Get rid of your expired medications on Saturday, April 28

The U.S. Drug Enforcement Administration is holding a prescription drug take-back day this Saturday, April 28, 2018, from 10 a.m to 2 p.m. at locations across the country. You can use this free, no-questions-asked service to get rid of medications that have expired or that you no longer need. Visit the DEA’s website to find a collection site near you.

Safely getting rid of your medications helps keep children and pets from getting into them, and medication take-back events can help prevent medications from getting into the water supply.

To coincide with this take-back event, the FDA this week posted a redesigned page dedicated to medication disposal.

Also check out the medication disposal video below, put together a few years ago by University of Vermont students in collaboration with the NNEPC’s Vermont educator.

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Alert: Adulterated “spice” in Chicago area

The Chicago area has seen a significant number of cases of people using synthetic cannabinoids (spice, K2, fake weed, etc.) that have been adulterated with brodifacoum. This is a rat poison that can cause profound and prolonged anticoagulation with unmeasurable INRs and clinically significant bleeding.

These patients have required 100s of milligrams of vitamin K and this needs to be continued at high doses as an outpatient as well. It is not clear if all of these have been identified via screening or with bleeding.

There have been at least 2 deaths so far. In the past few days, there were some cases/products identified in Maryland as well.

The NNEPC sees a fair amount of what is described as “spice” although we don’t really know what that actually means. It’s hard to know exactly what chemicals make up that particular “spice”—there is no quality assurance in illicit drug production.

These patients are treated similarly to a warfarin overdose but they can be anticoagulated for a very long time and outpatient therapy can be prolonged. Compliance may be difficult in this population as well.

As far as we know there have not been any cases in Maine, New Hampshire or Vermont, but we need to be alert to the possibility as it is not unexpected that this could end up here.

Please don’t hesitate to call the NNEPC at 1-800-222-1222 with any questions.

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Brushing up on fluoride for kids and adults

What are the benefits of fluoride?

Fluoride is a naturally occurring mineral that can help prevent tooth decay by strengthening the enamel of your teeth. It is added to most types of toothpaste, as well as many other dental products, such as mouthwash. It is also added to the public water supply in many areas to help support dental health. Dentists sometimes prescribe fluoride supplements, such as tablets, especially for people who do not get fluoride from their water.

Should children use fluoride?

Fluoride is beneficial for dental health for people of all ages. As of 2014, both the American Dental Association and the American Academy of Pediatrics recommend using fluoride toothpaste beginning with a child’s first tooth. This will help prevent cavities, which is important for your child’s overall health and development.

Can fluoride be poisonous?

Fluoride is safe when used properly, and swallowing small amounts is not harmful.

Swallowing too much fluoride at once can irritate your stomach.

Regularly swallowing too much fluoride for a long time—such as having too much fluoride in your well water for several years—can lead to a condition called fluorosis. Dental fluorosis develops in children before their baby or adult teeth are fully formed, and causes streaks or spots on the teeth. It is usually not harmful to overall health. Skeletal fluorosis, which affects the bones, is not common in the United States.

A smear of toothpaste and a pea-sized amount
American Dental Association photo showing a smear of toothpaste for children under 3 years old (left) and a pea-sized amount for children 3-6 years (right).

How can I use fluoride safely?

For young children, follow the American Dental Association’s guidelines for tooth brushing:

  • For children up to 3 years old, use just a smear of fluoride toothpaste—about the size of a grain of rice.
  • For children age 3 to 6, use a pea-sized amount
  • Watch young children when they brush to make sure they spit out rather than swallow the toothpaste.

Store toothpaste and other dental products up high, out of the reach of young children. Keep them separate from medications and food to prevent accidental poisonings.

When using dental products, carefully follow the directions from your dentist or on the product label.

What about training toothpaste?

While some companies still make training toothpaste or other fluoride-free toothpaste for young children, the American Dental Association strongly recommends using small amounts of fluoride toothpaste as described above. Fluoride-free toothpaste will not help prevent cavities. Using a smear amount of fluoride toothpaste to brush your child’s teeth is safe, even if your child accidentally swallows the toothpaste.

