Dr. Alexander Garrard, Clinical Managing DirectorWashington Poison CenterAgarrard@wapc.org

2

1970s -1980s

1990’s 2000-2010 2010 - 20121950s -1960s 2013-2014

16 PCs in WA

1992: DOH recommends PC consolidation

Economic Pressure;4 PCs remain in WA

2005: WAPC participates in HRSA; Hire Exec Dir.

6/2013: Renew Bldg Lease w/ 45% reduction

1993: RCW 18.76 creates WAPC as 501c3 non-profit; Led by Dr. Robertson

2000: CDC helps fund PCs

2006: Hire New Med Dir. replacing Dr. R.

2008: Public Law 110-377

2008/9: Budget 36% cut; Layoffs

2010: Receive SCHIP funding

2012: Lauch Vet Pets

2014: Oper’l Study; New E.D., Med Dir & Clin. Mging Dir; Cancelled VetPets

Our History

2012: Lewin Study Published, Values PC

2014-5: Launch Toxic Trend Rpts (Cannabis, E-Cig), Agency Collaboration “FreakNight”“Resolution”

Our Washington Poison & Drug Information Center Mission:

To prevent harm from poisoning through expertise, collaboration,

professional, and public education

RCW 18.76 Poison Information system. Statewide ProgramPublic Law 110-377 Primary poison defense for U.S. (1993)Public Law 110-377 “Poison Center Support, Enhancement, and Awareness Act of 2008”

RCW 18.76 Poison Information system. Statewide ProgramPublic Law 110-377 Primary poison defense for U.S.

(1) Twenty-four hour emergency telephone management and treatment referral of victims of poisoning and overdose incidents, to include determining whether treatment can be accomplished at the scene of the incident or transport to an emergency treatment or other facility is required, and carrying out telephone follow-up to assure that adequate care is provided;

(2) Providing information to health professionals involved in management of poisoning and overdose victims;

(3) Coordination and development of community education programs designed to inform the public and members of the health professions of poison prevention and treatment methods and to improve awareness of poisoning and overdose problems, occupational risks, and environmental exposures; and

(4) Coordination of outreach units whose primary functions shall be to inform the public about poison problems and prevention methods, how to utilize the poison center, and other toxicology issues.

Public Law 110-377

“Poison Center Support, Enhancement, and Awareness Act of 2008” …

(1) “Poison control centers are the primary defense of the United States against injury and deaths resulting from poisoning.”

(7) “Real-time data collected ..an important source of information for the detection, monitoring, and response for contamination of the air, water, pharmaceutical, or food supply.”

(8) In the event of a terrorist event, poison control centers will be relied upon as a critical source for the accurate medical information and public health emergency response concerning the treatment of patients who have had an exposure to a chemical, radiological, or biological agent.”

Who Do We Serve?

• 7.06 million people• 22.9% under the age of 18

years• 6.4% under the age of 5 years• 13.6% 65 years and over

• 98 acute care hospitals• EMTs/Paramedics• Law Enforcement• Federal/State/County

Departments of Health and Agencies

• Medical/Pharmaceutical Teaching Institutions

• And more…

On-Call Toxicologists

• 24 hour access to board-certified toxicologists with backgrounds in emergency medicine and pharmacology

Dr. Chen Dr. ValentoDr. Garrard

On-Call:Dr. Melissa HallidayDr. Thomas Martin (independent)Dr. Suzan Mazor (Seattle Childrens)Dr. Carl Skinner (Madigan)

Certified Specialists in Poison Information• PharmDs, RNs, PIPs with a combined 260+ years of experience

WAPC by the numbers• Over 63,000 inbound calls to WAPC in 2014

• 54,715 were human exposures

• Over 90% managed at home• Trip to hospital or physician avoided – cost savings!

