Research article
Emergency Department Visits for Overdoses of Acetaminophen-Containing Products

https://doi.org/10.1016/j.amepre.2011.02.026Get rights and content

Background

Limited national data on the circumstances of acetaminophen overdoses have hindered identification and implementation of prevention strategies.

Purpose

To estimate the frequency of and characterize risks for emergency department visits for acetaminophen overdoses that were not related to abuse in the U.S.

Methods

Data were collected from two components of the National Electronic Injury Surveillance System from January 1, 2006, through December 31, 2007, and analyzed from 2009 to 2010 to estimate the annual number of emergency department visits for non-abuse-related acetaminophen overdose by patient demographics, treatments, and type and amount of acetaminophen-containing product ingested.

Results

There were an estimated 78,414 emergency department visits (95% CI=63655, 93172) annually for non-abuse-related overdoses of acetaminophen-containing products. Most emergency department visits for acetaminophen overdose were for self-directed violence (69.8%, 95% CI=66.4%, 73.2%), with the highest rate among patients aged 15–24 years (46.4 per 100,000 individuals per year). Unsupervised ingestions by children aged <6 years accounted for 13.4% (95% CI=11.0%, 15.9%) of visits for acetaminophen overdoses (42.5 per 100,000 individuals per year). Therapeutic misadventures accounted for 16.7% (95% CI=14.0%, 19.5%) of visits and most involved overuse for medicinal effects (56.1%, 95% CI=50.6%, 61.6%) rather than use of multiple acetaminophen-containing products or dose confusion.

Conclusions

Non-abuse-related overdoses of acetaminophen products lead to many emergency department visits each year, particularly emergency department visits for self-directed violence. Acetaminophen overdose prevention efforts will likely need to be multidimensional.

Introduction

Acetaminophen has been used to treat pain and fever for more than 50 years. It is sold over the counter (OTC) as a single-ingredient product or in combination with other ingredients to treat symptoms of allergies, colds and upper respiratory tract infections, migraines, sleep disorders, and other conditions. To treat more severe pain, acetaminophen is combined with opioid analgesics in numerous prescription products. A 1-week prevalence survey found that acetaminophen, taken either as a single ingredient or in a combination product, was the most commonly used drug among adults in the U.S.1 Combination acetaminophen/hydrocodone products have been the most frequently dispensed prescription drugs in the U.S. since 1997.2

Acetaminophen is considered to be safe and effective when used as directed; however, because of its relatively narrow therapeutic index, exceeding the maximum recommended dose can lead to liver toxicity. For adults, a single dose of 10–15 g can cause hepatic necrosis, and for some the toxicity threshold may be lower.3, 4 Manifestations of toxicity range from abnormal liver function tests to acute liver failure (ALF) and death,5 and the U.S. Food and Drug Administration (FDA) convened an advisory committee meeting in June 2009 to review data on liver injury related to use of acetaminophen and to suggest potential harm-reduction strategies.6

Previous assessments of acetaminophen-related overdoses and liver injury in the U.S. have been based on data from single institutions,7 tertiary care centers,8, 9 or surveillance systems that are no longer operational.10 Data on the context of and risk factors for acetaminophen overdoses and the specific type of acetaminophen-containing products involved are limited.11 Therefore, nationally representative public health surveillance data were analyzed to characterize emergency department visits for non-abuse-related acetaminophen overdoses in the U.S.

Section snippets

Data Source

National estimates of the number of emergency department visits for overdoses involving acetaminophen-containing products were based on data from two components of the National Electronic Injury Surveillance System (NEISS)—the Cooperative Adverse Drug Event Surveillance project (NEISS–CADES) and a special study of the All Injury Program (NEISS–AIP) on self-directed violence.

Both NEISS–CADES and NEISS–AIP use the same national stratified probability sample of 63 hospitals with a minimum of six

Results

Based on 2717 total cases, an estimated 78,414 emergency department visits (95% CI=63655, 93172 visits) occurred annually for overdoses of acetaminophen-containing products, excluding overdoses related to recreational drug use or abuse. Most emergency department visits for overdoses of acetaminophen-containing products (69.8%, 95% CI=66.4%, 73.2%) involved self-directed violence; the remaining visits (30.2%, 95% CI=26.8%, 33.6%) involved unintentional overdoses. Unintentional overdoses included

Discussion

This is the first study that we are aware of that uses nationally representative surveillance data to describe non-abuse-related overdoses involving acetaminophen-containing products by patient intent, patient demographics, and type of acetaminophen product.

Conclusion

Non-abuse-related overdoses of acetaminophen-containing products are involved in many emergency department visits each year, particularly emergency department visits for self-directed violence. Nationally representative data on acetaminophen-related emergency department visits can help target interventions to have the greatest potential for minimizing harms while preserving options for pain management and symptom relief.

Acknowledgments

This investigation was funded by the CDC. We thank Kelly Weidenbach, MPH, Victor Johnson (Northrop–Grumman contractors for CDC), Lee Annest, PhD, and Tadesse Haileyesus, MS, of CDC, and Tom Schroeder, MS, Cathy Irish, BS, Joel Friedman, BA, and staff of the Division of Hazard and Injury Data Systems, U.S. Consumer Product Safety Commission for assistance with data collection and processing. We thank Nadine Shehab, PharmD, MPH, of CDC for assistance with programming and thoughtful contributions

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