Trends in Analgesic Self-poisoning in West-Fife, 1971-1985

All admissions for analgesic self-poisoning to a district poisonsunit over a 15-year period have been reviewed. During this timeoverdose with analgesic drugs increased to represent almosthalf of all admissions for self-poisoning. The types of analgesicstaken in overdose also changed significantly during the periodof this review. Aspirin and Distalgesic poisoning declined inincidence and more cases of self-poisoning by paracetamol andnon-steroidal anti-inflammatory agents were seen. The impactof these changes on the medical management and outcome of deliberateself-poisoning is analysed. The reasons behind the trends describedin this paper are assessed and their implications for futureprevention and treatment are discussed.     

Self Poisoning in Children: A ten year Survey

Abstract

All children, 17 years of age or less, admitted to the Children's Hospital of Hacettepe University Medical Center in Ankara during the period of 1975 to 1984 with a diagnosis of poisoning were studied.

Of the 1188 cases reviewed, mode of poisoning was deliberate self-poisoning in a total of 152 cases (12.8%). Drugs accounted for 95.4%, insecticides for 3.9% and carbon monoxide for only 0.7% of the overall suicide attempts or gestures.

Analgesics and tranquilizers were the most common agents encountered, however the major drug used for self-poisoning was a barbiturate containing analgesic, Optalidon.

The incidence of self-poisoning was 79.0% in the age group 13-17 of the overall poison admissions and in all of the age groups self-poisoning showed a significant (p < 0.001) sex difference with definite prevalance of girls.     

Self-poisoning: current trends and practice in a U.K. teaching hospital

The epidemiology of deliberate self-poisoning presentations to the emergency department (ED) of Ninewells Hospital was reviewed over a six-month period. The results were related to previously published Scottish data. During the six month period, 530 patients presented (2.1% of total). There was a female preponderance with over 65% of patients aged less than 40 years. Patients lived more commonly in areas of higher deprivation. The drugs most commonly involved were paracetamol (39.25%) and antidepressants (35.1%). Of the presentatons 80.2% required no treatment apart from basic observations. Only 1.51% received activated charcoal and no gastric lavages were performed. Of the presentations, 75.6% were discharged after observation in the ED, 8.9% were admitted to a psychiatric hospital and 5.5% were admitted to general medicine department. Deliberate self-poisoning continues to be a major cause of hospital admissions in Scotland. In Tayside, it is predominantly a problem of the young and socially deprived. Consistent with recent national trends, paracetamol was the most common drug relating to overdose. The use of an ED observation ward is supported as a vast majority of patients are admitted for less than 24 hours and require no active treatment.     

Changing patterns of self-poisoning in a UK health district

Details of admissions to a dedicated district poisons treatment unit in South Glamorgan were analysed to assess changes in self-poisoning patterns between 1987-1988 and 1992-1993. Self-poisoning rates increased in both men and women, with male rates showing a relatively larger increase, resulting in a fall in female to male ratio for person- based rates from 1.33:1 to 1.13:1. The highest age-specific rates in both period were found in 15-19-year-old females. Paracetamol was the most commonly ingested poison in 1992-1993, with 43.4% of episodes involving its use, compared with 31.3% of episodes in 1987-88. Antidepressant involvement in self-poisoning also increased from 11.3% of episodes in 1987-1988 to 17.6% of episodes in 1992-1993. Repetition of self-poisoning was relatively common, with 18% of admissions per year in 1992-1993 representing repeats. Although hospital admission increased in this health district over the study periods, this was not reflected in an increase in in-patient all-cause mortality, which was only 0.5% in 1987-1988 and 0.1% in 1992-1993.      

Relative toxicity of venlafaxine and selective serotonin reuptake inhibitors in overdose compared to tricyclic antidepressants

