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Casey D, Geulayov G, Bale E, Brand F, Clements C, Kapur N, Ness J, Patel A, Waters K, Hawton K. Paracetamol self-poisoning: Epidemiological study of trends and patient characteristics from the multicentre study of self-harm in England. J Affect Disord 2020; 276:699-706. [PMID: 32871703 DOI: 10.1016/j.jad.2020.07.091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/18/2020] [Accepted: 07/05/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Paracetamol is frequently used for intentional self-poisoning, especially in the UK, despite pack size restrictions introduced in 1998. Knowing more about paracetamol self-poisoning may identify further approaches to prevention. METHODS We used data from the Multicentre Study of Self-harm in England for 2004-2014 to calculate incidence rates of presentations to Emergency Departments following self-poisoning with pure paracetamol alone. National estimates for England for 2011-2014 were extrapolated using indirect age-standardised rates. The characteristics of individuals taking paracetamol overdoses and the size of the overdoses were investigated. RESULTS A third of 54,863 intentional overdoses presenting to the five Emergency Departments involved paracetamol without other drugs (N = 18,011), taken by 13,171 individuals (63.4% female). The proportion of paracetamol self-poisonings was similar in the three centres. Extrapolation suggested there were approximately 50,000 paracetamol overdoses in England annually during 2011-2014. Females had higher rates of paracetamol overdose than males. Males and older individuals took larger overdoses. Nearly a quarter of individuals (24.2%) consumed more than 32 tablets. Alcohol was involved in 53.7% of paracetamol overdoses. LIMITATIONS Data were collected in three centres with predominantly urban populations. Extrapolation from local to national rates should be interpreted with caution. CONCLUSIONS Paracetamol overdose remains a major problem in the UK. It is more common in females and younger patients, but males and older patients consume larger overdoses. Consideration should be given to further restriction in pack sizes and sources of sales, in keeping with those of several other European countries.
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Affiliation(s)
- Deborah Casey
- Centre for Suicide Research, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Galit Geulayov
- Centre for Suicide Research, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Elizabeth Bale
- Centre for Suicide Research, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Fiona Brand
- Centre for Suicide Research, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust
| | - Caroline Clements
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, UK
| | - Navneet Kapur
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre, UK; NIHR Patient Safety Translational Research Centre, University of Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Jennifer Ness
- Centre for Self-harm and Suicide Prevention Research, Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Anita Patel
- Centre for Self-harm and Suicide Prevention Research, Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Keith Waters
- Centre for Self-harm and Suicide Prevention Research, Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust.
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Martinez-De la Torre A, Weiler S, Bräm DS, Allemann SS, Kupferschmidt H, Burden AM. National Poison Center Calls Before vs After Availability of High-Dose Acetaminophen (Paracetamol) Tablets in Switzerland. JAMA Netw Open 2020; 3:e2022897. [PMID: 33112400 PMCID: PMC7593813 DOI: 10.1001/jamanetworkopen.2020.22897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Acetaminophen (paracetamol) is among the most widely used pain medications worldwide; while safe within the therapeutic range, intake exceeding 4000 mg/d can lead to hepatotoxicity. Prior evidence suggests that limiting the availability of large quantities of acetaminophen is associated with decreased acetaminophen-related poisonings and mortality; in Switzerland, 500-mg tablets are available over-the-counter (OTC) and, as of October 2003, 1000-mg tablets are available with prescription. OBJECTIVE To evaluate the association of adding 1000-mg acetaminophen tablets to the Swiss market with utilization and poisonings. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used a quasi-experimental interrupted time series analysis to evaluate 15 790 acetaminophen poison records from January 1, 2000, to December 31, 2018. All calls for acetaminophen-related poisonings identified from the National Swiss Poisons Centre and all sales for oral acetaminophen tablets (prescription and OTC) dispensed between January 2000 and December 2018 were included. EXPOSURE October 3, 2003 (Q4 2003), was defined as the intervention date, corresponding to the date of market entry for 1000-mg acetaminophen tablets in Switzerland. MAIN OUTCOMES AND MEASURES The primary outcome was the number of quarterly acetaminophen-related poison calls to the National Poison Centre. Additional outcomes included quarterly sales for acetaminophen and change in poisoning circumstances, stratified by preintervention and postintervention periods and by formulation (ie, 500-mg and 1000-mg tablets). RESULTS Between 2000 and 2018, 15 790 acetaminophen-related poisoning calls were identified, of which 10 628 (67.3%) were regarding women, and the mean (SD) age of patients was 25.2 (18.2) years. The interrupted time series analysis identified a significant increase in the slope for the number of reported poisonings following the intervention point, particularly for accidental circumstances (z score, -3.62; P < .001). In the preintervention period, 120 of 961 poisonings (15.3%) involved a dose greater than 10 000 mg, while for the postintervention period, 1140 of 5696 (30.6%) had a dose larger than 10 000 mg (P < .001). There was a rapid uptake in 1000-mg acetaminophen sales, while sales of the 500-mg tablet decreased slightly. Since 2012, a mean (SD) of 20.7 million (1.4 million) 1000-mg tablets were dispensed quarterly compared with 2.7 million (0.5 million) 500-mg tablets. CONCLUSIONS AND RELEVANCE This study found a significant increase in acetaminophen dispensing and acetaminophen-related poisonings in Switzerland following the approval of 1000-mg tablets in 2003. The availability of 1000-mg acetaminophen should be re-evaluated to minimize the potential for accidental poisonings.
