Naloxone use by Aotearoa New Zealand emergency medical services, 2017-2021.

OBJECTIVE: Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future. METHODS: A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017-2021) and Wellington Free Ambulance (2018-2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described. RESULTS: There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population-years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min. CONCLUSIONS: A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care.

A retrospective analysis of therapeutic drug exposures in New Zealand National Poisons Centre data 2018-2020.

OBJECTIVE: The New Zealand National Poisons Centre advises the general public and health professionals on management of exposures to various substances. The epidemiology of medicine exposures was used to characterise inappropriate use of medicines across age groups. METHODS: Data from contacts in 2018-2020 were analysed: patient demographics (age, gender), number of therapeutic substances, and advice given. The most frequent individual therapeutic substance exposures across age groups and the reasons for these occurring were determined. RESULTS: A total of 76% of children's (aged 0-12 or unknown child) exposures were exploratory in nature, involving a variety of medicines. Youth (aged 13-19) had frequently engaged in intentional self-poisoning (61% of their exposures), and most commonly by exposure to paracetamol, antidepressants, and quetiapine. Adults (aged 20-64) and older adults (aged 65 and over) were frequently affected by therapeutic errors (50% and 86% of their exposures, respectively). Adults were most frequently exposed to paracetamol, codeine, tramadol, antidepressants, and hypnotics, while older adults were exposed to paracetamol and various cardiac medications. CONCLUSIONS: Types of inappropriate medicine exposures vary in different age groups. IMPLICATIONS FOR PUBLIC HEALTH: Poisons centre data add to pharmacovigilance monitoring of potential harm from medicines and inform medication safety policies and interventions.

Specialist medical toxicologist consultations provided by the New Zealand National Poisons Centre, 2018-2020.

AIMS: The National Poisons Centre (NPC) provides 24/7 specialist medical toxicologist consultations to healthcare professionals regarding the clinical management of poisoning cases. The use of toxicologist services was investigated to characterise the extent and content of consults to inform further development of this service. METHODS: A retrospective analysis of 2018-2020 medical toxicologist consultations summarised contact numbers, professional backgrounds and district health boards (DHBs) of the people contacting the NPC, and the patient(s) and substance(s) involved. RESULTS: There were 3,451 medical toxicologist consultations with 2,400 (67%) provided directly to healthcare professionals. Crude rates of consults increased across all DHBs. Of all 2,603 therapeutic substances that were consulted about during the study period, 1,492 (57.3%) were drugs affecting the nervous system, and paracetamol was the most common individual drug (528; 20.3%). Of all 1,185 non-therapeutic substance exposures that were advised on, 66 (5.6%) were unidentified mushrooms, 51 (4.3%) unidentified substances, and 47 (4.0%) lead exposures. CONCLUSIONS: There was increasing utilisation of the NPC service by healthcare professionals from all 24 areas of the country, covering a wide range of substance exposures and scenarios. The growing utilisation suggests healthcare professionals derive value from this consultation service for the care of their patients.

A retrospective analysis of calls to the New Zealand National Poisons Centre regarding Pacific patients.

AIMS: Poisoning is a common type of injury in New Zealand. The New Zealand National Poisons Centre (NZNPC) offers a free 24/7 specialist assessment service for enquiries about substance exposures for all New Zealanders. This study aimed to characterise calls to the NZNPC relating to Pasifika patients to explore the potential for unmet need or health disparity in this area. METHODS: A retrospective analysis of 2018-2019 human exposure call data was performed. Patients were stratified into three groups: those with at least one Pacific ethnicity listed (Pasifika); those with known ethnicities but no Pacific ethnicity listed (non-Pasifika); those of unknown ethnicity (unknown). Demographic variables and substance groups were described. RESULTS: Of the 40,185 human exposure patients, 1,367 (3.4%) were Pasifika, 24,892 (61.9%) were non-Pasifika and 13,926 (34.7%) were of unknown ethnicity. The median age of Pasifika patients was 2.0 years, with 78.0% aged 0-5, and the exposure most commonly involved a liquid product (46.6%) and a simple analgesic (8.3%). CONCLUSIONS: The NZNPC receives a relatively small number of calls about exposures to Pasifika patients, especially given the youthful population demographic. It is unclear whether there is unmet need for this service, and this study suggests the need for further research.

