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NIHR Signal Paracetamol and alcohol are the most common substances taken by young people and rates of poisoning are increasing

Published on 11 December 2018

doi: 10.3310/signal-000694

The rates of the five most common types of poisoning in young people have increased three to five-fold from 1998 to 2014 and is cause for concern.

A study including more than 1.7 million young people aged 10 to 24 in the UK found records of 31,509 people who had been treated for poisoning (2% of the total). Where the substance was recorded, 40% of poisonings involved paracetamol, and 33% involved alcohol. Other substances used included non-steroidal anti-inflammatory drugs, antidepressants and opioid painkillers, but these were less common.

The study found that 67% of poisoning episodes were intentional self-harm, while in 26% of cases the intent was unclear or not specified in the record.

This study highlights the growing number of young people who are taking poisonous levels of readily accessible painkillers and alcoholic drinks.

Share your views on the research.

Why was this study needed?

As many as one in seven young people in the UK self-harm, and poisoning is the most common self-harm event that receives medical attention. However, there are few up to date studies of poisoning, internationally or in the UK, which look specifically at young people from a range of backgrounds and areas.

While the National Suicide Prevention Strategy says primary care has a “key role” to play in suicide prevention and managing people at risk of self-harm, it is difficult to do this without access to up-to-date information on what substances young people take and where they were obtained.

This study aimed to estimate the incidence of poisonings treated by medical professionals among young people in England, and to look at the types of poisoning substance taken and the trends over 16 years.

What did this study do?

This cohort study used data collected by the Clinical Practice Research Datalink, a registry of anonymised medical records from general practices. It used records from the 395 practices with records linked to Hospital Episode Statistics data and Office for National Statistics mortality data.

The researchers created a cohort of 1,736,527 people aged 10 to 24, and searched the databases for records of poisoning episodes. They looked at age, sex, poisoning substance and changes in rates of recording over time, from 1998 to 2014.

This large study is likely to provide an accurate picture of the patterns of poisonings in young people across the UK.

What did it find?

  • The researchers found records of 40,333 poisoning episodes involving 31,509 young people, with poisoning substance recorded in 57.8% of cases. In 7,420 cases (31.8%) more than one poisoning substance was recorded.
  • Paracetamol accounted for 9,289 poisoning events (39.8% of episodes) while alcohol accounted for 7,635 (32.7%). Non-steroidal anti-inflammatory drugs (NSAIDs) accounted for 11.6% of events, antidepressants including SSRIs and SNRIs for 10.2% of events and opioids for 7.6%.
  • Benzodiazepines, aspirin, psychostimulants, antiepileptic and sedative hypnotic drugs each accounted for between 3% and 5% of events, while tricyclic antidepressants accounted for 2.7% of events.
  • Poisonings involving the five most common substances (paracetamol, alcohol, NSAIDs, SSRI/SNRI antidepressants and opioids) all increased three to five-fold between 1998 and 2014, in both sexes. This was more pronounced among girls aged 16 to 18. The biggest group increase among boys aged 19 to 24 was for opioid poisoning.
  • Young people from poorer areas were around twice as likely to be poisoned compared with the least deprived groups. This gradient was steepest for opioid poisonings in males with a 3.5-fold increase in poisoning incidence in the most compared with the least deprived group (adjusted incidence rate ratio 3.46, 95% confidence interval 2.24 to 5.36).

What does current guidance say on this issue?

The National Suicide Prevention Strategy identifies the following groups as high risk: young and middle-aged men, people in the care of mental health services, people with a history of self-harm, people in contact with the criminal justice system, and specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers.

The strategy calls for “tailored interventions” to improve the mental health of children and young people to reduce suicide risk. It adds “one of the most effective ways to prevent suicide is to reduce access to high-lethality means of suicide” and “safe prescribing can help to restrict access to some toxic drugs.”

What are the implications?

This study showed a three to five-fold increase in poisoning in young people by common substances. The two most commonly used substances, paracetamol and alcohol, are available for general sale to people over 18, making their restriction more difficult. As almost half the substances were not recorded at all in poisoning incidents, the role of common substances may be even greater than reported here.

