Upstate New York Poison Center marks 65 years of advising about dangerous substances

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The Upstate New York Poison Center marks 65 years of service this year, so I'm talking today with someone who's worked at the poison center for more than 26 years. Dr. Christine Stork is clinical director of the poison center and a professor specializing in overdose, poisoning toxicity and emergency medicine. Welcome to The Informed Patient Dr. Stork.

Christine Stork, PharmD: Hi, thank you so much for having me today.

Host Amber Smith: I'd like to start with some history because the late 1950s, when the poison center began, the times were quite a bit different than they are today. Rock and roll music was new. Television was becoming a popular form of entertainment. The babies born when World War II ended were growing into teenagers. So what about this era made it the right time to start a poison center?

Christine Stork, PharmD: Well, a couple of things happened. In the 1950s, not much was known about poisoning, but then a study came out showing a large amount of morbidity and mortality related to unintentional poisoning in children. So as a result of that, people started being concerned about toxicology. Kind of at the same time, just as background, there were a lot of babies being born and also kind of an industrial revolution. So a lot of new products were available in the home, a lot of new pharmaceuticals. And remember, way back in the 1930s was when our first medications became available. There really weren't a lot of pharmaceutical products, or products over the counter, before that time. So there was just a big upsurge in things being available to the public, as well as a lot of kind of small children available at the same time.

Host Amber Smith: Was there much scientific knowledge at that time about what happened when someone ingested something that was poisonous?

Christine Stork, PharmD: No, there really wasn't. If you go back and look at the first toxicology textbooks, they're rather thin, and they've grown exponentially over time. So there wasn't much known. There was not much known, sometimes, about the products themselves. You know, what was in, "Dr. Smith's Ointment?" That was the label of the product, and at that time it was not required to have the label ingredients included. So that was one of the first big roles of the poison center during that time.

Host Amber Smith: How were overdoses treated?

Christine Stork, PharmD: I think rather supportively. If you go back and look at some of the literature there wasn't, again, a lot of information about antidotes. There weren't a lot of antidotes. That wasn't a lot of information as to best practices. So people just did what they thought they should do. If you go back and look, you'll see literature of using opposite things to try to manage poisonings. A good example is phenobarbital was available way back then, and that causes sedation and eventually can cause people to stop breathing. So during that time, people tried to give stimulant medication to try to mitigate that. And in fact, they realized that that did not work or change the mortality scene after overdose of phenobarbital. So they kind of evolved over that time, and with the advent of the endotracheal tube, which is a breathing tube, which also was not available, if you think about in the early 1900s, they found that mortality instead of being 35% for something like phenobarbital was less than 5%. So lot of evolving medical practice, as well as medications during this time.

Host Amber Smith: When did child safe caps get introduced? And I wonder, did that have a big impact?

Christine Stork, PharmD: So, yes. I cannot remember the exact year that they came out, but if you look at the poison center deaths from aspirin in particular, there was lots of aspirin being used during this time. It was prior to the worrying about Reye's syndrome, so a lot of people used aspirin for pain. It was, THE pain medication. It was available in homes, and lots of children died. And that was the reason or the impetus behind safety caps. And once that happened, you know, now we have very few exposures in children to aspirin. So safety caps were a huge public health gesture and improved the wellness of children after their implementation.

We see something similar, a little bit more recently in the 1990s, with blister packing of iron. Iron was also a big problem in children, causing morbidity and mortality. Even though they were in safety caps, many times there was enough to kill a child within a prescription bottle. So if it was left open, it was a very small dose required. And once they were put into blister packs, we didn't see a tremendous amount of morbidity, even, with iron, much less mortality.

Host Amber Smith: Well, I want to ask you what you can tell us about what the poison center was like when it started. And I know you weren't there when it started. Have you talked with anyone or looked historically: was it in the hospital?

Christine Stork, PharmD: I know when it first started, it was part of the Onondaga County Department of Health. So that's how it was initiated. Its funding was rather shoestring, and the entire role of poison centers during that time in the 1950s was more of a pediatrician-to-pediatrician service. Because these pediatricians would be called about a child getting into a substance. They didn't know what was in the substance. So they would call the poison center, a pediatrician group, which then they went on to hire some people to help with that who looked up the ingredients on these cards. So there was like a microfiche and index card system that was the first databasing of what was contained in products. And that was the main role and what poison centers did during that time.

Host Amber Smith: Was it 24 hours?

Christine Stork, PharmD: I don't know for sure, but I do not believe so, because then later on when the poison center was staffed with nurses in -- I want to say the 1970s, 1980s -- it was located outside of Upstate pediatric emergency department. So it was right in the emergency department in kind of like a little closet area. And during the day the nurses would, again, provide that information, provide a little bit more management.During the overnight hours, the nurses and doctors in the emergency department would pick up that phone.

Host Amber Smith: If I hear you correctly, it started more for physicians to kind of share information among themselves. And today it's, well, physicians can still call for consults, but you get a lot of calls from the public, right?

Christine Stork, PharmD: Yes. It's been an evolution. I think during the 1970s and 1980s, it was largely the public calling. And in late 80s and into the 90s and through today, we're seeing a larger and larger component of healthcare professionals calling for advice from the poison center. Things have evolved continuously in terms of complexity of toxins and knowledge on how to treat poisonings and even the healthcare professionals, many of which don't receive specific training in poisoning and toxicology. So as of today, we're about 60/40. We still get 60% of our calls from the home setting, from parents, but 30 to 40% of our call volume is from healthcare professionals.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Dr. Christine Stork. She's the clinical director of the Upstate New York Poison center and a professor whose specialty is overdose, poisoning toxicity and emergency medicine. And I want to let listeners know they can reach the poison center at 1-800-222-1222.

