Medical Toxicology and Poison Prevention in Pediatrics with Dr. Anthony Pizon

Pittsburgh Poison Center | CHP.edu

Medical Toxicology | The University of Pittsburgh

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Amanda Poholek: From UPMC Children's Hospital of Pittsburgh, this is That's Pediatrics. I'm your host, Amanda Poholek, Assistant Professor of Pediatrics and Immunology.

Dr. Arvind Srinath: And I'm your co-host, Arvind Srinath, Associate Professor of Pediatrics in the Division of Pediatric Gastroenterology.

Dr. Poholek: Our guest today is Dr. Anthony Pizon. Dr. Anthony Pizon is Professor and Chief of the Medical Toxicology Division and Director of the Medical Toxicology Fellowship Program in the Department of Emergency Medicine here at UPMC Children's Hospital of Pittsburgh. Dr. Pizon received his medical degree at the University of Toledo, and completed his emergency medicine residency here at UPMC, followed by his medical toxicology fellowship training at Banner University Medical Center in Phoenix, Arizona.

Dr. Pizon is board-certified in emergency medicine, medical toxicology, and addiction medicine. In addition, he serves as the Vice President for the American College of Medical Toxicology. His research interests include the novel pharmaceutical management of withdrawal syndromes, the evaluation of cost-effective care provided by medical toxicologists, and biomarkers of hepatic injury after acetaminophen toxicity. His real passion lies in the education of fellows, residents and medical students, and I think, today, our listeners of this podcast.

Welcome to our show, Dr. Pizon.

Dr. Anthony Pizon: Thank you for having me.

Dr. Poholek: So can you just start with sharing a little bit about your path to medical toxicology and here to UPMC Children's?

Dr. Pizon: Yeah. It was a bit serendipitous, honestly. When I entered medical school, I loved pediatrics and that's where I thought I was headed was pediatrics. But then I fell in love with emergency medicine and did an emergency medicine residency. Later, as time went on, I got inspired to do a medical toxicology fellowship from some great mentors here at UPMC. There was no fellowship here, so I went away to Phoenix to do fellowship and came back to work with them as well. And it brought me back to Children's. So things come back full circle all the time.

Dr. Poholek: Yeah. Absolutely. So I would love to hear just sort of like, what does a typical service look like for you? And if you could share a little bit about what toxic substances do you see routinely, and whether these sort of stratify by age group.

Dr. Pizon: Yeah, definitely. We see really two big age groups. The one age group is the toddler, the interested toddler who's inquisitive and gets into everything. So if you leave a pill, a chemical, or whatever out, that little toddler gets into things. Then the other big age group we see are the adolescents. And these adolescents are either dabbling in illicit drugs, or they're dealing with depression and anxiety and overdosing on medications. So those are the two big categories of patients that we see.

Dr. Poholek: So in a typical service, do you go back and forth, pinging between these types of patients?

Dr. Pizon: Absolutely. Yeah. I mean, you can imagine, with toddlers, and there's a lots of opioids, parents dealing with substance use disorder and toddlers getting into the medicines. Medicinal marijuana is very easily accessible now. So we see a lot of that. And then unfortunately, I'm not sure the exact cause, a lot of theories out there, but a lot of kids are dealing with depression and anxiety right now, and they cope by taking too much of their medicines. So we're dealing with those two big patient populations right now.

Dr. Srinath: So with the increase in ingestions or exposures, I can't imagine the numbers that our local emergency rooms are seeing, or even floors are seeing too. When do they get you involved, for example, in the management?

Dr. Pizon: Really, any time chemicals or medications are involved, they call us and we have a primary admission service. So we will admit them here at Children's, which is a little bit unique for medical toxicology to have their own admission service. Normally, it's a consult only. But anytime... Basically, I tell them, if they're admitted for an overdose or chemical exposure or a drug-related issue, they should call us and we'll happily admit it. So that's normally how it goes.

Dr. Srinath: That's an amazing service you have, first of all, especially in the past few years too. 50 years of Pittsburgh Poison Center, how has technology evolved to help you with medical care?

Dr. Pizon: It makes things so easily accessible. We've made things a lot safer. The internet, you have Dr. Google, which is good and bad. So things are so accessible that people will often Google something, and depending where you go, it can make you super paranoid so call the poison center, or you can presume, "Oh, it's super safe. I don't need to worry about it, but then my child's not acting right." So Dr. Google unfortunately leads us astray. So technology could be good and bad, and I think that's probably where we get most of our interesting phone calls.

