Trends in deaths from drug overdose and poisoning in England and Wales 1993-1998

Association between disability-related budget reductions and increasing drug-related mortality across local authorities in Great Britain

BACKGROUND

Drug-related mortality in the UK rose markedly after 2012. Here we test the hypothesis that cuts to disability-related spending were associated with increased drug-related mortality across local governments in Great Britain.

METHODS

We regressed changes in drug-related death rates (years 2010-12 versus 2015-17) on local government disability-related budget reductions, adjusting for a range of regional, demographic, and economic factors. Budget reductions are captured with a combined measure of financial losses due to Incapacity Benefit and Disability Living Allowance reforms, expressed in pounds sterling per capita, per year. 364 local authorities across England, Scotland, and Wales were included in the study.

FINDINGS

Greater budget reductions were associated with greater increases in drug-related death rates. In the unadjusted model, each £100 per capita budget reduction was associated with an increase in drug-related death rates of 3.30 per 100 000 population (95% CI: 2.43 to 4.17). The magnitude of the association increased after adjusting for region and demographic factors (b = 4.84; 95% CI: 3.26 to 6.43). The association remained statistically significant after adjusting for a full set of controls, including baseline and trends in unemployment rates, median hourly pay, and gross disposable household income per capita (b = 4.41; 95% CI: 2.57 to 6.24).

CONCLUSION

Deeper cuts to local government spending in Great Britain in the 2010s were associated with larger increases in drug-related deaths.

Geographical Aspects of Recent Trends in Drug-Related Deaths, with a Focus on Intra-National Contextual Variation

BACKGROUND

Recent worldwide estimates are of 53 million users of opioids annually, and of 585,000 drug-related deaths, of which two thirds are due to opioids. There are considerable international differences in levels of drug death rates and substance abuse. However, there are also considerable variations within countries in drug misuse, overdose rates, and in drug death rates particularly. Wide intra-national variations characterize countries where drug deaths have risen fastest in recent years, such as the US and UK. Drug deaths are an outcome of drug misuse, which can ideally be studied at a relatively low spatial scale (e.g., US counties). The research literature suggests that small area variations in drug deaths to a considerable degree reflect contextual (place-related) factors as well as individual risk factors.

METHODS

We consider the role of area social status, social cohesion, segregation, urbanicity, and drug supply in an ecological regression analysis of county differences in drug deaths in the US during 2015-2017.

RESULTS

The analysis of US small area data highlights a range of factors which are statistically significant in explaining differences in drug deaths, but with no risk factor having a predominant role. Comparisons with other countries where small area drug mortality data have been analyzed show differences between countries in the impact of different contextual factors, but some common themes.

CONCLUSIONS

Intra-national differences in drug-related deaths are considerable, but there are significant research gaps in the evidence base for small area analysis of such deaths.

Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting

BACKGROUND

Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines.

METHODS

Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines.

RESULTS

In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability.

CONCLUSIONS

Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature

BACKGROUND

Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality.

OBJECTIVES

The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts.

RESULTS

We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally.

CONCLUSIONS

There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.

Organophosphate poisoning in the developed world - a single centre experience from here to the millennium

Organophosphate (OP) poisoning is still associated with high morbidity and mortality rates, both in resource-poor settings and in well-developed countries. Despite numerous publications dealing with this particular poison, detailed clinical data on more severe overdoses with these agents are relatively sparsely reported. A retrospective study was consequently conducted on 33 patients with OP poisoning admitted to our intensive care unit (ICU) to provide additional data on clinical features. We included moderate to severe poisonings between 2000 and 2012 who required admission to ICU. Patients ingested dimethyl-OPs in 19 cases, diethyl-OPs in 8 cases and otherwise classified OPs in 6 cases. Death (5/33) occurred rather late and only one of these fatalities died during on-going cholinergic crisis. Of the survivors (28/33), 71% recovered fully while 29% showed predominantly neurological disabilities before being transferred to neurologic rehabilitation. Aspiration pneumonia predominated in 27/33 patients and one patient died in refractory acute respiratory distress syndrome (ARDS). The intermediate syndrome occurred twice and cardiopulmonary resuscitation had to be performed in 6/33 patients. Fatalities showed a higher Poison-severity-score, APACHE-II-score and SOFA-score on admission compared with survivors and they showed significantly longer QTc-time in the ECG, lower systolic blood pressure and heart rate, a lower pH and a lower base excess on admission. Patients with diethyl-OPs required intubation significantly earlier and showed lower and more sustained inhibited activity of the plasma-cholinesterase on admission compared with patients ingesting dimethyl-OPs. Treatment with atropine and obidoxime was comparable between these groups and severity of poisoning, outcome, hemodynamics on admission, duration of mechanical ventilation and length of stay in the ICU did not significantly differ between the involved group of dimethyl- and diethyl-OPs. We conclude that the fatality rate in our patient cohort treated in a well-staffed and equipped ICU of a developed country is quite similarly high compared with the rate observed in developing countries. Patients died rather late when severe cholinergic crisis had mostly been overcome and death was therefore related to non-poison specific complications.