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine have been regarded as less toxic in overdose than tricyclic antidepressants (TCAs). Within the TCAs, dothiepin has greater toxicity. Venlafaxine may be more toxic than SSRIs. AIM: To assess the toxicity in overdose of venlafaxine and SSRIs compared to TCAs, and of dothiepin compared to other TCAs. DESIGN: Cohort study of prospectively collected data from the Hunter area, NSW, Australia. METHODS: First admissions with antidepressant deliberate self-poisoning (DSP) (November 1994 to April 2000) were identified; the presence of seizures, life-threatening arrhythmias, coma, serotonin toxicity or ICU admission, and QRS duration were noted. RESULTS: There were 538 admissions, with no deaths. The odds ratio (OR) for seizures with dothiepin vs. other TCAs was 3.4 (95%CI 1.2-9.9). Seizures occurred in 7/51 (14%) venlafaxine overdoses; all patients with seizures consumed > or =900 mg. The OR for seizures vs. TCAs was 4.4 (95%CI 1.4-13.8). Coma was less likely with venlafaxine and SSRIs. SSRIs, but not venlafaxine, were less likely to prolong the QRS to > or =100 ms. ICU admission was less likely for SSRIs. Serotonin toxicity was much more common with venlafaxine and SSRIs. DISCUSSION: Venlafaxine and dothiepin are pro-convulsant in overdose. Venlafaxine is more likely to cause serotonin toxicity, but less likely to cause coma than TCAs. SSRIs are less likely to cause coma, require ICU admission, or prolong the QRS, but are more likely to cause serotonin toxicity. Antidepressants other than TCAs or venlafaxine should be considered in patients at risk of seizure or suicide.     

Influences of the COVID-19 pandemic on admissions and clinical outcomes in mental health disorders and self-poisoning: Age- and sex-specific analysis

We measured rates of hospital admissions for mental health disorders and self-poisoning during the pandemic in patients without COVID-19, compared to those admitted before the pandemic. Data were collected from 01/04/2019 to 31/03/2021, including the pandemic period from 01/03/2020. There were 10 173 (47.7% men) from the pre-pandemic and 11 019 (47.5% men) from the pandemic periods; mean age = 68.3 year. During the pandemic, admission rates for mental health disorders and self-poisoning were higher for any given age and sex. Self-poisoning was increased with toxic substances, sedatives and psychotropic drugs, but reduced with nonopioid analgesics. Patients admitted with mental health disorders had lower readmission rates within 28 days during the pandemic, but did not differ in other outcomes. Outcomes from self-poisoning did not change between the two study periods.     

Drug-related admissions to an Australian hospital

This study was conducted to determine the prevalence of drug-related hospital admissions in southern Tasmania, Australia. The causes of consecutive admissions to medical wards of the Royal Hobart Hospital were reviewed. Comprehensive data were collected over a 10-week period on 691 admissions (median age: 67 years and range: 11–97 years; 50.8% males). Sixty-eight (9-8%) of the admissions were classified as being either probably or definitely drug-related. Most of these admissions were attributable to intentional overdose (38.2%) or an adverse drug reaction (30.9%). The overdoses often involved benzodiazepines or antipsychotics. Gastrointestinal bleeding related to the use of nonsteroidal anti-inflammatory drugs was the most common adverse drug reaction (38.1% of all reactions). Other drug-related admission categories were poor compliance (14.7%), dosage decrease or therapy cessation by a doctor producing an exacerbation of symptoms (7.4%), substance abuse (4.4%) and drug interaction (4.4%). Patients with a drug-related admission were, on average, younger than the other medical admissions, with no significant difference in gender. Patients admitted due to an overdose or substance abuse were younger than other drug-related admissions and non-drug related admissions. In conclusion, this study has determined that almost 10% of medical admissions to the hospital are drug-related and it is estimated that 40 to 50 elderly people are admitted each year suffering from gastrointestinal bleeding related to nonsteroidal anti-inflammatory drugs.     

Self-poisoning suicides in England: a multicentre study

BACKGROUND: Suicide by self-poisoning is an important cause of death worldwide. A substantial proportion of those with a fatal outcome may come into contact with medical services before they die. AIM: To estimate the proportion of self-poisoning suicides who reached hospital alive; to compare those who reached hospital alive with those who did not; to describe in detail the clinical characteristics and medical management of those dying in hospital. DESIGN: Retrospective audit. METHODS: We studied 24 coroners' jurisdictions across England, reviewing coroners' files and identifying all suicides by self-poisoning (drugs and other ingestible poisons) from 1 January 2001 to 31 December 2001. RESULTS: Of the 214 individuals who completed suicide by self-poisoning during the study period, 49 (23%) reached hospital alive. Those reaching hospital were more likely to be female, more likely to have ingested paracetamol and less likely to have ingested co-proxamol. In the hospital sample, the commonest causes of death were respiratory (n = 10), hepatic or hepatorenal (n = 8), cardiac (n = 5), or a result of hypoxic brain injury (n = 5). Only 18% of in-hospital deaths occurred within 24 h of the overdose. DISCUSSION: Extrapolating to England as a whole, we might expect 300 self-poisoning suicides per year to reach hospital alive (6% of all suicides). Improved medical management might produce a small but significant reduction in the rate of suicide. Such interventions should not be restricted to the emergency care domain. Further research will help to clarify the likely contribution of improved medical management to suicide prevention.     

