Drug-related calls received at National Poisons Information Centre, India: A 5-year retrospective record-based study

INTRODUCTION

Poisoning, including drug overdose, is a major cause of morbidity and mortality that requires immediate medical intervention and its incidence is higher in India when compared to several developed countries.^1,2 Poisoning is one of the major causes of death, as per the National Crime Records Bureau.³ Deliberate drug poisoning has been reported to account for a large number of patients (>210 000) hospitalized in the USA in 2010 and 1% of total emergency department visits in western countries, with an annual incidence of 2%–6%.^4–7 The prevalence of drug overdose in India has been reported to be about 10% according to hospital-based data.⁸ Although the majority of such cases may not have severe symptoms and do not require any intervention, a few cases that may develop complications require medical attention.⁹ According to a previous report, 22% of the total calls seeking information about management or any other aspect of poisoning received by the National Poisons Information Centre, All India Institute of Medical Sciences, New Delhi (NPIC), were related to pharmaceuticals.¹⁰

The emergence of the Covid-19 pandemic in late 2019 became a global health problem, and on 11 March 2020, the WHO declared it a pandemic and a public health emergency of international concern.¹¹ Many countries imposed lockdowns that restricted the movement of people, and a work-from-home culture was inculcated. In India, lockdown was observed in a scattered manner in different states. During these periods, the healthcare system was restricted mainly to emergency care. There are reports showing an increase in anxiety and depressive symptoms during the pandemic.^12–14 As many households keep stocks of drugs for chronic ailments, we evaluated the drug-related calls (DRC) received at the NPIC from January 2017 to December 2021. The changing pattern during Covid-19 and issues related to drug-related poisoning were also assessed.

METHODS

In a retrospective study, the call records of NPIC from 1 January 2017 to 31 December 2021 were analysed. The centre functions around the clock and provides poisoning management related information telephonically. Telephonic advice is sought by both the public and the treating physicians. The centre is equipped with 3 telephone lines, of which one is toll-free, and its services are available all over India. The details of the call record include demographic details of the patient, type of poison, mode of exposure and quantity of poison consumed, clinical findings, query and the treatment given. This information is also maintained as an easily retrievable record in an Excel sheet. The NPIC organizes symposia for healthcare professionals from time to time to create awareness, to update on current trends and one such event was organized in the first half of 2019. The centre remained functional and provided services during the Covid-19 pandemic as well. DRCs were retrieved for further analysis of various characteristics (caller, category, gender), drug types, regions (north, south, east, west, central) and age groups (infants, children and adolescents, young adults, older adults and elderly). As the first case of Covid-19 was reported in India on 30 January 2020, the study comprised two equivalent periods: (i) pre-Covid-19 (701 days before 30 January 2020) and (ii) Covid-19 (30 January 2020 and the next 700 days). The data was anonymized, and no information revealing the identity of the caller or the patient was included. Approval of the institutional ethics committee was obtained before starting the study (IEC-356/06.05.2022, RP-18/2022).

RESULTS

The call records showed an increasing trend in both total calls and DRCs received by the NPIC from 2017 to 2020, followed by a decline in 2021. During this period, a total of 26426 calls were answered at NPIC, of which 6377 were related to overdose/inappropriate use of drugs. Both total and DRCs were more in the Covid-19 period (12 752 and 3163) as compared to the preCovid-19 period (10 653 and 2457; p<0.002), and the DRCs ranged between 20% to 27% of total calls for all years and for both time periods (Table 1). Most DRCs were made by treating physicians (97% to 99%) in each group, while a small number of DRCs were made by others (patients or their family members). In 2017, the number of calls related to unintentional use of drugs was 4-fold higher than the intentional use (80% v. 20%), while the unintentional and intentional DRCs were 77% v. 23% in both the pre-Covid-19 and Covid-19 period. The number of calls for both unintentional and intentional intake of drugs was higher during the Covid-19 period as compared to the pre-Covid-19 period, though the difference was not statistically significant. There were more calls for males (56% to 59%) when compared to females (40% to 42%) in all the time periods; however, there was no significant difference between genders in the preCovid-19 and Covid-19 periods (p=0.8). There were only a few cases where gender was not mentioned in the records and were marked as unknown (0.5% to 2.0 %; Table 1).The calls related to antidepressants, antipsychotic and polypharmaceuticals were more (18 v. 0, 108 v. 0 and 364 v. 349) while those related to analgesics, benzodiazepines, thyroxine and the ‘others’ category were fewer (118 v. 152, 144 v. 218, 159 v. 320 and 1441 v. 2005) during the pre-Covid-19 period as compared to the Covid-19 period. The difference for these categories was statistically significant (p<0.001), though in the remaining categories, the number of calls was not significantly different between the two time periods.

