EPIDEMIOLOGY
The epidemiology of
poisoning
Euan A Sandilands
D Nicholas Bateman
Abstract
The epidemiology of poisoning can be studied from different perspec-
tives. These include overall mortality, hospital admission rates and en-
quiries to poisons information services. Accidental poisoning is most
common in children, but deliberate self-harm becomes predominant
in the teenage years and early adulthood. Understanding the patterns
of poisoning assists in developing suicide prevention strategies and
reducing the risks of accidental poisoning.
Keywords deliberate self-harm; epidemiology; poisoning; suicide
Introduction
Although there are several ways in which poisoning can pre-
sent, acute poisoning is the presentation with which doctors
are most familiar. Poisoning can, however, be chronic, result-
ing from sources such as the environment, food and water
supplies, or the industrial release of waste products (Table 1).
The reason for poisoning can be classified as ‘accidental’ or
‘deliberate’.
Data sources from which information on poisoning incidents
can be gleaned include mortality data on accidental poisoning
and suicide,1 hospital admission or discharge data, and enquiries
to poisons information services.2,3 In addition, some countries
collect information on chemical exposures, particularly those
involving population groups (chemical incidents).
Causes of poisoning
Patterns of poisoning vary with geographical location. In devel-
oping countries with rural economies, poisoning by pesticides
and herbicides is common. Patterns of habitation and work can
also expose populations in warmer countries to toxins from
snakes or spiders. Self-harm often involves agents that are
readily available and can reflect local tradition. For example, in
Sri Lanka pesticide and oleander poisonings are frequently
Euan A Sandilands MD FRCPE PGCert Med Ed is a Consultant in Clinical
Toxicology at the National Poisons Information Service (Edinburgh),
Royal Infirmary of Edinburgh and an Honorary Senior Clinical Lecturer
at the University of Edinburgh, UK. Competing interests: none
declared.
D Nicholas Bateman MD FRCP FRCPE FBPharmacolS FBTS FAACT FEAPCCT
is Honorary Professor in Clinical Toxicology at the University of
Edinburgh. Formerly he was Consultant Physician and Director of the
National Poisons Information Service (Edinburgh Unit) at the Royal
Infirmary, Edinburgh, UK. He is a Past President of the European
Association of Poison Centres and Clinical Toxicologists. Competing
interests: none declared.
MEDICINE 44:2
encountered problems, in China herbicide and pesticide poison-
ings are common, while in the UK paracetamol (acetaminophen)
is the most frequent poison taken deliberately.4e6
Obtaining estimates of the numbers of poisonings resulting
from pesticide and agrochemicals is extremely difficult as data
collection in developing countries is inconsistent, and probably
only the most severe poisonings are treated in hospital. Never-
theless, populations suffering such exposures are likely to run
into millions worldwide. In addition, mortality rates in devel-
oping countries are high, partly because of the availability of
potent, locally produced products that can be poorly labelled
and packaged, and partly because of difficulties in accessing
therapy where this is likely to affect outcome. The cost of anti-
dotes is also a significant problem, highlighted by the case of
oleander poisoning, for which digoxin antibody is effective in
treating toxicity but may not be affordable in developing
countries.5
In developed countries, the epidemiology of poisoning often
reflects prescribing practice and availability. From examining
poison centre enquiries, it is clear that antidepressants, hypnotics
and analgesics are among the most commonly ingested drugs in
the UK and USA.2,3 Various public health measures, such as
changes in product licensing and packaging, have been intro-
duced with the intention of reducing the burden of harm asso-
ciated with specific agents. In the UK, changes in pack size for
paracetamol caused an initial decline in use in overdose,7 but this
has been short-lived and rates subsequently increased to levels
above those before pack size legislation.8
Epidemiological data on poisoning were also used to support
the withdrawal of co-proxamol (paracetamol with dextro-
propoxyphene) in the UK in 2005 after it was demonstrated to
possess a significantly higher out-of-hospital mortality rate than
other paracetamoleopioid combinations.9 Pharmaceutical prod-
uct withdrawals can take several months to affect patterns of
overdose as products in the home are still available to be taken.
Nevertheless, a steady increase in deaths from codeine and tra-
madol poisoning has been observed since the withdrawal of co-
proxamol, with a significant increase in tramadol deaths,
mirrored by an increase in prescriptions, between 2009 and
2011.10 Finally, concurrent disease can also have an impact on
self-harm, and this has been shown for cancer.11
Information from poisons information centres can over-
estimate actual poisoning incidents, because many calls relate to
patients who have been exposed but not poisoned. These data
should, therefore, be interpreted with caution. Nevertheless, the
most common cause of calls to poisons information centres
within the UK relates to the ingestion of paracetamol.3
Mortality associated with poisoning
Suicide in the UK, as with many other European countries, has
been declining since 1995.12 The UK, Italy, Greece and Spain
currently demonstrate a relatively low suicide rate of approxi-
mately 8 deaths per 100,000, compared with 18 deaths per
100,000 population in the Baltic States and central Europe
(Hungary, Lithuania, Slovenia).12 In the USA, the suicide rate is
approximately 13 per 100,000 population, although suicide by
methods other than poisoning is more common, with self-
poisoning only accounting for 16% of all suicides in 2013.13
76 Ó 2015 Elsevier Ltd. All rights reserved.
 EPIDEMIOLOGY

