Self-poisoning with Drugs: A Worsening Situation

The incidence of self-poisoning with drugs has doubled in Sheffield in the past 10 years. It now causes almost 1 in 10 of all medical admissions and one in five of all medical emergencies; it is the second most common reason for emergency admission to medical beds.The average age of the patients has fallen; one in five has previously been admitted to hospital with self-poisoning. The drugs used are normally prescribed by a doctor and the types employed reflect national prescribing trends. It is estimated that over 70,000 self-poisoning cases may be admitted to hospitals in the United Kingdom each year.     

Budapest Registry of Self-poisoned patients

The majority of persons attempting suicide are young (peak in the 17–19 age group), female (68%), otherwise healthy, and use chemicals for this purpose (self-poisoning); 98% of these persons survive. Thus, survivors of self-poisoning present a unique model for the study of somatic and germinal mutagenic effects of large doses of chemicals in human beings. This recognition prompted the establishment of the Budapest Registry of Self-poisoned Patients in 1990. The recorded 11 847 cases used 20 324 drugs in 1990–1992. Benzodiazepines were the most popular drugs for self-poisoning. International collaboration by the use of molecular epidemiological methods seems to be promising in the self-poisoning model.     

Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital.

In a prospective clinical trial 312 cases of self-poisoning (276 patients) consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision as to "disposal." Junior doctors and nurses received some instruction in this work. Both groups of assessors asked for help from social workers when necessary. Once the medical teams had completed their assessments, psychiatrists provided most of the hospital treatment. Follow-up at one year showed no significant difference between the two groups of patients in the numbers who repeated their self-poisoning or self-injury (or both), or committed suicide. Provided junior doctors and nurses are taught to assess self-poisoned patients, we think medical teams can evaluate the suicidal risk and identify patients requiring psychiatric treatment or help from social workers, or both. Contrary to the Department of Health''s recommendation that all cases of deliberate self-poisoning should be seen by psychiatrists, we have reached the conclusion that physicians should decide for each of their patients if specialist psychiatric advice is necessary.     

Psychological and social evaluation in cases of deliberate self-poisoning seen in an accident department.

The outcome in 115 consecutive patients with mild self-poisoning seen by junior medical staff and discharged from the accident department was compared with that of 98 similar patients admitted to the medical wards. Psychiatrists saw only four patients in the accident department and 25 admissions. In making their assessments the junior medical staff considered psychosocial factors as well as the patients'' physical condition. Most patients recommended for further care, and discharged from the accident department, subsequently received it. Repetition rates were similar in the two groups and there had been no suicides when patients were followed up at one year. It is feasible for junior staff in an accident department to decide whether patients with self-poisoning need admission or may be discharged with or without subsequent referral for psychiatric or social work help.     

Admissions to Hospital due to Drugs

In a survey of adverse drug reactions in wards of two Belfast hospitals for 52 weeks in 1965–6, 2·9% of 1,268 patients seen were admitted to hospital because of adverse reactions to drugs taken for therapeutic reasons and 2·1% were admitted because of self-poisoning. Patients admitted because of adverse drug reactions were older than those admitted because of self-poisoning and stayed in hospital longer. Among the drugs which caused the adverse reactions were digitalis preparations, antibiotics, corticosteroids, anticoagulants, analgesics, and tranquillizers. Hypersensitivity and side-effect types of reactions were the most common. Barbiturates were the most frequently used drugs in suicidal attempts.     

Prescribing trends in bipolar disorder: cohort study in the United Kingdom THIN primary care database 1995-2009

Objectives

To determine changes in prescribing patterns in primary care of antipsychotic and mood stabiliser medication in a representative sample of patients with bipolar disorder in the United Kingdom over a fifteen year period and association with socio-demographic factors.

Methods

We identified 4700 patients in the Health Improvement Network (THIN) primary care database, who had received treatment for bipolar disorder between 1995 and 2009. The proportion of time for which each individual was prescribed a particular medication was studied, along with variation by sex, age and social depravation status (quintiles of Townsend scores). The number of drugs an individual was taking within a particular year was also examined.