• Approximately 75% originate from households• 56% of calls involve children under 6 years of age• 2,758 exposures in Clark County

• 1,789 in pediatrics (65%)• 2,164 managed on site (non-HCF)• 308 treated/evaluated and released from ED• 50 admitted to ICUs

WA

PC

’s T

op

10

Lis

ts f

or

2014

Top 10 Categories for 13-19 year olds

1. Analgesics

2. Antidepressants

3. Antihistamines

4. Stimulants and street drugs

5. Sedative/hypnotics and BZDs

6. Cough and Cold preparations

7. Cleaning substances

8. Cosmetics/Personal Care Products

9. Anticonvulsants

10. Cardiovascular Drugs

Top 10 Categories in Pediatrics ( < 13 years)

1. Cosmetics/Personal Care Products

2. Analgesics

3. Cleaning Substances

4. Foreign Bodies/toys

5. Topical preparations

6. Vitamins

7. Plants

8. Antihistamines

9. Dietary Supplements/Homeopathic

10. Gastrointestinal preparations

Top 10 Categories in Adults ( > 19 years)

1. Analgesics

2. Sedative-hypnotics and BZDs

3. Antidepressants

4. Cardiovascular drugs

5. Cleaning substances

6. Alcohols

7. Pesticides

8. Anticonvulsants

9. Hormones

10. Antihistamines

Cost Savings of Poison Centers

Lewin Study on Value of the Poison Center System, 2012

Poisoning and drug overdoses were the leading cause of injury death in 2012.

What are E-Cigarettes?• A noncombustible product employing a

device containing a mechanical heating element, battery, or circuit which is used to heat a liquid contained in cartridges for the purpose of direct inhalation of the resultant vapor (as defined by HB 5124)

• Unregulated by the Federal Food, Drug and, Cosmetic Act (Chapter V)

• Contains highly concentrated liquid nicotine, up to 24 mg/mL in 15 mL bottle• 1 gallon refill bottles also available

• Highly toxic in kids in small amounts• Less than a mouthful

Deal or No Deal?

29,155 cigarettesat 13 mg of nicotineper cigarette

1,456 cigarette packs

1 gallon = 3,785 mLs = 378,500 mg of pharmaceutical grade nicotine

Clinical Symptoms of Nicotine Toxicity• Symptoms can range from…

• Nausea and vomiting• Agitation• Tachycardia• Hypertension• Seizures• Coma• Death

• IV injection• Ingestion

• First fatality from ingestion in 11/2014 in a 1 year old in NY

Formaldehyde in E-Cigarettes

• Study from Portland, OR• E-cigs release higher

concentrations of formaldehyde-releasing agents than nicotine

• Propylene glycol and glycerol formaldehyde

• IARC Group 1• Asbestos• Arsenic• benzene1Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N

Engl J Med 2015;372:392-4.

Why Are Teens and Adults Using E-Cigarettes?

• Lower cost of entry (estimated at 10-20% of cost of combustibles in WA based on legislative testimony)

• 30mg/ml of liquid nicotine = ~3 cigarette• Readily availability at convenience stores, gas stations, independent vape shops• Liquid Nicotine flavors & names that appeal to teens and young adults (candy,

liquor, drugs “ecstasy”, minty, etc.) • Devices have a high-tech design and advertising (including social media and

celebrity endorsement) is targeted directly to teen/young adult market• Supposed “Health Benefit” for Smoking Cessation or Athletic Performance

Enhancement (no scientific evidence)• Graduation strategy employed which encourages use with lower levels of nicotine

and progress to higher levels• Impact of “2nd hand smoke” from vaping not known

Disturbing Trend in Washington State

2007 2008 2009 2010 2011 2012 2013 20140

20

40

60

80

100

120

140

160

180

200

19

13

50

133

0 0 0 2

19 18

76

182

Total Human E-Cigarette Exposures 2007 - 2014

Annual Pediatric ExposuresAnnual Total

Year

Tota

l Exp

osur

e Ca

lls

WAPC E-Cig Exposure Data

N = 133;182

< 1 1 - 3 years old

4 - 5 years old

Child 6-12 years

Teen 13-19 years

0

20

40

60

80

100

120

Pediatric E-Cigarette Exposures for 2014

Age group

Nu

mb

er o

f E

xpo

sure

s

Pierce

Spoka

neKing

Snohomish

Thurst

onKits

ap

Whatc

omClar

k

Chelan

Cowlitz

5

10

15

20

25

30

35

Top Ten Counties with E-Cigarette Exposures for 2013 and 2014

20142013

Washington Counties

Num

ber o

f Exp

osur

es

E-Cigarettes in Clark County

< 1 1 year 2 years 3 years 4 years 5 years 6-12 years

13-19 years

20-29 years

30-39 years

40-49 years

50-59 years

60-69 years

70-79 years

80-89 years

>= 90 years

0

1

2

3

E-Cigarettes by Age in Clark County 2013 to 2014

20142013

Num

ber o

f Exp

osur

es

WAPC E-Cigarette Data

Chest pain (incl. noncardiac)

