These articles top my list of the best medical toxicology papers from the past year, and they can change the way you approach common problems in and out of the emergency department this year.
Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients
Riccoboni ST, Darracq MA
J Emerg Med
It's 3 a.m., the ED is barely under control, the waiting room is full, and places where patients can lie down—or even sit—are at a premium. Fortunately, you just cleared a young man with a history of psychiatric illness after a careful history, physical examination, and mental assessment. He is alert and cooperative with normal vital signs.
You call the receiving mental health facility to arrange transfer. The person on the other end listens to your presentation, and then asks, “But what does the urine drug screen show?”
The urine drug screen is one of the least reliable tests in emergency medicine. It is neither sensitive nor specific, and false-negatives abound because routine drug screens do not pick up a wide range of drugs that can cause behavioral changes. Various psychiatric (and other) medications will also erroneously be detected as drugs of abuse, resulting in many false-positives. (See table.) Even a true-positive may not establish recent use or intoxication but may represent exposure days or even weeks before.
The authors of this study retrospectively reviewed the charts of 205 patients transferred to a behavioral health hospital, comparing those on whom a urine drug screen was obtained (n=89) with those on whom it was not (n=116). A great majority of urine drug screens (89%) were obtained because the psychiatric facility requested it after the patient had been cleared. The authors found that the screen never reversed the medical clearance and did not affect length of stay.
It did, however, delay transfer and result in a charge of $235 per test. Interestingly, the review showed that the results of the urine drug screen were not even documented in psychiatric hospital records more than 75 percent of the time. The authors concluded that the screen was of little benefit for acute psychiatric illness, and hypothesized that “the external request for a [urine drug screen] is often a ‘stall’ tactic employed to delay transfer.”
ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders
Moss MJ, Warrick BJ, et al.
Clin Toxicol [Phila]
A police officer became ill after he briefly touched a white powder during a drug bust, according to an article in the Morning Journal of Lorain, OH. The substance was not identified in the article, but the area's police chief was quoted saying, “It only takes one granule (of carfentanyl [sic]) to kill an adult.” (May 14, 2017; http://bit.ly/2PaPNn0.) The officer did not respond to a standard dose of naloxone but needed it three more times before his symptoms resolved, according to the report.
That paranoia about dying from minimal skin contact with fentanyl or fentanyl analogs spread not only to police but also to first responders and even judges, some of whom banned drug samples as evidence in their courtrooms. Canadian morticians were so worried they might be exposed to a critical dose of fentanyl while embalming their clients that they started stocking naloxone. All that kerfuffle and not a shred of evidence that powdered fentanyl or any of its analogs is effectively absorbed through unbroken skin.
A position statement endorsed by the American College of Medical Toxicology and the American Association of Clinical Toxicologists tries to restore some sanity to the discussion. The authors pointed out that the “risk of clinically significant exposure to emergency responders is extremely low” and that “incidental dermal absorption [of fentanyl or its analogs] is unlikely to cause opioid toxicity.” They suggested that nitrile gloves provide sufficient personal protection for handling these drugs in routine cases, with the possible addition of a fitted N95 respiratory filter if the drug were aerosolized or its particles suspended in the air.
The statement recommended that naloxone be used only for patients with objective evidence of hypoventilation after exposure, not those merely feeling strangely. The authors suggested that no evidence indicates naloxone doses higher than usual (that is, 10 mg total) would be necessary or advisable in these cases.
The Next Stage of Buprenorphine Care for Opioid Use Disorder
Martin SA, Chiodo LM, et al.
Ann Intern Med
2018 Oct 23 [Epub ahead of print]
The partial opioid agonist buprenorphine (Suboxone) was approved by the FDA in 2002 for treating opioid use disorder. Guidelines were established on the knowledge and experience available at that time, which was before the opioid crisis and before fentanyl and its analogs started showing up regularly in street drugs. Given the increasing need for effective addiction treatment, the initial recommendations for buprenorphine now seem unnecessarily restrictive.
The 2004 Substance Abuse and Mental Health Services Administration guidelines recommended that initial buprenorphine induction be administered under direct observation in a medical setting to avoid withdrawal. It currently suggests that induction can be carried out at home, a change that should eliminate a major barrier to treatment. This paper discusses seven areas in which the approach to using buprenorphine has been updated. It's a must-read.
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