Patterns of medicine use in the year prior to death by suicide: an Australian population-based case series study.

Background: Prescribed medicines are commonly used to treat mental health conditions but are also often implicated in suicide death by poisoning. This was a descriptive study quantifying changes in dispensing and initiation of antidepressants, benzodiazepines, and antipsychotics in the year prior to death by suicide. Methods: In this Australian population-based case series, we used national coronial data linked with dispensing claims for all people ≥10 years who died by suicide (2013-2019). Our primary outcome was change in aggregate weekly medicine dispensing the year before death, quantified using piecewise linear regression stratified by cause of death (medicine poisoning vs other causes). Our secondary outcome was change in medicine initiation rates. This study was performed between June 2021 and July 2023. Findings: Our study included 14,207 people (24% female, median age 44 years). In the year prior to death, we observed higher rates of nervous system medicine use in people who died by medicine poisoning compared with those that did not: antidepressants (62.4% vs 42.9%), benzodiazepines (51.4% vs 29.0%), antipsychotics (25.6% vs 17.1%), opioids (43.8% vs 23.4%). For benzodiazepines, among people who died by medicine poisoning the slope (rate of increase) changed from 0.18 (95% CI -0.01, 0.37) to 4.12 (95% CI 0.98, 7.26) dispensings per 1000 people per week at 8 weeks prior to death. Among people who died of other causes, the slope changed from 0.18 (95% CI 0.14, 0.22) to 2.41 (95% CI 1.90, 2.91) also at 8 weeks prior to death. For antidepressants, among people who died of medicine poisoning we observed no change in the slope. Among people who died of other causes, the slope increased from 0.18 (95% CI 0.09, 0.28) to 1.68 (95% CI 1.20, 2.15) at 14 weeks prior to death. Interpretation: Dispensing of antidepressants and benzodiazepines increased more rapidly closer to date of death, regardless of medicine involvement in death. This suggests these changes may reflect worsening symptoms or increased help seeking and that the method of death by suicide may be due to greater means access. However, findings need to be interpreted with caution as our analyses were performed on aggregate data and may not reflect person-level changes. Funding: This study is funded by a grant from the Australian National Health and Medical Research Council (NHMRC) and the Translational Australian Clinical Toxicology Research (TACT) Group.

The impact of cannabis legalization and decriminalization on acute poisoning: A systematic review.

BACKGROUND AND AIMS: Many countries have recently legalized medicinal and recreational cannabis. With increasing use and access come the potential for harms. We aimed to examine the effect of cannabis legalization/decriminalization on acute poisoning. METHODS: A systematic review and meta-analysis registered with PROSPERO (CRD42022323437). We searched Embase, Medline, Scopus and Cochrane Central Register of Controlled Trials from inception to March 2022. No restrictions on language, age or geography were applied. Abstracts from three main clinical toxicology conferences were hand-searched. Included studies had to report on poisonings before and after changes in cannabis legislation, including legalization and decriminalization of medicinal and recreational cannabis. Where possible, relative risk (RR) of poisoning after legalization (versus before) was calculated and pooled. Risk of bias was assessed with ROBINS-I. RESULTS: Of the 1065 articles retrieved, 30 met inclusion criteria (including 10 conference abstracts). Studies used data from the United States, Canada and Thailand. Studies examined legalization of medicinal cannabis (n = 14) and decriminalization or legalization of recreational cannabis (n = 21). Common data sources included poisons centre records (n = 18) and hospital presentations/admissions (n = 15, individual studies could report multiple intervention types and multiple data sources). Most studies (n = 19) investigated paediatric poisoning. Most (n = 24) reported an increase in poisonings; however, the magnitude varied greatly. Twenty studies were included in quantitative analysis, with RRs ranging from 0.81 to 29.00. Our pooled estimate indicated an increase in poisoning after legalization [RR = 3.56, 95% confidence interval (CI) = 2.43-5.20], which was greater in studies that focused on paediatric patients (RR = 4.31, 95% CI = 2.30-8.07). CONCLUSIONS: Most studies on the effect of medicinal or recreational cannabis legalization/decriminalization on acute poisoning reported a rise in cannabis poisoning after legalization/decriminalization. Most evidence is from US legalization, despite legalization and decriminalization in many countries.

Substances Detected During Coroner Postmortem Toxicology Analyses in Poisoning- and Nonpoisoning-Related Suicides.

