Opioid exposure associated with poppy consumption reported to poison control centers and the U.S. Food and Drug Administration

Figures & data

Figure 1. Flow diagram of exposures included in this study.

Table 1. Intentionality and Outcome of NPDS Exposures Indicating Poppy, 2000–2018, by Age^a.

	Under Age 13 (n = 199)	Age 13+ (n = 392)
	n (%)	n (%)
Intentionality
Intentional- Abuse	1	141
Intentional- Misuse	2	38
Intentional- Suspected suicide	0	20
Intentional- Unknown	0	16
Other- Withdrawal	0	6
Total Intentional or Withdrawal	3 (1.5)	221 (56.4)
Unintentional- Environmental	0	4
Unintentional- Food Poisoning	5	9
Unintentional- General	175	68
Unintentional- Misuse	4	17
Unintentional- Therapeutic error	0	2
Unintentional- Unknown	0	3
Total Unintentional	184 (92.5)	103 (26.2)
Adverse Reaction- Drug	0	9
Adverse Reaction- Food	8	46
Adverse Reaction- Other	2	2
Total Adverse Reaction	10 (5.0)	57 (14.5)
Other- Contamination/tampering	1	2
Other- Malicious	1	2
Total Other	2 (1.0)	4 (1.0)
Unknown Reason	0	7 (1.8)
Outcome
Minor effect	9 (4.5)	71 (18.1)
Moderate effect	2 (1.0)	76 (19.4)
Major effect	0	27 (6.9)
Death	0	4 (1.0)
No effect	57 (28.6)	31 (7.9)
Not followed, judged as nontoxic	50 (25.1)	32 (8.2)
Not followed, minimal clinical effects possible	63 (31.7)	79 (20.2)
Not followed, judged as potentially toxic exposure	5 (2.5)	38 (9.7)
Unrelated effect, exposure was probably not responsible for the effect	13 (6.5)	34 (8.7)

^aAll percentages are column percentages.

Table 2. Characteristics of NPDS Exposures Indicating Poppy, Age 13+, 2000–2018, by Intentionality^a.

	Total	Intentional^b	Unintentional^c
	(n = 392)	(n = 221)	(n = 171)
	Rate per population*100,000
Age (n = 338)^d
13–19	0.28	0.19	0.10
20–29	0.29	0.22	0.06
30–39	0.14	0.07	0.07
40–49	0.06	0.03	0.04
50–59	0.06	0.03	0.03
60+	0.03		0.03
Region
Northeast	0.12	0.06	0.06
Midwest	0.16	0.10	0.06
South	0.10	0.06	0.04
West	0.14	0.08	0.06
	n (%)	n (%)	n (%)
Sex
Male	222 (56.6)	160 (72.4)	62 (36.3)
Female	170 (43.4)	61 (27.6)	109 (63.7)
Number of Products
Single	290 (74.0)	144 (65.2)	146 (85.4)
Multiple	102 (26.0)	77 (34.8)	25 (14.6)
Formulation
Solid (tablets, capsules)	106 (27.0)	55 (24.9)	51 (29.8)
Liquid	77 (19.6)	64 (29.0)	13 (7.6)
Powder/Granules	47 (12.0)	27 (12.2)	20 (11.7)
Aerosol/mist/spray/gas	1 (0.0)	1 (0.5)
Unknown	19 (4.8)	12 (5.4)	7 (4.1)
Blank	32 (8.2)	7 (3.2)	25 (14.6)
Other	110 (28.1)	55 (24.9)	55 (32.2)
Chronicity
Acute	331 (84.4)	173 (78.3)	158 (92.4)
Chronic	24 (6.1)	18 (8.1)	8 (4.7)
Acute-on-chronic	23 (5.9)	19 (8.6)	4 (2.3)
Unknown	14 (3.6)	11 (5.0)	3 (1.8)

^aIncludes intentional and withdrawal exposure types.

^bIncludes unintentional, adverse reaction, unknown, and other exposure types.

^cExcludes 54 “Unknown adult >20 years”.

^dAll percentages are column percentages.

