A multicentre study of coproxamol poisoning suicides based on coroners' records in England

Hotel Suicides in Australia 2006-2017

Background: This study investigated the frequency, characteristics, and geospatial clustering of hotel suicides in Australia to inform suicide prevention efforts. Aims: (1) To determine the proportion of suicide deaths that occurred in hotels, (2) to determine differences in demographic characteristics of hotel deaths compared to other locations, (3) to assess level of planning, and (4) to determine whether these deaths form geographic clusters amenable to targeted suicide prevention activities. Methods: Archival data on suicide mortality were used to examine associations between incident location (hotels, home, away from home), demographic characteristics, and suicide means. Kernel density visualization was used to assess geospatial clustering of hotel suicides, and the degree of planning involved was assessed using the modified Suicide Intent Scale. Results: Hotels accounted for 2% of all suicide deaths and 6.2% of suicides occurring away from home. Females were over-represented (p < .0001), as were deaths by drug overdoses (p < .0001) and falls (p < .0001). Approximately 40% of incidents occurred within seven geospatial clusters. 85% of those who died were state residents, with a median distance from home of 13.0 km. Most individuals checked in to the hotel alone, for short stays, and displayed a high degree of suicidal planning. Limitations: Coronial records had limited information on narrative circumstances of deaths; other indicators of risk may not have been identified. A comparison against a general population of hotel guests, rather than all other suicide deaths would be more useful in terms of preventative activities, however these data were not readily available. Conclusion: This study identified characteristics, behaviors, and geographic locations associated with hotel suicides to inform training of hotel staff to recognize and respond to signs of risk. Males of working age who live locally and arrive alone for short stays could be considered at a higher risk of suicide, and prevention efforts should be prioritized in the identified high-risk areas.

Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence

Disclosure of suicidal ideation and behaviours, defined as thoughts, plans, or attempts, to other people provides opportunity for intervention and prevention. This study is the first to meta-analyze all available studies to estimate the prevalence of disclosure, to whom people disclose, and examine factors that influence disclosure. Databases were searched for studies reporting samples of people who had experienced suicidal ideation or behaviours (including those who had died by suicide) and whether they had disclosed this. Almost 100 studies (k = 94, N participants = 1,044,629) were included in the overall prevalance analysis. The results showed less than half of people disclosed suicidal ideation or behaviour: 45.9% (95%CI 41.9-49.9%, PI 12.3-81.8%; k = 94). High heterogeneity, common to prevalence studies, was found (Q[93] = 130,584, p < .001; I² = 99.9%). No publication bias was detected. Removing outliers did not change the prevalence estimate, but provided tighter prediction intervals: 45.6% (95%CI 43.4-47.9%, PI 35.8-55.7%; k = 33). Disclosure was related to higher prevalence of psychiatric disorders, female gender, and a longer timeframe of suicidal ideation or behaviour. Prevalence of disclosure was lower among people who died by suicide, relative to community samples, and lower when reported verbally rather than written online. Disclosure, and proportions of disclosures, to family members, was numerically higher than to friends or professionals, but could not be directly compared. In conclusion, between 50 and 60% of people do not disclose their suicidal ideation and behaviours to other people, and therefore remain unidentified and potentially untreated.

Repeat Self-Harm Following Hospital-Presenting Intentional Drug Overdose among Young People-A National Registry Study

Background: The incidence of hospital-presenting self-harm peaks among young people, who most often engage in intentional drug overdose (IDO). The risk of self-harm repetition is high among young people and switching methods between self-harm episodes is common. However, little is known about their patterns of repetition and switching following IDO. This study aimed to investigate repeat self-harm and method-switching following hospital-presenting IDO among young people. Methods: Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 10–24 years during 2009–2018 were examined. Cox proportional hazards regression models with associated hazard ratios (HRs), survival curves and Poisson regression models with risk ratios (RRs), were used to examine risk factors for repetition and method-switching. Results: During 2009–2018, 16,800 young people presented following IDO. Within 12 months, 2136 young people repeated self-harm. Factors associated with repetition included being male (HR = 1.13, 95% CI: 1.03–1.24), aged 10–17 years (HR = 1.29, 95% CI: 1.18–1.41), consuming ≥ 50 tablets (HR = 1.27, 95% CI: 1.07–1.49) and taking benzodiazepines (HR = 1.67, 95% CI: 1.40–1.98) or antidepressants (HR = 1.36, 95% CI: 1.18–1.56). The cumulative risk for switching method was 2.4% (95% CI: 2.2–2.7). Method-switching was most likely to occur for males (RR = 1.36; 95% CI: 1.09–1.69) and for those who took illegal drugs (RR = 1.63; 95% CI: 1.19–2.25). Conclusion: Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.

