Drug and non-drug intoxications in Germany: an analysis of hospital diagnosis data from the GBE database

>> Already published international analyzes show, for example, connections between parents' level of education, gender, age, professional status and ethnicity with unintentional poisoning of children, drug overdoses and high-risk drinking (Paljärvi et al. 2013, Ayubi et al. 2016, Brady et al. 2017)
The frequency of various intoxications may be subject to regional and temporal changes. The spectrum of toxic substances in poisoning inquiries/cases differs between the member states of the European Union (EU) (Hahn & Feistkorn, 2019). The group of adverse drug reactions and intoxications with alcohol and drugs has been the most common cause of poison-induced hospitalizations in Germany for years (Wollenschläger, 2008; Hahn & Feistkorn, 2019). Poison information centers and the Federal Institute for Risk Assessment (BfR) can register side effects and cases of poisoning with new medications as part of pharmacovigilance. However, there is currently no viable, systematic national monitoring in Germany as part of a toxicovigilance system (Hahn & Feistkorn, 2019).
Against the background of an often strong focus on poisonings caused by alcohol and drugs as well as few available statistical analyzes of poisonings, the aim was to change the frequency of hospital diagnoses of drug-related (T36.* - T50.*) and non-drug-related poisonings (T51 .*–T65.*) in Germany for the years 2008-2017. Possible differences at the federal state level, in relation to gender and between different age groups should be examined. In addition, potential correlations between changes in the number of poisonings and sociodemographic data in the years considered should be analyzed.
methods
Data sources
This study was a retrospective analysis of hospital diagnosis data on drug and non-drug poisonings. The drug poisonings were based on the ICD-10 codes T36.* – T50.* (poisonings by medicines, drugs and biologically active substances) (GBEa) and the non-drug poisonings were based on the ICD-10 codes T51.* – T65. * (Toxic effects of substances primarily used for non-medical purposes) (GBEb). The corresponding age-standardized case numbers of drug and non-drug poisonings per 100,000 inhabitants were taken from the federal health reporting information system (GBE database) (GBEa,b).
Data for the years 2008-2017 were retrieved by gender and age group. Furthermore, the age-standardized number of cases per 100,000 inhabitants of drug and non-drug poisoning were used for 2017, both for Germany as a whole and for the individual federal states (GBEa,b). Only diagnostic data from people residing in Germany were used.
All of the following data was taken from the corresponding sources for the years 2008-2017. Income per capita was obtained from the federal and state statistical offices (BW). The number of causes of death due to intentional self-harm (suicides) were taken from the GENESIS database of the Federal Statistical Office (GENESIS).
The unemployment rates, the proportion of people aged ≥15 years based on general educational qualifications and the number of households with housing benefit in the years examined could be taken from the Federal Statistical Office (DESTATISa,b,c). The hospital diagnosis data (age-standardized cases/100,000 inhabitants) for the ICD-10 codes F10.* (mental and behavioral disorders caused by alcohol), F10.* – F19.* (mental and behavioral disorders caused by psychotropic substances) and F32.* (depressive episode) were also taken from the GBE database (GBEc,d,e).
Since this study was a retrospective analysis of published diagnostic data, approval from the ethics committee of the HSD Hochschule Döpfer was not necessary for its implementation.
statistical evaluation
The chi-square test was used to analyze the change in age-standardized hospital cases per 100,000 inhabitants (rate) of drug and non-drug poisonings over the years 2008-2017. Odds ratios (OR) and the associated 95% confidence intervals (95% CI) were calculated for the years 2009 to 2017 compared to the age-standardized rate of the reference year 2008. The chi-square test was also used to analyze gender-specific differences in the years 2008 to 2017, the age-specific differences in the years 2008 and 2017 and the federal state-specific differences in 2017. The age-standardized diagnosis rates for men, 45-54 year olds and the diagnosis rate for Germany as a whole were set as the corresponding references.
To determine correlations between changes in age-standardized diagnosis rates of drug and non-drug poisoning over the years 2008 to 2017 and socio-
The Spearman correlation (rho) was used to determine economic and health factors in the corresponding years.