Table 3. Route of Exposure, Symptoms, Therapies, and Management Site in NPDS Single-Product Exposures Indicating Poppy, Age 13+, 2000–2018^a.

	n (%)
Route of Exposure	n = 290
Ingestion	274 (94.4)
Parenteral	9 (3.1)
Inhalation/nasal	6 (2.1)
Rectal	1 (0.3)
Symptoms	n = 193^b
Drowsiness/lethargy	48 (24.9)
Vomiting	44 (22.8)
Nausea	41 (21.2)
Tachycardia	30 (15.5)
Respiratory depression	24 (12.4)
Agitation	18 (9.3)
Dizziness/vertigo	17 (8.8)
Abdominal pain	14 (7.3)
Hypotension	13 (6.7)
Miosis	13 (6.7)
Headache	12 (6.2)
Hypertension	12 (6.2)
Diarrhea	10 (5.2)
Other	56 (29.0)
Therapies	n = 124^c
Fluids, IV	46 (37.1)
Dilute/irrigate/wash	33 (26.6)
Naloxone	30 (24.2)
Oxygen	21 (16.9)
Antiemetics	15 (12.1)
Antibiotics	12 (9.7)
Benzodiazepines	9 (7.3)
Vasopressors	9 (7.3)
Other	28 (22.6)
Management Site	n = 151^d
Treated/evaluated and released	59 (39.1)
Lost to follow-up/ left AMA	34 (22.5)
Admitted to critical care unit	26 (17.2)
Admitted to non-critical care unit	18 (11.9)
Refused referral/did not arrive	14 (9.3)

AMA: against medical advice.

^aTable includes all symptoms and therapies documented in at least 5% of cases of which information on symptoms and therapies was recorded.

^bCases with at least one symptom recorded, among a total of 290 single-product exposures.

^cCases with at least one therapy administered.

^dCases treated in or referred to a HCF.

Figure 2. Annual rate of NPDS exposures indicating poppy, 2000–2018^a. ^aCall rates were adjusted for the decline in overall volume of National Poison Data System exposure cases by normalizing reporting rates to 2000.

Table 4. Poppy-related overdoses and deaths in the United States from CAERS (2004–2018), FAERS (1968–2018), and NPDS (2000–2018).