Accidental poisonings from non-pharmaceutical agents are also

Useful definitions
C Suicide e an intentional act resulting in death
C Accidental poisoning e an exposure to a poison resulting in
symptoms that arises by an accidental action. It is common in
young children but can occur in adults in the home, in the
workplace or as a result of fire or transport accident
C Deliberate poisoning e forms part of the spectrum of disorders
now classified as deliberate self-harm. It has also in the past been
referred to as parasuicide, although this term is now outdated
C Occupational poisoning e occurs in the context of employment
C Environmental poisoning e refers to exposure resulting from
presence of a chemical in air, food or water
Table 1
Epidemiology of poisoning
In the UK, self-poisoning is an unusual condition in medical
practice in that it predominantly affects younger adults, with the
highest incidence between the ages of 15 and 35 years.11
Although traditionally considered a disorder of young females,
self-poisoning is increasingly affecting men and women to a
similar extent. In 2013, 41% of all drug-related deaths in females
in the UK were defined as suicide, representing a 9% reduction
compared with the previous year and continuing a downward
trend since 2009. By contrast, 29% of drug-related deaths in
males in 2013 were defined as suicide, representing a 12% in-
crease from 2012 to 587 deaths, the highest number of drug-
related male suicides since 2005.1 Although less common, self-
poisoning also affects the elderly population, where the impact
on morbidity and mortality can be greater due to the wider
availability of toxic medications and greater pre-existing co-
morbidity in this population.14
The largest proportion of drug-related deaths in the UK,
however, is due to accidental poisonings (66% of male and 55%
of female drug-related deaths in 2013).1 This figure is likely to
include many cases where the intent is unclear, such as deaths
due to recreational drug use, a particularly important issue
currently with the rising use of novel psychoactive substances.15
an important source of morbidity and mortality, with 2463 hos-
pital admissions between 2001 and 2010 in England being due to
carbon monoxide poisoning.16 Deliberate carbon monoxide self-
poisoning also accounted for 2171 hospital admissions in En-
gland over the same period.16
Patterns of mortality in the UK (Table 2) at least partly reflect
the types of agent ingested (Table 3), although figures from 2011
onwards are not directly comparable to those prior to 2010 due to
a new version of the International Classification of Diseases 10th
edition classification being introduced by the Office of National
Statistics.1 Similar data are available for the USA, demonstrating
that of the 83% of poisoning deaths due to pharmaceutical agents
in 2012, drugs of abuse, opioid analgesics, cardiovascular and
antidepressant medications were most commonly impli-
cated.17,18 A comparison of prescribing figures to mortality rates
can also provide an index of relative toxicity (Table 4).19 Mor-
tality associated with antidepressant poisoning has reduced since
the introduction of serotonin reuptake inhibitors as first-line
agents over tricyclic antidepressants.17 Further analysis of these
data allow identification of specific agents particularly associated
with toxicity.19
In the UK, guidelines on the prescription of dosulepin were
adjusted in light of the high incidence of dosulepin-related deaths
so that only health professionals with experience in psychiatry
should prescribe this drug, with additional advice that its use was
discouraged in new patients.10 Other control measures such as
child-resistant blister packs and a maximum dispensary limit
were also introduced. Although a reduction in dosulepin-related
deaths has been observed, it is unclear to what extent these
control measures had a direct effect on this reduction.
Childhood poisoning
The epidemiology of child poisoning varies significantly from
that of adults. Under the age of 5 years, children explore the
environment around them and frequently place objects in their
mouth. This results in a large number of enquiries to poisons
centres but a relatively low rate of serious poisoning in children.3
Over the age of 5, the rate of poisoning falls as accidental
ingestion becomes less likely, but it begins to rise again above the

Numbers of deaths related to drug poisoning by sex and underlying causea in England and Wales 2009e2013b
Cause Sex 2009 2010 2011 2012 2013

Mental and behavioural disorders due to drug use (excluding alcohol and tobacco) Male 586 504 86 72 92
(F11eF16, xF18eF19) Female 101 96 17 29 29
Accidental poisoning by drugs, medicaments and biological substances (X40eX44) Male 983 899 1107 1104 1351
Female 305 369 445 437 511
Intentional self-poisoning by drugs, medicaments and biological substances Male 524 482 576 525 587
(X60eX64), and poisoning by drugs, medicaments and biological substances, Female 374 391 418 422 383
undetermined intent (Y10eY14)
Assault by drugs, medicaments and biological substances (X85) Male 5 5 3 5 2
1
Data from UK statistics from England and Wales.
a
Cause of death was defined using the International Classification of Diseases, Tenth Revision (ICD-10) codes given in the table.
b
Figures are for deaths registered in each calendar year.

