Antidepressant exposures associated with exploratory behavior among young children reported to United States poison control centers, 2000-2020.

PURPOSE: This study investigates characteristics and trends of antidepressant exposures among children <6 years old related to exploratory behavior reported to US poison control centers. METHODS: Using data from the National Poison Data System for 2000-2020, population-based annual exposure rates by sex, antidepressant category, serious medical outcome, and health care facility admission were analyzed and odds ratios to assess associations of exposure type and antidepressant category with medical outcome and admission were calculated. RESULTS: There were 215 909 first-ranked unintentional exploratory exposures involving antidepressants among children <6 years old during the study period, averaging 10 281 annually. Most cases were <3 years old (77.8%), involved a single substance (86.9%), and did not receive treatment at a health care facility (57.6%); however, 7.9% were admitted and 3.4% had serious medical outcomes, including 13 deaths. SSRIs were involved in 56.9% of all cases. Compared with SSRIs, bupropion (OR: 5.22, 95% CI: 4.68-5.82), TCAs (OR: 3.74, 95% CI: 3.44-4.07), SNRIs (OR: 2.39, 95% CI: 2.11-2.71), and lithium salts (OR: 2.00, 95% CI: 1.63-2.46) were more likely to be associated with a serious medical outcome. TCAs were the first-ranked substance in 7 of the 13 deaths. CONCLUSIONS: Although most unintentional antidepressant exposures related to pediatric exploratory behavior were inconsequential, an important minority of cases required admission to a HCF or had a serious medical outcome, including 13 deaths. Therefore, increased efforts to prevent these exposures among young children are needed, including public education and improved medication packaging.

Magnet Injuries in Children: An Analysis of the National Poison Data System from 2008 to 2019.

OBJECTIVE: To examine, using the National Poison Data System (the data warehouse for poison control centers in the US), magnet foreign body injuries in pediatric patients. We sought to report demographic data, outcome data, and case trends between 2008 and 2019. STUDY DESIGN: We conducted a retrospective analysis of the National Poison Data System for patients younger than 19 years of age with a magnet "exposure," which poison centers define as an ingestion, inhalation, injection, or dermal exposure to a poison. RESULTS: A total of 5738 magnet exposures were identified. Most were male (3169; 55%), <6 years old (3572; 62%), with an unintentional injury (4828; 84%). There were 222 patients (3.9%) with a confirmed medical "effect," defined as signs, symptoms, and clinical findings not including therapeutic interventions (eg, endoscopy). There was a 33% decrease in cases from 418 (2008-2011) to 281 per year (2012-2017) after high-powered magnet sets were removed from the market. Calls subsequently increased 444% to 1249 per year (2018-2019) after high-powered magnet sets re-entered the market. Cases from 2018 and 2019 increased across all age groups and account for 39% of magnet cases since 2008. CONCLUSIONS: Significant increases in magnet injuries correspond to time periods in which high-powered magnet sets were sold, including a 444% increase since 2018. These results reflect the increased need for preventative or legislative efforts.

Prevalence and Clinical Characteristics of Unintentional Ingestion of Marijuana in Children Younger Than 6 Years in States With and Without Legalized Marijuana Laws.

OBJECTIVE: The aim of this study was to examine the relationship between state marijuana legalization and the rates of unintentional ingestions of marijuana in children younger than 6 years. METHODS: This was a retrospective review of all marijuana ingestions in the National Poison Data System in children younger than 6 years between January 1, 2000, and July 31, 2017. Data analysis from NPDS included, age, sex, state and year of occurrence, clinical effects, therapies, health care facility utilization, and medical outcome. Population of children younger than 6 years was obtained from the US Census Bureau. Public records search provided state legal status of marijuana and year of state marijuana legalization. RESULTS: From 2000 through 2008, there was no significant change in the annual number or rate of ingestions of marijuana in children younger than 6 years across the United States. Following 2009, there was mean annual increase of 27% per year, rising to 742 ingestions per year or 2.98 ingestions per 100,000 population, respectively, in 2017. More than 70% of all cases occurred in states with legalized marijuana. Of all pediatric patients, 54.6% received some form of hospital-based care, of which 7.5% required critical care. Pediatric patients experienced a wide range of symptoms from drowsiness and confusion, to seizures and coma. Medical treatments ranged from hydration therapy to sedation and intubation. Poison centers safely managed 23.4% of these pediatric cases by phone, without the need for hospital evaluation. CONCLUSION: There was a strong association between the legalization of marijuana and ingestions of marijuana by children younger than 6 years.

