Chloroquine death highlights importance of medication safety during pandemic

In a high-profile case last month, an Arizona man died and his wife needed to be hospitalized after they swallowed an aquarium product to try to prevent getting COVID-19. The product contained a form of chloroquine, a chemical that is also found an anti-malaria drug.

The medical forms of chloroquine and a related chemical, hydroxychloroquine, are prescribed for certain conditions, like lupus and rheumatoid arthritis. They are still being studied as a possible treatment for COVID-19, and because of the pandemic, the FDA is allowing doctors to give these drugs to COVID-19 patients in certain circumstances. However, it’s important to understand that these medications are only safe if used in very specific ways, and they can be dangerous or even deadly if they are used in the wrong way.

This is not the only instance of people taking unsafe steps to try to prevent the illness. In some cases people have become sick after taking medications meant for cows, because the medications are used to prevent other types of coronaviruses—not the one that causes COVID-19—in those animals. Animal medications have not been tested on humans and therefore cannot be considered safe and effective.

We are all trying to do our best to prevent the spread of COVID-19, and medication safety is as important as ever. Here are some important things to remember:

  • Only take prescription medications if they have been prescribed to you. Follow your doctor’s instructions carefully, and don’t share your prescription medications with anybody else.
  • Only use over-the-counter medications for reasons listed on the product label, and carefully follow all the instructions on the label.
  • Do not use nonmedical products to treat an illness or condition, unless your doctor tells you to.

While there are studies underway, experts are not yet sure whether hydroxychloroquine, chloroquine or other medications will prevent or treat COVID-19. The best things we can do right now are to follow these basic guidelines:

  • Stay home except when necessary.
  • Wash your hands frequently—or use hand sanitizer if soap and water aren’t available—and avoid touching your face.
  • Keep at least 6 feet away from people who don’t live with you.
  • Wear a face covering in public—remembering to still stay 6 feet away from others.

Please see the CDC’s website for a full list of recommendations.

Posted in COVID-19, Medication Safety, National News | Comments Off on Chloroquine death highlights importance of medication safety during pandemic

Effects of marijuana use during pregnancy and breastfeeding

Download this as a printable fact sheet


Studies suggest that using marijuana while pregnant or breastfeeding may have negative affects on the baby’s development. While these studies have been limited so far, the Northern New England Poison Center recommends avoiding marijuana use if you are pregnant, planning to become pregnant, or breastfeeding.

Marijuana Use During Pregnancy

THC, the chemical in marijuana that causes the high, crosses the placenta into the fetus during pregnancy. Babies exposed to THC in the womb may have some increased risks.

  • Birth defects. The baby may be more likely to have defects related to:
    • Brain and skull development
    • Heart development
    • Development of the esophagus, intestines and diaphragm
  • Premature birth. The baby may:
    • Be born early
    • Have a low birth weight
    • Need special hospital care
  • Behavior and learning problems in life. These can include:
    • Hyperactivity
    • Impulsiveness
    • Inattention
    • Trouble with reading and spelling
    • Trouble with abstract reasoning and visual problem solving

Marijuana Use While Breastfeeding

THC enters breast milk and will be passed on to the baby when breastfeeding. Even after stopping use, marijuana will remain in the milk for days. Pumping and dumping may lower the baby’s THC exposure but it will not eliminate it.

It’s unclear at this time what effect marijuana use while breastfeeding has on a child’s long-term development.


There is not enough research to say for sure how marijuana use in pregnancy or while breastfeeding will affect the baby. Findings are often based on small numbers of people, and many mothers in the available studies also smoked tobacco, drank alcohol or used other drugs. The effects of use while breastfeeding are especially hard to single out because many mothers also used marijuana during pregnancy, which likely has a larger effect.

However, there is enough evidence of possible negative effects that the American College of Obstetricians and Gynecologists recommends that marijuana be avoided during pregnancy. In addition, it is best for women who are breastfeeding to avoid using marijuana because of the possible negative effects.

Further Reading

Ryan, S.A., et al., Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes. Pediatrics, 2018. 142(3).

Posted in Health Care Providers, Medication Safety, Poison Prevention, Regional News, Substance Abuse | Comments Off on Effects of marijuana use during pregnancy and breastfeeding

Podcast: Suicide attempts in Vermont

In the latest episode of our Poison Ed podcast, NNEPC Vermont educator Gayle Finkelstein sits down with Dr. Thomas Delaney and Dr. Rebecca Bell of the University of Vermont’s Larner College of Medicine to talk about trends in self-poisoning among Vermont youth. Listen below.


