Unintentional Overdose Research Articles

Effect of an emergency department opioid prescription policy on prescribing patterns

BackgroundStaten Island University Hospital is located in NYC, where the opioid epidemic has resulted in significant mortalities from unintentional overdoses. In 2013 as a response to the rising threat to our community, our Emergency Department (ED) administration adopted a clinical practice policy focused on decreasing the prescription of controlled substances. The effects of this policy on our provider prescription patterns are presented here. MethodsA retrospective chart review of patients prescribed opioids from the ED before and after policy implementation was performed. Dates chosen for analysis was November 1, 2012 through January 31, 2013 and November 1, 2013 through January 31, 2014; these time periods were used to serve as a seasonally comparative group pre and post clinical practice policy implementation. Opioids written for the treatment of cough, and for children under eighteen were excluded from analysis. Patient age, sex, diagnoses, and prescription formulation, strength, and pill number was recorded for each patient receiving an opioid prescription. ResultsThere was a drop in the total prescriptions from 1756 to 1128 without a change in the average number of pills (12.78 vs 12.44) or average total dose prescribed (69.39 vs 68.98) mg of morphine equivalent per prescription. Additionally, there were sizable reductions in opioid prescriptions written for arthralgias/myalgias, dental pain, soft tissue injuries, and headaches. ConclusionThe opioid clinical policy had a clear effect in decreasing the number of patients prescribed opioids. Such policies may be the key to reducing the epidemic and saving lives from unintentional opioid overdoses.

A retrospective review of unintentional opioid overdose risk and mitigating factors among acutely injured trauma patients

BackgroundOpioid medication to treat acutely injured patients is usual care in trauma settings. A higher prevalence of alcohol and other substance misuse in this population compared to the general population increases the vulnerability of such patients to both misuse of their prescribed opioids, and also unintentional opioid overdose. The primary purpose of this study was to assess the prevalence of substance use and unintentional opioid overdose risk among acutely injured trauma patients, and to examine the frequency and predictors of high opioid dose at discharge. MethodsA retrospective electronic medical record (EMR) review of three-months of data from two Level 1 trauma centers. We assessed the prevalence of substance misuse, unintentional opioid overdose risk, and presence of documentation of clinical strategies to mitigate these risks, such as co-prescription of the opioid agonist naloxone. ResultsIn total, 352 patient EMRs were examined. Over 40% of the patients reviewed had at least one indication of substance misuse (42.5% [95%CI: 37.3, 47.7]); at least 1 unintentional opioid overdose risk factor was identified in 240 EMR reviewed (68.2% [95%CI: 63.3, 73.1]). Dose of opioid medication was not significantly different for patients with substance misuse versus those without. There was no co-prescription of naloxone for any of the discharged patients. ConclusionsOur results indicate that despite the high rates of substance misuse, the potential for misuse, dependence and unintentional overdose risk from prescribed opioid medications are prevalent among acutely injured trauma patients. Prescribing after acute trauma care should address these risk factors.

Development of Syndrome Definitions for Acute Unintentional Drug and Heroin Overdose