Effect of the market withdrawal of dextropropoxyphene on use of other prescribed analgesics

Background and aims Dextropropoxyphene (DXP) is a synthetic opioid that was prescribed worldwide for mild to moderate pain. It was withdrawn from the European market in 2009. In this study we aim to investigate the effect of the market withdrawal of dextropropoxyphene in Norway on overall use of opioids and other analgesics at an individual level. Methods Data were collected from the nationwide Norwegian Prescription Database (NorPD). It covers all prescription of drugs from 01 January 2004 from Norwegian pharmacies dispensed to individuals outside institutions. The study period was divided in two 2-year periods from 01 September 2008 to 31 August 2010, and from the market withdrawal of DXP on 01 September 2010 to 31 August 2012. We included every individual that filled at least one prescription of dextropropoxyphene in the first 2-year period in our study population. In this study dextropropoxyphene, codeine and tramadol are defined as "weak opioids", and all other opioids are termed "strong opioids". Results Nine thousand one hundred and seventy-one individuals were included in our study population. Four thousand two hundred and ninety filled a prescription of DXP only once and were classified as "single users", 2,990 were users with prescriptions of up to 200 defined daily doses (DDD) over the first 2-year period, or "sporadic users", and 1,886 were classified high users with over 200 DDDs over a 2-year period. After the market withdrawal 8,392 continued to be prescribed analgesics or benzodiazepines. In the single user group, the proportion of users of weak opioids decreased from 69.5% to 57.6%, whereas the proportion of users of strong opioids was unchanged. Among the sporadic user group, the proportion of users of weak opioids went from 69.7% to 71.0%, the proportion using tramadol from 39.1% to 43.9%, and the users of strong opioids from 25.8% to 31.3%. In the high user group, there was an increase in the number of users of strong opioids from 37.8% to 51.4%. The amount of strong opioids prescribed in the high user group increased from a mean of 262.5 DDD to a mean of 398.3 DDD in the following 2 years. The amount of tramadol increased in all groups and was 3 times as high in the high user group after market withdrawal of DXP. Conclusions Our study showed that the withdrawal of DXP lead to an increase in prescription of other analgesics. The proportion of users increased in all three groups and so did the prescribed amount of other analgesics. Both the proportion of users of other opioids and the amount prescribed increased considerably. However, 1 in 10 earlier users of DXP stopped using prescribed analgesics altogether in the following 2 years. The increase in use among earlier high users of DXP was most striking. Implications This study documents markedly increased prescriptions of other opioids after withdrawal of dextropropoxyphene due to its high risk of serious complications. However, consequences of the increased use of opioids among earlier high users of DXP such as changes in risk of poisonings, accidental deaths and suicides remain to be investigated.

Impulsive suicide attempts among young people-A prospective multicentre cohort study in Sweden

BACKGROUND

We aimed to compare the prevalence of impulsive suicide attempts (ISA) among young adults and those over 25 who present at hospital in connection with attempted suicide. We also aimed to identify factors associated with ISA in young adults and to assess medical severity as well as the probability of repeated suicide attempts in this age group.

METHOD

A prospective multicentre cohort study included hospital known cases of suicide attempt (N = 666). The prevalence of ISA was compared between young adults (18-25) and adults aged > 26. We used logistic regression models to identify factors associated with ISA, associations of ISA with high medical severity and prediction of new fatal or non-fatal suicide attempts within 6 months.

RESULTS

43.7% of the young patients had made an ISA, and 30.2% among those aged > 26 (p = 0.001). Among the young, substance use disorder was associated with ISA; crude odds ratio (OR) 2.0 (1.0-4.2), and adjusted OR 2.1 (0.99-4.4). Affective disorder and unemployment/ sickness absence implied lower odds of ISA. ISA resulted in injuries of high medical severity as often as more planned attempts and non-fatal or fatal repetition within 6 months was equally common (30%) in both groups.

LIMITATIONS

The study was set in psychiatric emergency services, which limits the generalizability.

CONCLUSIONS

Clinicians should acknowledge that suicide attempts among youth often occur without previous planning and may result in medically severe injuries. The probability of new fatal or non-fatal suicide attempts should be kept in mind also after an impulsive suicide attempt.

