Consumption, overdose and death from analgesics during a period of over-the-counter availability of paracetamol in Denmark

Central nervous system-active drug abused and overdose in children: a worldwide exploratory study using the WHO pharmacovigilance database

Recent epidemiological studies have reported an increase in central nervous system (CNS)-active drug abuse rates in paediatric settings, raising several public health concerns. No study to date has explored this issue worldwide. We performed an extensive analysis of drugs abuse/overdose reported for children in the last decade by using the largest pharmacovigilance database, i.e. the VigiBase, collecting adverse drug reaction reports that involved at least one suspect drug belonging to the Anatomical Therapeutic Chemical code "Nervous System" through the Standardised Medical Dictionary for Drug Regulatory Affairs Queries for Drug abuse. 8.682 reports matched our criteria. An increase in reporting activity was observed, starting from 2014; an intentional overdose was reported more frequently than an accidental one, with a difference between age groups. We retrieved 997 reports with death outcome. These referred more to adolescents (n = 538) than subjects of any other paediatric age group. Paracetamol and opioid analgesics were the most common suspect drugs in deaths across all age groups due to hypoxic-ischaemic encephalopathy, brain death, and cardio-respiratory arrest.Conclusion: The number of reports associated with drug abuse and overdose is increasing (for opioid and paracetamol-containing products) and a considerable number of adverse drug reactions are serious. Data on the patterns of use of such medicines from each country may help in implementing strategies of risk-minimisation and renewing healthcare recommendations worldwide. An increased clinical awareness of drug abuse and overdose is warranted, while continuing to provide effective treatments. What is Known: • The large increase in paediatric prescriptions for CNS-active drugs in the last 20 years has recently raised public health concerns about drug abuse and overdose. • No study to date has examined this issue in paediatric patients worldwide. What is New: • The number of paediatric reports associated with CNS drug abuse and intentional overdose is increasing, including those with fatal outcome; over 4 years; more than 35% of the reports was entered from European countries. • Opioid and paracetamol were most frequently suspected for ADRs with fatal outcome across all age groups, due to hypoxic-ischaemic encephalopathy and cardio-respiratory arrest, suggesting the need to implement strategies of risk-minimisation.

Paracetamol: overdose-induced oxidative stress toxicity, metabolism, and protective effects of various compounds in vivo and in vitro

Paracetamol (APAP) is one of the most widely used and popular over-the-counter analgesic and antipyretic drugs in the world when used at therapeutic doses. APAP overdose can cause severe liver injury, liver necrosis and kidney damage in human beings and animals. Many studies indicate that oxidative stress is involved in the various toxicities associated with APAP, and various antioxidants were evaluated to investigate their protective roles against APAP-induced liver and kidney toxicities. To date, almost no review has addressed the APAP toxicity in relation to oxidative stress. This review updates the research conducted over the past decades into the production of reactive oxygen species (ROS), reactive nitrogen species (RNS), and oxidative stress as a result of APAP treatments, and ultimately their correlation with the toxicity and metabolism of APAP. The metabolism of APAP involves various CYP450 enzymes, through which oxidative stress might occur, and such metabolic factors are reviewed within. The therapeutics of a variety of compounds against APAP-induced organ damage based on their anti-oxidative effects is also discussed, in order to further understand the role of oxidative stress in APAP-induced toxicity. This review will throw new light on the critical roles of oxidative stress in APAP-induced toxicity, as well as on the contradictions and blind spots that still exist in the understanding of APAP toxicity, the cellular effects in terms of organ injury and cell signaling pathways, and finally strategies to help remedy such against oxidative damage.

Paracetamol intoxications: a retrospective population-based study in Iceland

OBJECTIVE

Paracetamol is the most common cause of acute liver failure (ALF) in many countries. Much data on paracetamol toxicity originate from liver transplant centers and tertiary referral institutions. The authors analyzed the population-based annual incidence of paracetamol overdoses and ALF, and described the risk factors for hepatotoxicity.

METHODS

A search was undertaken for the diagnosis of paracetamol overdoses in the diagnoses registry of the National University Hospital of Iceland from 2004 to 2009 serving a population of 219,249 inhabitants. Relevant information was collected from medical records.