ObjectiveTo develop and evaluate syndrome definitions for the identificationof acute unintentional drug overdose events including opioid, heroin,and unspecified substances among emergency department (ED) visitsin Virginia.IntroductionNationally, deaths due to opioid overdose have continuallyincreased for the past 15 years1. Deaths specifically related to heroinincreased more than four-fold between 2002 and 20142. Hospitalinpatient discharge data provide information on non-fatal overdoses,but include a significant lag in reporting time3. Syndromic ED visitdata provide near real-time identification of public health issues andcan be leveraged to inform public health actions on the emergingthreat of drug overdose.MethodsVirginia Department of Health (VDH) developed two syndromedefinitions in 2014 to capture acute unintentional drug overdoseevents among syndromic ED visit data. Syndrome 1 captured visitsfor overdose, whether or not a specific substance was mentioned.Syndrome 2 captured only visits for heroin overdose. Definitionswere based on free-text terms found within the chief complaintand standardized text or International Classification of Diseases(ICD) codes within the diagnosis field. In 2016, both definitionswere revised to identify additional inclusion and exclusion criteriaaccording to CDC guidance documentation and syndrome definitionsused by other state jurisdictions.Microsoft SQL was used to modify both definitions based on thenewly identified chief complaint and diagnosis criteria. Record leveldata were analyzed for their adherence to established criteria using aniterative evaluation process.The scope of Syndrome 1 (2016) was narrowed from the 2014version by excluding visits for non-opioid substances, heroin, andnon-acute indicators. It included chief complaint and diagnosisterms related to opioids, unspecified substance overdose, narcotics,and Narcan or naloxone, and excluded terms related to suicide,alcohol overdose alone, withdrawal, detoxification, rehab, addiction,constipation, chronic pain, and any specified non-opioid drug ormedication. Syndrome 2 (2016) included chief complaint or diagnosisterms mentioning heroin overdose and excluded suicide, withdrawal,detoxification, rehab, and addiction. Visits with mention of suicide,rehab, or addiction were identified during the evaluation process,resulting in the exclusion of these terms in the revised query.From January 1, 2015 to July 31, 2016, the number of visitscaptured by the revised syndrome definitions was compared to thenumber captured by the 2014 definitions. Correlation coefficientswere calculated using SAS 9.3.ResultsThe revised Syndrome 1 found 4296 fewer ED visits(29% decrease) for acute unintentional drug overdose betweenJanuary 1, 2015 and July 31, 2016 compared to the 2014 definition.Despite the drop in volume, the monthly trends were similar forthe 2014 and 2016 definitions (correlation coefficient = 0.95,p < 0.001). For the same time period, the revised Syndrome 2 definitionreturned 108 fewer visits (6% decrease) for acute unintentional heroinoverdose. The monthly trends were also similar for the 2014 and 2016definitions (correlation coefficient = 0.98, p < 0.001).ConclusionsBoth revised syndrome definitions improved specificity incapturing overdose visits as Syndrome 1 (2016) identified 29% fewervisits and Syndrome 2 (2016) identified 6% fewer visits found to beunrelated to the desired overdose criteria.When developing the revised syndrome definitions, VDH decidedto exclude non-acute drug-related visits. Terms such as addiction,detoxification, rehab, withdrawal, chronic pain, and constipation wereindicative of habitual drug use or abuse instead of acute overdose andwere thus excluded. In narrowing the scope of Syndrome 1, VDHalso identified and excluded visits for specified drug and medicationoverdose. Together, these expanded exclusion criteria resulted ingreater specificity with both updated syndromes.These revised syndrome definitions enable VDH to better trackopioid and heroin overdose trends in near real-time and overextended time periods which can be used to inform public healthactions. Limitations include the inconsistency of diagnosis codingamong syndromic data submitters, which may lead to geographicunderrepresentation of unintentional drug overdose visits based onthe location of health care systems. VDH will continue to evaluate andrefine these overdose syndrome definitions as this emerging healthissue evolves.

Observational study to calculate addictive risk to opioids: a validation study of a predictive algorithm to evaluate opioid use disorder.

BackgroundOpioid abuse in chronic pain patients is a major public health issue, with rapidly increasing addiction rates and deaths from unintentional overdose more than quadrupling since 1999.PurposeThis study seeks to determine the predictability of aberrant behavior to opioids using a comprehensive scoring algorithm incorporating phenotypic risk factors and neuroscience-associated single-nucleotide polymorphisms (SNPs).Patients and methodsThe Proove Opioid Risk (POR) algorithm determines the predictability of aberrant behavior to opioids using a comprehensive scoring algorithm incorporating phenotypic risk factors and neuroscience-associated SNPs. In a validation study with 258 subjects with diagnosed opioid use disorder (OUD) and 650 controls who reported using opioids, the POR successfully categorized patients at high and moderate risks of opioid misuse or abuse with 95.7% sensitivity. Regardless of changes in the prevalence of opioid misuse or abuse, the sensitivity of POR remained >95%.ConclusionThe POR correctly stratifies patients into low-, moderate-, and high-risk categories to appropriately identify patients at need for additional guidance, monitoring, or treatment changes.

