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CONTEXT: Illicit opioid use and heroin treatment admissions among individuals age 50+ have increased. Little research has, however, examined correlates of illicit opioid overdose deaths in this age group before or during the COVID-19 pandemic or the healthcare services used in these cases. METHODS: The sample included illicit opioid (heroin, fentanyl, or other synthetic, nonpharmaceutical opioids) poisoning cases age 50+ (N=5,576) in the National Poison Data System, 2015–2020. Using descriptive statistics and logistic regression models, we report changes in overdose death rates during the study period and associations of death with healthcare service use, naloxone administration, and clinical and demographic characteristics. RESULTS: The 6-year average overdose death rate from illicit opioids among those age 50+ was 2.9%, increasing from 1.4% in 2015 to 4.0% in 2019 and 3.6% in 2020. Logistic regression results showed that exposure year was not a significant factor in the odds of overdose death; however, odds were significantly higher among cases that were not managed at any healthcare facility (AOR=4.60, 95% CI=3.19–6.63) and lower among those who received naloxone therapy (AOR=0.64, 95% CI=0.45–0.92). The odds of death were also higher among cases involving exposure at own or another’s home and co-use of prescription opioids, alcohol, and other illicit drugs. CONCLUSIONS: Although the NPDS did not show increases in illicit opioid overdose death rates among cases age 50+ in 2020 compared to 2019, overdose deaths were greater among cases that were not managed at HCF and did not receive naloxone therapy. Many appear to have died before they received any intervention to prevent death. Improved access to healthcare services and social support and access to naloxone therapy for older adults with opioid use problems are needed.

High rates of opioid overdose and suicide among the 50+ age group call for an examination of suicidal intent in overdose incidents. Using 2015-2020 National Poison Data System opioid poisoning cases aged 50+ (

CONTEXT: Older adults are less likely than younger adults to receive naloxone therapy. Given high rates of prescription opioid use/misuse and increasing illicit opioid use among older adults, factors associated with naloxone administration for older opioid poisoning cases need examination. METHODS: We analyzed the 83,135 opioid-involved cases aged 50+ from the 2015–2020 National Poison Data System. Single-variable logistic regression was used to examine associations of naloxone administration with demographic factors, exposure site/reason, medical outcomes, management site/level of care, clinical effects, and other interventions. Multivariable logistic regression models were fit to examine associations of naloxone administration with different types of opioids. RESULTS: Over the six years, the proportion of prescription opioid cases that received naloxone therapy increased steadily from 21.9% to 28.4%. The proportion of illicit opioid cases that received naloxone therapy was 51.9% in 2015 and 59.8% in 2020 with a high of 64.4% in 2019. In 2020, the death rate for illicit opioid cases without naloxone therapy was 31.4% compared to 2.3% for those with the therapy. Cases managed at healthcare facilities (HCF) had higher odds of receiving naloxone therapy. Among prescription opioid cases, naloxone therapy rates among older and female cases and those managed at non-HCF settings were especially low even for major medical outcomes. Cases involving oxycodone, morphine, methadone, prescription fentanyl, hydromorphone, oxymorphone, and other/unknown opioids had higher odds of naloxone administration. DISCUSSION: Rates of naloxone therapy for older prescription opioid poisoning cases need improvement. While rates were higher among illicit opioid cases, the drop in 2020 and the sharp increase in deaths among illicit opioid cases without naloxone therapy confirm the importance of access to this life-saving intervention. CONCLUSIONS: Increased naloxone co-prescribing and other means of facilitating access to naloxone are needed to prevent opioid poisoning deaths among older adults who use prescription opioids.