Patterns of poisoning and drug overdosage and their outcome among in-patients admitted to the emergency medicine department of a tertiary care hospital

BACKGROUND

Poisoning and drug overdose (DO) are important health problems in developing countries. These emergencies are associated with high mortality and morbidity. Different factors affect the final outcome of patients. This study aims to review the pattern of poisoning and DO in an urban tertiary care hospital and also the determinants and final outcome of patients with poisoning and DO.

MATERIALS AND METHODS

Observational, retrospective hospital records-based study at a tertiary care hospital (15 months). Data on demography, hospitalization, complications, type of poison/drug and outcome of patients with poisoning and DO were collected. Data were analyzed using descriptive statistics, Chi square test and ANOVA. P < 0.05 was considered significant.

RESULTS

Of the total of 296 records, 213 were included (122 poisoning, 91 DO). Organophosphates (OP) (32.5%), pyrethroids (17.2%) and organocarbamates (12.2%) were the commonly used poisons. Sedatives and antiepileptics (21% each) were the common DOs. Poisoning among men was greater than that among women (P < 0.001). Outcome parameters of hospital stay and ventilator requirement were significant (P < 0.001). The overall case fatality rate was 2.4%.

CONCLUSIONS

OP compounds were the most common among poisons, while sedatives were frequently consumed drugs. Young adults from urban areas were the common victims with suicidal intention. Regulations, educational awareness and poison information centers will help to reduce the growth of this public health problem.

Age-related changes in the hepatic pharmacology and toxicology of paracetamol

Optimal pharmacotherapy is determined when the pharmacokinetics and pharmacodynamics of the drug are understood. However, the age-related changes in pharmacokinetics and pharmacodynamics, as well as the increased interindividual variation mean optimal dose selection are a challenge for prescribing in older adults. Poor understanding of how hepatic clearance and toxicity are different with age results in suboptimal dose selection, poor efficacy, and/or increased toxicity. Of particular concern is the analgesic paracetamol which has been in use for more than 50 years and is consumed by a large proportion of older adults. Paracetamol is considered to be a relatively safe drug; however, caution must be taken because of its potential for toxicity. Paracetamol-induced liver injury from accidental overdose accounts for up to 55% of cases in older adults. Better understanding of how age affects the hepatic clearance and toxicity of drugs will contribute to evidence-based prescribing for older people, leading to fewer adverse drug reactions without loss of benefit.

A systematic review of research examining benzodiazepine-related mortality

PURPOSE

This paper will review literature examining the association of benzodiazepine use and mortality.

METHODS

An extensive literature review was undertaken to locate all English-language published articles that examine mortality risk associated with use of benzodiazepines from 1990 onwards.

RESULTS

Six cohort studies meeting the criteria above were identified. The results were mixed. Three of the studies assessed elderly populations and did not find an increased risk of death associated with benzodiazepine use, whereas another study of the general population did find an increased risk, particularly for older age groups. A study of a middle aged population found that regular benzodiazepine use was associated with an increased mortality risk, and a study of 'drug misusers' found a significant relationship between regular use of non-prescribed benzodiazepines and fatal overdose. Three retrospective population-based registry studies were also identified. The first unveiled a high relative risk (RR) of death due to benzodiazepine poisoning versus other outcomes in patients 60 or older when compared to those under 60. A positive but non-significant association between benzodiazepine use and driver-responsible fatalities in on-road motor vehicle accidents was reported. Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug.

CONCLUSION

On the basis of existing research there is limited data examining independent effects of illicit benzodiazepine use upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use.

Incidence and antecedents of nonmedical prescription opioid use in four US communities. The Coronary Artery Risk Development in Young Adults (CARDIA) prospective cohort study

BACKGROUND

Nonmedical use of prescription opioids has emerged as a major public health problem during the last decade, but direct measures of incidence and predisposing factors are lacking.

METHODS

We prospectively measured incidence and antecedents of nonmedical prescription opioid use in The Coronary Artery Risk Development in Young Adults study among 28-40-year-old African- and European-American men and women with no prior history of nonmedical opioid use.

RESULTS

Among 3163 participants, 23 reported new nonmedical prescription opioid use in 2000-2001 (5-year incidence 0.7%; 95%CI: 0.4-1.0%). All 23 had previously reported marijuana use (p<0.001). Five-year incidence was significantly higher among European-American men (OR=3.3; 95%CI: 1.3-8.3), and among participants reporting a history of amphetamine use (OR=24; 95%CI: 6.9-83) or medical opioid use for treatment of pain (OR=8.6; 95%CI: 2.5-30). These associations remained strong when examined among marijuana users and after adjusting for demographics, social factors, and other antecedent substance use. Amphetamine use was the best single predictor of future nonmedical use (sensitivity 87%, specificity 79%).