The distribution of DRCs was different in different regions of the country, and a higher number of calls were received from the north and south regions in both periods. There was an increase in DRCs during Covid-19 in all the regions compared to the pre-Covid-19 period (Table 2). A few calls for which region was not known were not significantly different between the pre-Covid-19 and Covid-19 periods. Maximum calls were received from healthcare centres located in Delhi, followed by Karnataka and Maharashtra. There was a significant difference in state-wise poisoning calls when comparing the two time periods. In a post-hoc analysis, the difference was found to be significant for Bihar, Chandigarh, Delhi, Haryana, Karnataka, Kerala, Punjab, Tamil Nadu and Telangana. Of these states, an increase in the total number of calls was observed for Bihar, Chandigarh, Karnataka, Kerala, Tamil Nadu and Telangana in the Covid-19 period compared to the pre-Covid-19 period, while there was a decrease in other states.

There was a significant change in the number of calls age-group-wise (p<0.001). The DRCs in children and adolescent groups were significantly higher as compared to other age groups. There was a decrease in DRCs in infants during Covid-19 as compared to pre-Covid-19, while DRCs increased during Covid-19 in children and adolescents, young adults, older adults and elderly people (Table 3).

The Covid-19 period comprised two lockdown phases in India, i.e. 24 March 2020 to 31 May 2020 and 5 April 2021 to 15 June 2021. No significant difference was found between DRCs when lockdown and unlock phases were compared.

The records showed that most patients were asymptomatic after intake of drugs when they contacted the centre. However, common symptoms and signs in some included vomiting and diarrhoea, drowsiness, restlessness, hypotension, anxiety, palpitations and headache. In most cases, calls were made soon after drug intake, and the queries related to line of management, signs and symptoms to be observed later, observation period, benefit of gastric lavage, possibility of enhancing drug excretion, drug interaction in case of mixed drugs, and delayed effects that might appear, if any.

DISCUSSION

There was a marked increase in the number of DRCs received by the NPIC during the study period. There was a gradual increase in poisoning-related calls from 2018 onwards, with a peak occurring in 2020. Such an increase could have resulted due to awareness about the centre amongst healthcare professionals at the beginning of 2019 through the symposium and among the public through smartphone usage for information retrieval and telephonic connectivity from all parts of the country.^15,16 The increase could have also resulted from the changing scenario during the Covid-19 pandemic and the lockdown imposed in 2020. There was a slight decline in the year 2021, possibly due to restricted activities of all kinds, closure of non-essential services and adoption of cluster containment strategies in areas where Covid-19 positivity was high.

During Covid-19, the number of both total and DRCs was higher compared to the pre-Covid-19 period, as also reported by poison centres in the USA, Canada, and Jordan, while South Africa, France and Italy reported a decrease.^17–23 Most calls to the poison control centre in Italy were made by private citizens, whereas in our study, the majority of DRCs were made by the treating physicians regarding asymptomatic or non-serious cases, primarily focusing on the possibility of late effects, observation period, enhancing excretion of the drug and drug interaction.²² Very few calls were made by others seeking immediate remedial measures or healthcare referral advice. A study has shown that, despite the pandemic and healthcare professionals focusing on Covid-19, poisoning-related visits increased during the lockdown.²⁴

The suicide rate in India has been reported to be nearly double compared to the rest of the world, and most of such cases are due to intentional ingestion of poisons, including drugs.²⁵ According to the emergency department of a teaching hospital in north India, the majority of acute poisoning cases relate to suicidal attempt (57%) as compared to accidental exposure (34%), and in 13% of the cases, overdose of a drug is the reason for hospital visit.²⁶ We found that 20% to 27% calls received by NPIC during the study period were related to the intake of drugs, where calls due to unintentional intake of drugs were about 4-fold higher than those due to intentional intake. There was an increase in the number of DRCs from 2017 to 2021 and during Covid-19 as compared to the pre-Covid-19 period, possibly due to the availability of prescription drugs over the counter, self-medication, stockpiling of drugs for chronic illnesses, hoarding the drugs due to lockdown, anticipating a shortage of supply and Covid-19-related restrictions.