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Why you should keep products in their original containers

“Keep products in their original containers.” Whether it’s a medication, a cleaner or an automotive product, this is one of our top tips for preventing poisonings, because mistakes are easy to make!

Windshield washer fluid and antifreeze
Keeping automotive products like windshield washer fluid and antifreeze in their original containers can help prevent poisonings. Photo by Paul Cooper, used under Creative Commons 2.0.

For example, every year we receive dozens of calls about people accidentally drinking automotive products that were placed in drink bottles. It’s a mistake that adults are just as likely to make as kids.

Maybe you were out of windshield washer fluid and your friend poured some of theirs into a sports drink bottle for you. Or perhaps you needed to drain off some antifreeze and collected it in a soda bottle. If they’re not in the original container, these products can easily end up in your mouth instead of your car!

If for some reason you have to keep a product in a drink bottle or some other container, peel off all the original drink labeling, make sure you clearly mark what is in the bottle, and store it up high, out of the reach of children and pets, with the cap on tight. Always store products in a separate area from any food or drink.

Always put products away as soon as you are done using them to prevent poisonings among young children. Remember that a bad smell is not enough to keep a kid from drinking something.

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Ways the poison center helps school nurses

The poison center is a great resource for school nurses. Not only does the poison center offer quick, expert treatment advice for possible poisonings of students and staff, it also can answer questions about a wide variety of medications and other products. The poison center provides educational materials and programming, as well as in-person education.

The Northern New England Poison Center receives about 500 calls a year from school nurses in Maine, New Hampshire and Vermont. Here are just a few of the situations the poison center helped school nurses with in the past couple years:

  • Photo of a school hallway by Henry de Saussure Copeland
    School hallway photo by Henry de Saussure Copeland. Creative Commons 2.0.

    A 6-year-old boy ate sumac berries found near the school.

  • Four students ages 7-10 all drank some hand sanitizer.
  • An 11-year-old boy was sprayed in the eye with a water-conditioning chemical by another student.
  • A 13-year-old girl got formaldehyde in her eye while dissecting a frog in science class.
  • A 16-year-old boy accidentally took a double dose of his ADHD medication.
  • A student’s cellphone caught on fire and released fumes in the cafeteria.
  • A school bus had a potential antifreeze leak into the passenger compartment.

The poison center also helps school nurses in cases where students have abused substances or tried to harm themselves.

Besides cases of possible poisoning, the NNEPC, answers questions for school nurses about products used in the school, medications, trends in substance abuse and more. It offers lessons for use in the classroom on topics such as electronic cigarettes and caffeine, and trainings for school nurses on current poisoning topics, such as opioids and synthetic drugs of abuse.

The poison center is here for school nurses and everybody else, 24 hours a day, 365 days a year. Just call 1-800-222-1222, chat online or text POISON to 85511.

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Choosing Wisely: Toxicology

Choosing Wisely logoThe Choosing Wisely campaign, conceived by the National Physicians Alliance, provides evidenced-based and practical recommendations in a number of clinical disciplines to help patients and physicians make good decisions. The campaign focuses on clearing up misconceptions and avoiding unnecessary and costly interventions.

The American College of Medical Toxicology and the American Academy of Clinical Toxicology have created a list of 10 items that are relevant to primary, emergency, and specialty care providers regarding specific toxicological treatment and evaluation.

The Northern New England Poison Center has nurses, physicians and pharmacists ready to assist you 24/7. Let us help you choose wisely when a toxicology-related question arises, or even if you are unsure if it’s toxicology related. Call 1-800-222-1222.

Choosing Wisely, Toxicology: Ten Things Physicians and Patients Should Question
American College of Medical Toxicology and American Academy of Clinical Toxicology

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Stay safe this Halloween

Jack-O'-Lantern
Jack-O’-Lantern by William Warby. Creative Commons.

For many of us October means Halloween—picking out costumes, carving pumpkins, and maybe dipping into the candy stash a little too early!