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Affiliation(s)
- Adrian Martinez-De la Torre
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
| | - Stefan Weiler
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Dominic Stefan Bräm
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
| | | | - Hugo Kupferschmidt
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Andrea M. Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
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Jung KY, Kim T, Hwang SY, Yoon H, Shin TG, Sim MS, Jo IJ, Cha WC. Availability of drug at convenient stores is not associated with an increased incidence of their poisoning. Pharmacoepidemiol Drug Saf 2019; 28:536-543. [PMID: 30848006 DOI: 10.1002/pds.4760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/19/2019] [Accepted: 01/25/2019] [Indexed: 11/10/2022]
Abstract
PURPOSE In late 2012, South Korea revised the Pharmaceutical Affairs Act to make selected medications including acetaminophen, ibuprofen, and cold medications available in nonpharmacy outlets, including the 24-hour convenient stores (CVS). The objective of this study was to identify whether the characteristics and trend of self-poisonings associated with these medications were altered after the legislative change. METHODS A retrospective study was performed using national data from the Emergency Department (ED)-based Injury In-depth Surveillance database. The patients diagnosed with poisoning were sorted from 2011 to 2016 and included in the study. As the Act was implemented from 2013, the demographic characteristics and clinical outcomes were compared before and after January 2013. A piecewise regression analysis was performed to determine the association between the monthly use of acetaminophen, medication for cold, and nonsteroidal anti-inflammatory drugs (NSAIDs) and the incidence of total poisonings before and after the January 2013. RESULTS Among 1 536 277 patients included in the database, 17 523 patients diagnosed with poisoning were enrolled. After the legislative change, the etiology of poisoning did not change, although the frequency of hospitalization from ED was significantly increased. The monthly trend for poisoning due to acetaminophen, cold medications, and NSAIDs showed no significant slope change between before and after the legislative change. The proportional use of acetaminophen and cold medications was significantly decreased, while that of NSAIDs was unchanged before and after the legislative change. CONCLUSIONS The change in the Pharmaceutical Affairs Act was not associated with any change in the monthly frequency of medication-related poisoning.
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Affiliation(s)
- Kwang Yul Jung
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Kennedy C, Duggan E, Bennett K, Williams DJ. Rates of reported codeine-related poisonings and codeine prescribing following new national guidance in Ireland. Pharmacoepidemiol Drug Saf 2019; 28:106-111. [DOI: 10.1002/pds.4725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/15/2018] [Accepted: 12/05/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Cormac Kennedy
- Department of Geriatrics and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Edel Duggan
- National Poisons Information Centre; Beaumont Hospital; Dublin Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin 2 Ireland
| | - David J. Williams
- Department of Geriatrics and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
- Department of Geriatrics and Stroke Medicine; Beaumont Hospital; Dublin 9 Ireland
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Are we finally making progress with suicide and self-harm? An overview of the history, epidemiology and evidence for prevention. Ir J Psychol Med 2018; 35:95-101. [PMID: 30115199 DOI: 10.1017/ipm.2017.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Ireland's suicide rate is falling, but suicide and self-harm remain substantial societal problems. It is not possible to predict suicide at the level of the individual but good primary care, good mental health care and good social care all likely reduce risk. In terms of targeted interventions, public health measures, such as paracetamol pack size regulations, have the best evidence base to support them. Despite increased public and professional discussion, much remains to be done to provide effective, coordinated support to those at risk of suicide and those bereaved. In 2016, there were up to 300 different groups providing support. Clearly, a coordinated, effective and compassionate approach is needed, linking community and state resources meaningfully with each other. Approaches rooted outside of core mental health services will be vital: addressing alcohol problems and other addictions, reducing homelessness, reforming the criminal justice system and improving social care.
