IJMS Vol 42, No 4, July 2017 Review Article A Narrative Review of Acute Adult Poisoning in Iran Samira Alinejad1, MD; Abstract Nasim Zamani2, MD; Mohammad Abdollahi3, PhD; Poisoning is a frequent cause of referral to medical emergencies Omid Mehrpour1, MD and a major health problem around the world, especially in developing countries. We aimed to review the epidemiology and pattern of adult poisoning in Iran in order to facilitate the 1Medical Toxicology and Drug Abuse early diagnosis and management of poisoning. The pattern of Research Center (MTDRC), Birjand University of Medical Sciences, poisoning is different in various parts of Iran. Pharmaceutical Birjand, Iran; compounds were the most common cause of poisoning in most 2 Department of Clinical Toxicology, parts of Iran. Pesticide-related toxicities were more common in Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, northern agricultural regions, whereas bites and stings were seen Tehran, Iran; more commonly in southern Iran. Carbon monoxide poisoning 3Toxicology and Diseases Group, Pharmaceutical Sciences Research was common in cities with many motor vehicles such as Tehran Center, Tehran University of Medical and in colder climates such as in northern and western regions due Sciences, Tehran, Iran to inadequately vented gas appliances such as stoves and heaters. Correspondence: Majoon Birjandi (containing cannabis) is a unique substance used Omid Mehrpour, MD; in eastern Iran. Poisoning by opioids, tramadol, and pesticides Medical Toxicology and Drug Abuse (organophosphate and aluminum phosphide) has remained a Research Center (MTDRC), Birjand University of Medical Sciences common hazard in Iran. Poisoning-associated morbidity and (BUMS), Moallem Avenue, Zip mortality rates vary by region and have changed over time due Code: 97178-53577, Birjand, Iran. to the introduction of new drugs and chemicals. Early diagnosis Tel\Fax: +98 56 32381270 Email: [email protected] and proper treatment may be lifesaving; thus, understanding the Received: 18 September 2016 general pattern of poisoning in different regions is important. Revised: 07 January 2017 Accepted: 22 January 2017 Please cite this article as: Alinejad S, Zamani N, Abdollahi M, Mehrpour O. A Narrative Review of Acute Adult Poisoning in Iran. Iran J Med Sci. What’s Known 2017;42(4):327-346. • In Iran, poisoning is one of the Keywords ● Epidemiology ● Iran ● Medicine ● Pesticides most common causes of hospitalization ● Poisoning ● Stings ● Toxicity and the 2nd leading cause of mortality. The pattern of poisoning is dissimilar in different regions of Iran. Understanding the common pattern of poisoning in different regions can contribute to early Introduction diagnosis and treatment of poisoning. Pharmaceutical compounds, pesticides, Intentional or accidental exposure to poisons and drugs is a stings, and bites are the most common typical problem in medical emergencies and a major health causes of poisoning in Iran. problem in developed or developing countries.1-6 It is estimated What’s New that poisoning accounts for over 1 million morbidities worldwide annually.7 Fatality rates are estimated to be as high as 20% in • Medications were the most common some regions, and over 200,000 individuals are predicted by cause of poisoning in most parts of Iran. the World Health Organization to die as a result of pesticide Pesticides were more common in northern poisoning alone each year.7 Poisoning is the most common type regions, whereas bites and stings were more commonly reported in southern Iran. of lethal self-harm in Asian countries in that it accounts for more 8 Majoon Birjandi (containing cannabis) than 60% of all deaths. is a unique substance used in eastern In developing countries with insufficient drug and chemical Iran. Poisoning by opioids, tramadol, regulations, lack of surveillance systems and easy access to more and pesticides (organophosphate and aluminum phosphide) remains common toxic drugs or chemicals have been blamed for higher poisoning 9 in Iran. Moreover, lead poisoning due to rates. The higher toxicity of available poisons in the developing opium use is another recently recognized countries and the shortage of medical services in these countries hazard in Iran. In addition, medicinal plants, contribute to higher mortality rates due to poisoning (10%–20% often considered safe, could also be toxic. in comparison with 0.5%–1% in