Factors associated with suicides in Wolverhampton: Relevance of local audits exploring preventability

Suicide rates and associated risk factors are known to change over time. The periodic evaluation of suicides in a particular locality may identify specific issues that may help in prevention efforts. The profile of 146 consecutive cases with suicide, open and narrative verdicts between January 2004 and July 2011 in Wolverhampton was studied in order to explore associated factors. Specific information about methods, mental health issues and stressors was collected. There was considerable variation in suicides in different wards of the city, with higher occurrences in inner-city areas. Male suicides were three times more common, and they were significantly younger than in female suicides. Common methods were hanging (52.7%) and poisoning (21.9%) involving a wide range of drugs. Life events were reported in 52.1% suicides, most frequently relational problems (28.1%), followed by physical illness and bereavement. Mental-health factors were associated with 63.0% of suicides, predominantly depression (45.9%) and alcohol and drug abuse (6.8%). The majority of the suicide victims (63.0%) were not in contact with mental-health services, including: most men (68.8%), young suicides up to age 34 (78.6%), the elderly (69.2%) and Asians (70.0%). A considerable proportion of these suicides had mental-health issues, mainly depression (42.4%) and alcohol or drug abuse (6.5%). Significantly more of them (69.6% vs. 22.2%) had stressors compared with suicides known to mental-health services. The findings of the study highlighted risk factors that may help prioritising intervention initiatives. It appears that local suicide audits may complement national information on suicide in designing appropriate local suicide-prevention strategies.

The communication of suicidal intentions: a meta-analysis

BACKGROUND

Among the myths that are often cited about suicide is that 'people who talk about killing themselves rarely die by suicide', but the evidence seems to contradict this statement. The aim of this study was to conduct a meta-analysis of studies reporting a prevalence of suicide communication (SC), and to examine the diagnostic accuracy of SC towards suicide in case-control reports.

METHOD

Eligible studies had to examine data relative to completed suicides and report the prevalence of SC. Data relative to sample characteristics, study definition, modality and recipient of the SC were coded.

RESULTS

We included 36 studies, conducted on a total of 14 601 completed suicides. The overall proportion of SC was 44.5% [95% confidence interval (CI) 35.4-53.8], with large heterogeneity (I 2 = 98.8%) and significant publication bias. The prevalence of SC was negatively associated with the detection of verbal communication as the sole means of SC and, positively, with study methodological quality. Based on seven case-control studies, SC was associated with an odds ratio of 4.66 for suicide (95% CI 3.00-7.25) and was characterized by sufficient diagnostic accuracy only if studies on adolescents were removed.

CONCLUSION

Available data suggest that SC occurs in nearly half of subjects who go on to die by suicide, but this figure is likely to be an underestimate given the operational definitions of SC. At present, SC seems associated with overall insufficient accuracy towards subsequent suicide, although further rigorous studies are warranted to draw definite conclusions on this issue.

Characteristic Risk Factors Associated with Planned versus Impulsive Suicide Attempters

OBJECTIVE

The present study aimed to investigate predictors for planned suicide attempters.

METHODS

This study included 1,003 patients who attempted suicide and visited emergency department. They were divided into two groups, planned suicide attempters (SAs; n=133 [13.3%]) and impulsive SAs (n=870, [86.7%]), and the demographic variables, clinical characteristics, factors related to suicide, and psychiatric resources of the groups were compared.

RESULTS

Major depressive disorder and substance use disorders were more common among planned SAs than among impulsive SAs. Additionally, the planned SAs were older, more likely to be divorced, separated or widowed, and more likely to have comorbid medical illnesses, severe depression, higher suicidality, and self-blaming tendencies than the impulsive SAs. Financial problems and physical illnesses were more common in planned SAs but interpersonal conflicts were more frequent in impulsive SAs. Planned SAs had fewer previous suicide attempts but these were more serious suicide attempts. The presence of the hope to die, a written will, and suicidal ideation of a repetitive, intense, and continuous nature were predictive of planned SAs.

CONCLUSION

The present findings demonstrated that planned SAs had more severe psychopathology and medical illnesses than impulsive SAs. Therefore, screening for depression, substance use disorders, and suicidal plans among old and medically ill patients may be important for preventing suicide attempts.

The influence of propoxyphene withdrawal on opioid use in veterans

PURPOSE

Our aim is to determine if propoxyphene withdrawal from the US market was associated with opioid continuation, continued chronic opioid use, and secondary propoxyphene-related adverse events (emergency department visits, opioid-related events, and acetaminophen toxicity).

METHODS

Medical service use and pharmacy data from 19/11/08 to 19/11/11 were collected from the national Veterans Healthcare Administration healthcare databases. A quasi-experimental pre-post retrospective cohort design utilizing a historical comparison group provided the study framework. Logistic regression controlling for baseline covariates was used to estimate the effect of propoxyphene withdrawal.

