Matthew K. Griswold

Self-identification of nonpharmaceutical fentanyl exposure following heroin overdose

Abstract Objective: To compare user self-identification of nonpharmaceutical fentanyl exposure with confirmatory urine drug testing in emergency department (ED) patients presenting after heroin overdose. Methods: This was a cross-sectional study of adult ED patients who presented after a heroin overdose requiring naloxone administration. Participants provided verbal consent after which they were asked a series of questions regarding their knowledge, attitudes and beliefs toward heroin and nonpharmaceutical fentanyl. Participants also provided urine samples, which were analyzed using liquid chromatography coupled to quadrupole time-of-flight mass spectrometry to identify the presence of fentanyl, heroin metabolites, other clandestine opioids, common pharmaceuticals and drugs of abuse. Results: Thirty participants were enrolled in the study period. Ten participants (33%) had never required naloxone for an overdose in the past, 20 participants (67%) reported recent abstinence, and 12 participants (40%) reported concomitant cocaine use. Naloxone was detected in all urine drug screens. Heroin or its metabolites were detected in almost all samples (93.3%), as were fentanyl (96.7%) and its metabolite, norfentanyl (93.3%). Acetylfentanyl was identified in nine samples (30%) while U-47700 was present in two samples (6.7%). Sixteen participants self-identified fentanyl in their heroin (sensitivity 55%); participants were inconsistent in their qualitative ability to identify fentanyl in heroin. Conclusions: Heroin users presenting to the ED after heroin overdose requiring naloxone are unable to accurately identify the presence of nonpharmaceutical fentanyl in heroin. Additionally, cutting edge drug testing methodologies identified fentanyl exposures in 96.7% of our patients, as well as unexpected clandestine opioids (like acetylfentanyl and U-47700).

Drugs and Medical Devices: Adverse Events and the Impact on Women’s Health

A large number of medications and medical devices removed from the market by the US Food and Drug Administration over the past 4 decades specifically posed greater health risks to women. This article reviews the historical background of sex and gender in clinical research policy and describes several approved drugs and devices targeted for use in women that have caused major morbidity and mortality. The intended population for the medications and devices, population affected, approval process, and the basic and legal actions taken against the medication/drug company are also discussed. It is recognized that women are still at risk for harm from unsafe medications and devices, and continued improvements in legislation that promotes inclusion of sex and gender into the design and analysis of research will improve safety for both men and women.

Acceptability and perceived utility of drone technology among emergency medical service responders and incident commanders for mass casualty incident management

OBJECTIVE This study seeks to understand the acceptability and perceived utility of unmanned aerial vehicle (UAV) technology to Mass Casualty Incidents (MCI) scene management. DESIGN Qualitative questionnaires regarding the ease of operation, perceived usefulness, and training time to operate UAVs were administered to Emergency Medical Technicians (n = 15). SETTING A Single Urban New England Academic Tertiary Care Medical Center. PARTICIPANTS Front-line emergency medical service (EMS) providers and senior EMS personnel in Incident Commander roles. CONCLUSIONS Data from this pilot study indicate that EMS responders are accepting to deploying and operating UAV technology in a disaster scenario. Additionally, they perceived UAV technology as easy to adopt yet impactful in improving MCI scene management.

Cryptomarket drug acquisition leading to furanyl fentanyl overdose

Fentanyl and its analogs are used to produce extremely potent drugs that are fueling striking increases in US overdose deaths. Surveillance for these fentanyl analogs is challenging due to limitations of currently available drug testing; additionally, users are frequently unaware of the individual opioids to which they are exposed in overdose [1]. Online cryptomarkets facilitate the purchase of high-potency opioids by individuals who are seeking to conceal their drug purchases from law enforcement; new strategies to obscure these transactions allow individuals to obtain home delivery of illicit opioids via the United States Postal Service. A previously healthy 23-year-old man was found unresponsive in bed. First responders observed symptoms consistent with opioid toxicity; they immediately administered supplemental oxygen and 4 mg of intramuscular (IM) naloxone. Following naloxone administration, the patient awoke, becoming tremulous and tachycardic (180/min). He subsequently received 2 mg of IM lorazepam for agitation and tremor. In the emergency department (ED), the patient’s initial vital signs were notable for a heart rate of 155 beats per min, respiratory rate of 36 breaths per min, and oxygen saturation of 90% on a non-rebreather mask. His physical examination was consistent with mild precipitated opioid withdrawal. He had no stigmata of recent injection drug use. His chest radiograph showed perihilar haziness consistent with pulmonary edema. A urinary catheter was placed 5 h following ED presentation due to urinary retention and an inability to void. Two simultaneous urine specimens were obtained; one went to the hospital lab for clinical purposes, while the other was sent to a reference laboratory for advanced analytical testing. The patient was admitted to a critical care setting for hypoxic respiratory failure and non-cardiogenic pulmonary edema. With supportive care his clinical status improved and he was discharged on hospital day 3. Our team contacted the patient after discharge to ascertain the circumstances by which he obtained the furanyl fentanyl. He reported purchasing “Synthetic China White Heroin #4” from the cryptomarket, AlphaBay, with the intent to purchase fentanyl. His knowledge of AlphaBay and the “Dark Web” stemmed from news articles about the discovery and termination of the original Silk Road marketplace. This patient used reddit.com as an educational resource to access cryptomarkets securely and privately. Based on his investigations, he downloaded “The Onion Router” (TOR, an anonymizing proxy network) and purchased a Virtual Private Network (VPN) to further obscure his IP address and true location. To complete the transaction, he purchased a cryptocurrency, Bitcoin, from coinbase.com. The Bitcoin was transferred through a series of online wallets until ultimately being deposited to AlphaBay, where the purchase was made. He specifically described researching and undertaking these steps to conceal the transaction and avoid criminal prosecution. The patient specifically sought drugs from a domestic seller to prevent his purchase from being seized by United States Customs and Border Protection. He bought 1 g of “Synthetic China White Heroin #4” for the equivalent of

