Malcolm Dobbin

Childhood poisoning: Access and prevention

Objectives: To investigate the circumstances and means of access to six poisoning agents by children under 5 years of age and to make recommendations for countermeasures and strategies for implementation.

Increasing deaths involving oxycodone, Victoria, Australia, 2000–09

Objective In light of an emerging epidemic identified in the United States and Canada, to identify trends in fatal drug toxicity involving oxycodone and the demographic characteristics and indicators of socioeconomic disadvantage of the deceased. Study design Population-based observational study in Victoria, Australia. Population Decedents whose death was reported to the Victorian Coroner between 2000 and 2009 and where oxycodone was detected. Main outcome measures Association between supply of oxycodone and deaths. Demographic characteristics of decedents. Rate ratios of the rural or metropolitan location and socioeconomic indicators of disadvantage of the deceased. Results Supply to Victoria has increased nine-fold from 7.5 mg per capita in 2000 to 67.5 mg per capita in 2009. Detection of oxycodone in deaths reported to the Victorian Coroner has increased from 4 (0.08/100 000 population) in 2000 to 97 (1.78/100 000 population) in 2009—a 21-fold increase in deaths. Of the 320 cases described, 53.8% (172) were the result of drug toxicity. Of these, 52.3% were unintentional and 19.8% intentional self-harm; the remaining 27.9% are either still under investigation by the coroner or intent is unknown. Drug toxicity deaths were overrepresented in both rural areas and areas indexed with high levels of disadvantage. Conclusions The substantial increase in the number of deaths involving oxycodone is strongly and significantly associated with the increase in supply. Most drug toxicity deaths involving oxycodone were unintentional. This newly identified trend in fatalities in Victoria supports concerns that a pattern of increasing deaths involving oxycodone is emerging globally.

Regulatory responses to over-the-counter codeine analgesic misuse in Australia, New Zealand and the United Kingdom.

Objective: Analysis of the policy response by Australias National Drugs and Poisons Schedule Committee (NDPSC) and comparison with recommendations by expert advisory committees in New Zealand and the United Kingdom.

Increasing the benefits and reducing the harms of prescription opioid analgesics.

ISSUES Consumption of prescription opioid analgesics (POAs) in Australia has increased steadily in recent years, raising concerns of increasing harms including overdose and dependence, as has occurred in the USA. APPROACH Exposition of the Royal Australasian College of Physicians Prescription Opioid Policy with reference to the published literature, drawing out principles for harm reduction for psychoactive pharmaceutical drugs. KEY FINDINGS Complex professional, patient, regulatory and market factors influence health professionals balancing the benefits and harms of POAs. Owing to the potential for diversion, overlapping markets probably exist for pharmaceutical opioids used for populations with cancer pain, chronic non-cancer pain, and people dependent on pharmaceutical and illicit opioids (including those needing opioid substitution treatment). Attempts to reduce or restrict supply in one area may increase demand in others. There is a need to consider new harm reduction strategies for people with problematic pharmaceutical opioid use. These people are demographically not well characterised, and may be distinct from the more familiar population of injection drug users. IMPLICATIONS Harm reduction is a valid approach for POAs. However, the role of health professionals as gatekeepers of opioid supply, the need to optimise health benefits of POAs, and the likely interplay of complex market forces among populations consuming opioids have no close parallel in harm reduction for other substances. This poses fundamentally different challenges. CONCLUSIONS Reducing inappropriate supply and demand for POAs while maximising their benefits and minimising their harms may improve health outcomes.

Eucalyptus oil poisoning among young children: mechanisms of access and the potential for prevention

Abstract: We studied unintentional paediatric eucalyptus oil poisoning to identify potential intervention strategies. The epidemiology of paediatric eucalyptus oil poisoning in Victoria was determined by analysis of four databases. The sequence of events preceding ingestion was examined by a telephone survey involving 109 parents or guardians of children under five years involved in an actual or suspected ingestion of eucalyptus oil. Such children were identified prospectively from all callers during a nine–month period to the Victorian Poisons Information Centre and those presenting to the emergency departments of the participating hospitals of the Victorian Injury Surveillance System. Eucalyptus oil was a leading agent associated with hospitalisation for poisoning among Victorian children aged under five years. In the telephone survey, 90 incidents were found to involve vaporiser solutions, 15 eucalyptus oil preparations, and the remainder other eucalyptus–oil–containing products of a medicinal nature. Regardless of the type of product, 74 per cent gained access via a home vaporiser unit, most frequently placed at ground level. Although amounts ingested are usually small, the reported range of toxic doses is wide, necessitating at least a medical assessment following ingestion. Potential countermeasures identified in a consultative workshop included: discontinuing the use of eucalyptus oil as a therapeutic agent; confirmation that vaporiser–well residues are nontoxic; removal of barriers to product reregistration following safety–related modifications; improved child–resistant closures; discouraging vaporiser use for respiratory infections among young children; and development and dissemination of protocols for treatment of suspected ingestion.