Importance: Determining the association between drug use and suicide is complicated but can help to inform targeted suicide prevention strategies. Objective: To examine the substances prevalent in poisoning- and nonpoisoning-related suicides in Australia. Design, Setting, and Participants: This was a multiple-year, cross-sectional study of suicides from July 2013 to October 2019 in Australia with toxicology data available in a national coronial database. The cause of death was classified as poisoning related if any type of poisoning was determined by the coroner to contribute to the cause of death. Prevalence ratios (PRs) were calculated to compare substance detection in poisoning- vs nonpoisoning-related suicides. Data were analyzed from October 2021 to April 2023. Exposures: All substances detected in decedents at the time of death according to toxicology reports were recorded. Main Outcome(s) and Measure(s): The most common individual substances and substance classes were identified. From these, blood concentrations of substances of interest were analyzed, and the most commonly occurring combinations of substance classes were listed. Results: Toxicology was performed on 13 664 suicide decedents (median [IQR] age, 44 [31-57] years; 10 350 male [76%]). From these, 3397 (25%) were poisoning-related suicides (median [IQR] age, 50 [38-63] years; 2124 male [63%]). The remainder were classified as nonpoisoning-related suicides (median [IQR] age, 42 [29-55] years; 8226 male [80%]). PRs for common medicine classes being detected in poisoning-related suicides compared with nonpoisoning-related suicides were as follows: antidepressants (PR, 1.63; 95% CI, 1.54-1.73), benzodiazepines (PR, 2.01; 95% CI, 1.90-2.13), nonopioid analgesics/anti-inflammatory drugs (PR, 1.88; 95% CI, 1.78-2.00), and opioids (PR, 2.72; 95% CI, 2.58-2.87). Alcohol (as ethanol ≥0.03 g/100 mL) was almost equally prevalent in poisoning- and nonpoisoning-related deaths (PR, 1.07; 95% CI, 1.01-1.14), whereas amphetamines (PR, 0.68; 95% CI, 0.61-0.77) and cannabinoids (PR, 0.67; 95% CI, 0.60-0.74) were detected more often in nonpoisoning-related suicides. Combinations of multiple sedative agents in poisoning-related suicides were common. Conclusions and Relevance: Both poisoning- and nonpoisoning-related suicide deaths featured a high prevalence of psychotropic medicines or potential intoxication, which suggests the association of suicide with poor mental health and substance misuse. Findings suggest that substances with a high involvement in poisoning-related suicides should be prescribed cautiously, including antidepressants that are toxic in overdose, sedatives, opioids, and potentially lethal combinations.

Association Between Means Restriction of Poison and Method-Specific Suicide Rates: A Systematic Review.

Importance: Suicide is a major and preventable cause of death worldwide. Means restriction aims to reduce the rate of completed suicides by limiting public access to lethal suicide methods. Means restriction of agents used in poisoning is more controversial because there is potential to switch to other lethal methods. Objective: To identify the changes in suicide rate by the targeted poison and the corresponding changes in suicide by other methods. Evidence Review: Five databases (MEDLINE, Embase, Scopus, PsycInfo, and Web of Science) were searched for studies on national means restriction of poison that were published in the English language from inception until December 31, 2019. Of the 7657 articles that were screened by title and abstract, 62 studies were included in the analysis. Findings: Sixty-two studies from 26 countries in Europe, the US, Australia, Asia, and the United Kingdom were included in the review. The studies included restrictions on pesticides (15 countries), domestic gas (14 countries), motor vehicle exhaust (9 countries), and pharmaceuticals (8 countries). The median (IQR) change in method-specific suicide rates was -1.18 (-2.03 to -0.46) per 100 000 people after restrictions, whereas the median (IQR) change in other methods of suicide (not the restricted poison) was -0.09 (-2.22 to 1.65) per 100 000 people. Decreases in suicide by the restricted poison were not associated with increases in suicide by other methods. An estimated 57 355 poison-specific suicides annually (before the interventions were implemented) may have benefited the most from means restriction. Conclusions and Relevance: This systematic review found that means restriction of poison was associated with decreased method-specific suicide rates without an equivalent shift toward the use of other methods. Suicide prevention strategies need to address both individuals who are at risk and population-level policies.

Medicine shortages in Fiji: A qualitative exploration of stakeholders' views.

OBJECTIVES: Medicine access is a human right; yet, concerningly, there are international instances of shortages. Quantitative data has allowed WHO to propose global solutions; however, individualised understanding of specific regions is still required to work towards national solutions. Fiji has an established issue with medication supply and the aim of this study was to use qualitative methods to gain a fuller understanding of this context. METHODS: Semi-structured interviews were used to gain the perspective of key stakeholders involved in the Fijian medicine supply chain in regards to causes, impacts and possible solutions of medicine shortages. Thematic analysis was used to analyse the interview data. RESULTS: In total, 48 stakeholders participated and the information was synthesised into three main themes, causes, impacts and solutions and the sub-themes including; political, system and patient causes, adverse health effects on patients, professional dissatisfaction, monetary loss and loss of faith in the health system, workarounds, operation improvements, government intervention and education and training. CONCLUSIONS: The situation in Fiji is not dissimilar to other instances of shortages around the world and hence international solutions like that proposed by WHO are feasible; however, they must be modified to be uniquely Fijian to work in this context.