Co-proxamol and suicide

Restriction of availability of means for suicide is a key strategy for its prevention. This approach has been shown to be effective by the reduction in deaths after recent UK legislation that reduced the pack sizes of analgesics and previous restriction on prescribing toxic sedatives.

Co-proxamol is a prescription-only analgesic that combines paracetamol and dextropropoxyphene. Respiratory depression and consequent death may occur with overdose due to ingestion of excessive dextropropoxyphene. Concern about the number of such deaths was expressed by the BMJ as long ago as 1980.

A recent BMJ paper examined the incidence of suicides due to co-proxamol compared with tricyclic antidepressants and paracetamol, and to compare fatality rates for self-poisonings with these drugs.

The study looked at routinely collected national and local data on suicides and self poisonings and records of suicides in England and Wales 1997-9; non-fatal self poisonings in Oxford District 1997-9.

Data sources used were the Office for National Statistics and Oxford monitoring system for attempted suicide. The incidence of suicides with co-proxamol or tricyclic antidepressants or paracetamol was measured as were the ratios of fatal to non-fatal self poisonings.

Co-proxamol alone accounted for 5% of all suicides. Of 4162 drug related suicides, 18% (766) involved co-proxamol alone, 22% (927) tricyclic antidepressants alone, and 9% (368) paracetamol alone. A higher proportion of suicides in the 10-24 year age group were due to co-proxamol than in the other age groups. The odds of dying after overdose with co-proxamol was 2.3 times (95% confidence interval 2.1 to 2.5) that for tricyclic antidepressants and 28.1 times (24.9 to 32.9) that for paracetamol.

They concluded that self poisoning with co-proxamol is particularly dangerous and contributes substantially to drug related suicides. Restricting availability for co-proxamol could have an important role in suicide prevention.

Ref: web

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Counselling in primary care

This Cochrane Review searched 10 electronic databases, hand-searched specialist journals, as well as consulting experts. The updated review used six databases, including specialist trials registers. Randomised and controlled trials were eligible that tested the hypothesis that counsellors treating patients in primary care are more effective than usual care provided by the GP or alternative mental health treatments.

Participants were patients consulting a GP with psychological or psychosocial problems. Intervention by a counsellor was undefined other than counsellors had to have been trained to the British standard for accreditation. Outcomes measured were clinical effectiveness of psychological outcomes like depressive symptoms and measures of social function.

Seven trials were included from 12 publications, with 444 patients given counselling and 297 given usual care. On a quality scoring system all scored reasonably well, but how many of these trials were randomised or used blinded outcome assessments is not mentioned in this review.

With counselling there was a small increase in the percentage of patients having a reliable and clinically meaningful change over the short term (under 9 months).

It is relevant to compare the weight and quality of evidence we have here with the weight and quality of evidence we expect from a newly introduced pharmacological therapy. The trials say nothing about possible harms. For instance, might there be rare but serious harm from counselling that outweighs any possible small benefit?

Ref:web

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New Guidelines from NICE

Three new sets of guidelines came out from NICE at the end of June: on preoperative testing, head injury and infection control. Two are briefly mentioned here.

The National Institute for Clinical Excellence has issued guidance on when to use routine preoperative tests in elective surgery, according to the type of surgery planned, patient’s age, and co-morbidity.

The guidance is designed to ensure that preoperative tests are carried out systematically in all hospitals in England and Wales on the basis of risk assessment.

It makes recommendations about the appropriateness of carrying out simple tests such as plain chest radiography, resting electrocardiography, full blood count, haemostasis, renal function, and blood glucose.

These are tabulated on "look-up" charts where the need for a particular test is assessed according to the complexity of surgery, the patient’s age, and comorbidity. There is very little evidence on the impact of preoperative testing on outcomes, so a consensus approach was using in developing the guidance, involving two parallel groups of experts in the field to achieve robust decisions.

Around five million elective surgical procedures are carried out each year by the NHS in England. Many hospitals test patients before surgery for a range of conditions that might affect their treatment. However, the number and type of tests performed vary considerably.

Prompt assessment, early computed tomography (CT), and better access to rehabilitation for patients with minor injuries are key recommendations in national guidelines on head injury published.

The National Institute for Clinical Excellence (NICE) guidance also makes evidence based recommendations on the management of patients with head injury, defined as any trauma to the head, other than superficial injuries to the face; from initial assessment through to hospital discharge and rehabilitation.

The guidance recommends that all patients presenting to emergency departments with a head injury should be triaged by a trained member of staff within 15 minutes of arrival. Patients should be assessed and classified using the Glasgow coma scale and its derivative, the Glasgow coma score.

Patients should get imaging early, rather than admission and observation for neurological deterioration,  the guidance proposes. CT imaging of the head is recommended as the primary investigation of choice for the detection of acute, clinically important brain injuries.

Head Injury: Triage, Assessment, Investigation and Early Management and preoperative testing are available or copies can be ordered from the NHS Response Line, tel 0870 1555 455.

Ref:web

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