dr. alexander garrard, clinical managing director washington poison center [email protected]
TRANSCRIPT
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Dr. Alexander Garrard, Clinical Managing DirectorWashington Poison [email protected]
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2
1970s -1980s
1990’s 2000-2010 2010 - 20121950s -1960s 2013-2014
16 PCs in WA
1992: DOH recommends PC consolidation
Economic Pressure;4 PCs remain in WA
2005: WAPC participates in HRSA; Hire Exec Dir.
6/2013: Renew Bldg Lease w/ 45% reduction
1993: RCW 18.76 creates WAPC as 501c3 non-profit; Led by Dr. Robertson
2000: CDC helps fund PCs
2006: Hire New Med Dir. replacing Dr. R.
2008: Public Law 110-377
2008/9: Budget 36% cut; Layoffs
2010: Receive SCHIP funding
2012: Lauch Vet Pets
2014: Oper’l Study; New E.D., Med Dir & Clin. Mging Dir; Cancelled VetPets
Our History
2012: Lewin Study Published, Values PC
2014-5: Launch Toxic Trend Rpts (Cannabis, E-Cig), Agency Collaboration “FreakNight”“Resolution”
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Our Washington Poison & Drug Information Center Mission:
To prevent harm from poisoning through expertise, collaboration,
professional, and public education
RCW 18.76 Poison Information system. Statewide ProgramPublic Law 110-377 Primary poison defense for U.S. (1993)Public Law 110-377 “Poison Center Support, Enhancement, and Awareness Act of 2008”
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RCW 18.76 Poison Information system. Statewide ProgramPublic Law 110-377 Primary poison defense for U.S.
(1) Twenty-four hour emergency telephone management and treatment referral of victims of poisoning and overdose incidents, to include determining whether treatment can be accomplished at the scene of the incident or transport to an emergency treatment or other facility is required, and carrying out telephone follow-up to assure that adequate care is provided;
(2) Providing information to health professionals involved in management of poisoning and overdose victims;
(3) Coordination and development of community education programs designed to inform the public and members of the health professions of poison prevention and treatment methods and to improve awareness of poisoning and overdose problems, occupational risks, and environmental exposures; and
(4) Coordination of outreach units whose primary functions shall be to inform the public about poison problems and prevention methods, how to utilize the poison center, and other toxicology issues.
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Public Law 110-377
“Poison Center Support, Enhancement, and Awareness Act of 2008” …
(1) “Poison control centers are the primary defense of the United States against injury and deaths resulting from poisoning.”
(7) “Real-time data collected ..an important source of information for the detection, monitoring, and response for contamination of the air, water, pharmaceutical, or food supply.”
(8) In the event of a terrorist event, poison control centers will be relied upon as a critical source for the accurate medical information and public health emergency response concerning the treatment of patients who have had an exposure to a chemical, radiological, or biological agent.”
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Who Do We Serve?
• 7.06 million people• 22.9% under the age of 18
years• 6.4% under the age of 5 years• 13.6% 65 years and over
• 98 acute care hospitals• EMTs/Paramedics• Law Enforcement• Federal/State/County
Departments of Health and Agencies
• Medical/Pharmaceutical Teaching Institutions
• And more…
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On-Call Toxicologists
• 24 hour access to board-certified toxicologists with backgrounds in emergency medicine and pharmacology
Dr. Chen Dr. ValentoDr. Garrard
On-Call:Dr. Melissa HallidayDr. Thomas Martin (independent)Dr. Suzan Mazor (Seattle Childrens)Dr. Carl Skinner (Madigan)
Certified Specialists in Poison Information• PharmDs, RNs, PIPs with a combined 260+ years of experience
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WAPC by the numbers• Over 63,000 inbound calls to WAPC in 2014
• 54,715 were human exposures
• Over 90% managed at home• Trip to hospital or physician avoided – cost savings!
