The number of intentional overdoses involving common over-the-counter and prescription drugs has increased steeply among young people in the last decade, according to new data provided to The Globe and Mail by the Canadian Institute for Health Information.
The number of cases roughly doubled for children and teenagers in Alberta and Ontario, the two provinces for which data were available, in two categories of drugs that include over-the-counter painkiller medications and prescriptions for drugs such as antidepressants and sedatives, according to the CIHI data, which tracked emergency-department visits.
For children under the age of 13, the number of intentional overdoses, while still small, nearly tripled, between 2010 and 2018.
The data correspond with findings in an Ontario study, published Monday in the journal Clinical Toxicology, that analyzed rising rates of intentional overdoses among youth between 2010 and 2015. The study found that acetaminophen, most well-known by its brand name Tylenol, was the most commonly used drug, followed by antidepressants and then non-steroidal anti-inflammatory drugs, such as Advil.
The danger of acetaminophen has prompted experts to call for Health Canada to restrict higher doses of the drug and the number of pills that can be sold at one time. The move has been taken in other countries, where research suggests that restrictions contributed to a reduction in suicides and self-harm incidents.
“It makes no sense having stores selling huge bottles of Tylenol," said Eric Yoshida, a liver specialist at Vancouver General Hospital and the chair of the medical advisory committee for the Canadian Liver Foundation. “That is a recipe for disaster.”
Easy access is the main factor in the type of the drugs being used, researchers say. Tylenol and Advil are both easy to buy, sold in bulk and ubiquitous in Canadian homes. Prescriptions of antidepressants have also risen over the last several decades, making them readily available in medicine cabinets.
The CIHI numbers group drugs into categories based on hospital codes and don’t identify how many overdoses specifically involved acetaminophen, for example, or particular antidepressants, but they do show evidence of a stark increase.
In 2018, for young people under age 19 in both Ontario and Alberta combined, CIHI recorded 1,752 cases involving drugs such as non-opioid painkillers, non-steroid anti-inflammatories and aspirin, up from 935 in 2010. (For children under the age of 13, there was 99 incidents in both provinces in 2018, compared to 27 in 2010.)
For drugs in the category that includes antidepressants and sedatives, cases among those under 19 rose to 1,986 from 737. (For children under 13, CIHI record 61 cases in 2018, compared with 16 in 2011. Alberta data are not available for the previous year.)
Acetaminophen can cause acute liver failure, especially when combined with alcohol. The rates of overdose in the Ontario study were significantly higher among girls, a worrisome finding given new evidence suggesting that woman are more vulnerable to liver failure caused by acetaminophen overdose than men.
In 1998, Britain restricted the amount of acetaminophen that people could purchase at one time, to 32 pills in pharmacies and 16 or 24 tablets in other retail stores.
In Denmark, the sale of painkillers, including acetaminophen, is prohibited to young people under the age of 18. This restriction was cited in a recent study as one reason why self-harm rates have not risen in the country, unlike the increase observed in many other Western countries.
Dr. Yoshida argued the harm outweighs the benefits in selling acetaminophen at high doses and in large quantities. But barring a ban, he said, at the very least, extra-strength versions of the drug should be kept behind the pharmacy counter, to prevent a young person from buying it and to ensure a pharmacist can counsel consumers on the risk.
“All it takes is Health Canada to change the rules about how over-the-counter drugs can be dispensed,” he said.
In 2016, after a safety review, Health Canada announced new labelling guidelines for acetaminophen and limited the strength allowed in prescriptions that combined another drug. The review also considered reducing the dose available for sale, but a Health Canada spokesperson said in a statement that there was insufficient scientific evidence that this step would improve safety, citing concerns that changes might drive consumers to other drugs.
Barry Power, a spokesperson for the Canadian Pharmacists Association, said that restricting acetaminophen “would require a change in mindset" for Canadians and would create access issues for some patients, such as those with chronic pain. He suggested that parents place all their medications in a secure, high-traffic location in the house and resist bulk purchases. “If you are concerned about a child who may be suicidal, then I would lock [the medication] up,” he said.
But David Juurlink, a drug-safety expert at the University of Toronto and a co-author of the Ontario study, said restricting access to the drug merits another national conversation – given its toxicity and ubiquitous presence in Canadian stores and homes.
“It might seem odd to take a drug that is used by the kilotonne around the world every year, and that has been on our shelves for decades, and suddenly reduce access to it,” he said. “But if public perception were aligned with what we know about the pharmacology of this drug, I think people would be much more sympathetic to reducing access to higher doses and large bottles.”
Almost all teenagers who go to the emergency department for an intentional overdose survive. (Acetaminophen overdoses, for example, can be treated with an antidote if people get to hospital quickly.) In about half of the cases, they go home without being hospitalized.
But they often return to the emergency department and have a significantly higher risk of suicide and accidental death compared with a control group of peers – a pattern that suggests a clear need for long-term follow-up care, said Yaron Finkelstein, an emergency medicine specialist at Toronto’s Hospital for Sick Children and a co-author of the Ontario study.
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Erin Anderssen