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Goedecke T, Morales DR, Pacurariu A, Kurz X. Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations. Br J Clin Pharmacol 2018; 84:419-433. [PMID: 29105853 PMCID: PMC5809349 DOI: 10.1111/bcp.13469] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research. METHODS We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted. RESULTS From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%). CONCLUSION Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.
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Affiliation(s)
- Thomas Goedecke
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
| | - Daniel R. Morales
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Division of Population Health SciencesUniversity of DundeeDundeeDD2 4BFUK
| | - Alexandra Pacurariu
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Dutch Medicines Evaluation Board3531AHUtrechtThe Netherlands
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
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Morthorst BR, Erlangsen A, Nordentoft M, Hawton K, Hoegberg LCG, Dalhoff KP. Availability of Paracetamol Sold Over the Counter in Europe: A Descriptive Cross-Sectional International Survey of Pack Size Restriction. Basic Clin Pharmacol Toxicol 2018; 122:643-649. [DOI: 10.1111/bcpt.12959] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/27/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Britt Reuter Morthorst
- Faculty of Medical and Health Science; University of Copenhagen; Copenhagen Denmark
- Danish Research Institute for Suicide Prevention; Research Unit; Mental Health Centre Copenhagen; Copenhagen Denmark
| | - Annette Erlangsen
- Danish Research Institute for Suicide Prevention; Research Unit; Mental Health Centre Copenhagen; Copenhagen Denmark
- Department of Mental Health; Johns Hopkins School of Public Health; Baltimore MD USA
- Institute of Regional Health Research; University of Southern Denmark; Odense Denmark
| | - Merete Nordentoft
- Faculty of Medical and Health Science; University of Copenhagen; Copenhagen Denmark
- Danish Research Institute for Suicide Prevention; Research Unit; Mental Health Centre Copenhagen; Copenhagen Denmark
| | - Keith Hawton
- Centre for Suicide Research; University Department of Psychiatry; Oxford University; Oxford UK
| | | | - Kim Peder Dalhoff
- Department of Clinical Pharmacology and Clinical Toxicology; Copenhagen University Hospital Bispebjerg and Frederiksberg; Copenhagen Denmark
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8
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Gulmez SE, Larrey D, Pageaux GP, Bernuau J, Bissoli F, Horsmans Y, Thorburn D, McCormick PA, Stricker B, Toussi M, Lignot-Maleyran S, Micon S, Hamoud F, Lassalle R, Jové J, Blin P, Moore N. Liver transplant associated with paracetamol overdose: results from the seven-country SALT study. Br J Clin Pharmacol 2015; 80:599-606. [PMID: 26017643 DOI: 10.1111/bcp.12635] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/24/2015] [Accepted: 03/03/2015] [Indexed: 02/05/2023] Open
Abstract
AIMS Acute drug overdose, especially with paracetamol, may cause acute liver failure leading to registration for transplantation (ALFT). Population statistics and between-country differences for ALFT related to overdose have been poorly described. The aim of the present study was to evaluate overdose ALFT in the multi-country Study of Acute Liver Transplantation (SALT). METHODS All adult overdose-related ALFT, with or without suicidal intent, in France, Greece, Ireland, Italy, the Netherlands, Portugal and the UK between 2005 and 2007 were identified from liver transplant registries and hospital records. These were compared with whole-country and per capita use of paracetamol. RESULTS Six hundred cases of ALFT were identified in 52 of 57 eligible transplant centres, of which 114 involved overdose (72 intentional, 10 non-intentional, 32 uncertain). Overdose represented 20% of all-cause ALFT: Ireland 52%, UK 28%, France 18%, the Netherlands 8%, and Italy 1%. Overdose ALFT were mostly females (61%), mean age 33.6 ± 10.9 years. A total of 111 (97%) of the overdoses involved paracetamol. Event rates ranged from one ALFT for 20.7 tons of paracetamol in Ireland, to one for 1074 tons in Italy and one case in 60 million inhabitants over 3 years in Italy to one case in 286 000 inhabitants per year in Ireland. Per-country event rates for non-overdose ALFT exposed to paracetamol were between 2.5 and 4.0 per million treatment-years sold. CONCLUSIONS Paracetamol overdose was found to represent one-sixth of all-cause ALFT. There was a 50-fold difference in Europe in the rates of paracetamol overdose ALFT, and a 200-fold difference per million inhabitants.