Cleaning and Disinfectant Chemical Exposures and Temporal Associations with COVID-19 - National Poison Data System, United States, January 1, 2020-March 31, 2020.

On January 19, 2020, the state of Washington reported the first U.S. laboratory-confirmed case of coronavirus disease 2019 (COVID-19) caused by infection with SARS-CoV-2 (1). As of April 19, a total of 720,630 COVID-19 cases and 37,202 associated deaths* had been reported to CDC from all 50 states, the District of Columbia, and four U.S. territories (2). CDC recommends, with precautions, the proper cleaning and disinfection of high-touch surfaces to help mitigate the transmission of SARS-CoV-2 (3). To assess whether there might be a possible association between COVID-19 cleaning recommendations from public health agencies and the media and the number of chemical exposures reported to the National Poison Data System (NPDS), CDC and the American Association of Poison Control Centers surveillance team compared the number of exposures reported for the period January-March 2020 with the number of reports during the same 3-month period in 2018 and 2019. Fifty-five poison centers in the United States provide free, 24-hour professional advice and medical management information regarding exposures to poisons, chemicals, drugs, and medications. Call data from poison centers are uploaded in near real-time to NPDS. During January-March 2020, poison centers received 45,550 exposure calls related to cleaners (28,158) and disinfectants (17,392), representing overall increases of 20.4% and 16.4% from January-March 2019 (37,822) and January-March 2018 (39,122), respectively. Although NPDS data do not provide information showing a definite link between exposures and COVID-19 cleaning efforts, there appears to be a clear temporal association with increased use of these products.

Suicide-related over-the-counter analgesic exposures reported to United States poison control centers, 2000-2018.

PURPOSE: To investigate suicide-related over-the-counter (OTC) analgesic medication exposures among individuals ≥6 years old reported to United States (US) poison control centers. METHODS: Data from the National Poison Data System for the years 2000-2018 were retrospectively analyzed. RESULTS: From 2000 to 2018, US poison control centers recorded 549 807 suicide-related cases involving OTC analgesics, including 327 781 cases (59.6%) admitted to the hospital and 1745 deaths (0.3%). Most cases involved a single substance (67.5%) and occurred among females (72.7%) and individuals 6-19 years old (49.7%). Overall, the rate of exposures increased significantly by 33.5% from 2000 to 2018, primarily driven by the increasing exposure rate among 6- to 19-year-old females. From 2000 to 2018, exposure rates for acetaminophen and ibuprofen increased, while that for acetylsalicylic acid decreased. Additionally, the proportion of cases resulting in a serious medical outcome or healthcare facility admission increased for all types of OTC analgesics. Acetaminophen and acetylsalicylic acid accounted for 48.0% and 18.5% of cases, respectively, and 64.5% and 32.6% of deaths, respectively. Both acetaminophen and acetylsalicylic acid had greater odds of healthcare facility admission (ORs 2.56 and 2.63, respectively) and serious medical outcomes (ORs 2.54 and 4.90, respectively) compared with ibuprofen. CONCLUSIONS: The rate of suicide-related OTC analgesic cases is increasing. Acetaminophen and acetylsalicylic acid cases are associated with greater morbidity and mortality. Prevention efforts should include implementing unit-dose packaging requirements and restrictions on package sizes and purchase quantities for acetaminophen and acetylsalicylic acid products to reduce access to large quantities of these analgesics.

Veterinary-Prescribed Buprenorphine Ingestion in a 2-Year-Old Girl.

