Changes in the pattern of drug overdoses

Hospital-treated deliberate self-poisoning in the older adult: Identifying specific clinical assessment needs

BACKGROUND

Hospital-treated deliberate self-poisoning is common, with a median patient age of around 33 years. Clinicians are less familiar with assessing older adults with self-poisoning and little is known about their specific clinical requirements.

OBJECTIVE

To identify clinically important factors in the older-age population by comparing older adults (65+ years) with middle-aged adults (45-64 years) during an index episode of hospital-treated deliberate self-poisoning.

METHODS

A prospective, longitudinal, cohort study of people presenting to a regional referral centre for deliberate self-poisoning (Calvary Mater Newcastle, Australia) over a 10-year period (2003-2013). We compared older-aged adults with middle-aged adults on demographic, toxicological and psychiatric variables and modelled independent predictors of referral for psychiatric hospitalisation on discharge with logistic regression.

RESULTS

There were (n = 157) older-aged and (n = 925) middle-aged adults. The older-aged group was similar to the middle-aged group in several ways: proportion living alone, reporting suicidal ideation/planning, prescribed antidepressant and antipsychotic drugs, and with a psychiatric diagnosis. However, the older-aged group were also different in several ways: greater proportion with cognitive impairment, higher medical morbidity, longer length of stay, and greater prescription and ingestion of benzodiazepines in the deliberate self-poisoning event. Older age was not a predictor of referral for psychiatric hospitalisation in the multivariate model.

CONCLUSION

Older-aged patients treated for deliberate self-poisoning have a range of clinical needs including ones that are both similar to and different from middle-aged patients. Individual clinical assessment to identify these needs should be followed by targeted interventions, including reduced exposure to benzodiazepines.

Refining the World Health Organization Definition: Predicting Autopsy-Defined Sudden Arrhythmic Deaths Among Presumed Sudden Cardiac Deaths in the POST SCD Study

BACKGROUND

Conventional definitions of sudden cardiac death (SCD) presume cardiac cause. We studied the World Health Organization-defined SCDs autopsied in the POST SCD study (Postmortem Systematic Investigation of SCD) to determine whether premortem characteristics could identify autopsy-defined sudden arrhythmic death (SAD) among presumed SCDs.

METHODS

Between January 2, 2011, and January 4, 2016, we prospectively identified all 615 World Health Organization-defined SCDs (144 witnessed) 18 to 90 years in San Francisco County for medical record review and autopsy via medical examiner surveillance. Autopsy-defined SADs had no extracardiac or acute heart failure cause of death. We used 2 nested sets of premortem predictors-an emergency medical system set and a comprehensive set adding medical record data-to develop Least Absolute Selection and Shrinkage Operator models of SAD among witnessed and unwitnessed cohorts.

RESULTS

Of 615 presumed SCDs, 348 (57%) were autopsy-defined SAD. For witnessed cases, the emergency medical system model (area under the receiver operator curve 0.75 [0.67-0.82]) included presenting rhythm of ventricular tachycardia/fibrillation and pulseless electrical activity, while the comprehensive (area under the receiver operator curve 0.78 [0.70-0.84]) added depression. If only ventricular tachycardia/fibrillation witnessed cases (n=48) were classified as SAD, sensitivity was 0.46 (0.36-0.57), and specificity was 0.90 (0.79-0.97). For unwitnessed cases, the emergency medical system model (area under the receiver operator curve 0.68 [0.64-0.73]) included black race, male sex, age, and time since last seen normal, while the comprehensive (area under the receiver operator curve 0.75 [0.71-0.79]) added use of β-blockers, antidepressants, QT-prolonging drugs, opiates, illicit drugs, and dyslipidemia. If only unwitnessed cases <1 hour (n=59) were classified as SAD, sensitivity was 0.18 (0.13-0.22) and specificity was 0.95 (0.90-0.97).

