Journal of Medical Toxicology最新文献

{"title":"The Extraction of Morphine and Codeine by Brewing Poppy Seed Tea using Real-World Quantities and Methods.","authors":"Keahi M Horowitz, Danthy Hoang, Steven Kazmierczak, Rachel Castelli","doi":"10.1007/s13181-026-01118-8","DOIUrl":"10.1007/s13181-026-01118-8","url":null,"abstract":"<p><p>INTRODUCTION: People have attempted to extract opiates from the surface of unwashed poppy seeds for recreational consumption. However, the opiate quantity within these homemade poppy seed teas is not well known, complicating risk assessment. Prior studies investigating this have used small volume samples made using laboratory-grade equipment, which may not accurately reflect opiate extractions attainable by laypersons. We quantified opiate extraction using recipes, ingredients, and equipment available to the public and at real-world volumes. METHODS: This is a two-part experiment. In the first part, we identified which of eight brewing techniques – collectively representing the possible combinations of variables we identified from our search of online forums – yielded the highest concentration of morphine and codeine. In the second part, the technique identified in the first part was applied to a composite recipe derived from recommendations found on publicly accessible online forums. Three replicates (A-C) of full volume recipes using each of three seed brands (1–3) were made using commonly available equipment. Morphine and codeine concentrations were measured using liquid chromatography/tandem-electrospray mass spectrometry. RESULTS: For part 1, all techniques yielded morphine (range: 138–2873 ng/mL) and codeine (range: 41–1083 ng/mL), but technique 2 produced the greatest yields. For part 2, technique 2 was applied to real-world equipment and ingredient ratios yielding samples with morphine concentrations of 1837–19,483 ng/mL and codeine concentrations of 296–20125 ng/mL. CONCLUSIONS: Brewing poppy seed tea using techniques and proportions replicating real-world extractions produce widely variable quantities of morphine and codeine, including some that may be clinically relevant. </p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"305-309"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076808/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147444065","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"n-Hexane-Toxic Neuropathy Presenting with Cauda Equina Inflammation.","authors":"Rika Nohara, Hiroya Kuwahara, Honami Kawai, Tatsuhiko Sano, Kinya Ishikawa, Takashi Kanda, Yoichiro Nishida","doi":"10.1007/s13181-026-01135-7","DOIUrl":"10.1007/s13181-026-01135-7","url":null,"abstract":"<p><p>BACKGROUND: Habitual exposure to n-hexane can cause polyneuropathy through axonal degeneration and secondary demyelination. To our knowledge, n-hexane-toxic neuropathy presenting with a cauda equina-like syndrome has not previously been reported. CASE PRESENTATION: A 55-year-old man developed sensory and motor polyneuropathy over a 3-month period, with nerve conduction studies indicating demyelination. Initial treatment for suspected chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with steroids and plasma exchange was ineffective, leading to worsening symptoms. The patient and his colleagues were found to have been habitually exposed to n-hexane in their printing work, and a sural nerve biopsy revealed the pathological findings typical of n-hexane-toxic neuropathy. Notably, cauda equina inflammation was observed on MRI and in the cerebrospinal fluid. Following intravenous immunoglobulin therapy, both neurological symptoms and findings from nerve conduction studies, MRI, and cerebrospinal fluid analysis gradually improved, eventually leading the absence of impairment in activities of daily living. CONCLUSION: In cases of polyneuropathy accompanied by inflammation of the cauda equina, and if exposure to n-hexane cannot be ruled out, sural nerve biopsy could be considered to assess for n-hexane-toxic neuropathy. </p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"326-330"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076710/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147512792","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Interpreting Fentanyl and Norfentanyl Concentrations among Patients Seen in the Emergency Department after a Nonfatal Opioid Overdose: A Multicenter Study.","authors":"Jessica T Kent, Rachel Culbreth, Jacob A Lebin, Keith Burkhart, Robert G Hendrickson, Zachary D W Dezman, Kim Aldy, Jeffrey Brent, Alyssa Falise, Sharan Campleman, Barry K Logan, Michael Levine, Michael Chary, Alex Krotulski, Jeanmarie Perrone, Paul Wax","doi":"10.1007/s13181-026-01132-w","DOIUrl":"10.1007/s13181-026-01132-w","url":null,"abstract":"<p><p>BACKGROUND: Fentanyl concentrations are typically interpreted in