RESULTS

There were 24,328 subjects (policy affected n = 10,747; comparison n = 13,581) meeting inclusion criteria. In the policy-affected cohort, 10.6% of users ceased using opioids, and 26.6% stopped chronic opioid use compared with 3.8% and 13.5% in the historical comparison cohort, respectively. Those in the policy-affected cohort were 2.7 (95%CI: 2.5-2.8) and 3.2 (95%CI: 2.9-3.6) times more likely than those in the historical comparison cohort to discontinue chronic opioid and any opioid use, respectively. Changes in adverse events and Emergency Department (ED) visits were not different between policy-affected and historical comparison cohorts (p > 0.05).

CONCLUSIONS

The withdrawal of propoxyphene-containing products resulted in rapid and virtually complete elimination in propoxyphene prescribing in the veterans population; however, nearly 90% of regular users of propoxyphene switched to an alternate opioid, and three quarters continued to use opioids chronically.

Impulsive suicide attempts: a systematic literature review of definitions, characteristics and risk factors

BACKGROUND

Extensive research on impulsive suicide attempts, but lack of agreement on the use of this term indicates the need for a systematic literature review of the area. The aim of this review was to examine definitions and likely correlates of impulsive attempts.

METHODS

A search of Medline, Psychinfo, Scopus, Proquest and Web of Knowledge databases was conducted. Additional articles were identified using the cross-referencing function of Google Scholar.

RESULTS

179 relevant papers were identified. Four different groups of research criteria used to assess suicide attempt impulsivity emerged: (a) time-related criteria, (b) absence of proximal planning/preparations, (c) presence of suicide plan in lifetime/previous year, and (d) other. Subsequent analysis used these criteria to compare results from different studies on 20 most researched hypotheses. Conclusions regarding the characteristics of impulsive attempts are more consistent than those on the risk factors specific to such attempts. No risk factors were identified that uniformly related to suicide attempt impulsivity across all criteria groups, but relationships emerged between separate criteria and specific characteristics of suicide attempters.

LIMITATIONS

Only published articles were included. Large inconsistencies in methods of the studies included in this review prevented comparison of effect sizes.

CONCLUSIONS

The vast disparities in findings on risk factors for impulsive suicide attempts among different criteria groups suggest the need to address the methodological issues in defining suicide attempt impulsivity before further research into correlates of such attempts can effectively progress. Specific recommendations are offered for necessary research.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To 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).

Methods

There 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.

Conclusion

Within 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 registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Propoxyphene and the risk of out-of-hospital death

PURPOSE

The opioid analgesic propoxyphene was withdrawn from the US market in 2010, motivated by concerns regarding fatality in overdose and adverse cardiac effects, including prolongation of the QT interval. These concerns were based on case reports, summary vital statistics, and surrogate endpoint studies.

METHODS

Using the linked Tennessee Medicaid database (1992-2007), we conducted a retrospective cohort study that compared risk of sudden cardiac, medication toxicity, and total out-of-hospital death for propoxyphene users with that for comparable nonusers of any prescribed opioid analgesic and users of hydrocodone, an opioid with similar indications. Cohort members had 1,873,500 propoxyphene prescriptions, 1,873,500 matched nonuser control periods, and 936,750 matched hydrocodone prescriptions.

RESULTS

Current propoxyphene users had no increased risk for sudden cardiac death (versus nonusers: hazard ratio [HR] = 1.00 [0.81-1.23]; versus current hydrocodone users: HR = 0.91 [0.68-1.21]) but did have increased risk for medication toxicity deaths (versus nonusers: HR = 1.85 [1.07-3.19], p = 0.027; versus current hydrocodone users: HR = 2.10 [0.87-5.10], p = 0.100). Because toxicity deaths were a small proportion of study deaths, total out-of-hospital mortality differed by less than 10% between the study groups and was not significantly elevated for propoxyphene (versus nonusers: HR = 1.09 [0.95-1.25]; versus current hydrocodone users: HR = 1.06 [0.87-1.29] ).

CONCLUSIONS

Our findings support the concern that propoxyphene has greater toxicity in overdose but do not provide evidence that it increases the risk of sudden cardiac death.

The use of the Internet by people who die by suicide in England: a cross sectional study

BACKGROUND

There is widespread concern regarding the possible influence of the Internet on suicidal behaviour. The aim of this study was to estimate the prevalence and characteristics of Internet-related suicide in England.

METHODS

Cross sectional study based on detailed review of the inquest reports of suicides occurring in the areas served by 12 Coroners in England. Evidence of Internet use in relation to the suicide was sought for each death.

