76 Restriction of access to drugs and medications in suicide prevention

Suicide by prescription drugs and medications is a very common method of suicide in many countries. In 1972, Oliver and Hetzel first called attention to the adverse effects of easy availability of medications in Australia; they also reported that restriction of drugs and medications decreased the rate of suicides. Results for different countries support these observations; yet there is a lack of impact on clinical practice. Experiences from some countries are presented, which suggests, despite great variation around the world, that the way physicians and other mental health professionals act needs to be more congruent with existing evidence-based knowledge. Of course, even if medication is associated to risk, it can be asked if restriction makes a difference. The sparse research suggests that restriction of access to drugs and medications reduces the suicide rate. Governments and the WHO could be involved more; for example, to promote educational programmes, and to define standards and agreements among pharmaceutical companies, national health services, medical associations, and the population in general. Much more research and clinical action are needed.

Restriction of drugs and medications is consistent with a report on suicide prevention of the World Health Organization (WHO). After careful analysis of all measures by an international team of researchers, headed by Bertolote (1993), a series of tactics to prevent suicide that had support in the scientific literature were proposed. The team provided some basic steps for the prevention of suicide, among them controlling the environment: e.g. gun possession control, detoxification of domestic gas, detoxification of car emissions, and control of toxic substance availability.

Controlling the environment is not foreign to practising clinicians worldwide (Leenaars 2005). Restriction of access to drugs or control of medications—or toxic substance—availability is common practice. In 1972, Oliver and Hetzel first called attention to the adverse effects of easy availability of medication in Australia. They examined the mortality data for the period of 1955 to 1970 in Australia; a period of significant increase in suicide, and the increase of availability of sedative agents. They found that the increase of suicide with prescription drugs wholly accounted for the increase in the suicide rate, although it was difficult to establish definitively that sedatives and, in particular, barbiturates were the cause. These substances were, however, overwhelmingly implicated. Concern mounted, not only about the deaths, but also about abuse and other mismanagements.

To test this hypothesis further, they studied a 1967 law that restricted the allowable quantity of sedatives, controlled the strength of barbiturates, and allowed for no repeats of the prescriptions. Data showed that after the law was introduced, there was not only a decline in usage, but also a decrease in suicides, as well as in undetermined causes of deaths. Thus it was concluded that the falling rates of suicide in Australia were genuine, and furthermore, the data showed that there were no substitutions with other means of suicide. They concluded that a causal relationship underlies the association observed between the ready availability of potentially lethal quantities of therapeutic substances and death by self-injury from this cause. Suicide by other means had been largely unchanged; thus, the data showed no substitution with other drugs or other methods. Finally, they concluded that a proportion of deaths, due to drug ingestion, would not have occurred had the means not been so readily available.

Oliver and Hetzel suggested measures to diminish the ready availability of medications by individual wrapping of pills, and the restriction of usage by better education of all concerned.

There are further studies on the five continents to support Oliver and Hetzel's observation. An array of current studies, as well as some observations from the continents and implications worldwide, is presented.

In the United States from 1960 to 1974, Lester (1990a) found that the suicide rate using barbiturates was associated with the annual sales of barbiturates, and with the accidental death rate from barbiturates. Lester (1990b) found that in the US from 1950 to 1984, the accidental death rate from prescription drugs, specifically from barbiturates, was positively associated with the suicide rates from these methods. Lester and Abe (1990) replicated this result for all medicaments in Japan. Thus these countries show the same result as noted in Australia.

Gunnell et al. (1997) found that British sales of paracetamol, and the rate of attempting suicide with paracetamol in the Oxford area, were positively associated for 1976–1993. The same was found also for France as a whole. The attempted and completed suicide rates by paracetamol were positively associated in both Britain and France over time. In France, however, paracetamol is sold in smaller amounts (package limit in the UK was 12 grams, where in France it was 8 grams), and the attempted suicide rate using paracetamol was lower in France than in Britain (Gunnell et al. 1997).

In Sweden, Isacsson and colleagues (1995) found that suicide rates were higher for antipsychotics and anxiolytics, and lower for analgesics. Analysis of the data indicated that the number of suicides by each medication, and the number of prescriptions, was strongly positively associated. Furthermore, in Sweden, Carlsten et al. (1996) found that the suicide rate using barbiturates declined as the sales of barbiturates declined rapidly from 1977–1992, and the same parallel was found for analgesics and for neuroleptics/antidepressants. Sundquist et al. (1996) found that, in southern Sweden, the greater the sales of tranquillizers and hypnotics/sedatives in the municipalities, the higher the suicide rate; however, this pattern was not evident for antidepressants or neuroleptics. Of course, correlations imply associations and not necessarily causality; other factors, such as mental health conditions in the region, may also have accounted for the results.

