Acute and chronic drug abuse emergencies in Metropolitan Toronto

Early warning indicators of changes in patterns of drug use in Australia

This report examines potential sources for a data system to serve as an 'early' warning of changes in drug use in the community. The system would measure changes in drug use to allow the managers of drug and alcohol programmes to adapt their services to meet the changing needs of their clients. The topic was addressed by identifying the 'dimensions of drug use' relevant to early warning. Three criteria for inclusion in an early warning network were identified: timeliness, volume of data, and complementarity with other indicators. Each indicator was evaluated against the early warning criteria and dimensions of drug use issues. The result was a list of six indicators which could form an early warning network in Australia: a collection based on general hospital casualty reports, ambulance officer reports of drug overdoses, telephone advice service data, data from key informants, profiles of clients in drug dependence treatment centres and the users of needle exchange centres.

Analysis of acute adult poisoning in a 6-year period and factors affecting the hospital stay

Case management of adult patients with acute poisoning in a university-based emergency department to determine the factors that affect duration of hospital stay was assessed. In this survey, data were obtained for the period between January 1, 1997 and December 31, 2002 at the emergency department (ED). Case analyses of 2229 patients older than 14 years of age were reviewed. Of all patients, 725 (32.5%) were male, 801 (35.9%) were younger than 20, and 540 (24.2%) were older than 30 years. Mean ages of patients were 29.3+/-13.2 for the males and 23.8+/-9.6 for the females (P<.001). During the study, the greatest number of patients were admitted in May (11.0%). Suicidal poisoning was the observed etiology in the majority of cases (76.4%). Moreover, the mortality rate due to poisoning was 3.9%. Drug ingestion was the most frequent means of poisoning (59.0%), followed by pesticides (19.0%). The rate of poisoning with multiple drugs has declined over time, whereas the rate owing to psychoactive drugs has increased markedly. The mean length of hospital stay was 2.9+/-1.8 days and the proportion of patients who stayed for longer than 2 days was 44.3%. The mean length of hospital stay was longer for males, those older than 30 years, those who had been poisoned unintentionally, and for confused and unconscious patients and those who had arrived to ED more than 2 hours after the event. This study suggests that morbidity for adult patients with poisoning varied by sex, age, and season. Length of hospital stay was affected by sex, age, arrival time to ED, mode of transport, severity of poisoning, and type of agent.

Anxiolytic-hypnotic drugs: relationships between prescribing, abuse and suicide

In 1978 the third largest Swedish city, Malmö, known to have the highest suicide frequency in the country, was found to have a higher prescription rate (defined daily doses (DDD) per 1,000 inhabitants per day) of anxiolytic-hypnotic drugs (AHD) than the country, the corresponding county, other counties, and other cities, including the largest (Stockholm) and second largest (Göteborg = Gothenburg) cities. Barbiturate prescribing in Malmö was 40% higher than in Stockholm and 90% higher than in Göteborg, and the frequency of suicide due to barbiturates was three-times higher than in Göteborg. A small proportion (2.4% of all AHD-prescribing doctors) of private practitioners wrote a large percentage (24%) of all AHD prescriptions. Prescription surveillance and an information campaign in Malmö were accompanied by a 4-year decrease in AHD prescribing (12%), in AHD abuse (40%), in barbiturate prescribing (45%), and in barbiturate suicides (70%). The total suicide rate was reduced by 25%. There was no corresponding 4-year increase in suicide due to other drugs, or by other means, but after 5 to 7 years there was an increase in suicide by non-pharmacological means. The contribution of benzodiazepines to the frequency of suicide was very small, whereas their contribution to AHD abuse was considerable. In Göteborg, where no corresponding intervention was carried out, there was also a reduction in barbiturate prescribing (34%) and in barbiturate suicides (45%), but in contrast there was a continuous increase both in overall AHD and benzodiazepine prescribing, surpassing Malmö after 5 years. Far from a reduction there was a 7-year increase in the overall frequency of suicide. Apparently, AHD abuse and suicide can be greatly reduced by restricted prescribing of AHD, and this may but need not be accompanied by an increase in suicide by other means. Targeted drug information campaigns may assist in changing prescription patterns and their medical and social impact.

