Co-proxamol and suicide: preventing the continuing toll of overdose deaths

Parliament in action: Drug withdrawals and policy changes in the U.K

Previous studies on changes in health policies theorize such changes either as crises responses, or as the outcome of longer-term stakeholder conflicts. In this paper, we propose that parliaments function as overlooked, intermediate actors that contribute to translating the interests of stakeholders into policy changes. We study the role of parliament connecting policy makers and stakeholders in the context of drug regulation. Based on three high-profile cases of drug withdrawals between 1991 and 2005 in the United Kingdom (triazolam, rofecoxib, and co-proxamol), we distinguish partisan-political, individual-idiosyncratic, and collective-institutional pathways of parliamentary action on drug withdrawals. Distinguishing direct and indirect actions, we argue that indirect courses of action, including advocacy and educational work, can be just as effective as regular legislative endeavours, under certain conditions.

Medication used in intentional drug overdose in Flanders 2008-2013

Background

Intentional drug overdose is the most common method of self-harm. As psychiatric disorders are very common in self-harm patients, the medication used to treat these disorders can become the means for the self-harm act. The present study aimed at investigating an association between the use of prescribed medication (analgesics and antipyretics, anti-epileptics, antipsychotics, antidepressants and psychostimulants) as a method of self-harm and prescription rates of this medication in Flanders. We investigated the possible effect of gender, alcohol use during the self-harm act and a history of self-harm.

Methods

Data from the multicenter study of self-harm in Flanders between 2008 and 2013 were used. The significance of differences in percentages was calculated by GEE and the strength by odds ratios (OR).

Results

There was an increase in the odds of using antidepressants (0.8%) and antipsychotics (2%) among females when the rate of prescription increases. Analgesics and antipyretics (39.3/1,000) and antidepressants (124.9/1,000) were the most commonly prescribed drugs among females. Antidepressants (63.9/1,000) and antipsychotics (26.5/1,000) were the most commonly prescribed drugs among males. Antidepressants and analgesics and antipyretics were the most frequently used medications for self-harm. Analgesics and antipyretics during the self-harm act were more common among first-timers, while repeaters more commonly overdosed using antipsychotics and antidepressants.

Conclusion

These findings suggest that the availability of medication via prescriptions plays an important role in the choice of the medication ingested during the self-harm act. Precautions are necessary when prescribing medication, including restrictions on the number of prescriptions and the return of unused medication to pharmacies after cessation of treatment. These issues should be a focus of attention in the education and training of physicians and pharmacists.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Increase in Self-Injury as a Method of Self-Harm in Ghent, Belgium: 1987-2013

Background

Self-harm is a major health care problem and changes in its prevalence and characteristics can have important implications for suicide prevention. The objective was to describe trends in the epidemiology of self-harm based on emergency department (A&E departments) visits over a 26-year period in Ghent, Belgium.

Methods

We analyzed data on all self-harm presentations from the three large general hospitals in Ghent between 1987 and 2013. We investigated trends in prevalence (events by year per 100.000), methods and alcohol use.

Results

Rates of self-harm steadily decreased during the 26-year study period. In general female rates of self-harm were higher than male rates. The mean patient age was 35 years. The most commonly used method of self-harm was self-poisoning by means of an overdose of medication (80.8%), followed by cutting (10.2%) and hanging (4.2%). Psychotropics (including antidepressants, benzodiazepines, barbiturates and other tranquilizers) were the most frequently used drugs (74.5%). A proportional increase in the use of self-injurious methods in self-harm was highly significant, more specifically in the use of hanging, jumping from heights and the use of other violent methods such as the use of firearms, jumping before a moving object or other traffic related injury.