RESULTS

A total of 1913 drug-related poisoning episodes were identified and reviewed, 352 (18%) involved paracetamol overdoses. The annual incidence of paracetamol overdoses declined from 30.0 (2004) to 16.0/100,000 per year (2009) (p < 0.05). The female/male ratio was 3.0 and the largest age group was 16-25 years. After the initial examination, 26% were discharged home. Hospitalized index visits were 182 with accidental overdoses constituting 16 (9%) with no gender difference. Compared with intentional overdose the accidental group had higher aminotransferases (p < 0.005). ALF occurred in 3.8% (7/182) of the index visits and the incidence was 0.7/100,000 per year. In the intentional group, 1.2% (2/163) developed ALF versus 25% (4/16) of the accidental group (p = 0.001). Only one patient died from ALF and none underwent liver transplantation.

CONCLUSION

The annual incidence of paracetamol overdoses was high in this population-based study but declined. Young females with intentional overdose accounted for most of the cases, whereas accidental overdoses were more common in older patients. The occurrence of ALF was low and mostly associated with accidental overdose.

Hospital admission for non-fatal poisoning with weak analgesics and risk for subsequent suicide: a population study

BACKGROUND

Poisoning with weak analgesics is a major public health problem because of easy accessibility of the compounds; however, few studies have investigated their influence on subsequent suicide in the context of subjects' psychiatric status and other factors.

METHOD

This nested case-control study was based on the entire Danish population including all 21,169 suicide cases and 423,128 matched population controls. Data on hospital admissions for poisoning and confounding factors were retrieved from national medical and administrative registries. Conditional logistic regression was used to compute relative risk.

RESULTS

A prior hospital admission for poisoning with weak non-opioid analgesics significantly increased the risk of subsequent suicide [crude incidence rate ratio (IRR) 24.7, 95% confidence interval (CI) 22.1-27.6], and the effect of paracetamol poisoning was substantially stronger than that of poisoning with salicylates or non-steroidal anti-inflammatory drugs (NSAIDs). This association could not be explained by confounding from socio-economic or psychiatric factors. The elevated risk was extremely high during the first week following the overdose (adjusted IRR 738.9, 95% CI 173.9-3139.1), then declined over time but still remained significantly high 3 years later (adjusted IRR 4.2, 95% CI 3.5-5.0). Moreover, a history of weak analgesic poisoning significantly interacted with a person's psychiatric history, increasing the risk for subsequent suicide substantially more for persons with no history of psychiatric hospitalization than did it for those with such a history.

CONCLUSIONS

A history of non-fatal poisoning with weak analgesics is a strong predictor for subsequent suicide. These results emphasize the importance of intensive psychiatric care of patients following overdose.

Factors associated with choice of psychotropic drugs used for intentional drug overdose

INTRODUCTION

Knowledge of the factors influencing the choice of drugs used for intentional drug overdose (IDO) may allow the reduction of IDO lethality.

OBJECTIVES

To assess with which frequency subjects with intentional overdose of psychotropic drugs ingest their own psychotropic drug treatment, and whether prescription of a drug may be a factor influencing the choice of drugs used for the IDO.

METHODS

Demographic characteristics, psychiatric history, and currently prescribed psychotropic drug treatment were collected for all the patients (n = 1,654) admitted to an emergency department (ED) for IDO with psychotropic drugs (anxiolytics, hypnotics, antidepressants, neuroleptics and mood stabilizers) over a period of 18 months. Drugs ingested for the IDO were compared in subjects who had ingested at least one psychotropic drug that was prescribed for them and subjects who had ingested psychotropic drugs not prescribed for them using multivariate logistic regression.

RESULTS

Two-thirds of the patients ingested during the IDO at least one of their own prescribed psychotropic drugs. Compared with the subjects who had ingested psychotropic drugs not prescribed for them, they were more likely to have a history of psychiatric hospitalization (OR 4.2; 95%CI 3.1-5.5), of being a psychiatric outpatient (OR 3.9; 95%CI 3.0-5.1), of parasuicide (OR 2.5; 95%CI 1.9-3.3) and a serious IDO (OR 2; 95%CI 1.4-2.9). Independently from age and psychiatric hospitalization history, they ingested during the IDO more often antidepressants (OR 4.4; 95%CI 3.0-6.4), antipsychotics (OR 2.9; 95%CI 1.7-4.8) and mood stabilizers (OR 4.1; 95%CI 1.6-10.7). No association was found with prescription for overdose of hypnotic (OR 1.1; 95%CI 0.8-1.5), anxiolytic (OR 1.2; 95%CI 0.9-1.7) or paracetamol (OR 1.0; 95%CI 0.5-2.1).

