Trends in opioid exposures among young children reported to United States poison centers from 2016 to 2023.

INTRODUCTION: The objective of this study was to update and expand on previous studies of opioid exposures among young children reported to America's Poison Centers, and to describe how fentanyl and medications for opioid use disorder have contributed. METHODS: This retrospective study investigated 34,632 reports of single-substance opioid exposure from 2016 to 2023 involving pediatric patients aged one month to six years old. Descriptive statistics, tests for data normality, and significance testing were performed where applicable. RESULTS: Of 34,632 reported exposures, 96.7% were unintentional. The median age of exposure was 2.0 years (IQR 1.33-3.0 years). Reported exposures decreased by 57.5% over the study period (r = -0.96; P < 0.001). However, there was a 300% absolute increase in deaths and major effects (r = 0.96; P < 0.001). Exposures resulting in minor, no effect, not followed, or unable to follow decreased 66.2% (r = -0.99; P < 0.001). Buprenorphine was most frequently involved, comprising 23.4% of reported exposures. Buprenorphine (OR 1.93; P < 0.001) and methadone (OR 14.98; P < 0.001) were associated with an increased risk of severe effects when compared to other prescription drugs (OR: 1). There was an absolute increase of 512% over time in reports of heroin, fentanyl, synthetic non-pharmaceutical opioids (r = 0.92; P < 0.001), which were also associated with severe effects (OR 20.1; P < 0.001). DISCUSSION: Pediatric opioid exposures have previously been reported to be relatively stable. It is likely the 57.5% reduction is exaggerated due to underreporting from health care providers. However, decreases in exposures are presumed to be balanced throughout the dataset and, therefore, without differential impact on other points of analysis. Our study highlights the continued need for enhanced poisoning prevention strategies. CONCLUSIONS: The relative severity of poisonings reported to poison centers worsened over the study period. The opioids implicated have shifted away from hydrocodone, oxycodone, and tramadol, and towards fentanyl and buprenorphine.

Attempted Self-Harm with Elemental Thallium Purchased Online: Case Report with Analytical Confirmation.

INTRODUCTION: Thallium is a highly toxic metal, with most publications demonstrating poisoning from thallium salts. We report on a patient with elevated serum and urine thallium concentrations from an intentional ingestion of elemental thallium purchased from the internet for self-harm. CASE REPORT: The regional poison center was contacted about an 18-year-old man who ingested a fragment from a 100-gram bar reported to be elemental thallium. Serial serum and urine thallium concentrations were obtained. Prussian blue was started on hospital day (HD) 2. A metal fragment was seen on abdominal x-ray and removed via colonoscopy on HD3. The ingested fragment was analyzed via inductively coupled plasma mass spectrometry (ICP-MS) and found to be 87.0% elemental thallium. The initial serum thallium concentration obtained on HD1 was 423.5 mcg/L (reference range < 5.1 mcg/L), which subsequently decreased to 4.5 mcg/L, 29 days after the ingestion. An initial random urine thallium concentration obtained on HD 3 was 1850.5 mcg/g creatinine (reference range < 0.4 mcg/g creatinine). The patient remained hospitalized for 23 days and, when seen in follow-up, had not developed any signs or symptoms of thallium toxicity. DISCUSSION: Elemental thallium ingestion is a rare toxicologic exposure, with limited published clinical and analytical experience to guide management. This case report describes a patient with ingestion of elemental thallium who developed elevated serum and urine thallium concentrations and was treated with Prussian blue. Despite having elevated serum and urine thallium concentrations consistent with previous fatal exposures, more evidence is needed to understand the differences between elemental thallium and thallium salts.

Preventing Pediatric Opioid Poisoning: Unusual Sources and Scenarios.

This retrospective study analyzed 230 pediatric opioid exposures from a statewide poison control center over a 5-year period. Most exposures involved pharmaceutical opioids and children below 2-years-old. Narrative details were reviewed to identify uncommon sources of opioids involved in poisoning and highlight the need for tailored prevention strategies and guidance.

Management patterns of multiple magnet ingestion reported to New Jersey Poison Information and Education System.