Conclusion

This epidemiological study showed an increase in the use of high-lethality methods in self-harm which has important implications for suicide prevention. As restrictions in the availability of these methods are difficult or impossible to achieve, prevention programmes will have to emphasize the role of thorough psychosocial assessment and adequate follow-up care of self-harm patients.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Six-year follow-up of impact of co-proxamol withdrawal in England and Wales on prescribing and deaths: time-series study

BACKGROUND

The analgesic co-proxamol (paracetamol/dextropropoxyphene combination) has been widely involved in fatal poisoning. Concerns about its safety/effectiveness profile and widespread use for suicidal poisoning prompted its withdrawal in the UK in 2005, with partial withdrawal between 2005 and 2007, and full withdrawal in 2008. Our objective in this study was to assess the association between co-proxamol withdrawal and prescribing and deaths in England and Wales in 2005-2010 compared with 1998-2004, including estimation of possible substitution effects by other analgesics.

METHODS AND FINDINGS

We obtained prescribing data from the NHS Health and Social Care Information Centre (England) and Prescribing Services Partneriaeth Cydwasanaethau GIG Cymru (Wales), and mortality data from the Office for National Statistics. We carried out an interrupted time-series analysis of prescribing and deaths (suicide, open verdicts, accidental poisonings) involving single analgesics. The reduction in prescribing of co-proxamol following its withdrawal in 2005 was accompanied by increases in prescribing of several other analgesics (co-codamol, paracetamol, codeine, co-dydramol, tramadol, oxycodone, and morphine) during 2005-2010 compared with 1998-2004. These changes were associated with major reductions in deaths due to poisoning with co-proxamol receiving verdicts of suicide and undetermined cause of -21 deaths (95% CI -34 to -8) per quarter, equating to approximately 500 fewer suicide deaths (-61%) over the 6 years 2005-2010, and -25 deaths (95% CI -38 to -12) per quarter, equating to 600 fewer deaths (-62%) when accidental poisoning deaths were included. There was little observed change in deaths involving other analgesics, apart from an increase in oxycodone poisonings, but numbers were small. Limitations were that the study was based on deaths involving single drugs alone and changes in deaths involving prescribed morphine could not be assessed.

CONCLUSIONS

During the 6 years following the withdrawal of co-proxamol in the UK, there was a major reduction in poisoning deaths involving this drug, without apparent significant increase in deaths involving other analgesics.

Impact of withdrawal of the analgesic Co-proxamol on nonfatal self-poisoning in the UK

BACKGROUND

In early 2005 the UK Committee on Safety of Medicines (CSM) announced gradual withdrawal of the analgesic co-proxamol because of its adverse benefit/safety ratio, especially its use for intentional and accidental fatal poisoning. Prescriptions of co-proxamol were reduced in the 3-year withdrawal phase (2005 to 2007) following the CSM announcement.

AIMS

To assess the impact of the CSM announcement in January 2005 to withdraw co-proxamol on nonfatal self-poisoning with co-proxamol and other analgesics.

METHODS

Interrupted time series analysis of general hospital presentations for nonfatal self-poisoning (five hospitals in three centers in England), comparing the 3-year withdrawal period 2005-2007 with 2000-2004.

RESULTS

A marked reduction in the number of episodes of nonfatal self-poisoning episodes involving co-proxamol was found following the CSM announcement (an estimated 62% over the period 2005 to 2007 compared to 2000 to 2004). There was no evidence of an increase in nonfatal self-poisoning episodes involving other analgesics (co-codamol, codeine, co-dydramol, dihydrocodeine, and tramadol) in relation to the CSM announcement over the same period, nor a change in the number of all episodes of self-poisoning.

LIMITATIONS

Data were from three centers only.

CONCLUSIONS

The impact of the policy appears to have reduced nonfatal self-poisoning with co-proxamol without significant substitution with other analgesics. This finding is in keeping with that for suicide.

Pain Challenges at the End of Life - Pain and Palliative Care Collaboration

Pain and symptom management at the end of life remains suboptimal.Pain physicians are uniquely placed to provide interventions for patients with difficult to manage pain.Interventions such as acupuncture, radiofrequency ablation, neurolysis together with regional analgesia including neuraxial techniques and spinal cordotomy may provide the patient with improved analgesia.

