Patients presenting with acute poisoning to an outpatient emergency clinic: a one-year observational study in Oslo, Norway

The majority of the 2923 poisonings were AOSAs, and the most frequent toxic agents were ethanol, heroin, benzodiazepines, and amphetamine. One in five patients were hospitalised. Half of the ethanol poisonings in patients under the age of 26 were in females. Most young patients with ethanol poisoning presented during weekends.

Patients were registered consecutively during one year to ensure that all poisonings were included, and to encompass seasonal variations. Though some patients declined to participate, the study gives a nearly complete picture of the poisonings seen at the OAEOC. It does not, however, give the full picture of poisoning in Oslo, mainly because the most severely poisoned patients are not treated at the OAEOC. There are approximately 120 deaths from poisoning in Oslo annually, 80–90 % occur outside the health services and are declared dead on site [15, 18]. Some 700 poisonings per year bypass the OAEOC on their way to Oslo hospitals, most of them poisonings with pharmaceuticals triaged by the ambulance service [10, 15]. In 2003, 750 patients were discharged on site by the ambulance service, mainly after treatment for opioid poisoning [10]. However, most poisonings with substances of abuse in Oslo are treated at the OAEOC [9, 15]. Thus, this study should be a good indicator of trends and changes in this category of poisonings in Oslo.

No toxicological screening tests are done at the OAEOC, except for ethanol breath analyser test. No confirmative tests were done in this study, rendering the diagnosis of toxic agents uncertain. This is a major limitation. However, the study mirrors the actual clinical situation in emergency settings such as the OAEOC. There may also be inter-rater differences in the diagnostic assessments, as many physicians participated.

Some co-categorisations make the results less precise. Both amphetamine and methamphetamine are probably present in the amphetamine category. Users in Oslo rarely distinguish between them, but Norwegian police has seized more methamphetamine than amphetamine since 2003 [19]. In 2008 Z-hypnotics made up 15 % of the sedatives [9]. Developments, however, cannot be traced, as Z-hypnotics were categorised as benzodiazepines in the present study. From comments written on the registration forms it is evident that poisonings with synthetic cannabinoids first appeared at the OAEOC in the fall of 2011. However, no separate category had been made on the registration forms, and they were categorised as cannabis.

The number of poisonings treated at the OAEOC has increased by 24 % since 2008 [9]. In comparison, the population of Oslo has grown by 8 %. Thus, the increase observed from 2003 to 2008 [9] has continued. GHB poisonings more than doubled (148 % increase), and there were substantial increases in ethanol (36 %), amphetamine (40 %) and cocaine (66 %) poisonings. In contrast, there was a decrease in fire smoke exposures. The proportions of ambulance referrals, hospital admissions and suicide attempts were largely unchanged since 2008 [9].

Total sales of alcohol in Norway has been stable since 2007, and total consumption among adolescents and young adults had been decreasing from 2003 to 2008 [19]. Still, the number of acute ethanol poisonings at the OAEOC has increased, many of them, as elsewhere [20, 21], in young patients in weekends. Studies from different European cities also report an increase in the number of ethanol poisonings over the last decade, especially among young adults and adolescents [4, 21‐23]. It is possible that a segment of the younger population drink larger quantities than before, as some studies have shown [5, 23, 24]. If so, this is a disconcerting trend, as binge drinking carries the risk of serious consequences [25, 26].

Half of the young patients with ethanol poisoning were female. Though most studies report a majority of males [4, 5, 20, 21], similar findings have been reported from Slovakia [23], and a Swiss study showed an increasing number of young females with ethanol poisoning [22]. About 80 % of Norwegians under the age of 20 report having drunk alcohol. The proportion has been slightly larger for females than males during the last decades [19]. However, young females presenting with ethanol poisoning as often as young males, has not been reported in Norway before.

The increase in GHB poisoning is probably a reflection of more widespread use in Norway, consistent with the increase in police seizures [19].

Poisonings with novel central stimulant drugs were hardly seen. This contrasts with findings from the UK [2]. Ecstasy poisonings were few, similar to in the UK [2], and consistent with decreasing seizures by Norwegian police [19]. Poisoning with these substances may have been misclassified as amphetamine or cocaine, both increased compared to 2008 [9]. Amphetamine still dominated, as has been usual in Norway [27].

The widespread combination of opioids with benzodiazepines and central stimulants is worrying [28, 29]. Most fatal poisonings in Oslo are due to opioids, usually combined with other agents [15, 18, 30].

In 2008, 48 % of the patients were discharged without follow-up [9]. This proportion was reduced to 36 % in this study, mainly because many patients were enrolled in a new follow-up program for the young run by the Emergency Social Services. A major incitement for creating this program was the large proportion of patients discharged without follow-up shown in the 2008 study. The emergency setting is an opportunity for interventions to reduce alcohol and drug use and abuse, and such interventions should be encouraged [31, 32].

Only two percent of patients with suicidal intention were discharged without follow-up, a reassuring finding, as these patients have a higher risk of future suicide [1]. Compared to 2008, patients were referred to psychiatric outpatient treatment rather than hospitalised, after suicide attempts [9]. More detailed data on the follow-up initiated from the OAEOC, and whether the patients actually presented at the institution they were referred to, will be presented in separate articles.

This study shows the wide range of poisonings treated in a primary care setting. Four fifths of the patients with acute poisoning brought to the OAEOC were treated locally and discharged without transfer to hospital, as in the previous studies [9, 10], and no patients died at the OAEOC. As long as the patients in need of hospital management are identified and transferred, it seems sensible to treat poisoned patients in primary care outpatient emergency clinics.