CONCLUSION

Prescription of the psychotropic drugs plays an important role in the choice of the drugs ingested for the IDO. It might make potentially "dangerous" drugs available for the patient. Physicians have always to balance the benefit of the treatment against the risk of drug overdose.

The association between admission for poisoning with paracetamol or other weak analgesics and subsequent admission for psychiatric disorder: a Danish nationwide case-control study

BACKGROUND

Many cases of paracetamol poisoning are with suicidal intent, but the association between paracetamol poisoning and subsequent psychiatric disorder is unknown.

AIM

To examine the association between poisoning with paracetamol or other weak analgesics and subsequent psychiatric disorder.

METHODS

The study was set in a nested case-control design and based on nationwide Danish registers. We identified all patients diagnosed with schizophrenia, affective disorder or eating disorder in 1994-1998 and matched population controls. We estimated the relative risk of these psychiatric disorders after admission for paracetamol or nonparacetamol poisoning, adjusting for income, employment and marital status.

RESULTS

We included 12,603 cases with psychiatric disorder, and 1.2% had a diagnosis of poisoning compared with 0.2% of the 252,060 matched population controls. Compared with those with no diagnoses of weak analgesic poisoning, the risk of schizophrenia increased 3.9-fold after paracetamol poisoning, and 2.0-fold after nonparacetamol poisoning. The risk of affective disorder increased 12.2-fold after paracetamol poisoning and 2.6-fold after nonparacetamol poisoning. The risk of eating disorder increased 5.0-fold after paracetamol poisoning, and 2.2-fold after nonparacetamol poisoning. The risk of a diagnosis of psychiatric disorder was very high immediately after poisoning and remained increased for more than 10 years.

CONCLUSIONS

Paracetamol poisoning is a strong risk marker for psychiatric disorder, particularly affective disorders.

Co-proxamol and suicide: preventing the continuing toll of overdose deaths

Restricting means for suicide is a key element in suicide prevention strategies of all countries where these have been introduced. Preventing deaths from analgesic overdoses is highlighted in the National Suicide Prevention Strategy for England. The problem of self-poisoning with the prescription-only drug co-proxamol (dextropropoxyphene plus paracetamol) has received attention in several countries. We have conducted a review of the international literature related to possible strategies to tackle this problem. In England and Wales in 1997-1999, 18% of drug-related suicides involved co-proxamol; these constituted 5% of all suicides. Death usually results from the toxic effects of dextropropoxyphene on respiration or cardiac function. Death from co-proxamol overdose may occur rapidly, the lethal dose can be relatively low, and the effects are potentiated by alcohol and other CNS depressants. The majority of co-proxamol overdose deaths occur before hospital treatment can be received. The risk can extend to others in the household of the person for whom the drug is prescribed. While there is limited evidence that educational strategies have been effective in reducing deaths from co-proxamol poisoning, initiatives in Scandinavia, Australia and the UK to restrict availability of co-proxamol have produced promising results. Given the paucity of evidence for superior therapeutic efficacy of co-proxamol over other less toxic analgesics, there are good reasons to question whether it should continue to be prescribed.

UK legislation on analgesic packs: before and after study of long term effect on poisonings

OBJECTIVE

To evaluate the long term effect of legislation limiting the size of packs of analgesics sold over the counter.

DESIGN

Before and after study.

SETTING

Suicides in England and Wales, data from six liver units in England and Scotland and five general hospitals in England, and UK data on sales of analgesics, between September 1993 and September 2002.

DATA SOURCES

Office for National Statistics; six liver units in England and Scotland; monitoring systems in general hospitals in Oxford, Manchester, and Derby; and Intercontinental Medical Statistics Health UK.

MAIN OUTCOME MEASURES

Deaths by suicidal overdose with paracetamol, salicylates, or ibuprofen; numbers of patients admitted to liver units, listed for liver transplant, and undergoing transplantations for paracetamol induced hepatotoxicity; non-fatal self poisonings with analgesics and numbers of tablets taken; and sales figures for analgesics.