RESULTS

Altogether inquest reports for 593 suicides (all methods) in 2005 and 166 suicides using specific methods in 2006-7 were assessed. There was evidence of a direct Internet contribution in nine (1.5% 95%CI 0.7 to 2.9%) of the 593 suicides in 2005. In seven (77.8%) of the cases the individuals had used the Internet to research the methods of suicide they used. Five (55.6%) individuals had used 'unusual' high-lethality methods, whereas such methods were only used in 1.7% of all suicides (p<0.001). There was evidence of Internet involvement in 2.4% (0.7% to 6.1%) of the suicides in 2006-2007. None of the Internet-related suicides appeared to occur as part of a suicide pact.

LIMITATIONS

The contribution of the Internet to suicide rates may be under-estimated in this analysis as Coroners are unlikely to comprehensively pursue the possibility of Internet involvement in all the deaths they investigate.

CONCLUSIONS

Easy access to information about suicide methods and pro-suicide web sites on the Internet appears to contribute to a small but significant proportion of suicides. A key impact of the Internet appears to be in relation to information concerning suicide methods.

Suicide by burning barbecue charcoal in England

BACKGROUND

Suicide by carbon monoxide poisoning from burning barbecue charcoal has become a common method of suicide in several Asian countries over the last 15 years. The characteristics of people using this method in Western countries have received little attention.

METHOD

We reviewed the inquest reports of 12 English Coroners (11% of all Coroners) to identify charcoal-burning suicides. We compared socio-demographic and clinical characteristics of suicide by charcoal burning occurring between 2005 and 2007 with suicides using other methods in 2005.

RESULTS

Eleven charcoal-burning suicides were identified; people using this method were younger (mean age 33.4 versus 44.8 years, P = 0.02), and more likely to be unemployed (70.0 versus 30.1%, P = 0.01) and unmarried (100 versus 70%, P = 0.04) than those using other methods. Charcoal-burning suicides had higher levels of contact with psychiatric services (80.0 versus 59.1%) and previous self-harm (63.6 versus 53.0%) compared with suicides using other methods, but these differences did not reach conventional levels of statistical significance. Over one-third of people dying by charcoal burning obtained information on this method from the Internet.

CONCLUSIONS

Working with media, including Internet Service Providers, and close monitoring of changes in the incidence of suicide using this method might help prevent an epidemic of charcoal-burning suicides such as that seen in some Asian countries.

Six-year follow-up of impact of co-proxamol withdrawal in England and Wales on prescribing and deaths: time-series study

BACKGROUND

The analgesic co-proxamol (paracetamol/dextropropoxyphene combination) has been widely involved in fatal poisoning. Concerns about its safety/effectiveness profile and widespread use for suicidal poisoning prompted its withdrawal in the UK in 2005, with partial withdrawal between 2005 and 2007, and full withdrawal in 2008. Our objective in this study was to assess the association between co-proxamol withdrawal and prescribing and deaths in England and Wales in 2005-2010 compared with 1998-2004, including estimation of possible substitution effects by other analgesics.

METHODS AND FINDINGS

We obtained prescribing data from the NHS Health and Social Care Information Centre (England) and Prescribing Services Partneriaeth Cydwasanaethau GIG Cymru (Wales), and mortality data from the Office for National Statistics. We carried out an interrupted time-series analysis of prescribing and deaths (suicide, open verdicts, accidental poisonings) involving single analgesics. The reduction in prescribing of co-proxamol following its withdrawal in 2005 was accompanied by increases in prescribing of several other analgesics (co-codamol, paracetamol, codeine, co-dydramol, tramadol, oxycodone, and morphine) during 2005-2010 compared with 1998-2004. These changes were associated with major reductions in deaths due to poisoning with co-proxamol receiving verdicts of suicide and undetermined cause of -21 deaths (95% CI -34 to -8) per quarter, equating to approximately 500 fewer suicide deaths (-61%) over the 6 years 2005-2010, and -25 deaths (95% CI -38 to -12) per quarter, equating to 600 fewer deaths (-62%) when accidental poisoning deaths were included. There was little observed change in deaths involving other analgesics, apart from an increase in oxycodone poisonings, but numbers were small. Limitations were that the study was based on deaths involving single drugs alone and changes in deaths involving prescribed morphine could not be assessed.

CONCLUSIONS

During the 6 years following the withdrawal of co-proxamol in the UK, there was a major reduction in poisoning deaths involving this drug, without apparent significant increase in deaths involving other analgesics.

Impact of withdrawal of the analgesic Co-proxamol on nonfatal self-poisoning in the UK

BACKGROUND

In early 2005 the UK Committee on Safety of Medicines (CSM) announced gradual withdrawal of the analgesic co-proxamol because of its adverse benefit/safety ratio, especially its use for intentional and accidental fatal poisoning. Prescriptions of co-proxamol were reduced in the 3-year withdrawal phase (2005 to 2007) following the CSM announcement.

