ORIGINAL PAPER

Pattern of Drug Overdose and Chemical Poisoning AmongPatients Attending an Emergency Department, Western SaudiArabia

Mohamad Bakhaidar • Saber Jan • Fayssal Farahat •

Ahmad Attar • Basim Alsaywid • Wesam Abuznadah

� Springer Science+Business Media New York 2014

Abstract Poisoning is a medical emergency that repre-

sent a major health problem all over the world. Studies on

drug overdose and chemical poisoning are very limited in

Saudi Arabia (SA). We aimed to describe the current pat-

tern and assess risk factors of drug overdose and chemical

poisoning in King Khalid National Guard hospital, Jeddah,

SA. Medical records of patients attended emergency

department in King Khalid National Guard hospital during

the period from January 2008 to December 2012 due to

drug overdose and chemical poisoning were reviewed. A

total of 129 cases were included in the study. The majority

of the population was Saudi (97.7 %), and almost half of

them were females (54.3 %). Children under 12 years were

the most affected age group (44.2 %). Drug overdose was

the most common cause of poisoning (92.2 %). Analgesics

and non-steroidal anti-inflammatory drugs represented the

highest percentage of used medications (20.4 %). The most

commonly reported symptoms were symptoms of the

central nervous system (57.4 %) followed by GIT

symptoms (41.9 %). Intentional poisoning was reported in

34 cases (26.4 %). Female patients were significantly more

likely to attempt suicide than male patients (OR = 7.22,

95 % CI = 1.70, 30.62). Children continue to be at high

risk for medication and chemical poisoning. Accessibility

to medications at homes encountered for most of poisoning

cases among children. Implementing methods to raise

public awareness and minimize children access to medi-

cations would significantly contribute to reducing burden

of this problem on the community.

Keywords Poisoning � Drug overdose � Emergency

service � Saudi Arabia

Introduction

Poisoning is a medical emergency representing a health

problem all over the world with an incidence rate that

varies from one place to another [1, 2]. In 2010, more than

40,000 deaths occurred in United States as a result of

unintentional poisoning which made poisoning the leading

cause of injury deaths [3]. Moreover, the poisoning death

rate nearly tripled in the period from 1980 to 2008 and the

percentage of poisoning deaths that were caused by drugs,

in particular, increased from about 60 to about 90 % [4].

Children poisoning causes significant morbidity and mor-

tality in children throughout the world [5]. Most of child-

hood poisonings are accidental and are preventable [5].

Lately, drug overdose started to get global attention due to

the higher rate of drug overdose morbidity and mortality

while being a preventable cause of death [6]. In Saudi

Arabia, studies of the pattern of poisoning among adults

and children have been conducted in Riyadh, Al-Qassim,

Najran and Makkah [7–11]. In Jeddah (the second largest

M. Bakhaidar

Faculty of Medicine, King Abdulaziz University, Jeddah,

Saudi Arabia

S. Jan

College of Medicine, Taibah University, Madinah, Saudi Arabia

F. Farahat (&) � A. Attar � B. Alsaywid � W. Abuznadah

King Abdulaziz Medical City (KAMC), King Saud bin

AbdulAziz University for Health Sciences (KSAU-HS), King

Abdullah International Medical Research Center (KAIMRC),

Jeddah, Saudi Arabia

e-mail: farahatfa@ngha.med.sa

F. Farahat

Public Health and Community Medicine Department, Menoufia

University, Menoufia, Egypt

123

J Community Health

DOI 10.1007/s10900-014-9895-x

city in Saudi Arabia), only two studies describing pattern of

poisoning and drug overdose were reported. Ghaznawi

et al. [12] reviewed files of poisoning cases reported to

Jeddah Poison Control Center over an 18-month period

(from April 1989 to September 1990). Al-Hazmi in 1998,

also described the pattern of poisoning in children below

12 years during the period from January 1994 to December

1996 in King Abdulaziz University, Jeddah [13]. In recent

years, pattern of poisoning and drug overdose is changing

worldwide [14, 15]. Knowledge about this important public

health issue would help in assessing the magnitude of the

problem and formulating specific interventional measures

to prevent and control drug overdose and chemical poi-

soning in Saudi Arabia. To the knowledge of the authors,

no other studies have been reported in Jeddah since 1998

(more than 20 years ago), thus this study was conducted to

provide an update of the current pattern of chemical poi-

soning and drug overdose in Jeddah, western Saudi Arabia.