The number of DRCs was higher for males as compared to females and the gender prevalence was not very different among all time periods. In general, the number of poisoning cases, including drug overdose, has been reported to be higher for males compared to females, and there was an increase in these cases during lockdown.^{8,10,21,27,28} Contrary to our findings,Anthony and Kulkarni have reported that women outnumbered men (75% v. 25%) with regard to drug overdose based on the medical records of the patients admitted to the emergency medicine department.²⁷ Such a discrepancy could have resulted from the ingestion of higher drug doses requiring hospitalization, although all these cases improved. The authors also state that sedatives, antiepileptics, anti-depressants and paracetamol are common drugs whose overdose has been reported to cause poisoning.²⁷ We found that the patterns of intake of drugs were similar to those of studies conducted in south India, where benzodiazepines were the most common drug.^29,30 Most calls to NPIC involved multiple drugs, with higher call numbers for analgesics, benzodiazepines, thyroxine, and other drugs during Covid-19 compared to pre-Covid-19, some of which were also reported by John et al.³⁰ This suggests indiscriminate drug ingestion and stockpiling, possibly due to the easy availability of drugs at home during lockdown. The increase in drug use for self-harm during Covid-19 reflects the distress caused by uncertainty during the pandemic.

Region-wise analysis of data revealed that DRCs were higher in the north and south regions. The NPIC being based in the north region could be one of the reasons for the highest number of calls from this region. These calls were significantly more during Covid-19 in the south region. The first Covid-19-positive case was confirmed in Kerala, and the first death due to coronavirus was confirmed in Karnataka in early 2020.³¹ Besides, general fear about the disease and its spread, various other socio-economic reasons, personal and family concerns resulted in a higher incidence of suicide in south India during Covid-19.¹ Of the various modes employed to cause self-harm, drug overdoses (25% to 26%) and agrochemical (26% to 28%) intake were most common in all the phases, i.e. pre-lockdown, lockdown, and unlock phases, compared to a similar period in the previous year. The percentage of drug overdose cases reported by John et al. is in consonance with the percentage of DRCs received in our study.³⁰ There was an increase in DRCs during Covid-19 in other regions of the country as well. In India, 10% cases of poisoning have been reported to be due to drug overdose.⁸ Our study is the first of its kind where DRCs were analysed in different regions of the country, and based on these findings, the prevalence of drug overdose was found to be higher in both the north and south regions compared to the rest of the country. Earlier the NPIC reported an increase in the number of telephone calls related to inappropriate use of hand sanitiser during the lockdown period of Covid-19, as compared to the pre-lockdown period in the north and south zones of India.³²

The incidence and mode of poisoning vary as per the age group. Studies have shown that the incidence of poisoning is high in children up to the age of 6 years, and most of such cases are due to unintentional exposure to the poison.¹⁰ In line with these findings, our study showed that significant DRCs were received for infants during the pre-Covid-19 period. However, there was a decline in DRCs during the Covid-19 period, probably because parents were available at home, as most employers allowed work from home. Contrary to the findings of our study, there was no change in call numbers during the lockdown and the equivalent control period of the year 2019, as per the poison control centre database from Italy.²² We also found an increase in DRCs in the age group 1 to 18 years in both the pre-Covid-19 and Covid-19 periods. Both toddlers and small children have a tendency to put everything in their mouths and have an exploratory nature, which makes them more vulnerable to unintentional self-harm. Drugs and medications have been found to be the leading cause of poisoning in children in India.³³ These findings also point towards a lack of awareness among parents on how to store toxic products including drugs, and in the absence of such precautions, small children have easy access to them, and hence, there was an increase in drug overdose or drug poisoning. It is important to note that the DRCs were highest in children and adolescents in our study, and thereafter, with an increase in age, there was a decline. Geller et al. also reported the highest number of emergency department visits among persons between 11 and 19 years of age in the USA.² According to the USA poison centre, there was an increase in calls related to suicidal intent in adolescents and an increase in exposure to over-the-counter medication and mood stabilisers during the pandemic compared to previous years.^34,35 An increase in DRCs in adolescents, adults and the elderly during Covid-19 could be explained by social distancing strategies. Forced isolation may have resulted in emotional distress, resulting in increased drug intake. The incidence of poisoning was lower in older adults and the elderly in comparison to young adults, similar to previous reports.²⁹ Further, the drug overdose in some elderly people could have been unintentional and due to medication error.³⁶

Conclusion

Over 5 years, the NPIC observed an increasing trend in DRCs, which is in line with the total number of calls received by the centre. The comparison of pre-Covid-19 and Covid-19 periods revealed an increase in DRCs in different regions of the country, especially in the south of India, and in children and adolescents during Covid-19.