The NNEPC’s educators for New Hampshire and Vermont, Laurie Warnock and Gayle Finkelstein, sit down to discuss cannabidiol, better known as CBD, in the latest episode of our Poison Ed podcast. What is CBD? Can it be used to treat any medical conditions? Are there concerns about safety or side effects?
The Northern New England Poison Center manages several cases of methotrexate toxicity every year. While some are acute overdoses, many more are due to therapeutic error, which can lead to serious toxicity and death.
Methotrexate is prescribed in the outpatient setting in the treatment of rheumatoid arthritis, psoriasis or other autoimmune diseases. Dosing is often weekly, which can be confusing to the patient, family, caregiver or health care provider. Several cases in which significant toxicity developed were the result of the patients taking their weekly dose of methotrexate daily for several days to a month. One case resulted in a fatality. Others resulted in prolonged hospitalization and treatment.
Methotrexate is a chemotherapeutic agent that is structurally similar to folic acid. It inhibits dihydrofolate reductase. This inhibition interferes with DNA synthesis and repair, and cell reproduction. Toxicity results in the death of rapidly dividing cells throughout the body. Clinical effects of toxicity include:
- Nausea, vomiting and diarrhea
- Renal failure
- Myelosuppression (leukopenia, pancytopenia, thrombocytopenia)
- Acute lung injury
- Neurologic symptoms
Toxic effects can begin days to weeks after methotrexate administration. Treatment includes aggressive supportive care and use of antidotes such as leucovorin and glucarpidase.
Although the non-oncologic use of methotrexate has been on the High-Alert Medications List provided by the Institute for Safe Medication Practices for more than 15 years, errors still occur. This is a national problem and was the focus of an August 2018 ISMP Call to Action.
First, it’s important for every provider involved in the patient’s care to counsel the patient or caregiver during each encounter about appropriate use of methotrexate. The counseling should be repeated each time a patient transitions between home, hospital and nursing home/residential care.
- Emphasize weekly, rather than daily dosing.
- Explain the dangers of daily dosing.
- Have the patient repeat the dosing and adverse effect information.
Support this counseling with written information.
- Include “weekly” in the label directions and avoid vague terms such as “take as directed.”
- Specify a day of the week other than Monday, and fully spell out the day.
- Use a medication calendar to emphasize weekly dosing.
Limit the prescription to a 30-day supply (4 doses, rather than 30), and confirm an oncology diagnosis in any patient with an order for daily methotrexate.
Also confirm dosing whenever a patient reports adverse effects, especially rash, mucositis and/or fever, but also vague gastrointestinal, weakness or fatigue complaints.
The Northern New England Poison Center’s specialists and toxicologists are available 24 hours a day, 7 days a week to assist in the assessment and management of potential methotrexate toxicity. We can be reached by phone at 1-800-222-1222, online chat or text message by sending the word POISON to 85511.
In honor of National Poison Prevention Week, March 17-23, 2019, Vermont educator Gayle Finkelstein and New Hampshire educator Laurie Warnock sit down to talk about what makes the poison center an indispensable tool for so many people.
When the weather gets warmer, it’s time to clean up and clean out! Besides dusting and scrubbing your living space, spring cleaning is a good time to make sure you get rid of possible poisons that you no longer need, such as expired medications.
One good way to clean out your medicine cabinet is to take your expired or unneeded medications to a take-back event. For several years, the DEA has been holding medication take-back events twice a year at locations across the country—typically a local police department. Visit the DEA’s site to see if there is an event happening soon and to find a location near you.
Even if there are no take-back events coming up, it’s important to get rid of old medications in a timely manner to help prevent poisonings. Visit our medication disposal page for some other suggestions safely getting rid of medications.
Spring cleaning is also a good time to make sure you’ve gotten rid of all your household hazardous waste. This includes all items that contain chemicals that can be harmful to health or the environment. If the label says the product is toxic, corrosive, reactive, explosive, ignitable or flammable, it is likely hazardous waste and cannot be thrown in your regular trash.
Household hazardous waste can include electronics, certain types of batteries, paint, mercury-containing products such as thermometers and fluorescent light bulbs, pesticides, gasoline and certain cleaning products. Many towns have special hazardous waste collection days when you can get rid of these items safely.
|Compact fluorescent light bulbs contain some mercury, and should be disposed of as hazardous waste. Photo from SFHazWaste, Creative Commons.|
The best way to find out how to dispose of these items is to call your town office.
You can find more information regarding disposal in your state online:
There are also many alternatives to using hazardous products. The EPA’s Safer Choice Standard identifies products that are still effective but safer for people and the environment.