INTRODUCTION: Ingestion of buprenorphine by young children is on the rise and can lead to life-threatening consequences and death. Exposure most often occurs when a child acquires the medication intended for adult use. However, buprenorphine is also prescribed by veterinarians and may be sent home, typically in non-child-resistant packaging, to be administered to the family pet. CASE: A previously healthy 2-year-old girl weighing 11.36 kg was found with a 1-mL syringe containing 0.6 mg/mL of buprenorphine in her mouth. The syringe had been in a plastic bag provided to the family by their veterinarian for the family dog. She was hospitalized for 24 hours but remained asymptomatic and was discharged healthy. This type of exposure to buprenorphine has not previously been described in the literature. CONCLUSIONS: Having this unsecured medication in the home increases the potential risk of exposure for young children and associated health consequences. Pediatricians should be aware of the potential dangers that veterinary pharmaceuticals can pose and educate parents about proper storage of medications. In addition, veterinarians should take extra precautions when dispensing these medications to pet owners with children.

Sex- and Age-specific Increases in Suicide Attempts by Self-Poisoning in the United States among Youth and Young Adults from 2000 to 2018.

OBJECTIVE: To evaluate the incidence and outcomes from intentional suspected-suicide self-poisoning in children and young adults ages 10-24 years old from 2000 to 2018. STUDY DESIGN: Retrospective review of intentional suspected-suicide self-poisoning cases reported to the National Poison Data System from US poison centers from 2000 to 2018 for patients 10-24 years old. For comparison of annual rates, population data by year of age were obtained from the US Census Bureau. We evaluated changes in the annual incidence, the annual rate per 100 000 population, and the medical outcome by patient age and sex. RESULTS: There were 1 627 825 intentional suspected-suicide self-poisoning cases, of which 1 162 147 (71%) were female. In children 10-15 years old from 2000 to 2010, there was a decrease in number and rate per 100 000 population followed by a significant increase (from 125% to 299%) from 2011 to 2018. In children 10-18 years old, the increase from 2011 to 2018 was driven predominantly by females. In 19-24 years old age groups, there was a temporal delay and reduced increase in slope compared with the younger groups. There were 340 563 moderate outcomes, 45 857 major outcomes, and 1404 deaths. The percentage of cases with a serious outcome, major effect, or death increased over time and with age. CONCLUSIONS: The incidence and rate of suicide attempts using self-poisoning in children less than 19 years old increased significantly after 2011, occurring predominantly in young girls. There has been an increase in the severity of outcomes independent of age or sex.

Antidepressant and antipsychotic medication errors reported to United States poison control centers.

PURPOSE: To investigate unintentional therapeutic medication errors associated with antidepressant and antipsychotic medications in the United States and expand current knowledge on the types of errors commonly associated with these medications. METHODS: A retrospective analysis of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications was conducted using data from the National Poison Data System. RESULTS: From 2000 to 2012, poison control centers received 207 670 calls reporting unintentional therapeutic errors associated with antidepressant or antipsychotic medications that occurred outside of a health care facility, averaging 15 975 errors annually. The rate of antidepressant-related errors increased by 50.6% from 2000 to 2004, decreased by 6.5% from 2004 to 2006, and then increased 13.0% from 2006 to 2012. The rate of errors related to antipsychotic medications increased by 99.7% from 2000 to 2004 and then increased by 8.8% from 2004 to 2012. Overall, 70.1% of reported errors occurred among adults, and 59.3% were among females. The medications most frequently associated with errors were selective serotonin reuptake inhibitors (30.3%), atypical antipsychotics (24.1%), and other types of antidepressants (21.5%). Most medication errors took place when an individual inadvertently took or was given a medication twice (41.0%), inadvertently took someone else's medication (15.6%), or took the wrong medication (15.6%). CONCLUSIONS: This study provides a comprehensive overview of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications. The frequency and rate of these errors increased significantly from 2000 to 2012. Given that use of these medications is increasing in the US, this study provides important information about the epidemiology of the associated medication errors.

Analgesic-Related Medication Errors Reported to US Poison Control Centers.