Date of Event	Age (y)	Sex	State	Poppy Form, Dose, and Source	Other Drugs (by history)	Positive Drug Labs	Response to Naloxone	Symptoms	Outcome	Source Database
7/2/2004	27	Male	VA	Seeds obtained from the internet	Melatonin; Quetiapine; Paroxetine	Opiates	Administered, response unknown	Coma/unarousable; Aspiration; Subcortical infarcts; Serotonin syndrome v. neuroleptic malignant syndrome; Cyanotic; Seizure; Hyperthermia	Unknown	NPDS
1/10/2005	19	Male	WI	Tea, 3.75 lbs Poppy obtained from the internet	Robitussin DM	Opiates	Administered, response unknown	Coma/unarousable; Aspiration; Pneumonia; Hypoglycemia; Mydriasis	Survival	NPDS
2/19/2008	23	Male	MI	Tea	Clonazepam	None mentioned	Administered, responded repeatedly	Coma/unarousable; Pinpoint pupils; Respiratory depression	Survival	NPDS
8/23/2008	17	Male	TN	Tea	None mentioned	Opiates; Propoxyphene; Benzodiazepines; THC	Administered, responded	Coma/unarousable; Anoxic brain rhabdomyolysis; Myocardial infarction; Elevated LFTs; Elevated troponin	Death	NPDS
1/18/2010	28	Male	UT	Tea	Phenazepam, Tramadol	Opiates; Benzodiazepines	Administered, responded	Respiratory depression; Seizure; Hypothermia	Survival	NPDS
9/7/2010	>20	Male	MA	Unknown	None mentioned	None mentioned	Administered, responded repeatedly	Coma/unarousable; Respiratory depression; Apnea	Survival
7/25/2014	15	Male	NE	Tea	Hydrocodone; Alprazolam; Downers; THC	Opiates; Benzodiazepines; THC	Administered, response unknown	Coma/unarousable; Liver failure; Rhabdomyolysis; Renal failure; Elevated LFTs; Elevated lipase; Hypoglycemia	Survival	NPDS
8/2/2014	44	Male	WI	Tea	None mentioned	Opiates	Administered, response unknown	Coma/unarousable; Hypotension; Bloody diarrhea	Survival	NPDS
2/6/2015	19	Male	AL	Tea	Clonazepam	Opiates; Benzodiazepines; THC	Administered, response unknown	Coma/unarousable; Rhabdomyolysis; Hypoxemia; Pneumonia; Elevated troponin	Survival	NPDS
5/7/2015	20	Male	Note specified	Tea Brand: Poppy Seed Wash	None mentioned	None mentioned	Unknown if administered	Coma/unarousable; Pupils fixed and dilated; Frothing from nose and mouth; Pulmonary edema	Death	CAERS & FAERS
8/9/2015	54	Female	Not specified	Not tea, 1 lb/d Brand: Sincerely Nuts	None mentioned	None mentioned	Unknown if administered	Coma/unarousable; Stomach cramps; Vomiting	Death (bowel obstruction)	CAERS
12/13/2015	28	Male	WA	Tea	None mentioned	None mentioned	Administered, responded	Coma/unarousable; Urinary retention; Vomiting	Survival	NPDS
1/31/2016	22	Male	CA	Unknown	Diphenhydramine	Opiates	Unknown if administered	Coma/unarousable; Pinpoint pupils; Hypotension; ARDS; Renal failure; Hypernatremia	Death	NPDS
2/21/2016	21	Male	Not specified	Tea Seeds obtained at local health food store	Adderall	Opiates	Unknown if administered	Coma/unarousable;	Death	FAERS
2/23/2016	24	Male	FL	Tea Brand: Nodding Turtle Special Preserve European Premium Poppy Seeds	Lamotrigine; Fluoxetine	Morphine; Codeine; Hydromorphone Laudanosine; Alprazolam; Lamotrigine; THC; Mitragynine; Norfluoxetine; Detrolevo-methorphan	Unknown if administered	None mentioned	Death	CAERS & FAERS
3/15/2016	21	Female	RI	Tea	None mentioned	None mentioned	Administered, responded repeatedly	Coma/unarousable; Pin point pupils; Cyanosis; Apnea; Tinnitus	Survival	NPDS
4/12/2016	22	Male	OH	Tea, 1.5 lbs	None mentioned	None mentioned	Administered	Coma/unarousable; Respiratory depression; Pinpoint pupils; Cyanosis; Fever; Hypotension; Tachycardia; Diaphoresis; Hypoglycemia; Cough/choke; Elevated creatinine	Survival	NPDS
5/24/2016	26	Male	TX	Tea, 5 lbs	None mentioned	Opiates; Benzodiazepines	Administered	Respiratory depression; Hypercapnia	Survival	NPDS
5/30/2016	26	Male	TX	Tea	None mentioned	Opiates	Unknown if administered	Coma/unarousable; Respiratory depression; Hypotension; Fever	Survival (attempted suicide)	NPDS
9/17/2016	20	Male	MA	Tea	Phenibut; Psilocybin; THC	Opiates; Benzodiazepines; THC	Administered, responded	Coma/unarousable; Respiratory acidemia; Aspiration pneumonitis	Survival	NPDS
1/7/2017	58	Female	NC	Tea	None mentioned	None mentioned	Administered	Coma/unarousable; Apnea	Survival	NPDS
2/23/2017	25	Male	IL	Unknown	None mentioned	Opiates	Unknown if administered	Coma/unarousable; Hypotension; Respiratory arrest; Pulmonary edema; Hypoglycemia	Death (suicide)	NPDS
3/5/2017	22	Male	CA	0.75 lb	Diphenhydramine; Alcohol	Opiates; Benzodiazepines	Administered, responded	Hypotension; Renal failure; Pale diaphoretic; Rhabdomyolysis; Vomiting	Survival	NPDS
4/3/2018	24	Male	AR	Tea, 5 lbs	None mentioned	None mentioned	Unknown if administered	Coma/unarousable	Death	CAERS
Redacted	29	Female	PA	Tea	None mentioned	None mentioned	Administered	Coma/unarousable; Respiratory depression; Cyanosis	Survival	NPDS
Redacted	28	Female	OR	Tea	Trazodone; Fluvoxamine; Clonazepam	Opiates; Hydrocodone; Hydromorphone	Administered, responded	Coma/unarousable; Respiratory depression; Hypotension; Hearing deficits	Survival	NPDS