Gayle Finkelstein: Welcome to Poison Ed. This is Gayle Finkelstein, Vermont educator from the Northern New England Poison Center.

Today we are going to talk about suicide in Vermont, specifically focusing on self-poisoning suicide attempts. I’m joined by two guest speakers: Dr. Thomas Delaney, assistant professor at the University of Vermont’s Larner College of Medicine, Department of Pediatrics; and Dr. Rebecca Bell, pediatric critical care physician and assistant professor in the Department of Pediatrics at the Larner College of Medicine at the University of Vermont. Thank you both for joining us today.

I would like to start off helping our listeners understand the relationship between suicide attempts and poisons.

Using data from the National Poison Data System, which reports information from all 55 poison control centers across the country, researchers found more than 1.6 million children and young adults aged 10 to 24 years attempted suicide by poisoning between 2000 and 2018. The number of children and young adults who have attempted suicide by poisoning has increased in the United States over the past several years. There was a significant increase in the rate of attempts between 2011 and 2018 that was driven predominantly by girls and young women. A total of 71% of all cases reported in a recent study published in the Journal of Pediatrics involved females. While the study’s data cannot point to a specific reason behind the increase in self-poisoning, it was noted that social media and internet use have increased significantly during the same period.

The Northern New England poison Center continues to see high numbers of calls from health care providers seeking management consultation, most often related to self-harm attempts. We are seeing females more than males attempting suicide. For females, the 13- to 19-year-old age category had the highest number of cases, and for males it was 20- to 39-year-olds. Suspected suicide attempt remains a significant concern, accounting for 14% of exposures this past year from Vermont.

Dr. Delaney, what recent trends in the Vermont data and U.S. suicide deaths are you seeing?

Dr. Thomas Delaney: Well, unfortunately, Vermont suicide death rates have been trending in the wrong direction for a long time, with over a 30% increase in the rates since 1999. We use rates of people per 100,000 in order to compare across different states and between states and the U.S. as a whole. Nationally, suicide death rates have also been increasing, and the U.S. in recent years has basically been catching up with Vermont’s already higher rates. The trends that we’re seeing are pretty much holding for middle-aged and older people as well as for younger people.

GF: Why are the suicide rates in Vermont so high?

TD: Well that’s a huge question, and it’s really important to distinguish between suicide attempts and suicide deaths, and especially important to note that when we’re talking about young people who attempt to take their lives, they have about 25 suicide attempts for every death and that’s a really different picture than what we see for middle-aged and older folks, who have fewer attempts but are more likely to die from their attempts.

We also have to acknowledge that every person who dies by suicide has their own circumstances, and the causes of the suicide death are often not clear and very complicated. So what’s true for a population of people, which is really what I’m talking about, may not be true for the individuals from the population. And when we think about population-level risk factors that are higher in Vermont:

  • We have an older population—so, we’re one of the oldest states in the U.S. in terms of our mean and median ages
  • We have a high rate of military participation—so there is this effect where nationally veterans die by suicide at a rate about twice the rest of the adult population, and we do have a lot of veterans in our state
  • We have high rates of binge drinking, which is also correlated with suicide deaths
  • We are also a very white state, and interestingly, when we think about different racial groups and suicide risk, white, Caucasian people actually have higher rates than some ethnic minorities and racial groups have.

So I think that’s pretty much the big population-level risk factors. The one I left off—and that is really notable—is the high rates of firearm ownership, as well. So there is a correlation between states having higher rates and easier access to firearms and having higher suicide death rates.

GF: When you identify the specific groups that may be at higher risk, is there one specific group that stands out?

TD: Well when we look at people who actually die by suicide, if you look retrospectively at what they were dealing with, you do see that people who were struggling with serious mental illness and experiencing chronic life stressors are at higher risk for dying by suicide. And in Vermont we see that veterans, as I already mentioned, are about twice as likely to die by suicide than are the rest of the adult population.

In general when we’re thinking about suicide in middle-aged and older people, a lot of times we’re talking about males. So there are, for those ages it’s about four males who die by suicide for every female, and many of those people who die actually fall into the other categories—for example, of struggling with substance abuse, being veterans, rural, social isolation, things like that.