Objective: This study investigates the characteristics and trends of medication errors involving analgesic medications. Design and Methods: A retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012. Results: From 2000 through 2012, the NPDS received 533,763 reports of analgesic-related medication errors, averaging 41,059 medication errors annually. Overall, the rate of analgesic-related medication errors reported to the NPDS increased significantly by 82.6% from 2000 to 2009, followed by a 5.7% nonsignificant decrease from 2009 to 2012. Among the analgesic categories, rates of both acetaminophen-related and opioid-related medication errors reported to the NPDS increased during 2000-2009, but the opioid error rate leveled off during 2009-2012, while the acetaminophen error rate decreased by 17.9%. Analgesic-related medication errors involved nonsteroidal anti-inflammatory drugs (37.0%), acetaminophen (35.5%), and opioids (23.2%). Children five years or younger accounted for 38.8% of analgesics-related medication errors. Most (90.2%) analgesic-related medication errors were managed on-site, rather than at a health care facility; 1.6% were admitted to a hospital, and 1.5% experienced serious medical outcomes, including 145 deaths. The most common type of medication error was inadvertently taking/given the medication twice (26.6%). Conclusion: Analgesic-related medication errors are common, and although most do not result in clinical consequences, they can have serious adverse outcomes. Initiatives associated with the decrease in acetaminophen-related medication errors among young children merit additional research and potential replication as a model combining government policy and multisectoral collaboration.

Non-Health Care Facility Cardiovascular Medication Errors in the United States.

BACKGROUND: Prior studies have not examined national trends and characteristics of unintentional non-health care facility (HCF) medication errors associated with cardiovascular drugs. OBJECTIVE: To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. METHODS: A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. RESULTS: There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 ( P < 0.001) and the highest rates were among older adults. Most cases (83.6%) did not require treatment at a HCF. Serious medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were ß-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). CONCLUSIONS: This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.

An Observational Study of the Factor Xa Inhibitors Rivaroxaban and Apixaban as Reported to Eight Poison Centers.

STUDY OBJECTIVE: Rivaroxaban and apixaban are part of a new group of oral anticoagulants targeting factor Xa and approved by the Food and Drug Administration in 2011 and 2012. These oral anticoagulants are administered at fixed daily doses, without the need for laboratory-guided adjustments. There are limited data available on supratherapeutic doses or overdose of the oral Xa inhibitors. This study characterizes the clinical effect in patients exposed to rivaroxaban and apixaban. METHODS: A retrospective study collected data from 8 regional poison centers covering 9 states. Cases were initially identified by a search of the poison centers' databases for case mentions involving a human exposure to Xarelto, rivaroxaban, Eliquis, or apixaban. Inclusion criteria included single-substance exposure. Exclusion criteria were animal exposure, polysubstance exposure, or information call. Data for the study were collected by individual chart review, including case narratives, and compiled into a single data set. RESULTS: There were 223 patients: 124 (56%) were female patients, mean age was 60 years, and 20 were children younger than 12 years (9%). One hundred ninety-eight patients ingested rivaroxaban (89%) and 25 ingested apixaban (11%). Dose was reported in 182 rivaroxaban patients, with a mean dose of 64.5 mg (range 15 to 1,200 mg), and in 21 apixaban patients, with a mean dose of 9.6 mg (range 2.5 to 20 mg). For rivaroxaban, prothrombin time was measured in 49 patients (25%) and elevated in 7; partial thromboplastin time, measured in 49 (25%) and elevated in 5; and international normalized ratio, measured in 61 (31%) and elevated in 13. For apixaban, prothrombin time was measured in 6 patients (24%) and elevated in none; partial thromboplastin time, measure in 6 (24%) and elevated in none; and international normalized ratio, measured in 5 patients (20%) and elevated in none. Bleeding was reported in 15 patients (7%): 11 rivaroxaban and 4 apixaban. The site of bleeding was gastrointestinal (8), oral (2), nose (1), bruising (1), urine (1), and subdural (1). The subdural bleeding occurred after fall and head injury. All cases with bleeding involved long-term ingestions. Coagulation test results were normal in most patients with bleeding: prothrombin time 5 of 6 (83%), partial thromboplastin time 5 of 6 (83%), and international normalized ratio 5 of 9 (55%). Blood products were used in 7 rivaroxaban patients (1 suicide) and 3 apixaban patients. No bleeding or altered coagulation test results occurred in children, which all involved a one-time ingestion. All 12 suicide attempts involved rivaroxaban: altered coagulation test results occurred for 5 patients (42%), no bleeding occurred in any suicide attempt patient, 1 patient was treated with fresh frozen plasma (international normalized ratio 12.47), and dose by patient history did not predict risk of altered coagulation or bleeding. Two rivaroxaban patients experienced elevation of hepatic transaminase levels greater than 1,000 U/L. CONCLUSION: Bleeding after Xa inhibitor ingestion as a single agent is uncommon. Prothrombin time, partial thromboplastin time, or international normalized ratio may be elevated in a minority of cases but appears unreliable to measure risk of bleeding. Massive acute ingestion in suicide attempt may result in significant anticoagulation. Single exploratory ingestion by children was not associated with toxicity.

