New street drugs, toxic chemicals, and pharmaceuticals appear constantly, making it extremely difficult to keep current on all the information needed to diagnose and treat toxicology patients. Fortunately, there is a vast amount of accessible, reasonably reliable information available on the Internet that clinicians can use to stay up-to-date and help manage unusual cases.
Say a 19-year-old man is brought to your emergency department. He is obviously hallucinating. His friends say he is tripping on a drug called “Nexus.” Where would you go to find out more about this preparation?
The first reference I'd turn to would be the Vaults of Erowid (www.erowid.org), an amazingly extensive compilation of information relating to all types of street drugs. Founded in 1995, Erowid's goal is to provide accurate and nonjudgmental information about the use of psychoactive plants and chemicals. The attempt to remain nonjudgmental has led to criticism that Erowid is, in essence, acting as a cheerleader for the drug culture, and that the site frequently minimizes potential adverse drug effects.
Critics also have pointed out that not all the information on the site is completely reliable. Any textbook in toxicology or emergency medicine will inevitably have material that is questionable or out-of-date. My experience with Erowid is that the information is generally accurate and more current than textbooks whose chapters may have been written several years before publication.
Searching Erowid for “Nexus” reveals that it is 2C-B, a psychedelic phenethylamine that causes intense hallucinations and has effects lasting up to eight hours. Erowid also provides links to the U.S. Drug Enforcement Administration's 2001 ruling making 2C-B a Schedule I controlled substance, as well as the Department of Justice information bulletin about the drug and a number of related articles from the popular press. There also are several reports submitted by users describing their experiences with the drug. These, of course, should be read with some caution because it is impossible to confirm if the writers are reliable or actually consumed the specific chemical they claim to be describing.
Lycaeum (www.lycaeum.org) is somewhat similar to Erowid, but it is less comprehensive. The site's purpose is to “absorb all available entheogenic knowledge, cross-reference it for you, and make it browseable through an intuitive interface.” I had to look up “entheogenic,” which is defined as “a psychoactive substance used in a religious or shamanic context.” Searching for “Nexus” on Lycaeum did not produce any hits, but the term “2C-B” did connect to some helpful material. Unfortunately, a number of posted links are broken, and the site does not seem to be well-maintained.
The Centers for Disease Control and Prevention posts its essential publication Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr) each week as a downloadable pdf file. An RSS feed is also available. While much of the material in the report involves infectious disease outbreaks, there is occasionally important information about toxic exposures. When hemodialysis patients develop allergic reactions attributed to contaminated batches of heparin or when cases of foodborne botulism in Texas and Indiana are traced back to improperly prepared hot dog chili sauce, you will read about it first in MMWR. Also worth monitoring is the U.S. Food and Drug Administration Medwatch (www.fda.gov/medwatch), which lists recent changes in pharmaceutical package inserts, drug recalls, and other important safety information concerning products regulated by the FDA.
The CDC also produces the Emergency Preparedness & Response site (www.bt.cdc.gov), with information for health care professionals about managing mass casualty incidents involving blast injuries, burns, biological or chemical agents, and radiation exposure.
Other Tox Web Sites
The Household Products Database (http://householdproducts.nlm.nih.gov) is produced by the National Institutes of Health and the National Library of Medicine, and provides information about the acute and chronic health effects of various products commonly found around the home, as well as contact phone numbers for the product manufacturers.
The Cornell University Poisonous Plants Informational Database (www.ansci.cornell.edu/plants) has good pictures of toxic flora and links to other useful resources on the web.
The Kentucky Snake Identification site (www.kentuckysnakes.org) can help pinpoint the exact reptile that bit your patient. It classifies snakes according to pattern, and has many up-close-and-personal images.
The Dartmouth Toxic Metals Research Program (www.dartmouth.edu/∼toxmetal) has brief informative essays on the toxic history of arsenic, mercury, lead, and a number of other poisonous elements.
Finally, Mark Mycyk, MD, an emergency physician and medical toxicologist at Northwestern University, has recently started a monthly audio review dedicated to covering “anything and everything that's toxworthy.” Each issue includes music, a puzzler, toxicology-related news stories, and reviews of six current and classic toxicology articles. It is available for download by free subscription from the iTunes store; just search for “Chicago Toxcast.” It's well worth your attention.
Toxicology Web Sites
- ▪ Vaults of Erowid: www.erowid.org
- ▪ Lycaeum: www.lycaeum.org
- ▪ Morbidity and Mortality Weekly Report: www.cdc.gov/mmwr
- ▪ Medwatch: www.fda.gov/medwatch
- ▪ Emergency Preparedness & Response: www.bt.cdc.gov
- ▪ Household Products Database: http://householdproducts.nlm.nih.gov
- ▪ Cornell University Poisonous Plants Informational Database: www.ansci.cornell.edu/plants
- ▪ Kentucky Snake Identification: www.kentuckysnakes.org
- ▪ Dartmouth Toxic Metals Research Program: www.dartmouth.edu/∼toxmetal
- ▪ Chicago Toxcast: Free subscription at iTunes.