Senior Thesis: The State of Substance Abuse and Toxicology in Dominican RepublicCynthia Santos M.D.

Overdose is a Significant Issue in Both High and Low Income Countries

Since 2008 Overdose Deaths Are the Leading Cause of Accidental Death in the United States

1) Non-communicable diseases: 13,390 DALYs1. Neuropsychiatric (incl substance

abuse) 3,5852. Cardiovascular disease 3,317

2) Communicable, maternal, perinatal, and nutritional deficiencies: 5,798 DALYs

NCD Country Profiles. Dominican Republic. Geneva: WHO, 2011.

Substance Abuse is Now a Leading Cause of Death in the DR:

The Burden of Illness in the DR Illustrated Through Disability-Adjusted Life Years (DALYs) per 100,000

Chronic Environmental Contaminants Are Also a Neglected

Issue in Dominican RepublicReductions in Blood Lead Levels as a Result of Environmental Intervention in Haina, DR Bret Ericson, Cynthia Santos M.D.

“Blood lead levels (BLLs) were taken on four instances between 2009 and 2014.”

“After the mass removal of lead…BLLs decreased from 25.6 ug/dl  (n=77) to 6.15 ug/dl (n=82) in children.”

Not to Mention Hazards from Pesticides…

“DR stands out as being ranked fourth in the number of fruit and vegetable shipments halted by the U.S. for pesticide residues.”

Despite the increasing overdose mortality worldwide, there is a lack of studies in the Caribbean or in the Dominican

Republic

Background▪ Substance abuse is now a leading cause of death.

▪However, there is no formal training in toxicology, no poison control centers, and relatively little access to appropriate laboratory testing, antidote administration, and specialty referral centers. 

Objectives1)To survey patients, medical students, and residents in Santiago regarding

-previous toxicological exposures (household or occupational) -the use of home remedies -substance abuse-and awareness of acute and chronic ingestions on the burden of disease

2)To design and implement a curriculum written in Spanish to teach core principles about the management of overdose patients to medical students, and residents of family medicine and emergency medicine.

Survey Methods▪ An 89-item survey was distributed and consisted of the following sections:

-demographics-previous toxicological exposures and medical encounters-storage and disposal practices of potential household toxins-traditional remedy practices, alcohol use, prescription pain medication use,

and illicit substance abuse

•Survey respondents were either 1) patients in the waiting room areas of the EDs and clinics at Juan XXIII or

Cabral Hospitals2) community members participating in a basic responder training course held at

Juan XIII3) medical students enrolled in Pontificia Universidad Católica Madre y Maestra

(PUCMMM) 4) family medicine residents at Juan XXIII Hospital 5) emergency medicine residents at Cabral Hospital

Curriculum MethodsI) A 72-page curriculum was written in Spanish -help with editing and translations

Ruben Olmedo MDReynolds Kairus, NYC paramedic and current PUCMM medical studentGeorge Layton, toxicology specialist and medical student in Texas 5 PUCMM medical students Fanny Alerhand, retired Mexican school teacher

II) A 12-item pretest and posttest was given to students and residents enrolled in the course.

III) The curriculum was made available online through the Global Educational Toxicology Uniting Project (GETUP), supported by the American College of Medical Toxicology. http://www.acmt.net/Links.html

Survey Results

History of Previous Exposure: (multiple responces allowed)Students/Residents  Community

heavy alcohol use (daily drinker or binge drinker) 2 (4.88%) 31(23.1%)daily prescription pain medication use 1 (2.44%) 5(3.73%)regular illicit drug use (marijuana, cocaine, heroine, ecstasy, LSD, acid, PCP, etc) 3(7.32%) 10(7.46%)accidental substance overdose requiring medical attention 2 (4.88%) 4(2.99%)intentional substance overdose requiring medical attention 0 (0%) 1(0.75%)accidental prescription drug overdose requiring medical attention 1 (2.44%) 2(1.49%)intentional prescription drug overdose requiring medical attention 0 (0%) 1(0.75%)accidental exposure to household products requiring medical attention 2 (4.88%) 3(2.24%)intentional exposore to household products requiring medical attention 0(0%) 0 (0%)total accidental or intentional overdose of any substance requiring medical attention 5 (1.22%) 11(8.21%)

175 surveys were distributed: -134 community individuals -22 medical residents -19 medical students

16 survey responders (9%) were exposed to toxic substances in the past and sought medical treatment.