AIMS

To assess the impact of the CSM announcement in January 2005 to withdraw co-proxamol on nonfatal self-poisoning with co-proxamol and other analgesics.

METHODS

Interrupted time series analysis of general hospital presentations for nonfatal self-poisoning (five hospitals in three centers in England), comparing the 3-year withdrawal period 2005-2007 with 2000-2004.

RESULTS

A marked reduction in the number of episodes of nonfatal self-poisoning episodes involving co-proxamol was found following the CSM announcement (an estimated 62% over the period 2005 to 2007 compared to 2000 to 2004). There was no evidence of an increase in nonfatal self-poisoning episodes involving other analgesics (co-codamol, codeine, co-dydramol, dihydrocodeine, and tramadol) in relation to the CSM announcement over the same period, nor a change in the number of all episodes of self-poisoning.

LIMITATIONS

Data were from three centers only.

CONCLUSIONS

The impact of the policy appears to have reduced nonfatal self-poisoning with co-proxamol without significant substitution with other analgesics. This finding is in keeping with that for suicide.

Drug suicide: a sex-equal cause of death in 16 European countries

Background

There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84).

Methods

Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated.

Results

No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk.

Conclusions

Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Reporting rate of adverse drug reactions to the French pharmacovigilance system with three step 2 analgesic drugs: dextropropoxyphene, tramadol and codeine (in combination with paracetamol)

AIMS

Three 'weak' opioid analgesics in association with paracetamol are marketed in France as step 2 analgesics: dextropropoxyphene, tramadol and codeine. These combinations are involved in several adverse drug reactions (ADRs), but no data are available about their comparative reporting rate. The aim was to compare the reporting rate of ADRs between tramadol/paracetamol (TRM+P), codeine/paracetamol (COD+P) and dextropropoxyphene/paracetamol (DXP+P).

METHODS

All spontaneous reports submitted to the French Pharmacovigilance Database from 1 January 1987 to 31 December 2006 suspected to be induced by one of the three step 2 analgesic combinations (DXP+P, TRM+P, COD+P) were extracted. Their consumption for the same period was obtained from the French Drug Agency. The number of ADRs, serious ADRs and different organ classes of ADRs were compared according to their consumption. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each variable using DXP+P as reference.

RESULTS

The reporting rate of ADRs was calculated as 24.9/100 000 person-years for DXP+P, 44.5/100 000 person-years for TRM+P and 12.5/100 000 person-years for COD+P. The reporting rate (OR 0.56, 95% CI 0.50, 0.63) and 'seriousness>>' (OR 0.65, 95% CI 0.53, 0.80) of ADRs were significantly higher with TRM+P than with DXP+P. However, hepatobiliary ADRs were significantly more frequent with the DXP+P combination (OR 2.62, 95% CI 1.59, 4.37). In contrast, the reporting rate (OR 1.99, 95% CI 1.82, 2.18) and 'seriousness' (OR 2.64, 95% CI 2.24, 3.11) of ADRs were significantly higher with DXP+P than with COD+P.

CONCLUSIONS

Among the three step 2 analgesic combinations, reporting rate and 'seriousness' of ADRs are the highest with TRM+P and the lowest with COD+P. Our study suggests that the safety profile of DXP+P is worst than that of COD+P.

Method of suicide in the mentally ill: a national clinical survey

Comparisons of psychiatric patients who die by suicide using different methods are scarce. We aimed to establish the methods of suicide used by those who are currently or have recently been in contact with mental health services in England and Wales (N = 6,203), and describe the social and clinical characteristics of suicides by different methods. We found that hanging, self-poisoning, and jumping (from a height or in front of a moving vehicle) were the most common methods of suicide, accounting for 79% of all deaths. The implications of these and other findings are discussed.

Effect of withdrawal of co-proxamol on prescribing and deaths from drug poisoning in England and Wales: time series analysis

OBJECTIVE

To assess the effect of the UK Committee on Safety of Medicines' announcement in January 2005 of withdrawal of co-proxamol on analgesic prescribing and poisoning mortality.

DESIGN

Interrupted time series analysis for 1998-2007.

SETTING

England and Wales.

DATA SOURCES

Prescribing data from the prescription statistics department of the Information Centre for Health and Social Care (England) and the Prescribing Services Unit, Health Solutions Wales (Wales). Mortality data from the Office for National Statistics.

MAIN OUTCOME MEASURES

Prescriptions. Deaths from drug poisoning (suicides, open verdicts, accidental poisonings) involving single analgesics.

