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Background: Patients with recreational drug and ethanol poisoning often present with reduced consciousness, coma, or disorientation. It is often unclear if there was recent head trauma. Algorithms to perform cranial computed tomography (cCT) like the Canadian CT Head Rule (CCHR), the National Emergency X-Radiography Utilization Study Head CT Decision Instrument (NEXUS DI), or the New Orleans Criteria (NOC) exist for patients with head trauma. It is unclear whether these algorithms can be applied to this patient collective. Methods: This is a retrospective data analysis of patients admitted to our emergency department with drug or ethanol poisoning in 2019. Minors < 16 years were excluded. The primary outcome was fracture/bleeding in cCT, the secondary outcome was neurosurgical intervention. These results were calculated: 1. Sensitivity and negative predictive value (NPV) of the CCHR, NEXUS DI, and NOC. 2. Uni- and multivariate analysis of risk factors for critical findings. 3. The Munich cCT Rule sensitivity and NPV. Results: A total of 420 patients were included. cCT was performed in 120 patients. Eight patients had fracture/bleeding in cCT, two required neurosurgical intervention. The number of patients at risk, sensitivity, and NPV for critical cCT findings were as follows: CCHR 57/25%/98.3%, NEXUS DI 239/100%/100%, NOC 420/100%/100%. The sensitivity and NPV for neurosurgical intervention were as follows: CCHR 50%/99.7%, NEXUS DI 100%/100%, NOC 100%/100%. In univariate analysis, these findings correlated significantly with the following critical findings: accident, injury, injury above clavicle, head wound, anisocoria, ethanol in serum > 2 g/L, hypotension, drug ingestion, GCS < 8, focal neurological deficit, age > 60, and cerebellar symptoms. Via chi-square recursive partitioning analysis, we created the Munich cCT Rule which is positive for intoxicated patients if both an accident and an ethanol level > 2 g/L are present. This identified 70 patients at risk. It excluded fracture/bleeding and neurosurgical intervention with a sensitivity and NPV of 100%. Conclusions: Fracture/bleeding in cCT in intoxicated patients is rare. Performing unnecessary cCTs should be avoided. The Munich cCT Rule for patients with recreational drug and ethanol poisoning may help rule out critical findings and is superior to the NEXUS DI and NOC. It also has a 100% sensitivity which the CCHR (25%) is lacking. [ABSTRACT FROM AUTHOR]

Background: Toxicological analysis of patients with acute recreational drug poisoning can improve our understanding of substance use patterns, clinical symptoms, and improve treatment. Patient history alone may be incomplete or misleading. The objective was to assess the differences in patient history and analytical results, to describe the clinical characteristics, implications and hospital management, and to describe the drug use pattern over time. Methods: A retrospective study including all patients admitted to our toxicology unit with recreational drug toxicity and analytical testing from October 2014 to December 2022. Results: 872 patients were included. Patient history revealed a median of one ingested substance class: opiates/opioids, benzodiazepines/Z-drugs, and Pregabalin were predominant. Urine analysis revealed a median of three ingested substance classes (p < 0.001). Benzodiazepines/Z-drugs, Pregabalin, and THC were severely underreported. Agitation and aggression, anxiety, hallucinations, and psychosis were frequent, associated with cocaine, cathinone/phenethylamine, and amphetamine/MDMA detection and required sedation. Coma was also frequent, associated with opiate/opioid, benzodiazepine/Z-drug, GBL/GHB, and Pregabalin detection and required intubation, and/or application of Naloxone and/or Flumazenil. Twelve patients arrived in cardiac arrest; all were positive for opiates/opioids. Four patients died: three with Benzodiazepines/Z-drugs, Pregabalin and opiates/opioids detected, one with cathinones/phenethylamines detected. While cathinones/phenethylamines and synthetic cannabinoid receptor agonists were mainly detected between 2014–2016, detection decreased significantly between 2017–2022 after NPS legislation passed. Pregabalin detection increased. Conclusions: Patient history is inaccurate, and patients frequently underreport ingested drugs. Opiates and opioids are still the main cause of morbidity and mortality. Pregabalin is increasingly abused. NPS legislation effectively decreased cathinone/phenethylamine and synthetic cannabinoid receptor agonist overdoses. [ABSTRACT FROM AUTHOR]