Dr. Srinath: And along those lines, have there been major enhancements in terms of a diagnostic perspectives where technology has helped you over the past 10, 20, or even 30 years?

Dr. Pizon: Our drug testing capabilities have really blossomed in terms of the technology. I don't want to bore your listeners to death, but we can detect, gosh darn, almost anything in a person's urine pretty easily. I mean, there's some exceptions, of course, but the amount of detail that we can go dial down on drug testing is pretty good. Certainly, we miss things, it's not infallible, but we do it a lot for confirming what a kid may have been exposed to or if there's a child abuse issue to confirm that the drugs were related. So the ability to do these very sophisticated drug tests have really helped us.

Dr. Srinath: That's amazing.

Dr. Poholek: Yeah. I wonder if we can kind of get back to the two different age groups. So starting with the toddlers, as a parent, we hear all the time about locking up our cleaning solutions, keeping our drugs away from kids and making sure they're in safe places. Are there specific substances, particularly sort of thinking about toddlers, that you think don't really receive adequate attention that are still posing a consistent threat, that despite 50 years of the Poison Center and that kind of trying to train people of what they need to be thinking about, where are we still missing the gaps?

Dr. Pizon: Yeah, I think parents are largely pretty good at locking up chemicals. Where we see the biggest problems are grandparents is one area, where they're just not used to little kids around. And of course, grandparents tend to have medications that could be pretty harmful to children, blood pressure medications, for example, or blood thinners. So that's one thing.

The other big issue we deal with are parents and family members dealing with substance use disorder. And you can imagine, if there are illicit drugs available, they're not typically locked up or secured. The other big category is medical marijuana too. Medical marijuana, that's really blossomed in terms of number of pediatric exposures we've seen too. So those are probably the biggest factors. The grandparents aren't used to it. And then the illicit drugs or medicinal drugs that maybe aren't carefully put away.

Dr. Poholek: So, can I ask what is probably a really naive question, so what specifically are the real dangers to a toddler for medicinal marijuana? It sounds like it's obviously dangerous, but more specifically, what happens?

Dr. Pizon: Yeah. It's funny because, not funny, but it's interesting that, in adults who use too much marijuana, it's not typically a problem. On the adult side, we never admit an adult with a marijuana exposure. But in children, the marijuana now is much more concentrated and potent than it was even a decade ago. And children are often eating substances that are unknown to have marijuana in it because it looks like a gummy, it looks like a brownie, it looks like a candy. And when you ingest marijuana, these high concentrations, it lingers around longer, so these toddlers are sicker for a day or more. And in children, you see more hypotension. You see more apnea or lack of breathing as well. So unfortunately, some of these kids we've actually had to put on pressers in the ICU or monitor their airway. So it's certainly much more concerning in a toddler than exposures in adults.

Dr. Poholek: That's really important to know, and I definitely think that that's not something that's out there. As we see more and more medicinal marijuana use, that feels like it should be something that is far more clear to the general public as well as to parents. So then kind of pivoting to the other side of the adolescents, obviously, we know drug and alcohol use is a consistent concern, ever since I was an adolescent. What do you feel like is the latest research that tells us about tackling this challenging issue, and how do you approach it from a medical toxicology perspective?

Dr. Pizon: Unfortunately, when we're involved, we're often kind of on the later end. These children have been using drugs for a while, so we're sort of sometimes the bottom, where these kids are hitting rock bottom per se, if there could be.

So what I would recommend is having parents intervene earlier. I think parents, we sometimes, I mean, I'm a parent of four children, we get a little bit lackadaisical. And those darn phones, they're so engrossed in those phones. You have to be involved in their daily activities, in what they're doing on their phone. And really being a nosy parent, I think is the best way of putting it, because these children are really good at hiding their activities and what they may be dabbling in. Then it's not til the child is in a coma in the hospital that parents start rifling through their phone and recognize, wow, this has been a problem for a while.

And it really stems from bullying online, social media, experimentation with drugs. So you really have to engage your kids early and let them know that the family's a safe place to discuss this, really involve yourself in their day-to-day activities so you can recognize any issues sooner than later.

Dr. Srinath: So I think that's a great segue because we're hearing the horrible effects of these increasingly common substances. And how do you educate families about prevention, particularly for the toddler age group, right? Grandparents or even medical marijuana, preventing this from happening again?