Patients and Methods

This is a retrospective chart review study. It was conducted in

King Khalid National Guard hospital, western Saudi Arabia,

(a 500-bed hospital, serving National Guard employees and

their families). Medical records of all patients who attended

emergency department during the period from January 2008

to December 2012 due to drug overdose and chemical poi-

soning have been reviewed by the investigators. Cases were

identified based on ICD-10 classification. A checklist for data

collection was developed based on the Saudi Ministry of

Health (MOH) reporting form for drug over dosage or

chemical poisoning. The checklist included: age, gender,

nationality, place of the incident, date and time of exposure,

time of hospital arrival, condition of patient at time of arrival

to hospital, vital signs, type of poisoning, route of exposure,

signs and symptoms, treatment given, patients’ outcome and

length of hospital stay.

The collected data were analyzed using SPSS statistical

program version 20, Chicago IL. Chi-square test has been

used to compare categorical variables. Multivariate

logistic regression analysis was applied to determine

predictors of intentional poisoning among the studied

population. Level of statistical significance was deter-

mined at p \ 0.05. This study has been approved by the

ethical committee of King Abdullah International Medical

Research center (KAIMRC).

Results

During the period from January 2008 to December 2012, a

total of 129 cases were presented to the emergency

department at King Khalid National Guard hospital due to

chemical poisoning or drug overdose. The majority of the

studied population were Saudis (n = 126, 97.7 %), and just

over half of the patients were females (n = 69, 54.3 %).

Children under 12 years old represented 44.2 % (n = 57)

of the population. The age group (1–5 years) represented

most of the afflicted children (n = 50, 87.7 %) (Table 1).

Summer time was the most common season for poi-

soning (n = 50 cases, 38.8 %). The annual incidence of

cases was approximately uniform throughout the years

from 2009 to 2012 while there were a relatively lower

number of cases during the year 2008 (Table 1).

Drug overdose represented the most common cause of

poisoning (n = 119, 92.2 %) while chemical poisoning

accounted for only nine cases (7.0 %). Poisoning with both

drugs and chemicals was reported in one single case

(Table 2). Analgesics and non-steroidal anti-inflammatory

drugs (NSAIDs) were the most commonly encountered

drugs (n = 32, 20.4 %) followed by anticonvulsants

(n = 27, 17.2 %) and antihypertensives (n = 18, 11.5 %)

(Fig. 1).

Intentional poisoning was accounted for 26.4 % of

cases. Age group from 12 to 35 years was accounted for

the highest percentage of intentional poisoning cases

Table 1 Number and percent of cases according to age, gender,

season and year of chemical poison/drug overdose incidence

Variable Number of patients (%)

n = 129

Age

Below 12 years 57 (44.2 %)

From 12 to 35 years 43 (33.3 %)

Above 35 years 29 (22.5 %)

Children \12 years old

Infants (below one year) 4 (7.0 %)

Children (1–5 years) 50 (87.7 %)

Children (6–12 years) 3 (5.3 %)

Gender

Male 58 (45.7 %)

Female 69 (54.3 %)

Time of occurence

June–August 50 (38.8 %)

September–November 31 (24.0 %)

December–February 26 (20.2 %)

March–May 22 (17.1 %)

Occurrence per year

2008 16 (12.4 %)

2009 28 (21.7 %)

2010 30 (23.3 %)

2011 27 (20.9 %)

2012 28 (21.7 %)

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(85.3 %) (Table 2). Multivariate logistic regression ana-

lysis was done to study the predictors of intentional poi-

soning in the studied population. Age and gender, were

entered into the model. Patients between 12 and 35 years

old were significantly more likely to attempt intentional

poisoning compared to those more than 35 years old

(OR = 13.75, 95 % CI = 2.59, 75.02). Female patients

were significantly more likely to attempt suicide than male

patients (OR = 7.22, 95 % CI = 1.70, 30.62).

