Results from the STRIDA project. Matilda Bäckberg PhD, M.Sc.Pharm The Swedish Poisons Information Centre

Transcription

1 Results from the STRIDA project Matilda Bäckberg PhD, M.Sc.Pharm The Swedish Poisons Information Centre

2 No. of calls Statistics from telephone service 1800 Amfetamin Amphetamine 1600 Cannabis Ecstasy/MDMA 1400 GHB Kokain Cocaine 1200 Opioider Opioids Nya droger/okända 1000 NPS/Unknown > 4 inquiries/day related to NPS Year

3 Actions taken: Increased the number of colleagues focusing on new drugs Weekly screening of NPS-related cases Launched STRIDA

4 Samverkansprojekt kring Toxicitetsutredning och Riskbedömning av InternetDroger baserat på laboratorieanalyser Collaborative project on toxicity evaluation and risk assessment of Internet drugs based on laboratory analyzes

5 The STRIDA Project Hospitals all over Sweden 1. Inquiry/Treatment guidelines The Poisons Information Centre 4. Medical records 3. Analytical results 2. Blood/Urine samples Karolinska University Laboratory/ Karolinska Institutet 5. Data review (Re-analysis) Information about new psychoactive substances

6 The procedure of STRIDA Urine and serum samples from drug exposed patients are sent for analysis PIC reference number instructions: laboratory order form urine serum preaddressed reply envelope

7 No. of calls Statistics from telephone service 1800 Amfetamin Amphetamine Cannabis 1600 Ecstasy/MDMA 1400 GHB Kokain Cocaine 1200 Opioider Opioids Nya NPS/Unknown droger/okända Year

8 No. of cases Increasing number of STRIDA cases

9 At Karolinska University Laboratory I. Screening of well-known substances of abuse - Depending on screening results: Verification II. Specific analysis of: - New Psychoactive Substances (NPS) - Plant- and fungi-related drugs - Pharmaceutical-related drugs

10 Specific analysis of NPS 1-Benzylpiperazine 5-MAPB Methylone DL B-NBOMe 5-MeO-DiPT MT-45 5-IT 25C-NBOMe 5-MeO-MiPT Naphyrone 2-MAPB 25D-NBOMe 6-APB (2-aminopropyl)benzofuran) N-Ethyl-2-CB a-pep 25H-NBOMe 6-APDB N-ethylnorketamine MTTA (Meftetramine) 25I-NBOMe AH-7921 N-etylbuphedrone (NEB) 4-methylbuphedrone 2C-B (2-(4-brom-2,5-dimetoxifenetylamin) α-ppp (alfa-pyrrolidinopropiophenone) Nitracaine Butyrfentanyl (Butyryl fentanyl) 2C-E α-pvp (alfa-pyrrolidinopentiophenone) O-DM-cis-Tramadol Thiothinone 2C-P AMT (α-methyltryptamine) Pentedrone bk-2c-b 2-DPMP (Desoxypipradol) 168 Bromo-dragonfly NPS, Pentylone Nov 2015 W-18 2-Fluoroamphetamine Buphedrone pfpp (para-fluorophenylpiperazine) 4F-pentedrone 2-FMA (2-fluoromethamphetamine) Butylone PMA (para-metoxyamphetamine) 5-MeO-NiPT 2-MMC (2-Methylmethcathinone) Desoxy-D2PM p-meppp 4-CMC 3,4-CTMP (Dichloromethylphenidate) Dimethocaine PMMA 2-EAPB 3,4-DMMC (3,4-dimethylmethcathinone) DiPT (diisopropyltryptamine) Pyrovalerone EFLEA 3-FMA (3-fluoromethamphetamine) DMT (N,N-Dimethyltryptamine) TFMPP Acetylfentanyl 3-FMC (3-Fluoromethcathinone) DOB α-pbp (α-pyrrolidinobutiophenone) MXP (2-MeO-diphenidine) 3-MMC (3-Methylmethcathinone) DOC (2,5-dimetoxy-4-chloroamphetamine) Flubromazepam 4-BMC 4-AcO-DMT (O-Acetylpsilocin) DPT (Dipropyltryptamine) Pyrazolam 3-MEC 4-EMC (4-Ethylmethcathinone) Etaqualone Diklazepam 6-MAPB 4-FA (4-Fluoroamphetamine) Etizolam Meklonazepam PV-8 4-Fluorotropocaine Ethylphenidate 25N-NBOMe 4F-PV8 4-FMA (4-fluoromethamphetamine) Ethylone C30-NBOMe nifoxipam 4-MEC (4-Methylethcathinone) Flefedron (4-Fluoromethcathinone) 3-Meo-PCP deschloro-etizolam 4-MeO-PCP mcpp (meta-chlorophenylpiperazine) 4F-PVP flutazolam 4-Methylamphetamine MDAI α-pvt clonazolam 4-OH-MET MDPV (3,4-methylendioxypyrovalerone) W-15 2-APB 5-APB (5-(2-aminopropyl)benzofuran) Metedrone Eskalin 5-MeO-EiPT 5-APDB Mephedrone (4-MMC) 3C-P Coluracetam 5-EAPB Methiopropamine (MPA) Metoxypiperamide Difenidin 1-(4-fluorophenyl)-2-(piperidin-1-1-(4-fluorophenyl)-2-(1- Methkcathinone yl)pentan-1-one methylethylamino)pentan-1-on Dimetylsildenafil 5-IAI (5-lodo-2-aminoindane) Methoxetamine Allylescaline (AL) Dipentylon MDPHP p-fluorococaine PV9 Nefiracetam