• Approximately 75% originate from households• 56% of calls involve children under 6 years of age• 2,758 exposures in Clark County
• 1,789 in pediatrics (65%)• 2,164 managed on site (non-HCF)• 308 treated/evaluated and released from ED• 50 admitted to ICUs
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WA
PC
’s T
op
10
Lis
ts f
or
2014
Top 10 Categories for 13-19 year olds
1. Analgesics
2. Antidepressants
3. Antihistamines
4. Stimulants and street drugs
5. Sedative/hypnotics and BZDs
6. Cough and Cold preparations
7. Cleaning substances
8. Cosmetics/Personal Care Products
9. Anticonvulsants
10. Cardiovascular Drugs
Top 10 Categories in Pediatrics ( < 13 years)
1. Cosmetics/Personal Care Products
2. Analgesics
3. Cleaning Substances
4. Foreign Bodies/toys
5. Topical preparations
6. Vitamins
7. Plants
8. Antihistamines
9. Dietary Supplements/Homeopathic
10. Gastrointestinal preparations
Top 10 Categories in Adults ( > 19 years)
1. Analgesics
2. Sedative-hypnotics and BZDs
3. Antidepressants
4. Cardiovascular drugs
5. Cleaning substances
6. Alcohols
7. Pesticides
8. Anticonvulsants
9. Hormones
10. Antihistamines
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Cost Savings of Poison Centers
Lewin Study on Value of the Poison Center System, 2012
Poisoning and drug overdoses were the leading cause of injury death in 2012.
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What are E-Cigarettes?• A noncombustible product employing a
device containing a mechanical heating element, battery, or circuit which is used to heat a liquid contained in cartridges for the purpose of direct inhalation of the resultant vapor (as defined by HB 5124)
• Unregulated by the Federal Food, Drug and, Cosmetic Act (Chapter V)
• Contains highly concentrated liquid nicotine, up to 24 mg/mL in 15 mL bottle• 1 gallon refill bottles also available
• Highly toxic in kids in small amounts• Less than a mouthful
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Deal or No Deal?
29,155 cigarettesat 13 mg of nicotineper cigarette
1,456 cigarette packs
1 gallon = 3,785 mLs = 378,500 mg of pharmaceutical grade nicotine
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Clinical Symptoms of Nicotine Toxicity• Symptoms can range from…
• Nausea and vomiting• Agitation• Tachycardia• Hypertension• Seizures• Coma• Death
• IV injection• Ingestion
• First fatality from ingestion in 11/2014 in a 1 year old in NY
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Formaldehyde in E-Cigarettes
• Study from Portland, OR• E-cigs release higher
concentrations of formaldehyde-releasing agents than nicotine
• Propylene glycol and glycerol formaldehyde
• IARC Group 1• Asbestos• Arsenic• benzene1Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N
Engl J Med 2015;372:392-4.
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Why Are Teens and Adults Using E-Cigarettes?
• Lower cost of entry (estimated at 10-20% of cost of combustibles in WA based on legislative testimony)
• 30mg/ml of liquid nicotine = ~3 cigarette• Readily availability at convenience stores, gas stations, independent vape shops• Liquid Nicotine flavors & names that appeal to teens and young adults (candy,
liquor, drugs “ecstasy”, minty, etc.) • Devices have a high-tech design and advertising (including social media and
celebrity endorsement) is targeted directly to teen/young adult market• Supposed “Health Benefit” for Smoking Cessation or Athletic Performance
Enhancement (no scientific evidence)• Graduation strategy employed which encourages use with lower levels of nicotine
and progress to higher levels• Impact of “2nd hand smoke” from vaping not known
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Disturbing Trend in Washington State
2007 2008 2009 2010 2011 2012 2013 20140
20
40
60
80
100
120
140
160
180
200
19
13
50
133
0 0 0 2
19 18
76
182
Total Human E-Cigarette Exposures 2007 - 2014
Annual Pediatric ExposuresAnnual Total
Year
Tota
l Exp
osur
e Ca
lls
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WAPC E-Cig Exposure Data
N = 133;182
< 1 1 - 3 years old
4 - 5 years old
Child 6-12 years
Teen 13-19 years
0
20
40
60
80
100
120
Pediatric E-Cigarette Exposures for 2014
Age group
Nu
mb
er o