A fatal case of intoxication after an unsuspected combined intake of verapamil and atenolol

Calcium channel blockers (CCBs) and s-blockers are used, combined or individually, in the treatment of hypertension, angina pectoris, cardiac arrhythmias, and other disorders. However, cardiogenic shock has been reported as a rare complication associated with the combination of verapamil and s-blockers that can be resolved by medical intervention. We describe the case of a 35-year-old woman who developed a fatal cardiogenic shock after an unintentional overdose of verapamil (calcium channel blocker) and atenolol (s-blocker) that was discovered only after autopsy and toxicological analyses.

Characterization of the Ability of Diazepam to Reverse Prescription Opioid Tolerance

We are experiencing an unprecedented opioid overdose epidemic with over 120 people dying every day. Most individuals who become tolerant and dependent on opioids, including the prescription opioids oxycodone and hydrocodone, co‐abuse other substances. The most widely co‐abused drug is ethanol but other CNS depressants such as diazepam and other benzodiazepines are also co‐abused. Several studies suggest that ethanol and benzodiazepines may play a role in as much as 80% of unintentional overdose deaths involving opioids. Postmortem examination of individuals who have died from chronic administration of opioids and ethanol had lower blood levels of opioids than individuals who overdosed on opioids alone. Similar results have not been reported in individuals co‐abusing diazepam. Following the hourly subcutaneous administration of the acute ED80 dose for a total of 7 injections, we observed a significant shift of the dose response curve indicating a 5‐fold tolerance to morphine, a 1.5‐fold tolerance to oxycodone, and a 2‐fold tolerance to hydrocodone in the mouse tail immersion assay. The intraperitoneal administration of 0.5 mg/kg diazepam, a dose that has no observable behavioral effect on its own, 50 minutes before testing fully reversed antinociceptive tolerance to morphine and oxycodone. Hydrocodone tolerance was not fully reversed at doses lower than 2 mg/kg diazepam. There was no potentiation of acute opioid effects. Conversely, opioid tolerance in the stretching assay, a measurement of visceral pain, was not reversed by diazepam. Further research into the differences of opioid tolerance mechanisms can lead to new insights for the development of drugs that decrease the risk of opioid overdosing and the development of drugs to relieve severe pain with limited tolerance.Support or Funding InformationSupported by USPHS Grants RO1 DA036975 and T32DA007027.

Health implications and management of women with opioid use disorder

Opioid use disorder has risen to epidemic proportions in the United States at an alarming rate in the past decade and is considered a leading public health concern. Women have a higher rate of acute and chronic pain conditions and are more likely to be prescribed opioids for pain management. The disproportionate incidence of opioid use, misuse, and progression to heroin and injectable drug use among reproductive age women is associated with increased morbidity and mortality. Of particular concern are the unique health risks opioid-dependent women face including immune system alterations, endocrinopathies, diminished fertility, psychosocial isolation, interpersonal violence, and unintentional overdose. Opioid use in pregnancy is associated with negative maternal and neonatal consequences and requires comprehensive, multidisciplinary services for the co-occurring medical, mental health, infectious disease, social stressors, and legal issues. Neonatal abstinence syndrome is linked to a cluster of physiological withdrawal symptoms and considered the primary adverse outcome of opioid exposure in newborns. Maternal medication-assisted treatment with methadone or buprenorphine to decrease the negative effects of neonatal withdrawal is the standard of care for opioid use disorders in pregnancy. The complexity of services required for maternal opioid use disorders requires collaborative and multidisciplinary management strategies to optimize maternal and neonatal outcomes.

