Odd Martin Vallersnes

Epidemic of poisoning caused by scopolamine disguised as Rohypnol™ tablets

Objective. An epidemic of scopolamine poisonings occurred in Oslo in 2008 among users of illicit drugs, caused by fake Rohypnol™ pills. The clinical features, diagnostic process, and handling of the epidemic are presented. Methods. Suspected cases of scopolamine poisoning were extracted by reviewing registration forms from an ongoing prospective clinical study of acute poisonings in Oslo. Medical records of extracted contacts were examined and cases included according to specified clinical criteria. Results. Forty-four cases of probable scopolamine poisoning were registered. Main clinical features were mydriasis, visual hallucinations, plucking behavior, agitation, and coma. No clinical diagnosis of anticholinergic syndrome was made prior to forensic analysis of the tablets, the most frequent diagnosis up to this point being unspecified drug-induced psychosis. Later in the epidemic, scopolamine poisoning became the dominating diagnosis. Ten patients were admitted to psychiatric hospitals, the rest recovered in medical units, or left health care against medical advice. Discussion. Scopolamine poisonings are rare, but the resulting anticholinergic syndrome is well described. The syndrome was not recognized until the forensic analysis result strikingly changed how the patients were diagnosed and handled. A unique aspect of this epidemic was the intoxicating agent being scopolamine-containing tablets looking like Rohypnol™, sold and used under the impression of being the latter. Conclusion. Recognizing the anticholinergic syndrome is important to provide proper treatment. Forensic analysis was the key to correct diagnosis in this outbreak, demonstrating its importance in verifying an epidemic of poisoning by fake drugs.

Underestimated impact of novel psychoactive substances: laboratory confirmation of recreational drug toxicity in Oslo, Norway

Abstract Context: Recreational drug toxicity is frequent. Availability of new psychoactive substances is steadily increasing. However, data with verified analyses from clinical settings are limited. To evaluate the impact of novel psychoactive substances (NPS) on recreational drug toxicity in Oslo, Norway, we analysed samples from a selection of patients. Methods: All the patients presenting with recreational drug toxicity at the Oslo Accident and Emergency Outpatient Clinic (OAEOC) and at the Oslo University Hospital (OUH) were registered from April through September 2014. Oral fluid samples were collected at the OAEOC. Blood samples were collected at the OUH. The samples were screened using ultra-high performance liquid chromatography – tandem mass spectrometry (UHPLC-MS/MS). Results: Nine hundred and sixty-four cases were included, 841 (87.2%) at the OAEOC and 123 (12.8%) at the OUH. A total of 55 oral fluid samples (OAEOC) and 103 blood samples (OUH) could be analysed. NPS were not clinically suspected in any of the screened cases. At the outpatient clinic, the most commonly found substances were clonazepam in 42/55 (76.4%) cases, amfetamines in 40/55 (72.7%) and heroin in 39/55 (70.9%). In seven (12.7%) cases NPS were detected: 4-methylamfetamine in three cases, dimethyltryptamine in two, methylone in one, and N,N-dimethyl-3,4-methylenedioxyamfetamine in one. Among the hospital patients, the most commonly found substances were clonazepam in 51/103 (49.5%) cases, amfetamines in 48/103 (46.6%), heroin in 31/103 (30.1%), and diazepam in 30/103 (29.1%). In five (4.9%) cases NPS were detected: JWH-210 in two cases, AM-2201 in two, and 5-EAPB in one. Conclusion: NPS were clinically not suspected, though found in eight percent of cases. Still, the vast majority of patients treated for recreational drug toxicity in Oslo have taken classical drugs. Management of these patients should be based on their clinical condition. However, it is highly important to be alert to atypical presentations possibly resulting from unsuspected drugs.

Mortality, morbidity and follow-up after acute poisoning by substances of abuse: A prospective observational cohort study:

Aims: Despite the excess mortality and morbidity associated with acute poisoning by substances of abuse, follow-up is frequently not organised. We assessed morbidity, including repeated poisoning, and follow-up after acute poisoning by substances of abuse through charting contacts with health services. We also charted short-term mortality. Methods: Patients 12 years and older treated for acute poisoning by substances of abuse at a primary care emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We retrieved information from national registers on fatalities, hospital admissions, and contacts at outpatient specialist health services and with general practitioners (GPs), during the 90 days following a poisoning episode. Results: We included 1731 patients treated for 2343 poisoning episodes. During the 90 days following the poisoning, 31% of the patients were treated at somatic hospitals, 9% admitted to psychiatric hospitals, 37% in treatment at outpatient psychiatric/addiction specialist health services, 55% saw their GP, while 34% had no follow-up. The short-term mortality rate was 2.0%, eight times higher than expected. Increasing age, suicidal intention, opioid poisoning, and severe mental illness were associated with increased risk of death. Increasing age, male gender, opioid poisoning, and severe mental illness were associated with repeated poisoning. Patients with increased risk of repeated poisoning were more likely to be in follow-up at outpatient specialist psychiatric/addiction services and in contact with their GP. Conclusions: Follow-up measures seem targeted to those most in need, though one out of three had none. The mortality rate calls for concern.

