 6 cases (0.03%) had a potentially serious clinical effect requiring emergency hospital management. The literature search revealed 2326 ingestion cases of nontoxic products from 635,000 citations in 50 different databases. Of these, 28 cases (1.2%) described an effect, although none was described as significant. CONCLUSIONS: Poisoning protocols for pediatric ingestions of substances or products we deemed as nontoxic were rarely associated with significant outcomes. However, non-dose-related potentially life-threatening effects are possible. Therefore, use of nontoxic protocols by other health care practitioners for telephone triage or by the public directly requires further study to be valid. Our study suggests that the term nontoxic is misleading and recommends that it be replaced with "minimally toxic" as a more appropriate term for identifying the lowest level of risk of toxicity from a substance or product.

Effects of a major earthquake on calls to regional poison control centers

We retrospectively evaluated the effect of the Loma Prieta earthquake on calls to 2 designated regional poison control centers (San Francisco and Santa Clara) in the area. In the immediate 12 hours after the earthquake, there was an initial drop (31

) in call volume,related to telephone system overload and other technical problems. Calls from Bay Area counties outside of San Francisco and Santa Clara decreased more dramatically than those from within the host counties where the poison control centers are located. In the next 2 days, each poison control center then handled a 27

increase in call volume. Requests for information regarding safety of water supplies and other environmental concerns were significantly increased. The number of cases of actual poisoning exposure decreased, particularly poison and drug ingestions in children. Most calls directly related to the earthquake included spills and leaks of hazardous materials and questions about water and food safety. Regional poison control centers play an essential role in the emergency medical response to major disasters and are critically dependent on an operational telephone system(AU)