While a little spookiness is part of the fun, none of us want anything actually scary to happen. Follow these tips for a fun and safe Halloween:

  • Dress trick-or-treaters in brightly colored costumes made of flame-resistant materials. Add reflective tape to costumes or trick-or-treat bags to make sure your child is visible after it gets dark.
  • If you use makeup, test it on a small area of skin first. Keep an eye out for skin irritation or an allergic reaction, such as a rash or itching. If this happens, remove the makeup right away with soap and water. Remove all makeup before bedtime to prevent skin and eye irritation.
  • Keep an eye on kids playing with glow sticks. They can break and sometimes children chew them open. The insides of a glow stick can irritate the skin and eyes and cause an upset stomach.
  • Bring along your own candy to give your children while trick-or-treating so they will not eat candy you have not inspected from their bags.
  • Inspect all treats before kids eat them. Only eat treats that are in their original, unopened wrappers. Throw out candies with wrappers that are faded, have holes, tears or signs of rewrapping.
  • Keep candy, such as chocolate, away from dogs and other pets. It can be poisonous to them.
  • Keep candle-lit jack-o-lanterns off doorsteps and out of the way of foot traffic. They can be a fire hazard for trick-or-treaters with long or flowing costumes.
  • Keep dry ice out of drinking glasses. Dry ice can cause frostbite if it touches your skin or mouth.

Most importantly, always supervise your child, and remember you can call the poison center at any hour at 1-800-222-1222 or chat online if your child chews on or swallows something that may be harmful.

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Make poison prevention part of your emergency preparedness plan

The right preparation can help you get through an emergency. For a poisoning, that includes having the poison center help line, 1-800-222-1222 saved in your phone.

For other emergencies, such as natural disasters, it’s important to be prepared to take care of yourself and your family for at least three days. Follow these three steps from the Federal Emergency Management Agency:

  1. Family prepares for emergencies
    Every September is National Preparedness Month. Photo from ready.gov.

    Make a kit

    • Pull together items your family will need during a disaster. Visit www.ready.gov for a list.
    • Make sure your kit includes at least a three-day supply of any medications you need.
    • Keep the kit out of the reach of children.
  2. Make a plan
    • Choose someone you know in a different town that you can have your family call if you are separated.
    • Set up a meeting place for your family to gather.
    • Check with your workplace and your children’s schools to find out what their emergency plans are.
  3. Be informed
    • Learn about different types of emergencies and how they can affect your family. This will help you make quick changes to your family plan. Visit www.ready.gov for a list of possible dangers you could face.                                                                        

You can be prepared for personal emergencies by saving other important help lines in your phone. Visit the NNEPC’s R U Prepared program page for more information.

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Fentanyl and carfentanil exposures in first responders

Download this as a printable fact sheet

Summary

The risk of significant opioid exposure is minimal for first responders who encounter fentanyl, carfentanil or other fentanyl analogs in the field. The evidence suggests that limited precautions, such as nitrile gloves, provide sufficient protection from harm. Use of excessive protective equipment could delay patient care and prevent first responders from performing their duties well.

Background

Fentanyl and fentanyl analogs, such as carfentanil, are very powerful opioid drugs sometimes found in or sold as heroin, leading to accidental overdoses. First responders have concerns about the risk associated with performing their duties when these drugs may be involved. The Drug Enforcement Agency and the National Institute for Occupational Safety and Health have warned of potentially significant harm and suggested protective equipment. Anecdotal reports suggest that minimal exposure while performing normal duties can cause dizziness or feeling like one’s body is “shutting down.” However, no reports have yet involved clinical effects consistent with a significant opioid poisoning. The evidence to date indicates there is minimal risk to first responders encountering patients who have overdosed on these substances or encountering situations involving small amounts of the drugs. First responders need to balance safety with mobility and efficiency.

Risks

Risks from inhalation, skin exposure and eye exposure are all minimal.

