A national case fatality study of drugs taken in intentional overdose

Substances Detected During Coroner Postmortem Toxicology Analyses in Poisoning- and Nonpoisoning-Related Suicides

Importance

Determining the association between drug use and suicide is complicated but can help to inform targeted suicide prevention strategies.

Objective

To examine the substances prevalent in poisoning- and nonpoisoning-related suicides in Australia.

Design, Setting, and Participants

This was a multiple-year, cross-sectional study of suicides from July 2013 to October 2019 in Australia with toxicology data available in a national coronial database. The cause of death was classified as poisoning related if any type of poisoning was determined by the coroner to contribute to the cause of death. Prevalence ratios (PRs) were calculated to compare substance detection in poisoning- vs nonpoisoning-related suicides. Data were analyzed from October 2021 to April 2023.

Exposures

All substances detected in decedents at the time of death according to toxicology reports were recorded.

Main Outcome(s) and Measure(s)

The most common individual substances and substance classes were identified. From these, blood concentrations of substances of interest were analyzed, and the most commonly occurring combinations of substance classes were listed.

Results

Toxicology was performed on 13 664 suicide decedents (median [IQR] age, 44 [31-57] years; 10 350 male [76%]). From these, 3397 (25%) were poisoning-related suicides (median [IQR] age, 50 [38-63] years; 2124 male [63%]). The remainder were classified as nonpoisoning-related suicides (median [IQR] age, 42 [29-55] years; 8226 male [80%]). PRs for common medicine classes being detected in poisoning-related suicides compared with nonpoisoning-related suicides were as follows: antidepressants (PR, 1.63; 95% CI, 1.54-1.73), benzodiazepines (PR, 2.01; 95% CI, 1.90-2.13), nonopioid analgesics/anti-inflammatory drugs (PR, 1.88; 95% CI, 1.78-2.00), and opioids (PR, 2.72; 95% CI, 2.58-2.87). Alcohol (as ethanol ≥0.03 g/100 mL) was almost equally prevalent in poisoning- and nonpoisoning-related deaths (PR, 1.07; 95% CI, 1.01-1.14), whereas amphetamines (PR, 0.68; 95% CI, 0.61-0.77) and cannabinoids (PR, 0.67; 95% CI, 0.60-0.74) were detected more often in nonpoisoning-related suicides. Combinations of multiple sedative agents in poisoning-related suicides were common.

Conclusions and Relevance

Both poisoning- and nonpoisoning-related suicide deaths featured a high prevalence of psychotropic medicines or potential intoxication, which suggests the association of suicide with poor mental health and substance misuse. Findings suggest that substances with a high involvement in poisoning-related suicides should be prescribed cautiously, including antidepressants that are toxic in overdose, sedatives, opioids, and potentially lethal combinations.

Attempted suicide: does lethality matter?

OBJECTIVES

To investigate whether high-lethality suicide attempters align to the demographic and clinical features observed in completed suicide in the national and international literature, and whether low-lethality attempters more closely align with the clinical profile of non-attempter ideators.

METHODS

A retrospective chart review of adult suicide ideators and attempters presenting to an urban tertiary care hospital was performed. Suicide ideators (n = 50) and attempters (n = 50) were coded for variables including demographics and clinical characteristics (e.g. psychiatric diagnosis and previous suicide attempt). Method and lethality of suicide attempt were coded using the medical Lethality Rating Scale.

RESULTS

High-lethality attempters were more likely to be younger in age than low-lethality attempters (p = 0.026) and ideators (p = 0.041). The lethality scores of suicide attempts were significantly inversely correlated with age (p = 0.017).

CONCLUSIONS

Our study adds to the small but increasing body of literature investigating the characteristics of high-lethality suicide attempters and suggests younger adult age is a risk factor for a high-lethality attempt. Further understanding of this unique group would be aided by widespread agreement on the definition of a high-lethality suicide attempt and longitudinal studies of this cohort.

Psilocybin microdosers demonstrate greater observed improvements in mood and mental health at one month relative to non-microdosing controls

Psilocybin microdosing involves repeated self-administration of mushrooms containing psilocybin at doses small enough to not impact regular functioning. Microdose practices are diverse and include combining psilocybin with substances such as lion’s mane mushrooms (Hericium erinaceus; HE) and niacin (vitamin-B3). Public uptake of microdosing has outpaced evidence, mandating further prospective research. Using a naturalistic, observational design, we followed psilocybin microdosers (n = 953) and non-microdosing comparators (n = 180) for approximately 30 days and identified small- to medium-sized improvements in mood and mental health that were generally consistent across gender, age and presence of mental health concerns, as we all as improvements in psychomotor performance that were specific to older adults. Supplementary analyses indicated that combining psilocybin with HE and B3 did not impact changes in mood and mental health. However, among older microdosers combining psilocybin, HE and B3 was associated with psychomotor improvements relative to psilocybin alone and psilocybin and HE. Our findings of mood and mental health improvements associated with psilocybin microdosing add to previous studies of psychedelic microdosing by using a comparator group and by examining the consistency of effects across age, gender, and mental health. Findings regarding the combination of psilocybin, HE and B3 are novel and highlight the need for further research to confirm and elucidate these apparent effects.

