Professor Paul I Dargan

Guy’s and St Thomas’ NHS Foundation Trust

and King’s College London, London, UK

Member, Scientific Committee EMCDDA

Sources of Data on Acute Drug Toxicity

� Systematic data is available & reported on

– Prevalence of drug use

– Drug seizures

– Problematic drug use

– Drug-related deaths

� There is no systematic data collated on

acute drug (and NPS) toxicity

– Despite this being a key public

health indicator on the impact of drug

use on the population

Acute Drug Toxicity Data

Why is systematic data on

acute drug toxicity not

available?

� Hospital admissions (discharges) coded using ICD-10

� ICD-10 codes: not available for most drugs

� No: amphetamine, methamphetamine, MDMA, ketamine,

GHB … and definitely not NPS

� Yes: heroin, cocaine, LSD

– But cases often coded by presenting feature

e.g. chest pain, coma, convulsion, psychosis

– In most countries only admitted patients are coded

Hospital Coding of Acute Drug Toxicity

13.2% appropriate ICD-10 code to be able to identify

as acute drug toxicity

Hospital Coding of Acute Drug Toxicity

Hospital Coding of Acute Drug Toxicity

Therefore not possible to automate

data collection on acute drug toxicity

to facilitate national data collection

Potential sources of information on acute drug toxicity

� Data triangulation from a variety of imperfect

sources to minimise the limitations and ↑strength of

the combination

� In vitro pharmacological studies, animal studies

� Internet discussion forums

� User and sub-population surveys

� Poisons Information Services

� Clinical reports from ED presentations

– Linked sentinel centres

� All European countries (and 54% countries worldwide)

have at least one poisons centre

– Some public & health care professional (HCP) access,

some HCP access only

� Provide information to clinicians on management of

drug toxicity AND collect data on these case

– Generally this data is only reported within local or

national poisons centre reports

� Can collate data on

– Geographical/time patterns, clinical patterns of toxicity

BUT

� Data collection is second-hand, self-reported drugs

� Requires clinicians to contact poisons service (maybe less

likely to call about familiar drugs) AND report all used drugs

� May get multiple calls about one case

� Often don’t have outcome data

� For NPS needs awareness of NPS by poisons centre/clinicians

Enquiries regarding 61 drugs/NPS

- 1561 telephone enquiries

- 58,649 TOXBASE (online database) accesses

STRIDA Project� Collaboration between Swedish Poisons Information

Centre (PIC) and Karolinska Institute

– calls to Swedish PIC relating to potential NPS

toxicity, blood/urine samples sent for analysis

– clinical data combined with analytical results

� Powerful dataset of analytically confirmed acute NPS

toxicity: 9 case series published to date

Emergency Department Data

� Collection of data recorded in the medical notes

� Gold standard = analytically confirmed

– Need access / funding for specialist analyses,

– Generally requires patient consent

� Labour intensive

– Requires interest, time and finance

– Will generally only happen in centres with a specialist

clinical toxicology interest: “SENTINEL” centres

– Sentinel centres can be linked to allow intra and trans

national comparisons

Drug Abuse Warning Network (DAWN)

� US data collection 1972-2011

– Using weighted cluster sampling

– From metropolitan areas in 37 States (complete

coverage of 13 States)

– Data on acute drug toxicity, deaths and other

indicators of drug-related harm

� May continue from 201617 through the US National

Hospital Care Survey

0

50

100

150

200

250

300

2006 2007 2008 2009 2010

Year of presentation

Num

ber

of p

rese

ntat

ions

Cocaine

GHB/GBL

MDMA

Ketamine

Cannabis

Amphetamine

Methamphetamine

Volatile Nitrites

LSD

Magic Mushrooms

Novel Pyschoactive Drugs

The Euro-DEN project has financial support from the DPIP/ISEC

Programme of the European Union

Network of 16

specialist ED,

clilnical toxicology

centres

� Data collection on alll acute drug toxicity

presentations to the centre

– Enable analysis of geographical and seasonal trends

– Data on clinical patterns / severity of toxicity,

treatment and outcome

� First year of data collection Oct 2013 – Sept 2014

– 5,529 cases involving 8,709 substances

� Continuing as Euro-DEN Plus with 19 sentinel centres

Clinical Features

Disposition from ER

Length of hospital stay

440 NPS cases reported to Euro-DEN in Year 1

484 different NPS reported

� Cathinones were most common (378)

– 245 mephedrone, 92 methedrone, 22 MDPV

� Non-cathinone cases (106)

– Branded NPS 48, SCRA 26

0

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100

150

200

250

300

350

Den

mar

k

Esto

nia

Fran

ceGer

man

y

Irelan

d

Nor

way

Poland

Spain

Switze

rlan

d UK

cou

nt

of

pre

sen

tati

on

s

Conclusions� Significant potential for acute harm associated drug use

� Limited European data collection systems and no

systematic reporting

� Poisons information services can provide useful

information: need to be co-ordinated; STRIDA provides

powerful analytically confirmed NPS case series

� Euro-DEN project is novel pan-European co-ordinated

approach to collecting Emergency Department data

– Snapshot sampling currently being explored

The ideal would be an acute harm indicator for reporting to

ECMDDA: hospital and poisons centre data