We know that when we’re thinking about younger people, LGBTQ young people in Vermont—and this is based on the Vermont Youth Risk Behavior Survey—they’re about three times more likely to have felt sad or hopeless every day for the past two weeks, and that’s a marker for major depressive disorder. And the same young people are about four times more likely to have hurt themselves on purpose compared to non-LGBTQ young people. LGBTQ young people in Vermont are also about four times more likely to have made a suicide plan in the past year and four and a half times more likely to have made an actual suicide attempt.

Also thinking about young people and increased risks, we know that students of color are about 50% more likely to have made a suicide plan in the past year, as well as being more than 50% more likely to have made a suicide attempt. We also know that young people and indeed people of all ages with a history of trauma are at elevated risk for suicide deaths and attempts.

GF: Dr. Bell, what is your experience as a physician regarding youth and deliberate self-poisoning?

Dr. Rebecca Bell: So I work in the Pediatric Intensive Care Unit, so my patients, who are in the Pediatric ICU from a self-poisoning are either critically ill, so experiencing really severe symptoms or are at high risk of experiencing severe symptoms or even death.

What I’ve noticed with my patients is that there’s quite a range. So, many youth have a history of a serious mental health illness like depression or anxiety, but some do not have that history. All of them have some sort of trigger that lead to their self-poisonings, and what my patients generally tell me once they feel better and they can talk about their experience is that maybe they’ve been feeling down or maybe they haven’t been feeling down, but regardless they get in a fight with their parent or friend or something happens at school or something happens on social media, and they take medicines, and oftentimes, afterwards, they tell someone. So they tell a parent, or even more often they tell a friend about the self-poisoning. And what I’ve noticed in Vermont among my patients is that young people are really good at getting help for their friends. So oftentimes the young person will take medicine, then after some time period will text a friend and say what they’ve done, and that friend will immediately tell a parent who then gets help. So that I have found to be really important.

And I think that, you know, young people, every young person is at risk for a self-poisoning, because young people are more impulsive than adults and they engage in more impulsive behaviors, and things that happen in their life that may seem a little bit trivial once you’re older can seem really, really important and young people can be really distressed. So again this breakup of a relationship, or an event at school where someone gets bullied, those can be really, really distressing for young people, and young people are at risk for that happening. So we really want to encourage all families to create safe environments in the home, so that when they have one of these events that they don’t have access to medications are other things that could hurt them.

GF: I had mentioned earlier about a recent study looking at national suicide and self-poisoning, especially regarding sex- and age-specific suicide attempts by self-poisoning. This report indicates that the first episode of deliberate self-poisoning is a strong predictor of subsequent suicide and premature death. While almost all individuals survive their first hospital presentation for self-poisoning, the risk of subsequent suicide was more than fortyfold higher in these patients than among population-based controls.

The highest number of cases nationally poison centers received was in the 13- to 18-year-old age category. For children under 19 years of age the annual suicide attempts by self-poisoning doubled from 2000 to 2018. Serious outcomes also increased 235%.

Overall, suicide attempt rates are increasing in Vermont. The Northern New England Poison Center reported 5,459 suicide attempt cases between 2009 and 2018, with 23 of these resulting in death.

Dr. Delaney, why is having Vermont self-poisoning data is so important?

TD: I think there’s a couple reasons why this is really important data for us to look at. So, Vermont can really differ from other parts of the country and indeed from other parts of New England and the Northeast. We already talked about how we’re a little bit different in terms of owning firearms and some other characteristics as well.

So having these data is really a way of informing and maybe even developing new prevention programs. So we can think about community education. One thing that I’m really interested in is provider education. So how do you support health care, mental health care providers to maybe do screenings? Or how to effectively intervene or make effective referrals to other types of providers when there has been an episode of intentional self-poisoning. And ideally we’d want to use the data and different types of public health approaches to get upstream and actually be preventing the suicide attempts in the first place.

It’s probably also really important that we raise awareness among community members and families and caregivers because ultimately they’re going to be doing a lot of the actual sort of safety steps and a lot of the initial responses when there is a risk of somebody engaging in self-poisoning.

GF: Dr. Delaney, what is the difference between risk factors and warning signs?