If you have questions about medications or household products, contact the NNEPC. We are here to help 24/7. Just call 1-800-222-1222, chat online or text POISON to 85511.
Ticks! Just thinking about them can make your skin crawl. With growing populations of ticks in northern New England, there is a good chance you or someone you know has been bitten by one. Tick bites are a concern because certain species can transmit diseases.
The tick we worry about most in our region is the black-legged tick, also known as the deer tick, which can carry Lyme disease. Recorded cases of Lyme are increasing across northern New England. Besides Lyme disease, various types of ticks in the region can transmit anaplasmosis, babesiosis, Borrelia miyamotoi, ehrlichiosis, and Powassan virus. While symptoms of tick-borne diseases vary, they typically include flu-like symptoms such as fever, headache, chills and body pains.
Ticks are most active in late spring and early summer when young ticks, known as nymphs, are looking for an animal to feed on, and then again in October and November when adult ticks are looking for another meal before colder weather arrives. Some species, including the deer tick, are active whenever the temperature is above 40 degrees, even in the winter.
New potential concern
Many recent reports have focused on the lone star tick, which is found throughout the eastern and southern United States. This tick’s range may extend to the southern edges of northern New England, but cases of lone star tick bites in the region are rare. Experts suspect most of these cases are the result of people traveling to other areas, where the lone star tick is more established. However, this tick’s range is likely to expand, and health departments in our region are monitoring the situation.
Lone star ticks are typically easy to identify. Females have a single white or gold dot, or “lone star,” on their back, while males have white spots or streaks on the outer edge of their body.
Lone star ticks can carry several diseases, including Bourbon virus, Heartland virus, southern tick-associated rash illness, tularemia, and ehrlichiosis. The most attention-getting reports have involved cases of allergic reactions to red meat following bites from lone star ticks. Scientists are still working to better understand this connection.
Keeping track of the problem
The northern New England states are interested in monitoring ticks. The University of Maine Cooperative Extension and the New Hampshire Department of Agriculture offer free tick identification, while the Vermont Department of Health will identify potential lone star ticks. Vermont also has a crowd-sourced tick tracker that you can contribute to.
How can you prevent tick bites?
When possible, avoid tick habitat, such as wooded and brushy areas with high grass and leaf litter.
If you are going into tick habitat, follow these steps:
- Treat your clothing and camping gear with a product containing 0.5% permethrin, carefully following the instructions on the product label. Pre-treated clothing and gear are also available from some stores.
- Wear light-colored clothing to make it easier to spot ticks crawling on you.
- Wear long pants and socks and tuck your pant legs into your socks.
- Use an EPA-registered insect repellent such as DEET.
- Check yourself, your children, your pets and all clothing as soon as you come back inside. Shower as soon as possible.
- If you do find a tick, remove it as soon as possible using fine-tipped tweezers. The CDC has full instructions.
If you develop symptoms after a tick bite, contact your health care provider.
For more information
The CDC has a thorough guide to common ticks in the United States and the diseases they carry. In addition, the Northern New England Poison Center can be a resource for questions about tick bites and tick-borne diseases. Call 1-800-222-1222, chat online or text the word POISON to 85511.
A carbon monoxide alarm is one of your most important tools for preventing poisonings in your home. Carbon monoxide is a poisonous gas that you can’t see or smell. It’s created when fuels like wood, oil and coal are burned. It can enter your home if your heating equipment or other appliances are not working properly. If it goes undetected, carbon monoxide can kill you.
Every home needs at least one carbon monoxide alarm. An alarm will let you know if there are unsafe amounts of carbon monoxide in your home. But how do you know which one to buy?
What to look for in a carbon monoxide alarm
There are just a couple things you need to look for:
- UL standard. Choose a carbon monoxide alarm that’s been tested to meet Underwriters Laboratories standard 2034. These alarms have been tested by a Nationally Recognized Testing Laboratory and will have the laboratory’s symbol on them—UL and ETL are among the most common. The alarm should say “UL listed” or indicate that it conforms to UL standard 2034. A complete list of recognized testing labs is available on OSHA’s website.
- Battery-powered. Many alarms run on batteries only, but if the alarm plugs in or is hardwired into your home’s electricity, make sure it has battery backup. Many cases of carbon monoxide poisoning happen during power outages, so it’s important to know your alarm will still work without electricity.
A basic carbon monoxide alarm that you install yourself typically costs between $20 and $50. More complicated alarms can cost more, and hardwired systems will need professional installation.
What do I do after I purchase my carbon monoxide alarm?
The first thing to do after purchasing an alarm is to read the product instructions. These will include important information such as:
- The types of alerts your alarm gives. For example, the alarm may give rapid beeps when there is too much carbon monoxide in your home and less frequent “chirps” to indicate the battery is too low. Each alarm is different.
