Letter to the Editor
Identification of the drug of abuse flakka (α-PVP) as suspicion of chemical submission in the Emergency Department of a tertiary hospital
Identificación de la droga de abuso flakka (α-PVP) como sospecha de sumisión química no probada en Urgencias de un hospital terciario
Cesáreo Fernández Alonsoa,b,
, Oscar Quintela Jorgec, Andrés Sebastián Santiago Sáezb,d
Corresponding author
a Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
b Comisión contra la Violencia, Hospital Clínico San Carlos, Madrid, Spain
c Servicio de Química, Instituto Nacional de Toxicología y Ciencias Forenses, Madrid, Spain
d Servicio de Medicina Legal, Hospital Clínico San Carlos, Madrid, Spain
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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" => "Oscar" "apellidos" => "Quintela Jorge" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Andrés Sebastián" "apellidos" => "Santiago Sáez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Comisión contra la Violencia, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Química, Instituto Nacional de Toxicología y Ciencias Forenses, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Legal, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Identificación de la droga de abuso <span class="elsevierStyleItalic">flakka</span> (<span class="elsevierStyleBold">α</span>-PVP) como sospecha de sumisión química no probada en Urgencias de un hospital terciario" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chemical submission (CS), from French <span class="elsevierStyleItalic">soumission chimique</span>, is understood to be a person's consumption of psychoactive substances without their knowledge in order to cause a change in their alertness, consciousness or judgement,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> usually with the intent to commit sexual crimes and theft<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> against them, among others reasons. Emergency services are at the forefront of care for patients who suffer any type of acute intoxication, for which it has up-to-date protocols.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> There are a number of recommended medical and legal guidelines for cases of suspected CS.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 53-year-old male of Spanish nationality, with no medical history except anxiety and a normal consumption of benzodiazepines, who visited the A&E of Hospital Clínico San Carlos in the summer of 2015. The patient reported having inhaled a white substance provided by unknown people resulting in an ATM robbery in public, along with psychomotor restlessness, chest pains and palpitations that persisted for about 6<span class="elsevierStyleHsp" style=""></span>h, until his visit. No significant findings were observed in the physical examination. Additional tests found mild leukocytosis and acute renal failure. The toxin analysis, through an immunoassay of urine, detected benzodiazepines, but no cocaine, amphetamines, opiates or cannabis metabolites were identified. The hospital CS registration and legal protocol was activated which involves the extraction of biological samples (blood and urine) and subsequent storage under chain of custody before the patient signs an informed consent. The patient was also advised to report the incident to the police. After two cardiac enzyme analysis, electrocardiograms with no abnormality and confirmation of haemodynamic stability, the patient was discharged after 10<span class="elsevierStyleHsp" style=""></span>h. Six months later an analysis of the patient's biological samples was performed at the National Institute of Toxicology and Forensic Sciences (INTCF), which detected nordiacepam (<0.1<span class="elsevierStyleHsp" style=""></span>mg/l) and α-pyrrolidinovalerophenone (α-PVP) 0.009<span class="elsevierStyleHsp" style=""></span>mg/l; in addition the urine sample tested positive for α-PVP, lorazepam, oxazepam and metamizol. The results indicated that the patient was exposed to those drugs and the drug of abuse α-PVP.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The clinical case presented is of interest as confirmation of non-fatal consumption of the drug of abuse α-PVP, although this is not the first time that it has been identified in our country (previous communications from the Hospital de Son Espases in Palma de Mallorca).</p><p id="par0020" class="elsevierStylePara elsevierViewall">α-PVP is a substance belonging to the synthetic cathinone group, similar to the phenylalkylamines present in the <span class="elsevierStyleItalic">Catha edulis</span> plant, and like them, they are structurally related to amphetamines. α-PVP is capable of producing sympathomimetic toxicity. Although it has already been seen as a powder to be snorted or as <span class="elsevierStyleItalic">flakka</span> tablets, more recently stashes have been seized in which the substance is harmlessly marketed as “bath salts”.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The hypothesis that this is a case of chemical submission or vulnerability of <span class="elsevierStyleItalic">flakka</span> and/or benzodiazepines has not been proven. The aforementioned facts are unclear and the <span class="elsevierStyleItalic">flakka</span> concentrations found were extraordinarily low. Chances are that the patient voluntarily sniffed <span class="elsevierStyleItalic">flakka</span> thinking it was cocaine.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We also emphasise the importance of having a protocol for possible cases of CS that is recommended by the Commission against Violence from that hospital. Similarly, we value and look forward to continuing collaboration with the INTCF, without which it would not have been possible to detect an unknown, emerging toxic in our context.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> With these improvements in performance and coordination we can provide higher quality care.</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: Fernández Alonso C, Quintela Jorge O, Santiago Sáez AS. Identificación de la droga de abuso <span class="elsevierStyleItalic">flakka</span> (α-PVP) como sospecha de sumisión química no probada en Urgencias de un hospital terciario. Med Clin (Barc). 2016;147:227–228.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sumisión química: epidemiología y claves para su diagnóstico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Cruz-Landeira" 1 => "O. Quintela-Jorge" 2 => "M. 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Nogué" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2014" "volumen" => "26" "paginaInicial" => "472" "paginaFinal" => "480" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack254168" "titulo" => "Acknowledgements" "texto" => "<p id="par0035" class="elsevierStylePara elsevierViewall">All Accident and Emergency Department professionals, members of the Commission against Violence at the Hospital Clínico San Carlos and INTCF professionals who have collaborated with their effort and dedication.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014700000005/v1_201611300117/S238702061630540X/v1_201611300117/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014700000005/v1_201611300117/S238702061630540X/v1_201611300117/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061630540X?idApp=UINPBA00004N" ]