Bupropion overdose: QTc prolongation and its clinical significance

OBJECTIVE: To investigate the cardiotoxicity of bupropion hydrochloride in deliberate self-poisoning. METHODS: A prospective study was conducted in a national poisons information center (PIC) of cases of adult deliberate self-poisoning with medical record follow-up of the patients. Fifty-nine cases of bupropion deliberate self-poisoning managed in the hospital, in which the New South Wales PIC was contacted for advice, were evaluated from November 2000 through July 2001. Clinical effects and electrocardiographic (ECG) parameters (QRS, QT, QTc) were the main outcome measures. RESULTS: ECGs were available for 17 of the 59 patients for analysis, 9 patients (53%) were women, and median patient age was 28 years (interquartile range 22-37). The mean +/- SD ingested bupropion dose was 3.8 +/- 3.1 g. Tachycardia occurred in 13 patients (76%; 95% CI 50 to 93) and hypertension in 8 patients (47%). There were no reports of hypotension or arrhythmias. There was a significantly increased QTc of 461 +/- 34 msec in the patients with bupropion overdose compared with previously developed controls; 13 of the 17 cases had a QTc >440 msec (76%; 95% CI 50 to 93). The uncorrected QT interval did not differ from that of controls. CONCLUSIONS: A moderately prolonged QTc (>440 msec) is common in bupropion overdose. However, this may not be a result of intrinsic cardiac toxicity, but overcorrection of the QTc due to the tachycardia that occurs. It is important that the QTc is interpreted with caution in overdoses of agents that cause significant tachycardia (>100 beats/min).     

Medical management of deliberate drug overdose: A neglected area for suicide prevention?

Objectives: Overdoses account for a quarter of all suicides in England. The number of people who survive the immediate effects of their overdose long enough to reach medical attention, but who subsequently die in hospital is unknown. The aim of this study was to determine the proportion of overdose suicides dying in hospital and describe their sociodemographic characteristics.

Method: Cross sectional analysis of routinely collected Hospital Episode Statistics data for England (1997 to 1999) to identify hospital admissions for overdose among people aged 12+ and the outcome of these admissions.

Results: Between 1997 and 1999 there were 233 756 hospital admissions for overdose, 1149 (0.5%) of these ended in the death of the patient such deaths accounted for 29% of all overdose suicides and 7% of total suicides. The median time between admission and death was three days (interquartile range one to nine days). The most commonly identified drugs taken in fatal overdose were paracetamol compounds, benzodiazepines, and tricyclic/tetracyclic antidepressants.

Conclusion: Around a quarter of all overdose suicide deaths occur subsequent to hospital admission. Further more detailed research is required to discover if better pre-admission and inhospital medical management of those taking serious overdoses may prevent some of these deaths.

     

Prospective study on admissions for iatrogenic adverse effects in the emergency service of hospital university center in Poitiers

Hospital admissions resulting from an adverse drug reaction have been studied in the emergency unit of the university hospital in Poitiers during a 27-day period. This prospective study consisted in documenting all observations considered as an ADR by the medical practitioner in charge of the patient. There were 1235 hospital admissions to the emergency unit during the study period. Thirty-one (2.5 per cent) of admissions were considered to be drug-related. Women were more often affected than men. Patients with ADR were classified taking into account the type of pathology and the drug responsible for the effect. Dermatological and gastrointestinal reactions were predominant. Antibiotic and analgesic drugs were the most common drug groups implicated in causing an ADR.     

Cyclic antidepressant overdose: A review of current management strategies

Cyclic antidepressant (CA) overdose can produce life-threatening seizures, hypotension, and dysrhythmias. It accounts for up to half of all overdose-related adult intensive care unit admissions and is the leading cause of death from drug overdose in patients arriving at the emergency department alive. Several factors contribute to the significant morbidity and mortality associated with CA overdose. First, CAs are widely prescribed and are dispensed to patients at increased risk for attempting suicide. Second, drugs of this class generally have a low therapeutic toxic ratio. Third, in the majority of fatal cases, the patient dies before reaching a hospital. Finally, and of greatest significance for the clinician, the presenting signs and symptoms of CA overdose may be missed by the physician, even in cases of severe toxicity. Therefore, CAs must be considered early in any case of suspected overdose, and all such cases should be managed as potentially fatal ones. The following case demonstrates the current approach to the patient with significant CA toxicity.     

