Characteristics and Outcomes of Patients Admitted with Drug Overdose

Characteristics and Outcomes of Patients Admitted with Drug Overdose in an Intensive Care Unit of Metropolitan Australian hospital
Results
Table 1. Patient Demographics
ICU Admissions during study period 3169
OD Admissions (% amongst total admissions) 255
Percentage of ICU admissions during study period with overdose 8.1%
No. Patients with Repeat Admissions 18/257
Gender Males=95 Females=129 Transgender=1
Among Multiple Presenters 5 male
13 female
Age Mean age (males): 39.3+ 15.4
Mean age (females): 40.6+ 13.8
Mean APACHE-III sore 53.3+ 26
Survival to ICU Discharge
Survival to Hospital Discharge 98.1%
97.3%
The demographics of the patients indicated that the percentage of drug overdose patients were around 1/10th of the total patients who presented with a drug overdose at the hospital. Therefore, the patients who were admitted were critical and needed immediate intervention. The mean age groups of male and female were approximately the same. This finding indicates that drug overdose occurred in the middle ages. However, the percentage of females who presented with drug overdose were significantly higher than males (p<0.01). The mean APACHE scores were high, which warranted ICU admissions in around 8.1% of overdose patients.
Table 2 and 3: Hospital Demographics & Discharge Destination
Mean (SD) Median (IQR) Range
Hospital LOS (days) 4.26 (6.91) 2.88 (1.8 – 4.8) 0.21 – 99.1
ICU LOS (days) 2.48 (2.15) 1.94 (1.08 – 3.02) 0.2 – 18.9
Length of Mechanical
Ventilation (days) 1.

68 (1.78) 1.25 (0.75 – 1.8) 0.2 – 15.6
Discharge Destination ( / 256)
Home
Discharged Home directly from ICU Left against medical advice 190
80 (42.1%)
27 (14.2%)
Psychiatric In-patient services 46
Sub-acute/rehab 6
Transferred to another acute hospital 6
Deceased 7 (2.7%)
Palliative Care 1
From tables 2 & 3, it becomes evident that 42.1% individuals with drug overdose were directly discharged to home care facilities. This indicates the promptness and efficacy of the health care set up to manage patients drug overdose. The casualties were rare and accounted for 2.7% of all overdose patients admitted to the hospital.
Table 4: Overdose Patients with Psychiatric Comorbidities
Psych. Comorbidities N ( / 255) %
Depression 156 61.2%
Anxiety 53 20.8%
Personality Disorder 66 25.9%
Bipolar Affective Disorder 45 17.6%
Epilepsy 7 2.7%
Schizophrenia 22 8.6%
Eating Disorder 9 3.5%
PTSD 9 3.5%
Other* 16 6.3%
*Includes Adjustment Disorder, Obsessive Compulsive Disorder, Unspecified Psychosis,
Schizoaffective Disorder, Dissociative Disorder, etc.
From Table 4, it is clearly indicated that various psychiatric disorders accounted for drug overdose, out of which Depression, Anxiety and Personality disorders accounted the most.
Table 5: Overdose Patients (Abuse and Addicted) and type of Drug used
N (%)
Hx Drug Addiction/Abuse 137 (53.7%)
ETOH 73 (53.3%)
Opiates 36 (26.3%)
Amphetamines 47 (34.3%)
Marijuana 40 (29.2%)
BZD 16 (11.7%)
Recreational Drugs* 20 (14.6%)
Other** 2 (1.5%)
Unspecified/Unknown*** 8 (5.8%)
* Recreational drugs = Cocaine, GHB, Solvents, LSD, MDMA, Synthetic Cannabis
** Other = Quetiapine, Steroids
*** Unspecified = notes only state ‘polysubstance abuse’, ‘IVDU’, or ‘drug abuse’.
From table 5, it is noted that choice of drugs used by overdose patients were ETOH, Opiates, Amphetamines and Marijuana. Therefore, analgesics and mood elevators were primarily used for overdose purposes. The results reflect a possibility that individuals who were suffering from chronic pin overdosed on opiate analgesics for their clinical condition. On the other hand, recreational drugs and mood elevators may have been used for addictive purposes. Moreover, opiates and recreational drugs are freely available over the counter, and that is probably the reason such classes of drugs were most used for abuse. Benzodiazepine was used by approximately 11.7 % individuals and these patients might be suffering from severe depressive disorders and have easy accessibility to such medications.
Table 6: Life stressors which induced Drug Overdose
Precipitating event/stressor N (%)
Life stressor identified 147
Relationship issues/argument 72 (49%)
Accommodation issues 6 (4.1%)
Legal issues 6 (4.1%)
Custodial issues 7 (4.8%)
Post-natal depression 2 (1.4%)
Significant illness or injury 20 (13.6%)
Bereavement 12 (8.2%)
Context of drug addiction or abuse 9 (6.1%)
Acute exacerbation of psychiatric
illness 9 (6.1%)
Other 5 (3.4%)
Table 6 indicated that drug overdose was influenced and stimulated by various life stressors. Relationship issues accounted for the major episodes of drug abuse or overdose. Interestingly, significant illness or injury might also stimulate end of life decisions, which may induce drug overdose.
Table7: Cause of overdose related to psychiatric comorbidity and risk prediction
History of Multiple OD
Presentations No history of prior OD
Presentations Any Psychiatric
Diagnosis 85.8% 64.2% OR = 3.38, p < 0.001
Table 7 reflects that the majority of patients who present with multiple drug overdoses were far more at risk of carrying a psychiatric disease. The data reflected that any psychiatric disease increases the risk of multiple overdoses by 3.38 times compared to individuals who do not have an earlier history of a drug overdose. The specific category and risk estimated from odds-ratio are different across various psychiatric diseases (as reflected in Table 8). The data reveals that any individual who presents with multiple episodes of drug overdose should be suspected for a psychiatric disorder. Schizophrenia, Personality disorders, depression carry a significant risk of drug overdoses. However, alcohol does not increase the risk of multiple presentations compared to individuals who do not have an earlier history of overdose.
Depression 68.7% 53.3% OR = 1.92, p = 0.018
Personality Disorder 43.3% 6.7% OR = 10.68, p < 0.001
Bipolar Affective
Disorder 23.9% 10.8% OR = 2.58, p = 0.011
Schizophrenia 13.4% 3.3% OR = 4.5, p = 0.008
History of Drug or
Alcohol abuse or addiction 55.2% 52.5% OR = 1.42, p = 0.27