Use of analgesics in intentional drug overdose presentations to hospital before and after the withdrawal of distalgesic from the Irish market

BACKGROUND

Distalgesic, the prescription-only analgesic compound of paracetamol (325 mg) and dextropropoxyphene (32.5 mg) known as co-proxamol in the UK, was withdrawn from the Irish market as of January 2006. This study aimed to evaluate the impact of the withdrawal of distalgesic in terms of intentional drug overdose (IDO) presentations to hospital emergency departments (EDs) nationally.

METHODS

A total of 42,849 IDO presentations to 37 of the 40 hospitals EDs operating in Ireland in 2003-2008 were recorded according to standardised procedures. Data on sales of paracetamol-containing drugs to retail pharmacies for the period 1998-2008 were obtained from IMS Health.

RESULTS

The withdrawal of distalgesic from the Irish market resulted in an immediate reduction in sales to retail pharmacies from 40 million tablets in 2005 to 500,000 tablets in 2006 while there was a 48% increase in sales of other prescription compound analgesics. The rate of IDO presentations to hospital involving distalgesic in 2006-2008 was 84% lower than in the three years before it was withdrawn (10.0 per 100,000). There was a 44% increase in the rate of IDO presentations involving other prescription compound analgesics but the magnitude of this rate increase was five times smaller than the magnitude of the decrease in distalgesic-related IDO presentations. There was a decreasing trend in the rate of presentations involving any paracetamol-containing drug that began in the years before the distalgesic withdrawal.

CONCLUSIONS

The withdrawal of distalgesic has had positive benefits in terms of IDO presentations to hospital in Ireland and provides evidence supporting the restriction of availability of means as a prevention strategy for suicidal behaviour.

Effect of withdrawal of co-proxamol on prescribing and deaths from drug poisoning in England and Wales: time series analysis

OBJECTIVE

To assess the effect of the UK Committee on Safety of Medicines' announcement in January 2005 of withdrawal of co-proxamol on analgesic prescribing and poisoning mortality.

DESIGN

Interrupted time series analysis for 1998-2007.

SETTING

England and Wales.

DATA SOURCES

Prescribing data from the prescription statistics department of the Information Centre for Health and Social Care (England) and the Prescribing Services Unit, Health Solutions Wales (Wales). Mortality data from the Office for National Statistics.

MAIN OUTCOME MEASURES

Prescriptions. Deaths from drug poisoning (suicides, open verdicts, accidental poisonings) involving single analgesics.

RESULTS

A steep reduction in prescribing of co-proxamol occurred in the post-intervention period 2005-7, such that number of prescriptions fell by an average of 859 (95% confidence interval 653 to 1065) thousand per quarter, equating to an overall decrease of about 59%. Prescribing of some other analgesics (co-codamol, paracetamol, co-dydramol, and codeine) increased significantly during this time. These changes were associated with a major reduction in deaths involving co-proxamol compared with the expected number of deaths (an estimated 295 fewer suicides and 349 fewer deaths including accidental poisonings), but no statistical evidence for an increase in deaths involving either other analgesics or other drugs.

CONCLUSIONS

Major changes in prescribing after the announcement of the withdrawal of co-proxamol have had a marked beneficial effect on poisoning mortality involving this drug, with little evidence of substitution of suicide method related to increased prescribing of other analgesics.