forensic contexts using postmortem and driving under the influence data, both of which have important limitations. This study describes fentanyl and norfentanyl concentrations measured in an acute, clinical setting among patients presenting to the emergency department with a suspected opioid overdose. METHODS: A prospective observational study was performed utilizing the Toxicology Investigators Consortium (ToxIC) Drug Overdose Toxico-Surveillance (DOTS) Reporting Program enrolling patients ≥ 13 years old from April 2023 to July 2024 following a life-threatening overdose treated at 17 EDs within the United States. Fentanyl and norfentanyl concentrations were determined by liquid chromatography tandem quadrupole mass spectrometry (lower limit of quantification (LLOQ) 1 ng/mL). Fentanyl and norfentanyl concentrations were summarized using descriptive statistics and stratified by time of ED presentation to blood collection. Fentanyl concentrations were also stratified by norfentanyl concentrations. RESULTS: Three hundred and thirty-one patients presented with a clinical presentation consistent with an opioid overdose and were included in the study. Of these, 248 (74.9%) had fentanyl concentrations above the LLOQ. The median concentration of fentanyl and norfentanyl was 4.5 ng/mL (IQR: 2.4, 8.8) and 2.7 ng/mL (IQR:1.6, 5.3), respectively. The median time to blood draw was 165 min. The median fentanyl/norfentanyl (F/NF) ratio was 0.5 (IQR: 0.4, 1.0). CONCLUSIONS: Quantitative fentanyl and norfentanyl concentrations in the acute emergency department setting among patients with a suspected opioid overdose were lower than those in the postmortem literature with significant toxicity observed at levels below the LLOQ. Use of an arbitrary F/NF ratio of 1 did not delineate acute exposure. </p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"286-295"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076824/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147355587","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"N-Acetylcysteine Dose and Treatment Duration in High-Risk Acetaminophen Ingestions Treated Within Eight Hours: A Retrospective Cohort Study.","authors":"C James Watson, Michael D Simpson, Nishita Saraiya, Christopher A Wilkosz, Michael B Yu, Michele M Burns, Mark J Neavyn, Karen E Simone, Tania D Strout","doi":"10.1007/s13181-026-01129-5","DOIUrl":"10.1007/s13181-026-01129-5","url":null,"abstract":"<p><p>INTRODUCTION: Toxicologists may use high dose n-acetylcysteine (HD-NAC) for early-treated high-risk acetaminophen ingestions (EHRAI) given concerns over standard NAC (S-NAC) dosing’s efficacy. We utilize the novel, clinically relevant outcome of mean additional 16-hour NAC maintenance infusions (NMI) to evaluate differences in treatment duration for EHRAI patients treated with S-NAC versus HD-NAC. METHODS: Retrospective multistate poison center study from 1/1/2019-7/4/2024 of patients ≥ 13-years-old who were treated with S-NAC or HD-NAC within eight hours of a high-risk acetaminophen ingestion. The primary outcome was mean additional NMI. Secondary outcomes were NAC infusion duration, hepatotoxicity, coagulopathy, transplant, and death. Sensitivity analyses evaluated for robustness of findings. RESULTS: Of 127 included cases, 52.0% (66/127) received HD-NAC. 7.1% (9/127) had anti-peristaltic co-ingestions. HD-NAC cases received more fomepizole (23.1% versus 1.6%; difference 21.1%). Acetaminophen concentrations controlled for time since ingestion were similar (mean acetaminophen ratio for HD-NAC: 2.7, IQR: 2.3, 3.3 versus S-NAC: 2.4, IQR: 2.2, 2.7; difference − 0.3). 26.0% (33/127) received NMI solely for residual detectable serum acetaminophen. There was no difference in mean additional NMI (HD-NAC: 0.53 versus S-NAC: 0.38; p = 0.240). Median NAC infusion durations were equal across groups (21.0; IQR: 21.0, 37.0; difference 0.0) (p = 0.137). One patient per group developed hepatotoxicity; there were no transplants or deaths. Sensitivity analyses yielded similar results. CONCLUSIONS: We found no difference in mean NMI for EHRAI based on NAC dose. These findings support additional NMI as an objective, common, clinically relevant outcome for acetaminophen toxicity research. </p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"253-262"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076740/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147486339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rhabdomyolysis and Acute Kidney Injury after Use of 3-Methyl-PCP: A Case Report.","authors":"Aaron B Deutsch, Natalie E Ebeling-Koning, Alex J Krotulski, Sara E Walton, Kenneth D Katz","doi":"10.1007/s13181-026-01122-y","DOIUrl":"10.1007/s13181-026-01122-y","url":null,"abstract":"<p><strong>Introduction: </strong>Dissociative agents, such as phencyclidine (PCP) and ketamine, belong to the arylcyclohexylamine class. During illicit synthesis, numerous analogs of PCP can be produced. To date, over 60 psychoactive \"designer\" derivatives have been identified, and most are undetectable by standard drug testing. This case describes the first laboratory-confirmed use of 3-methyl-PCP, a novel arylcyclohexylamine dissociative anesthetic.