Death Rates from Unintentional and Undetermined Prescription Opioid Overdoses and Dispensing Rates of Controlled Prescription Opioid Analgesics - 2011-2015.

Death Rates from Unintentional and Undetermined Prescription Opioid Overdoses and Dispensing Rates of Controlled Prescription Opioid Analgesics - 2011-2015.

Le paracétamol : connaissance, usage et risque de surdosage en patientèle urbaine de médecine générale. Étude prospective descriptive transversale

Acetaminophen is the most involved active substance in both unintentional and intentional drug poisoning. However, its availability outside community pharmacies is being debated in France. We made, via a self-administered questionnaire, a prospective assessment of knowledge, use and acetaminophen overdose risk in patients consulting their general practitioner, in the Metz Métropole urban area, between May2015and February2016. We estimated the prevalence of potential unintentional overdosage by capture-recapture method. Among 819responding patients, only 17.9% had a sufficient knowledge and 20.3% were at risk for potential unintentional overdose. The risk was higher for patients aged over 55years or belonging to socioprofessional categories of laborers and inactive. A good knowledge score was a protective factor for overdose risk (P<0.0001). The liver toxicity of acetaminophen was particularly unknown. The prevalence of potential unintentional acetaminophen overdose was estimated at 1to2% of the population. Proposing acetaminophen outside of pharmacies cannot be recommended in France in such conditions. Information campaigns are needed to limit the risk of unintentional overdose and its consequences on liver toxicity.

Strategies and policies to address the opioid epidemic: A case study of Ohio

ObjectiveTo describe the strategies and policies implemented in Ohio to improve opioid safety and to discuss the role that pharmacists can play in implementing, promoting, and enhancing the effectiveness of these policies. SettingOhio has the fifth highest rate of drug overdose deaths (24.6 deaths per 100,000) in the United States. Unintentional drug overdose has become the leading cause of injury-related death in Ohio. In 2015, there were 3050 overdose deaths in Ohio, and in 2014 there were an estimated 12,847 overdose events reversed by emergency medical services with naloxone. Practice descriptionNot applicable. Practice policy innovationIn 2011, the Governor's Cabinet Opiate Action Team was created to implement a multifaceted strategy, in part (1) to promote the responsible use of opioids, (2) to reduce the supply of opioids, and (3) to support overdose prevention and expand access to naloxone. Innovations to assist these goals include the development of Ohio guidelines on the responsible use of opioids, mandatory use of Ohio's prescription drug monitoring program, closing pill mills, promotion of drug take-back programs and increased access to naloxone and public health campaigns. EvaluationNot applicable. ResultsSince the development of the Governor's Cabinet Opiate Action Team, there were 81 million fewer doses of opioids dispensed to Ohio patients in 2015 compared with 782 million doses dispensed in 2011. As such, the proportion of unintentional drug overdose deaths involving prescription opioids has reduced from 45% in 2011 to 22% in 2015. ConclusionStrong political support was crucial in Ohio to facilitate the rapid implementation opioid overdose prevention programs and the promotion of public awareness campaigns. However, the misuse and abuse of prescription opioids are complex problems requiring a comprehensive and multifaceted approach. Pharmacists are identified as a crucial component of the state strategy to addressing opioid abuse by promoting responsible prescribing and adopting prevention practices.

Limited Knowledge of Acetaminophen in Patients with Liver Disease.