Children under the age of 12 years represented 55.6 %

of those discharged within 24 h from their arrival to the

ER. Adults tend to stay longer in the hospital (p \ 0.05)

(Table 2). About 70.3 % of cases were clinically stable at

time of presentation to ER. Nevertheless, only 8.5 % of the

patients were discharged home without admission while

91.5 % were admitted to the hospital (67.4 % were

admitted to regular wards, 7 % to ICU/PICU and 17.1 % to

ICU then regular ward). No death sequel has been reported.

Fifty-eight patients (45 %) were given activated charcoal

which made it the most common treatment given.

Discussion

This retrospective chart review studied the pattern of poi-

soning and drug overdose in King Khalid hospital during a

Table 2 Comparing age groups

according to cause of poisoning,

circumstances of exposure and

length of hospital stay

Variable Number of patients (%)

Overall total

(n = 129)

Children (Less than

12 years)

(n = 57)

Adolescents and

adults (12–35 years)

(n = 43)

Adults (older

than 35 years)

(n = 29)

Cause of poisoning

Drug overdose 119 (92.2 %) 51 (42.9 %) 39 (32.8 %) 29 (24.4 %)

Chemical poisoning 9 (7.0 %) 6 (66.7 %) 3 (33.3 %) 0 (0.0 %)

Both 1 (0.8 %) 0 (0.0 %) 1 (100.0 %) 0 (0.0 %)

Circumstances of exposure

Intentional 34 (26.4 %) 3 (8.8 %) 29 (85.3 %) 2 (5.9 %)

Accidental 89 (69.0 %) 53 (59.6 %) 12 (13.5 %) 24 (27.0 %)

Doubtful intentional 6 (4.7 %) 1 (16.7 %) 2 (33.3 %) 3 (50.0 %)

Length of hospital stay

\24 h 54 (41.9 %) 30 (55.6 %) 14 (25.9 %) 10 (18.5 %)

24–48 h 32 (24.8 %) 19 (59.4 %) 12 (37.5 %) 1 (3.1 %)

48–72 h 20 (15.5 %) 4 (20.0 %) 9 (45.0 %) 7 (35.0 %)

More than 72 h 23 (17.8 %) 4 (17.0 %) 8 (34.8 %) 11 (47.8 %)

Fig. 1 Type of drugs reported

according to patients’ age

groups

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123

five-year period from January 2008 to December 2012.

Majority of patients were Saudis, since the studied hospital

is serving National Guard employees and their families.

Children below the age of 12 years accounted for (44.2 %)

of the cases, representing the main age group affected. This

finding has been reported in other similar studies in Saudi

Arabia [7–9, 11, 12]. However, Hegazy et al. [10] reported that

age group (14–35) years has been accounted for the highest

percentage (43.33 %) followed by the group of children below

the age of 14 years (39.4 %). Among children\12 years old,

under 5 year-old children were the highest affected group

(87.7 %). This comes in accordance with other similar studies

in Saudi Arabia [7, 9–13, 16]. This pattern is likely to be

attributed to the exploratory behaviors and curiosity of this age

group [16]. Availability of over-the-counter medications and

the increased tendency to use them have resulted in abundance

of drugs that can be found inside Saudi homes. Additionally,

most of these drugs’ containers are not childproof [17], and

consequently contribute to the increased risk of poisoning

among children.

Summer time is usually the season when most of poisoning

cases occurred in Saudi Arabia [10, 16, 18]. Summer is the

school vacation season when most of children stay indoors

with limited outdoor activities. Additionally, many Saudi

parents may leave their children at homes under supervision

of expatriate servants or care of older siblings for longer

periods either for shopping or participating in social events

(e.g. marriage ceremonies which occur mostly during sum-

mer). Spending more time indoor, where uncontrolled med-

ications and chemicals are available, and possible decreased

vigilance, all may take part in exposing children to more

danger of poisoning during summer. A prospective study

design may help exploring the magnitude of parent supervi-

sion on exposure of children to hazardous chemicals or drugs.