</p><p><strong>Case report: </strong>A 29-year-old man presented to the emergency department after a drug overdose experiencing encephalopathy, tachycardia, hypertension, nystagmus and diaphoresis. Diagnostics revealed severe rhabdomyolysis and acute kidney injury. During hospitalization, the patient disclosed the use of 3-methyl-PCP obtained online. The drug product and biological specimens were sent to the Center for Forensic Science Research and Education (CFSRE) for comprehensive drug testing, which confirmed the presence of 3-methyl-PCP using gas chromatography-mass spectrometry and liquid chromatography-quadrupole time-of-flight mass spectrometry.</p><p><strong>Discussion: </strong>This confirmed case of 3-methyl-PCP intoxication not only demonstrates the potential for severe injury, but also the public health risks of rapidly emerging and unregulated dissociative synthetic anesthetics. Entities such as the CSFRE NPS Discovery Program's early drug warning system can prove critical for both timely clinical response and public health protection.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"316-320"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076847/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147326262","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk Factors Associated with Deterioration in Sedative Drug Overdose.","authors":"Pramod Chandru, Kayla Schriber, Helene Benedicte Fabrin Brasted, Earl Butler, Naren Gunja","doi":"10.1007/s13181-026-01120-0","DOIUrl":"10.1007/s13181-026-01120-0","url":null,"abstract":"<p><p>BACKGROUND: Sedative overdoses, particularly involving opioids, γ-hydroxybutyrate (GHB), and benzodiazepines, are an increasing contributor to toxicology admissions and intensive care unit (ICU) utilisation in Australia. While pharmacological mechanisms are well characterised, identifying which patients will deteriorate remains challenging. Existing risk stratification tools, such as the Glasgow Coma Scale (GCS), lack toxicology-specific nuance and may not adequately account for early physiological derangement, highlighting the need for improved, patient-centred risk assessment. AIMS: To evaluate clinical and exposure-related features associated with ICU admission, endotracheal intubation, and in-hospital complications following sedative overdose. METHODS: This retrospective cohort study included patients referred to a district toxicology service with suspected sedative overdose between November 2022 and November 2023. Data extracted from electronic medical records included demographics, ingestion characteristics, clinical course, and investigation results. Sedatives were defined by central nervous system depressant effects. Outcomes were ICU admission, endotracheal intubation, and in-hospital complications. Associations were examined using univariable analyses and multivariable logistic regression; venous pH was modelled separately using penalised logistic regression. RESULTS: A total of 374 patients were included. Common agents were benzodiazepines (32.1%), opioids (29.1%), and GHB (20.6%). In-hospital complications occurred in 35.8% of patients, ICU admission in 17.9%, and intubation in 13.6%. After adjustment, ICU admission was independently associated with lower venous pH and non-benzodiazepine GABA-ergic agent ingestion (e.g. pregabalin and Z-drugs) (adjusted OR 3.35, p = 0.04). Lower venous pH was consistently associated with all adverse outcomes. The model-estimated probability of intubation increased non-linearly with worsening acidaemia, rising from 8% at pH 7.35 to 66% at pH 7.20. In-hospital complications were independently associated with opioid ingestion (adjusted OR 3.81, p < 0.001) and lower GCS, while intubation was associated with lower GCS and lower venous pH. GHB ingestion was inversely associated with intubation. CONCLUSION: Lower GCS, reduced venous pH, and ingestion of high-risk sedative agents—particularly opioids and non-benzodiazepine GABA-ergic ingestion —were key features associated with clinical deterioration in sedative overdose. These findings support multifactorial, toxicology-specific risk stratification incorporating early physiological and pharmacological markers, with prospective validation required before clinical implementation. </p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"296-304"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076744/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147369670","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acute