Epidemiological surveillance of opioid-related episodes in an emergency room of Barcelona, Spain (1979-1989)

In the early 80's opioid addiction was a low prevalence problem in Spain, grew enormously during that decade and became the most important risk factor for AIDS in recent years. The limitations of assessing the prevalence of illegal drug use by means of standard epidemiological methods lead, worldwide, to the use of indirect indicators. A Register of Toxicological Emergencies, developed for research purposes and containing data from 1979 to 1989 at the Hospital del Mar (Barcelona) is described. Results for opioid-related emergencies are presented, showing an epidemic increase in the number of such emergencies after 1981. The total number of opioid-related emergencies was 18,042 with a mean of 2.23 opioid-related emergency admissions per client throughout the whole period, implying that some 8000 persons were seen. In episodes from non-arrestees, mean age increased slightly over time, the male/female ratio being 2.5; withdrawal was the more frequent reason for attendance (53%), overdose accounting for 9% of admissions, and other medical conditions for 33%. Non-arrested women were more likely to attend for other medical conditions and overdoses than men. The importance of this kind of register as well as its limitations for assessing the trend of opioid use prevalence is discussed.

Benzodiazepines: a major problem. Introduction

Benzodiazepine use is prevalent. Moreover, benzodiazepine abuse, addiction, tolerance, and dependence occur commonly with benzodiazepine use. Confusion arises in assessing the nature and magnitude of benzodiazepine use and its consequences. Abuse, addiction, tolerance, and dependence occur in medical and nonmedical populations, but the studies do not clearly differentiate the benzodiazepine use between these two populations. The nonmedical use in medical populations is underestimated and underdiagnosed. The nonmedical use is also misdiagnosed in nonmedical populations as medical use. Clearer definitions and usage of the terms of abuse, addiction, tolerance, and dependence would result in accurate diagnosis and proper treatment of the disorders associated with benzodiazepine use, that is, anxiety and depressive disorders, alcoholism, and other drug addictions.

Addiction to and dependence on benzodiazepines. Diagnostic confusion in clinical practice and research studies

Considerable confusion continues to surround basic concepts for abuse, addiction, tolerance, and dependence. Clinicians may be making decisions about prescribing these medications without clear definitions and distinctions. The terms are not equivalent in meaning and should not be used interchangeably in clinical application. Moreover, they may occur together or independently and are not etiologically related. Abuse is improper use outside the standard norms. Abuse implies a violation component and a control over the use of the drug. Addiction is a preoccupation with the acquisition and compulsive use of and a pattern of relapse to drugs is spite of adverse consequences. Pervasive to the criteria is a loss of control over drug use and a lack of volitional component in the drug use. In spite of problems in definitions, studies have clearly shown that abuse, addiction, tolerance, and dependence develop commonly in benzodiazepine use.

Benzodiazepines: tolerance, dependence, abuse, and addiction

Many recent studies have clearly documented the development of tolerance, dependence, and addiction to benzodiazepines. In spite of these studies and reviews of the literature, confusion remains regarding the risk and benefits of the use of benzodiazepines in medical practice. The source of the confusion arises in part from the lack of clarity in the definitions of tolerance, dependence, and addiction. The distinctions among these important terms are frequently obscured in research studies and, especially, in clinical practice. In addition, the practice of separating medical from nonmedical populations in reports of benzodiazepine dependence is misleading. The overlap between medical and nonmedical benzodiazepine users is large, so that many of these individuals fall into both categories. These and other points should be considered as serious questions to the safety and freedom from dependence and addiction in any drug-using population.

Classification of overdose/self-poisoning presentations to an accident and emergency department

A simple classification system of overdoses presenting to a hospital emergency department is described. Five major overdose categories were developed (accidental, suicidal behavior, recreational/experimentation, compulsive use, and an indeterminate category), which were divided into 10 subcategories. A prospective survey at an inner-city hospital in Sydney classified 199 consecutive self-poisoning presentations as being due to compulsive drug use in 38% of cases; suicidal gesture as a reaction to stress, 17%; adverse reactions to recreational or experimental use, 15%; suicidal gesture to influence others, 7%; genuine accident or noncompliance with medication, 6%; genuine suicide attempt, 3%; and pseudo-overdose, 3%. The reason for the overdose was uncertain in the remainder of the cases. Additional data are also presented, including the types of drugs involved in each overdose category. Categories of overdose may be useful in psychosocial assessment for follow-up interventions, assist in research, and help reduce negative attitudes toward overdoses.

