Non-fatal overdose with a new synthetic opioid. / Ikke-fatal overdose med nytt syntetisk opioid.

A young man experienced respiratory arrest at home, and cardiopulmonary resuscitation was performed. The patient received naloxone with good effect and was admitted to hospital. He disclosed opioid use, but no substances were detected in routine drug screenings.

Oxazepam Detected in Urine 79 Days After Withdrawal of Diazepam: A Case Report.

ABSTRACT: Patients suffering from substance use disorder, including for instance benzodiazepines, may have comorbidity with attention deficit hyperactivity disorder (ADHD). Centrally acting stimulants play an important role in the treatment of ADHD. Before such treatment can be initiated, withdrawal of benzodiazepines may be necessary. Urine testing is the preferred method for monitoring adherence in benzodiazepine withdrawal, but there is a lack of studies reporting detection time. Here, we report a case of a 30-year-old woman with substance use disorder and ADHD who had detectable metabolites of diazepam 79 days after withdrawal. To our knowledge, no cases with detection time equivalent to this have previously been published. This case report serves as an example that clinicians may need to consider interindividual pharmacokinetic characteristics when interpreting the results of urine drug tests, and that a positive urine test may still be consistent with abstinence from a certain drug. In the current case, a high body mass index and a genetic polymorphism gave a reasonable explanation for the prolonged detection of diazepam metabolites.

An apathetic child with hallucinations. / Et apatisk barn med hallusinasjoner.

BACKGROUND: Lysergic acid diethylamide (LSD) is a potent, hallucinogenic substance that distorts the perception, state of consciousness and behaviour of the user. LSD poisonings are rare in children and may be difficult to recognise based on clinical symptoms alone. CASE PRESENTATION: A young boy was admitted to the hospital because of bizarre behaviour and reduced responsiveness towards his parents. At first, he was agitated. Later he fell silent and became apathetic. He suffered from ataxia and showed signs of visual hallucinations. A conclusive diagnosis of LSD poisoning was made possible through targeted and specific laboratory testing of blood and urine samples. The patient recovered completely without any specific treatment. INTERPRETATION: We urge doctors who examine paediatric patients with acute and unexplained neuropsychiatric symptoms or abnormal behaviour to consider drug intoxication as a possible differential diagnosis. Blood and urine samples from such patients should be obtained as soon as possible and analysed for a broad spectrum of substances. No antidote exists for LSD. If sedation is required due to convulsions, tachycardia, agitation, or frightening hallucinations, treatment with a benzodiazepine, such as diazepam or midazolam, is recommended.

Should more patients be offered treatment with cannabinoids? / Bør flere tilbys behandling med cannabinoider?

Today, a small but growing number of patients in Norway are prescribed cannabinoids for medical use. Despite the large focus on their potential as medicines, there is limited scientific knowledge about the positive effects, adverse effects, long-term effects and interaction potential of cannabinoids.

Reference ranges for antiepileptic drugs revisited: a practical approach to establish national guidelines.

BACKGROUND AND OBJECTIVE: Laboratories sometimes use different reference ranges for the same antiepileptic drug (AED), particularly for new and poorly investigated drugs. This may contribute to misunderstandings, concerns or inappropriate dose changes, which in turn may affect therapeutic effect, drug safety or treatment adherence. Therefore, the Norwegian Association of Clinical Pharmacology wished to update and harmonize the reference ranges for AEDs and establish national guidelines for Norway. METHODS: A working group collected information on the reference ranges used by Norwegian laboratories for all commonly used AEDs. These reference ranges were compared to recent recommendations by the International League Against Epilepsy, current literature, applicable clinical studies, reference ranges used by leading Northern European epilepsy centers outside of Norway, and routine data derived from Norwegian laboratory databases. RESULTS: Reference ranges varied between laboratories for four of 23 available AEDs (lamotrigine, valproate, eslicarbazepine and oxcarbazepine). For four AEDs (brivaracetam, perampanel, stiripentol and sulthiame), reference ranges had not previously been established. In total, 13 reference ranges were either harmonized, updated or newly established. No changes were applied to the remaining 10 AEDs. CONCLUSION: Updated and harmonized reference ranges are now available for 22 of the 23 AEDs available in Norway. The exception is vigabatrin (reference range not applicable). Revision of reference ranges is an important part of pharmacovigilance of AEDs and must be a continuous process based on current literature and clinical experience.