Comparing characteristics of suicide to non-suicide drug poisoning deaths, by sex, in Ireland

BACKGROUND

Suicide by drug poisoning is potentially preventable; however, evidence on associated risk factors by sex is limited.

AIM

To assist in understanding how individual and social contextual factors, and specific drugs, influence risk of suicide compared to non-suicide drug poisoning deaths, and how this differs by sex.

METHODS

Data were extracted from the National Drug-Related Deaths Index. Analysis included univariable and multivariable logistic regression to estimate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for factors associated with suicide drug poisoning deaths (SDPD) (primary outcome) compared with non-suicide drug poisoning deaths (NSDPD) and stratified by sex.

RESULTS

SDPD accounted for 240 (22%) of 1114 poisoning deaths, the majority among men (n = 147, 61%). Increasing age, mental ill health (AOR 7.85, 95% CI: 5.46-11.28), chronic pain (AOR 5.57, 95% CI: 3.28-9.46), and history of previous overdose (AOR 5.06, 95% CI: 3.39-7.56) were associated with increased odds of SDPD, with similar results for both sexes. The main drugs associated with SDPD were non-opioid analgesics (OR 4.06 [95% CI 2.66-6.18]), antipsychotics (OR 2.42 [95% CI 1.63-3.60]) and antidepressants (OR 2.18 [95% CI 1.59-2.97]). Pregabalin was associated with SDPD among women only.

LIMITATIONS

Secondary analysis of coronial data on drug poisoning deaths therefore findings may not be relevant to suicide deaths in general.

CONCLUSIONS

Ongoing monitoring for signs of suicidal intent in individuals with mental illness, chronic pain, overdose, and/or prescribed mental health medications may identify individuals in need of additional intervention.

Poison center consultation reduces hospital length of stay

CONTEXT

Prior studies have observed shorter lengths of stay when practitioners consult a US poison control center (PCC) regarding hospitalized toxicology patients, but the most recent study used data from 2010. Since then, the implementation of the Affordable Care Act, a trend toward shorter hospitalizations and substantial adjustments in hospital charges have occurred.

METHODS

This is a retrospective study of administrative hospital data and poison center data obtained from the Wisconsin Hospital Association and Wisconsin Poison Center for patients treated from 2010 to 2017. Stratified analysis was used to investigate the potential effects of PCC consultation on hospitalization. Univariate and multivariable regression analysis was used to characterize which factors were associated with an increased rate of PCC consultation.

DISCUSSION

127,224 hospitalized cases were found, of which 44,628 were entered into a stratified hospital charge and length of stay analysis. PCC consultation was associated with an 11.6 h (95% CI 10.4-13.0 h) shorter mean length of stay overall, with children aged 0-6 having a larger reduction of 1.18 days. While total charges were higher by $600 in PCC consultation cases in the overall analysis (95% CI $390-$777), mean charges in patients aged 0-6 were $6695 lower when the PCC was consulted. PCC consultation was more likely to occur in cases involving children and adolescents, intentional overdoses (versus accidental or unknown intent), and women.

CONCLUSIONS

Our findings suggest that PCC consultation should be encouraged to potentially shorten hospitalizations of poisoned patients, and for pediatric patients in particular. Intentionality and demographic factors affect the rate of PCC consultation for overdose, but the nature of these relationships is unclear.

The lethality of suicide methods: A systematic review and meta-analysis

BACKGROUND

The use of suicide methods largely determines the outcome of suicide acts. However, no existing meta-analysis has assessed the case fatality rates (CFRs) by different suicide methods. The current study aimed to fill this gap.

METHODS

We searched Scopus, Web of Science, PubMed, ProQuest and Embase for studies reporting method-specific CFRs in suicide, published from inception to 31 December 2020. A random-effect model meta-analysis was applied to compute pooled estimates.

RESULTS

Of 10,708 studies screened, 34 studies were included in the meta-analysis. Based on the suicide acts that resulted in death or hospitalization, firearms were found to be the most lethal method (CFR:89.7%), followed by hanging/suffocation (84.5%), drowning (80.4%), gas poisoning (56.6%), jumping (46.7%), drug/liquid poisoning (8.0%) and cutting (4.0%). The rank of the lethality for different methods remained relatively stable across study setting, sex and age group. Method-specific CFRs for males and females were similar for most suicide methods, while method-CFRs were specifically higher in older adults.