11 The Medical Product Agency Collaboration initiated 2 years ago. 1-2 items/week. Method: LC QTOF MS/MS, NMR (NMR is needed to separate several structural isomers with equal molecular weight) Results: Within a few days to months depending on priority

12 THE SUPERMAN OUTBREAK

13 Age (y)/gender 17/man 21/man Exposure 2 Superman pills Unknown Prehospital Seizures Clinical signs on Seizures, hyperthermia (>42 C) admission Clinical course Multiorgan failure. Elevation of liver enzymes, rhabdomyolysis, oliguric renal failure and DIC Treatment Sedation and intubation. External cooling. Dialysis. (Acetylcystein treatment). Plasma- och trombocyte transfusions. Full inotropic and vasopressor support. Clinical outcome Recovery. Slow gradual progress. Prolonged need of hemodialysis. Renal parameter routinely followed for 1 month. STRIDA analysis PMMA, PMA, methedrone, fentanyl, amphetamine, cannabis, cocaine, ethanol and bensodiazepine metabolites Death, despite full intensive care support ~1 day from admission PMMA, PMA, methedrone, amphetamine, morphine, cannabis, ethanol and bensodiazepine metabolites

14 Super-quick analysis of the pill by the Swedish MPA The Swedish pill: PMMA 169 mg and amphetamine 9 mg The Dutch pill: PMMA 173 mg and amphetamine 10 mg The 4 Spanish pills: PMMA mg and amphetamine 6-11 mg The Polish pills: Content of PMMA, unknown amount The National Board of Forensic Medicine: 7 deaths, Dec 2014 to Jan 2015 in Sweden (UK, Norway, Belgium, Poland)

15 Another example of notification of new harmful drug N N HO O N HO MT-45 Morphine

16 Example of notification of new harmful drug

17 MT-45 expected and unexpected symptoms Man, 30-years old. Known abuse of amphetamine and cannabis in his teens. He was found by his girlfriend unresponsive with wheezing breaths in the morning. He had swallowed MT-45 powder, an amount large as a thumbnail. Ambulance arrived. SpO 2 = 50%. Naloxon (0.4 mg) gave insufficient response and assisted ventilation was needed during transport. At hospital the patient was intubated and put on ventilator. He had signs of aspiration and severe acute left ventricular dysfunction. During the following 24 hours the patient s clinical condition improved. He was weaned off inotropic agents and was extubated. A follow-up cardiac ultrasound had shown a markedly improved left ventricular function. Upon awakening he was found perfectly lucid but was almost completely deaf. Through written notes he communicated that he had injected MT-45 the evening before admission. An audiogram two weeks after the intoxication showed a persistent pronounced sensorineural hearing impairment. STRIDA-analysis: MT-45 in both urine and blood.

18 Evaluation of new drugs MT-45

19 Evaluation of new drugs

20 # of pos. samples NPS are continuously introduced MXE 5-IT Ethylphenidate 3-MMC 3-/4-MeO-PCP

21 Legislation impact on MDPV MDPV banned

22 Summary of the STRIDA project Analytically confirmed cases of NPS intoxication from ED/ICU all over Sweden ~2300 cases since 2010 A well-developed consultation service system to Swedish emergency and intensive care. Anonymized medical records from hospital stay are easily shared with us. Detected new substances and the associated clinical characteristics are evaluated. Good view of trends related to acute NPS intoxications in Sweden and identification serious intoxications. Limitations: Does not give information about asymptomatic patients, non-acute exposures or chronic use, or clinical course following hospital discharge Lack of reference materials Project funding: personnel/instrumentation

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