Trends in drug poisoning of youth patients after the deregulation of over the counter drug sales

1. Introduction

Since 15 November 2012, the South Korean government amended the law to make some medicines available at 24-hour convenient stores (CVS), which had previously been sold at pharmacies alone. The drugs available at the CVS are as follows: antipyrine acetaminophen and ibuprofen syrup, cold medicine, digestive medicine and pain relief patches. The proportion of youth who attempt suicide by drug poisoning with non-prescription drugs, such as acetaminophen (AAP) and non-steroidal anti-inflammatory drugs (NSAIDs) is large [1]. Therefore, any increase in drug accessibility to the drug may influence in drug poisoning patterns and outcome severity [2, 3].

Youth suicide is a worldwide phenomenon and a serious health issue [4, 5]. Suicide is the second leading cause of death in individuals aged between 15–29, which is defined as youth [6]. The proportion of youth attempting suicide is continually increasing. From 2014–2017, the suicide rate among youth in the United States increased by an annual average of 10% [7]. The suicide rate among South Korean youth is 8.2 per 100,000, which is 1.4 times higher than the Organisation for Economic Cooperation and Development (OECD) average [8]. Furthermore, the primary cause of death in individuals between 9 and 24 years of age from 2011–2018 was suicide. In 2018, the percentage deaths caused by suicide increased approximately 4% compared with the previous year [9].

When classifying suicide in Korea according to the methods, the report shows that 51.3 percent of deaths are by hanging, 16.5 percent of fell down, and 16.5 percent by gas intoxication [10]. However, in the study by Kim et al. [11], based on the emergency department (ED), 55.8 percent of suicide attempts were drug poisoning. The study by Min et al. [12] also reports that 48.6 percent of suicide attempts were by drug poisoning. As a method of suicide attempts, it has been reported that poison is used by 70 percent up to 96.5 percent [13, 14]. Although there are not many studies on adolescents’ drug poisoning, according to the previous studies, the largest portion of adolescents choose drug poisoning as a suicide attempt method. Therefore, a characteristic analysis of poisoning-related suicide attempts in the youth and an evaluation of differences with adults is important to establish countermeasures that will prevent deaths from poisoning. However, investigation into suicide by poisoning suicide in youths is sparse.

Few reports have studied the impact of legislation, and the results are controversial [15, 16, 17]. Furthermore, no specific data have been reported on youth drug intoxication. Therefore, the aim of this study was to evaluate the impact of legislation on youth patients who are admitted to hospital following drug intoxication.

2. Methods

2.1 Study design and population

This study retrospectively reviewed data registered in the Emergency Department-based Injury In-depth Surveillance (EDIIS) database in South Korea from January 2007 to December 2018. This database has been developed and operated by the Korea Centers for Disease Control and Prevention (KCDC).

Since 2006, 23 emergency centers have participated in EIIDS implementation to proactively collect demographic features and injury-related factors for patients visiting the ED. Hospitals participating in this research were tertiary university hospitals, where the final treatment for severe emergency patients is provided for over 30,000 patients per year and over six specialized emergency department specialists. Participating emergency centers are prospectively investigating and entering 58 common items as damage-related items (If the damage is poisoning, the poisoning substance code must be entered). Moreover, the participating institutions were subdivided into six in-depth investigation divisions, and six emergency centers participated in the poisoning department to investigate three additional in-depth investigation items: the amount of poisoning substances, the reason for poisoning, and the source of poisoning substances.

The inclusion criteria of this study were (1) patients who were admitted due to poisoning intentionally; and (2) aged between 15 and 24 years. Exclusion criteria were (1) poisoning from non-drug sources, such as pesticides, carbon monoxide, herbicides, and corrosive agents. The flow chart of our study is presented in Fig. 1.

Fig. 1.Study flow diagram. EDIIS: Emergency Department-based Injury In-depth Surveillance. *Medicine includes prescription drugs and non-prescription drugs. Medicine included acetaminophen, non-steroidal anti-inflammatory drugs, cold medicine, digestives, tranquilizer, antidepressants, antiepileptics and cardiovascular medicine.

3. Result

4. Discussion

This study is a retrospective analysis of intentional drug poisoning trends among the youth over six years (2007–2012, 2013–2018) before and after the implementation of the CVS OTC sales on 15 November 2012 in South Korea. We demonstrated that there is positive relationship between intentional AAP poisoning and severity after legislation.