CONCLUSIONS

This study is the first meta-analysis that provides significant evidence for the wide variation of the lethality of suicide methods. Restricting highly lethal methods based on local context is vital in suicide prevention.

Opioids in the United Kingdom: safety and surveillance during COVID-19

PURPOSE OF REVIEW

Opioid use is prevalent in the United Kingdom and prior to the COVID-19 pandemic it had been recognized that the safety of opioids was an important issue to be monitored by the UK medicines regulatory agency. With the emergence of COVID-19, this requirement has been even greater. This review was undertaken to determine the impact of the pandemic on safety and surveillance of opioids in the United Kingdom.

RECENT FINDINGS

During the COVID-19 pandemic, the surveillance of opioids in the United Kingdom continued, although primary research was often conducted with data prior to the pandemic. Of those studies that were conducted while the pandemic was ongoing, access to opioids (or opioid substitution therapy) and the subsequent effect on patient safety was the main theme.

SUMMARY

In the United Kingdom, changes in accessibility to the healthcare system and how healthcare providers operated during the COVID-19 pandemic may have had unintended consequences on use and safety of opioids, due to the shift in focus to preventing COVID-19 from overwhelming the healthcare system. The findings from this review support the need to continue surveillance in the United Kingdom, including the impact of the COVID-19 pandemic on opioid utilization and safety.

Predictors of clinical severity in subjects attending the Emergency Department for substance use: a ten-year cross-sectional study

OBJECTIVE

Substance-related referrals to the Emergency Department (ED) are rising. Multiple substance use is frequent, and psychiatric patients represent a high-risk population. Our study aimed at identifying risk factors for increased severity in ED attendances for substance use.

METHODS

We retrospectively evaluated consecutive patients attending the ED over ten years for substance-related problems, subdivided according to the triage code as having a life-threatening (LT), potentially life-threatening (P-LT), and non-life-threatening (N-LT) condition.

RESULTS

Substance/drug intake for deliberate self-harm was a risk factor for being classified as LT compared to both P-LT (OR = 6.357; p ≤ 0.001) and N-LT (OR = 28.19; p ≤ 0.001). Suicide attempts (OR = 4.435; p = 0.022) and multiple substance use (OR = 1.513; p = 0.009) resulted as risk factors for P-LT, compared to N-LT. Psychiatric diagnosis (OR = 1.942; p = 0.042) and multiple substance use (OR = 1.668; p = 0.047) were risk factors for being classified as LT rather than N-LT.

CONCLUSIONS

In our sample, self-harming overdoses were the strongest risk factor for highest overall severity in a real-world setting. Psychiatric disorders and multiple substance use also increased the risk for greater severity at presentation. Substance use worsens patients' clinical picture and management, suggesting the need for consultation-liaison psychiatry services in emergency contexts and highlighting the role of EDs as key sites for identification and early intervention.

The impact of guidance on the supply of codeine-containing products on their use in intentional drug overdose

Background

Concerns about the misuse of codeine led to the introduction of guidance restricting the supply of over-the-counter (OTC) codeine-containing products in Ireland in 2010. The aim of this study was to examine the impact of this guidance on the national rate of hospital-presenting self-harm involving codeine-related intentional drug overdose (IDO).

Methods

Presentations involving IDO to Irish general hospitals between 1 January 2007 and 31 December 2013, as recorded by the National Self-Harm Registry Ireland, were analyzed. Event-based rates per 100 000 were calculated using national population data. Poisson regression models were used to assess rate changes between pre- and post-guidance periods and to calculate excess presentations.

Results

Between January 2007 and December 2013, a total of 57 759 IDOs were recorded, with 4789 (8.3%) involving a codeine-containing product. The rate of codeine-related IDOs was 20% lower in the period following implementation of the guidance (incidence rate ratio: 0.80; 95% CI: 0.75 to 0.85), representing a total of 509 (95% CI: −624, −387) fewer codeine-related IDOs in that period. Reductions were observed across all ages and were more pronounced for females (0.76, 0.71 to 0.82) than males (0.87, 0.79 to 0.97). The rate of IDOs involving other drugs decreased by 3% in the same period (0.97, 0.95 to 0.98).

Conclusion

Our findings indicate that the rate of codeine-related IDOs was significantly lower in the period following the implementation of the guidance. There is a large body of evidence supporting the restriction of potentially harmful medication as an effective strategy in suicide prevention.