- How to position your alarm. For example, how far you need to keep the alarm from appliances, furniture and the corners of your walls and ceiling.
- What the expected life of your alarm is. The sensors in a carbon monoxide alarm do lose their effectiveness after time—typically 5-7 years—so be sure to know when it’s time to replace yours.
Where do I put my carbon monoxide alarm?
Place a carbon monoxide alarm in the hallway in each part of your home where people sleep, so that you can be sure it will wake you if there is a problem during the night. We also recommend that you have at least one alarm on each level of your house (for example, basement, first floor and second floor) for the most safety.
Each alarm should be placed on the ceiling or high on the wall. Avoid putting alarms in the kitchen, above any fuel-burning appliance, or near a heating vent. Keep alarms free from furniture and drapes.
What should I do if my alarm is going off?
If your carbon monoxide alarm is going off, get to fresh air right away and call 911 or your local fire department. Once the fire department is on the way, call the poison center at 1-800-222-1222 for first aid advice.
If your alarm is beeping to indicate the batteries are low, replace them as soon as possible.
Do not remove your alarm’s batteries. The NNEPC has managed poisonings in which people ignored their alarm or removed its batteries to stop it from beeping.
Remember, the NNEPC is also available in non-emergency situations to help with questions about carbon monoxide or home safety. Call 1-800-222-1222, chat online, or text POISON to 85511.
Every year the Northern New England Poison Center helps patients who have become sick after misidentifying mushrooms they picked to eat. Among NNEPC cases, mistakes made while foraging are the second most common cause of serious mushroom poisonings, behind only people who become sick after taking psychedelic mushrooms on purpose.
Foraging mistakes don’t just happen among people who are new to mushroom gathering. Many of our cases involve people who have been foraging for years.
What are some mushrooms that cause poisonings in our area?
The most common case of mistaken mushroom identity we handle at the NNEPC involves the poisonous jack o’lantern mushroom (Omphalotus illudens), which can be mistaken for edible golden chanterelles (Cantharellus cibarius). Other poisonous lookalikes that are common problems in our region include:
- The lilac brown bolete (Tylopilus eximius), mistaken for the edible king bolete (Boletus edulis complex)
- The false morel (Gyromitra esculenta), mistaken for the yellow morel (Morchella esculenta)
- The pigskin puffballs (species within Scleroderma), mistaken for edible puffballs (various species within Calvatia and Lycoperdon)
What symptoms do poisonous mushrooms cause?
Most poisonous mushrooms are stomach irritants and cause symptoms like stomach ache, vomiting, cramps and/or diarrhea, which can sometimes be severe. These usually appear within 30 minutes, though they may take longer.
However, more dangerous mushrooms do not cause symptoms for 6 hours or longer after eating them. While these poisonings may also start with stomach cramps and diarrhea, they can lead to more severe effects. These can include seizures or damage to your liver or kidneys. Most patients recover with hospital care, but these effects can be fatal.
What should I do if someone gets sick after eating a wild mushroom?
- Call the poison center right away at 1-800-222-1222. The poison center can help identify the mushroom and determine what treatment is needed.
- If possible, take some pictures of the mushroom or one just like that you can send to the poison center. Take one picture showing the side view of the mushroom next to a ruler, coin, pen or other object to show the size. Take another picture showing underneath the mushroom’s cap, and one from the top.
- Information about where the mushroom was growing can also help the poison center—on wood or out of the ground, in the forest or on the lawn, etc.
How can I prevent poisonings from foraging?
Foraging always carries some risk. Even people who have been doing it for years can make mistakes or have unexpected reactions. Avoiding foraging is the only way to be 100% safe.
If you are going to forage, take some training from an expert first. The North American Mycological Association has a list of mushroom clubs, including ones in Maine and New Hampshire, that may have information on available trainings. A training should cover not just identification, but also safe storage and cooking.
If you have recently been poisoned by a wild mushroom, you can help prevent future mushroom poisonings by submitting a report about your experience to the North American Mycological Association Poison Case Registry.
Looking similar to a USB flash drive and easily hidden, Juul electronic cigarettes have rapidly grown in use among teenagers. Dubbed by some the “iPhone of e-cigarettes,” Juuls are so popular that “juuling” has become a verb, a particular type of “vaping,” the word used to describe e-cigarette use in general.
Like other e-cigarettes, Juuls consist of a mouthpiece, a reservoir for liquid nicotine solution, a heating element and a battery. E-cigarettes come in many forms, from slim “vape pens” to palm-sized rectangular “box mods,” with a wide range of customized devices on display across the internet. Juuls are easy to use, helping to make them the top brand of e-cigarette—they account for 55% of overall sales—and they are also easy to hide, making them popular among high school and even middle school students, raising concerns among school systems across the country.