The purpose of this review is to compare the treatment of alcohol addiction from different perspectives: On one hand, the perspective of an American psychotherapist, on the other hand, the perspective of a German acute care and addiction medicine physician. The authors provide an in-depth review comparing various strategies for treating alcohol dependence. This paper focuses on acute care, rehabilitation, psychotherapy, motivational interviewing, harm reduction, and psychopharmacology as the primary therapeutic modalities for treating alcohol addiction. This is investigated in the context of the author's respective healthcare and rehabilitation systems and cultural particularities relevant to alcohol use disorder. Based on the literature review, the authors found that the main treatment modalities were common in both countries, regardless of cultural differences. Germany has an overall lower regulation on alcohol (including a lower drinking age) and a higher alcohol per capita consumption with fewer lifetime abstainers in former drinkers. One major finding between the two countries is that the access to the professional addiction aid system is more accessible in Germany compared to the United States. On the contrary, the self-help sector within the United States is much more developed, utilized and accepted by healthcare and rehabilitation professionals. Overall, both countries' healthcare systems are making intentional efforts to address and improve the treatment of alcohol use disorder. Improving research for evidence-based treatment will need to expand in order to stay current with the challenges and trends in alcohol use in both countries. [ABSTRACT FROM AUTHOR]

To independently validate the negative predictive value of the Tanta University risk model for intensive care requirements in poison center telephone consultations with other physicians. This study included 400 consecutive patients with acute poisoning. Clinical and laboratory parameters were recorded during the initial consultation with the poison center. Patients who were already ventilated or on vasopressors at the time of consultation were excluded. The Tanta University risk model score was calculated from the data according to the following equation: Tanta University risk model score = 1.966*Glasgow Coma Scale + 0.329*oxygen saturation (percent) + 0.212*diastolic blood pressure (mmHg) − 0.27*respiratory rate (breaths/minute) + 0.33*standard bicarbonate (mmol/L). Twenty-four hours later, the patients' courses were followed up by telephone. The Tanta University risk model was then compared to a composite endpoint indicating the requirement for admission to an intensive care unit (vasopressors, need for intubation, or death). Four hundred patients with acute poisoning were included. Thirty-seven patients had a complicated clinical course as defined by the composite endpoint. Receiver operating characteristic analysis revealed the area under the curve to be 0.87 (95 percent confidence interval 0.83–0.90). An unfavorable Tanta University risk model score was defined as less than 73.46, using a cut-off derived from a previous study of an unrelated series of patients with acute poisoning admitted to our service. Thirty-one of 37 patients with complicated courses had an unfavorable Tanta University risk model score compared to six patients with complicated courses among 306 patients with a favorable Tanta University risk model score (P < 0.0002, Fisher's exact test). Sixty-three patients had an unfavorable Tanta University risk model score but an uneventful course. The negative predictive value of the Tanta University risk model was 0.98 (95 percent confidence interval 0.96–0.99), sensitivity was 0.84, and specificity 0.83. In the present study of poison center telephone consultations, the Tanta University risk model was significantly related to the outcomes in patients with acute poisoning. Patients with a favorable Tanta University risk model score (greater than or equal to 73.46) were unlikely to need intensive care unit level of care. [ABSTRACT FROM AUTHOR]

Artificial intelligences (AIs) are emerging in the field of medical informatics in many areas. They are mostly used for diagnosis support in medical imaging but have potential uses in many other fields of medicine where large datasets are available. To develop an artificial intelligence (AI) "ToxNet", a machine-learning based computer-aided diagnosis (CADx) system, which aims to predict poisons based on patient's symptoms and metadata from our Poison Control Center (PCC) data. To prove its accuracy and compare it against medical doctors (MDs). The CADx system was developed and trained using data from 781,278 calls recorded in our PCC database from 2001 to 2019. All cases were mono-intoxications. Patient symptoms and meta-information (e.g., age group, sex, etiology, toxin point of entry, weekday, etc.) were provided. In the pilot phase, the AI was trained on 10 substances, the AI's prediction was compared to naïve matching, literature matching, a multi-layer perceptron (MLP), and the graph attention network (GAT). The trained AI's accuracy was then compared to 10 medical doctors in an individual and in an identical dataset. The dataset was then expanded to 28 substances and the predictions and comparisons repeated. In the pilot, the prediction performance in a set of 8995 patients with 10 substances was 0.66 ± 0.01 (F1 micro score). Our CADx system was significantly superior to naïve matching, literature matching, MLP, and GAT (p < 0.005). It outperformed our physicians experienced in clinical toxicology in the individual and identical dataset. In the extended dataset, our CADx system was able to predict the correct toxin in a set of 36,033 patients with 28 substances with an overall performance of 0.27 ± 0.01 (F1 micro score), also significantly superior to naïve matching, literature matching, MLP, and GAT. It also outperformed our MDs. Our AI trained on a large PCC database works well for poison prediction in these experiments. With further research, it might become a valuable aid for physicians in predicting unknown substances and might be the first step into AI use in PCCs. [ABSTRACT FROM AUTHOR]