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Affiliation(s)
- Sinem Ezgi Gulmez
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | | | | | | | - Franco Bissoli
- Department of Internal Medicine, Clinica San Gaudenzio, Novara, Italy
| | - Yves Horsmans
- Department of Gastroenterology, Louvain Catholic University, Louvain, Belgium
| | | | - P Aiden McCormick
- Liver Unit, St Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Bruno Stricker
- Department of Epidemiology, Erasmus University, Rotterdam, Netherlands
| | | | | | - Sophie Micon
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Fatima Hamoud
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Régis Lassalle
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Jérémy Jové
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Patrick Blin
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Nicholas Moore
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
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Murphy OC, Kelleher C, Malone KM. Demographic trends in suicide in the UK and Ireland 1980–2010. Ir J Med Sci 2014; 184:227-35. [DOI: 10.1007/s11845-014-1092-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 02/14/2014] [Indexed: 11/24/2022]
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Gunnell D, Hawton K, Bennewith O, Cooper J, Simkin S, Donovan J, Evans J, Longson D, O'Connor S, Kapur N. A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England. PROGRAMME GRANTS FOR APPLIED RESEARCH 2013. [DOI: 10.3310/pgfar01010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
ObjectivesTo 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).MethodsThere 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.ConclusionWithin 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 registrationA pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - K Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - O Bennewith
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Cooper
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - S Simkin
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - J Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Evans
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Avon and Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
| | - D Longson
- Manchester Mental Health and Social Care Trust, Manchester, UK
| | - S O'Connor
- Avon and Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
| | - N Kapur
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
- Manchester Mental Health and Social Care Trust, Manchester, UK
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11
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Tormey WP, Srinivasan R, Moore T. Biochemical toxicology and suicide in Ireland: a laboratory study. Ir J Med Sci 2012. [DOI: 10.1007/s11845-012-0879-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hawton K, Bergen H, Simkin S, Arensman E, Corcoran P, Cooper J, Waters K, Gunnell D, Kapur N. Impact of different pack sizes of paracetamol in the United Kingdom and Ireland on intentional overdoses: a comparative study. BMC Public Health 2011; 11:460. [PMID: 21663604 PMCID: PMC3125378 DOI: 10.1186/1471-2458-11-460] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 06/10/2011] [Indexed: 12/04/2022] Open
Abstract
Background In order to reduce fatal self-poisoning legislation was introduced in the UK in 1998 to restrict pack sizes of paracetamol sold in pharmacies (maximum 32 tablets) and non-pharmacy outlets (maximum 16 tablets), and in Ireland in 2001, but with smaller maximum pack sizes (24 and 12 tablets). Our aim was to determine whether this resulted in smaller overdoses of paracetamol in Ireland compared with the UK. Methods We used data on general hospital presentations for non-fatal self-harm for 2002 - 2007 from the Multicentre Study of Self-harm in England (six hospitals), and from the National Registry of Deliberate Self-harm in Ireland. We compared sizes of overdoses of paracetamol in the two settings. Results There were clear peaks in numbers of non-fatal overdoses, associated with maximum pack sizes of paracetamol in pharmacy and non-pharmacy outlets in both England and Ireland. Significantly more pack equivalents (based on maximum non-pharmacy pack sizes) were used in overdoses in Ireland (mean 2.63, 95% CI 2.57-2.69) compared with England (2.07, 95% CI 2.03-2.10). The overall size of overdoses did not differ significantly between England (median 22, interquartile range (IQR) 15-32) and Ireland (median 24, IQR 12-36). Conclusions The difference in paracetamol pack size legislation between England and Ireland does not appear to have resulted in a major difference in sizes of overdoses. This is because more pack equivalents are taken in overdoses in Ireland, possibly reflecting differing enforcement of sales advice. Differences in access to clinical services may also be relevant.