RESULTS

Suicidal deaths from paracetamol and salicylates were reduced by 22% (95% confidence interval 11% to 32%) in the year after the change in legislation on 16 September 1998, and this reduction persisted in the next two years. Liver unit admissions and liver transplants for paracetamol induced hepatotoxicity were reduced by around 30% in the four years after the legislation. Numbers of paracetamol and salicylate tablets in non-fatal overdoses were reduced in the three years after the legislation. Large overdoses were reduced by 20% (9% to 29%) for paracetamol and by 39% (14% to 57%) for salicylates in the second and third years after the legislation. Ibuprofen overdoses increased after the legislation, but with little or no effect on deaths.

CONCLUSION

Legislation restricting pack sizes of analgesics in the United Kingdom has been beneficial. A further reduction in pack sizes could prevent more deaths.

Acetaminophen Availability Increases in Canada with No Increase in the Incidence of Reports of Inpatient Hospitalizations with Acetaminophen Overdose and Acute Liver Toxicity

In September 1999, several Canadian provinces had place-of-sale restrictions lifted that had limited the sale of acetaminophen >325 mg and packages >24 tablets (any strength) to pharmacies only. This allowed the sale of all strengths of immediate-release acetaminophen in all package sizes in nonpharmacy locations. This study's purpose was to explore the effect that lifting restrictions on acetaminophen place of sale may have had on reported hospitalizations in Canada related to acetaminophen overdose toxicity. Using hospital discharge data, provinces with no preexisting restrictions on place of sale were compared with those in which restrictions were lifted in September 1999. Cases of reported APAP overdose included ICD-9/9-CM code 965.4, ICD-9 code E850.2, or ICD-9-CM code E850.4. Cases with reported acute liver toxicity included ICD-9/9-CM codes 570, 572.2, 572.4, V42.7, or procedure code 50.5. There were no significant differences between the 1.5-year periods pre- and post-September 1999 in annual incidence rates per 100,000 persons ages >/=12 years of hospitalizations reported with acetaminophen overdose, either overall or limited to those with death as an outcome, or in hospitalization reports with both acetaminophen overdose and acute liver toxicity, either overall (provinces with no restrictions: pre = 0.70, post = 0.80, P = 0.6328; provinces with restrictions lifted in September 1999: pre = 0.49, post = 0.47, P = 0.8649) or limited to those with death as an outcome (provinces with no restrictions: pre = 0.22, post = 0.12, P = 0.3030; provinces with restrictions lifted in September 1999: pre = 0.13, post = 0.09, P = 0.3589). In conclusion, the decision to lift Canadian place-of-sale restrictions increased acetaminophen availability and did not increase the rate of reported hospitalizations related to acetaminophen overdose toxicity.

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.

Management of paracetamol poisoning

Paracetamol is the most common substance involved in self-poisoning in the UK. The main advances made over the past five years in the management of early paracetamol poisoning, identification of risk factors for paracetamol poisoning, understanding of the mechanisms and management of late paracetamol poisoning and issues concerning the prevention of paracetamol poisoning are discussed.

Paracetamol recall: a natural experiment influencing analgesic poisoning

OBJECTIVES

To determine whether the occurrence of paracetamol and non-paracetamol analgesic deliberate self-poisoning (DSP) and accidental paediatric poisoning was affected by two periods of recall of paracetamol products.

DESIGN

Retrospective, observational audit of proportions of poisonings with tablet and capsule formulations of paracetamol, ibuprofen and aspirin products during two recall periods compared with the number of poisonings during the same periods of the previous three years.

SETTING

A national poisons information centre and a regional toxicology service.

MAIN OUTCOME MEASURES

Rates of DSP and accidental paediatric poisoning with paracetamol, ibuprofen and aspirin.

RESULTS

During the two recall periods, there was a significant increase in ibuprofen DSP calls to the poisons information centre (RR, 1.86; 95% Cl, 1.41-2.44; P = 0.001). There was no significant change in paracetamol or aspirin DSP calls over the two recall periods. However, there was a non-significant reduction in DSP calls with paracetamol in the first recall period alone (P = 0.057). There was a significant increase in the proportion of aspirin DSP presentations for the toxicology service (RR, 3.33; 95% CI, 0.97-11.4; P = 0.043), but no significant changes in paracetamol and ibuprofen DSP presentations. For accidental paediatric ingestions there was a significant increase in the proportion of ibuprofen calls (RR, 2.35; 95% CI, 1.85-2.98; P = 0.001), but no significant change in paracetamol or aspirin calls.