Therapeutic errors involving diabetes medications reported to United States poison centers.

BACKGROUND: To investigate the characteristics and trends of therapeutic errors that occur outside of healthcare facilities involving diabetes medications reported to US poison centers. METHODS: National Poison Data System data from 2000 to 2021 were retrospectively analyzed. RESULTS: There were 157,623 exposure cases of non-healthcare facility-related therapeutic errors associated with diabetes medications as the primary substance reported to US poison centers from 2000 to 2021. The rate of all therapeutic errors involving diabetes medications increased by 279.8% from 2000 to 2011, followed by a slower 15.0% increase to 2021. Half (50.1%) of the exposure cases were treated/evaluated and released and 44.1% did not receive treatment in a healthcare facility; however, 9.9% experienced a serious medical outcome, including 17 fatalities, and 1.0% were admitted to a critical care unit and 2.2% to a non-critical care unit. Insulin had the highest rates of therapeutic errors and serious medical outcomes, while sulfonylureas and insulin had the highest medical hospital admission rates. Metformin accounted for 59% (n = 10) of fatalities. CONCLUSIONS: Although most cases of therapeutic errors involving diabetes medications had no or minimal clinical consequences, an important minority were associated with a serious medical outcome or medical hospital admission. Increased efforts to prevent therapeutic errors involving diabetes medications are warranted.

Delta-8 Tetrahydrocannabinol Exposures Reported to US Poison Centers: Variations Among US States and Regions and Associations with Public Policy.

INTRODUCTION: This study investigated exposures involving ∆8-tetrahydrocannabinol (∆8-THC) reported to US poison centers (PCs), including variation among states and regions. It evaluated whether the ∆8-THC exposure rate was lower among states with ∆8-THC regulations and states where cannabis (∆9-THC) use was legal. METHODS: National Poison Data System data for ∆8-THC exposures in 2021-2022 were analyzed, including comparisons of state and regional population-based exposure rates. RESULTS: There were 4,925 exposures involving ∆8-THC as the primary substance reported to US PCs from January 1, 2021, to December 31, 2022, with 69.8% of these reported in the US South. The rate of exposure per 100,000 US population increased by 79.2% from 0.53 in 2021 to 0.95 in 2022. In 2022, the mean rate of ∆8-THC exposures in states where cannabis use was illegal was 1.64 per 100,000 population (95% CI: 1.08-2.20) compared with 0.52 (95% CI: 0.29-0.76) in states where cannabis use was legal (P = 0.0010). In 2022, the mean rate of ∆8-THC exposures in states where ∆8-THC was unregulated was 1.36 per 100,000 population (95% CI: 0.95-1.77) compared with 0.17 (95% CI: 0.06-0.27) in states where ∆8-THC was banned (P < 0.0001). CONCLUSIONS: The rate of ∆8-THC exposures reported to US PCs increased by 79% from 2021 to 2022, with the US South accounting for more than two-thirds of exposures. The rate of ∆8-THC exposures reported to PCs was significantly lower among states where ∆8-THC was banned and among states where cannabis use was legal. Consistent regulation of ∆8-THC across all states should be adopted.

Delta-8 tetrahydrocannabinol, delta-10 tetrahydrocannabinol, and tetrahydrocannabinol-O acetate exposures reported to America's Poison Centers.