E-cigarettes do not contain many of the known cancer-causing ingredients found in traditional cigarettes, which may make them a less harmful choice for adults who already smoke, although it is unclear at this point whether they are an effective way to help people quit. Meanwhile, as of 2016, vaping as a fad had introduced more than 750,000 teenagers who had never smoked to nicotine, a highly addictive substance.
While some e-cigarettes have nicotine-free versions, this is not the case with Juuls, which have some of the highest nicotine concentrations on the market. In addition to the potential for addiction, this also makes it easy for teens to overuse. Many calls to the NNEPC related to e-cigarettes involve teens and adults who have become sick from overusing these products, experiencing symptoms such as headache, upset stomach and anxiety. On top of this, many teens may not realize Juuls contain nicotine. A recent study found that nearly 2 in 3 teens and young adults who used Juuls did not realize that all Juuls contain nicotine.
The long-term effects of e-cigarette use won’t be known for some time, but there is strong evidence that introducing addictive substances to teens’ developing brains can make them more susceptible to other addictions later in life. One study has also found that teens that use e-cigarettes are more likely to transition to traditional cigarettes, as well.
It’s important for teens to understand the risks related to e-cigarette use. The surgeon general’s office and the CDC have produced a tip sheet for parents to get the conversation started about nicotine use.
If someone is feeling sick after using e-cigarettes or tobacco products, call the poison center right away at 1-800-222-1222, chat online or text POISON to 85511.
The FDA has strengthened its warnings about benzocaine, a medication used to numb pain that is included in some over-the-counter teething products. Though it’s rare, swallowing benzocaine can cause a dangerous condition called methemoglobinemia, in which not enough oxygen is carried in the blood.
The latest FDA warning states that benzocaine products should not be used in children younger than 2 years. It also calls on manufacturers to stop marketing benzocaine products for teething and to add a warning about methemoglobinemia to the product label.
What are some ways that you can relieve your child’s teething pain, without using numbing medications like Orajel or Anbesol?
- Gently massage your child’s gums.
- Give your child something firm and cool to chew on. Make sure it is clean, and large enough that they can’t choke on it, and supervise them closely. Some possibilities are a chilled teething ring or pacifier; a cool, wet washcloth; a chilled cucumber or carrot; or hard, unsweetened teething crackers. Avoid using frozen items. They may be too hard or uncomfortably cold.
- Comfort and distract your child. Sing a favorite song, read a book, rock your child, or gently message them. Breastfeeding can also help.
- If your child is in a lot of discomfort, your doctor may recommend giving them some over-the-counter pain-relieving medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin or Advil). Always check with your child’s doctor before giving medication, and carefully follow the directions on the product label.
If you have given your child an over-the-counter medication that contains benzocaine, or if you have question about the risk of using these products, call the poison center at 1-800-222-1222 chat online or text POISON to 85511.
The Northern New England Poison Center is your local resource for antidote management. Our poison specialists and toxicologists are available 24/7 to assist health care professionals in the medical management of patients who require a specific antidote or antivenom. We also help health care facilities determine which antidotes to stock, and can assist in finding antidotes or suggest other options in the case of a shortage.
To help hospital staff make stocking decisions about antidotes, in May 2018 we released the NNEPC Antidote Chart. This tool lays out many of the more common antidotes the poison center may recommend in treating poisoned patients, explaining what each antidote is used for, the dosing parameters, and how much is generally needed on hand to treat a patient initially. Not every hospital will require every antidote listed in the chart, and the poison center is available to help determine your hospital’s needs by calling 1-800-222-1222.
To help make these assessments, the NNEPC conducts a periodic hospital antidote survey to find out which antidotes each hospital in the region regularly stocks. Your participation is crucial to helping the poison center determine where to send patients, or where to obtain an antidote that is not stocked by every hospital.
Remember, the NNEPC Antidote Chart is only a reference and not a substitute for calling the poison center. Each patient and circumstance is unique, and we urge you to contact the NNEPC at 1-800-222-1222 for consultation and assistance in dosing individual patients.
The NNEPC’s state educators—Rebecca Miller (Maine), Laurie Warnock (New Hampshire) and Gayle Finkelstein (Vermont) have been contacting hospitals in the region to deliver complimentary copies of the antidote chart to pharmacy and ED staff and to discuss other ways the poison center can be a resource for you. To arrange a meeting, email your state’s educator (link in the name above). You can also download the antidote chart or order a physical copy at cost through our website.