RESULTS

A steep reduction in prescribing of co-proxamol occurred in the post-intervention period 2005-7, such that number of prescriptions fell by an average of 859 (95% confidence interval 653 to 1065) thousand per quarter, equating to an overall decrease of about 59%. Prescribing of some other analgesics (co-codamol, paracetamol, co-dydramol, and codeine) increased significantly during this time. These changes were associated with a major reduction in deaths involving co-proxamol compared with the expected number of deaths (an estimated 295 fewer suicides and 349 fewer deaths including accidental poisonings), but no statistical evidence for an increase in deaths involving either other analgesics or other drugs.

CONCLUSIONS

Major changes in prescribing after the announcement of the withdrawal of co-proxamol have had a marked beneficial effect on poisoning mortality involving this drug, with little evidence of substitution of suicide method related to increased prescribing of other analgesics.

Dextropropoxyphene withdrawal from a French university hospital: impact on analgesic drug consumption

Dextropropoxyphene is a weak opioid analgesic, widely used as a step 2 analgesic (according to WHO classification) in combination with peripheral analgesics, mainly paracetamol. Recent data have underlined its poor analgesic efficacy (in comparison with paracetamol), risks of serious adverse drug reactions (i.e. hepatic reactions, hallucinations, abuse, withdrawal symptoms, hypoglycaemia), possible lethality after overdose, its risk of accumulation in patients with renal failure or in elderly people and some pharmacokinetic insufficiencies (i.e. different half-lives for dextropropoxyphene and paracetamol). Taking into account these data, the drug committee of the Toulouse University Hospital (France) decided to withdraw dextropropoxyphene from the hospital formulary since 1 June 2005. The aim of our study was to investigate the consequences of this withdrawal by comparing use of analgesic drugs in Toulouse University Hospital before (2004) and after (2006) dextropropoxyphene withdrawal (using defined daily dose for 1000 hospitalization-days as the unit measure). Before withdrawal, dextropropoxyphene (in combination with paracetamol) was the second most used analgesic drug after paracetamol alone. After dextropropoxyphene withdrawal, total consumption of analgesic drugs decreased by 4.6% (2006 vs. 2004). There was a 28% decrease in consumption of step 2 analgesics [with an increase in oral tramadol and a slight decrease in codeine (in combination with paracetamol)]. During the same period, step 1 analgesic consumption increased by 11% (mainly paracetamol) and that of step 3 analgesics slightly decreased (-8%). These results show that dextropropoxyphene withdrawal was not associated with a marked switch in prescriptions towards other analgesic drugs. This paper underlines the interest of a hospital-based drug committee to promote rational drug use. Finally, the present data allow us to discuss putative misuse of dextropropoxyphene.

Co-proxamol withdrawal has reduced suicide from drugs in Scotland

AIM

To determine what effect the withdrawal of co-proxamol from the UK market has had on mortality from poisoning in Scotland.

METHODS

This was a retrospective, observational study of mortality relating to poisoning by single agents in Scotland for the period 2000-2006. Mortality data were obtained from the General Register Office Scotland, and primary care prescribing data from the Information and Statistics Division of the Scottish Executive Health Department.

RESULTS

A significant reduction in the proportion of poisoning deaths due to co-proxamol was observed following legislation [mean 2000-2004, 37 deaths (21.8% of total poisoning deaths); 2006, 10 (7.8%); P < 0.0001]. The most significant reduction was seen in male out-of-hospital deaths [mean 2000-2004, 17 (21.8%); 2006, two (2.9%); P < 0.0001]. This was associated with a decline in prescriptions by 60% within 6 months of legislation. The total number of poisoning deaths also fell, slightly earlier than the full impact on co-proxamol deaths (mean 2000-2004, 171.2; mean 2005-2006, 129.5; P = 0.005).

CONCLUSIONS

Legislation has resulted in a major reduction in the number of deaths associated with co-proxamol poisoning in Scotland, with no compensatory rise in mortality from poisonings from other common analgesics. We estimate from this study that a minimum of 300 lives across the UK will have been saved by the withdrawal of co-proxamol.

Co-proxamol overdose is associated with a 10-fold excess mortality compared with other paracetamol combination analgesics

AIMS

To assess the relative toxicity of co-proxamol in overdose in comparison to the 2 other paracetamol-opioid combination products, co-codamol and co-dydramol.