INTRODUCTION: Since the passage of the Farm Bill in 2018, the availability of synthetic tetrahydrocannabinols has increased, including delta-8 tetrahydrocannabinol, delta-10 tetrahydrocannabinol, and tetrahydrocannabinol-O acetate. The objective of this study is to investigate the characteristics of delta-8 tetrahydrocannabinol, delta-10 tetrahydrocannabinol, and tetrahydrocannabinol-O acetate exposures reported to United States poison centers from 2021 to 2022. METHODS: National Poison Data System data were analyzed, including year, individual demographics, substance category and type, reason for exposure, highest level of health care received, and medical outcome. United States Census Bureau data were used to calculate population-based rates. RESULTS: There were 5,022 reported cases involving delta-8 tetrahydrocannabinol, delta-10 tetrahydrocannabinol, and tetrahydrocannabinol-O acetate as the primary substance reported to United States poison centers from 1 January 2021 to 31 December 2022. The rate of exposure per 100,000 United States population increased by 89.1 percent from 0.55 in 2021 to 1.04 in 2022. Children less than 6 years old accounted for 30.1 percent of cases, with a mode at age 2 years (representing 8.9 percent of cases). Most cases involved delta-8 tetrahydrocannabinol (98.1 percent), were single-substance exposures (94.3 percent), or occurred in a residence (95.9 percent). Ingestions accounted for 94.2 percent of cases, including 95.1 percent among children less than 6 years old. The leading reason for exposure was unintentional-general (40.2 percent), followed by abuse (33.1 percent). The most common related clinical effects were mild central nervous system depression (25.0 percent), tachycardia (23.0 percent), and agitation (15.6 percent). More than one-third (38.4 percent) of cases experienced a serious medical outcome, and 10.3 percent were admitted to a noncritical care unit and 5.3 percent to a critical care unit. DISCUSSION AND LIMITATIONS: The National Poison Data System is limited by its passive surveillance design. Delta-8 tetrahydrocannabinol, delta-10 tetrahydrocannabinol, and tetrahydrocannabinol-O acetate have toxic effects, and reports to United States poison centers increased from 2021 to 2022. Unintentional ingestions by young children are of particular concern. CONCLUSIONS: Opportunities exist to improve regulation, with accompanying enforcement, of these products and to educate the public about their potential toxicity.

Glucagon-Like Peptide-1 Receptor Agonist Cases Reported to United States Poison Centers, 2017-2022.

INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are a class of medications for management of diabetes and obesity. The objective of this study is to characterize the epidemiology of GLP-1RA cases reported to US poison centers. METHODS: We analyzed cases involving a GLP-1RA reported to the National Poison Data System during 2017-2022. RESULTS: There were 5,713 single-substance exposure cases reported to US poison centers involving a GLP-1RA. Most cases were among females (71.3%) and attributable to therapeutic errors (79.9%). More than one-fifth (22.4%) of cases were evaluated in a healthcare facility, including 0.9% admitted to a critical care unit and 4.1% admitted to a non-critical care unit. Serious medical outcomes were described in 6.2% of cases, including one fatality. The rate of cases per one million US population increased from 1.16 in 2017 to 3.49 in 2021, followed by a rapid increase of 80.9% to 6.32 in 2022. Trends for rates of serious medical outcomes and admissions to a healthcare facility showed similar patterns with 129.9% and 95.8% increases, respectively, from 2021 to 2022. CONCLUSIONS: Most GLP-1RA cases reported to US poison centers were associated with no or minimal effects and did not require referral for medical treatment; however, a notable minority of individuals experienced a serious medical outcome or healthcare facility admission. The rate of reported cases increased during the study period, including an 80.9% increase from 2021 to 2022. Opportunities exist to improve provider and patient awareness of the adverse effects of these medications.

Evaluation of the relationship of xylazine and fentanyl blood concentrations among fentanyl-associated fatalities.