Enquiries to the New Zealand National Poisons Centre in 2018.

OBJECTIVE: A retrospective analysis of enquiries made to the New Zealand National Poisons Centre (NZNPC) in 2018; which includes direct contacts through telephone of caller, patient and exposure substance characteristics, and indirect contacts through the internet of page hits by New Zealand (NZ) healthcare professionals on the TOXINZ poisons information database. METHODS: All calls made to the NZNPC, and TOXINZ page hits by NZ based healthcare professionals, from 1 January to 31 December 2018 were analysed. For calls, caller location and relationship to the patient, reason and site for the exposure, patient demographics and the management advice given by NZNPC were described. Substance classes and most frequently encountered individual agents were described for both call data and web page hits to TOXINZ. RESULTS: There were 25 330 calls to the NZNPC and 39 028 TOXINZ web page hits in 2018. Most callers were members of the public (79.4%), calling from residential settings (77.2%), reporting an exposure which had occurred in a residential setting (88.2%) because of child exploratory behaviour (50.3%), and which involved a person aged 0-4 years (50.3%) who could be managed at home (74.3%). TOXINZ searches mostly involved therapeutics, especially paracetamol. CONCLUSIONS: In 2018, the NZNPC provided assessment and/or advice in 64 358 enquiries, comprising 25 330 direct contacts and 39 028 indirect contacts. The NZNPC provides specialised services regularly used by both members of the public and healthcare professionals that contributes to the clinical management of poisoned and potentially poisoned patients in NZ.

Prescribers aware: a cross-sectional study from New Zealand emergency departments on the substances used in intentional self-poisoning and their sources.

INTRODUCTION Intentional self-poisoning or self-harm through poisoning, is a common cause of presentations to emergency departments (EDs). National datasets do not allow identification of the substances most commonly used in hospital-treated intentional self-poisoning in New Zealand, nor do they capture sources of these substances. AIM To investigate the specific substances used in intentional self-poisoning and the sources from which they are obtained. METHODS In this cross-sectional study, information about the demographics and presentation particulars of intentional self-poisoning patients aged ≥16 years, presenting to three public EDs, as well as the substances they used in the self-poisoning event and the sources of these agents, were collected prospectively. RESULTS A total of 102 patients were recruited from the potentially eligible 1137 intentional self-poisoning patients presenting to the three EDs during the study period. Seventy per cent used their own prescription medications and 24% used medicines they purchased themselves. Paracetamol and ethanol were most commonly encountered substances. Patients presented a median of 1.9h after exposure (interquartile range 1.0-3.3h), 62% self-referred, 60% presented to the ED in the evening or at night and 66% were triaged into Australasian Triage Scale 3 (to be seen within 30min). Two-thirds were referred to emergency psychiatric services. DISCUSSION Collecting specific substance information, such as from this study, can assist in planning specific activities to prevent intentional self-poisoning. As most people used their prescribed medicines, the findings can inform and assist doctors in their prescribing practices when they manage patients at risk of self-poisoning.

Stocks of paracetamol products stored in urban New Zealand households: A cross-sectional study.

BACKGROUND: Intentional self-harm is a common cause of hospital presentations in New Zealand and across the world, and self-poisoning is the most common method of self-harm. Paracetamol (acetaminophen) is frequently used in impulsive intentional overdoses, where ease of access may determine the choice of substance. OBJECTIVE: This cross-sectional study aimed to determine how much paracetamol is present and therefore accessible in urban New Zealand households, and sources from where it has been obtained. This information is not currently available through any other means, but could inform New Zealand drug policy on access to paracetamol. METHODS: Random cluster-sampling of households was performed in major urban areas of two cities in New Zealand, and the paracetamol-containing products, quantities, and sources were recorded. Population estimates of proportions of various types of paracetamol products were calculated. RESULTS: A total of 174 of the 201 study households (86.6%) had at least one paracetamol product. Study households had mostly prescription products (78.2% of total mass), and a median of 24.0 g paracetamol present per household (inter-quartile range 6.0-54.0 g). Prescribed paracetamol was the main source of large stock. Based on the study findings, 53% of New Zealand households had 30 g or more paracetamol present, and 36% had 30 g or more of prescribed paracetamol, specifically. CONCLUSIONS: This study highlights the importance of assessing whether and how much paracetamol is truly needed when prescribing and dispensing it. Convenience of appropriate access to therapeutic paracetamol needs to be balanced with preventing unnecessary accumulation of paracetamol stocks in households and inappropriate access to it. Prescribers and pharmacists need to be aware of the risks of such accumulation and assess the therapeutic needs of their patients. Public initiatives should be rolled out at regular intervals to encourage people to return unused or expired medicines to pharmacies for safe disposal.