CONCLUSIONS

Reduced paracetamol availability increased poisoning with alternative analgesics, but had little effect on the incidence of paracetamol poisoning. Restriction of paracetamol-containing products may inadvertently increase poisoning with potentially more toxic agents.

Improvements in the packaging of drugs and chemicals may reduce the likelihood of severe intentional poisonings in adults

Because of the inconvenience and longer time required to punch out the tablets, strip packaging may reduce the number of tablets that can be readily swallowed by adults with self-poisonings. In fact, hospital-based studies of paracetamol poisoning in the U.K. and Hong Kong have shown that blister packs were associated with fewer tablets being ingested and large overdoses were mostly from loose preparations. In Australia, following the change in packaging for carbamazepine from bottles of tablets to blister packs, a marked decrease in the reported number of tablets ingested by patients was seen. Reducing the maximum number of tablets that can be available in individual preparations or prescriptions may also reduce the likelihood of severe poisonings. In France, but not in the UK, the content of each pack of paracetamol has been legally limited to 8 g. This was thought to be one reason why severe liver damage and deaths after paracetamol poisonings are less common in France than in the UK. Medicated oils containing methyl salicylate pose the threat of rapid-onset, severe salicylate poisoning if swallowed. To reduce the amount of methyl salicylate that can be readily swallowed, the methyl salicylate content and the size of the bottle and its opening should be restricted. In adults with Dettol poisoning, serious complications such as pulmonary aspiration are more likely if a large amount is ingested. Similarly, the risk may be reduced by restricting the size of bottle and its opening.

Use of paracetamol for suicide and non-fatal poisoning in the UK and France: are restrictions on availability justified?

OBJECTIVE

To investigate the relationship between the availability of paracetamol and its use for overdose and suicide.

DESIGN

Analysis of routinely collected information on time trends for paracetamol suicides, non-fatal overdoses, and sales.

SETTING

England and Wales and France.

RESULTS

There were strong correlations between trends in paracetamol sales in the UK and trends in non-fatal paracetamol overdose in Oxford between 1976 and 1993 (Spearman's r = 0.86; 95% confidence interval (CI) 0.54, 0.96) and between paracetamol sales and non-fatal overdoses in France between 1974 and 1990 (r = 0.99; 95% CI 0.97, 1.00). Sales figures were also correlated with paracetamol related suicides in both England and Wales, 1983-91 (r = 0.72; 95% CI 0.11, 0.94) and France, 1974-90 (r = 0.79; 95% CI 0.50, 0.92). Similarly strong relationships were observed between trends in non-fatal overdoses and suicide by paracetamol poisoning in England and Wales (r = 0.85; 95% CI 0.61, 0.95) and France (r = 0.79; 95% CI 0.50, 0.92). It is estimated that approximately 32,000 overdoses involving paracetamol occur annually in England and Wales. Fatality rates from paracetamol overdose were four times as high in England and Wales (0.4%, 95% CI 0.38, 0.46) as in France (0.1%, 95% CI 0.06, 0.17).

CONCLUSION

Trends towards greater availability of paracetamol are paralleled by increases in its use for both non-fatal overdose and suicide. Paracetamol related morbidity and mortality seem to be less frequent in France where the quantity of paracetamol in a single purchase is limited. Although not conclusive, these data add to a body of evidence which suggests that restrictions in the quantity of paracetamol available as a single purchase in the UK may reduce suicide and liver failure related to paracetamol.

Membrane toxicity of opioids measured by protozoan motility

The acute toxicity of some opioid drugs cannot solely be explained by a specific interaction with the opioid receptor. The anaesthetic-like membrane effect of 10 opioid agents and the antagonist naloxone was determined and correlated with their hydrophobicity. The inhibitory effect of drugs on protozoan motility was used as a measure of their membrane toxicity, measured by the reduction in swimming speed of Tetrahymena pyriformis using an image analysis system. Hydrophobicity was determined as the n-octanol/water partition coefficient, at pH 7.4, 37 degrees C. Opioid agents dose-dependently reduced the swimming speed of Tetrahymena pyriformis with a wide range of IC50 values. Some weak opioid agents were shown to have high protozoan immobilising potency comparable to quinidine, an agent with known membrane stabilising activity. Norpropoxyphene, the metabolite of dextropropoxyphene, with little affinity for the opioid receptor, also had a high potency. The inhibition of protozoan motility by these opioid agents was not antagonised by the opioid receptor antagonist naloxone; moreover an additive inhibitory action was demonstrated when opioid agents were combined with naloxone. The effect of opioid agents on protozoan motility was closely correlated with their partition coefficient but not with their known affinity for opioid receptors. These results suggest that opioid agents possess differing degrees of membrane depressant action independent from their interaction with the opioid receptor, and have a potential for causing depressant effects on excitable tissues.