INTRODUCTION: Illicit fentanyl and fentanyl-analogs have produced a devastating increase in opioid fatalities in the United States. Increasingly, xylazine has been found in the illicit fentanyl supply. The role of xylazine in fentanyl intoxication remains unclear. We reviewed coroner records to evaluate trends and effects associated with xylazine in fentanyl-related fatalities. METHODS: This is a retrospective cohort study of all deaths reported to the Franklin County Coroner's Office in Ohio from 1 January 2019 to 16 March 2023, in which fentanyl was determined causative or contributory to death. Cases identified as fentanyl-associated fatalities were separated into two groups based on whether or not xylazine was also detected. RESULTS: There were 3,052 fentanyl-related fatalities during the study period. 4.8 percent of these decedents also tested positive for xylazine. There was no meaningful demographic difference between fentanyl-related fatalities in which xylazine was detected versus those without xylazine detected. There was a mean of 726 fentanyl-associated fatalities per year, with a peak of 846 deaths in 2020 and a decline thereafter. The percentage of fentanyl-related fatalities with xylazine detected increased in linear fashion from 2.7 percent in 2019 to 6.6 percent in 2022. The median fentanyl concentration was 17.0 µg/L (inter-quartile range: 7.9, 27.0) in cases with xylazine detected and 10.0 µg/L (inter-quartile range: 5.6, 18.0) without xylazine. The odds of a fentanyl concentration greater than 40 µg/L in cases with xylazine detected was more than twice as great (odds ratio: 2.41; 95 percent confidence interval: 1.58-3.64) than that in cases without xylazine detected. CONCLUSIONS: Postmortem fentanyl concentrations were greater in cases with xylazine detected than those without xylazine detected. Though it is unclear why patients who were exposed to xylazine tolerated higher opioid doses prior to succumbing to death, we postulate that xylazine may act to competitively antagonize some degree of mu-opioid receptor binding by opioids.

A descriptive study of adverse events from clenbuterol misuse and abuse for weight loss and bodybuilding.

BACKGROUND: Clenbuterol is a ß2-agonist approved in the United States for veterinary use in nonfood animals. Clenbuterol use is emerging among bodybuilders and fitness enthusiasts attracted to the hypertrophic and lipolytic effects. CASES: This was a retrospective chart review of clenbuterol exposures reported to 2 poison control centers. Misuse of clenbuterol for weight loss and bodybuilding was reported in 11 of 13 clenbuterol users. Reported clinical effects included tachycardia, widened pulse pressure, tachypnea, hypokalemia, hyperglycemia, ST changes on electrocardiogram (ECG), elevated troponin, elevated creatine phosphokinase (CPK), palpitations, chest pain, and tremor. Measured serum clenbuterol concentration was 2983 pg/mL post 4.5 mg ingestion. Co-ingestants included T3 and anabolic steroids. Treatments included activated charcoal, benzodiazepines, ß-blockers, potassium replacement, and intravenous (IV) fluid. CONCLUSIONS: There is an increasing use of the Internet for illicit drug use for bodybuilding and weight loss purposes. These patients may not present as the stereotype of illicit drug abusers, but as healthy athletic low-risk patients. Clinical effects persisted greater than 24 hours with evidence of myocardial injury in 2 patients. Clenbuterol is increasingly being abused within the bodybuilding subculture. These cases illustrate the hidden dangers of clenbuterol abuse among bodybuilders and fitness enthusiasts.

Hydrocarbon ingestions among individuals younger than 20 years old reported to United States Poison Centers, 2000-2021.

BACKGROUND: Hydrocarbon-based products have many household and commercial uses and exposure to these substances is common. Severe clinical effects can occur if these products are ingested. This study investigated the characteristics and trends of hydrocarbon ingestions reported to United States Poison Centers. METHODS: Data from the National Poison Data System were analyzed for cases of hydrocarbon ingestion among individuals < 20 years old reported to United States Poison Centers from January 1, 2000 through December 31, 2021. RESULTS: There were 284,085 hydrocarbon ingestions reported during the 22-year study period in which a hydrocarbon was the first-ranked substance. Most of these cases occurred among children < 6 years old (83.2%), males (64.6%), at a residence (96.5%), were single-substance exposures (98.3%), and were managed on-site rather than in a health care facility (74.9%). However, 4.5% of cases were associated with a serious medical outcome, including 34 deaths. Thirty-two deaths were among children < 6 years old and most were associated with aspiration. Gasolines accounted for 24.6% of total cases, followed by lubricating oils and/or motor oils (19.9%), other types of hydrocarbons (14.9%), lamp oils (11.3%), and lighter fluids and/or naphtha (10.3%). The rate of hydrocarbon ingestions among United States youth < 20 years old decreased significantly (p < 0.0001) by 66.5% from 2000 to 2021. The greatest rate decrease was observed among lamp oils (- 78.4%, p < 0.0001), followed by gasolines (- 75.9%, p < 0.0001). CONCLUSIONS: Although the rate of hydrocarbon ingestions decreased during the study period and most reported cases resulted in non-serious outcomes, the number of cases remains high with a non-trivial minority (4.5%) of cases associated with a serious medical outcome, including death. Most deaths were among children < 6 years old. This underscores the need to increase primary prevention efforts, especially for young children.