So what percent of the calls to the poison center today are focused on children?

Christine Stork, PharmD: It depends on how you define children. So we still get about 60% of our calls from the home setting. Of those, a large majority are for children. Mostly, again, toddler children. We do get calls from the home about adolescents and older children. In the hospital setting, historically, I would say in the past five to 10 years, we're moving toward a much higher percentage of calls about adolescents. Adolescent self-harm has gone up dramatically in the past 10 years, if you look at some of the data out there. So while we were called, mostly, from, healthcare professionals about adults in the past, that's been inching down into the adolescent age group.

Host Amber Smith: Interesting. What are the most common items that you get called for, from homes, about toddler accidental ingestions?

Christine Stork, PharmD: The most common things that we get called about are cleaning supplies, cosmetic agents, things like silica gel, so shoe desiccants is a very popular call to the poison center as well. So, things that you find around the home, things that if you have a toddler in your house, and you turn your head for a minute, they grab: toothpaste, all those sorts of things, cleaning agents. We do get calls about prescription medications and over-the-counter medications, but they're not the majority of calls that we get.

Host Amber Smith: Well, I understand some of the most common poisoning emergencies today involve analgesics and antidepressants. Is that because of the prevalence of those medicines in homes?

Christine Stork, PharmD: You know, I think there's two things involved. Now, the prevalence of having analgesics in the home that are over the counter probably accounts for the large exposures to analgesics, both in unintentional exposures, as well as intentional self-harm. You know, people who are depressed or anxious who are on antidepressants have access to those agents. So that is likely the cause, although not studied real well as to why those people have exposures to those agents.

Host Amber Smith: Well, it seems like the poison center sometimes functions as an early warning system. I'm thinking about the alerts from the poison center when the colorful laundry detergent pods came onto the market and children would put them in their mouths, the poison center was pointing out that, that can be harmful. Sometimes we'll hear about batches of illegal drugs that are found to contain really potent chemicals like fentanyl. Do you see the role of the poison center to inform society, in general, about things that could be dangerous?

Christine Stork, PharmD: Yes. I think in recent years, the role of the poison center in public health has increased dramatically. I'm not sure that everyone is aware that every time someone calls the poison center, the data -- meaning the exposure and the symptoms, not the patient identifying data -- but the exposure and the symptoms is auto uploaded to the National Poison Data System every eight minutes. So to identify trends and problems that are occurring in real time is a big role of poison centers. If an alert occurs due to that -- so we have anomaly monitors to look for strange things in our call volume -- those are set to trip the public health messaging, or an evaluation. So that occurs with our National Poison Data System. We do that in conjunction with the Centers for Disease Control and also our state and local departments of health. So things like laundry pods, yes, are identified through that system. When, if you think back several years ago, we had a spike or spice exposure. So in April on a Tuesday morning, we got an anomaly alert that we had a significant increase in calls with regard to that from healthcare facilities. So that is an example of identifying a public health issue. So in response to that, in terms of public health, we will send out alerts. We'll tell people what to watch for. We'll tell people, what we think is going on. We'll do that within the public, so if many of you may have heard some of those things, the poison center says to watch out, for example, or we'll also talk to the healthcare facilities, provide them some management expertise. In that one, I remember a lot of prehospital communications because some of those patients were rather agitated and it was a problem for the prehospital individuals.

I know now we're looking at, or we're concerned about edible marijuana within New York state with its legality that has increased in pediatric patients. So we'll see whether that has goes up dramatically. It has already gone up without it being sold or regulated to be sold yet. So we're looking to see if that becomes a bigger problem, but we want , parents and caregivers to know that that could be a problem for children, in particular.

Host Amber Smith: Well, I know the word poison is in your name, but do you hear from people who have questions about the prescription they got, you know, maybe they picked it up from the pharmacy and they got home and, you know, they forgot to ask about how to take it or what not to take with it. Do you get those calls too?

Christine Stork, PharmD: Yeah, we do. If you look at poison in the broader context, everything is a poison. It's the dose that defines the poison. So when you think about the types of calls we get, I know we've been talking about prescription drug overdoses, but also, a double dose, a drug interaction and adverse drug reaction, someone who has an organ toxicity due to taking their medication, someone who smells something in their environment, carbon monoxide, bites, stings, something got into their eye. There's a whole host of things that are considered poisons. So where we're not just there for people who toddlers get into things are intentional self harm cases. Anything that can cause toxicity to humans are things that we would get involved with.

Host Amber Smith: Do you have any predictions for how the poison center or the field of toxicology is likely to evolve over the next 65 years?

Christine Stork, PharmD: What I can say is that it will. I'm sure that will be nothing like it is today in 65 years, because the knowledge base and how we do business is changing. I think more recently you'll see things like being able to text the poison center, or being able to have a web based interaction with the poison center. I see that coming in the next maybe two or three years, which would be, um, really interesting to see how that pans out, especially for people who like to use electronics to interact with people. I think that'll be a great thing and an advantage. But with the evolution of things that are out there, exposures that we have kind of subdivisions of specialties within toxicology. I think all of that will look different and certainly in the next 65 years.

Host Amber Smith: I appreciate you making time for this interview, Dr. Stork.

Christine Stork, PharmD: Thank you very much for having me again.

Host Amber Smith: My guest has been Dr. Christine Stork, a professor and clinical director at the Upstate New York Poison Center. And I want to let listeners know they can reach the poison center at 1 800-222-1222. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/Informed

I'm your host, Amber Smith, thanking you for listening.