Objectives: To examine relationships between polypharmacy and level of healthcare service use among prescription opioid poisoning cases age 50 and older. Methods: Data came from the American Association of Poison Control Center’s National Poison Data System, 2015-2020. We used multinomial logistic regression to examine the study questions. Results: Of the 77 946 cases with prescription opioid exposures, 64.5% were managed at a healthcare facility (HCF). Of HCF-managed cases, 41.2% were treated/evaluated and released and 21.3% and 37.5% were admitted for noncritical care and critical care, respectively. Medications for cardiovascular disease, benzodiazepines, other types of sedatives/hypnotics, antipsychotics, muscle relaxants, acetaminophen, and gabapentin were associated with increased risk of admission to both noncritical and critical care compared to treatment/evaluation and release. Acetaminophen use had the highest relative risk ratios (RRRs) for noncritical care (1.70, 95% CI = 1.51-1.91) and critical care (1.56, 95% CI = 1.39-1.76). Each additional medication/substance used was associated with 1.14 (95% CI = 1.11-1.17) and 1.19 (95% CI = 1.16-1.22) greater risk of noncritical and critical care admissions, respectively. Conclusions: Among older-adult poison control center cases for prescription opioid exposures, co-use of several commonly prescribed/used medicines was associated with increased risk of admissions to both noncritical and critical care units. Careful monitoring of medication use among older adults who use prescription opioids may reduce the risk of unintentional and intentional opioid poisoning.

Context Rates of prescription opioid (PO) prescribing and filling remain high, and illicit opioid (IO) use has increased among late middle-aged and older adults. Research on PO and IO poisoning and their impacts among these age groups is needed. Methods Data came from 2015 to 2020 poison control center cases aged 50+ (N = 83,135). We used χ2 tests to examine changes over the study period in the numbers of PO and IO cases, type of opioids used, exposure reasons, and medical outcomes. We fit multinomial logistic regression models to examine the associations of medical outcomes with exposure reasons and other medication/substance involvement. Results Between 2015/2016 and 2020, the numbers and shares of PO-only cases steadily declined, but IO cases, with or without PO, nearly tripled, constituting almost 10% of all PCC opioid cases aged 50+ in 2020. The rates of intentional misuse/abuse increased among both PO-only and IO (with/without PO) cases during the study period, and the death rate among IO cases sharply increased in 2020. Compared to adverse reactions or other unintentional exposures, intentional misuse/abuse and suspected suicides were associated with significantly higher risks of serious outcomes (e.g., risk of death from intentional misuse/abuse: RRR = 22.11, 95% CI = 16.74-29.20 in PO-only cases and RRR = 6.95, 95% CI = 2.37-20.39 in IO cases with/without PO). The use of most other medications and substances was also significantly associated with serious outcomes. Discussion Among older adults, medical outcomes in opioid poisoning cases have become more serious in recent years as intentional misuse/abuse became more common. Opioid use disorder treatment should be readily available and accessible, and alternatives to PO prescribing should be considered. Conclusions Among individuals aged 50+, PO poisoning cases decreased, but IO cases increased sharply from 2015 to 2020 with concomitant increases in intentional misuse/abuse and serious medical outcomes.

A significant proportion of individuals aged 50+ in the U.S. use cannabis for medical or recreational purposes, sometimes with adverse effects. Given differences in cannabis use among men and women, we examined sex differences in (1) cannabis forms used, (2) exposure reasons, and (3) medical outcomes in older-adult poison control center (PCC) cases.Data came from the American Association of Poison Control Centers' National Poison Data System, 2009-2019. We focused on the 3633 cases aged 50+ in which plant and other non-synthetic cannabinoid cannabis forms were the only or primary substance. Logistic regression was used to examine associations of sex with cannabis forms. Multinomial logistic regression models were fit to examine associations of sex with exposure reasons (therapeutic errors/adverse reactions, intentional misuse/abuse, other) and medical outcomes (no-to-minimal, moderate, or major effects).Females constituted 57.4% of cases. In multivariable analyses, female cases had 1.20 (95% CI = 1.01-1.43) greater odds of involving cannabis forms other than plant forms and 1.93 greater odds (95% CI = 1.66-2.24) of therapeutic errors/adverse effects compared to intentional misuse/abuse. Older age and occurrence in recreational-cannabis-legal states were positively associated with other cannabis forms. Older age, recreational and/or medical cannabis-legal states, CBD, pharmaceuticals, concentrated extracts, and chronic exposure were associated with higher odds of therapeutic errors/adverse effects. Sex was not significantly associated with medical outcomes.Female cases compose a large share of PCC cases aged 50+ and are associated with higher odds of involving cannabis forms other than plants and therapeutic errors/adverse reactions compared to intentional misuse/abuse.