Occurrence of intentional poisoning in the current study

(26.4 %) is very close to previously published reports in

Saudi Arabia [7, 8, 11]. Hegazy et al. [10] reported a higher

percentage of intentional poisoning (51.0 %) and they

attributed this percentage to the increased presence of

females and adults older than 14 years (about 60 % each)

in their study. In the current study, multivariate regression

analysis showed that being a female and between 13 and

35 years old are the significant predictors of suicidal

attempt. A retrospective chart review in Riyadh, Saudi

Arabia reported that females are more likely to attempt

suicide however the difference was not statistically sig-

nificant [7]. Although data on specific reasons for suicide

attempts in our study was not available, another study by

Dabbas et al. [19] reported that the main precipitating

factor for deliberately self-harm among adult Jordanian

females was family violence, including physical and psy-

chological abuse often by the spouse. Alarming reports

from different Arab countries showed increased physical

and psychological violence against women [19–21]. On the

other hand, Ghaznawi et al. [12] (more than 20 years ago)

reported a lower suicide rate (7.79 %). They attributed this

lower percentage compared to other reports to the Islam

religion condemnation and strictly proscription of inten-

tional self-destruction (suicide). However, the observed

relative difference in suicide attempts incidence may

reflect in part the change of pattern of using medications or

having medications at homes throughout the past 20 year-

period.

Drug over dosage was the most common cause of poi-

soning for both adults and children in the current study.

This came in accordance with most studies in Saudi Arabia

[7, 9, 10, 16–18, 22]. On the contrary, Al-Hazmi [13]

accounted exposure to hydrocarbon chemicals (HCNs) as

the most common cause of poisoning among children

(40 %) followed by drug overdose (34.3 %). Also, Moaz-

zam et al. [8] accounted chemical poisoning as the most

common cause of poisoning (57.9 %) followed by drugs

(42.1 %).

Analgesics and NSAIDs were the most commonly used

drugs by both adults and children, which conform with

most international [23, 24] and national studies [7, 10, 18,

25]. Meanwhile, equal percentage of CNS and analgesic

medications (10.1 % each) was reported by Moazzam et al.

[8] Saddique accounted CNS depressants as the most

common drug poison followed by analgesics [9]. The easy

accessibility to simple analgesics (over-the-counter medi-

cation) made them the first cause of drug poisoning.

Awareness should be raised to keep drugs in safe places,

away from children’s accessibility. We reported CNS

symptoms as the most common symptoms followed by GIT

symptoms similarly to Al-Shehri [18]. However, these

findings are in contrast to some other national studies

where GIT systems were the most common reported

symptoms [8, 10].

The percentage of patients admitted to inpatient wards,

PICU/ICU or both in the current study was relatively

higher (91.5 %) compared to previous studies in Saudi

Arabia. Hegazy et al. [10], Al-Jaser et al. [26], and Al-

Shehri [18] reported admission percentages of 80, 75.7, and

85 %, respectively. Local studies reported that around

80 % of children have been discharged within the first 48 h

similar to the current study [13, 16, 22]. Meanwhile, our

study showed that (47.4 %, n = 27) of children stayed in

the hospital for more than 24 h. A relatively lower per-

centage was reported in other local studies where around

35 % of children stayed in hospital for more than 24 h [13,

16]. Thus, it would be worth to assess cost of hospital stay

due to drug overdose and chemical poisoning and its bur-

den on healthcare system in future studies.

Limitations of this study are mainly related to nature of

the study design, where some data are missed or

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123

incomplete. Moreover, data were reported from single

institute serving special group of Saudi population

(National Guard military employees and their families) in

the western region of Saudi Arabia, however, children

continue to be at high risk for exposure to drug or chemical

poisoning, mainly because of the easy accessibility to these

compounds at homes. Community health education pro-

grams should be expanded to raise public awareness on

appropriate child supervision and safe practices for main-

taining medications and chemicals out of reach of children.

Applying child-resistant packaging for medications and

dangerous household chemicals should be a requirement

for approving packages for over-the-counter medications

especially analgesics and NSAIDs, a practice that proved

dramatic reductions in paracetamol and salicylate poison-

ings in the UK [12].

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