Presentations to the emergency department with non-medical use of benzodiazepines and Z-drugs: profiling and relation to sales data.

BACKGROUND: Non-medical use of benzodiazepines and Z-drugs is common; however, there is limited information available on the extent of harm related to this in Europe, as well as the relationship between misuse and availability. AIM: To describe presentations to the emergency department in Europe related to the recreational use of benzodiazepines and Z-drugs and compare regional differences in these presentations with legal drug sales of benzodiazepines and Z-drugs within each country. METHODS: Emergency department presentations with recreational misuse of benzodiazepines and Z-drugs were obtained from the Euro-DEN dataset for the period from October 2013 to September 2015; data extracted included demographics, clinical features, reported coused drugs, and outcome data. Sales figures obtained by QuintilesIMS™ (Atlanta, Georgia) were used to compare regional differences in the proportion of benzodiazepines and Z-drugs in the emergency department presentations and legal drug sales across Europe. RESULTS: Over the 2 years, there were 2119 presentations to the Euro-DEN project associated with recreational use of benzodiazepines and/or Z-drugs (19.3% of all Euro-DEN presentations). Presentations with 25 different benzodiazepines and Z-drugs were registered in all countries, most (1809/2340 registered benzodiazepines and Z-drugs, 77.3%) of which were prescription drugs. In 24.9%, the benzodiazepine was not specified. Where the benzodiazepine/Z-drug was known, the most frequently used benzodiazepines and Z-drugs were respectively clonazepam (29.5% of presentations), diazepam (19.9%), alprazolam (11.7%), and zopiclone (9.4%). The proportions of types of benzodiazepines/Z-drugs related to ED-presentations varied between countries. There was a moderate (Spain, UK, Switzerland) to high (France, Ireland, Norway) positive correlation between ED presentations and sales data (Spearman Row's correlation 0.66-0.80, p < 0.005), with higher correlation in countries with higher ED presentation rates. CONCLUSION: Presentations to the emergency department associated with the non-medical use of benzodiazepines and/or Z-drugs are common, with variation in the benzodiazepines and/or Z-drugs between countries. There was a moderate to high correlation with sales data, with higher correlation in countries with higher ED presentation rates. However, this is not the only explanation for the variation in non-medical use and in the harm associated with the non-medical use of benzodiazepines/Z-drugs.

Isotonitazene, a novel psychoactive substance opioid, detected in two cases following a local surge in opioid overdoses.

BACKGROUND: Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity. AIM: There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples. METHODS: Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database. RESULTS: There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml). CONCLUSION: We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations.

Concurrent Use of Benzodiazepine by Heroin Users-What Are the Prevalence and the Risks Associated with This Pattern of Use?

INTRODUCTION: Polydrug use involving heroin and benzodiazepines is common. The potential risk of additive pharmacological effects may be associated with poorer outcomes in patients who use benzodiazepines together with heroin. The aim of this study was to determine the clinical picture of patients presenting to the emergency department following acute drug toxicity involving heroin and benzodiazepines. METHODS: Exposure information, clinical data and outcome of acute drug toxicity presentations were collected between 1 October 2013 and 30 September 2014 as part of the European Drug Emergencies Network (Euro-DEN) project. The database was interrogated to identify patients who had taken heroin with or without benzodiazepine(s). RESULTS: A total of 1345 presentations involving acute heroin toxicity were identified: 492 had used one or more non-heroin/benzodiazepine drug and were not further considered in this study; 662 were lone heroin users and 191 had co-used heroin with one or more benzodiazepines. Co-users were more likely than lone heroin users to have reduced respiratory rate at presentation 12.7 ± 4.9 vs 13.6 ± 4.4 (p = 0.02) and require admission to hospital 18.3 vs 9.8% (p < 0.01). There were no differences in critical care admission rates 3.1 vs 3.9% (p = 0.83) or length of stay 4 h 59 min vs 5 h 32 min (p = 0.23). The 3 most common benzodiazepines were clonazepam, diazepam, and alprazolam. No differences were observed for clinical features between the three benzodiazepines. CONCLUSION: This study shows that co-use of heroin and benzodiazepines is common, although the overall outcomes between co-users of heroin and benzodiazepines and heroin-only users were similar.