Background and Aims: Unintentional acetaminophen overdose remains the leading cause of acute liver failure in the United States. Patients with underlying liver disease are at higher risk of poor outcomes from acetaminophen overdose. Limited knowledge of acetaminophen may be a preventable contributor to elevated rates of overdose and thus acute liver failure. The purpose of this study is to assess knowledge of acetaminophen dosing and presence of acetaminophen in common combination products in patients with liver disease.Methods: We performed a cross-sectional study of patients with liver disease at the Pfleger Liver Institute at the University of California, Los Angeles between June 2015 and August 2016. Patients completed a demographic questionnaire and an acetaminophen knowledge survey. Additional information was obtained from the medical record.Results: Of 401 patients with liver disease, 30 (15.7%) were able to correctly identify that people without liver disease can safely take up to 4 g/day of acetaminophen. The majority of patients (79.9%–86.8%) did not know that Norco® (hydrocone/acetaminophen), Vicodin® (hydrocone/acetaminophen) and Percocet® (oxycodone/acetaminophen) contained acetaminophen. Only 45.3% of the patients knew that Tylenol® #3 contained acetaminophen.Conclusions: We conclude that patients with liver disease have critically low levels of knowledge of acetaminophen, putting them at risk both of acetaminophen overdose, as well as undermedication, and inadequate management of chronic pain. We recommend an increase in education efforts regarding acetaminophen dosage and its safety in the setting of liver disease. Increasing education for those at risk of low acetaminophen knowledge is essential to minimizing acetaminophen overdose rates and optimizing pain management.

Evaluation of Non-Natural Deaths among Veterans: New Mexico Medical Examiner-Investigated Deaths, 2002-2011.

While it is recognized that veterans have increased rates of depression, post-traumatic stress disorder (PTSD), suicide, and substance use disorders, rates of homicide and unintentional injury deaths in veterans have been minimally investigated. We evaluated all non-natural deaths in New Mexico veterans between 2002 and 2011 in comparison with non-natural deaths among non-veterans. We reviewed all decedents in New Mexico with a history of military service and investigated by the medical examiner, excluding natural deaths and deaths due to fall from standing height. The most common manner of death was unintentional injury (62%), most of these deaths due to motor vehicle accidents (29%) followed by unintentional overdose (26%). Suicide rates among veterans were consistently higher than the general population. The most common mechanism of suicide in men was gunshot wound (72%), and intentional overdose in women (49%). Services are needed for veterans that are tailored to all ages and both sexes.

The Opioid Epidemic and Orthopedic Outcomes: Implications and Strategies

There has been a recent rise in efforts to recognize and curtail the detrimental effects of nontherapeutic opioid use. Diversion of prescribed opioids for nontherapeutic use has led to many unforeseen consequences at the individual and societal levels, and has led many to term our current state as an opioid epidemic. It is important to address the consequences of opioid use in the setting of both therapeutic and nontherapeutic use. The downside of nontherapeutic opioid use is very clear with a striking increase in addiction and unintentional overdose deaths in our country. The subtler features of the opioid epidemic are unexpected consequences of therapeutic opioid use. Perhaps in an effort to better identify and treat pain, opioids are increasingly prescribed without an awareness of the potential detrimental impact of therapeutic opioid usage. Recent studies have highlighted the negative consequences of preoperative opioid use. Therapeutic opioid use before orthopedic surgery is now recognized to be associated with worse clinical outcomes after surgery. This article addresses the disproportionate use of opioids in the United States, the role of physicians and orthopedic surgeons, individual and societal impacts, and some potential ways to address the opioid epidemic.

Social context and perspectives of non-medical prescription opioid use among young adults in Rhode Island: A qualitative study.

This pilot study examined the context of nonmedical prescription opioid (NMPO) use and related risk behaviors among young adults in Rhode Island, a New England region with markedly high prevalence of NMPO use and overdose mortality. We conducted semi-structured interviews (n = 13) with young adults (18-29 year-olds) who reported current or recent NMPO use. We also conducted focus groups (two groups, n = 14 total) with professional service providers recruited from service organizations. Data were audio-recorded, transcribed, and key themes were analyzed. Participants discussed high levels of access to prescription opioids for nonmedical use via prescriptions originally provided to family and friends. The contexts described by participants included social environments such as parties, in which mixing opiates with benzodiazepines, alcohol or other types of drugs, and incidents of unintentional overdose were reported. Participants attributed risk for overdose to individual-level factors (eg, users who "couldn't handle it"), rather than contextual factors, and described negative reactions to being labeled as an "addict" or "addicted." Professional service providers had first-hand experience with young adults in treatment settings, yet limited exposure to young adults who were treatment-naïve. Young adult NMPO users described social settings where polysubstance use and pill use were common, and highlighted an aversion to being labeled as having a substance use disorder. To reduce harms of NMPO use among young adults, interventions should address the social context in which drug use and risk behaviors occur. (Am J Addict 2016;25:659-665).