CONCLUSIONS

Our models identify premortem characteristics that can better specify autopsy-defined SAD among presumed SCDs and suggest the World Health Organization definition can be improved by restricting witnessed SCDs to ventricular tachycardia/fibrillation or nonpulseless electrical activity rhythms and unwitnessed cases to <1 hour since last normal, at the cost of sensitivity.

Methods of deliberate self-harm in Pakistan

Reports of deliberate self-harm (DSH) are rare from Pakistan where psychotropic drugs can be obtained ‘over the counter’. A retrospective analysis of 302 index cases presenting to a university hospital in Karachi showed self-poisoning with benzodiazepines as the most common method, followed by organophosphate insecticides. Salicylates and non-opiate analgesics were significantly absent from our series. Implications of these findings are discussed.

Drug and chemical poisoning admissions at a teaching hospital in Malaysia

A retrospective review of medical records was carried out to determine the pattern of drug and chemical poisoning cases admitted to a teaching hospital in Malaysia. Medical records of patients admitted during the period January 1987 to December 1995 were reviewed. They accounted for 0.2% of total admissions during the period. While all ages were represented, there was predominance of children, which showed little change throughout the nine-year period. Of all cases of poisoning, 77.8% were unintentional, 12.6% intentional and 9.6% were undetermined. Kerosene, pesticides and medicinal substances remained the common agents associated with poisoning. A significant number of patients sought treatment elsewhere before being admitted to the hospital. Of those who came directly to the hospital, many were presented late in the course of their poisoning. Only seven patients died and none were children. This study supports the need for greater emphasis on prevention of poisoning in children and among farmers in the state.

[Successful treatment of polymedicamentous poisoning with metoprolol, diltiazem and cilazapril]

INTRODUCTION

Poisoning caused by drugs with cardiodepressive effects is an urgent condition in medicine which is associated with high mortality rate regardless of modern therapeutic methods. Accidental or intentional poisoning whit these drugs produces heart activity depression and cardiovascular collapse as consequences. Current therapy for severe poisoning caused by beta-blockers and calcium channel blockers includes both unspecific and specific antidote therapy whit glucagon, as well as application of adrenergic drugs, calcium, phosphodiesterase inhibitors and hyperinsulinemia/euglycemia therapy. However, even whit the application of these drugs, prompt measures of unspecific detoxication therapy and cardiopulmonary reanimation are crucial for survival of patients with severe poisoning.

CASE REPORT

A 28-year-old female patient was hospitalized for cardiogenic shock and altered state of conscioussnes (Glasgow coma score = 4), caused by acute poisoning with 2 g of metoprolol (Presolol), 1.8 g of diltiazem (Cortiazem) and 50 mg of cilazapril (Zobox). Prolonged cardiopulmonary resuscitation was applied during the first 16 hours of hospitalization, including administration of crystaline solutions (8 L), 17 mg of adrenaline, 4 mg of atropine, 4 mg of glucagone and 1.6 g of dopamine, with electro-stimulation by temporary pacemaker and mechanical ventilation. In a defined time period, normalized state of consciousness was registered, mechanical ventilation was stopped and normal heart activity and hemodynamic stability were accomplished. During hospitalization the patient was treated for mild pneumonia and after ten days, completely recovered, was released and sent to home treatment.

CONCLUSION

Prompt measures of cardiopulmonary resuscitation and multidisciplinary treatment in intensive care units significantly increase the chances of complete recovery of a patient with severe poisoning caused by drugs with cardiodepressive efects.

Demographic, geographic, and temporal patterns of ambulance runs for suspected opiate overdose in Rhode Island, 1997-20021

We examine ambulance runs for suspected opiate overdose from 1997 to 2002 using a Rhode Island Department of Health database. Of the 8,763 ambulance runs for overdoses, 18.6% were for suspected opiate overdoses. Most cases were males under age 54. Suspected opiate overdoses were more likely to occur in a private residence, were more frequent on Fridays and Saturdays, and peaked in incidence around 9:00 p.m. The incidence rate of suspected opiate overdose by year was similar. The study results may help identify areas for preventive intervention and demonstrate the limitation of using naloxone as a marker of opiate overdose events.