Suspected suicides and suicide attempts involving antipsychotic or sedative-hypnotic medications reported to America's Poison Centers, 2000-2021.

OBJECTIVE: To investigate the patterns and trends of suspected suicides and suicide attempts involving antipsychotic or sedative-hypnotic medications reported to United States poison centers. METHODS: Data from the National Poison Data System for 2000 through 2021 were retrospectively analyzed. RESULTS: There were 972,975 suspected suicides and suicide attempts with antipsychotics or sedative-hypnotics ranked as the primary substance reported to poison centers from 2000-2021, averaging 44,226 cases annually. Most (85.6%) cases occurred among individuals >19 years old, females accounted for 63.5% of cases, and 51.8% were single-substance exposures. The rate of reported exposures per 100,000 United States population increased significantly from 27.2 in 2000 to 49.1 in 2008 (P < 0.0001), then plateaued to 49.6 in 2016 (P = 0.1497), followed by a significant decrease to 38.7 in 2021 (P < 0.0001). Individuals 13-19 years old demonstrated the greatest increase in rate from 28.4 in 2000 to 79.6 in 2021 (P < 0.0001). Approximately half (48.8%) of primary substance exposures were benzodiazepines, followed by antipsychotic medications (36.7%) and other types of sedative/hypnotic/anti-anxiety or antipsychotic medications (14.6%). Most primary substance exposures were admitted to a critical care or non-critical care unit (43.3%) or directly to a psychiatric facility (27.9%), and 36.1% were associated with in a serious medical outcome, including 1,330 deaths. Individuals >49 years old were more likely to experience a serious medical outcome (relative risk = 1.25, 95% CI: 1.24-1.26), including death (relative risk = 3.06, 95% CI: 2.74-3.41), or be admitted to a critical care or non-critical care unit (relative risk = 1.24, 95% CI: 1.23-1.24) than younger individuals. CONCLUSIONS: Suspected suicides and suicide attempts involving antipsychotic or sedative-hypnotic medications increased during the 22-year study period, especially among individuals 13-19 years old, and these cases often had severe clinical consequences. Based on the characteristics and trends identified in this study, increased prevention efforts are warranted to help prevent these suspected suicides and suicide attempts.

Pediatric Suspected Suicides and Nonfatal Suicide Attempts Reported to United States Poison Control Centers Before and During the COVID-19 Pandemic.

INTRODUCTION: This study investigated the characteristics and compared the trends of pediatric suspected suicide and nonfatal suicide attempts reported to United States (US) poison control centers (PCCs) before and during the first year of the COVID-19 pandemic. METHODS: An interrupted time series analysis using an ARIMA model was conducted to evaluate the trends of suspected suicides and nonfatal suicide attempts among children 6-19 years old reported to the National Poison Data System during March 2020 through February 2021 (pandemic period) compared with March 2017 through February 2020 (pre-pandemic period). RESULTS: The annual number of cases of suspected suicides and nonfatal suicide attempts increased by 4.5% (6095/136,194) among children 6-19 years old during March 2020 through February 2021 compared with the average annual number during the previous three pre-pandemic years. There were 11,876 fewer cases than expected from March 2020 to February 2021, attributable to a decrease in cases during the initial three pandemic months. The average monthly and average daily number of suspected suicides and nonfatal suicide attempts among children 6-12 years old and 13-19 years old was higher during school months than non-school months and weekdays than weekends during both the pre-pandemic and pandemic periods. CONCLUSIONS: There was a greater than expected decrease in the number of suspected suicides and nonfatal suicide attempts among children 6-19 years old reported to US PCCs during the early pandemic months, followed by an increase in cases. Recognizing these patterns can help guide an appropriate public health response to similar future crises.