f E
xpo
sure
s
Pierce
Spoka
neKing
Snohomish
Thurst
onKits
ap
Whatc
omClar
k
Chelan
Cowlitz
5
10
15
20
25
30
35
Top Ten Counties with E-Cigarette Exposures for 2013 and 2014
20142013
Washington Counties
Num
ber o
f Exp
osur
es
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E-Cigarettes in Clark County
< 1 1 year 2 years 3 years 4 years 5 years 6-12 years
13-19 years
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
70-79 years
80-89 years
>= 90 years
0
1
2
3
E-Cigarettes by Age in Clark County 2013 to 2014
20142013
Num
ber o
f Exp
osur
es
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WAPC E-Cigarette Data
Chest pain (incl. noncardiac)
Erythema/flushed
Diarrhea
Pallor
Diaphoresis
Throat irritation
Red eye/conjunctivitis
Headache
Tachycardia
Abdominal Pain
Dizziness/vertigo
Cough/choke
Drowsiness/lethargy
Other
Agitated/irritable
Irritation/pain
Nausea
Vomiting
5 10 15 20 25 30 35
Most Commonly Reported Symptoms in 2014
Total Number of Occurrences
Sym
ptom
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E-Cigarettes in Clark County
• Abdominal pain, N/V, and throat irritation most common symptoms
No follow-up, min-imal toxicity
Minor effect Unrelated effect
1
2
3
4
5
6
7
8
Medical Outcomes in Clark County for E-Cigarettes 2013-
2014
Medical Outcome
Num
ber o
f Exp
osur
es
City # of Exposures
Vancouver 8
Washougal 1
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WAPC E-Cigarette Data
Ingestion69%
Dermal19%
Inhalation/nasal5%
Ocular7%
Otic0%
Most Common Routes of Exposure for 2014
Route Total
Ingestion 144
Dermal 40
Ocular 14
Inhalation/Nasal 11
Otic 1
Total 210
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Little Winona
• 22-month old Winona drank half a 15 mL bottle
• “Eyes were rolling back in her head and she was just flopping around”
• Mom called WAPC for help
• Winona ended up in the hospital overnight for treatment and observation
http://www.king5.com/story/news/local/2014/10/05/ecig-vapor-child-dangers/16758397/
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Marijuana in WA State• I-692 permitted patient with certain medical conditions to
use medical marijuana (passed 1998)• Cachexia, cancer, HIV/AIDS, epilepsy, chronic pain, glaucoma, etc.• Up to 24 oz of useable marijuana or 15 marijuana plants, or
participates in collective garden
• Technically illegal under WA and federal law to possess, buy or sell medical marijuana• Provides an affirmative defense to criminal prosecution if a
qualified patient possesses the allowable amount
• I-692 different from I-502
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Marijuana in WA State• I-502 (passed 2012) essentially legalized marijuana for
recreational use by…• Removing state-law prohibitions against production, processing
and selling of marijuana• Allowed limited possession of marijuana for 21+ years• Established a system of taxing marijuana
• Individuals 21 years and older may possess and use…• 1 ounce of usable marijuana• 16 ounces of marijuana-infused product in solid form; or• 72 ounces of marijuana-infused product in liquid form.• Marijuana-related drug paraphernalia.
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Location, Location, Location• 334 current retail outlets allotted for recreational
marijuana• King County: 61 shops• Puyallup County: 31 shops• Snohomish County: 35 shops• Clark County: 15 shops
• 115 retail shops reporting sales
• Estimated 1,100 medical dispensaries operating in the state
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Marijuana Edibles
• Both medical and recreational marijuana available in WA state• Recreational highly regulated i.e.
few edibles• Medical marijuana largely
unregulated with many different edibles
• Approximately 250 medical marijuana dispensaries in Seattle
• No standardized packaging, labeling, warning labels
• Product branding attractive to pediatrics
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Challenging Edibles
• THC content higher than in years past• Potency increased 2-7x since
70s
• Kinetics are very different compared to smoking marijuana• 2 – 3 hours versus minutes
• Marijuana edibles scored• 10 doses of 10 mg each in
one candy bar• Who eats 1/10th of a candy
bar?