Acute poisoning: initial management and sources of information.

Poisoning is responsible for 2-3 per cent of attendances to urban A&F. departments in the UK each year ( MacNamara et al 1996 ). It accounts for about 7 per cent of accidents in children under five years of age ( Consumer Safety Unit 1995 ). The National Poison Information Service (NPIS) deals with hundreds of emergency telephone enquiries every day. and the number of such calls has risen sharply in recent years. Figure 1 demonstrates the annual call load of NPIS (London). A&E nurses account for 42 per cent of these telephone enquiries.

Does the distinction between killing and letting die justify some forms of euthanasia?

Nurses will often be at the forefront in a health care team which decides that it is ethically acceptable to allow a particular patient to die but the possibility of actually killing another patient who requests his own death is met with heartfelt resistance. This paper explores the distinction between killing and letting die and the connection these arguments have with justifications for euthanasia. Two practical examples of killing and letting die are analysed. Various issues are examined including the active-passive distinction, the difference between causing and preventing a death and the probability of outcome. Justifications for euthanasia are then revisited and some concluding remarks made.

A review of lay health beliefs research: insights for nursing practice in health promotion.

Recent sociological research in the field of lay health and illness beliefs is reviewed and discussed in the light of nursing practice in health promotion. How the findings might deepen nurses' understanding of difficulties in adhering to desired health behaviours is outlined. The distinctions between 'public' and 'private' accounts of health, the 'taken-for-grantedness' of health, the emotive nature of health and the difficulty of accessing 'unpolluted' lay views of health is considered. The implications for nurses working in health promotion are discussed. There is a need for further research into the relationship between health beliefs and behaviour, the health beliefs of various groups within society and a need to examine how health beliefs arise and change.

What changes in health behaviour might nurses logically expect from their health education work?

This paper examines nurses' health education work from a philosophical perspective. Two key concepts, choice and autonomy, are explored by analysing examples of the health education work of the practice nurse and the health visitor. As a result, the question, 'what changes in health behaviour might nurses logically expect from their health education work?' is considered. The individualistic assumption within nurses' health education work, that individual patients and clients face certain choices and are able to exert some control over their health status, is reviewed. Choices related to healthy eating, for example, are recognized to be constrained by issues such as finance, time and social circumstances. The choice not to smoke is similarly constrained, for example, by social deprivation, cultural patterns and advertising. The paper both rejects an overly determined conception of patients and clients where they are viewed as unable to make any choices, but also cautions against the danger of victim-blaming. Constraints on patients' and clients' autonomy in health education by nurses are also considered. These limitations on health education work include, for example, a lack of scientific knowledge related to an individual's propensity to develop disease. In contrast, health education work within nursing may also be seen as enabling people to be more autonomous in relation to their health by imparting knowledge about health risks. Health education work by nurses thus emerges from the analysis as a constrained but valuable activity.

The health care needs of ethnic minority groups: are nurses and individuals playing their part?

The UKCC Code of Professional Conduct for nurses, midwives and health visitors stresses the need to have an understanding of the social and cultural determinants of health and illness. There is as yet little evidence of what might constitute good practice in this area and it is difficult to ascertain why this basic philosophy is not translated into action. Indeed, the nursing and midwifery professions' ability to deliver adequate and appropriate health care more generally to Britain's multiracial, multicultural population has been questioned. This literature review presents evidence which strongly suggests that although we are living in a multicultural society patients from minority ethnic groups are additionally disadvantaged because the initiatives by nurses, and others working in the National Health Service, to meet their health care needs are inadequate and often inappropriate.