The 2025 ACMT Ward and Ryan Donovan Memorial Fund lecture was presented by Daniel Ciccarone, MD, MPH from Department of Family and Community Medicine at the University of California San Francisco (UCSF). This article is an edited version of his keynote address during ACMT's 2025 Annual Scientific Meeting. During the course of his talk, Dr. Ciccarone discussed polysubstance use in the "Fentanyl-plus" era. The epidemiology and economics of the four waves of opioid overdose deaths were examined, and promising harm reduction strategies to assist in reducing overdose mortality were highlighted.

Hexahydrocannabinol (HHC) is a semi-synthetic hydrogenated derivative of delta-9-tetrahydrocannabinol (THC). HHC emerged within global markets in 2021and has been detected within unregulated cannabis products.

2,4-dinitrophenol (DNP) is an uncoupler of oxidative phosphorylation and is highly toxic in overdose.

Calcium channel antagonists contribute to many overdose related deaths each year and treatment options are limited. Hydroxocobalamin has shown promise in reversal of multiple shock states, and we evaluated its use in the treatment of nifedipine-induced shock in a swine model.

Significant cases of methemoglobinemia will cause a signal interference in traditional dual-wavelength pulse oximetry leading to the classic finding of “refractory hypoxemia”. As smartwatches begin to incorporate pulse oximetry capabilities, it is unclear whether these devices will demonstrate the same type of interference in the presence of methemoglobinemia. This article reports a case where a patient’s Apple Watch© reported a hypoxemia alert in the setting of phenazopyridine induce methemoglobinemia.

Copperheads and cottonmouths are responsible for most snake envenomations in Louisiana. While the United States Food and Drug Administration has approved both Crotalidae polyvalent immune Fab (FabAV) and Crotalidae immune F(ab') (Fab2AV) for Agkistrodon envenomations, data is limited comparing their efficacies for this indication.

In recent years, medical toxicology research has evolved from relying heavily on case reports and case series to more rigorous methodologies, including randomized controlled trials and high-quality systematic reviews. Engaging patients as partners in research is increasingly recognized as a promising approach to generate evidence that is trusted, meaningful, and useful to clinicians, policymakers, as well as patients and community members. The American College of Medical Toxicology (ACMT) recently conducted a patient engagement project to promote meaningful research engagement with patients who have lived experiences with overdoses. This review intends to provide an overview of patient-centered outcomes research (PCOR) for the field of medical toxicology, which includes study design considerations, planning for recruitment of patients and stakeholders, and supporting sustainable partnerships.

Fomepizole has been suggested as adjunctive therapy for severe acetaminophen poisoning though clinical efficacy is unknown. We sought to determine trends in the use of fomepizole for acetaminophen poisoning.

Cyanide poisoning poses an ongoing threat to military personnel and civilian populations. FDA approved antidotes require intravenous administration which can be challenging to accomplish in austere environments. Intranasal (IN) delivery is an innovative approach to developing easy to administer medical countermeasures for field use. Rapid absorption through the nasal mucosa and passage of dimethyl trisulfide across the blood-brain barrier could enhance effectiveness in mitigating cyanide toxicity.

C4 is a plastic explosive commonly used in military applications, and is predominantly composed of cyclonite or RDX (Royal Demolition Explosive). C4 toxicity is a documented but not commonly known cause of altered mental status and recurrent seizures.