  • Inhalation: Even in circumstances involving manufacturing of fentanyl and analogs, nearly 200 minutes of exposure is required to reach a starting dose of fentanyl. It is extremely unlikely a significant exposure would occur in a first responder.
  • Dermal: Therapeutic fentanyl patches intended for skin absorption require prolonged contact time, an occluded area and a delivery system. Short exposure to powder which is then brushed or washed off with water would be extremely unlikely to lead to significant absorption. Note: Alcohol hand sanitizers will not remove the drug and may increase absorption.
  • Ocular: Eye contact is unlikely, but should be avoided.

Treatment

Naloxone is indicated only for a patient who has respiratory depression—a patient breathing very slowly or not at all. These patients will also be unarousable or unconscious. Although limited information is available related to fentanyl and its analogs, animal data suggest that humans should respond to naloxone in these cases. Note that large doses, greater than 10 mg, are unlikely to be helpful.

Recommendations

Standard precautions are reasonable, despite limited data.

  • Recognize opioid effects:
    • Drowsiness (naloxone NOT indicated)
    • Pinpoint pupils (naloxone NOT indicated)
    • Respiratory depression (naloxone indicated)
  • Dermal protection:
    • Use nitrile gloves for routine handling (evidence processing)
    • Wear coveralls in heavily contaminated areas
  • Eye protection:
    • Safety goggles/glasses if face splashing is expected (unlikely)
  • Respiratory protection:
    • N95 or P100 ONLY IF there are significant amounts of powder in the air (unlikely)
  • After skin or eye exposure:
    • Wash with large amounts of water if the skin or eyes are exposed
    • Do not use hand sanitizer

Adapted from the ACMT/AACT position statement “Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders.”

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How to use bug spray safely

Summer is here and many of us in northern New England will be spending more time outside. It’s a busy time for everyone, including the Northern New England Poison Center. During the warmer months, the poison center manages many calls about pesticides, such as insect repellents, often referred to as bug spray.

Insect repellents with DEET can be very effective at preventing bites from mosquitos, ticks and other pests. This can this help you avoid pain and itchiness from bites, and also help prevent diseases such as Lyme. Depending on the amount of DEET in the product, an insect repellent will keep ticks away for two to ten hours, and mosquitoes for two to twelve hours.

Use insect repellents safely by following these steps: 

  • Read the directions on the product label each time you use it, and follow the directions carefully.
  • Do not apply insect repellent over cuts, wounds, or irritated skin.
  • Do not apply it near your eyes or mouth.
  • Wash the product off with soap and water once you are indoors, and wash treated clothing before you wear it again.
  • Call the poison center at 1-800-222-1222 if you spray into eyes or get in mouth, or if you think you are having a bad reaction to DEET.

Take special care with children. Products with a concentration of 30% DEET or less have been shown to be safe for children older than two months. An adult should always apply insect repellents to children. Avoid using the product on children’s hands.

Pesticide SafetyGuide to reading a pesticide label

Pesticides include many more products than just insect repellents, though. Common pesticides found in the home include weed killers, ant traps, flea treatments, rat poison and disinfectants. Every product classified as a pesticide is required to give standard information on the label. Click on the graphic to the right for a guide to reading a pesticide label.

Here are some general tips for using pesticides safely:

  • Read and carefully follow the directions on the pesticide label for use, safety, storage and disposal. Read the label each time you use the product.
  • Use pesticides in a well-ventilated area and keep kids and pets away during application.
  • Never use an outdoor-use pesticides indoors.
  • Store all pesticides out of reach of children and pets.
  • Keep pesticides in their original labeled containers, and store them separately from food, drinks, medications and other products.
  • If you have pesticides you no longer need, be sure to dispose of them properly. Call your town office or local waste facility to find out the best way to get rid of these products in your community.

If someone swallows or inhales a pesticide, or gets one in their eyes or on their skin, call the poison center at 1-800-222-1222, chat online or text POISON to 85511. The poison center is available 24/7, and all calls are free and confidential.

For general questions about the choosing, storing or using pesticides, call the National Pesticide Information Center at 1-800-858-7378 or visit npic.orst.edu.

Crossposted with the UVM Medical Center blog.

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