Erythema/flushed

Diarrhea

Pallor

Diaphoresis

Throat irritation

Red eye/conjunctivitis

Headache

Tachycardia

Abdominal Pain

Dizziness/vertigo

Cough/choke

Drowsiness/lethargy

Other

Agitated/irritable

Irritation/pain

Nausea

Vomiting

5 10 15 20 25 30 35

Most Commonly Reported Symptoms in 2014

Total Number of Occurrences

Sym

ptom

E-Cigarettes in Clark County

• Abdominal pain, N/V, and throat irritation most common symptoms

No follow-up, min-imal toxicity

Minor effect Unrelated effect

1

2

3

4

5

6

7

8

Medical Outcomes in Clark County for E-Cigarettes 2013-

2014

Medical Outcome

Num

ber o

f Exp

osur

es

City # of Exposures

Vancouver 8

Washougal 1

WAPC E-Cigarette Data

Ingestion69%

Dermal19%

Inhalation/nasal5%

Ocular7%

Otic0%

Most Common Routes of Exposure for 2014

Route Total

Ingestion 144

Dermal 40

Ocular 14

Inhalation/Nasal 11

Otic 1

Total 210

Little Winona

• 22-month old Winona drank half a 15 mL bottle

• “Eyes were rolling back in her head and she was just flopping around”

• Mom called WAPC for help

• Winona ended up in the hospital overnight for treatment and observation

http://www.king5.com/story/news/local/2014/10/05/ecig-vapor-child-dangers/16758397/

Marijuana in WA State• I-692 permitted patient with certain medical conditions to

use medical marijuana (passed 1998)• Cachexia, cancer, HIV/AIDS, epilepsy, chronic pain, glaucoma, etc.• Up to 24 oz of useable marijuana or 15 marijuana plants, or

participates in collective garden

• Technically illegal under WA and federal law to possess, buy or sell medical marijuana• Provides an affirmative defense to criminal prosecution if a

qualified patient possesses the allowable amount

• I-692 different from I-502

Marijuana in WA State• I-502 (passed 2012) essentially legalized marijuana for

recreational use by…• Removing state-law prohibitions against production, processing

and selling of marijuana• Allowed limited possession of marijuana for 21+ years• Established a system of taxing marijuana

• Individuals 21 years and older may possess and use…• 1 ounce of usable marijuana• 16 ounces of marijuana-infused product in solid form; or• 72 ounces of marijuana-infused product in liquid form.• Marijuana-related drug paraphernalia.

Location, Location, Location• 334 current retail outlets allotted for recreational

marijuana• King County: 61 shops• Puyallup County: 31 shops• Snohomish County: 35 shops• Clark County: 15 shops

• 115 retail shops reporting sales

• Estimated 1,100 medical dispensaries operating in the state

Marijuana Edibles

• Both medical and recreational marijuana available in WA state• Recreational highly regulated i.e.

few edibles• Medical marijuana largely

unregulated with many different edibles

• Approximately 250 medical marijuana dispensaries in Seattle

• No standardized packaging, labeling, warning labels

• Product branding attractive to pediatrics

Challenging Edibles

• THC content higher than in years past• Potency increased 2-7x since

70s

• Kinetics are very different compared to smoking marijuana• 2 – 3 hours versus minutes

• Marijuana edibles scored• 10 doses of 10 mg each in

one candy bar• Who eats 1/10th of a candy

bar?