Increased awareness of their potential dangers might help families reduce the stockpiles of some medicines and take care over storage. Healthcare providers including pharmacists could show further caution in checking over the counter dispensing to young people.

This study cannot tell us why these numbers have risen or what works best in preventing risks.

Other substances used in poisoning episodes include commonly-prescribed drugs. The rise in strong painkiller and antidepressant poisoning among children and young people has occurred at the same time as a rise in the prescribing of these drugs. This is an established risk from US evidence, and this study indicates similar emerging risks in the UK. The figures provide a warning that all such prescribing must be evaluated regarding risk, and children or young people taking these medications must be carefully monitored.

Citation and Funding

Tyrrell EG, Kendrick D, Sayal K, Orton E. Poisoning substances taken by young people: a population-based cohort study. Br J Gen Pract. 2018;68(675):e703-10. 

The study was funded by the National Institute for Health Research In-Practice Fellowship and the National Institute for Health Research School for Primary Care Research.

Bibliography

HM Government. Preventing suicide in England: A cross-government outcomes strategy to save lives. London: HM Government; 2012.

Why was this study needed?

As many as one in seven young people in the UK self-harm, and poisoning is the most common self-harm event that receives medical attention. However, there are few up to date studies of poisoning, internationally or in the UK, which look specifically at young people from a range of backgrounds and areas.

While the National Suicide Prevention Strategy says primary care has a “key role” to play in suicide prevention and managing people at risk of self-harm, it is difficult to do this without access to up-to-date information on what substances young people take and where they were obtained.

This study aimed to estimate the incidence of poisonings treated by medical professionals among young people in England, and to look at the types of poisoning substance taken and the trends over 16 years.

What did this study do?

This cohort study used data collected by the Clinical Practice Research Datalink, a registry of anonymised medical records from general practices. It used records from the 395 practices with records linked to Hospital Episode Statistics data and Office for National Statistics mortality data.

The researchers created a cohort of 1,736,527 people aged 10 to 24, and searched the databases for records of poisoning episodes. They looked at age, sex, poisoning substance and changes in rates of recording over time, from 1998 to 2014.

This large study is likely to provide an accurate picture of the patterns of poisonings in young people across the UK.

What did it find?

  • The researchers found records of 40,333 poisoning episodes involving 31,509 young people, with poisoning substance recorded in 57.8% of cases. In 7,420 cases (31.8%) more than one poisoning substance was recorded.
  • Paracetamol accounted for 9,289 poisoning events (39.8% of episodes) while alcohol accounted for 7,635 (32.7%). Non-steroidal anti-inflammatory drugs (NSAIDs) accounted for 11.6% of events, antidepressants including SSRIs and SNRIs for 10.2% of events and opioids for 7.6%.
  • Benzodiazepines, aspirin, psychostimulants, antiepileptic and sedative hypnotic drugs each accounted for between 3% and 5% of events, while tricyclic antidepressants accounted for 2.7% of events.
  • Poisonings involving the five most common substances (paracetamol, alcohol, NSAIDs, SSRI/SNRI antidepressants and opioids) all increased three to five-fold between 1998 and 2014, in both sexes. This was more pronounced among girls aged 16 to 18. The biggest group increase among boys aged 19 to 24 was for opioid poisoning.
  • Young people from poorer areas were around twice as likely to be poisoned compared with the least deprived groups. This gradient was steepest for opioid poisonings in males with a 3.5-fold increase in poisoning incidence in the most compared with the least deprived group (adjusted incidence rate ratio 3.46, 95% confidence interval 2.24 to 5.36).

What does current guidance say on this issue?

The National Suicide Prevention Strategy identifies the following groups as high risk: young and middle-aged men, people in the care of mental health services, people with a history of self-harm, people in contact with the criminal justice system, and specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers.

The strategy calls for “tailored interventions” to improve the mental health of children and young people to reduce suicide risk. It adds “one of the most effective ways to prevent suicide is to reduce access to high-lethality means of suicide” and “safe prescribing can help to restrict access to some toxic drugs.”

What are the implications?

This study showed a three to five-fold increase in poisoning in young people by common substances. The two most commonly used substances, paracetamol and alcohol, are available for general sale to people over 18, making their restriction more difficult. As almost half the substances were not recorded at all in poisoning incidents, the role of common substances may be even greater than reported here.