Over-the-counter analgesics: a toxicology perspective

The decision to use any analgesic is a balance of benefit and risk. In the case of analgesics, it is important to balance the therapeutic benefit against both the risk in therapeutic use and the risk (and ease of treatment) in overdose. Paracetamol in therapeutic dose carries little risk of adverse events. Less than 0.1% of the estimated 30 million paracetamol users in the United Kingdom attend hospital with a paracetamol overdose each year, and approximately 200 people die, most of whom presented late or did not receive antidote, N-acetylcysteine, within 12 hours. Nonsteriodal anti-inflammatory drugs (NSAIDs) have greater adverse effects in therapeutic use than paracetamol but also have a lower incidence of severe features or death in overdose. There is no antidote available for NSAID poisoning. Aspirin carries both significant adverse effects in therapeutic dose and a substantial risk in overdose, for which there is no antidote. Its risk-benefit profile is probably the poorest of all analgesics currently available over-the-counter (OTC); this is reflected in current trends both in analgesic use and overdose figures. Although a number of options to reduce deaths from poisoning by OTC analgesics have been considered, few are practical, and all must take account of the public health benefits provided by these drugs. A perspective should be retained that the vast majority of the population in Australia, the United States, the United Kingdom, and Denmark derive therapeutic benefit from OTC analgesics and do not take them in overdose. The majority of those who do take overdoses come to little or no harm. Management of serious poisoning by paracetamol, aspirin, or NSAIDs remains a medical challenge.     

Recurrent overdose: patient characteristics, habits, and outcomes.

OBJECTIVES: Patients who overdose repeatedly on drugs and poisons (repeaters) are of major concern. This study aimed to examine the demographics, types of drugs ingested, associated self inflicted trauma, and medium term outcome of repeaters and to compare these patients with those who overdosed on one occasion only (single presenters) during the study period. METHODS: The study was undertaken in the emergency department of a large, provincial Australian hospital. A retrospective case note examination was made for all patients who presented, after drug overdose, during the two year study period. These patients were also followed up for a further 12 months after the study period. RESULTS: The study identified 335 single presenters and 46 repeaters. Females formed about two thirds of each group but repeaters tended to be older (p > 0.05) and to present more frequently before midnight (p > 0.05). Significantly more repeat presentations were triaged to the low priority categories 4 or 5 (odds ratio (OR) 0.48; 95% confidence interval (CI) 0.26 to 0.90, p = 0.023) and this group required fewer admissions to the hospital (OR 1.85; 95% CI 1.16 to 2.93, p = 0.009). Repeaters tended to take single drug overdoses. There were significantly more paracetamol only overdoses (OR 0.54; 95% CI 0.32 to 0.92, p = 0.024) and neuroleptic only overdoses (OR 0.27; 95% CI 0.11 to 0.67, p = 0.005) in the repeater group. More repeaters caused self inflicted trauma during the study period (OR 0.20; 95% CI 0.06 to 0.64, p = 0.007). No repeater completed suicide during the study or the 12 month follow up periods but repeaters presented more frequently, after overdose, during follow up (OR 0.38; 95% CI 0.13 to 1.11, p = 0.078). CONCLUSIONS: The study concludes that there are some significant differences between patients who overdose repeatedly and those who overdose on one occasion only. The study findings suggest that the medium term suicidal risk for repeaters is relatively low. However, this risk will vary and individual patients must be assessed thoroughly and managed accordingly.     