Copper Toxicity: Succimer Makes you Less Blue.","authors":"Ivan Ivanov, Waleed Abouelela, Tyler Debbie, Denise Fernández, Lewis S Nelson, Anita Mudan","doi":"10.1007/s13181-026-01117-9","DOIUrl":"10.1007/s13181-026-01117-9","url":null,"abstract":"<p><strong>Introduction: </strong>Acute copper toxicity is a rare occurrence, and management guidelines are not based on robust evidence. Treatment recommendations are often extrapolated from those of chronic copper intoxication and the management of Wilson's disease. Although D-penicillamine, EDTA, and dimercaprol have varying success, we describe the use of chelation with succimer monotherapy in a patient with acute copper salt ingestion with subsequent improvement of clinical status and copper concentrations.</p><p><strong>Case report: </strong>A 38-year-old woman presented to an ED after ingestion of liquid copper fungicide containing 27.5% copper diammonia diacetate complex. The regional poison center initially recommended D-penicillamine along with supportive care. Due to the lack of availability of D-penicillamine, succimer was chosen as an alternative agent. The patient developed mild hemolysis and liver injury during her stay, but did not develop any kidney injury. She had a Zargar 2A caustic injury to the stomach and duodenal bulb. She received succimer for a total of 10 days, and copper concentrations decreased from 1,295 mcg/dL (reference range: 80-158 mcg/dL) to normal levels before discharge.</p><p><strong>Discussion: </strong>There is limited evidence surrounding chelation therapy in acute copper poisoning. We describe a case of a patient who clinically improved while receiving aggressive supportive care and associated succimer monotherapy after acute ingestion of a copper compound.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"321-325"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076733/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147325987","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Redefining Hemp: Public Law 119-37 and the Future of Cannabinoid Products.","authors":"David Harris Schaffer, Natalie E Ebeling-Koning, Kim-Long R Nguyen","doi":"10.1007/s13181-026-01131-x","DOIUrl":"10.1007/s13181-026-01131-x","url":null,"abstract":"","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"336-337"},"PeriodicalIF":2.6,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076736/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147458184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Western Bush Viper (Atheris chlorechis) Envenomation: A Case Report.","authors":"Tyler F Willing, Kenneth D Katz, Matthew D Cook, Lauren Augustine","doi":"10.1007/s13181-026-01127-7","DOIUrl":"10.1007/s13181-026-01127-7","url":null,"abstract":"<p><p>INTRODUCTION: Western bush viper (Atheris chlorechis) envenomation is rarely encountered worldwide and has been reported only very rarely in the United States (U.S.). Although there is no antivenom (AV) specific to Atheris species, polyvalent AVs are used to treat closely related species. We discuss the case of a 49-year-old female exotic snake breeder in the U.S. who was bitten on her left thumb by a Western bush viper. CASE REPORT: The patient was initially evaluated at a community hospital emergency department before being transported to a tertiary care center for both AV administration and medical toxicologist evaluation. The patient received two vials of exotic polyvalent AV (Inoserp™ PAN-AFRICA) obtained from a nearby regional zoo for worsening cytotoxicity and an additional two vials for thrombocytopenia. Her extremity swelling, pain and laboratory values improved after AV administration, and the patient was discharged on hospital day three in stable condition. DISCUSSION: Envenomations by exotic snakes present challenges in care. If a potentially life-threatening envenomation occurs, clinicians should consult with a regional poison control center and medical toxicologist to facilitate locating both optimal AV and treatment facilities. </p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"331-335"},"PeriodicalIF":2.0,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076757/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147326247","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"ACMT Position Statement Revision: Preventing Cannabis Exposures in Children.","authors":"Robert Hendrickson, Andrew Stolbach","doi":"10.1007/s13181-025-01114-4","DOIUrl":"10.1007/s13181-025-01114-4","url":null,"abstract":"","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"341-344"},"PeriodicalIF":2.6,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13076804/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147458163","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}