Follow-up after acute poisoning by substances of abuse: a prospective observational cohort study

Abstract Objective: To chart follow-up of patients after acute poisoning by substances of abuse, register whether patients referred to specialist health services attended, and whether patients contacted a general practitioner (GP) after the poisoning episode. Design: Observational cohort study. Setting: A primary care emergency outpatient clinic in Oslo, Norway. Subjects: Patients ≥12 years treated for acute poisoning by substances of abuse were included consecutively from October 2011 to September 2012. Main outcome measures: Follow-up initiated at discharge, proportion of cases in which referred patients attended within three months, and proportion of cases in which the patient consulted a GP the first month following discharge. Results: There were 2343 episodes of acute poisoning by substances of abuse. In 391 (17%) cases the patient was hospitalised, including 49 (2%) in psychiatric wards. In 235 (10%) cases the patient was referred to specialist health services, in 91 (4%) advised to see their GP, in 82 (3%) to contact social services, in 74 (3%) allotted place in a homeless shelter, and in 93 (4%) other follow-up was initiated. In 1096 (47%) cases, the patient was discharged without follow-up, and in a further 324 (14%), the patient self-discharged. When referred to specialist health services, in 200/235 (85%) cases the patient attended within three months. Among all discharges, in 527/1952 (27%) cases the patient consulted a GP within one month. When advised to see their GP, in 45/91 (49%) cases the patient did. Conclusion: Attendance was high for follow-up initiated after acute poisoning by substances of abuse. KEY POINTS Despite poor long-term prognosis, patients treated for acute poisoning by substances of abuse are frequently not referred to follow-up. Nearly all patients referred to specialist health services attended, indicating the acute poisoning as an opportune moment for intervention. Advising patients to contact their GP was significantly associated with patients consulting the GP, but few patients were so advised. One out of three patients was discharged without follow-up, and there seems to be an unused potential for GP involvement.

Factors associated with rapidly repeated acute poisoning by substances of abuse: a prospective observational cohort study

ObjectiveWe have previously found that 9% of patients treated for acute poisoning by substances of abuse in a primary care emergency outpatient setting presented with a new poisoning within a week. We now identify factors associated with rapidly repeated acute poisoning by substances of abuse.ResultsIn 169/1952 (9%) cases of acute poisoning by substances of abuse included consecutively from October 2011 through September 2012 at a primary care emergency outpatient clinic in Oslo, Norway, the patient re-presented within a week with a new poisoning. Homeless patients were more likely to re-present, adjusted odds ratio (AOR) 2.0 (95% confidence interval (CI) 1.3–3.2, p = 0.003), as were self-discharging patients, AOR 1.7 (95% CI 1.2–2.4, p = 0.007), and patients with an opioid as main toxic agent, AOR 1.5 (95% CI 1.0–2.3, p = 0.028). There was no statistically significant association between rapid re-presentation and severe mental illness or suicidal intention.

Living conditions in the districts of Oslo and poisonings by substances of abuse treated at casualty clinic level

BACKGROUND Use of and acute poisoning by substances of abuse represent a major health problem and are often linked to social destitution. We describe associations between place of residence, living conditions and the incidence of poisoning by substances of abuse in Oslo. MATERIAL AND METHOD All patients who were 12 years of age or older and resident in Oslo and who were treated for acute poisoning by substances of abuse at the Oslo Accident and Emergency Outpatient Clinic (OAEOC) were included prospectively for a continuous period of one year, from October 2011 to September 2012. The 15 districts of Oslo were categorised into three groups of living conditions, from the best (I) to the poorest (III) living conditions, based on the City of Oslos living conditions index. Homeless people were grouped separately. The incidence of poisoning by substances of abuse treated in the OAEOC was estimated. RESULTS Of a total of 1,560 poisonings by substances of abuse, 1,094 cases (70%) affected men. The median age was 41 years. The most frequent toxic agents were ethanol, with 915 cases (59%), and heroin, with 249 cases (16%). The incidence of poisoning by substances of abuse treated in the OAEOC per year per 1,000 inhabitants amounted to 1.75 in living conditions group I, to 2.76 in living conditions group II and 3.41 in living conditions group III. Living conditions group III had a significantly higher incidence than living conditions group II (p < 0.001), and living conditions group II had a significantly higher incidence than living conditions group I (p < 0.001). INTERPRETATION The incidence of acute poisoning by substances of abuse was higher, the poorer the living conditions in the district.

Adolescent with respiratory impairments and short-lived fever.

A boy in his early teens attended the casualty clinic with his father after a day of fever, headache, shortness of breath, dizziness and soreness over much of his body. He had not had a cough. The patient was previously healthy and used no medication. Upon examination he did not appear to have respiratory difficulties, had no retractions and no use of the accessory muscles. Slight wheezing could be heard upon expiration. He had a respiratory rate of 20/minute and normal peripheral capillary oxygen saturation of 98 %. Pulse was 120 beats/minute, temperature measured aurally 38.2 °C and CRP 11 mg/l (< 5). He was able to swallow, had normal tonsils, no swelling of the lymph nodes in the neck and normal heart sounds. Two years previously, the patient had experienced gastrointestinal symptoms, including dysphagia, vomiting and nausea, but a thorough work-up in hospital had not revealed anything amiss. The year before that, he had had palpitations and had undergone 24-hour ECG and cardiac ultrasound. No abnormalities were found, and he had no such problems now.