Increasing numbers of older adults use cannabis and cannabis-derived products that can have adverse effects. This study examined management site and level of healthcare services for older adult poison control center cases involving cannabis products. Using the American Association of Poison Control Centers' (PCC) National Poison Data System, 2016-2019, we extracted the 3109 cases aged 50+ for which cannabis was the only or primary substance. Multinomial logistic regression models were fit to examine associations between specific cannabis forms and management/care site (on site [mostly at home], at a healthcare facility [HCF], or no follow-up due to referral refusal or leaving against medical advice) and level of healthcare services for cases managed at a HCF. The results show that between 2016 and 2019, PCC cannabis cases involving older adults increased twofold, largely due to cases of cannabidiol, edibles, and concentrated extracts. Plant form and synthetic cannabinoid cases declined substantially. Compared to plant forms, synthetic cannabinoid cases had 4.22 (95% CI = 2.59-6.89) greater odds of being managed at, rather than outside, a HCF and 2.17 (1.42-3.31) greater odds of critical care unit admission. Although e-cigarette cases, compared to plant form cases, had lower odds of being managed at a HCF, HCF-managed e-cigarette cases had 3.43 greater odds (95% CI = 1.08-10.88) of critical care unit admission. Synthetic cannabinoid cases also had 1.86 (95% CI = 1.03-3.35) greater odds of no follow-up, and the presence of a secondary substance was also a significant factor. Stricter regulations for listing chemical ingredients and providing safety guidelines are needed for cannabis-derived products.

Older (aged 50+) cannabis users are growing in numbers, but research on poison control center (PCC) cases has not focused on them. In this study, we examined: (1) changing trends in cannabis forms reported in PCC cases; (2) demographic and clinical factors associated with different cannabis forms; and (3) associations between cannabis forms and medical outcomes.We used the American Association of Poison Control Centers' National Poison Data System (NPDS), January 1, 2009-December 31, 2019, to examine the 5201 cases aged 50+ in which cannabis was the only or primary substance. Following descriptive analyses, multinomial logistic regression was fit to examine associations of three cannabis forms (dried/undried plant, other preparations, and synthetic cannabinoids/e-cigarettes for cannabis delivery) with cases' demographic and clinical characteristics, and binary logistic regression was fit to examine associations of medical outcomes (major/potentially major vs. nonmajor) with cannabis forms.Cannabis-related cases involving older adults increased 18-fold (from 61 to 1074) between 2009 and 2019. Compared to plant forms, other preparations had 51.24 times greater odds of appearing in 2018-2019 than in 2009-2011 (95% CI = 27.74-94.67), and synthetic cannabinoids/e-cigarettes had 2.19 times greater odds of appearing in 2014-2015 (95% CI = 1.64-2.93) but lower odds of appearing in 2016-2017 (RRR = 0.67, 95% CI = 0.50-0.89). Other preparations were positively associated with older age, adverse reactions, and suicide attempts but negatively associated with medical cannabis legal states. Synthetic cannabinoids/e-cigarettes were positively associated with being male, intentional misuse/abuse, and chronic use. Compared to plant forms, major medical outcomes/death were less likely among those who used other preparations (OR = 0.75, 95% CI = 0.56-0.99) but more likely among those who used synthetic cannabinoids/e-cigarettes (OR = 2.07, 95% CI = 1.60-2.66).Although PCC cannabis cases involving older adults are relatively few, cases of other cannabis preparations than plant forms increased rapidly in recent years while cases of synthetic cannabinoids decreased. The rate of major medical outcomes also appears to be high.

