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ORIGINAL ARTICLE
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Profile of patients presenting with deliberate drug overdose and outcome


 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission18-Dec-2021
Date of Decision21-Mar-2022
Date of Acceptance20-Apr-2022

Correspondence Address:
Kundavaram P P. Abhilash,
Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_715_20

  Abstract 


Background: Deliberate self-poisoning (DSP) is one of the leading causes of mortality and morbidity in India. Drug overdose is one of the most common methods for the same and is a growing public health concern globally. It is important to know the spectrum of drugs used for the same and to identify any specific groups at risk. Methodology: This retrospective cohort study included patients presenting with medication drug overdose to the emergency department (ED) from January 2017 to December 2018. Patient data were obtained from the ED triage registry software and clinical workstation. Following this, their hospital outcome was determined. Results: During the study period, 1802 patients presented with DSP among which drug overdose comprised 27.6% (498/1802). The mean age was 32.8 years (SD-12.6) with a higher incidence in the age group comprising young adults (16–30 years, 52%), majority being females (68%). The most commonly consumed drugs belonged to the drug class of benzodiazepines (22%), NSAIDs (19.2%), antihistamines (15%), antidepressants (12%), and antipsychotics (10.2%). The mortality rate was 0.2%. Conclusion: Benzodiazepines were the most commonly consumed class of drugs used for DSP, followed closely by NSAIDs. Drug overdose showed a higher incidence in the age group of highly productive young adults. The incidence exhibited a seasonal pattern with peak in April and May. Although the mortality rate following drug overdose remains low, drug overdose is a commonly used method for DSP and continues to be a growing public health concern.

Keywords: Benzodiazepines, deliberate self-poisoning, drug overdose



How to cite this URL:
Sanjay M, Rabbi AS, Jain A, P. Abhilash KP. Profile of patients presenting with deliberate drug overdose and outcome. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=346453




  Introduction Top


Deliberate self-poisoning (DSP) is the intentional ingestion of substances never intended for human consumption or of more than a prescribed amount of medicinal substances, whether or not there is evidence that the act was intended to result in death.[1] It is a leading cause of morbidity and mortality in India and around the world and is a growing public health concern, which places a great burden on the emergency medical services.[2] It is unfortunate to see more than 1,00,000 people committing suicide in India.[3] The majority of these cases belong to the young adults who are the major working force behind the development of the nation.[4] The reduction of suicide mortality has been prioritized by the World Health Organization (WHO) as a global target and has been included as an indicator in the United Nations Sustainable Development Goals (SDGs) under target 3.4, the WHO 13th General Programme of Work 2019–2023 and the WHO Mental Health Action Plan 2013–2030.[5],[6]

DSP is seen across all age groups and geographical areas with a wide variation in the methods used.[7] The most common modes of DSP, in our geographic locality, have been agrochemical poisoning followed by drug overdose, whereas hanging and poisoning are the leading causes in India.[2],[8],[9] Regulations on the availability and use of certain prescription drugs in India are practically non-existent. The ease of accessibility of drugs to the common man makes them a common mode of DSP for the vulnerable population.

A wide variety of drugs are available over the counter and it is important to know the spectrum of drugs most commonly exploited for DSP in order to better understand their clinical presentation and be well equipped to handle these emergencies. Hence, we conducted this study in our Emergency Department (ED) to determine the drugs most commonly used for DSP, any specific groups affected by the same and their hospital outcome so as to improve physician awareness and knowledge regarding management of the same.


  Materials and Methods Top


Study design

This was a retrospective cohort study.

Setting

The study was conducted in the ED of a large tertiary care hospital in South India. The ED is a 50-bedded department and tends to about 300 patients each day including toxicology and other patients.

Participants

All patients presenting with DSP were screened. We recruited all patients presenting with drug overdose to our ED during the study period of 2 years (January 2017 to December 2018). We excluded patients with missing charts and the ones who were brought dead.

Variables

The charts were reviewed and the relevant details of history, clinical findings, and management were documented in the study form. The management and outcome of the patients with regards to ED management, hospital admission, discharge, and death were documented.

Outcome variable

ED management, hospital admission rate, and mortality.

Bias

Exposure or outcome assessment could not be controlled because it is a retrospective study. Instead, we relied on others for accurate record keeping.

Study size

Based on a previous study by Anthony and Kulkarni,[10] sample size with an estimated prevalence of 42.7% and a precision of 5% was calculated to be 543 patients. Therefore, we recruited patients over a two-year study period.

Statistical analysis

Data were analyzed using Statistical Package for Social Sciences for Windows (SPSS Inc. Released 2007, version 23.0. Armonk, NY, USA). Continuous variables are presented as mean (standard deviation). Categorical and nominal variables are presented as percentages.

Ethical considerations

This study was approved by the Institutional Review Board prior to the commencement of the study (IRB Min no: 12269 dated 25.09.2019). Patient confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.


