1. National profile and trends
1.2 Drug related acute emergencies
1.2.1 Drug-related acute emergencies
The information on drug-related acute emergences/poisonings are available, but not yet for a whole country. Similarly, to previous years, this article only demonstrates the statistics of treated adult patients, examined and treated for illicit drug poisoning in UMC Ljubljana, a secondary hospital in the Ljubljana region with ca. 600,000 residents. The Rules on reporting, collecting and arranging of data on poisonings in Slovenia (Official Gazette of the Republic of Slovenia, No. 38/00), which include cases of poisoning by NPS, stipulate that all legal and natural persons pursuing medical activity are required to promptly report cases of poisoning to the Slovenian Register of Intoxications, kept by the Centre for Poisoning at the UMCL Division of Internal Medicine. Intoxication data must be sent within 24 hours or on the first working day that follows, i.e.:
in case of hospital treated poisonings following a discharge diagnosis,
in case of clinically treated poisonings following a diagnosis, reasonable doubt for poisoning or following a change in diagnosis (if changed to poisoning),
following the receipt of an autopsy report confirming poisoning.
More about the monitoring system is described in (Sources and methodology).
1.2.2 Toxicology of drug-related acute emergencies
In 2019, the emergency medical clinic of UMC Ljubljana examined 23,996 patients in total. They treated 158 patients for illicit drug poisoning, which is 20 patients less than in 2018. This is the second highest number of illicit drug poisonings in the observed period (Figure 6).
Figure 6.Number of cases treated for illicit drug poisoning at the UMC Ljubljana, Division for Internal Medicine, 2010–2020
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
The number of patients poisoned with illicit drugs in 2020 was represented 0.57 % of all treated patients in emergency medical clinics (Figure 7).The incidence of illicit drug poisoning in the Ljubljana region in 2020 was 22/100,000 residents.
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number of cases
Year
Figure 7. Proportion of cases treated for illicit drug poisoning at the UMC Ljubljana, Division for Internal Medicine, compared to all patients treated, 2010–2020
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
Table 5 shows types drugs used by intoxicated adult patients who were treated at the UMC Ljubljana internal clinic. The number of used drugs in Table 5 is larger than the number of intoxicated patients shown in Figure 6 since drug users often take several different drugs at the same time.
Table 5. Illicit drugs that caused acute emergencies in patients treated at the UMC Ljubljana, Division for Internal Medicine, 2010 to 2020
Illicit drug Number of drugs
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
(n=61) (n=55) (n=61) (n=104) (n=164) (n=193) (n=226) (n=191) (n=257) (n=230) (n=186)
Heroin 35 9 8 14 34 44 42 26 38 32 42
Cocaine 12 10 12 14 34 45 54 49 65 60 45
Cannabis 6 16 23 27 53 64 59 59 57 65 48
LSD 0 0 1 1 1 1 3 2 2 4 3
GHB, GBL, BD 2 2 5 31 19 17 31 18 34 31 20
Amphetamine-type stimulants (amphetamine,
methamphetamine, MDMA and similar) 3 17 12 15 13 17 27 22 34 28 13
New psychoactive substances (NPS) 3 1 0 2 10 5 10 11 4 5 2
Ketamine 0 0 0 0 0 0 0 0 0 0 2
Psilocybe 0 0 0 0 0 0 0 0 0 0 2
Unknown drug 0 0 0 0 0 0 0 4 23 5 9
Total 61 55 61 104 164 193 226 191 257 230 186
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
The number of NPS is relatively low in the last few years (Table 6).
0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Proportion
Year
Table 4.New psychoactive substances that caused acute emergencies in patients treated at the UMC Ljubljana, Division for Internal Medicine, 2010 to 2019
NPS Number of drugs
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Synthetic cathinones (3-mmc) 2 1 0 2 3 3 7 4 3 3 1
Synthetic cannabinoids 0 0 0 0 3 0 0 0 1 0 0
Other NPS (2Cl, 2-CP, NBOMe, DTM,
2-oxo-PCE, 2-MeO-PCE, unidentified tryptamine, 2F-DCK 1 0 0 0 4 2 3 3 0 2 1
Total 3 1 0 2 10 5 10 7 4 5 2
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
The frequency of illicit drug poisonings in UMC has been monitored since 2004. Figure 8 shows the number of people intoxicated with heroin and cocaine since beginning of monitoring.
Figure 8. Number of cases with acute heroin and cocaine-induced emergencies treated at the UMC Ljubljana, Division for Internal Medicine, 2004–20120
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
Figure 8 shows that heroin poisonings gradually increasing again since 2012. In 2020, we notified more heroin poisonings than in the last four years. Since 2017, there is an increasing trend of heroin poisonings. The number of cocaine poisonings are increasing since 2008. In 2018 we observed the highest number of cocaine poisonings so far with 65 cases, which means that the number of cocaine poisonings exceeded the number of cocaine poisonings by 70%. Cocaine intoxication was then, for the first time, the most commonly used illicit drug in patients treated in emergency unit of UMC Ljubljana. In 2019, the number of cocaine poisonings decreased slightly, but the proportion of cocaine poisonings in relation to the heroin poisonings increased, as in 2019, they treated twice as many cocaine poisonings as with heroin. In 2020 the number of cocaine poisonings have further declined, which could be also due to the COVID-19 pandemic.