Results

In 1995, 40.6% of patients with bipolar disorder were prescribed a psychotropic medication at least twice. By 2009 this had increased to 78.5% of patients. Valproate registered with the greatest increase in use (22.7%) followed by olanzapine (15.7%) and quetiapine (9.9%). There were differences by age and sex; with young (18–30 year old) women having the biggest increase in proportion of time on medication. There were no differences by social deprivation status. By 2009, 34.2% of women of childbearing age were treated with valproate.

Conclusions

Lithium use overall remained relatively constant, whilst second generation antipsychotic and valproate use increased dramatically. Changes in prescribing practice preceded published trial evidence, especially with the use of second generation antipsychotics, perhaps with inferences being made from treatment of schizophrenia and use of first generation antipsychotics. Women of childbearing age were prescribed valproate frequently, against best advice.     

Promiscuous ligands and attractive cavities: how do the inhaled anesthetics work?

The inhaled anesthetics were officially introduced to American medicine more than 160 years ago and rank among the most important medical advances in our time. These drugs are used to render patients insensible over twenty million times each year and are the most dangerous of all drugs that physicians currently use. An entire medical specialty, anesthesiology, has arisen out of the need for the special training to administer them safely. Nevertheless, side effects, toxicity, and long-term cognitive problems continue to plague their use, especially in the very sick or aged. Hence, it is essential that we develop an understanding of their molecular pharmacology so that safer alternatives can be developed.     

Deaths of drug addicts in the United Kingdom 1967-81.

A search of the Home Office index of notified drug addicts identified 1499 deaths during 1967-81, of which 226 (15%) were of therapeutic addicts--that is, patients who had become addicted during medical treatment with a notifiable drug--and 1273 (85%) were of non-therapeutic addicts. The crude mortality fell from 23.5/1000/year for the period 1968-70 to 18.4/1000/year for 1978-80. Altogether 416 addicts aged under 50 at notification died after 1972, which was 16 times the number of deaths expected in a population with a similar age and sex composition. A more detailed examination of the cohorts of addicts notified each year showed little variation between them in the first two years of follow up. Nineteen addicts (1.6%) had died by 31 December of the year of their notification and 39 (3.3%) one year later. These figures may be an indication of the clinical course of addiction. Most deaths of non-therapeutic addicts in which a drug was implicated (939 cases (74%] were due to medically prescribed drugs--barbiturates at first and later opiates such as dipipanone hydrochloride and dextromoramide. Heroin was implicated in only 65 (7%) of these deaths. The Home Office index is a valuable source for identifying drugs of abuse and serious problems of addiction. The fact that prescribed drugs are causing the death of so many addicts demands a response from the medical profession.     

Deliberate self-poisoning: a study in London casualty departments.

During a prospective study of the whole spectrum of drug-related problems treated in one month by 62 casualty departments in the Greater London area, 949 cases of deliberate self-poisoning were identified. Nearly three-quarters of the patients were under the age of 40 years and in all age groups women outnumbered men. Psychoactive drugs of some sort were used in 673 incidents (71%) and ordinary analgesics and other drugs were used in 252 (27%). The incidence of polydrug overdose (423; 45%) was much higher than that found in other studies. In at least 256 incidents (27%) there was a history of repeated overdose in the previous 12 months. Comparison with other studies showed a steady decline in the use of barbiturates in deliberate self-poisoning but an increase in the use of non-barbiturate hypnotics, minor tranquilisers, and antidepressants.     

Strain differences in phenobarbital-induced teratogenesis in mice

Anticonvulsant drugs are widely prescribed medications known to complicate more than 11,500 pregnancies each year in the United States. Although there is no clear consensus as to the teratogenicity of all of the clinically available compounds, it appears that most anticonvulsant drugs can induce congenital abnormalities in susceptible individuals. In a study designed to examine the role of the genotype on sensitivity to phenobarbital-induced malformations, three highly inbred mouse strains (SWV, C57BL/6J, and LM/Bc) received the drug via chronic oral administration. Phenobarbital was found to have a significant teratogenic potential in mice, resulting in skeletal, cardiac, renal, neural, and urogenital defects in a dose-related fashion. The LM/Bc strain was most sensitive to phenobarbital, with 46.7% of the fetuses exposed to the highest maternal plasma concentrations having malformations. C57BL/6J fetuses were the most resistant strain, with only 28.6% abnormalities.     

