Letter to the Editor
Methoxetamine-associated emergencies. First Spanish descriptions of this new drug
Urgencias asociadas al consumo de metoxetamina. Primeras descripciones en España de esta nueva droga
a Sección de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
b Grupo de investigación Urgencias: procesos y patologías, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
c Laboratorio de Toxicología, Centro de Diagnóstico Biomédico, Hospital Clínic, Barcelona, Spain
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First Spanish descriptions of this new drug" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "416" "paginaFinal" => "417" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Santiago Nogué, Miguel Galicia, Marina Parra, Jordi To-Figueras" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Santiago" "apellidos" => "Nogué" "email" => array:1 [ 0 => "SNOGUE@clinic.ub.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Miguel" "apellidos" => "Galicia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Marina" "apellidos" => "Parra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Jordi" "apellidos" => "To-Figueras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sección de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de investigación Urgencias: procesos y patologías, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Laboratorio de Toxicología, Centro de Diagnóstico Biomédico, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Urgencias asociadas al consumo de metoxetamina. Primeras descripciones en España de esta nueva droga" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Drug abuse is a reality in virtually every country in the world. In Spain, the latest report of the Spanish Observatory of Drugs and Drug Abuse<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> shows that the prevalence of consumption in the last 12 months of illegal drugs in the Spanish population aged from 15 to 64 years is very high for cannabis (10.6%) and cocaine (5.4%), moderate for amphetamine derivatives (1.4%) and low for hallucinogens (0.5%) and heroin (0.1%).</p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the major challenges that health professionals attending these drug users face is the growing invasion of new substances. For example, 317 new illegal psychoactive products were identified in Europe in the period from 2005 to 2013.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> New drugs mean new toxicological hazards on various organs, new analytical challenges to identify them and new questions for emergency physicians and toxicologists on the therapy to be used in the adverse reactions caused by consumption and overdose.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2010, a first case of methoxetamine (MXE) overdose was reported, and soon after, the first fatal case.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> MXE is a derivative of ketamine, which has been introduced among users of other drugs of abuse for their ability to induce hallucinogenic and dissociative disorders, but without the side effects, mainly urological, of Ketamine. It has been seized in powder form in various European countries and in Spain it has been identified in samples sold as ketamine, ecstasy, cocaine, speed or mephedrone.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> But to date, overdose or adverse reactions have not been reported in our country. This is why we believe our experience to be of interest.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our experience is on 3 patients treated in the emergency department from 31 August to 6 September 2014. The first case was a 24 year-old male, referred after an episode of seizures associated with traumatic brain injury. He admitted having smoked “methoxyamphetamine” and cocaine, sniffed ketamine and drunk alcohol immediately before the episode. He was conscious at hospital admission, but disconnected from the environment, and an intense psychomotor agitation, requiring initial administration of diazepam, with subsequent continuous intravenous infusion of midazolam and eventually, mechanical containment. In the initial Enzyme-Linked Immunosorbent Assay at the Laboratory of the Emergency Department, urine was positive for ketamine and benzoylecgonine (cocaine metabolite), and negative for amphetamines (cutoff value [cv]: 1000<span class="elsevierStyleHsp" style=""></span>ng/ml), benzodiazepines (cv 200<span class="elsevierStyleHsp" style=""></span>ng/ml), cannabis (cv 50<span class="elsevierStyleHsp" style=""></span>ng/ml), methadone (cv 300<span class="elsevierStyleHsp" style=""></span>n/ml) and codeine/morphine (cv 300<span class="elsevierStyleHsp" style=""></span>ng/ml). The determination of blood ethanol was negative (<0.2<span class="elsevierStyleHsp" style=""></span>g/l). Urinalysis by gas chromatography–mass spectrometry (GC–MS) confirmed the presence of cocaine and metabolites, as well as ketamine and metabolites, and also MXE, not detecting methoxyamphetamine. Cranial CT scan was normal. The patient gradually improved and was discharged without complications 8<span class="elsevierStyleHsp" style=""></span>h after admission.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cases 2 and 3 are women aged 20 and 23 years attending the emergency department simultaneously and by their own means. Both said they had been victims of sexual assault under the influence of a chemical submission. They acknowledged having met a group of men hours before and waking up in a state of confusion and disorientation, with distorted images, difficulty to react and signs of having been sexually assaulted. Both acknowledged having consumed alcohol, and one of them having used cocaine and other unidentified substances, and suffer, from that moment on, from an episode of amnesia during several hours. Sexual assault protocol was activated and samples were taken for toxicological analysis. In the first woman, the immunoassay was positive for cocaine and GC–MS detected MXE and confirmed the presence of cocaine. In the second, ethanol levels in blood were 0.4<span class="elsevierStyleHsp" style=""></span>g/l. The immunoassay was only positive for cocaine and GC–MS detected MXE and confirmed the presence of cocaine metabolites. After medical–legal assessment, they were discharged.</p><p id="par0030" class="elsevierStylePara elsevierViewall">MXE has an affinity for N-methyl-<span class="elsevierStyleSmallCaps">d</span>-aspartate receptors, such as ketamine, and for the serotonin transporter, such as phencyclidine, stimulating release and blocking dopamine reuptake.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Is is commonly used intranasally. It is supplied in powder form and administration is around 40<span class="elsevierStyleHsp" style=""></span>mg per dose. Many websites offer the purchase of this product intended for “non-human consumption”.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The expected effects are euphoria, empathy, social interaction, tranquility, visual hallucinations, enhanced sensory perceptions and dissociation of the physical body (out of the body). Its side effects include dysarthria, poor concentration, incoordination of movements, anxiety, paranoia and psychomotor agitation. And its toxic effects include panic attacks, extreme violence, confusion, disorientation, amnesia, seizures and heart rate disorders.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Over 20 deaths associated with the consumption of MXE have been reported, with laboratory confirmation, but in all cases other drugs were also present.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> There is no known antidote and treatment is symptomatic.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cases reported correspond to the adverse/toxic effects described for MXE. These cases confirm a profile of young consumers and in a context of simultaneous use of other drugs. Its potential role as an inducer of psychomotor agitation, seizures and to facilitate sexual assault must be taken into account in the emergency services, medical and legal institutes and toxicology laboratories.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nogué S, Galicia M, Parra M, To-Figueras J. Urgencias asociadas al consumo de metoxetamina. Primeras descripciones en España de esta nueva droga. Med Clin (Barc). 2015;145:416–417.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Observatorio Español de la Droga y las Toxicomanías. Informe 2011. 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Jankowski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2478/s13382-014-0290-8" "Revista" => array:6 [ "tituloSerie" => "Int J Occup Med Environ Health" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "683" "paginaFinal" => "689" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25060403" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014500000009/v2_201605020201/S238702061600187X/v2_201605020201/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014500000009/v2_201605020201/S238702061600187X/v2_201605020201/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061600187X?idApp=UINPBA00004N" ]
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