Dr. Pizon: Yeah, I mean, we have resources to lock stuff up and put it away. And to your point earlier, I don't think most people recognize the harm in marijuana. We've really come full circle. They've done lots of studies that show that our perceptions of the harm from marijuana have really diminished. Most people don't feel marijuana is as damaging as we're discovering it is now. So it's more ubiquitous, especially if mom and dad are using it. Children have the perception that it's okay because it's a medicinal product now. But parents still have to be super cautious in protecting it, locking it, putting it away. Because a lot of these marijuana products, as you know, look like it could be a food product. I know. If I left a gummy on my countertop, my kids, it'd be gone in a heartbeat.

Dr. Srinath: Right. Right, right.

Dr. Poholek: Yeah. Well, I mean, half the vitamins we give our kids are in gummy formats, right?

Dr. Pizon: Absolutely.

Dr. Poholek: And there's snacks come in gummy formats. So certainly, a child would not be able to distinguish those two things at all.

Dr. Pizon: Absolutely.

Dr. Poholek: Yeah. I wonder if it's a little bit like alcohol. We don't leave alcohol lying about for our children, so.

Dr. Pizon: Exactly. That traditionally has been the easy access item. You may have a liquor cabinet that's not locked and kids can go in there and explore. And now, marijuana and these other drugs have been the new exploratory medications to dabble in.

Dr. Srinath: And it's normalized to be out. They're normalized to be outside, right?

Dr. Pizon: Exactly.

Dr. Srinath: What are the long term effects of these ingestions, particularly medical marijuana in children?

Dr. Pizon: It's good you asked that because I used to be of the mindset, legalize marijuana. People will use it like alcohol. It won't be a big problem. But we're noticing now that it's really a problem for our children. And children who get into marijuana, particularly who start using marijuana before the age of 18, have much higher incidents of psychiatric illness. So we know it's ramping up psychiatric illness in these children. We know it decreases memory and learning processing as well. So we know there are, in animal studies too, in terms of memory processing and learning and the neural connections are changing these animals when it's used at a younger age. So we don't have all the details figured out, but we are learning that it definitely does have downstream long-term implications. So keeping children out of marijuana is our best bet at this moment.

Dr. Srinath: Wow. Is that part of the discussion you have with families or is it too soon to bring that up?

Dr. Pizon: No. I mean, I try to talk to them. I mean, most parents are really engaged and interested and want to help their children and what they can do. So having those open conversations are the best opportunity to do so. Because, I mean, I'm sure you have children too, they seem less likely to listen to their parents, but maybe an outsider, they will listen.

Dr. Srinath: You nailed it. You nailed it. Exactly so.

Dr. Poholek: So given that we've sort of had 50 years of the Pittsburgh Poison Center, which is really an amazing milestone, I'm kind of curious how the Poison Center has changed, maybe particularly in the last five or 10 years. The world has definitely changed in 50 years. So when we started the Poison Center, I'm sure there were some clear visions. What is the vision of the Poison Center now? What are the goals?

Dr. Pizon: The goals have really remained the same in terms of providing a nice resource to family members to access medical information quickly when there's a poisoning exposure. Because honestly, one of the biggest values to the Poison Center is keeping kids out of the hospital, because most of the exposures, as you can imagine, are non-toxic. And where would a parent go with their exposed child but to the emergency department that's already overwhelmed. So, the Poison Center does a great job of keeping those children out of the hospital. You can stay at home. We'll call you back, check on your child. So those kinds of things have been a really good value and been a mainstay to the Poison Centers.

Now, the Poison Centers are really looking at more savvy technology because people are less likely to pick up their phone and call. They want to text. And so that's the newest and greatest thing. Unfortunately, we haven't gotten there yet, but I think that's where we need to go. And that's where a lot of the leadership in Poison Centers is headed to have an app, a texting avenue to contact back and forth.

Dr. Poholek: Yeah. Or I guess I'm kind of curious, thinking about an app that I would use as a parent, how often, and this sort of links into another question I had, which is sort of what are the most challenging cases they've managed, how often do parents come in and know for sure what was ingested, versus "My kid's behaving weird and I think they might have gotten into something and I don't know what it is."?

Dr. Pizon: Yeah. I think the vast majority know. Because most kids ingest what they have access to in terms of prescription medicines and what's in the house. And parents know, in this day and age, with social media too, kids are pretty quick to place on social media that they did this too, which honestly, most kids, it's a cry for help, which is thankfully so. They're dealing with stress and anxiety and depression, and they take something. They put it on social media and it's quickly recognized. So fortunately, most people know.