TD: Right, so I think of risk factors as being things that are more static and longer term. So a risk factor could be something like struggling with mental illness, where you were previously diagnosed and it may be better over time or a little worse over time, but it’s just something that’s present there for you.

I think of warning size signs as being much more in the moment, and they might be represented as a specific behavior or specific language. So a sort of classic warning sign is people who already have risk factors present may give away their possessions, for example, or they may verbalize something like “I won’t be here next week” or “I won’t be around much longer.” I’d called those warning signs.

GF: OK, and Dr. Bell, what are the clinical impacts on young people who are hospitalized for poisoning suicide attempts?

RB: So we have a number of different treatment modalities we can use in the Pediatric ICU to help take care of youth who are critically ill from their self-poisoning. So we can support their breathing if needed, sometimes with a ventilator if necessary. We can support their heart, their blood pressure, we can treat arrhythmias, treat seizures, fix electrolyte abnormalities. We’ve had to put some young people on dialysis. So in the ICU we have a lot of ways to make young people better. Some medications have antidotes that we can give as well.

But these young people are really sick, sometimes for many days, and there’s always a risky period where we’re not sure if there’s going to be long-term effects, long-term effects on their organs. So it can be a pretty tense time in the ICU for the young person, for their family.

And then once they’ve recovered, they will all end up going to an inpatient psychiatric facility where they can get intensive psychiatric care. Then when they are discharged home there’s a plan made between the psychiatric facility, the pediatrician at home, the family and whatever other therapy and counseling they need when they go home to make a real, again, safe environment for the young person when they leave.

GF: OK, and Dr. Delaney, how is Vermont addressing this problem?

TD: Well Vermont’s really ramped up their efforts in recent years I would say. So as one example, the legislature is supporting the Department of Mental Health to do an initiative called Zero Suicide. So the Department of Mental Health is teaming with the Center for Health and Learning and the Vermont Suicide Prevention Center, and they’re working with the designated agency system that is responsible for a lot of the community-based mental health care in the state, and they’re doing things like doing a lot of workforce development—so training on suicide-specific treatment modalities. For example, there’s one called CAMS—collaborative assessment and management of suicidality. And there’s other aspects of Zero Suicide, as well.

And there’s a big focus on fixing some of the gaps in the system. So one of the gaps that we’ve heard about in the past in our state, and certainly in other places, is handoffs between people who show up in the emergency department who have suicidal ideation or suicide attempt and just then making sure that they actually wind up starting to get care once they’re out of the emergency department. Certainly making links between inpatient hospitalization and care once those people are discharged that Dr. Bell mentioned.

And a lot of education and outreach to mental health providers and community-based providers who weren’t necessarily getting a lot of the suicide prevention-specific sort of training and opportunities that now they’re getting a lot more of. And we know there’s some evidence that actually having those trainings makes the mental health care system and probably also health care providers be more effective in helping their patients.

GF: And Dr. Bell, what are things that all families should be doing in order to keep people from accessing poisons?

RB: Well we tell all families that they should keep medications truly inaccessible to young people, even adolescents. So that means locking up medications, it means when a young person is on a prescription medication that the parent should be the one who sort of controls that medication and gives the young person the medication, and that helps, one, prevent the young person from taking a bunch of that medication, and also makes sure that they’re actually getting it on time when they need it.

And one thing families oftentimes underestimate is how serious and dangerous over-the-counter medications can be. So, many of the patients that I see in my PICU are there and critically ill from over-the-counter medications. So we often don’t think of that as being potentially dangerous, but it can be. So even over-the counter-medications I would say try not to buy in bulk, and again, I would keep those inaccessible and have the young person ask for them and you can give it to them in a controlled manner. And the same thing with of course the parents’ prescription medication. So really all medications should be really inaccessible to the young person.

GF: How about in terms of health care providers, regarding intentional self-poisoning in young people—do you have any advice?

RB: Yeah, I would say all health care providers should really think about, when they’re prescribing a medication, about whether there’s a young person in the house. So I do see some patients who come in who have taken their parent’s medication, for instance, and so if you’re a health care provider, even if you’re treating adults, asking about children in the house is really important, so that if you’re prescribing something that can be dangerous in large quantities that you’re providing some counseling on how to keep that medication inaccessible to the young person. Oftentimes I see cases where, say, a health care provider is prescribing something to an adult or a young person that they’re going to try to see if it helps their symptoms, and then it doesn’t really work, and then you’ve got now this bottle of medications in the home. So I think following up on that, “Oh that medication didn’t work—why don’t you bring that in next time and I can discard that for you?” or the family can discard that. So not having a lot of medication sort of hanging around. And then I think counseling families, again, on keeping medications out of reach.