Japan offers an interesting test of Oliver and Hetzel's finding. In Japan, prior to 1961, barbiturates were available over the counter without a prescription. From February 1961, the Pharmacy Act S.49 required prescriptions both for barbiturates and meprobamate. Lester and Abe (1989) examined the use of sedatives for suicide prior to and after the implementation of the Act. The suicide rate using sedatives and hypnotics peaked at 7.05 per 1,000,000 per year in 1958. Thereafter, the suicide rate by sedatives and hypnotics declined consistently. When the Pharmacy Act was implemented in 1961, the suicide rate using sedatives and hypnotics was already declining; however, the decline did increase a little after the implementation of the Act. Furthermore, the suicide rate by all other methods was examined for the same time period: it began declining even earlier, after 1955 in fact, and continued to decline until 1965. There was thus no increase in other methods after the Act, and no evidence that people switched methods for suicide once prescriptions were required for sedatives and hypnotics.

In the United Kingdom (UK), both Brewer and Farmer (1985) and Forster and Frost (1985) noted that completed and at-tempted suicide by overdoses paralleled the prescription rate for hypnotics, tranquillizers and other psychotropic drugs. Forster and Frost estimated that 1000 fewer prescriptions resulted in 3.8 fewer attempted suicides. Similar associations have been noted in Scotland (McMurray et al. 1987) and Australia (Buckley et al. 1995). Thus, data from the different continents support the practice of the restriction of access to lethal medications.

Controlling the availability of medication may be the most viable strategy to prevent suicide. Yet despite the recommendations of the WHO, and the research indicating the importance of education of the suicidal person and their families on the importance of having medication locked up or under control when a person is suicidal (Leenaars 2005), there continues to be a lack of impact on clinical practice globally. Wislar and colleagues research (1998), for example, exemplifies this absence. They conducted a chart review in an emergency department of a hospital of youths receiving mental health evaluation, with 40 per cent being suicide-related events. Suicide-related events were defined as behaviour involving self-directed injuries, e.g. cutting, jumping, or thoughts about self-injury or death. Chart reviews provided no evidence that means restriction education was provided to the young patients and/or their parents. Wisler et al.'s study, including other similar experiences, calls for greater attention by physicians and other mental health professionals to controlling the environment in the treatment of suicidal patients. Oliver and Hetzel stated the same, but also called for other strategies, such as surveillance and restricting the prescribed amount and/or dosage.

Over 30 years ago, Oliver and Hetzel noted that the implications of their findings were obvious. The more recent studies support the ‘obvious’; yet there is a lack of application. Even in countries such as the US and Canada, where medication can be obtained only by prescription, there is, as Wislar and colleagues (1998) showed, a lack of application, both in policies and in the individual clinical practice. Physicians and other mental health professionals' knowledge and attitudes need to be reshaped.

In order to obtain information on the present topic from a geographically broader area, the first author asked some people on each continent to reflect on the issues at hand (Gaspar Baquedano, Mexico; Chris Cantor, Australia; John Connolly, Ireland; Emilio Ovuga, Uganda; Silvia Palaez Remigio, Uruguay, and Lakshmi Vijayakumar, India). They were asked specifically, once they read the research to date, to reflect on the role of the physician, and on the way medications are obtained by prescription or over the counter.

Countries like Australia, Canada, Ireland, and the US require prescriptions, but in Mexico, medications without prescriptions are easily accessible in pharmacies. Physicians in Mexico are also prone to hand out large quantities of medication to patients. This, as in other regions, is a reflection of the belief by the government, and the people themselves, that if you have medications then the health system is adequate. In much of Latin America, the situation is the same. In Uruguay, for example, only medical doctors can prescribe medication. However, if a person wants to buy a drug, they can buy it without a prescription, but at higher prices. Psychotropic drugs cannot be obtained without a physician's prescription. There are restrictions in place regarding the sale of such drugs as neuroleptics, benzodiazapines and antidepressants. People are encouraged to visit the doctor and, as a result, can buy medication at cheaper prices. If a person wants other non-psychotropic drugs (many lethal), they are always available. Of course people can stockpile money to obtain the drugs, even if they are poor, just as they can stockpile available drugs.

Availability of lethal means increases the environmental fraction of the suicide risk (WHO 2006). It is, furthermore, easy to conclude, as elsewhere, that poverty dictates availability—not legislation—if there is any. In other countries, the state is even worse. In India, for example, drugs can be easily obtained in drug stores. Even though there is legislation, the majority of psychotropic medications are available without physician's prescription. This situation is repeated in much of Asia. Africa is no different; Uganda, for example, lacks legislation to control drugs. Therefore, even before one introduces means restriction, the very control of availability needs to be managed. Physicians and health professionals need to strongly support public health action; and in countries where there is a lack of knowledge about suicide risks (e.g. a lack of sufficient labelling of potential lethality by pharmaceutical companies), in many regions and legislation, these should be implemented immediately.