For all analyses, a p value of ≤0.05 was considered statistically significant. The analyzes were carried out using the PSPP and JASP programs (GNU 2015, JASP 2020).
Results
Poisonings between 2008 and 2017
In the case of drug poisonings, with the exception of 2011, a steady decline in age-standardized diagnosis rates was observed from 2008 to 2017 (Fig. 1). In 2015 (OR: 0.60 [95% CI: 0.39; 0.94]; p=0.023), 2016 (OR: 0.55 [95% CI: 0.35; 0.86]; p= 0.008) and 2017 (OR: 0.51 [95% CI: 0.32; 0.81]; p=0.004), the differences in rates were significantly smaller compared to the diagnosis rate in 2008. In all calendar years considered, women had the higher rate Risk of drug poisoning compared to men, with the risk only being significantly higher in 2008 to 2013 (Table 1).
For non-drug poisonings, there was also a steady decline in age-standardized diagnosis rates per 100,000 inhabitants from 2012 onwards compared to 2008 (Fig. 1).
However, in no year was there a significant difference compared to the reference year 2008. Women had a numerically lower risk of non-drug poisoning than men in each year, although the difference was not significant between the two genders in any year (Table 1).
The analysis of the age-standardized rates by age group showed that drug poisonings in 2008 in the age groups of 15-24 years old (OR: 1.67 [95% CI: 1.17; 2.38]; p = 0.005) and Significantly higher rates occurred in 75+ year olds (OR: 2.02 [95% CI: 1.43, 2.86]; p≤0.001) compared to the reference age group of 45-54 year olds. In contrast, the rate was significantly lower among those under 15 years of age (OR: 0.60 [0.38; 0.96]; p=0.03) (Table 2).
In 2017, only among 15-24 year olds (OR: 2.31 [95% CI: 1.41; 3.76]; p=0.001) was the age-standardized diagnosis rate significantly higher compared to the reference age group. When it came to non-drug poisonings, there were no significant differences in the age groups in the two years under consideration, 2008 and 2017 (Table 2).
In 2017, the age-standardized diagnosis rates of drug poisoning in all federal states were comparable to the rate in Germany as a whole (Fig. 2). The analysis of the age-standardized diagnosis rates of non-drug poisoning also showed that, with one exception, all federal states showed non-significant differences and thus comparable rates to the rate for Germany as a whole. The exception mentioned was determined for Berlin, where the risk of non-drug poisoning was significantly increased by 52% (OR: 0.48 [95% CI: 0, 22; 1.01) p=0.048] was lower compared to Germany as a whole.

Correlations between poisonings and socioeconomic/health factors
A significant inverse correlation between the decrease in age-standardized cases per 100,000 inhabitants was found for both drug-related (rho: -0.924; p<0.001) and non-drug-related (rho: -0.894; p<0.001) poisonings with the increase in income per capita be determined between 2008 and 2017 (Table 3). Also with the proportion of people with a medium level of maturity (rho: -0.911; p<0.001 or rho: -0.868; p=0.001) and technical college/university entrance qualification (rho: -0.924; p<0.001 or rho: -0.881; p<0.001), significant inverse correlations were determined with the decrease in poisonings. The proportion of people with a secondary school diploma in the calendar years under consideration, however, correlated non-inversely with the decrease in drug (rho: 0.924; p < 0.001) and non-drug poisoning (rho: 0.881; p < 0.001). The unemployment rates in the years 2008 to 2017 also correlated significantly with the age-standardized rates of drug (rho: 0.912; p < 0.001) and non-drug poisoning (rho: 0.875; p < 0.001). A significant correlation could also be calculated for the number of households with housing benefit between 2008 and 2017 as well as for drug (rho: 0.736; p=0.015) and non-drug (rho: 0.705; p=0.023) poisonings.