There is limited information on the effect of scheduling a drug as a controlled substance with comparable data from both a pre-scheduling and post-scheduling time period.To investigate the temporal changes on poisoning cases involving tramadol in 4 states: 2 states where it has been scheduled and 2 where it is not scheduled.Databases were searched for all cases involving tramadol reported from 2003 through 2009 at 6 regional poison centers that served Arkansas, Kentucky, Ohio, and West Virginia. To allow for comparison based on population, state population estimates were obtained from the US Census Bureau.Over the 7-year study period, the number of tramadol cases increased from 401 per year to 1009 cases per year. The mean annual increase in tramadol cases for all 4 states ranged from 8.8% to 14.1%. Post-scheduling in Arkansas and Kentucky, there was a mean decrease in cases of 4% and 31%, respectively. During this same period, the comparison states of West Virginia and Ohio showed a continued increase of 14% and 23%, respectively. The mean annual increase in tramadol cases per 100,000 population for all 4 states ranged from 16% to 31%. Post-scheduling of tramadol, there was an annual decrease in tramadol human exposures of 5% to 31% in Arkansas and Kentucky, respectively. During this same period, West Virginia and Ohio showed a continued annual increase of 14%.The decrease in the number of cases of tramadol exposure following its addition to the schedule of controlled substances in Kentucky and Arkansas suggests that adding a drug to the schedule of controlled substances may result in a decrease in poisoning exposures related to that drug.

The incidence of seizures after unintentional bupropion ingestion in children aged6 years has been reported as 0.2%. However, in many poison centers,80% of these patients are referred to the Emergency Department (ED) for evaluation.To evaluate if all unintentional pediatric bupropion ingestions require referral to a health care facility (HCF), or what fraction of these could be managed safely at home.A retrospective chart review was conducted of all bupropion ingestions in children aged6 years for 2000-2006 from four regional poison centers. Exclusion criteria were lack of follow-up or multiple drug ingestion.Of 407 patients, 209 (51%) were male. Mean age was 2.2 years (SD +/- 1.0). There were 329 patients (81%) seen in a HCF, of which 143 (35%) were hospitalized; 77 patients (19%) were observed at home. Symptoms occurred in 73 patients (18%): sinus tachycardia (n = 50), nausea/vomiting (n = 32), hyperactivity (n = 17), seizure (n = 3), hallucinations (n = 2), and hypertension (n = 2). The mean heart rate of patients with sinus tachycardia (n = 50, 12.3%) was 137 beats/min (SD +/- 13), with a range of 112-172 beats/min. Mean dosage of those with tachycardia was 24 mg/kg. In the 2 patients with hypertension, the maximum recorded blood pressures were 145/80 mm Hg (2-year-old boy) and 137/90 mm Hg (2-year-old girl), with heart rates of 122 and 125 beats/min, respectively. Dose ingested and patient weight was known for 218 patients. Mean dosage ingested was 12.2 mg/kg, with a range of 2.6-64 mg/kg. Eighty-eight percent of patients with a known dosage ingested20 mg/kg.A high percentage of children continue to be seen in a HCF. Concern from the higher incidence of severe effects seen with intentional adult exposures may be one of the reasons for this cautious approach.Unintentional pediatric bupropion ingestions resulted in clinical effects that rarely required any HCF intervention. Isolated unintentional bupropion ingestion ofor= 10 mg/kg may not require referral to a health care facility.