METHODS

Data collected over a 2-year period (July 2000-June 2002) was used to estimate the frequency of overdose and death for the three most popular paracetamol-opioid compound analgesics. Prescription data for Scotland and Edinburgh, the number of overdoses (derived from overdose admissions in Edinburgh) or Poisons Information Service contacts in Scotland, and national death records were used to calculate a series of indicators relating morbidity (admissions), surrogates of morbidity (poisons enquiries by telephone or internet) and mortality to prescriptions.

RESULTS

When related to prescription volume overdoses involving co-proxamol in Scotland were 10 times more likely to be fatal (24.6 (19.7, 30.4)) when compared with co-codamol (2.0 (0.88, 4.0)) or co-dydramol (2.4 (0.5, 7.2)). In contrast there was no difference in the presentation rate or enquiry rates for these analgesics when corrected for prescriptions.

CONCLUSIONS

The excess hazard from co-proxamol is due to inherent toxicity rather than increased use in overdose. We estimate from this study that withdrawal of co-proxamol would prevent 39 excess deaths per annum in Scotland alone.

Deliberate self-harm in people aged 60 years and over: characteristics and outcome of a 20-year cohort

BACKGROUND

Little information is available about older deliberate self-harm (DSH) patients and their outcome.

METHODS

This study is a prospective investigation and follow-up of 730 consecutive patients (459 females and 271 males) aged 60 years and over who presented to a general hospital following DSH over a 20-year period, 1978-1997. Outcome has been examined in terms of repetition of DSH, and deaths by the end of 2000 identified through official death registers.

RESULTS

DSH involved self-poisoning in 88.6% of cases, 49.3% of the overdoses including paracetamol (acetaminophen), 24.0% minor tranquillizers, and 15.9% antidepressants. Nearly three-quarters of episodes involved high suicidal intent. Common problems preceding DSH were physical illness (46.1%), social isolation (33.5%), relationship problems with family (29.4%) or partner (25.9%), and bereavement or loss (16.7%). Repetition of DSH occurred in 15.3% of cases, 8.2% in the first year following DSH. By the end of 2000, 432/661 (65.4%) of traced patients had died. There were 30 suicides and open verdicts, which were 49 times and 33 times more frequent respectively than expected from general population death rates. Prior DSH before initial presentation was the main risk factor for suicide, with some evidence of high suicide intent being another factor. There were also excess deaths due to several types of physical disorder.

CONCLUSIONS

DSH in older people is closely related to suicide, both in terms of suicidal intent and risk of eventual suicide, especially when DSH is repeated. The range of problems experienced by older DSH patients requires extensive and multidisciplinary clinical interventions.

The usefulness of coroners' data on suicides for providing information relevant to prevention

Coroners' records are an accessible source of information on suicides. To assess their usefulness in relation to the investigation of specific methods of suicide, we examined coroners' records for 492 suicides across 24 jurisdictions in England. Generally data on demographic variables were well recorded. Information on contact with general practitioner and psychiatric services was less commonly available. Where those who had self-poisoned died in hospital, information on treatment and blood levels of drugs taken were not routinely available. For suicides by hanging, information on the source of ligature was frequently missing. Where firearms were used, information about licensing and storage were not routinely recorded. Generally there was wide variation across coroners in information relevant to specific methods. The use of standardized forms by coroners would assist studies of factors associated with suicide and potentially provide a representative source of information relevant to suicide prevention.

Self-poisoning suicides in England: a multicentre study

BACKGROUND

Suicide by self-poisoning is an important cause of death worldwide. A substantial proportion of those with a fatal outcome may come into contact with medical services before they die.

AIM

To estimate the proportion of self-poisoning suicides who reached hospital alive; to compare those who reached hospital alive with those who did not; to describe in detail the clinical characteristics and medical management of those dying in hospital.

DESIGN

Retrospective audit.

METHODS

We studied 24 coroners' jurisdictions across England, reviewing coroners' files and identifying all suicides by self-poisoning (drugs and other ingestible poisons) from 1 January 2001 to 31 December 2001.

RESULTS

Of the 214 individuals who completed suicide by self-poisoning during the study period, 49 (23%) reached hospital alive. Those reaching hospital were more likely to be female, more likely to have ingested paracetamol and less likely to have ingested co-proxamol. In the hospital sample, the commonest causes of death were respiratory (n = 10), hepatic or hepatorenal (n = 8), cardiac (n = 5), or a result of hypoxic brain injury (n = 5). Only 18% of in-hospital deaths occurred within 24 h of the overdose.

DISCUSSION

Extrapolating to England as a whole, we might expect 300 self-poisoning suicides per year to reach hospital alive (6% of all suicides). Improved medical management might produce a small but significant reduction in the rate of suicide. Such interventions should not be restricted to the emergency care domain. Further research will help to clarify the likely contribution of improved medical management to suicide prevention.