Declines in Opioid Prescribing After a Private Insurer Policy Change - Massachusetts, 2011-2015.

Overdose deaths involving opioid pain medications are epidemic in the United States, in part because of high opioid prescribing rates and associated abuse of these drugs (1). In 2014, nearly 2 million U.S. residents either abused or were dependent on prescription opioids (2). In Massachusetts, unintentional opioid-related overdose deaths, including deaths involving heroin, increased 45% from 2012 to 2013.* In 2014, the rate of these deaths reached 20.0 per 100,000, nearly 2.5 times higher than the U.S. rate overall (3,4). On July 1, 2012, Blue Cross Blue Shield of Massachusetts (BCBSMA), the largest insurer in the state with approximately 2.8 million members,† implemented a comprehensive opioid utilization program after learning that many of its members were receiving new prescriptions with a >30-day supply of opioids. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends avoiding opioids as a first-line therapy for chronic pain and limiting quantities when initiating opioids for acute pain (5). CDC analyzed BCBSMA prescription claims data for the period 2011-2015 to assess the effect of the new utilization program on opioid prescribing rates. During the first 3 years after policy implementation, the average monthly prescribing rate for opioids decreased almost 15%, from 34 per 1,000 members to 29. The percentage of BCBSMA members per month with current opioid prescriptions also declined. The temporal association between implementation of the program and statistically significant declines in both prescribing rates and proportion of members using opioids suggests that the BCBSMA initiative played a role in reducing the use of prescription opioids among its members. Public and private insurers in the United States could benefit from developing their own best practices for prescription opioid utilization that ensure accessible pain care, while reducing the risk for dependence and abuse associated with these drugs.

4.64 RISK FACTORS ASSOCIATED WITH A HISTORY OF OVERDOSE IN TRANSITIONAL AGE YOUTH WITH SUBSTANCE USE DISORDERS

Intentional and unintentional overdose (OD) are one of the leading causes of death in transitional-age youth (TAY) with substance use disorders (SUD). The main aims of this study are to identify substance use and mental health characteristics that are associated with a history of OD in youth presenting for SUD outpatient care.

Co-prescription of naloxone as a Universal Precautions model for patients on chronic opioid therapy—Observational study

ABSTRACTBackground: The epidemic of lethal prescription opioid overdose is one of the most pressing public health problems in the United States. In an ambulatory clinic setting, current practice guidelines suggest that health care providers should screen patient's aberrant drug-related behaviors. Given the difficulty of predicting which patients on chronic opioid therapy (COT) will experience opioid overdose, a new paradigm of harm reduction is called for. In previous studies, naloxone, an opioid antagonist, was given only to high-risk patients. However, if naloxone is co-prescribed in a Universal Precautions manner for all patients receiving COT, this may have a significant impact on intentional and unintentional opioid overdose deaths. Methods: Adult patients treated with COT for chronic noncancer pain are eligible study participants at the University of New Mexico Pain Center. The primary goal of this 1-year study was to develop an efficient Universal Precautions model for co-prescribing of naloxone with COT in the ambulatory clinic setting. Outcome measures included demographic data, detailed medical and substance use history, current morphine equivalent dose (MED), other “high-risk” medications used, and opioid misuse risk. Results: One hundred and sixty-four patients were enrolled in this study. All subjects were educated about the risks of opioid overdose and provided naloxone rescue kits. No overdoses occurred in the study population. Follow-up data illustrated that approximately 57% of the cohort had depressive disorder, the median MED was 90 mg/day, and the median Current Opioid Misuse Measure score (COMM) was 5.0. Conclusions: The ambulatory co-prescribing of naloxone in a Universal Precautions model for all patients prescribed COT can be adopted as a useful public health intervention. This study illustrates a model that can be used to educate patients, caregivers, and an interdisciplinary team of health care professionals in an academic medical center.