Introduction: Cannabis is the most common recreational drug worldwide and synthetic cannabinoid receptor agonists are currently the largest group of new psychoactive substances. The aim of this study was to compare the clinical features and outcomes of lone acute cannabis toxicity with lone acute synthetic cannabinoid receptor agonist toxicity in a large series of presentations to European emergency departments between 2013-2020., Methods: Self-reported drug exposure, clinical, and outcome data were extracted from the European Drug Emergencies Network Plus which is a surveillance network that records data on drug-related emergency department presentations to 36 centres in 24 European countries. Cannabis exposure was considered the control in all analyses. To compare the lone cannabis and lone synthetic cannabinoid receptor agonist groups, univariate analysis using chi squared testing was used for categorical variables and non-parametric Mann-Whitney U- testing for continuous variables. Statistical significance was defined as a P value of <0.05., Results: Between 2013-2020 there were 54,314 drug related presentations of which 2,657 were lone cannabis exposures and 503 lone synthetic cannabinoid receptor agonist exposures. Synthetic cannabinoid receptor agonist presentations had statistically significantly higher rates of drowsiness, coma, agitation, seizures and bradycardia at the time of presentation. Cannabis presentations were significantly more likely to have palpitations, chest pain, hypertension, tachycardia, anxiety, vomiting and headache., Discussion: Emergency department presentations involving lone synthetic cannabinoid receptor agonist exposures were more likely to have neuropsychiatric features and be admitted to a psychiatric ward, and lone cannabis exposures were more likely to have cardiovascular features. Previous studies have shown variability in the acute toxicity of synthetic cannabinoid receptor agonists compared with cannabis but there is little comparative data available on lone exposures. There is limited direct comparison in the current literature between lone synthetic cannabinoid receptor agonist and lone cannabis exposure, with only two previous poison centre series and two clinical series. Whilst this study is limited by self-report being used to identify the drug(s) involved in the presentations, previous studies have demonstrated that self-report is reliable in emergency department presentations with acute drug toxicity., Conclusion: This study directly compares presentations with acute drug toxicity related to the lone use of cannabis or synthetic cannabinoid receptor agonists. It supports previous findings of increased neuropsychiatric toxicity from synthetic cannabinoid receptor agonists compared to cannabis and provides further data on cardiovascular toxicity in lone cannabis use.

Background  Pregabalin is used e. g. for the treatment of neuropathic pain and anxiety disorder. Recently, its potential for abuse and addiction has become apparent. Methods  From 2008 - 2015, we searched our database for the term "Pregabalin", including all patients treated in our department and all calls to the Poison Information Centre (PIC) Munich.From October 2013 to September 2014, all patients were included in a cohort study who either were admitted with a drug intoxication or who presented themselves for a course of detoxification (except ethanol). Results  From 2008 - 2015, 263 patients with Pregabalin abuse were treated. The number of cases per year increased from 0 - 5 in 2008 - 2011 to 105 in 2015. In 2008, the PIC received 3 calls concerning Pregabalin abuse, in 2015 the number of calls was 71. From 2013 - 2014, 80 out of 370 patients had consumed Pregabalin. It was the fifth most frequently abused substance. Pregabalin users had consumed more additional substances than other patients (median 4 1 2 3 4 5 6 vs. 2 1 2 3 4 5 6, p < 0.001) and they were more often in an opioid substitution treatment (41.2 vs. 21.7 %, p < 0.001).The most co-abused drugs were benzodiazepines (66.3 %), methadone (48.8 %), buprenorphine (32.5 %) and heroin (22.5 %). 88.0 % of all intoxicated patients had moderate to severe symptoms of intoxication like impaired consciousness (74.0 %), respiratory distress, (40.0 %), agitation/aggressiveness (28.0 %), restlessness (14.0 %), hallucinations (8.0 %) or seizures (8.0 %).The semi-quantitative urine concentration was 51.4 ± 66.0 mg/g Creatinine for intoxicated patients and 26.1 ± 23.0 for patients admitted for detoxification (n = 58; p = 0.034). Discussion  Pregabalin abuse increases continuously and constitutes a significant health issue. Particularly patients with a history of substance abuse are vulnerable. Physicians should be aware of the substantial potential of Pregabalin for abuse and addiction and they should know the dangers of an intoxication., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)