Youth patients who visited the ED after ingesting drugs for self-harm are present in both periods. The number of patients who ingested AAPs increased after OTC CVS drug sales were available; however, the percentage of total drug poisonings remained statistically unchanged. The differences in ingestion of other OTCs, such as cold medicines, NSAIDs, and digestive drugs, were not significant; however, their rates decreased. Interestingly, the use of drugs before and after legislation were significantly increased in tranquilizers, antidepressants, and antiepileptics. Previous studies have shown that intentional AAP poison rates in youth patients is high [18, 19, 20]. Furthermore, the rate of prescription drugs in youth patients has increased. Table 3 showed increased ICU admission rates due to tranquilizer ingestion and increased GW and ICU admission rates due to antiepileptic ingestion in youth patients.

OTC sales in non-pharmacy stores have been shown in several studies. In Sweden, AAP has been sold in non-pharmacy outlets since 2009. This was associated with an increased frequency of AAP poisoning, which verified it was closely related to accessibility [21]. In Canada, AAP availability increased for 1.5 years after a nonpharmacy locations law was enforced in 1999 and the admission rate due to APP overdose toxicity did not increase [22]. Kim et al. [23] have conducted a study using intentional poisoned patient data collected from a single hospital from 2008 to 2016. They reported that APP poisonings decrease after OTC sales begin. Additionally, Kim et al. [24] have utilized EDIIS collected data from 2011 to 2014 to show that the deregulation of OTC sales was associated in increase drug poisonings overall; however, AAP poisoning decreased.

Previous studies have shown a difference in the sales of AAP; however, no significant differences were shown in admission rate or toxicity by overdose. By contrast, this study demonstrated an increase in GW and ICU admission rates in youth patients. Increased access to AAP did not affect the number of addictions; however, the severity of drug poisoning outcomes increased. In particular, in youth who are underweight, toxicity can occur with a smaller ingestion of APP than adults. AAP is an antidote drug that can cause permanent liver injury; it is the most common cause of liver failure in children [25]. Therefore, more attention should be paid to the increase in severity and preventive measures should be taken. In the case of other drugs, prescription care should be managed. Additionally, research to prevent poisoning should be considered, such as shortening the number of days of prescription for psychiatric disorders. Some reports have shown that the proportion of non-pharmacist APP sales has been steadily increasing since 2018 [26]. Therefore, the sales system should be considered, and policies should be conducted, such as reducing the number of purchases per day or the number of drugs within packages. Furthermore, education should be implemented for the youth and sellers. This includes public relations and campaigns at the national level, regular and systematic education, and the adoption of an electronic system for drug purchases.

This study has several limitations. First, this study uses the data of patients visiting 23 EDs nationwide; however, there it does not represent all patients in South Korea due to sampling bias. However, this study minimized selection bias because it used a large dataset with over 360,000 in 12 years. This is the longest period found in the current published studies. Second, this study is based on medical records; therefore, there may be omissions and errors in the impairment period. In particular, the data relates to youths; therefore, they or their guardian may provide false information. Third, the exact dosage, number of doses, presence of polydrug, or blood concentration are unknown. These data should be collected to determine the exact drug severity because each hospital may different ICU or GW admission standards. However, the admission standard is set for AAP intake; therefore, severity can be partially reflected as the admission rate. Forth, the database did not collect patients’ underlying diseases, especially the presence or absence of mental disease in detail. If the underlying disease is not corrected, interpretation bias may occur. Lastly, the database is not designed to classify medication sold at CVS; therefore, further prospective studies should be constructed to determine medicines by ingredient.

5. Conclusions

There is no statistical change in the intentional AAP poisoning ratio since OTC drug sales were introduced; however, GW and ICU admission rates increased significantly. This study demonstrated that there is positive relationship between intentional AAP poisoning and severity in youth after the introduction of new legislation.

Availability of data and materials

The data used to support the findings of this study are available from the corresponding author upon request.

Author contributions

JYL—designed the research study. SHL and DHL—performed the research. SHL—analyzed the data. JYL and SHL—wrote the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was approved by the institutional review board of Ewha Womans University Seoul Hospital, and the requirement for written informed consent was waived (IRB No: EUMC-015-002).

Acknowledgment

We would like to acknowledge our emergency department staffs for their support.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.