Sam Alfred1, Peter Stockham2, Emma Partridge3
1Emergency Physician & Clinical Toxicologist. Royal Adelaide Hospital (RAH), 2Principal Forensic Scientist, Toxicology. Forensic Science South Australia (FSSA), 3Forensic Scientist, Toxicology. Forensic Science South Australia (FSSA)
Quality data regarding patterns of illicit drug use in the community is available from a range of sources; however the accuracy of hospital level data is limited by the necessarily subjective attribution of a causative agent by treating clinicians.
We report on a process capable of accurately profiling illicit drug use, and deliverable in the Emergency Department setting.
Ethics approval was obtained with a waiver of consent. Patients who presented to the RAH Emergency Department with unusual or severe toxicity as consequence of drug use and a clinical requirement for intravenous access were enrolled. Laboratory logistics caped samples at 2 per week. The clinical data set targeted the setting of drug use, clinical toxidrome and outcome, and was designed to facilitate collection by clinical staff.
Six mL of blood from subjects was placed in a study fridge prior to transfer to FSSA. Sample treatment and extraction methodologies included protein precipitation, liquid-liquid extraction and solid phase extraction. Analysis techniques and instrumentation included enzyme linked immunosorbent assay (ELISA), gas chromatography with flame ionisation detector (GC-FID), liquid chromatography with diode array detector (LC-DAD), quadrupole time of flight mass spectrometer (LC-QTOF-MS) or triple quadrupole detector (LC-QQQ).
84 patients were enrolled (54 male, 30 female) with a mean age of 31yrs. Poly drug use was the norm with an average of 3.2 agents detected per patient, the most frequent of which were methamphetamine (38/84), amphetamine (33/84), benzodiazepines (31/84), ethanol (23/84, mean 0.152 g/dL), GHB (20/84), opiates (20/84), cocaine (13/84), and MDMA (13/84). 7 patients (0.8%) were clinically intoxicated without an identifiable agent on assay. We detected very few cannabinoid receptor agonists and no fentanyl derivatives, and are developing improved assays with a broader library to enhance detection. The majority of patients (42%) were managed and discharged from the Emergency Department or its Short Stay Ward, and Intensive Care was required in 19%. There were no deaths.
Our pilot study demonstrates that it is possible to accurately profile illicit drug use associated with hospital presentation, and has provided the basis for a successful research grant that will support expanded enrolments across 4 major hospitals in Adelaide.
Associate Professor Sam Alfred graduated from Adelaide University in 1996 before moving to Sydney and undertaking training in Emergency Medicine at Westmead Hospital. His early post fellowship years involved work in Emergency Medicine at St George Hospital, and retrieval medicine with the Sydney Aeromedical Retrieval Service. A move back to Adelaide in 2005 allowed the pursuit of both of these practices in a single location through MediFlight and the Emergency Department of the Royal Adelaide Hospital. A mounting interest in the field of Toxicology saw him subsequently complete a fellowship in Clinical Toxicology via the New South Wales Poison Centre, and he currently holds appointments in Emergency Medicine and Clinical Toxicology at the Royal Adelaide Hospital, and is a Medical Retrieval Consultant with the MedSTAR retrieval service. He is an Associate Professor in Acute Care Medicine at the University of Adelaide.