BACKGROUND: Ingestion of multiple high-powered neodymium rare-earth magnets poses a significant risk for gastrointestinal (GI) injury such as bowel perforation or ischemia. Given the rising incidence of rare earth magnetic ingestions and the corresponding increase in serious injuries in children, published guidelines recommend urgent endoscopic removal of all magnets within endoscopic reach in cases involving ingestions of two or more magnets. RESEARCH QUESTION: Do management patterns for multiple magnet ingestion align with current practice guidelines, and does hospital length of stay (LOS) differ based on the initial emergency department (ED) approach? METHODS: This is a retrospective chart review of consecutive patient encounters reported to the New Jersey Poison Information and Education System (NJPIES) between January 2021 and April 2022 involving multiple magnet ingestion. Potential cases were retrieved from the NJPIES TOXICALL® database, using substance codes relating to magnet or foreign body ingestion. Two-sample T tests were used to determine the statistical difference in the hospital LOS between the group of patients receiving early emergent esophagogastroduodenoscopy (EGD) versus those receiving expectant management on initial presentation. RESULTS: There was a difference in the average LOS of 2.7 days (p = 0.023) longer in the expectant management group with no medical complications in either group. Twenty-five percent or 2 out of 8 cases deviated from guidelines. CONCLUSION: The initial ED decision to pursue expectant management instead of attempting emergent EGD removal of magnets may result in prolonged hospitalization, increased risk for readmission, and delayed definitive removal of magnets due to nonprogression along the GI tract.

Poisonings After a Hurricane: Lessons From the New Jersey Poison Information and Education System (NJPIES) During and Following Hurricane Sandy.

OBJECTIVE: Hurricane Sandy made landfall in New Jersey on October 29, 2012, resulting in widespread power outages and gasoline shortages. These events led to potentially toxic exposures and the need for information related to poisons/toxins in the environment. This report characterizes the New Jersey Poison Information and Education System (NJPIES) call patterns in the days immediately preceding, during, and after Hurricane Sandy to identify areas in need of public health education and prevention. METHODS: We examined NJPIES case data from October through December 2012. Most Sandy-related calls had been coded as such by NJPIES staff. Additional Sandy-related cases were identified by performing a case narrative review. Descriptive analyses were performed for timing, case frequencies, exposure substances, gender, caller site, type of information requests, and other data. RESULTS: The most frequent Sandy-related exposures were gasoline and carbon monoxide (CO). Gasoline exposure cases were predominantly males and CO exposure cases, females (P < 0.0001). Other leading reasons for Sandy-related calls were poison information, food poisoning/spoilage information, and water contamination. CONCLUSIONS: This analysis identified the need for enhanced public health education and intervention to improve the handling of gasoline and encourage the proper use of gasoline-powered generators and cleaning and cooking equipment, thus reducing toxic exposures.

The Poison Center as a pandemic response: establishment and characteristics of a COVID-19 hotline through the New Jersey Poison Center.

BACKGROUND: Poison Centers are uniquely positioned to respond to an unprecedented public health threat such as the COVID-19 pandemic, as fully operational 24-h hotlines already staffed with healthcare professionals. METHODS: On January 27, 2020 the New Jersey Poison Information and Education System (NJPIES) agreed to operate the New Jersey Coronavirus Hotline. Call patterns, subject matter, and staffing and infrastructure strategies that were implemented to meet the demand are described. In addition, a sample of 1500 individual calls were collected and analyzed in an endeavor to describe call times, call days, area from which the call originated, callers to the hotline, primary language of the caller, and why a call was placed to the hotline. Binomial regression analysis was utilized in an attempt to identify significant patterns. RESULTS: Since the inception of the hotline through October 31, NJPIES responded to 57,579 calls for COVID-19 information. Most calls (68.7%) were regarding testing for COVID-19 and for general questions/symptoms. Call types varied when they were analyzed by time of day with calls for general questions/symptoms and where to get tested for COVID-19 showing a significant association for the early morning hours, how to obtain test results being significantly associated with the afternoon hours, and how to renew or obtain a medical license showing a significant association to the evening hours. We additionally noted that specific call types became significant when analyzed on a week-to-week basis and as specific events, like the enactment of the CARES Act of 2020, occurred. CONCLUSION: Although not the traditional role of a regional Poison Control Center, pandemic response synergizes with the workflow of this hotline because the infrastructure, staffing, and healthcare expertise are already present. Poison centers can rapidly adapt through scaling and process change to meet the needs of the public during times of public health threats.

Opioid-Associated Hearing Loss: A 20-Year Review from the New Jersey Poison Center.