Patient characteristics associated with nonprescription drug use in intentional overdose

OBJECTIVE

Over-the-counter (OTC) medications remain freely available to suicidal patients, despite their potential lethality and common use in suicide. The study's main objective was to identify patient characteristics, particularly psychiatric diagnosis associated with the use of OTC medications in intentional overdose.

METHODS

We retrospectively reviewed 95 charts from patients who presented to St Paul's Hospital from August 1, 1997, to July 31, 1998, with a discharge diagnosis of intentional drug overdose. Univariate analysis was carried out to identify potential risk markers for OTC medication use, and logistic regression was performed using these variables.

RESULTS

When the variables age, sex, and concurrent psychiatric diagnoses were controlled, use of OTC medications in overdose was significantly lower in patients with a DSM-IV diagnosis of substance abuse (OR 0.11, P = 0.005) and in those who possessed prescription medications at the time of overdose (OR 0.18, P = 0.007). Most patients in this cohort (82%) had at least 1 of these 2 traits. Although not statistically significant, younger patients appeared more likely to choose OTC medications for overdose.

CONCLUSION

Suicide-prone patients with a diagnosis of substance abuse and who possess prescription medications are unlikely to use OTC medications in overdose. For this cohort, this represents a relatively small proportion of patients whom clinicians should consider to be at greater risk for attempting suicide when using OTC medication, especially acetaminophen.

Predictors and prevention of nonfatal overdose among street-recruited injection heroin users in the San Francisco Bay Area, 1998-1999

OBJECTIVES

This study sought to determine prevalence of and risk factors for nonfatal recent overdose among street-recruited injection heroin users.

METHODS

From August 1998 through July 1999, 1427 heroin injectors were recruited from 6 inner-city neighborhoods in the San Francisco Bay Area, Calif, and interviewed. Factors hypothesized to be associated with recent overdose were analyzed with logistic regression.

RESULTS

Of the 1427 participants, 684 (48%) had had an overdose, 466 (33%) had experienced 2 or more overdose events, and 182 (13%) had had a recent overdose. In multiple logistic regression, being younger (adjusted odds ratio [OR] for each year of increasing age = 0.95; 95% confidence interval [CI] = 0.94, 0.97), having been arrested 3 or more times in the past year (adjusted OR = 2.50; 95% CI = 1.61, 3.87), drinking 4 or more alcoholic drinks per day (adjusted OR = 2.05; 95% CI = 1.37, 3.05), and having participated in methadone detoxification during the past year (adjusted OR = 1.47; 95% CI = 1.03, 2.09) were independently associated with recent overdose. Being homeless; identifying as gay, lesbian, bisexual, or transgender; having spent 5 or more years in prison or jail; and having engaged in sex work also were associated with recent overdose.

CONCLUSIONS

Targeted interventions that decrease risk for overdose are urgently needed.

Deliberate self-poisoning in an Irish county hospital

BACKGROUND

In 1997, 433 people committed suicide in Ireland, one-quarter of whom were less than 24 years of age.

AIM

To determine demographics, agent choice and source, suicidality and follow-up care of deliberate self-poisoning patients.

METHOD

Details of 111 patients admitted to one hospital in 1997 following drug overdose were studied retrospectively. Eleven had been accidental ingestions, the remaining 100 were deliberate self-poisoning.

RESULTS

Men accounted for 38% of the presentations and were more likely to have suicidal intent than women. An average of 2.3 different agents were used. Paracetamol was taken by 37%, hypnotics/anxiolytics by 33% and nonsteroidal anti-inflammatories by 17%. Alcohol was consumed synchronously by 51% and 17% fulfilled criteria for alcohol dependency. One-third of patients were clinically depressed. All six patients requiring ventilation had consumed a combination of tricyclic antidepressants and alcohol. There were no deaths.

