Dr Paul Dargan & Dr David Wood Consultant Clinical Toxicologists

1. Monitoring Drug Emergencies How and Why Should We Do It? Dr Paul Dargan & Dr David Wood Consultant Clinical Toxicologists Guy’s and St Thomas’ NHS Foundation Trust London, UK

2. Recreational Drugs • Recreational Drug use is common • Numerous National, European and International networks collect data on recreational drug use: i Population surveys of drug use • Life-time prevalence of drug use in Europe: • 22% cannabis • 3.6% cocaine • 2.8% ecstasy • Variations in pattern of use across EU EMCDDA Annual Report 2008

3. Recreational Drugs • Recreational Drug use is common • Numerous National, European and International networks collect data on recreational drug use: i Population surveys of drug use ii Drug seizures, crime reports / surveys iii Use of treatment agencies for problem drug use iv Drug-related fatalities • Less co-ordinated data on recreational drug toxicity

4. Acute Recreational Drug Toxicity • There is the potential for significant morbidity and mortality • This is dependent on the class of drug

5. Acute Recreational Drug Toxicity Stimulants Depressants GHB / GBL 1,4-butanediol Heroin Opium MDMA (ecstasy) Amphetamine Cocaine 1-benzylpiperazine Hallucinogenics LSD Ketamine Glaucine TFMPP

6. Acute Recreational Drug ToxicityWhat data is available? • No currently published National Datasets • Not routinely collected by EMCDDA Reitox National Focal Points Hospital coding of admissions (discharges): • Often only capture admitted patients • up to 50-75% managed in Emergency Departments or pre-hospital • Based on ICD-10

7. Acute Recreational Drug ToxicityICD-10 • ICD-10 codes: • Dependent on cases being coded appropriately • Not specific for all recreational drug presentations e.g. MDMA, amphetamines, ketamine, GHB not captured

8. ICD-10 recreational drug codes T40: Poisoning by narcotics and psychodysleptics

9. Acute Recreational Drug ToxicityOther Potential Datasets • Poisons Information Services • Only capture cases that clinicians call about • Ambulance / Pre-Hospital data sets • UK: >90% cases brought to hospital by ambulance • Ambulance datasets not widely available/published • No standard EU/International coding system • Pilot studies in UK: coding not sufficient to provide reliable / robust data on recreational drug toxicity

10. Acute Recreational Drug ToxicityOther Potential Datasets • Link in to other established, validated national clinical datasets • National Disease Registers • Stroke Registers • Cardiovascular Disease Registers • Would require novel data capture for recreational drug coding • Could potentially allow prospective follow up of a cohort of patients

11. Acute Recreational Drug ToxicityOther Potential Datasets • Single centre datasets • Collected within a hospital / city / region • Requires local interest, finance and logistics • Provide valuable information, with clinical detail, particularly in a high incidence area • e.g. London UK, Palma Mallorca, Oslo Norway

12. Acute Recreational Drug ToxicityOther Potential Datasets • Single centre datasets • Collected within a hospital / city / region • Potential to link these single centre datasets • Current EMCDDA funded pilot study led by us • Looking at data collection in London and Mallorca • Using a limited dataset • Demographics and exposure data • Basic clinical parameters and outcome

13. Acute Recreational Drug ToxicityOther Potential Datasets • Single centre datasets • Collected within a hospital / city / region • Potential to link these single centre datasets • Current EMCDDA funded pilot study led by us • Looking at data collection in London and Mallorca • Will allow comparison of epidemiology between specialist centres • Potential to expand to other centres

14. London Acute Recreational Drug Toxicity Data • Guy’s and St Thomas’ NHS Foundation Trust • Central London Teaching Hospital • Specialist Clinical Toxicology Service • Purpose designed database: • Detailed data on all poisoned patients • Full-time database scientist • 1600 acute poisoning presentations per year • 39% relate to recreational drug toxicity Greene SL Postgrad Med J 2008

16. Recreational Drug Presentations (2008)

17. Recent Trends and Other Results 2005-2008: • Increase in cocaine-related toxicity • Increase in GHB/GBL presentations • Increase in GBL:GHB ratio • Differences in pre-hospital and Emergency Department datasets • Methamphetamine toxicity is not an issue in London or elsewhere in the UK Wood DM QJM 2008, Wood DM Subst Use Misuse 2009

18. Users Self-Report vs Toxicological Screening • This and other similar datasets rely on users self-report • Studies suggest users self-report variable in determining the primary drug(s) responsible for toxicity West E Emerg Med Australas 2008, Brojnaas MA Clin Tox 2006 • Users self-report not useful in the context of: • Novel / emerging drugs • Mis-appropriated drugs

19. Novel Recreational Drugs • In the last 3 years we’ve detected 9 novel recreational drugs e.g. piperazines, glaucine, DOC, D2PM, cathinones • On an ad hoc basis using clinical suspicion in patients with an atypical history / clinical features • Increasing availability/use of novel recreational drugs • Incidence of novel recreational drug toxicity is unknown • This could only be determined using comprehensive toxicological screening in a busy specialist centre Wood DM Lancet 2007, Staack R Lancet 2007, Dargan PI EJCP 2008, Ovaska H EJEM 2008, Lidder S J Med Toxicol 2008, Wood DM J Med Toxicol 2008

20. Conclusions • Acute recreational drug toxicity: significant morbidity • ICD-10 not suitable for data collection: • Poor availability of national / EU data • Potential datasets • Links to established disease registers • Pooling of single centre, specialist datasets • Screening of recreational drug presentations in a large centre to determine • the drugs responsible for toxicity • incidence of novel recreational drug toxicity