BACKGROUND: Opioid-associated ototoxicity is a known complication of opioid exposure, although the mechanism remains unclear. While historically most closely linked to heroin and oxycodone, evolving reports suggest that it may be a class effect of opioids. However, the evidence is limited to case reports. METHODS: A retrospective review of the New Jersey Poison Center records (ToxiCALL®) identified cases that included both hearing loss and recent opioid exposure between January 1, 1999, and September 21, 2018. RESULTS: Forty-one cases were identified, mean age 29.4 years, 51% (n = 21) were male. Reported heroin exposures comprised 51% (n = 22), 18 of which were heroin alone. The next most commonly cited opioids were oxycodone (n = 7), methadone, (n = 4), and tramadol (n = 3). Hearing loss was described as tinnitus in 24% of cases, hypoacusis in 37% of cases, deafness in 29% of cases, and mixed tinnitus/hypoacusis in 10% of cases. Only 34% (n = 14) of cases were associated with a potential hypoxic event. Of the cases that documented resolution data, 21% (n = 4 of 19) reported no improvement at time of hospital discharge. DISCUSSION: Opioid-associated ototoxicity appears to be a hypoxia-independent adverse effect since most of the reported cases did not involve a known contributory hypoxic event. It occurs with a wide array of opioids, which supports an opioid receptor-mediated mechanism. The ototoxic effect may be self-limited in many patients. CONCLUSION: Opioid-associated ototoxicity was most commonly associated with heroin exposure and appeared independent of hypoxic events. Further investigation that clarifies the risk factors and long-term outcomes is needed.

Child and adolescent benzodiazepine exposure and overdose in the United States: 16 years of poison center data.

Background: Recently, there has been an increase in prescription drug abuse and related fatalities. Although opioid analgesics are commonly implicated, there have been significant increases in the prevalence of benzodiazepine exposures and overdoses.Objective: To describe national trends in pediatric benzodiazepine exposures from 2000 to 2015.Methods: A retrospective database analysis was conducted. Data regarding benzodiazepine exposures in children ages 0 to <18 years reported to participating United States poison centers from January 2000 through December 2015 were obtained from the National Poison Data System. Population data were obtained from the US Census Bureau to determine annual population estimates. Data were analyzed using chi-square tests.Results: A total of 296,838 pediatric benzodiazepine exposures were identified during the study period. The rate of pediatric benzodiazepine exposure increased 54% between 2000 and 2015. The severity of medical outcomes also increased, as did the prevalence of co-ingestion of multiple drugs, especially in children ages 12 to <18 years. Nearly half of all reported exposures in 2015 were documented as intentional abuse, misuse, or attempted suicide, reflecting a change from prior years. The most commonly identified pediatric benzodiazepines of exposures were alprazolam, clonazepam, and lorazepam.Conclusions: The rate and severity of reported pediatric benzodiazepine exposure is increasing over time. Adolescent exposures are of specific concern, as co-ingestion and intentional abuse were found to be more common in this group. Medical providers and caretakers should be cognizant of this growing epidemic to avoid preventable harm to adolescents, young children, and infants.

Bismuth Subsalicylate Coagulopathy in a Patient with Chronic Liver Disease.

Bismuth subsalicylate (BSS) is the active ingredient in over-the-counter antacid and antidiarrheal medications. Coagulopathy in the setting of acetylsalicylic acid toxicity is well documented but not in setting of bismuth subsalicylate overuse. We present a case report of coagulopathy from BSS poisoning in a patient with underlying cirrhosis. The patient's high prothrombin time suggests inhibition of vitamin K-dependent coagulation factors. The patient had decreased factor V activity, which is responsible for converting prothrombin to thrombin. Patients with cirrhosis often have hypoprothrombinemia which may be exacerbated by salicylate-induced coagulopathy. Given the widespread use of BSS products, physicians should recognize coagulopathy as a possible manifestation of toxicity especially in patients with underlying liver disease.

Loperamide misuse to avoid opioid withdrawal and to achieve a euphoric effect: high doses and high risk.