33 (19%) report heavy alcohol use. 6 (3%) use prescription pain medication daily.

21 (12%) have tried pesticides like Tres Pasitos, Paraquat, or Chinese Chalk.

32 (18%) practice home remedies.

History of personal use of Tres Pasitos (Aldicarb) ? Y/N 3(7.32%) 7(5.22%)History of personal use of Gramoxone (Paraquat)? Y/N 1 (2.4.%) 5(3.73%)History of personal use of Chinese Chalk or Miraculous Chalk as repellant? Y/N 1 (2.44%) 4(2.99%)If you are exposed to a potential toxin, what are the home remedies you practice? (free text response)    a) induce vomiting 2 (4.88%) 5(3.73%)b) drink a glass of milk 2 (4.88%) 9(6.72%)c) drink baking soda 1 (2.44%) 2(1.49%)d) drink camphor 1 (2.44%) 3(2.24%)e) consume oregano 0 (0%) 1(0.75%)f) drink oatmeal 0 (0%) 1(0.75%)g) drink water 1 (2.44%) 4(2.99%)# (total) who practice home remedies after potential exposure 7(17.1%) 25(18.7%)If exposed to a potential toxin, where would you seek medical treatment? (multiple responces allowed)    a) clinic 35 (85.4%) 130(97.0%)b) emergency room 41(100%) 132(98.5%)c) local pharmacy/medicinal store 1 (2.44%) 24(17.9%)

Questions about toxicological awareness (% answered correctly):

-community members 48%

-medical students/residents

62%

Which symptoms can lead poisoning cause? (multiple responses allowed)    a) neurological problems (learning disability, seizures) 39(95.1%)

98(73.1%)

b) cardiovascular damage (hypertension, peripheral vascular disease) 29(70.7%)

44(32.8%)

c) kidney problems 15(36.6%)35(26.1%

)% total correct responses 67.5% 44.0%What are potential sources of lead? (multiple responses allowed)    

a) gasoline35 (85.4%) 103(76.9

%)

b) paint (wall, ceramic dishware) 38(92.7%)91(67.9%

)

c) batteries 8(19.5%)39(29.1%

)

d) cosmetics (eye liner) 9(22.0%)27(20.1%

)

e) litargio 33(80.5%)74(55.2%

)

f) water 37(90.2%)89(66.4%

)% total correct responses 56.9% 52.6%

Which symptoms can insectides cause? (multiple responces allowed)    a) gastrointestinal effects (nausea, vomiting, obstruction, tissue death) 19(46.34%)

31(23.1%)

b) organ damage (lungs, liver, kidney, CNS, heart) 37(90.2%)62(46.3%

)c) cardiovascular effects (irregular rhythms, failure, shock) 25(61.0%)

58(43.3%)

d) neurological effects (delirium, seizures) 33(80.5%)19(14.18

%)e) abnormalities in vitals (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation) 29(70.7%)

13(9.70%)

f) death 37(90.2%)68(50.74

%)% total correct responses 73.15% 31.22%

▪The surveys and teaching efforts demonstrate that the burden of disease from overdose, substance abuse, and chronic ingestions in this area is high and underappreciated.

▪ Approximately 40% of respondents had potentially high risk practices

-heavy alcohol/substance abuse-use of potentially dangerous traditional remedies - household products that are either illegal, improperly labeled,

handled or consumed.

▪ Long-term goals of this project:-raise public awareness-enhance medical training in toxicology

Lessons Learned