However, the decrease in age-standardized rates of hospital-diagnosed drug and non-drug poisonings did not show any significant correlations with the number of suicides, the proportion of people without a school leaving certificate or the age-standardized F10.*–, F10.*– F19.*– and F32.*-. Cases per 100,000 inhabitants in the calendar years under consideration.
discussion
This analysis of age-standardized hospital diagnosis rates of drug and non-drug poisoning in Germany shows that cases decreased significantly from 2008 to 2017 and that differences exist between certain age groups. Furthermore, possible correlations between the decrease in cases and socio-economic factors could be identified.
There are correlations between the increase in income and the increase in the proportion of people in higher education groups with the decrease in poisonings in the years under consideration. Previously published data show comparable results with regard to high-risk alcohol consumption and accidental poisonings in children (Paljärvi et al. 2013; Ayubi et al. 2016). It is known that parents with longer training are associated with a lower risk of accidental poisoning of children compared to parents with shorter or no training (Ayubi et al. 2016). These data are supported by further analysis, which showed that the greater the social disadvantage, the higher the risk of medication (T36.* - T50.*) and non-medication (T51.* - T65.* ) Poisoning (Groom et al. 2006).
Based on our analysis, in 2017 only the population of 15-24 year olds was significantly more frequently affected by drug poisoning based on hospital diagnosis data, although in 2008 the <15 year olds, 15-24 year olds and 75+ year olds still showed significant differences to the reference group of 45-54 year olds showed. Furthermore, the OR for 15-24 year olds increased from 1.67 to 2.31 between 2008 and 2017, although the overall number of drug poisoning cases fell, indicating a relative increase in risk in this age group. In a meta-analysis on drug poisoning, however, the populations of 35-44 and 45-54 year olds had the highest risk of drug overdose (Brady et al. 2017). Another analysis from Australia showed that older people with dementia are at higher risk of poisoning (Mitchell et al. 2015).
Published data also shows that men are said to have a significantly higher risk of drug overdose (Brady et al. 2017). The data from the analysis presented here indicate that between 2008 and 2013 the risk of poisoning was significantly higher for women than for men. This is consistent with the finding that of the approximately 1.9 million drug addicts in Germany, around two thirds are women. In addition to multifactorial factors, more frequent visits to the doctor compared to men and less frequent consumption of alcohol are assumed to be the causes (DHS, 2020). The documented inquiries to GIZ (2020) for recorded poisoning substances show a clear increase in poisonings caused by psychotropic drugs, for example in 2011 (e.g. doxepin, diazepam, zopliclone, lorazepam). Men, on the other hand, showed a numerically higher risk of non-drug poisoning in our analysis, which could possibly be due to occupational poisoning. For example, many metals cause poisoning and are used in industry (e.g. mercury, lead, chromium or cadmium), in mining and manufacturing, as well as in the construction industry, in which men work disproportionately often (Federal Statistical Office, 2012; RKI, 2014 ).
There are no differences between the federal states in the frequency of hospital-diagnosed poisonings, even though significantly fewer non-medicinal poisonings occurred in Berlin. In our opinion, the number of cases and the level of significance as measured by the 95% CI were too small to draw definitive conclusions.
Based on the results of this analysis, a viable, systematic national monitoring as part of a toxicovigilance system, as mentioned by Hahn & Feist (2019), could help prevent poisonings, for example by quickly identifying trends. Furthermore, preventive measures, particularly with regard to drug poisoning, should be increasingly aimed at the 15-24 age group, women and financially and educationally disadvantaged groups. Interventions should, on the one hand, aim to network the health care actors involved in drug distribution (prescribing doctors, pharmacies, pharmaceutical industry, addiction counseling centers), but also not ignore the social responsibility for the risk groups described.
This analysis has several limitations:
• First, only hospital diagnostic data were used, so the actual rates of drug and non-drug poisoning could be higher.
• Second, the age-standardized rates were relatively low, as evidenced by the wide 95% confidence intervals.
• Third, only some socioeconomic factors were used to calculate correlations and it is possible that other factors may correlate with the decrease in poisonings.
Conclusions
Gender, age and social status play a role in the frequency of drug and non-drug poisoning. Despite a significant decrease in hospital-diagnosed poisonings, preventative measures, particularly with regard to drug-related poisonings, should increasingly focus on the 15-24 age group, women and financially and educationally disadvantaged groups. <<