Professor Paul I Dargan
Guy’s and St Thomas’ NHS Foundation Trust
and King’s College London, London, UK
Member, Scientific Committee EMCDDA
Sources of Data on Acute Drug Toxicity
� Systematic data is available & reported on
– Prevalence of drug use
– Drug seizures
– Problematic drug use
– Drug-related deaths
� There is no systematic data collated on
acute drug (and NPS) toxicity
– Despite this being a key public
health indicator on the impact of drug
use on the population
Acute Drug Toxicity Data
Why is systematic data on
acute drug toxicity not
available?
� Hospital admissions (discharges) coded using ICD-10
� ICD-10 codes: not available for most drugs
� No: amphetamine, methamphetamine, MDMA, ketamine,
GHB … and definitely not NPS
� Yes: heroin, cocaine, LSD
– But cases often coded by presenting feature
e.g. chest pain, coma, convulsion, psychosis
– In most countries only admitted patients are coded
Hospital Coding of Acute Drug Toxicity
13.2% appropriate ICD-10 code to be able to identify
as acute drug toxicity
Hospital Coding of Acute Drug Toxicity
Hospital Coding of Acute Drug Toxicity
Therefore not possible to automate
data collection on acute drug toxicity
to facilitate national data collection
Potential sources of information on acute drug toxicity
� Data triangulation from a variety of imperfect
sources to minimise the limitations and ↑strength of
the combination
� In vitro pharmacological studies, animal studies
� Internet discussion forums
� User and sub-population surveys
� Poisons Information Services
� Clinical reports from ED presentations
– Linked sentinel centres
� All European countries (and 54% countries worldwide)
have at least one poisons centre
– Some public & health care professional (HCP) access,
some HCP access only
� Provide information to clinicians on management of
drug toxicity AND collect data on these case
– Generally this data is only reported within local or
national poisons centre reports
� Can collate data on
– Geographical/time patterns, clinical patterns of toxicity
BUT
� Data collection is second-hand, self-reported drugs
� Requires clinicians to contact poisons service (maybe less
likely to call about familiar drugs) AND report all used drugs
� May get multiple calls about one case
� Often don’t have outcome data
� For NPS needs awareness of NPS by poisons centre/clinicians
Enquiries regarding 61 drugs/NPS
- 1561 telephone enquiries
- 58,649 TOXBASE (online database) accesses
STRIDA Project� Collaboration between Swedish Poisons Information
Centre (PIC) and Karolinska Institute
– calls to Swedish PIC relating to potential NPS
toxicity, blood/urine samples sent for analysis
– clinical data combined with analytical results
� Powerful dataset of analytically confirmed acute NPS
toxicity: 9 case series published to date
Emergency Department Data
� Collection of data recorded in the medical notes
� Gold standard = analytically confirmed
– Need access / funding for specialist analyses,
– Generally requires patient consent
� Labour intensive
– Requires interest, time and finance
– Will generally only happen in centres with a specialist
clinical toxicology interest: “SENTINEL” centres
– Sentinel centres can be linked to allow intra and trans
national comparisons
Drug Abuse Warning Network (DAWN)
� US data collection 1972-2011
– Using weighted cluster sampling
– From metropolitan areas in 37 States (complete
coverage of 13 States)
– Data on acute drug toxicity, deaths and other
indicators of drug-related harm
� May continue from 201617 through the US National
Hospital Care Survey
0
50
100
150
200
250
300
2006 2007 2008 2009 2010
Year of presentation
Num
ber
of p
rese
ntat
ions
Cocaine
GHB/GBL
MDMA
Ketamine
Cannabis
Amphetamine
Methamphetamine
Volatile Nitrites
LSD
Magic Mushrooms
Novel Pyschoactive Drugs
The Euro-DEN project has financial support from the DPIP/ISEC
Programme of the European Union
Network of 16
specialist ED,
clilnical toxicology
centres
� Data collection on alll acute drug toxicity
presentations to the centre
– Enable analysis of geographical and seasonal trends
– Data on clinical patterns / severity of toxicity,
treatment and outcome
� First year of data collection Oct 2013 – Sept 2014
– 5,529 cases involving 8,709 substances
� Continuing as Euro-DEN Plus with 19 sentinel centres
Clinical Features
Disposition from ER
Length of hospital stay
440 NPS cases reported to Euro-DEN in Year 1
484 different NPS reported
� Cathinones were most common (378)
– 245 mephedrone, 92 methedrone, 22 MDPV
� Non-cathinone cases (106)
– Branded NPS 48, SCRA 26
0
50
100
150
200
250
300
350
Den
mar
k
Esto
nia
Fran
ceGer
man
y
Irelan
d
Nor
way
Poland
Spain
Switze
rlan
d UK
cou
nt
of
pre
sen
tati
on
s
Conclusions� Significant potential for acute harm associated drug use
� Limited European data collection systems and no
systematic reporting
� Poisons information services can provide useful
information: need to be co-ordinated; STRIDA provides
powerful analytically confirmed NPS case series
� Euro-DEN project is novel pan-European co-ordinated
approach to collecting Emergency Department data
– Snapshot sampling currently being explored
The ideal would be an acute harm indicator for reporting to
ECMDDA: hospital and poisons centre data