To the Editor:
We read with interest the recently published paper about abuse cases collected in emergency departments (ED), in Europe.Citation1 It is stated that the systematic collection of data on ED presentation of toxicity related to new psychoactive substances (NPS) or classical substances in Europe are scarce with only one French center included in the European Drug Emergencies Network or Euro-DEN.Citation1,Citation2 Based on the statement that few cases of abuse or toxicity related to substance abuse are spontaneously notified to the addictovigilance center of Montpellier by ED, we wanted to use a different data source to assess the number of patients hospitalized in ED for such events. The database for cases extraction was the “Programme de Medicalisation des Systèmes d’Information” (PMSI) that provides medical and administrative information for all patients discharged from public and private hospitals. Cases were selected using the diagnostic codes according to the International Statistical Classification of Diseases and Related Health Problems, 10th edition [ICD-10].Citation3 Patients included in this analysis were those admitted to the ED during the period 2012–2013, with diagnosis codes related to mental and behavioral disorders due to use of psychoactive substances (F10 to F19).
The results of this analysis confirm that ED may be a significant source of collection of cases of abuse or toxicity related to substances. Among the 1073 events retrieved via the PMSI, analysis of observations allowed to retain 158 cases, mainly young men (71%, median age of 32.4 [range: 0.7–54] years). Hospitalization-related events were acute intoxication (35%) and toxicity related to the abuse (65%: infectious complications, acute cardiovascular disorders, withdrawal syndrome, and psychotic disorders). The outcome was favorable in 65% of cases. However, fifty events (31.6%) were considered severe (defined as a length of stay in hospital of > 5 days), with a median length of stay in hospital of 10.5 days [5–81]. In addition 4 patients died. Illicit substances were found in 74.5% of cases, mainly classical substances (92.6%, cocaine > cannabis > amphetamines). NPS accounted for only 7.4% of illicit substances: synthetic cathinones in 3 patients (pyrrolidinovalerophenone [PVP], mephedrone, and methylenedioxypyrovalerone [MDPV]), gammahydroxybutyrate in 3 patients, and ketamine in 5 patients. Prescribed drugs alone or in association with illicit substances were found in 25.5% of cases (buprenorphine, benzodiazepines, and methadone).
In our study, the majority of patients admitted to the ED more likely consumed “classical substances” and the NPS were scarcely met, as discussed by Heyerdahl et al.Citation1 The reasons could be a lack of awareness on the use of NPS, non-searchable patients, prioritization of the clinical management of the patient, and non-systematic toxicological detection of NPS. However, in our analysis, two cases of toxicity related to PVP and MDPV were previously reported spontaneously to the center of addictovigilance of Montpellier by the forensics department and the toxicology laboratory, given the severity of psychic complications and newness of substances.Citation4 Given the limitations of spontaneous reporting system, the use of periodic retrospective PMSI requests can be a useful tool for detection of cases of substance abuse.Citation5,Citation6 However, this retrospective analysis does not allow a rapid feedback to ED for obtaining complementary information: ask for toxicological analysis, patient, or entourage's interrogation. In addition, ICD-10 coding is not always accurate or specific to identify all cases. This is the first study in a region in France that uses the PMSI for reporting cases of abuse in the ED, and could be extended nationally.
As reported by Heyerdahl et al., systematic collection of data on ED is performed in France at regional and national level mainly via toxicologists and poisoning centers.Citation1 The systematic reporting of cases of substance abuse to regional addictovigilance center could increase the reporting rate, and allow an assessment of the abuse liability of new substances and a rapid feedback to ED. In order to meet these objectives, close collaborations should be established between the ED, addictovigilance centers, and toxicologists.
Declaration of interest
The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References
- Heyerdahl F, Hovda KE, Giraudon I, Yates C, Dines AM, Sedefov R, et al. Current European data collection on emergency department presentations with acute recreational drug toxicity: Gaps and national variations. Clin Toxicol 2014; 52:1005–1012.
- Wood DM, Heyerdahl F, Yates CB, Dines AM, Giraudon I, Hovda KE, et al. The European Drug Emergencies Network (Euro-DEN). Clin Toxicol 2014; 52:239–241.
- World Health Organization [Internet]. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Version for 2007; c1994/2006 [update 05/04/2006]. World Health Organization. Available at: http://apps.who.int/classifications/apps/icd/icd10online/
- Eiden C, Mathieu O, Cathala P, Debruyne D, Baccino E, Petit P, et al. Toxicity and death following recreational use of 2-pyrrolidino valerophenone. Clin Toxicol 2013; 51:899–903.
- Daveluy A, Miremont-Salamé G, Kostrzewa A, Couret A, Lacoin L, Lecomte C, et al. Identification of abuse and dependence cases through a hospital database. Pharmacoepidemiol Drug Saf 2012; 21:1344–1349.
- Jouanjus E, Pourcel L, Saivin S, Molinier L, Lapeyre-Mestre M. Use of multiple sources and capture-recapture method to estimate the frequency of hospitalizations related to drug abuse. Pharmacoepidemiol Drug Saf 2012; 21:733–741.