  Results Top


During the study period, 1802 patients presented with DSP to our ED with 27.6% incidence of drug overdose (n = 498) [Figure 1]. The mean age was 32.8 years (SD: 12.6) with women (68%) outnumbering men (32%). Young adults (16–30 years) were found to have a higher incidence (52%, n = 261) of attempted drug overdose as compared to the other age groups. Further details of baseline characteristics are shown in [Table 1] and examination findings at presentation are shown in [Table 2]. The most common class of drugs consumed were benzodiazepines (22%, n = 109), NSAIDs (19.2%, n = 96), antihistamines (15%, n = 73), antidepressants (12%, n = 60), and antipsychotics (10.2%, n = 51). Overall, paracetamol (16.2%, n = 81) followed by Alprazolam (8.8%, n = 44) were the most commonly used drugs [Figure 2]. On analysis of the seasonal pattern of case presentation, a rising trend leading to a peak was noticed in the months from March leading to May [Figure 2].
Table 1: Baseline Characteristics (n=498)

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Table 2: Examination findings at presentation

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Figure 1: STROBE diagram

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Figure 2: Seasonal pattern of drug overdose

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Though domestic fight was a common precipitating factor (38.5%, n = 192), most factors remained unknown (41.6%, n = 207). Among patients with poisoning, few arrived gasping (0.6%, n = 3), some required intubation (5.4%, n = 27), and half the patients (49.8%) were admitted. The majority (81.8%) were discharged from the hospital alive, either from ED or from the ward. A significant number (18%, n = 91) left ED against medical advice mainly due to poor prognosis or lack of beds. The mortality rate was 0.2% (n = 1) [Table 3].
Table 3: Emergency resuscitation and hospital outcome

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  Discussion Top


Our study aimed to investigate the incidence of DSP, a spectrum of drugs most commonly used for DSP in our geographical area, and the age group most commonly affected by the same. In comparison with a previous study done in the same institution in the years 2011–2013, the incidence of attempted drug overdose remained similar (29.8% in 2011–2013 and 27.6% in 2017–2018).[8]

DSP is a growing public health concern worldwide. Close to 800,000 people in the world die due to DSP each year, which accounts for one person every 40 seconds. According to the WHO database, DSP continues to be among the top 20 causes of mortality around the world with drug overdose being a common mode.[2],[11] The national suicide rate increased by 0.3 during the study period (9.9 in 2017 to 10.2 in 2018). The state of Tamil Nadu has been consistently reporting an alarmingly high number of suicides in India over the last 5 years (2015–2019).[3]

The sex distribution in our study showed a female preponderance with a female: male ratio of 2.11:1, which was comparable to the national data with an estimated female: male ratio of 2.17:1 and other similar studies conducted in Belgium, India, and Australia.[3],[8],[11],[12],[13],[14] Our study adds to the literature demonstrating a higher incidence in the younger age group of 16–30 years, which was consistent with the data from WHO global estimates and various other studies.[4],[9],[10],[13],[14],[15] The figures are dismal because this age group represents young adults and the working population vital for the growth of a developing country. The most common precipitating factor for DSP in our geographical area was domestic fights, which was consistent with the national data.[3] However, most factors remained unknown (41.5%, n = 207) which can be attributed to the lack of detailed psychiatric evaluation in the ED.

According to a study conducted by Vancayseele et al.[16] in Belgium, the most commonly ingested drugs during an act of DSP belonged to the drug class of antidepressants (20% in males and 25% in females) but these were not as common in our study population (12%, n = 60). Instead, benzodiazepines were found to be most common in our study population (22%, n = 109), which was similar to the results of other studies done by Hendrix et al.[12] in Belgium, Henderson et al.[13] in Australia, and Ichikura et al.[17] in Japan. Although benzodiazepines are relatively safe medications, acute overdose may induce respiratory depression resulting in coma and uncommonly death.[18]

According to this study, the most common drug for DSP was the analgesic, paracetamol (16.2%, n = 81). Paracetamol is cheap and easily available over the counter, which makes it a frequent drug of choice for the vulnerable population in cases of intentional poisoning. It is implicated in both intentional and accidental poisonings. Cases have been reported from the United Kingdom, Norway, New Zealand, and Australia with increasing frequency over the years.[19],[20],[21],[22],[23],[24],[25] Opioid drug overdose was fairly common in the western countries where it contributed to the majority of the overdose cases and the mortality rate almost quadrupled from 1.4 deaths/100,000 people in 1999 to 5.4 deaths/100,000 people in 2011.[26] However, opioids were consumed only by a small percentage of our study population (6%, n = 8).

These findings suggest a crucial role for physicians and pharmacies in this context. Effective interventions need to be implemented at both population and individual levels to prevent DSP attempts. The class of drugs most commonly exploited for DSP were found to be benzodiazepines, which are prescription drugs most commonly prescribed for anxiety and insomnia.[27] Therefore, one such intervention would be the implementation of stringent pharmacy regulations to prevent prescription drugs from being sold over the counter to patients without a doctor's prescription and a diagnosis. A restriction on the amount of drugs that can be sold at a time could help reduce undue accessibility. There are studies from the UK showing the improving trends in the number of cases, severity and mortality due to paracetamol poisoning following legislative restrictive packaging of paracetamol.[19],[20],[21] A close monitoring of intake is only possible through a national database. An example of such a database is the Prescription Drug Monitoring Programs (PDMP) as in the US, which contains information about the prescriber, dose, and supply of scheduled drugs prescribed to the patient and is accessible to pharmacies, prescribing physicians, and law-enforcing officials.[28],[29]

Limitations

One of the limitations of our study is the possibility of a patient selection and referral pattern bias because this study was conducted in a tertiary care center. Also, most precipitating factors were unknown (41.6%, n = 207), which could be due to a lack of detailed psychiatric evaluation in the ED. The accuracy of results relied on patient statements. Missing charts and incomplete data availability were among other limitations. The study hopes to shed light on the prevalence of DSP due to drug overdose in society.


  Conclusion Top


This study showed that benzodiazepines were the most commonly used class of drugs for DSP, followed closely by NSAIDs. There was a higher incidence of DSP noticed in the age group of highly productive young adults, 16–30 years with a peak in April and May. Although the mortality rate following drug overdose remains low, it is a commonly used method for DSP and continues to be a growing public health concern.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting in IRB Min no: 12269 dated 25th September 2019. We also certify that we have not plagiarized quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require an Institutional Review Board/Ethics Committee review and the corresponding protocol/approval number for the contents in this submission and have done a Plagiarism Check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

 
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