Dr Paul DarganDr Paul Dargan & Dr David Wood & Dr David WoodConsultant Clinical ToxicologistsConsultant Clinical Toxicologists

Guy’s and St Thomas’ NHS Foundation TrustGuy’s and St Thomas’ NHS Foundation Trust

London, UKLondon, UK

Monitoring Drug Monitoring Drug Emergencies Emergencies

How and Why Should We Do How and Why Should We Do It?It?

Recreational DrugsRecreational Drugs

EMCDDA Annual Report 2008

Recreational Drug use is common

Numerous National, European and International networks collect data on recreational drug use:

i Population surveys of drug use

Life-time prevalence of drug use in Europe:

– 22% cannabis

– 3.6% cocaine

– 2.8% ecstasy

– Variations in pattern of use across EU

Recreational DrugsRecreational Drugs Recreational Drug use is common

Numerous National, European and International networks collect data on recreational drug use:

i Population surveys of drug use

ii Drug seizures, crime reports / surveys

iii Use of treatment agencies for problem drug use

iv Drug-related fatalities

Less co-ordinated data on recreational drug toxicity

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

There is the potential for significant morbidity and mortality

This is dependent on the class of drug

Stimulants

Hallucinogenics

Depressants

MDMA (ecstasy)Amphetamine

Cocaine1-benzylpiperazine

GHB / GBL1,4-butanediol

HeroinOpium

LSDKetamineGlaucineTFMPP

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

What data is available?What data is available? No currently published National Datasets

Not routinely collected by EMCDDA Reitox National Focal Points

Hospital coding of admissions (discharges):

Often only capture admitted patients

– up to 50-75% managed in Emergency Departments or pre-hospital

Based on ICD-10

Acute Recreational Drug Acute Recreational Drug ToxicityToxicityICD-10ICD-10

ICD-10 codes:

– Dependent on cases being coded appropriately

– Not specific for all recreational drug presentations e.g. MDMA, amphetamines, ketamine, GHB not captured

T40.0 Opium

T40.1 Heroin

T40.2 Other opioids (codeine, morphine)

T40.3 Methadone

T40.4 Other synthetic narcotics (pethidine)

T40.5 Cocaine

T40.6 Other and unspecified narcotics

T40.7 Cannabis (derivatives)

T40.8 Lysergide [LSD]

T40.9 Other & unspecified psychodysleptics [hallucinogens] Mescaline, psilocin, psilocybine

ICD-10 recreational drug codes ICD-10 recreational drug codes T40: Poisoning by narcotics and T40: Poisoning by narcotics and

psychodyslepticspsychodysleptics

Poisons Information Services

– Only capture cases that clinicians call about

Ambulance / Pre-Hospital data sets

– UK: >90% cases brought to hospital by ambulance

– Ambulance datasets not widely available / published

– No standard EU / International coding system

– Pilot studies in UK: coding not sufficient to provide reliable / robust data on recreational drug toxicity

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

Other Potential DatasetsOther Potential Datasets

Link in to other established, validated national clinical datasets– National Disease Registers

– Stroke Registers

– Cardiovascular Disease Registers

Would require novel data capture for recreational drug coding

Could potentially allow prospective follow up of a cohort of patients

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

Other Potential DatasetsOther Potential Datasets

Single centre datasets

– Collected within a hospital / city / region

– Requires local interest, finance and logistics

– Provide valuable information, with clinical detail, particularly in a high incidence area

– e.g. London UK, Palma Mallorca, Oslo Norway

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

Other Potential DatasetsOther Potential Datasets

Single centre datasets

– Collected within a hospital / city / region

Potential to link these single centre datasets

– Current EMCDDA funded pilot study led by us

– Looking at data collection in London and Mallorca

– Using a limited dataset

- Demographics and exposure data

- Basic clinical parameters and outcome

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

Other Potential DatasetsOther Potential Datasets

Single centre datasets

– Collected within a hospital / city / region

Potential to link these single centre datasets

– Current EMCDDA funded pilot study led by us

– Looking at data collection in London and Mallorca

– Will allow comparison of epidemiology between specialist centres

– Potential to expand to other centres

Acute Recreational Drug Acute Recreational Drug ToxicityToxicity

Other Potential DatasetsOther Potential Datasets

London Acute Recreational Drug London Acute Recreational Drug Toxicity DataToxicity Data

Guy’s and St Thomas’ NHS Foundation Trust

– Central London Teaching Hospital

– Specialist Clinical Toxicology Service Purpose designed database:

– Detailed data on all poisoned patients

– Full-time database scientist

– 1600 acute poisoning presentations per year

– 39% relate to recreational drug toxicity

Greene SL Postgrad Med J 2008

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Recreational Drug Presentations Recreational Drug Presentations (2008)(2008)

Recent Trends and Other Recent Trends and Other ResultsResults

2005-2008: Increase in cocaine-related toxicity Increase in GHB/GBL presentations Increase in GBL:GHB ratio

Differences in pre-hospital and Emergency Department datasets

Methamphetamine toxicity is not an issue in London or elsewhere in the UK

Wood DM QJM 2008, Wood DM Subst Use Misuse 2009

Users Self-Report Users Self-Report vs vs

Toxicological ScreeningToxicological Screening This and other similar datasets rely on users

self-report Studies suggest users self-report variable in

determining the primary drug(s) responsible for toxicity West E Emerg Med Australas 2008, Brojnaas MA Clin Tox 2006

Users self-report not useful in the context of:– Novel / emerging drugs– Mis-appropriated drugs

Novel Recreational DrugsNovel Recreational Drugs In the last 3 years we’ve detected 9 novel recreational

drugs e.g. piperazines, glaucine, DOC, D2PM, cathinones

On an ad hoc basis using clinical suspicion in patients with an atypical history / clinical features

Increasing availability/use of novel recreational drugs

Incidence of novel recreational drug toxicity is unknown

This could only be determined using comprehensive toxicological screening in a busy specialist centre

Wood DM Lancet 2007, Staack R Lancet 2007, Dargan PI EJCP 2008, Ovaska H EJEM 2008, Lidder S J Med Toxicol 2008, Wood DM J Med Toxicol 2008

ConclusionsConclusions Acute recreational drug toxicity: significant

morbidity ICD-10 not suitable for data collection:

– Poor availability of national / EU data Potential datasets

– Links to established disease registers

– Pooling of single centre, specialist datasets Screening of recreational drug presentations in

a large centre to determine

– the drugs responsible for toxicity

– incidence of novel recreational drug toxicity