• Majority of patients present with…• Tachycardia• N/V• Agitated• Drowsy/lethargic• Confused• Hallucinations
• More children admitted for observation than e-cigarette exposures
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Staggering Trend in Exposures
January February March April May June July August September October November December0
5
10
15
20
25
30
35
Marijuana Exposures for 2014 and 2015 (YTD 3/18/15)
2014 Peds Cases2015 Peds Cases20152014
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Marijuana Highlights
< 11 ye
ar
2 years
3 years
4 years
5 years
Child 6-12 ye
ars
Teen
13-19 years
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
70-79 years
80-89 years
>= 90 ye
ars
Unknown ad
ult
10
20
30
40
50
60
70
Marijuana Exposures by Age ('13 - '15 YTD)
201320142015
Age Group
Num
ber o
f Exp
osur
es
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Marijuana Highlights
< 1 1 year 2 years 3 years 4 years 5 years Child 6-12 years Teen 13-19 years
10
20
30
40
50
60
70
Pediatric Marijuana Exposures ('13 - '15 YTD)
201320142015
Age Group
Num
ber o
f Exp
osur
es
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Marijuana Highlights
King Pierce Snohomish Spokane Thurston Yakima Clark Whatcom Klickitat Grays Harbor
10
20
30
40
50
60
70
80
90
Top Ten Counties with Marijuana Exposures for 2013 and 2014
20142013
Washington Counties
Num
ber o
f Exp
osur
es
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Marijuana Highlights: Clark County
1 year3 years
4 years
6-12 years
13-19 years
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
80-89 years
Unknown adult0
1
2
3
4
5
6
7
Marijuana Exposures by Age 2012 to 2015 YTD
2012201320142015
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Marijuana Highlights: Clark County
City # of Exposures
Camas 1
Vancouver 23
Yacolt 1
No follo
w-up, minim
al toxic
ity
Minor effect
Moderate
effect
No effect
2
4
6
8
10
12
14
Marijuana Medical Outcomes for 2012 - 2015 YTD
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New & Emerging Concerns• Electronic cigarettes being used to vaporize cannabis oil
• Hash oil highly concentrated• 30% to 90% THC
• Vape pens resembling asthma inhalers• Poisoning risk in kids with asthma
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New & Emerging Concerns• Butane Hash Oil manufacturing
• Dangerous process and explosive• Similar to methamphetamine production
• May 21st, 2014• Hash oil extraction in Puyallup, WA results in a series of explosions
that destroyed the car
• Liquid butane passed through tube filled with cannabis plant• Butane highly flammable
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New & Emerging Concerns• Variety of marijuana edibles available
• LCB tasked with approving recreational edibles• Medical marijuana edibles left large unregulated
• Cookies, candy, gummy bears, drinks, brownies, etc.
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Dangerous New Drugs on the Street
• Hallucinogenic amphetamines• Molly• Bath Salts
• Extreme agitation, hyperthermia, tachycardia, seizures and death
• Chemical Russian Roulette
• 1 recent death at FreakNight 2014
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38
3am 3am-7am12:45pm6pm-3am 6pm-7:45pm
FreakNight 2014 (2) day event begins in Seattle @ C-Link WaMu theater
WAPC consulted on 1 critical case
PHA sent to 500 contacts; FAX Blast sent to ER Depts of area hospitals
6:40am: 20 y/o Male expired
WAPC consulted on 2nd critical Molly OD case
Dr. Garrard conducts interviews (KOMO,KING5, KIRO, Seattle Times, FOX)
Create Molly Public Health Alert
6:41pm Seattle K.C. Pub Health contacts WAPC; Review PHA
C-Link cancels event
A night at the WAPC10/31/2014 - 11/01/2014
3pm-6pm
During event, large number of attendees transported to area hospitals
Dr. Garrard contacts event organizers to notify of death and Molly concerns as well as pending media announcement
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Public Health Alert and Media
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Toxic Trends Reports
• 11 Toxic Trends Report issued since July 2014
• 6,000+ emails sent• 264 media contacts• WAPC nationwide resource for marijuana and e-cigarette exposure in kids
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Toll-free, Confidential Poison Center Number
1-800-222-1222
Program Your Cell Phone!