The problems that affect availability of medications are, furthermore, complicated by violence (WHO 2002). In countries such as Uganda, owing to poverty and breakdown of essential drug regulatory mechanisms, following years of conflict and war, medications of all types are readily available, ranging from analgesics and antibiotics through psychotropics to pesticides. Where there is a lack of central regulatory mechanisms, in addition to large populations of rodents and insects, the role of physicians in controlling the amounts of permitted medications that they can prescribe is not sufficient, as people in Uganda often ingest large quantities of pesticides or swallow quartz cells from wrist watches, or a cocktail of analgesics, antibiotics and anti-malarial drugs in a bid to end their lives. Control of harmful medications will require multifaceted approach targeting, not only health providers and members of the general public, but also special groups including government officials, traders, farmers, insecticide producers, veterinarians, pharmacy specialists, owners of pharmacies, and drug companies.

Of course, the control of availability of medications and drugs, which can be used as a mean of suicide, is not sufficient. The control of medication involves not only a duty to restrict access to what are dangerous and lethal products when misused, but also to prescribe appropriately, rationally and adequately for mental illnesses. Physicians play a great and decisive role here. The prescribing of large quantities, as seen in Mexico, is lethal. One should prescribe according to risk; this will mean greater education for physicians. For example, Chris Cantor from Australia tells of a patient who was prescribed the sleeping tablet chloral hydrate. The GP had been concerned that benzodiazapines might be used for a suicide attempt, so chloral hydrate was prescribed instead. The physician had been attending to risk issues but prescribed the worst possible sleeping tablet. Each of the authors could report such individual cases. Information to physicians and health professionals is obviously incomplete, even in Australia, Europe, North America, Africa, Asia, and South America. Wislar et al.'s study (1998) further shows that patients and their families need to be educated, by encouraging them to dispose of excess unused tablets. This is especially important with patients who do not comply with treatment regimes. This leads to stockpiling of large amounts of unused medications that are readily accessible as a means of suicide, as well as posing a danger to others, particularly children, the elderly, and animals. This is, as noted, further complicated by the practice of prescribing large dosages in countries such as, for example, Mexico. This problem must be addressed as a matter of urgency. There is, for example, in Dublin, Ireland, a scheme that was introduced for the proper disposal of unused medication. The initiative involved not only physicians and pharmacists, but also the patients and their families. Public information on the dangers of medication, measures to control availability and dispose of medication is necessary worldwide.

A basic question from a public health perspective is: Does research support the positive effect of the implementation of strategies to control availability of drugs? The research cited indicated that the availability of medication is associated to risk. Thus, it can be asked, does restriction of access to drugs and medications reduce the risk? The research shows that this approach, indeed, has an influence on decreasing suicide rates; however, more studies are needed.

Melander et al. (1991) compared data in two towns in Sweden from 1978. One of the towns (Malmö) had instituted prescription surveillance, and an information campaign about medication use, after it was found that the city had the highest suicide rate and prescription rate for anxiolytic–hypnotic drugs (AHD) in the country. The campaign resulted in a 25 per cent decrease in suicide, a 12 per cent decrease in AHD prescriptions, and a 40 per cent decrease in AHD abuse. In the other comparable city (Gothenberg), where no such campaign was carried out, the suicide rates were found to increase during the following seven years. These observations suggest that restricting prescriptions can decrease AHD abuse and suicide.

Reducing the size of packs of paracetamol in the UK in 1998 resulted in a 31 per cent reduction in cases of self-poisoning with paracetamol in Birmingham (Hughes et al. 2003). In a recent review of studies Morgan and Majeed (2004) concluded that admissions to liver units, admissions for liver transplants and emergency room admissions for paracetamol poisoning had declined in the UK after the packaging restrictions in 1998.

Despite the clear evidence, since the work of Oliver and Hetzel 1972, restriction of easily available drugs and medication does not appear to be implemented on most continents. The facts are unequivocal. Oliver and Hetzel called for control of the availability of means for suicide. The way of obtaining prescriptions needs to be regulated; physicians and other mental health professionals can play a major role here, not only in education, but also in means restriction. The problem is, however, more complex; the references to the continents shows this. More can be done.

Governments and agencies need to be aware of these issues in order to promote international cooperation, establishing educational campaigns, and international agreements among pharmaceutical companies, national health services, and medical associations. Within the context of cultural sensitivities, international standards need to be developed. The WHO could be involved in defining standards, establish campaigns and international agreements among pharmaceutical companies, national health services, medical associations and populations in general. The implications of the research, as Oliver and Hetzel noted in 1972, are obvious: more practical applications are needed.