And I think it’s just really important for families to understand that adolescence is a difficult time and stressful things happen, and a lot of times I do see families who come in that are very surprised by the self-poisoning, and I just really want to emphasize that every young person is at risk for self-poisoning because things happen, stressful things happen, and when something’s accessible to them they may in an impulsive move use it. So remembering that really every adolescent is at risk.

GF: Well those are great points. The poison center also recommends keeping medicines up high and out of reach of children and teenagers, and to really remind parents to be mindful of all medications they keep in their house, and especially the old and expired medications should be disposed of safely, and if you are looking to find guidelines, you can either visit our website at the poison Center at, or also go to the Vermont health department’s website to see how you can properly dispose of your medications safely.

If children are prescribed any medication they need to be monitored like Dr. Bell said closely to ensure it’s being used correctly. Patients attempting suicide most often takes substances easily available to them like Dr. Bell had mentioned, especially over-the-counter medications and prescription medications. It’s also important to remember that many of the cases we see at our poison center and poison centers across the country involve multiple substances.

Do either of you have any other prevention strategies or resources you would like to share with our listeners?

TD: Yeah, I think just building off what Dr. Bell just mentioned, about adolescence being a tricky time for a lot of people, a piece of universal advice for parents and caregivers is to just check in with your kids. And that doesn’t mean necessarily prying—I have two teenage girls and I’m not allowed to pry into their lives at all—but even just checking in and saying “How are you doing?” or “How are things at school?” I think sometimes parents might be surprised by what they learn from doing that.

GF: And Dr. Bell, do you have anything else you want to share?

RB: No.

GF: OK, so our focus today has been on youth, but our poison center is also seeing an increase in patients attempting suicide in those over 60 years of age involving their own medicines. So some of these medications can be quite dangerous in overdose situations.

The Northern New England Poison Center is an integral part of the emergency medical care system and provides fast assistance and necessary assurance to residents and health care providers for Maine, New Hampshire and Vermont. In closing I would like to remind you that the poison center is available 24/7—it’s free and confidential—to help in poison emergencies or to just answer poison-related questions. You can reach the poison center toll-free at 1-800-222-1222, you can text POISON to 85511, or you can chat live at The poison center is an important resource available to everyone and it’s right at your fingertips.

So I’d really like to, again, thank Dr. Bell and Dr. Delaney for joining us today and sharing their expertise. Thank you very much.

TD: Thank you.

RB: Thanks for having us.

GF: Thank you for listening to this episode of Poison Ed. If you or someone you know is in crisis, we encourage you to get support by calling the National Suicide Prevention Lifeline at 1-800-273-TALK, that’s 1-800-273-8255. You can also get support by text. Send the word HOME, that’s H-O-M-E to 741741 from anywhere in the United States, or text VT, for Vermont to the same number, 741741, for Vermont-specific resources. Thank you.

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Foraging for mushrooms can be risky

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:

Lilac brown bolete, a toxic mushroom

The lilac brown bolete is a toxic mushroom, sometimes mistaken for the edible king bolete. Photo courtesy of Greg A. Marley.

  • 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.

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Podcast: What is CBD all about?

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?

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Methotrexate: Dosing for disaster

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
  • Mucositis
  • Stomatitis
  • Esophagitis
  • Renal failure
  • Rash
  • Myelosuppression (leukopenia, pancytopenia, thrombocytopenia)
  • Acute lung injury
  • Tachycardia
  • Hypotension
  • 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.

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Your poison center: A podcast from the NNEPC

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.


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Time to clean out old medications and hazardous waste

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.

DEA medication take-back logoOne 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.

CFL bulb
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.

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What are the tick risks in northern New England?

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.

Tick identification chart from the CDC

Tick identification chart from the CDC

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.

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How to choose a carbon monoxide alarm

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

Logos for UL and ETL

UL and Intertek (ETL) are two of OSHA’s Nationally Recognized Testing Laboratories.

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?

A carbon monoxide alarm

A carbon monoxide alarm will let you know if there is too much carbon monoxide in your home. CDC photo.

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.

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