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

2. Recreational Drugs EMCDDA Annual Report 2008  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

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

6. Acute Recreational Drug Toxicity What 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 Toxicity ICD-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. T40.0Opium T40.1Heroin T40.2Other opioids (codeine, morphine) T40.3Methadone T40.4Other synthetic narcotics (pethidine) T40.5Cocaine T40.6Other and unspecified narcotics T40.7Cannabis (derivatives) T40.8Lysergide [LSD] T40.9Other & unspecified psychodysleptics [hallucinogens] Mescaline, psilocin, psilocybine ICD-10 recreational drug codes T40: Poisoning by narcotics and psychodysleptics

9.  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 Acute Recreational Drug Toxicity Other Potential Datasets

10.  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 Acute Recreational Drug Toxicity Other Potential Datasets

11.  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 Acute Recreational Drug Toxicity Other Potential Datasets

12.  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 Acute Recreational Drug Toxicity Other Potential Datasets

13.  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 Acute Recreational Drug Toxicity Other Potential Datasets

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