A descriptive study of intentional self-poisoning from New Zealand national registry data.

OBJECTIVE: Understanding which population groups intentionally poison themselves by overdose and which substances are used are key to developing prevention efforts for such injuries. This paper uses Ministry of Health (MOH) data to explore the demographic characteristics of those who intentionally self-poison and the substances used, identifies limitations of existing data collections and makes recommendations for the future. METHODS: MOH mortality data from 2000 to 2012, and public hospital presentation data from 2000-2014 of cases of intentional self-poisoning (ISP), and poisoning of undetermined intent (UDP), were examined. RESULTS: Men were more at risk of fatal intentional poisonings, while young women and people from deprived areas were predominant in hospital presentations for ISP and UDP. While ICD-10 categories were available, there was limited information in the majority of MOH data about specific substances used in the poisonings. CONCLUSIONS: The current format of MOH data indicates that developing interventions to help young people and those living in deprived areas may be useful. Finding specific solutions is challenging when only limited nationwide substance-specific poisoning information is available. Implications for public health: Including specific substances in national data collections is important for addressing the public health challenge of intentional overdose morbidity and mortality.

Anticholinergic drug use and mortality among residents of long-term care facilities: a prospective cohort study.

Few studies have investigated the possible association between use of anticholinergic drugs and mortality. The objectives of this study were to investigate the prevalence and determinants of anticholinergic drug use and the possible association between anticholinergic drug use and mortality. Data were obtained from 53 long-term care wards in Helsinki, Finland, in 2003. Medication, diagnostic, and mortality data were available for 1004 residents. Each resident's anticholinergic load was calculated using the Anticholinergic Risk Scale (ARS). Cox proportional hazards models were used to investigate the risk of death among users with a mild anticholinergic load (ARS score 1-2) and high load (ARS score ≥3) compared with nonusers of anticholinergic drugs. Age, sex, and nutritional status were used as covariates. Among the 1004 residents, 455 (45%) were nonusers of anticholinergic drugs, 363 (36%) had a mild anticholinergic load, and 186 (19%) had a high anticholinergic load. One-year all-cause mortality rates were 28%, 29%, and 27%, respectively. Higher ARS scores were not associated with mortality (ARS score 1-2: hazard ratio 1.08; 95% confidence interval, 0.84-1.41; ARS score ≥3: hazard ratio 1.05; 95% confidence interval, 0.75-1.46). Anticholinergic drug use was common; however, high ARS scores were not associated with mortality. Further research is needed using alternative models and among different resident populations.

Release patterns of pregnancy associated plasma protein A (PAPP-A) in patients with acute coronary syndromes.

OBJECTIVE: Pregnancy associated plasma protein A (PAPP-A) has recently been shown to be associated with acute coronary syndromes (ACS). The goal of this study was to investigate its release patterns in patients with ACS. DESIGN: PAPP-A concentrations in plasma samples serially collected after admissions from 15 patients with ACS were measured. The levels of PAPP-A were compared with a reference range determined from 80 normal subjects. The associations between PAPP-A and myoglobin (Mb), C-reactive protein (CRP), fatty-acid-binding protein (FABP) and creatine kinase MB (CK-MB) were determined. RESULTS: Various release patterns were observed with 2-10-fold changes of PAPP-A in the different patients. Increases in PAPP-A levels above the reference range could appear early at 2 h or late at 30 h after onset of chest pain. Only in 4 of the 15 cases were significantly elevated PAPP-A levels detected before 6 h after onset. Elevations early after admission showed rapid decline whereas later elevations were more persistent. No associations between PAPP-A and Mb, CRP, FABP and CK-MB were found. However, a weak but significant association to cardiac troponin I (cTn I) was found. CONCLUSION: PAPP-A is an additional marker for ACS, but does not seem to be a useful early marker for acute myocardial infarction (AMI). The possible clinical utility of PAPP-A calls for extensive studies of chest pain patients using serial sampling combined with short- and long-term outcome studies.