Sorry, I forgot what the rest of the-

Dr. Poholek: Well, I was just thinking about that in the context of the app because I was thinking, if I'm a parent and I want to quickly search, "Oh, my kid just ate this, how bad is it?" So then it would have to know what they did. So I was kind of thinking about the question of how often do they know. But then, I guess, pivoting to the other side with my other question was, what are the most challenging cases that you see?

Dr. Pizon: Back to the app, the issue that's kind of stumped the app idea is, if you can type in harmful or whatnot drugs in there, people can use it in a sinister way and say, "Oh, how would I harm myself?"

Dr. Srinath: Right.

Dr. Poholek: I see. I see.

Dr. Pizon: That's the tricky part.

Dr. Poholek: Gotcha.

Dr. Pizon: But instead maybe having a chat back and forth. But in terms of... Sorry, you had asked again.

Dr. Poholek: No, that's okay. The most challenging cases.

Dr. Pizon: The most challenging cases tend to be children who are permanently harmed. The vast majority of our kids do well. Kids are so resilient and present quickly and do extremely well. But if you have a toddler or a young adolescent child who ingested something or exposed to something and now is permanently harmed, that's what always hurts your heart because these kids have such a bright future. I have kids of my own, and it just tugs at heartstrings. So when children are permanently injured, that's always the hardest patients to treat.

Dr. Poholek: Yeah. For sure.

Dr. Srinath: So we talked about the short and long term effects, limited and/or permanent. We talked about prevention. In this day and age, as you mentioned, hospitals are overwhelmed, right? There's a fear to go to present. How much awareness do you see on family members, and how does that affect coming to get care in terms of delays versus immediate?

Dr. Pizon: No, that's a good point. Most parents are pretty quick to treat their child one way or the other. There are issues, as you can imagine, parents dealing with substance use disorder, which is running rampant to our communities. And under those circumstances, parents may not be as aware because, and these are the circumstances where you had asked earlier, how often do parents know what their child got into? Sometimes, they'll recognize their child isn't acting right, and it may be a few hours before they recognize," Ooh, my child got into my illicit drugs or in my prescription medication that could be harmful." Particularly dealing with substance use, the stigma with substance use, the stigma with the legality of having illegal substances in the house, those are the problems where parents may be less apt to bring your child to the hospital.

But for the most part, I feel, even under those circumstances, parents call for help when needed.

Dr. Srinath: Can I pivot just for a minute here? And just because you provide such a huge service to the Pittsburgh community, as well as surrounding communities too, and I know you have a fellowship program as well which you direct. So what inspired you to go into medical toxicology? You described an inspirational mentor, and I'm hoping it might entice some people who are listening to think about going into your field.

Dr. Pizon: Yeah, thank you. I mean, I really appreciate that. It's funny that I'm interviewing applicants for our fellowship now, and you realize, the vast majority of these young applicants are inspired by someone that they've worked with. And I too was inspired by the young medical toxicology doctors who were here, and you get to see what they do and how they impact lives in a very impactful way. So that's what's really inspired me over the years, and you really kind of want to model that in helping people. And like I said, for the most part, it's really rewarding to take care of these young kids because they bounce back so quickly. They do so well. So yeah, there's lots of rewards and largely spawned by mentors along the way.

Dr. Srinath: That's amazing.

Dr. Poholek: We've really enjoyed having you on the show. Just as sort of a last question, is there anything that you think would surprise our listeners about being a medical toxicologist or about the things that you see?

Dr. Pizon: Honestly, with the sirens in the background.

Dr. Poholek: Yeah. Perfect timing. Emergency vehicles in the background.

Dr. Pizon: No. It's interesting. You get so commonplace in your specialty you don't think, what are the new exciting novel things or what's so exciting that people would like to know? I like to think we're just a fun group. We're the most fun group in the hospital. Maybe that's it.

Dr. Poholek: Clearly, yes.

Dr. Pizon: We know more about drugs than anybody else.

Dr. Poholek: Woo. Fantastic. Well, thank you so much for being on the show. This has really been interesting and informative for our listeners. We really appreciate your time.

Dr. Pizon: My pleasure. Thank you for having me.

Dr. Srinath: I echo Amanda, thank you so much, Dr. Pizon. Really appreciate it.

Dr. Pizon: Thank you.

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