Package Design Affects Accuracy Recognition for Medications.

Objective:Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors.Background:An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors.Method:In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated.Results:The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications.Conclusion:Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications.Application:A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose.

Dofetilide in Overdose: A Case Series from Poison Center Data.

Dofetilide is a class III antiarrhythmic used for treating atrial dysrhythmias. Though its adverse effects are well described in routine use, very little is known about dofetilide toxicity in overdose. This is a retrospective case series of consecutive patients reported to our poison center after dofetilide overdose. Twenty-seven cases were included. Seventeen patients were treated at a healthcare facility, and of these, eight were admitted. Twenty-one patients took one extra capsule, four took someone else's medication, one took three extra capsules, and one had a large intentional overdose. Ten patients had co-ingestants reported, including three QT-prolonging agents. No one required cardioversion, defibrillation, CPR, or overdrive pacing. The patient who reported taking 90 times his usual dose in suicide attempt was the only patient to have significant clinical effects. He experienced an 8-beat run of non-sustained ventricular tachycardia, frequent multifocal PVCs, and ventricular bigeminy. He received magnesium sulfate and potassium chloride supplementation. In this series, unintentional small overdoses did not result in significant clinical effects and were often managed successfully at home, despite the fact that information showing a single capsule can cause torsades. This study is limited by its small sample size, retrospective design, and reliance on incomplete information.

Good use and knowledge of paracetamol in self-medicated patients: Regional prospective study in community pharmacies

Paracetamol, the highest over-the-counter (OTC) selling drug in France, has become the first cause of acute hepatic failure [1] . Patient's knowledge of paracetamol has to date only been assessed in hospitalized patients. We aimed to assess good use and knowledge of paracetamol in patients in a realistic setting of self-medication in our region. We conducted a prospective observational study in randomly selected community pharmacies of Metz (France) agglomeration. Patients coming to buy OTC paracetamol for themselves or their family had to answer to an anonymous auto-questionnaire. After being asked about gender, age, weight, parenthood and chronic disease, the patient had to answer to 14 items about paracetamol indications, recommended maximal dose per intake and maximal daily dose, delay between 2 doses, consequences of overdosage and alcohol intake, and the need to adapt dosage to the body weight. The patient also had to identify drugs containing paracetamol among 6 usual drugs; and finally to tell how he gets information and circumstances that can lead him to stop self-medication and visit his general practitioner. Responses were individually and concomitantly analyzed through 3 scores: good use (5 points; good user if > 3), overdosage (4 points; positive if ≤ 3) and knowledge (9 points; good knowledge if > 6). Univariate and multivariate analysis were performed with SAS, version 9.3 (SAS Institute, Cary, NC). Twenty-four community pharmacies participated and 302 individual questionnaires were collected. Most of patients (84.4%) could be considered as “good users”. Independent factors of good use were a good knowledge of paracetamol (OR = 5.3; p < 0.0001) and more surprisingly, the fact of having no children (parenthood: OR = 0.1; p = 0.006). Responses corresponding to involuntary overdosage was mostly due to a too short interval between drug intakes (3 hours). Only 30.8% of patients were aware of liver toxicity of paracetamol and only 40.7% knew the risk of the association with alcohol. Both good use and knowledge were significantly higher in patients looking for information from their pharmacist, physician and package leaflet. Patients should be better informed about hepatotoxicity of paracetamol to warrant a better safety of its consumption by self-medication. Pharmacists and physicians have to remind patients the risk factors of unintentional overdose and liver toxicity and not hesitate to check if the patient may be at risk for overdosage. Package leaflets should also to be more informative.