BACKGROUND Diphenhydramine is frequently used in children, but the consequences of single unintended dose exposures in young children are unknown. METHODS We evaluated 2000-2001 American Association of Poison Control Centers-Toxic Exposure Surveillance data on children exposed to diphenhydramine ingestions. RESULTS Nine hundred twenty-six cases met the inclusion criteria; 49.1% were men, mean age was 29.7 +/- 13.0 months (range, 1-72 months). Approximately 85% of unintentional exposures occurred in 1- to 3-year-old children. The mean dose ingested was 6.4 +/- 6.1 mg/kg (median, 4.6 mg/kg). Thirty-two percent of patients were symptomatic: minor (29.4%), moderate (2.9%), and severe (0.11%). There was no relationship between dose and symptom severity. Diphenhydramine dose ingestion of 7.5 mg/kg or greater was not a predictor of severity (P = 0.47) CONCLUSIONS The relationship between ingested dose and severity of symptoms was insignificant.

Despite the frequency of use of citalopram, its clinical effects and pharmacokinetics in overdose in the pediatric patient are not well described. We describe the clinical course and drug levels following the ingestion of citalopram by a 10-month-old female.A 10 month-old female ingested an unknown amount of citalopram. Approximately 40 min after ingestion, the child developed horizontal nystagmus, followed by a generalized, tonic-clonic seizure that lasted 2 to 3 min very shortly thereafter. The child received 1 mg of midazolam intramuscularly (IM), followed by 1 mg of midazolam intravenously (IV) for termination of this seizure, and was given a loading dose of 20 mg/kg of fosphenytoin IV. Elective orotracheal intubation was done to protect the airway. Despite the use of midazolam and fosphenytoin, the child had another seizure approximately 85 min following the ingestion. A third seizure was noted at approximately 100 min post-ingestion. In the course of treatment, activated charcoal was administered via nasogastric tube, and IV midazolam and phenobarbital were given. The child was transferred to a nearby facility with pediatric intensive care capabilities in stable condition. The child did not experience any hypotension or dysrhythmia, and the electrocardiographic QTc and QRS complex were normal throughout the clinical course. During the subsequent 48 h, the child awoke and regained normal function. This child's recovery was uneventful, and the child was discharged home without sequelae. Plasma levels of citalopram were 1400 ng/ml, 583 ng/ml, 416 ng/ml, and 296 ng/ml, at one, six, 13, and 23 h post-ingestion, respectively. The first level likely represents a predistributional level with subsequent levels giving an elimination t1/2 of 17.38 h.We report a case of citalopram poisoning in a 10-month-old infant with refractory seizures, and an absence of cardiovascular events with subsequent excellent outcome. The elimination of the parent drug corresponds to an approximate t1/2 of 15-20 h in this single case.

Atomoxetine hydrochloride, a selective norepinephrine reuptake inhibitor was FDA approved for patients with attention-deficit/hyperactivity disorder. Little is known about adverse drug reactions of atomoxetine following an overdose among children. The objective of our study was to evaluate the type of atomoxetine adverse drug reactions in relation to dose.We evaluated children exposed to atomoxetine reported to a poison center from January-December 2004.Sixty-four cases met all inclusion criteria. Twenty-one patients had an adverse drug reaction (15 at dosage range 0.52-6.25 mg/kg): agitation, headache, erythema, rash, elevated blood pressure and heart rate, nausea, emesis, and lethargy. In 51 patients, weights were known: group 1 (n = 43) received higher than maximum recommended doses1.4 mg/kg and group 2 (n = 8) receivedor = 1.4 mg/kg. There were no differences in adverse drug reactions in group 1 versus 2. Eight patients were admitted to a healthcare facility and all were discharged without any sequelae. Hypertension occurred in 3 of 9 patients for whom blood pressure was recorded.At the doses reported, adverse drug reactions did not correlate with atomoxetine dose. Hypertension may occur in some patients following atomoxetine overdose.