. Table 8: Reflects the risk of multiple presentations due to a drug overdose on different psychiatric disorders.

Fig1: Reflects that Depression and Anxiety were the significant reasons for a drug overdose. The figure reflects that various psychiatric disorders that accounted for drug overdose were significantly different from one another. Depression, Anxiety and Personal disorder were the most common causes of a drug overdose.

Fig 2: Indicated the medical comorbidities which influenced drug abuse, chronic pain was the major contributor to drug overdose compared to other ailments. Apart from psychiatric comorbidities medical comorbidities also influenced drug overdose and correlations were found to be more in patients with chronic pain and hepatitis. Such overdoses might be related to a significant decrease in quality of life which indulges the thought of the end of life decision or such medications are consumed to alleviate the agony, and incidentally or accidentally lead to a drug overdose.

Fig3: Identifiable triggers that induced drug abuse. The predominant issue was relationship constraints. The figure reflected that the cause of drug abuse was diagnosed in around 98% individuals who presented with a drug overdose. Relationship issues accounted for most episodes of drug abuse and probably such individuals were frequently admitted in the ICU, for their condition.

Fig4: Indications that required ICU admission from emergency departments. Altered GCS was the major cause why individuals who presented with drug abuse were referred to the ICU. Moreover, hemodynamic monitoring was the next major cause which induced ICU admissions.

Fig 5: Represents the major classes of drugs used for intentional overdosing. The figure clearly demonstrated that benzodiazepines, anti-psychotics and anti-depressants were the major drug classes used for an intentional drug overdose. Hence, patients who were admitted for intentional drug overdose were sufferers from psychiatric and psychological ailments. Therefore, special care and close monitoring should be intervened in these patients, to prevent multiple incidences of a drug overdose. Interventions may be pharmacological or non-pharmacological. Strategies like psycho-counselling must be initiated as caregiving strategy, both in hospital settings and also in home care settings.
Discussion
The present study indicated that during 2010 to 2013, 8.1% patients admitted to the ICU of Frankston Hospital, with a drug overdose. Out of such patients, 7.8% patients had multiple admissions during the three-year period. The prevalence of ICU admissions varied on gender (56.57% females and 41.7% males). The study reflected that females were more prone and susceptible to a drug overdose. It may be speculated that males might have better-coping strategies to combat stress and depression compared to females. Such speculations were assumed to be true because the various forms of psychiatric disorders were more with females compared to males (69.4% versus 50.1%). The subcategory figures were personality disorders (43.3% versus 6.7%), depression (68.7% versus 53.3%), Bipolar disorders (23.9% versus 10.8%) and Schizophrenia (14.4% versus 3.3%). 52.8% of individuals who were admitted in the ICU during the three-year period had prior admissions for a drug overdose. Hence, it can be speculated that untreated psychiatric disorders and comorbid diseases may increase the prevalence of readmissions. In fact, individuals who had multiple admissions were diagnosed with more psychiatric disorders compared to the individuals who were admitted for the first time (p<0.001). Apart from psychiatric illness, chronic pain was the commonest co-morbid factor inducing a drug overdose. Individuals, who do not have a prior history of a drug overdose, used recreational drugs like amphetamines, marijuana, or alcohol for overdosing compared to the traditional drugs tranquilizers, anxiolytics or anti-depressants (12.5% versus 5.9%). On the other hand, individuals who had multiple admissions the drugs of choice used for overdose were Atypical-antipsychotics, tranquilizers, and sedatives. Moreover, the incidence of intentional overdose was more than accidental overdose, which reflected that patients with drug overdose have a self-harming behavior. In the current study, a life-threatening stressor was present in almost 57.6% of cases. Such stressors included family conflicts or terminal illness (cancer). Altered GCS was the most common reason the individuals were admitted in the ICU. Endotracheal intubation was the most common intervention used to treat the patients for washing out the drug. The Frankston hospital ICU effectively manages drug overdose patients as because the average length of ICU stays was 2.8 days and overall 43% patients were discharged directly to home from ICU.
Conclusion
The incidence of a drug overdose is prevalent across every country. Reports indicate that females are more prone to overdose than their male counterparts. To prevent drug overdose depression and anxiety must be managed in individuals, especially in the age range of 39 to 41 years in both the sexes. There should be restricted dispensing of mood elevators, antidepressants and anxiolytics, from the pharmacies. Chronic illness like pain and comorbid psychiatric disorders should be managed effectively. Family conflicts and professional stress must be minimized, through various coping strategies. Such interventions may help in preventing new and recurrent incidences of a drug overdose.