Does the order of second-line treatment in rheumatoid arthritis matter?

In a prospective study 88 patients, with rheumatoid arthritis who had stopped taking gold, penicillamine, or levamisole were randomly allocated to one of the alternative drugs and followed up for a minimum of one year. Concurrent studies of the effects of gold, penicillamine, and levamisole prescribed in 123 patients as the first second-line drug were used for comparison. No difference in toxicity or efficacy between primary and secondary use of gold or penicillamine was identified. Variation in the toxicity of levamisole could in part be accounted for by changes in the dose regimen over the four years of study. The length of the treatment-free interval between drugs did not influence subsequent development of toxicity. These results suggest that an adverse reaction to one of the three second-line drugs studied should not prejudice the selection of another.     

Prescription information leaflets: a pilot study in general practice.

Leaflets containing information about medicines were issued to 56 patients prescribed penicillins and 43 patients prescribed non-steroidal anti-inflammatory drugs. The patients were interviewed between four and 10 days later and their responses compared with those of 65 patients prescribed penicillin and 33 prescribed nonsteroidal anti-inflammatory drugs who did not receive a leaflet. Patients who received a leaflet were more likely to be completely satisfied with their treatment and with the information they had been given. They were also more likely to know the name of their medicine and much more aware of potential unwanted effects. Although there was no evidence that knowledge increased the incidence of adverse effects, when these did occur they were more likely to be recognised as being due to the medicine. Further studies of other leaflets are warranted, including leaflets for drugs that are taken long term.     

Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories

Objective To describe characteristics of dosing history in patients prescribed a once a day antihypertensive medication.Design Longitudinal database study.Setting Clinical studies archived in database for 1989-2006.Participants Patients who participated in the studies whose dosing histories were available through electronic monitoring.Main outcome measures Persistence with prescribed antihypertensive treatment and execution of their once a day drug dosing regimens.Results The database contained dosing histories of 4783 patients with hypertension. The data came from 21 phase IV clinical studies, with lengths ranging from 30 to 330 days and involving 43 different antihypertensive drugs, including angiotensin II receptor blockers (n=2088), calcium channel blockers (n=937), angiotensin converting enzyme inhibitors (n=665), β blockers (n=195), and diuretics (n=155). About half of the patients who were prescribed an antihypertensive drug had stopped taking it within one year. On any day, patients who were still engaged with the drug dosing regimen omitted about 10% of the scheduled doses: 42% of these omissions were of a single day’s dose, whereas 43% were part of a sequence of several days (three or more days—that is, drug “holidays”). Almost half of the patients had at least one drug holiday a year. The likelihood that a patient would discontinue treatment early was inversely related to the quality of his or her daily execution of the dosing regimen.Conclusions Early discontinuation of treatment and suboptimal daily execution of the prescribed regimens are the most common facets of poor adherence with once a day antihypertensive drug treatments. The shortfalls in drug exposure that these dosing errors create might be a common cause of low rates of blood pressure control and high variability in responses to prescribed antihypertensive drugs.     

Improving benzodiazepine prescribing in family practice through review and education.

Indications for and dosages of four commonly prescribed benzodiazepines were recorded at a family medicine centre with the aid of a computerized data collection system. Four guidelines were then developed for appropriate prescribing of these drugs: (a) benzodiazepines should be used less frequently with increasing age; (b) short-acting drugs are preferable to long-acting drugs; (c) patients 65 years of age and over should receive half the daily dose prescribed for younger patients; and (d) use of these drugs for more than 1 month should be discouraged. After a year''s observation it was evident that none of the guidelines were being followed. The 30 physicians in the practice were then informed of the findings by an educational program. Another 6 months of observation showed a reduction in the prescribing of benzodiazepines to patients 65 years of age and over, a significant shift to the use of short-acting benzodiazepines, and some reduction in the daily dose and duration of administration of diazepam. Thus, such a review of drug prescribing in family practice can be a practical and effective method of improving prescribing patterns.