CONCLUSIONS

Initiation of nonmedical prescription opioid use is generally rare in 28-40-year-old adults, but is observed to be more common with a previous history of substance abuse and legal access to opioids through prescription by a physician.

Comparison of the fatal toxicity index of zopiclone with benzodiazepines

BACKGROUND

Zopiclone is a hypnosedative structurally unrelated to the benzodiazepines but operating at the same receptor complex. Although zopiclone has been used in clinical practice for many years, relatively little is known of its relative toxicity in comparison with other hypnosedatives.

METHOD

Deaths, where hypnosedatives were implicated, in New Zealand (NZ) in 2001 were identified from a chemical injury database. Prescription and aggregate defined daily dose (DDD) data forNZ in 2001 were obtained from a national prescribing database. Rates of death per prescription and DDD, and relative rates between individual hypnosedatives and benzodiazepines, and their respective 95% CI were calculated.

RESULTS

Of the 200 poisoning deaths in NZ for 2001, 39 involved hypnosedatives, and zopiclone was involved in 12. Hypnosedatives were the sole agents in only one death and were the primary agents in eight deaths. Zopiclone was the sixth most commonly involved agent in poisoning deaths in NZ in 2001. The relative rate of death per prescription (95% CI) and DDD (95% CI) of zopiclone compared with benzodiazepines were 1.04 (0.49-2.05) and 0.59 (0.28-1.16), respectively. The relative rates of death per DDD (95% CI) for alprazolam and chlormethiazole compared with the other sedatives/anxiolytics were 6.2 (1.6-17.0) and 20.9 (2.5-79.8) respectively.

CONCLUSIONS

The fatal toxicity for zopiclone was not significantly different from that for benzodiazepines as a group when adjusted for usage, whereas alprazolam and chlormethiazole had greater toxicity. Hypnosedatives are contributory factors rather than primary substances in poisoning deaths.

Hospital discharges and 30-day case fatality for drug poisoning: a Danish population-based study from 1979 to 2002 with special emphasis on paracetamol

OBJECTIVE

To examine the number of hospital discharges and 30-day case fatalities due to drug poisoning based on data from a Danish County Hospital Discharge Registry from 1979 to 2002.

METHODS

All patients with a hospital discharge diagnosis of drug poisoning were identified and separated into groups taking: (1) opioid analgesics; (2) non-opioid analgesics; (3) anxiolytics; (4) antidepressants; (5) antipsychotics; or (6) non-specified. Paracetamol and salicylate were analysed separately. From 1994 to 2001, the total amount of drugs sold in the county was identified from a national drug database.

RESULTS

A total of 13,432 patients with a median age 41.5 years at discharge of whom 59% were females accounted for 20,249 discharges for drug poisoning. The overall number of discharges remained essentially stable around 170 discharges per 100,000 inhabitants per year. From the mid-1990's, paracetamol became the most frequently used drug in poisoning with the largest increase in female teenagers. Thirty-day case fatality in poisoning with opioids was 3.6% compared with around 1% in other drug categories. For most drug categories, a sale of around 80,000 defined daily doses was associated with one hospital discharge due to drug poisoning.

CONCLUSION

The overall number of hospital discharges remained stable and seems primarily related to amount of drugs available. With almost 10 years delay, the easier access to paracetamol was followed by an increase in hospitalisation due to poisoning with paracetamol. However, although the majority of hospitalisations were found in the younger age group, the highest mortality was seen among the elderly.

Trends in suicide from drug overdose in the elderly in England and Wales, 1993-1999

BACKGROUND

Drug overdose is a common method of suicide in the elderly. Hence, an understanding of current trends in epidemiology of these deaths is important when considering measures to decrease suicide rates.

METHODS

Analysis of the Office for National Statistics (ONS) database of deaths from overdose and poisoning. Suicide and undetermined deaths from drug overdose between 1993-1999 in the over 65 year olds were studied. Socio-demographic data from the four drug groups most commonly used in overdose were extracted, and age and sex specific mortality rates calculated. Enumeration districts were ranked into five quintiles based on their Carstairs scores, and death rates in each quintile for men and women calculated.

RESULTS

There were 1864 deaths from drug overdose during the study period. Suicide and undetermined death rates from drug overdose remained stable between 1993-1999. Drugs most commonly used in overdose were (in order) paracetamol (and related compounds), benzodiazepines, antidepressants, and opiates. Women comprised 62% of deaths. Death rates increased with age, with highest rates in men over 75 (37.7 deaths per million). Benzodiazepines showed the most marked increase with age. Co-proxamol comprised 32% of deaths from paracetamol compounds, and 95% of antidepressant deaths were due to tricyclic antidepressants. There was no association in women between Carstairs area deprivation and suicide rates; in men rates were highest in the most deprived areas.

CONCLUSION

Suicides in the over 65 year olds may be decreased by changes in prescription practice. Paracetamol, co-proxamol, tricyclic antidepressants and benzodiazepines should be prescribed with caution to the elderly with depression or at high risk of depression.