Table 2

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 EPIDEMIOLOGY

Numbers of deaths from drug poisoning overall and in terms of selected substances being mentioned, England and
Wales, 2009e2013a
2009 2010 2011 2012 2013

All deaths from drug poisoning 2878 2747 2652 2597 2955
Heroin and morphine 880 791 596 579 765
Methadone 408 355 486 414 429
All amphetamines 76 56 62 97 120
MDMA/ecstasy 27 8 13 31 43
Paramethoxyamphetamine/paramethoxymetamphetamine (PMA/PMMA) 0 0 1 20 29
Novel psychoactive substances 26 22 29 52 60
Cathinones 0 6 6 18 26
Mephedrone 0 6 5 12 18
All benzodiazepines 261 307 293 284 342
Diazepam 160 186 179 207 228
Zopiclone/zolpidem 79 67 71 83 86
All antidepressants 406 381 393 468 466
Tricyclic antidepressants (BNF 4.3.1) 219 194 200 233 235
Selective serotonin reuptake inhibitors (BNF 4.3.3) 113 136 127 158 150
Other antidepressants (BNF 4.3.4) 81 74 84 104 123
Paracetamol 255 199 207 182 226
Tramadol 87 132 154 175 220
Other opiates (including codeine and dihydrocodeine) 418 418 418 348 469
Helium 21 33 42 58 62

Data from UK statistics for England and Wales.1

a
Figures are for deaths registered in each calendar year.

Table 3

Deaths by suicide and undetermined intent related to antidepressants in England and Wales for people aged 10 years and
over, 2000e2006. Rates corrected by population and prescription volume to derive a fatal toxicity ratio
Drug Deaths in England Death rate UK prescriptions, Prescription rate Fatal toxicity ratio Relative
and Wales (n) per 100,000 (n) per 100,000 (95% confidence interval) toxicity indexa

Tricyclic antidepressants
Amitriptyline 395 0.1211 44,286,108 10,606 11.4 (10.3e12.6) 1.0
Clomipramine 39 0.0120 3,544,517 849 14.1 (10.0e19.3) 1.2
Dosulepin 589 0.1807 20,812,372 4984 36.3 (33.4e39.3) 3.2
Doxepin 22 0.0067 1,001,373 240 28.1 (17.6e42.6) 2.5
Imipramine 25 0.0077 2,575,206 617 12.4 (8.1e18.4) 1.1
Nortiptyline 5 0.0015 645,175 155 9.9 (3.2e23.2) 0.9
Trimipramine 13 0.0040 1,113,166 267 15.0 (8.0e25.6) 1.3
Selective serotonin reuptake inhibitors
Citalopram 50 0.0154 37,371,364 8950 1.7 (1.3e2.3) 0.15
Fluoxetine 17 0.0052 39,818,056 9536 0.5 (0.3e0.9) 0.05
Fluvoxamine 0 0 195,897 47 0 0
Paroxetine 10 0.0031 25,980,311 6222 0.5 (0.2e0.9) 0.04
Sertraline 8 0.0025 15,374,325 3682 0.7 (0.3e1.3) 0.06
Other antidepressant drugs
Mirtazepine 18 0.0055 6,386,479 1529 3.6 (2.1e5.7) 0.32
Venlafaxine 83 0.0255 20,100,751 4814 5.3 (4.2e6.6) 0.46

The fatal toxicity index represents drug-specific poisoning mortality relative to prescribing rates and is calculated from the mortality rate (numerator) and the prescribing
rate (denominator).
Adapted from Hawton et al.19
a
Index of toxicity relative to amitriptyline.

Table 4

MEDICINE 44:2 78 Ó 2015 Elsevier Ltd. All rights reserved.

 EPIDEMIOLOGY
age of 10 as self-harm starts to feature as a significant component
of poisoning.13,14,20 Recent data from the USA have confirmed
this bimodal age distribution of self-poisoning in children, with
accidental poisonings being common in children under the age of
6, and intentional self-poisonings being common in those over
the age of 6 years.21 The rate of intentional drug exposures in
children over the age of 6 has increased over the last 9 years (22/
1000 cases in 2003 versus 38/1000 cases in 2012), with this same
trend noted for every year above the age of 6 years.21 The highest
incidence of intentional exposures occurred in 17-year-olds, with
a rate of 593/1000 cases. The problem of childhood poisoning in
developing countries, as for adults, reflects availability, so this
increasing trend is probably, in some part, due to the evolving
array of substances that young people may expose themselves
too, most notably novel psychoactive substances.20 A 10-en&mimeType¼text%2Fhtml&containerItemId¼%2Fcontent
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