INTRODUCTION: Loperamide is a readily accessible nonprescription medication that is increasingly being used surreptitiously as an opioid substitute to alleviate the symptoms of acute opioid withdrawal. The objective of this study was to determine the clinical characteristics of patients with loperamide misuse and toxicity. METHODS: The ToxIC registry, a nationwide, prospectively collected cohort of patients evaluated by medical toxicologists was searched from November 2011-December 2016 for patients with loperamide exposure. Each record was reviewed to determine the circumstances, dose, clinical presentations, treatment, and outcomes associated with loperamide use. RESULTS: Twenty-six cases were identified, and both the absolute number and relative proportion of overall cases in the ToxIC registry increased annually. The median age was 27 and 54% were male. Of cases with known intent (n = 18), 12(67%) were misuse/abuse, 3(17%) were self-harm/suicide, and 3(17%) were pediatric exploratory ingestions. Circumstances for misuse included taking higher doses than labeled (n =7), avoiding withdrawal (n = 6), and gaining a pleasurable sensation (n =4). The dose was reported in nine cases and ranged from 4 mg to 400 mg. In patients seeking to avoid withdrawal doses were 160-400 mg/day; the most common reported dose was 200 mg. Reported ECG abnormalities included 10 cases of prolonged QTc (>500 ms), which consisted of misuse/abuse (n =6) and self-harm (n =1) exposures; six prolonged QRS (>120 ms); two first degree AV block; seven ventricular dysrhythmias, five of which were single-agent exposures. All but one ECG demonstrated prolonged QTc with a range of 566-749 ms. All patients with dysrhythmias in which dose were reported ingested ≥200 mg. CONCLUSIONS: The majority of patients had loperamide toxicity due to misuse/abuse, in-line with national trends. In patients avoiding withdrawal, doses >100 mg were observed. When taken in large doses (>200 mg), loperamide may cause significant cardiovascular effects, including QTc-prolongation and ventricular dysrhythmias.

Analysis of Phone Calls Regarding Fluoride Exposure made to New Jersey Poison Control Center from 2010 to 2012.

PURPOSE: The American Association of Poison Control Center's annual reports demonstrate that acute fluoride exposure is not an uncommon occurrence. Despite its prevalence, there has been little published research on the topic in the last 10 years. The purpose of this study was to calculate the incidence of acute fluoride toxicity and lethality as it occurs in New Jersey and provide a descriptive epidemiology of acute fluoride exposures. METHODS: The study design was retrospective in nature. Records of phone calls made by individuals reporting excessive fluoride exposure (in an amount greater than directed/prescribed) to New Jersey's poison control center, known as Poison Information and Education System from the years 2010 through 2012, were extracted from Toxicall® (Computer Automatic Systems, Inc.) database. A total of 2,476 human-only exposure records met the inclusion criteria and were analyzed. Incidence rates were calculated, and population characteristics, circumstances and medical outcomes of acute fluoride exposure cases were assessed and categorized. RESULTS: A total of 2,476 phone call records met the inclusion criteria. The fluoride exposures reported were from toothpaste with fluoride (49%, n=1,214), mouth rinse with fluoride (21.6%, n=536), multivitamin with fluoride (21.4%, n=530) and pure fluoride (0.08%, n=199). Medically speaking, 94.75% of calls were asymptomatic cases (n=2,346), 4.24% were symptomatic (n=105) and 1.01% were informational inquiries (n=25). Adverse symptoms reported were mostly minor (83.9% of symptomatic cases, n=88) and moderate (16.1% of symptomatic cases, n=17). The age group 18 months to 3 years of age showed the highest incidence of acute fluoride exposure (53.2%, n=1,317). There was a slightly higher incidence of acute fluoride exposures among males (n=1,317) vs. females (n=1,159). Most incidences occurred in the home (93.1% of records, n=2,305) and occurred unintentionally (96.7%, n=2,394). Calls were mainly made by the subject's mother (67.5%, n=1,671). CONCLUSION: Based on the data, there were no reports of lethality or toxicity due to acute fluoride exposure in New Jersey from 2010 through 2012. Symptomatic reports and informational inquiries were few. All adverse outcomes due to excessive fluoride intake were remedied with calcium as the antidote. Dental hygienists should educate patients on safety measures of fluoride-containing products and evaluate overall fluoride exposure prior to making recommendations. However, findings in this study suggest that levels of fluoride in available commercial products will not produce life-threatening events, even if taken in doses higher than recommended.

Incorporating the treatment of medical and psychiatric disorders in the critical care area.

Critical care areas are fast moving, often chaotic, and therefore confusing, even frightening, to patients attempting to understand what has happened to them. The nurse acts to mitigate these reactions by understanding the range of possibilities that can occur with patients, including potential psychiatric issues, and serving as patient advocate to ensure that appropriate treatment is initiated. Certainly there may be other psychiatric problems not described in the preceding text. The main possibilities are covered in this article. Assessing and acting early are tools the critical care nurse uses to meet patient needs and prevent behavioral problems that can interfere with life-preserving care.