CONCLUSION

Deliberate self-poisoning remains a significant problem. Paracetamol and alcohol use are particularly marked in this population. The combination of tricyclic antidepressant drugs and alcohol were the most dangerous.

Comparison of effect of ethanol and anticonvulsants on cardiovascular drug-modified cocaine toxicity

The anticonvulsant (AC drug)- or ethanol (EtOH)-modified effects of cardiovascular (CV) drugs against cocaine (COCA)-induced toxicity were examined in male ICR mice. Nontoxic doses of the CV drugs nimodipine (NIMO), prazosin (PRA), phentolamine (PHEN), propranolol (PRO), and enalapril (ENA) were used with or without the AC drugs diazepam (DZP), phenobarbital (PHB), phenytoin (PHY), and EtOH. Each CV drug combined with or without each AC drug was administered intraperitoneally (IP) 5 min before an IP injection of COCA 75 mg/kg. Of the CV drugs examined, PRA 5 mg/kg and PHEN 5 mg/kg protected against COCA-induced seizures, but only the alpha1-adrenergic blocking agent PRA protected against COCA-induced deaths. Of the AC drugs examined, DZP 5 mg/kg and PHB 50 mg/kg, as well as EtOH 3 g/kg, attenuated the severity of the COCA-induced seizures, but only PHB protected against COCA-induced deaths. The total mortality rate was significantly, often synergistically, decreased compared to the COCA-only group when the appropriate CV drugs were combined with the AC drugs: PRA 5 mg/kg in the EtOH-cotreated groups, PRA 5 mg/kg, PHEN 5 mg/kg or ENA 10 mg/kg in the DZP-cotreated groups, and NIMO 5 mg/kg, PRA 5 mg/kg, PHEN 5 mg/kg, or PRO 10 mg/kg in the PHB-cotreated groups. The decrease in the COCA concentration in the blood and/or brain was not always accompanied by an attenuation of the mortality rate. However, the attenuation of severe seizures by a single PRA, PHEN, DZP, or PHB cotreatment was accompanied by a decrease in the brain COCA concentration.

Flumazenil in drug overdose: randomized, placebo-controlled study to assess cost effectiveness

OBJECTIVE

To investigate cost effectiveness of administration of flumazenil to patients presenting with suspected acute drug overdose.

DESIGN

Double-blind, prospective, placebo-controlled randomized study.

SETTING

University teaching hospital.

PATIENTS

Forty-three adults presenting with suspected drug overdose and having a Glasgow Coma Scale (GCS) score of <13. Patients with known benzodiazepine/tricyclic ingestion were excluded.

INTERVENTIONS

Intravenous administration of flumazenil (up to 2 mg) or placebo.

MEASUREMENTS AND MAIN RESULTS

Individual patient costs were assessed and data aggregated for each treatment group. Major diagnostic and therapeutic interventions were recorded and between group comparisons performed. Clinical response to study drug administration was assessed by obtaining pre- and post-drug GCS scores and observation of the patient for at least 180 mins for signs of resedation. Aggregate cost or number of major diagnostic and therapeutic interventions were not different between groups. Patients randomized to the flumazenil group showed a marked increase in GCS score (7.4 to 11.8) compared with those in the placebo group (8.2 to 8.6).

CONCLUSION

Use of flumazenil in intentional drug overdose of unknown etiology is not cost effective.

The changing mental health of children and adolescents: evidence for a deterioration?

This paper reviews the evidence for changing patterns of mental health over time in childhood and youth in Western societies. The evidence suggests that the prevalence of major depression, substance abuse and offending behaviour, as well as the incidence of suicide, is increasing in adolescent populations, particularly among males. There are also indications that problem behaviours among younger children are becoming more common. There is no evidence of a deterioration in the adjustment of the pre-school population.