Each year poisonings account for approximately 37,000 deaths and at least 1.7 million emergency department visits in the United States.^2,3 Males have a nearly two-fold higher incidence of death than do females and 15% of adult poisoning deaths are attributed to suicide. Approximately 0.2% of poisoning deaths involve children younger than 5 years.² Of emergency department visits, typically 31% involve illicit drugs only, 28% involve pharmaceuticals only, 13% involve illicit drugs with alcohol, and 10% involve alcohol with pharmaceuticals.² Approximately 40% of emergency department visits for poisoning involve abuse of prescription and nonprescription drugs with one half of these patients taking multiple drugs. The number and rates of poisoning deaths from all circumstances have been increasing steadily, with a 90% overall increase from 1999 to 2006, representing 37,286 deaths in 2006.³ This increasing mortality trend has placed poisoning as the second leading cause of injury death overall and the leading cause of injury death of people 35 to 54 years of age. Poisoning deaths were most frequently due to drugs. The number of deaths from opioid analgesics has nearly tripled from 1999 to 2006 and opioids were involved in nearly 40% of all poisoning deaths in 2006.⁴

Several databases in the United States provide different levels of insight into and documentation of the poisoning problem (Table 14–2). Poisonings documented by U.S. poison centers are compiled in the annual report of the American Association of Poison Control Centers' National Poison Data System (AAPCC-NPDS).⁵ Although it represents the largest database on poisoning, it is not complete because it relies on individuals voluntarily contacting a poison control center. The AAPCC-NPDS dataset captures approximately 5% of the annual number of deaths from poisoning tabulated in death certificates.^5,6 Despite this shortcoming, AAPCC-NPDS provides valuable insight into the characteristics and frequency of poisonings. In the 2007 AAPCC-NPDS summary, 2,482,041 poisoning exposures were reported by 61 participating poison centers that served the entire United States.⁵ Children younger than 6 years accounted for 51% of cases. The home was the site of exposure in 93% of the cases, and a single substance was involved in 91% of cases. An acute exposure accounted for 91% of cases, 83% of which were unintentional or accidental exposures. Only 13% were intentional. Fatalities accounted for 1,239 (0.05%) cases, of which 3% were children younger than 6 years. The distribution of substances most frequently involved in pediatric and adult exposures differed; however, medicines were the most frequently involved (52%) substances (Table 14–3). Seventy-three percent of the poison exposures were treated at the scene, typically a home. In summary, children account for most of the reported poison exposures, but adults account for a greater proportion of life-threatening effects from poisoning.

TABLE 14-2 Comparison of Various Poisoning Databases

TABLE 14-3 Poison Exposure by Age Group and Fatal Outcome, Ranked in Decreasing Order

Economic Impact of Poisoning

Poisoning accounted for a total lifetime cost of $12.6 billion annually in 2003 dollars.⁷ Estimates of the lifetime cost of injury include related healthcare costs and lost lifetime earnings of the victim; however, they do not include the costs of suffering, reduced productivity of caregivers, or legal costs. The definition of poisoning for this economic estimate excluded poisoning from alcohol and illicit drugs.

Poison Prevention Strategies

The number of poisoning deaths in children has declined dramatically over the past four decades, due, in part, to the implementation of several poison prevention approaches.^7,8 These include the Poison Prevention Packaging Act (PPPA) of 1970, the evolution of regional poison control centers, the application of prompt first aid measures, improvements in overall critical care, development of less toxic product formulations, better clarity in the packaging and labeling of products, and public education on the risks and prevention of poisoning.⁹ Although all these factors play a role in minimizing poisoning dangers, particularly in children, the PPPA has perhaps had the most significant influence.⁸ The intent of the PPPA was to develop packaging that is difficult for children younger than 5 years to open or to obtain harmful amounts within a reasonable period of time. However, the packaging was not to be difficult for normal adults to use properly. Safety packaging is required for a number of products and product categories (Table 14–4). Child-resistant containers are not totally childproof and may be opened by children, which can result in poisoning. Despite the success of child-resistant containers, many adults disable the hardware or simply use no safety cap, thus placing children at risk. Fatigue of the packaging materials can occur, which underscores the need for new prescription ware for refills, as required in the PPPA.¹⁰

TABLE 14-4 Examples of Products Requiring Child-resistant Closures

Poison prevention requires constant vigilance because of new generations of families in which parents and grandparents must be educated on poisoning risks and prevention strategies. New products and changes in product formulations present different poisoning dangers and must be studied to provide optimal management. Strategies to prevent poisonings should consider the various psychosocial circumstances of poisoning (Table 14–5), prioritize risk groups and behaviors, and customize an intervention for specific situations.^11,12

TABLE 14-5 Psychosocial Characteristics of Poisoning Patients