Cross-reactivity of the CEDIA buprenorphine assay in drugs-of-abuse screening: influence of dose and metabolites of opioids.

PURPOSE: The cloned enzyme donor immunoassay (CEDIA) for buprenorphine is applied for both urine drugs-of-abuse screening and compliance monitoring. Sensitivity, specificity, and optimal cutoff of this assay have differed between studies. This may indicate that cross-reactivity has to be taken into account during assay evaluation. We therefore investigated the performance of the CEDIA buprenorphine assay for use in our patient population and explored the impact of cross-reactivity on assay accuracy. METHODS: The CEDIA buprenorphine assay and high-performance liquid chromatography-tandem mass spectrometry were employed to analyze drugs-of-abuse in urine samples from a healthy drug-naïve male volunteer after intake of two tablets of a prescription drug containing 400 mg paracetamol +30 mg codeine phosphate, and in urine samples (n=2,272) from drug-addicted patients. Receiver operating characteristic analyses were performed to express the diagnostic accuracy of the CEDIA buprenorphine assay. RESULTS: CEDIA buprenorphine was positive in one urine sample from the drug-naïve person after intake of the prescription drug. Twenty-five (1.1%) of the patient urine samples were positive for buprenorphine by CEDIA, but negative by high-performance liquid chromatography-tandem mass spectrometry. Codeine, morphine, and their respective metabolites were prevalent in samples that were false positive for buprenorphine. The specificity of the CEDIA buprenorphine assay increased to 99.7% when the cutoff was increased from 5 ng/mL to 10 ng/mL. CONCLUSION: Intake of a therapeutic dose of codeine can yield a false-positive CEDIA buprenorphine result. Additive effects from metabolites of codeine contribute to cross-reactivity in concentrations much lower than listed in the manufacturer's cross-reactivity guide. Raising the cutoff from 5 ng/mL to 10 ng/mL increased the diagnostic accuracy. Clinicians should be informed about the risk of false-positive results with the CEDIA buprenorphine assay.

[High incidence of work-related disease among asthmatics on sick-leave]. / Mye arbeidsrelatert sykdom blant astmatikere.

BACKGROUND: We have previously shown that work-related asthma is substantially underreported and usually not notified to the Labour Inspection Authority until it has become chronic and interferes with future work. The aim of this study was to evaluate whether conditions relating to individuals are important for the susceptibility to work-related asthma and to assess whether there is a correspondence between patients' and physicians' perception of the importance of exposure to work in relation to the disease. MATERIAL AND METHODS: Questionnaires were sent to 824 workers (56% women) aged 18-55 years, who had been on sick leave > 16 days in the years 2000-2003. The disease was classified as work-related asthma if the following questions were answered positively: "Have you ever had respiratory symptoms in relation to your work?" and "Did the symptoms improve on absence from work?" RESULTS: The response rate was 72%, 58% of the responders were women. 416 (70%) had work-related asthma. There were fewer smokers in the group with work-related asthma than among those without, atopy was equally prevalent. Occupational titles reflected the gender differences of the Norwegian labour force. Indoor climate at the workplace was stated as the most frequent provoking factor. The physicians suspected a relationship to work for about half of the 416, notification was only sent for 21% of the male and 10% of the female employees. INTERPRETATION: The importance of occupational exposure seems to be underestimated, especially for women with asthma. Neither atopy nor smoking increased the risk for work-related symptoms. Indoors climate at the work place was most often given as the reason for work-related symptoms. A reduction of exposure led to a reduction of symptoms for most individuals.