Recent increase in detection of alprazolam in Victorian heroin-related deaths.

Objectives: To examine the rate of detection of alprazolam among cases of heroin‐related death (HRD) in Victoria, including the relationship between alprazolam supply and HRDs.

Rodenticide poisoning among children

Abstract: We aimed to determine the nature, extent and sequence of events of accidental childhood poisoning with rodenticides and identify potential intervention strategies. Subjects were identified prospectively from callers to the Victorian Poisons Information Centre and those presenting to the Emergency Departments of hospitals participating in the Victorian Injury Surveillance System from 1 April to 31 December 1993. The events preceding rodenticide ingestion were examined via telephone questionnaire involving 128 parents or guardians of children under five years exposed to rodenticides. Rodenticides are not leading agents for severe poisoning but are a frequent and increasing cause of less severe poisoning. Most children (90 per cent) had obtained the rodenticide from the site at which it had been laid, usually by the caregiver (67 per cent), in the kitchen, lounge room or laundry, inside cupboards or wardrobes. In 69 per cent of these cases, respondents thought the site would not normally allow access to children. Only 13 per cent of children were admitted to hospital, although 41 per cent sought medical attention. Most caregivers (90 per cent) were aware of some dangers associated with rodenticides. Children usually ingest insufficient amounts of rodenticide to cause serious effects. However, medical assessment and monitoring of prothrombin times is often indicated, with a consequent cost to the healthcare system. Potential countermeasures, focusing on packaging and positioning of rodenticide baits, product reformulation, and the distribution of management guidelines for health workers, were identified. Implementation of the identified countermeasures was initiated by a workshop involving stakeholders from industry, research and health professions.

Automatic dishwasher detergent poisoning: opportunities for prevention

Abstract: We investigated the antecedents of ingestion of dishwashing machine detergent to enable the development of effective countermeasures. Parents who had sought advice from the Victorian Poisons Information Centre about dishwasher detergent poisoning exposures of their children were interviewed by telephone. Almost all the children (94 per cent) were aged between 6 and 29 months. Of the 61 children included in the survey, 53 (87 per cent) gained access to the detergent from the dishwasher. Of these, 50 (94 per cent) took the detergent from the dispenser on the internal surface of the door of the machine, and 38 (76 per cent) of these ingested detergent remaining in the dispenser after operation of the machine. Parents were present in the room on 78 per cent of occasions at the time of ingestion. Most parents (72 per cent) were aware of the toxicity of the detergents. Relocation of the dispenser or redesigning it to prevent access both before and after operation would have prevented most of the exposures to detergent. Altering the detergent to prevent caking or sludging might prevent many of the exposures to detergent remaining in the dispenser after operation of the machine. The level of prior knowledge about toxicity suggests that education or additional warnings are unlikely to contribute substantially to prevention of poisoning. Telephone call‐back to identified cases is a useful method of investigating complex poisoning problems and developing effective countermeasures.

Caution with the forthcoming rescheduling of over-the-counter codeine-containing analgesics

TO THE EDITOR: After extensive public consultation, the Therapeutic Goods Administrationannounced that all over-thecounter codeine preparations, including over-the-counter codeine-containing analgesics (OTC CCAs) will be rescheduled as prescription only in February 2018, citing the substantial risk of drug toxicity from deliberate misuse and the relative lack of efficacy compared with safer products.

Unintentional mortality associated with paracetamol and codeine preparations, with and without doxylamine, in Australia

INTRODUCTION Misuse of paracetamol, codeine and doxylamine combination analgesics may lead to addiction and mortality. This study aimed to (1) identify unintentional deaths in Australia associated with use of combination analgesic products containing paracetamol, codeine and doxylamine; (2) describe cases characteristics, including demographics and additional medication use; and (3) identify common factors associated with misuse and mortality of these medicines in Australia. DESIGN This retrospective case series analysed National Coronial Information System data to identify cases of unintentional death attributable to paracetamol, codeine and doxylamine products between 2002 and 2012. SETTING Three Eastern Australian states: New South Wales, Queensland, Victoria, comprising a population of approximately 18.6 million people. RESULTS 441 unintentional deaths attributed to paracetamol/codeine products were identified; doxylamine was detected in 102 cases (23%). Overall unintentional death rates rose from 0.9-per-million in 2002 to 3.6-per-million in 2009, declining to 1.9-per-million in 2012. Median age at time of death was 48, half of all cases occurred between 35-54 years of age, and 57% were female. Concomitant medication use was detected in 79% of cases, including benzodiazepines, other opioids, psychiatric medications, alcohol and illicit drugs. Behaviours consistent with drug misuse including doctor/pharmacy shopping, excessive dosages and extended use, were identified in 24% of cases. CONCLUSIONS This study identified 441 deaths associated with codeine-combination analgesic products across three Australian states; with an average of 40 deaths per year. Death commonly involved multiple substance use and abuse behaviours indicative of misuse and dependence.