Recurrent respiratory depression associated with fentanyl transdermal patch gel reservoir ingestion.

BACKGROUND: Opioid abuse is common in the United States and is currently on the rise. Fentanyl transdermal patches (FTPs) have been on the market since 1991, and have recently become a popular source of opioids for abusers. There are currently two distinct FTP designs available on the market today; a gel reservoir system and a matrix construct. The gel reservoirs of FTPs contain massive amounts of fentanyl and are easily extractable for abuse. Ingesting the gel reservoir of an FTP is potentially lethal. CASE SERIES: In this case series, 4 patients ingested the gel reservoir of an FTP and experienced severe and recurrent respiratory depression necessitating continuous naloxone infusions. All patients responded adequately to initial prehospital doses of naloxone (0.8-2 mg intravenous) but developed recurrent respiratory depression within 2 h of presentation to the hospital. CONCLUSION: The gel reservoir of an FTP contains massive amounts of fentanyl. Ingestion of the gel may cause severe and recurrent respiratory depression necessitating repeated naloxone boluses, continuous naloxone infusion, and a prolonged observation period.

A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD).

BACKGROUND: Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. METHODS: We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. RESULTS: Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI - 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI - 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01-1.09, standard arm difference .85 95% CI .34-1.37). CONCLUSIONS: A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03821103.

Overdose of propafenone surreptitiously sold as "Percocet".

BACKGROUND: Drug abuse is a common problem in the United States. Drugs can be acquired in many ways, and can be knowingly or mistakenly misrepresented when sold. Propafenone is an uncommonly encountered class IC antidysrhythmic that is a look-alike for the opioid, oxycodone/acetaminophen 5/325. OBJECTIVE: We report a case of propafenone overdose presenting with generalized tonic-clonic seizure and a widened QRS complex, occurring after the patient had reported ingesting "Percocet®" (Endo Pharmaceuticals, Chadds Ford, PA). CASE REPORT: A 17-year-old boy presented to the emergency department (ED) after a witnessed seizure lasting 2 min. The patient reported having ingested 6 "Percocet®" tablets that he purchased from a classmate. He noted feeling weak and dizzy approximately 3 h after the ingestion, just before the seizure. On arrival in the ED, the patient was awake and alert with a QRS length of 168 ms. A sodium bicarbonate bolus and infusion shortened the QRS length to 90 ms. The patient was discharged the following day with no further complications. The pills were identified as propafenone hydrochloride (HCl) 225-mg tablets. The classmate surreptitiously sold the pills as "Percocet®" due to their similar "512" imprint. CONCLUSIONS: Pharmaceutical drugs are often sold on the street, and often misrepresented. Propafenone HCl 225-mg is an uncommonly encountered pharmaceutical, but is a look-alike for oxycodone/acetaminophen 5/325. An overdose due to propafenone ingestion may present with seizures and a widened QRS complex.

A Case Report of a Novel Harm Reduction Intervention Used to Detect Opioid Overdose in the Emergency Department.

INTRODUCTION: As over 130 people die daily from opioid overdose in the United States, harm reduction strategies have become increasingly important. Because public restrooms are a common site for opioid overdose, emergency department waiting room restrooms (EDWRR) should be considered especially high-risk areas. CASE REPORT: We present the case of a patient found after a presumed opioid overdose in our EDWRR. Staff were alerted to his condition by a reverse motion detector (RMD), and rapidly treated him with naloxone. CONCLUSION: The RMD is a novel intervention that can save lives and should be considered in EDs with a high incidence of opioid overdose.

Oxcarbazepine-induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS).

This is an image and brief case report of a 13-year-old boy who presented with severe rash and systemic symptoms after starting oxcarbazepine. The patient was diagnosed and treated for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), a syndrome of fever, rash, and internal organ involvement secondary to medication administration. The image illustrates the rash seen with this drug reaction. The report is followed by a brief review of anticonvulsant hypersensitivity syndrome and DRESS.