Increased awareness of their potential dangers might help families reduce the stockpiles of some medicines and take care over storage. Healthcare providers including pharmacists could show further caution in checking over the counter dispensing to young people.

This study cannot tell us why these numbers have risen or what works best in preventing risks.

Other substances used in poisoning episodes include commonly-prescribed drugs. The rise in strong painkiller and antidepressant poisoning among children and young people has occurred at the same time as a rise in the prescribing of these drugs. This is an established risk from US evidence, and this study indicates similar emerging risks in the UK. The figures provide a warning that all such prescribing must be evaluated regarding risk, and children or young people taking these medications must be carefully monitored.

Citation and Funding

Tyrrell EG, Kendrick D, Sayal K, Orton E. Poisoning substances taken by young people: a population-based cohort study. Br J Gen Pract. 2018;68(675):e703-10. 

The study was funded by the National Institute for Health Research In-Practice Fellowship and the National Institute for Health Research School for Primary Care Research.

Bibliography

HM Government. Preventing suicide in England: A cross-government outcomes strategy to save lives. London: HM Government; 2012.

Poisoning substances taken by young people: a population-based cohort study

Published on 10 September 2018

Edward G Tyrrell, Denise Kendrick, Kapil Sayal and Elizabeth Orton

British Journal of General Practice , 2018

Background Globally, poisonings account for most medically-attended self-harm. Recent data on poisoning substances are lacking, but are needed to inform self-harm prevention. Aim To assess poisoning substance patterns and trends among 10–24-year-olds across England Design and setting Open cohort study of 1 736 527 young people, using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office for National Statistics mortality data, from 1998 to 2014. Method Poisoning substances were identified by ICD-10 or Read Codes. Incidence rates and adjusted incidence rate ratios (aIRR) were calculated for poisoning substances by age, sex, index of multiple deprivation, and calendar year. Results In total, 40 333 poisoning episodes were identified, with 57.8% specifying the substances involved. The most common substances were paracetamol (39.8%), alcohol (32.7%), non-steroidal anti-inflammatory drugs (NSAIDs) (11.6%), antidepressants (10.2%), and opioids (7.6%). Poisoning rates were highest at ages 16–18 years for females and 19–24 years for males. Opioid poisonings increased fivefold from 1998–2014 (females: aIRR 5.30, 95% confidence interval (CI) = 4.08 to 6.89; males: aIRR 5.11, 95% CI = 3.37 to 7.76), antidepressant poisonings three-to fourfold (females: aIRR 3.91, 95% CI = 3.18 to 4.80, males: aIRR 2.70, 95% CI = 2.04 to 3.58), aspirin/NSAID poisonings threefold (females: aIRR 2.84, 95% CI = 2.40 to 3.36, males: aIRR 2.76, 95% CI = 2.05 to 3.72) and paracetamol poisonings threefold in females (aIRR 2.87, 95% CI = 2.58 to 3.20). Across all substances poisoning incidence was higher in more disadvantaged groups, with the strongest gradient for opioid poisonings among males (aIRR 3.46, 95% CI = 2.24 to 5.36). Conclusion It is important that GPs raise awareness with families of the substances young people use to self-harm, especially the common use of over-the-counter medications. Quantities of medication prescribed to young people at risk of self-harm and their families should be limited, particularly analgesics and antidepressants.

Expert commentary

This UK research finds that commonly available, non-prescribed substances such as paracetamol, non-steroidal anti-inflammatories and alcohol, often in combination, account for many poisoning events amongst youth.

Restrictions already exist regarding alcohol and paracetamol, but as poisoning becomes more common, it is imperative that there is better public awareness of the risk of poisoning.

Better product labelling, improved communication between healthcare staff and patients/product purchasers about risk, and reducing amounts that can be prescribed or purchased in one consultation/transaction might reduce poisoning events.

However, the question remains why there has been such an increase in poisoning events amongst young people.

Dr Tomas Campbell, Consultant Clinical Psychologist, Cogito Psychological Services and NPsych Rehabilitation, London

The commentator declares no conflicting interests