Accidental copper sulfate toxicity after flame colorant ingestion

40 in Bitcoin. The package was shipped from a New York post office using United States Postal Service Priority Mail, containing a “dime bag” of white powder that “looked like * Kavita M. Babu kavita.babu@umassmemorial.org

Unsuspected Clenbuterol Toxicity in a Patient Using Intramuscular Testosterone

Metal salts used in the pyrotechnic industry as flame colorants are packaged in a manner similar to certain candies (Figure 1). We report a case of an unintentional ingestion of “Mystical Fire” colorant containing copper sulfate resulting in hepatic and renal toxicity, hemolysis, methemoglobinemia, and gastric injury treated with hemodialysis, surgical interventions, plasmapheresis, and chelation. A 60-year-old man with a history of diabetes, hypertension, hyperlipidemia, and coronary artery disease presented hours after unintentional ingestion of “Mystical Fire” flame colorant (15–18g copper sulfate), mistaking it for Pop RocksR candy (Figure 1). He had no history of pre-existing anemia, hepatic, or renal disease. He reported persistent blue emesis. His initial vital signs and physical exam were unremarkable. Four hours after presentation, he developed black emesis and abdominal pain. A chest X-ray was unremarkable. By hour eight, laboratory analysis was significant for refractory hyperkalemia and acute kidney injury (Table 1). He underwent emergent hemodialysis and was admitted to the intensive care unit. He received chelation therapy with British anti-Lewisite (BAL) and D-penicillamine. Serum copper level on day of presentation was 738mcg/dl. On day 2 of hospital admission, after stabilization, he underwent orotracheal intubation and upper endoscopy

What is This Rash

Clenbuterol is a beta-agonist that has been abused by fitness-oriented individuals for muscle growth and weight loss. We report a case of a 46-year-old man who presented tachycardic, hypokalemic, and hyperglycemic after injecting testosterone obtained from Brazil. He developed refractory hypotension and was started on an esmolol infusion for suspected beta-agonist toxicity. Laboratory analysis showed a detectable clenbuterol serum concentration. Analysis of an unopened ampule contained boldenone undecylenate, clenbuterol, and vitamin E. This case illustrates a novel exposure that caused beta-agonist toxicity and was treated successfully with rapid-onset beta blocker.

A Novel Oral Fluid Assay (LC-QTOF-MS) for the Detection of Fentanyl and Clandestine Opioids in Oral Fluid After Reported Heroin Overdose.

A 25-year-old man presented with generalized pruritic rash, fever, sore throat, facial and glandular swelling, right upper quadrant pain, anorexia, and nausea for 3 days. The rash initially erupted on his upper chest, spreading to his face and extremities over 24 h. A month prior he had experienced new-onset seizures, initially prescribed phenytoin 300 mg daily. Two weeks before presenting, phenytoin was discontinued and topiramate (100 mg bid) started. On exam, he appeared mildly ill. Diffuse, blanching, erythematous papules, and fine petechiae covered his face and body, sparing his palms and soles. There was mild facial edema and superficial erosions on his hard palate and mucosa of the lower lip (Fig. 1a, b, c), with tender cervical lymphadenopathy most prominent posteriorly. Labs were notable forWBC 27K/mm (18% atypical lymphocytes and 9 % eosinophils); PLT 139 K/mm; liver function tests (LFTs) AST 168 IU/L, ALT 350 IU/L, total bilirubin 4.2 mg/dL (direct 2.9 mg/dL); and urinalysis positive for blood. These findings weremost consistent with DRESS (drug rash with eosinophilia and systemic symptoms). The suspected exposure was phenytoin. The onset of symptoms 1 month after exposure fits the 2to 8-week delay characteristic of DRESS. Phenytoin is a known culprit [1]. There is scant evidence for topiramate-related DRESS, and published cases all involved other agents associated with DRESS. Since topiramate could not be excluded, it was discontinued and the patient started on levetiracetam. He was given oral corticosteroids and admitted. Biopsy demonstrated morbilliform drug eruption, typical of DRESS. Hepatitis, measles, EBV, CMV, HIV, and toxoplasmosis were excluded. ANA and cultures were negative. The rash