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Affiliation(s)
- Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK.
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Paracetamol availability in pharmacy and non-pharmacy outlets in Dublin, Ireland. Ir J Med Sci 2009; 178:79-82. [PMID: 19198976 DOI: 10.1007/s11845-008-0270-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 12/08/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In 2004, there were 11,092 presentations to Irish hospitals with deliberate self-harm, including 7,933 cases of drug overdose, of which 31% involved paracetamol. Limiting the availability of paracetamol reduces morbidity and mortality associated with paracetamol overdose. AIM The present study aimed to determine the level of compliance with statutory regulations governing the sale of paracetamol in Ireland. METHODS Researchers visited pharmacy (n = 20) and non-pharmacy outlets (newsagents, mini-markets and supermarkets) (n = 50) in Dublin city and attempted to purchase amounts of paracetamol that exceeded the statutory limits for a single transaction. RESULTS Amounts of paracetamol in excess of statutory limits for a single transaction were purchased in 50.0% of pharmacies, 81.8% of newsagents/mini-markets and 20.0% of supermarkets. One year later, we again visited pharmacy (n = 20) and non-pharmacy outlets (n = 50) in Dublin city and purchased amounts of paracetamol in excess of statutory limits in 50.0% of pharmacies, 52.3% of newsagents/mini-markets and 10.0% of supermarkets. CONCLUSION We recommend that (a) notwithstanding the improvement in compliance rates in newsagents/mini-markets, the sale of paracetamol in these outlets should be discontinued; (b) the sale of paracetamol in supermarkets should continue, although automated checkout tills should be appropriately re-programmed; and (c) there should be greater efforts to ensure compliance with statutory regulations in pharmacies.
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Morgan O, Hawkins L, Edwards N, Dargan P. Paracetamol (acetaminophen) pack size restrictions and poisoning severity: time trends in enquiries to a UK poisons centre. J Clin Pharm Ther 2007; 32:449-55. [PMID: 17875110 DOI: 10.1111/j.1365-2710.2007.00842.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE In September 1998, legislation was introduced in the United Kingdom to limit paracetamol pack sizes to 16 tablets of 500 mg at general sales outlets and 32 tablets of 500 mg at pharmacies. The effect of the regulations on severity of paracetamol poisoning is unclear. The aim of this study was to describe trends in the severity of paracetamol poisoning and to assess the impact of the 1998 Regulations on the enquiries to a UK poisons centre. METHODS We extracted data about the age, sex and number of tablets or capsules of paracetamol ingested by patients notified to Guy's and St Thomas' Poisons Unit (London, UK) between 1996 and 2004. RESULTS AND DISCUSSION During the study period, there were approximately 140 000 patients with suspected paracetamol poisoning, accounting for around 11% of all patients reported to the poisons unit. The median number of tablets fell from 25 to 20 for males and 20 to 16 for females after 1998. There was also a reduction in the proportion of patients who ingested 17-32 tablets (from 36% to 30%) and 33-100 tablets (from 25% to 19%). CONCLUSION Following the 1998 Regulations there was a decline in the severity, but not frequency, of paracetamol poisoning cases reported to Guy's and St Thomas' Poisons Unit. It is unclear whether the decline in severity was a direct consequence of the regulations.
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Affiliation(s)
- O Morgan
- Department of Primary Care and Social Medicine, Faculty of Medicine, Imperial College London, London, UK.
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Abstract
The authors discuss a new study that examined the change in deaths attributed to paracetamol poisoning in England and Wales in the six years before and after a legislated reduction in the maximum pack size.
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Affiliation(s)
- Nicholas A Buckley
- Department of Clinical Pharmacology and Toxicology, Australian National University Medical School, Canberra, Australian Capital Territory, Australia.
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