Expanding Its Niche in Modern Health Care
This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
The science of toxicology traces its roots to those early cave dwellers who
were the first to discover the abundance of poisons in the natural world.
Through what must have been catastrophic episodes of trial and error, our
ancestors learned how to extract lethal poisons from local flora and fauna to
better hunt and defend against invaders.
Later, humankind evolved to discover that toxic substances found in nature
could be used for purely evil purposes, such as the tragic events that took the
lives of Socrates (henbane), Cleopatra (snake venom) and Claudius (mushrooms).
The 16th century produced many free thinkers, including a notable Swiss
alchemist named Paracelsus, who recorded that "All substances are poisons; there
is none which is not a poison. The right dose differentiates a poison from a
Known as the father of toxicology, Paracelsus discovered that all substances
are poisons if exposure and absorption are excessive. At very low doses, even
the most toxic chemicals will cause no noticeable side effect on humans, while
at very high doses, essential substances like salt, oxygen and water will
potentially cause adverse effects ranging from sudden death to subtle changes
not immediately realized.
Fortunately, knowledge of how toxins damage the body has paralleled the
changing world of modern medicine. As we entered the 21st century, today's
toxicologists are benefiting from recent advancement in DNA and protein research
that explains toxic effects at the molecular level. In fact, an emerging field
known as toxicogenomics combines genomics and bioinformatics to identify and
characterize mechanisms of toxicity of compounds. It is now well established
that virtually all toxic effects are caused by changes in specific cellular
molecules and biochemicals.
Locally, the Division of Toxicology at UMass Memorial Medical Center provides
a broad range of consultation services for the management of the critically ill,
poisoned patient. The seven-member division, comprised of physicians and
toxicology specialists, provides management recommendations for an average of
four UMass Memorial Emergency Department (ED) patients per day. The group also
provides as many as 15 daily telephone consults to EDs throughout New England.
"A medical toxicologist is on call around the clock, and we welcome
consultation requests from all physicians and health care professionals," said
Edward Boyer, MD, PhD, chief of the division. "We accept the transfer of acutely
poisoned patients from other hospital emergency departments, facilitated through
a single phone call to our Life Flight air ambulance service."
Staff members in toxicology provide many additional clinical and
informational resources. The division's attending physicians assist clinicians
in identifying and managing unanticipated adverse drug events. They also offer
pharmacokinetic analysis of patients with comorbid illness requiring multiple
drug therapy in order to avoid unanticipated drug interaction.
On an outpatient basis, the Toxicology Division performs independent medical
evaluations of individuals who believe they were exposed to environmental or
occupational toxins. UMass Memorial toxicologists are recognized throughout New
England for expertise in assessing exposures to chemicals in the workplace and
provide consultation services to the Agency for Toxic Substances and Disease
Registry, and the Centers for Disease Control.
As a result of current global unrest following the events of September 11,
2001, UMass Memorial medical toxicologists are fully trained and equipped to
provide expert consultation for all forms of chemical terrorism. In addition,
the division serves as a key resource for first responders in Central
Massachusetts by assessing hazardous materials exposures. The division's
clinical activities in this area are augmented by staff member Steven Bird, MD,
who studies the mechanisms of toxicity of organophosphates, a class of chemicals
that are potent chemical weapons.
The staff is currently involved in several clinical studies, including a
National Institutes of Health funded project to assess the relationship between
the Internet and illicit drug usage, a project that has garnered national
attention and numerous network television appearances for Dr. Boyer, the study's
While the Internet has forever changed the way commerce is conducted around
the globe, those profiting from this powerful business enabler include merchants
of illegal drugs. As drug wheelers and dealers go high-tech, increased numbers
of children and teens are turning on by simply turning on their PCs.
Another problem facing toxicologists is the emergence of drugs that are being
used with other substances to produce specific neurobehavioral effects. Under a
presumption of legality, these items can be easily purchased from retail
outlets. "The number of patients who present in the ED for medical care
following use of these substances is low, but the increase is identified from
our investigations and patient interviews," said Dr. Boyer.
Currently, Dr. Boyer is the principal investigator for a research project to
study "club" drugs, so-called because popular usage occurs in nightclubs and
other entertainment venues. In recent years, this class of drugs has gained
popularity among teens and young adults. Dr. Boyer pointed out that the
availability of stronger drugs is producing immediate toxicity, as well as
"Ecstasy, GHB and ketamine are responsible for significant morbidity and
mortality," commented Dr. Boyer. "Also, over-the-counter medications such as
dextromethorphan are popular recreational drugs and are especially common among
12 to 15-year-olds. Abuse of pharmaceuticals like dextromethorphan may be
responsible for promoting significant illicit drug use in later years with
attendant health risks."
What is clear is that the diligence of today's ED toxicologists in studying
current drug use is yielding important trend data on emerging patterns and the
health consequences of substance abuse in the United States.
According to Greg Volturo, MD, chair, Department of Emergency Medicine, "Our
Emergency Department has the ability to care for a wide variety of toxicologic
emergencies utilizing the expertise of our toxicologists and specialists from
many departments, including emergency medicine, pediatrics, pharmacy, nephrology
and others. We are filling a significant health care need in Central New England
by providing a well-balanced toxicology consultation service to improve the
quality of care for those with potentially toxic exposures, including prescribed
medications, occupational and environmental concerns and widespread drug abuse."