Paracetamol self-poisoning. Characteristics, prevention and harm reduction

BACKGROUND

Paracetamol is now the most common drug used for self-poisoning in the UK and is associated with potentially fatal liver damage. Patients admitted to hospital because of paracetamol overdoses were studied in order to determine their characteristics and factors which might have deterred them from taking paracetamol or reduced the dangers of the overdose.

METHOD

Eighty patients were studied in hospital using a structured interview schedule, measures of depression and suicidal intent, information collected through the Oxford Monitoring System for Attempted Suicide, and the results of liver function tests.

RESULTS

Acute liver dysfunction (25 patients) was associated with consumption of more than 25 tablets (odds ration 4.46, 95% CI 1.31 to 17.41, P = 0.014). The proportionate use of tablets from blister packs (60%) and loose preparations (46%; 5 patients using both types) reflected their general availability. More of those who took tablets from a loose preparation consumed 25 or more tablets (69%) than those who used a blister-pack preparation (40%; odds ratio = 3.0, 95% CI 1.12 to 9.95, P = 0.028). Only 20 patients thought that any type of warning label would have deterred them from taking a paracetamol overdose.

CONCLUSIONS

Establishing a maximum number of tablets (e.g. 25) that can be available in individual preparations is likely to reduce the dangers of paracetamol self-poisoning. The potential effects of other measures are uncertain.

Medicine self-poisoning and the sources of the drugs in Lund, Sweden

The purpose of this study was to investigate the prevalence of toxic agents in attempted and completed suicides. The purpose was also to explore the sources of the drugs taken by suicide attempters. Verbal information on drug intake was collected from 280 suicide attempters during 1987-1990 in the Lund-Orup catchment area. Information on the sources of the drugs was collected from 143 of these attempters. The study also includes toxicological screening from 73 fatal poisonings in southern Sweden during 1989. According to verbal information, the most common drugs used by suicide attempters were benzodiazepines (51%), analgesics (29%) and antidepressants (20%). In suicide attempters, diazepam and levomepromazine were reported more than expected from prescription data. Toxicological screenings of fatal poisonings showed that benzodiazepines were most common (55%), followed by analgesics (38%), mainly propoxyphene (29%) and antidepressants (30%), mainly amitriptyline (22%). Amitriptyline and diazepam were more commonly detected in completed suicides than expected from prescription data. The most common sources of drugs to attempted suicides were physicians, and especially psychiatrists. We therefore conclude that continuous information to physicians on drug overdose is important, and it is also important to introduce alternative strategies to prevent suicidal behaviour.

Fatal poisonings in Jutland (Denmark) during the 1980s

During the period 1980 through 1989 a total of 1029 cases of fatal poisoning (638 men and 391 women) were examined at the Department of Forensic Medicine, Aarhus University, Denmark. In 68% of the cases death had been caused by drugs, whereas acute alcohol poisoning and carbon monoxide accounted for 15% and 14% of the cases, respectively. Alcohol was detected in more than half of the 1029 fatal poisoning cases, and in 42% of all cases the blood alcohol concentration was above 0.8 g/kg. In 57% of the cases death was categorized as accidental, only in 31% of the cases as suicide. Accidental deaths were especially predominant amongst drug and/or alcohol abusers. Propoxyphene was the drug found to have caused most fatal poisonings during the decade (30% of the drug-related deaths). Most of the propoxyphene-related deaths occurred during the early and mid-eighties. Barbiturate poisonings were quite frequent during the first half of the eighties. However, the number of deaths caused by barbiturates decreased significantly after 1986, when most barbiturates were withdrawn from the market. The number of deaths caused by narcotics and analgesics increased during the survey period, while no specific tendency was observed concerning antidepressants.