Substances of abuse include alcohol, nicotine, cannabinoids, opioids, sedatives, volatile solvents, stimulants, and hallucinogens. With the increasing prevalence of drug abuse in India, intensivists are likely to encounter more cases of intentional and accidental poisoning due to drugs of abuse. We aim to sensitize the intensivists to challenges involved in diagnosing and treating poisoning with drugs of abuse. We also aim to provide a hands-on primer that can augment the usual protocols of “approach to life-threatening poisoning”. A toxidrome approach along with urine drug testing can help in speedily arriving at a diagnosis and instituting definitive treatment. In this article, we discuss spurious alcohol poisoning (methanol poisoning), benzodiazepine, opioid, and stimulant poisoning in detail and poisoning due to other substances including newer psychoactive substances is discussed briefly.
National Crime Records Bureau. Accidental Deaths and Suicides India. New Delhi: Open Government Data Platform India; 2011–2015. Available from: https://data.gov.in/catalog/accidental-deaths-suicides-india-2015?filters%5Bfield_catalog_reference%5D=1916601&format=json&offset=12&limit=6&sort%5Bcreated%5D=desc.
WHO. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.
Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK. on behalf of the group of investigators for the National Survey on Extent and Pattern of Substance Use in India (2019), Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India 2019, Available from http://socialjustice.nic.in/writereaddata/UploadFile/Magnitude_Substance_Use_India_REPORT.pdf.
D'Silva J. India's problem with toxic alcohol. BMJ: British Medical Journal 2015;351:h4536. DOI: 10.1136/bmj.h4536.
Bennett Jr IL, Cary FH, Mitchell Jr GL, Cooper MN. Acute methyl alcohol poisoning: a review based on experiences in an outbreak of 323 cases. Medicine (Baltimore) 1953;32(4):431–463. DOI: 10.1097/00005792-195312000-00002.
Zakharov S, Pelclova D, Navratil T, Belacek J, Komarc M, Eddleston M, et al. Fomepizole versus ethanol in the treatment of acute methanol poisoning: comparison of clinical effectiveness in a mass poisoning outbreak. Clin Toxicol 2015;53(8):797–806. DOI: 10.3109/15563650.2015.1059946.
American Academy of Clinical toxicology Ad Hoc Committee on the treatment Guidelines for methanol Poisoning, Barceloux DG, Randall Bond G, Krenzelok EP, Cooper H, Allister Vale J. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol 2002;40(4):415–446.
Isbister GK, O'Regan L, Sibbritt D, Whyte IM. Alprazolam is relatively more toxic than other benzodiazepines in overdose. Br J Clin Pharmacol 2004;58(1):88–95. DOI: 10.1111/j.1365-2125.2004.02089.x.
Shalansky SJ, Naumann TL, Englander FA. Effect of Flumazenil on benzodiazepine-induced respiratory depression. Clin Pharm 1993;12(7):483–487.
Kreshak AA, Cantrell FL, Clark RF, Tomaszewski CA. A poison center's ten-year experience with Flumazenil administration to acutely poisoned adults. J Emerg Med 2012;43(4):677–682. DOI: 10.1016/j.jemermed.2012.01.059.
Friedman MS, Manini AF. Validation of criteria to guide Prehospital naloxone administration for drug-related altered mental status. J Med Toxicol 2016;12(3):270–275. DOI: 10.1007/s13181-016-0549-5.
Viglino D, Bourez D, Collomb-Muret R, Schwebel C, Tazarourte K, Dumanoir P, et al. Noninvasive end tidal CO2 is unhelpful in the prediction of complications in deliberate drug poisoning. Ann Emerg Med 2016;68(1):62.e1–70.e1. DOI: 10.1016/j.annemergmed.2015.11. 037.
Boyer EW. Management of opioid analgesic overdose. N Engl J Med 2012;367(2):146–155. DOI: 10.1056/NEJMra1202561.
Kariisa M, Scholl L, Wilson N, Seth P, Hoots B. Drug overdose deaths involving cocaine and psychostimulants with abuse potential—United States, 2003–2017. Morbidity and Mortality Weekly Report 2019;68(17):388. DOI: 10.15585/mmwr.mm6817a3.
European Monitoring Centre for Drugs and Drug Addiction (2018). Recent changes in Europe's cocaine market: results from an EMCDDA trendspotter study. Luxemborg 2018.
Richards JR, Smith NE, Moulin AK. Unintentional cannabis Ingestion in children: a systematic review. J Pediatr 2017;190:142–152. DOI: 10.1016/j.jpeds.2017.07.005.
Monte AA, Calello DP, Gerona RR, Hamad E, Campleman SL, Brent J, et al. Characteristics and treatment of patients with clinical illness due to synthetic cannabinoid inhalation reported by medical toxicologists: a ToxIC database study. J Med Toxicol 2017;13(2): 146–152. DOI: 10.1007/s13181-017-0605-9.
Passie T, Halpern JH, Stichtenoth DO, Emrich HM, Hintzen A. The pharmacology of lysergic acid diethylamide: a review. CNS Neurosci Ther 2008;14(4):295–314. DOI: 10.1111/j.1755-5949.2008.00059.x.
Halberstadt AL. Pharmacology and toxicology of N-benzylphenethylamine (“NBOMe”) hallucinogens. Curr Top Behav Neurosci 2017;32:283–311.