In last decade, the number of cannabis (THC) poisonings is increasing. Since 2014, cannabinoids are the most common illicit drug found in adults poisoned by drugs in Ljubljana, with exception in 2018 when they were outnumbered by cocaine poisoning. The number of THC poisonings doubled in 2014 compared to the year before. In 2015, we treated 64 cannabis users but between 2016 and 2018, the growing trend of THC poisonings stopped at around 60 cases per year, and in 2019 increased again to 65 caes. In 2020 the number of cannabis poisonings decreased a lot to 48 cases, probably due to
0 10 20 30 40 50 60 70
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number of cases
Year Heroin Cocaine
COVID-19 pandemic. Nevertheless, cannabis is still the most commonly used drug in emergency patients, although in recent years there has been a declining trend in the number of cannabis users in need of emergency medical care. We also noticing some poisonings with hashish oil, which comes from cannabis, but in most cases, these are older people suffering from other diseases (Figure 9).
Figure 9. Number of acute cannabis-induced emergencies treated at the UMC Ljubljana, Division for Internal Medicine, 2010–2020
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
In 2020, the number of Gamma-Hydroxybutyrate (GHB) and Gama Butyrolactone (GBL) poisonings was by a third less compare to previous years. In 2019 number of this poisonings was similar than in 2018, 2013 and 2016 when we recorded the highest number of these poisonings. In 2020, we had only one case of intoxication with GBL (Figure 10).
Figure 10. Number of cases treated for acute intoxication with GHB, GBL and BD at the UMC Ljubljana, Division for Internal Medicine, 2010–2020
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
The number of poisonings with so called “classical” amphetamine-like stimulants, including amphetamines, metamphetamines and MDMA and similar phenethylamines, halved in 2020 compared to 2019 and 2018 when we recorded the highest number of cases so far (Table 5). This, too, is probably
0 10 20 30 40 50 60 70
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number of cases
Year
0 5 10 15 20 25 30 35 40
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Nu,ber of cases
Year
GHB GBL BD
In 2020, we recorded only two cases of intoxication with new psychoactive substances (3-MMC and Brorphine). The decrease in the identified NPS is probably also a consequence of Covid-19 pandemic, and the termination of the SONDA project, which otherwise took place from 2016 to 2018 (Table 5, Figure 11).
Figure 11.Number of patients treated for acute intoxication with GHB, GBL, BD, Amphetamine-type stimulants and NPS at the UMC Ljubljana, Division for Internal Medicine, 2010–2020
Source: UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
1.2.3 Trends
In 2020, emergency examinations of drug addicts accounted for 0.57% of all examined patients in emergency internal medicine clinics in Ljubljana, which is less than in previous years. The most likely cause of this is probably the Covid-19 pandemic. In 2020, we observed only an increase in the proportion of heroin poisonings, while the number of poisonings with all other drugs decreased significantly.
Cannabis is still the most commonly found drug in intoxicated patients treated in the emergency room.
1.2.4. Additional information on drug-related acute emergencies
Consultations on drug poisoning within the 24-hour toxicological information service at the Clinical Toxicology and Pharmacology Center (CKTF) of the University Medical Center in Ljubljana (2020)
In the Center for Clinical Toxicology and Pharmacology of the University Medical Center in Ljubljana there is 24-hour information and consulting service offering help or consultations to physicians and other experts who treat acutely poisoned patients throughout Slovenia. They are collecting data about intoxicated persons and illicit drugs used since 2017. In 2020, they treated 122 intoxicated persons who used 166 illicit drugs (Figure 12, Table 5).
0 5 10 15 20 25 30 35 40
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number
Year
GHB, GBL, BD Amphetamine-type stimulans NPS
Figure 12. Number of cases of intoxication addressed as part of 24-hour information and consulting service at the Center for Clinical Toxicology and Pharmacology of the University Medical Center in Ljubljana, 2017– 2020
Source: TOVIS, UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
Table 7. Number of of illicit drugs used at cases of intoxication addressed as part of 24-hour information and consulting service at the Center for Clinical Toxicology and Pharmacology of the University Medical Center in Ljubljana, 2017 – 2020
Illicit drug Number of drugs used
2017 2018 2019 2020
Heroin 19 17 31 33
Cocaine 28 30 48 28
Cannabis 46 45 73 43
LSD 4 4 4 4
GHB, GBL, BD 14 20 33 15
Amphetamine-type stimulants 37 25 38 23
NPS (3-meo-PCE, 3-mmc, 5F-AKB48 32 30 24 11
Psilocibe 2 0 1 4
Unknown drug 0 0 7 5
Source: TOVIS, UMC Ljubljana, Division for Internal Medicine, Centre for Clinical Toxicology and Pharmacology
When interpreting the data on doctor's consultations, we must take into account that physicians call the toxicologist on duty only if they need help or advice. If they know the treatment of drug poisoning and have experience in the treatment of intoxicated people, they do not need the help of a toxicologist and do not call. Because of that the data in Figure 12 and Table 7 do not reflect the actual number and ratio of drugs used, e.g. doctors are less likely to call in heroin overdoses, as they are more familiar of such poisonings.
As part of the 24-hour toxicological information service of the CKTF of the University Medical Center in Ljubljana, in 2020 they dealt with fewer cases of poisoning with all types of drugs except heroin, which coincides with data on drug treatment in UKCL emergency clinics. Most likely, the decrease in the number of drug poisonings is due to the COVID-19 pandemic. Only the number of heroin poisonings have decreased.
0 50 100 150 200 250 300
2017 2018 2019 2020
Number of cases
Year