Online availability of dextropropoxyphene over time, 2003-2005

Online pharmacies are increasingly common, and some of them have been reported to inappropriately supply prescription-only medicines. Dextropropoxyphene-containing compounds are addictive and frequently implicated in fatalities occurring in the United Kingdom. We aimed here at assessing the online availability of dextropropoxyphene for purchase over a time-span of 2 years (September 2003-August 2005). A Google search was run in September 2003 using different sets of keywords and the first 100 links identified were thoroughly assessed. In March 2005, the same e-pharmacies websites identified at baseline were accessed again and a Google search using the same sets of keywords previously used was run as well. Furthermore, a specialized search with Froogle was run both in March and August 2005. Although an illegal practice in most countries, a number of websites willing to sell the compound internationally were identified at the time of the baseline search. In March 2005, the Google search for vending websites identified 361,000 links, compared with 40,000 18 months before. Only half of dextropropoxyphene vending e-pharmacies were still active by March 2005 but, at that point in time, access to Froogle apparently facilitated the task of online dextropropoxyphene purchase. By August 2005, however, the same Froogle search identified only one link aimed at online dextropropoxyphene shopping. In the United Kingdom, dextropropoxyphene-related products will be withdrawn later this year but this may have only limited impact on the availability of the compound. The emergence of Internet as an unregulated source of controlled substances is an important development that may have significant public health implications. This issue needs to be dealt with at both international and national level.

The hospital management of fatal self-poisoning in industrialized countries: an opportunity for suicide prevention?

Suicide by self-poisoning is a prevalent cause of death worldwide. A substantial proportion of individuals who poison themselves come into contact with medical services before they die. Our focus in the current study was the medical management of drug self-poisoning in industrialized countries and its possible contribution to suicide prevention. We reviewed the literature to determine the proportion of self-poisoning suicides who reach hospital alive, the sociodemographic and clinical characteristics of in-hospital overdose deaths, the in-hospital management this group of patients receives, and whether there are specific aspects of pre-hospital care and in-hospital management that have the potential to improve survival. Between 11% and 28% of individuals who died following deliberate ingestion of drugs reached hospital alive. The substances which were most frequently implicated in death were paracetamol (acetaminophen) and paracetamol compounds, tricyclic antidepressants, and benzodiazepines. Most patients received fairly intensive treatment, yet death may have been preventable in a small proportion of cases. Only one intervention (the administration of acetylcysteine) was shown to reduce mortality and this was in a highly selected group of patients (those who had ingested paracetamol and developed fulminant hepatic failure). It is possible that other interventions such as better airway management, the prompt administration of activated charcoal, and improved pre-hospital care may improve outcomes but their potential contribution to suicide prevention needs to be investigated in future studies.

[Trends in the pharmaceutical profile of intentional drug overdoses seen in the emergency room]

OBJECTIVES

The aim of the study was to investigate trends in substances used for acute self-administered drug overdoses (SADO).

METHOD

Review of all SADO emergency room visits over two 1-year periods during 1992-1993 (P1) and 2001-2002 (P2).

RESULTS

We compared 804 SADO episodes in P1 with 830 in P2. Patient characteristics did not differ significantly during the two periods (predominance of women: 66 vs 69%; mean age: 33 +/- 12 vs 37 +/- 13.5 years). Psychotropic drugs predominated in both periods (78 and 77%), but the prevalence of benzodiazepines declined (67 to 55%; p < 0.01) and that of antidepressants increased (9.5 to 15%; p < 0.01). Bromazepam was the ben-zodiazepine used most often during both periods (P1: 30% and P2: 35%), but the use of aprazolam increased (from 6 to 17%; p < 0.01). Among the antidepressants, the use of tricyclics decreased (from 43 to 14%; p < 0.01) and that of selective serotonin reuptake inhibitors increased (31 to 71%; p < 0.01). The proportion of benzodiazepine-related drugs increased over time (8.1 to 14%: p < 0.01). The other therapeutic classes remained quite similar to each other between P1 and P2, except for anti-inflammatories (P1: 1.3%, P2: 2.7%; p = 0.01). Among the analgesics, paracetamol alone or combined with other agents predominated (68 and 64% respectively), but use of opiate analgesics was fre-quent during the later period (2.7 vs 22%; p < 0.01).

CONCLUSION

The trend of the different pharmacological families used in SADO seen in the emergency room has not fundamentally changed over the past decade. However, qualitative changes within the drug classes require emergency physicians to update their knowledge of toxicology.