Relative Toxicity of Selective Serotonin Reuptake Inhibitors (SSRIs) in Overdose

Background: Selective serotonin reuptake inhibitors (SSRIs) have increasingly replaced tricyclic antidepressants (TCAs) in the treatment of depression. They appear to be safer in overdose, but there is little information on their spectrum of toxicity in overdose, or relative toxicity of each agent. Objective: To determine the effect of SSRIs in overdose, as a group, and the relative toxicity of five different SSRIs. Methods: A review of consecutive SSRI poisoning admissions to a single toxicology unit. Outcomes examined were length of stay [LOS], intensive care [ICU] admission rate, coma, seizures, electrocardiographic [ECG] abnormalities, and presence of serotonin syndrome [SS]. Logistic regression was used to model the outcome QTc > 440 msec. Results: There were 469 SSRI poisoning admissions analyzed after exclusions. The median LOS for all SSRI overdose admissions was 15.3 h (IQR: 10.5–21.3) and 30 of 469 (6.4%; 95% CI 4.3–9.0%) cases were admitted to ICU. The incidence of seizures was 1.9% and coma was 2.4%. Serotonin syndrome occurred in 14% of overdoses. Comparison of median QTc intervals of the five SSRIs was significantly different (p = 0.0002); citalopram (450 IQR: 436–484) was individually different to fluoxetine (p = 0.045), fluvoxamine (p = 0.022), paroxetine (p = 0.0002), and sertraline (p = 0.001). The proportion of citalopram overdoses with a QTc > 440 msec was 68%, differing significantly from sertraline (adjusted OR: 5.11 95% CI 2.32–11.27). Comparison of median QT intervals of the five SSRIs was statistically different (p = 0.026); citalopram (400 IQR: 380–440) was individually different from sertraline (p = 0.023). Conclusions: This study shows SSRIs are relatively safe in overdose despite serotonin syndrome being common. The exception was citalopram, which was significantly associated with QTc prolongation. We believe that cardiac monitoring should be considered in citalopram overdose, particularly with large ingestions and patients with associated cardiac disease.     

Comprehensive drug screening in decision making of patients attending the emergency department for suspected drug overdose

Objectives: This study aimed to evaluate the usefulness of a comprehensive drug screening method as a first line diagnostic tool on clinical decision making in patients attending an emergency department for suspected drug overdose in terms of agreement between physicians on patients' disposal.

Methods: Five emergency physicians retrospectively evaluated the records of 142 adult patients, admitted to the emergency department of a community hospital for suspected drug overdose. They were asked for an expert opinion on patients' disposal at the end of the observation period, based on paired records, with/without the results of a comprehensive drug screening.

Results: In the absence of the drug screening, a very poor agreement (κ statistics) was observed between physicians. When the drug screening was available, the interobserver agreement for decision on patients' disposal increased to the fair to good range (global agreement: from 0.238 (0.019) to 0.461 (0.020) (mean(SE)); p<0.001). The agreement also increased when admission to an intensive care unit, to a general ward, and discharge from hospital were separately analysed. The availability of drug screening would have saved 21.7% of hospital admissions and 53.3% of high dependency and/or intensive care unit admissions.

Conclusion: Comprehensive drug screening adds to decision making for patients attending an emergency department for suspected drug overdose, improving agreement among physicians on patients' disposal and potentially saving hospital resources.

     

Analgesics and warfarin. A case that brings up questions and cautions

This case report describes prolongation of a patient's prothrombin time and partial thromboplastin time possibly due to coadministration of warfarin and an overdose of an acetaminophen-propoxyphene combination analgesic. Patients receive warfarin for many indications, and concomitant use of an analgesic agent is commonly required. These patients should be closely observed if a combination acetaminophen-propoxyphene product is prescribed. Finally, patients receiving warfarin should be warned about the risks of use (and overdose) of unprescribed medications.     

N‐acetylcysteine‐induced headache in hospitalized patients with acute acetaminophen overdose

Intravenous N‐acetylcysteine (IV‐NAC) is usually regarded as a safe antidote to acetaminophen overdose. However, during infusion of the loading dose, adverse drug reactions such as a headache may occur. The objectives of this study were to investigate the prevalence of headache in patients presenting to hospital after acetaminophen overdose and to determine which clinical findings are most predictive of headache among these patients. This is a retrospective cohort study of hospital admissions for acute acetaminophen overdose that was conducted over a period of 4 years from January 1, 2005 to December 31, 2008. Demographic data, clinical characteristics, and predictors of headache were analyzed. spss 15 was used for data analysis. Two‐hundred and fifty‐five patients were studied; their mean age was 23.1 ± 1.6; 83.9% of them were women and 14.9% had a headache during hospitalization. Headache among patients was significantly associated with IV‐NAC administration (P = 0.001), intentional ingestion of drug (P = 0.04), acetaminophen concentration above ‘possible toxicity’ treatment line (P = 0.04), a high acetaminophen concentration (P = 0.04), and a long hospital stay (P = 0.03). Multiple logistic regression showed a significant risk factor for headache in patients administered IV‐NAC (P = 0.04). We recorded a high frequency of headache in patients with acute acetaminophen overdose in our geographical area. This study suggests that among those patients, the use of IV‐NAC is associated with an increased risk of headache.