Monitoring changing patterns of drug dependence in accident and emergency departments

A survey was made of drug dependent individuals attending the Accident and Emergency Departments in Greater London in July 1982 and the results were compared with those of an identical survey in July 1975. There was a significant reduction in the number of incidents involving drug dependent patients, the majority of whom attended hospital after a drug overdose; the proportion of suicidal attempts increased significantly in 1982. Barbiturates were taken less frequently in 1982, but heroin and anxiolytics were taken more often. Possible reactions to these findings are discussed and the continuing role of the Accident and Emergency Departments in monitoring changing patterns of drug abuse in emphasised.

Psychiatric disorder in the general hospital

There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric morbidity in in-patient, out-patient and casualty department populations, much of which is unrecognised by hospital doctors. We require a better classification of psychiatric disorder in the general hospital, improved research measures, and more evidence about the nature and course of the many different types of problem so that we can provide precise advice for their management of routine clinical practice.

A comparison of drug-related problems in London Accident and Emergency Departments 1975-1982

Drug-related incidents dealt with by ten Accident and Emergency departments in Greater London during July 1982 were compared with those obtained from an identical survey in 1975. The number of incidents remained high, but there was a significant reduction in them and in the number of drug dependent attenders, compared with 1975: hypnotic drugs were used in a significantly smaller percentage of drug overdoses, but there was increased use of minor tranquillisers. The possibility of using A & E departments to monitor drug misuse on a Regional basis is discussed.

Trends in self-poisoning with drugs in Newcastle, New South Wales, 1980-1982

A review has been carried out of 747 cases of self-poisoning with drugs which were treated in the three major Newcastle hospitals over the three-year period 1980-1982. The data obtained have been compared with earlier published data for the years 1976-1979. The number of patients who were admitted to hospital fell from 290 in 1980 to 226 in 1982. The most common drugs used were benzodiazepine (34.5% of cases) and antidepressant agents (9.1%), paracetamol (7.9%), barbiturates (7.1%) and phenothiazines (3.8%). Although this indicated a gratifying drop in the use of barbiturate drugs, the use of several drugs in combination in self-poisoning rose disturbingly. Five patients died in hospital; 23 who committed suicide with drugs were not admitted to hospital but were investigated by the Regional Forensic Pathologist.

Pharmacokinetic determinants of drug abuse and dependence. A conceptual perspective

Drugs that produce physical dependence or have similar pharmacological profiles to highly abused drugs are unlikely to be considered acceptable for marketing. Thus, the prediction of abuse and dependence becomes an important issue in the development of new psychotropic drugs. Both pharmacokinetic and non-pharmacokinetic factors play an important role in predicting dependence and abuse liability of drugs. Evidence for the importance of pharmacological factors includes: the demonstration of drug binding to receptors of abused drugs; tolerance; ability to maintain self-administration; and spontaneous or antagonist precipitated withdrawal. The pharmacokinetic properties that presumably contribute to persistent self-administration and abuse include rapid delivery of drug to the central nervous system (CNS), rapid absorption, low protein binding and high free drug clearance. The pharmacokinetic properties of a drug associated with dependence will include long half-life, low free drug clearance and presence of the drug in the body at high enough concentrations and for sufficient time to permit tolerance to develop. These properties have important clinical implications for treatment and research in the area of abuse and dependence liability of psychoactive drugs.

Effects of combined alcohol and benzodiazepine: a review

Both human and animal studies relating to the combined effects of alcohol and benzodiazepine (BZD) are reviewed. Although the combination of alcohol and BZD is sometimes associated with drug-induced deaths, drug overdoses and traffic accidents or fatalities, epidemiological information is lacking on the true extent of the combined abuse and on the patterns and prevalence of use of these two drugs. Since BZD are widely used for the short- and long-term treatment of alcoholics, these patients are deemed more at risk of developing BZD or alcohol/BZD dependence than the general population. There is a dire need for large-scale controlled studies concerning the efficacy of BZD in the long-term treatment of alcoholics. Compared to men, women are at a higher risk as far as the potential for BZD addiction is concerned, since they tend to use BZD more often. Epidemiologic studies on the patterns of use of BZD, alcohol or alcohol/BZD in pregnant women are called for. Animal models are also needed to ascertain whether prenatal exposure to both alcohol and BZD can impart long-lasting behavioral changes in the progeny. It is possible that BZD can exacerbate the damaging prenatal effects of alcohol.