Analysis and validation of putative substances involved in fatal poisonings.

Each year, poison control centers throughout the United States respond to over 4 million calls for help in treating individuals exposed to toxic substances. Although most cases develop no or minimal clinical effects, a small proportion of patients who receive medical care for overdoses with poison center consultation expire. When such cases are investigated by a medical examiner, the postmortem toxicology results may show substances other than those considered in the consultation with the poison center. We sought to determine the characteristics of discordance in fatal cases between the toxic substances reported to a regional poison control center and postmortem toxicology results. We conducted a retrospective study of the New Jersey regional poison control center records of all fatal cases between the years 1986 and 2006. Substances reported as putative agents to the poison center were compared to the postmortem toxicology results obtained by the medical examiner. The frequencies and characteristics surrounding discordance were examined. Of the 708 fatal cases reported to our poison center within the study period, complete postmortem toxicological evaluations were available for 206 (29.0%). Comparison of putative agents between information obtained by history and at postmortem evaluation showed discordance in 41 (19.9%). In a substantial number of fatal cases receiving poison center consultation, substances were found at the time of postmortem examination that were not considered in the poison center consultation. The reasons for this discordance may include a lack of thorough history-taking or a cognitive bias to the substances initially reported.

Poison control centers' role in glow product-related outbreak detection: implications for comprehensive surveillance system.

INTRODUCTION: The development of syndromic surveillance systems to detect bioterrorist attacks and emerging infectious diseases has become an important and challenging goal to many governmental agencies and healthcare authorities. This study utilized the sharp increase of glow product-related calls to demonstrate the utility of poison control data for early detection of potential outbreaks during the week of Halloween in 2007. METHODS: A review was conducted of the electronic records of exposures reported to the New Jersey Poison Information and Education System (NJPIES) Poison Control Hotline from 2002 through 2007 with generic code number 0201027 (glow products) set by the American Association of Poison Control Centers (AAPCC). Key information such as age, gender, time of the call, exposure reason, clinical effects, and medical outcomes along with telephone number, zip code, and county location were used in the analyses to determine the extent of the outbreak. RESULTS: Analyses included a total of 139 glow product-related calls during the week of Halloween in 2007 with a single-day high of 59 calls on Halloween Day. More than 90% of the glow product exposures were in children 1-10 years of age. The glow product-related calls on Halloween Day increased from 14 calls in 2002 to 59 calls in 2007, a 321% increase during a six-year period. CONCLUSIONS: Poison control centers in the United States are equipped with a unique and uniform input data collection system -- the National Poison Data System -- that provides an important data source in the development of a comprehensive surveillance system for early outbreak detection.

Evaluation of adverse drug reactions reported to a poison control center between 2000 and 2007.

PURPOSE: The likelihood of hospitalization caused by adverse drug reactions (ADRs) from commonly implicated therapeutic groups is discussed. METHODS: A retrospective analysis of the computerized records of exposure cases involving pharmaceutical substances reported to the New Jersey Poison Information and Education System (NJPIES) was conducted from 2000 through 2007. The cases in the National Poisoning Data System that were categorized as an ADR were included in the study set. Only reports involving a single drug were selected for inclusion in the analyses. Characteristics of the ADRs, such as the sex and age of the patient, the therapeutic group involved, and the medical outcome of the exposure, were examined. Reports of ADRs with the most frequently implicated therapeutic groups were analyzed based on whether the patients were managed onsite, referred to a health care facility, or managed at a health care facility. The Adverse Drug Reaction Hospitalization (ADRH) index was calculated for all therapeutic groups, but the focus of the analyses was on the groups that were implicated in 5% or more of all ADRs. RESULTS: A total of 454,520 cases of human poisoning exposure were reported to NJPIES from 2000 through 2007. Of these cases, 162,105 were exposures implicating a single drug, of which 5,461 (3.4%) were classified as an ADR. Of the 5,461 cases, 385 patients were admitted into a health care facility. Antidepressants had the highest ADRH index (20.4%) among the therapeutic groups implicated, and antimicrobials had the lowest (2.2%). CONCLUSION: The analyses revealed a substantial variation in the likelihood of hospitalization associated with ADRs within different therapeutic groups. Among the groups that were most frequently implicated in ADRs, antidepressants showed the highest probability for an ADR-related hospitalization, followed by dietary supplements, herbals, and homeopathics and then by sedatives, hypnotics, and antipsychotics.