OBJECTIVE: To generate national estimates of hydrocarbon-related exposures occurring in children ≤5 years of age who were treated in US emergency departments or called a regional poison control center. METHODS: This retrospective review compared hydrocarbon-related injuries that occurred from January 1, 2000, through December 31, 2009, that were reported to the National Poison Data System and the National Electronic Injury Surveillance System for children ≤5 years of age. RESULTS: From 2000 through 2009, the National Poison Data System reported 65 756 actual calls to regional poison centers, and the National Electronic Injury Surveillance System reported an estimated 40 158 emergency department visits for hydrocarbon-related injuries. Individuals involved were predominantly male and 1 to 2 years of age. Ingestion was the most common mechanism of injury, and most injuries did not result in hospitalization. The rate of emergency department visits and calls to poison centers decreased significantly (P < .0001) over the 10-year study period. Exposures to hydrocarbons demonstrated seasonal variation, with more occurrences in the summer months. CONCLUSIONS: The comparison of the two data sets illustrates a similar trend in hydrocarbon-related injuries in children. Although cases have declined, most likely due to existing prevention efforts, hydrocarbons are still a large source of preventable exposure and injury in children.

Poison control centers have been shown to be a cost-effective alternative to healthcare visits for poisoning exposures, yet emergency departments (ED) and urgent care centers (UCC) continue to be frequently accessed for poisoning exposures in young children. We sought to identify predictors of young children who obtain healthcare for a nontoxic poisoning exposure. Poisoning exposure cases for children ≤5 years old who sought ED, UCC, or clinic care between 2001 and 2005 from an urban regional pediatric hospital system were identified from poisoning ICD-9 codes in the hospital administrative data and from a poisoning designation in the National Electronic Injury Surveillance System (NEISS) data. Cases (n = 2,494) were reviewed and categorized as either toxic or nontoxic. Toxic exposures were those with more than minimal potential for clinical effects. Most cases were between 1 and 2 years old, male, White, enrolled in Medicaid, sought ED care, had no referring physician, and brought to the facility by a parent/guardian. Logistic regression analysis revealed that the odds of seeking healthcare for a nontoxic poisoning exposure were significantly greater if the child was African American, enrolled in Medicaid, had a non-medication related poisoning, and was brought to the healthcare site by a parent/guardian. Healthcare costs and unnecessary use of healthcare resources for nontoxic poisoning exposures could be reduced by educating parents and providers of children at high risk for inappropriate healthcare visits for nontoxic poisonings to initially contact the poison control center (1-800-222-1222).

An 11-day-old child inadvertently received a dose of intravenous acyclovir 750 mg (220 mg/kg). To our knowledge this is more than twice the largest dose ever reported administered to a neonate. The patient was treated with normal saline hydration and had a only a transient increase of serum creatinine.

Coricidin products seemed to be one of the over-the-counter medications being reportedly abused by adolescents, as observed from the Texas Poison Center Network data. This retrospective chart review investigated the occurrence of abuse, developed a patient profile, and defined the clinical effects resulting from the abuse of Coricidin products. Data collected from the Texas Poison Center Network Toxic Exposure Surveillance System database included human exposures between 1998 and 1999, patientsor = 10y old, intentional use or abuse, and single substance ingestion of I of the tablet formulations of Coricidin. Thirty-three cases from 1998 and 59 cases from 1999 were reviewed. Of these cases, 85% met the inclusion criteria. Of the 7 medications searched, only 4 substances were coded for: Coricidin D, Coricidin D (long acting), Coricidin D (cold, flusinus) and Coriciding HBP. These contain a combination of dextromethorphan hydrobromide, chlorpheniramine maleate, phenylpropanolamine hydrochloride, and acetaminophen. Of the 78 cases, 63% were male and 38% were female. The mean age was 14.67 years, 77% being between 13 to 17 years old. Eighteen different symptoms were reported: tachycardia 50%, somnolence 24.4%, mydriasis and hypertension 16.7%, agitation 12.8%, disorientation 10.3%, slurred speech 9%, ataxia 6.4%, vomiting 5.1%, dry mouth and hallucinations 3.9%, tremor 2.6%, and headache, dizziness, syncope, seizure, chest pain, and nystagmus each 1.3%; 12.8% of the calls originated from the school nurse. The incidence of abuse reported increased 60% from 1998 to 1999. This worrisome trend suggests increased abuse of these products.