• Majority of patients present with…• Tachycardia• N/V• Agitated• Drowsy/lethargic• Confused• Hallucinations

• More children admitted for observation than e-cigarette exposures

Staggering Trend in Exposures

January February March April May June July August September October November December0

5

10

15

20

25

30

35

Marijuana Exposures for 2014 and 2015 (YTD 3/18/15)

2014 Peds Cases2015 Peds Cases20152014

Marijuana Highlights

< 11 ye

ar

2 years

3 years

4 years

5 years

Child 6-12 ye

ars

Teen

13-19 years

20-29 years

30-39 years

40-49 years

50-59 years

60-69 years

70-79 years

80-89 years

>= 90 ye

ars

Unknown ad

ult

10

20

30

40

50

60

70

Marijuana Exposures by Age ('13 - '15 YTD)

201320142015

Age Group

Num

ber o

f Exp

osur

es

Marijuana Highlights

< 1 1 year 2 years 3 years 4 years 5 years Child 6-12 years Teen 13-19 years

10

20

30

40

50

60

70

Pediatric Marijuana Exposures ('13 - '15 YTD)

201320142015

Age Group

Num

ber o

f Exp

osur

es

Marijuana Highlights

King Pierce Snohomish Spokane Thurston Yakima Clark Whatcom Klickitat Grays Harbor

10

20

30

40

50

60

70

80

90

Top Ten Counties with Marijuana Exposures for 2013 and 2014

20142013

Washington Counties

Num

ber o

f Exp

osur

es

Marijuana Highlights: Clark County

1 year3 years

4 years

6-12 years

13-19 years

20-29 years

30-39 years

40-49 years

50-59 years

60-69 years

80-89 years

Unknown adult0

1

2

3

4

5

6

7

Marijuana Exposures by Age 2012 to 2015 YTD

2012201320142015

Marijuana Highlights: Clark County

City # of Exposures

Camas 1

Vancouver 23

Yacolt 1

No follo

w-up, minim

al toxic

ity

Minor effect

Moderate

effect

No effect

2

4

6

8

10

12

14

Marijuana Medical Outcomes for 2012 - 2015 YTD

New & Emerging Concerns• Electronic cigarettes being used to vaporize cannabis oil

• Hash oil highly concentrated• 30% to 90% THC

• Vape pens resembling asthma inhalers• Poisoning risk in kids with asthma

New & Emerging Concerns• Butane Hash Oil manufacturing

• Dangerous process and explosive• Similar to methamphetamine production

• May 21st, 2014• Hash oil extraction in Puyallup, WA results in a series of explosions

that destroyed the car

• Liquid butane passed through tube filled with cannabis plant• Butane highly flammable

New & Emerging Concerns• Variety of marijuana edibles available

• LCB tasked with approving recreational edibles• Medical marijuana edibles left large unregulated

• Cookies, candy, gummy bears, drinks, brownies, etc.

Dangerous New Drugs on the Street

• Hallucinogenic amphetamines• Molly• Bath Salts

• Extreme agitation, hyperthermia, tachycardia, seizures and death

• Chemical Russian Roulette

• 1 recent death at FreakNight 2014

38

3am 3am-7am12:45pm6pm-3am 6pm-7:45pm

FreakNight 2014 (2) day event begins in Seattle @ C-Link WaMu theater

WAPC consulted on 1 critical case

PHA sent to 500 contacts; FAX Blast sent to ER Depts of area hospitals

6:40am: 20 y/o Male expired

WAPC consulted on 2nd critical Molly OD case

Dr. Garrard conducts interviews (KOMO,KING5, KIRO, Seattle Times, FOX)

Create Molly Public Health Alert

6:41pm Seattle K.C. Pub Health contacts WAPC; Review PHA

C-Link cancels event

A night at the WAPC10/31/2014 - 11/01/2014

3pm-6pm

During event, large number of attendees transported to area hospitals

Dr. Garrard contacts event organizers to notify of death and Molly concerns as well as pending media announcement

Public Health Alert and Media

Toxic Trends Reports

• 11 Toxic Trends Report issued since July 2014

• 6,000+ emails sent• 264 media contacts• WAPC nationwide resource for marijuana and e-cigarette exposure in kids

Toll-free, Confidential Poison Center Number

1-800-222-1222

Program Your Cell Phone!