developed countries).10 Analyses Iran J Med Sci July 2017; Vol 42 No 4 327 Alinejad S, Zamani N, Abdollahi M, Mehrpour O recently made on the data from a few Asian Table 1: Summary table for the patients of the studies countries estimate that there may be 300,000 Region/Poison No. of No. of % of all intentional ingestions of pesticides in this region studies patients poisonings annually with suicidal purpose.11,12 North of Iran1 49 60542 100 Iran is a developing country with almost 80 Medicines 45605 75 million residents.1 Poisoning accounts for 15% to Substances 6141 10 13-15 20% of emergency department visits in Iran. Pesticides 6742 11 In 1991, Iran had the 91st rank of self-poisoning Bites 111 <1 in the world (111 suicides per year), which Others 1943 3 changed to 58th in 2003 (mean of 3,967 cases South of Iran2 16 49390 100 annually). Medicines 1695 3 Poison-associated morbidity and mortality Substances 556 1 rates vary by region and may change over Pesticides 162 1 a certain period of time as new drugs and Bites 46965 95 chemicals are introduced. Understanding the Others 12 <1 pattern of intoxication in a certain region would East of Iran3 7 9961 100 possibly contribute to the early diagnosis and Medicines 5191 47 treatment of poisoning.16,17 The pattern and Substances 1048 9 prevalence of various common toxic agents in Pesticides 1882 19 different parts of Iran were reviewed in order to determine the common poisoning patterns in Bites 1198 11 various parts of Iran. Others 1252 14 West of Iran4 7 1847 100 Pharmaceutical Compounds Medicines 568 30 Substances 226 12 Due to the general increase in the availability Pesticides 275 14 of medications, especially over-the-counter Bites 635 34 (OTC) products, pharmaceuticals were the Others 143 7 most common cause of poisoning In Iran.2,18,19 Center of Iran5 7 2049 100 Medications acting on the central nervous Medicines 960 46 system (CNS) are the most common ones used Substances 686 33 for self-harm throughout the developing world. Pesticides 46 2 Of the analgesics, acetaminophen is the most Bites 287 14 commonly used poison in some regions of Others 70 3 developing countries.10,20-22 1East Azerbaijani (Tabriz), West Azerbaijan (Urmia), In studies conducted in Shiraz, Kermanshah, Ardabil, Zanjan, Qazvin, Guilan (Rasht), Mazandaran 2 Isfahan, Tehran, and Razavi Khorasan (Sari), and Tehran; Khuzestan (Ahvaz, Ramhormoz, Izeh, and Ramshir), Sistan-Baluchistan, Fars (Shiraz), (Neishabour), pharmaceutical compounds Kerman (Rafsanjan), and Hormozgan (Bandar were the most common causes of poisoning Abbas); 3South Khorasan (Birjand) and Khorasan (table 1).23-28 Additionally, in studies conducted Razavi (Mashhad); 4Ilam, Chaharmahal and in Bandar Abbas, Gorgan, Kashan, Tabriz, Bakhtiari (Shahrekord), Kurdistan (Sanandaj), Kermanshah, Lorestan (Khorramabad), and Hamadan; and Tehran, pharmaceutical drug toxicity was 5Esfahan (Kashan) and Yazd the most common method of self–poisoning 29-34 (table 2). The most important pharmaceutical cause of death among non-narcotic drugs in drugs ingested were antidepressants, sedative- deaths referred to the Tehran Forensic Medicine hypnotics, antipsychotics, antiepileptics, Organization.42 acetaminophen, and opioids. A very commonly prescribed group of Intoxication with antidepressants, particularly medications consists of antiepileptic drugs tricyclic antidepressants (TCAs), is one of the most common causes of admission to (AEDs). The epidemiology of AED poisoning Iranian poisoning emergency departments.35 has not yet been well evaluated in developing Psychological problems and addiction are countries such as Iran. In a study conducted factors associated with TCA poisoning.36,37 in Tehran on patients poisoned with AEDs Antidepressants, especially TCAs, were the other than benzodiazepines, phenobarbital, leading cause of poisoning in Tehran7,36,38,39 carbamazepine, and sodium valproate and Urmia,40 and the 2nd most important cause accounted for most cases of poisoning (89%).43 of poisoning in Tabriz and Mazandaran.16,41 In Although benzodiazepines, TCAs, other addition, TCA poisoning was the most prevalent antidepressants, and antihypertensives were 328 Iran J Med Sci July 2017; Vol 42 No 4 Pattern of poisoning in Iran Iran JMedSci Table 2: Review of demographic findings in general epidemiological studies Author Region Study Most common cause of Most Dominant gender Dominant Dominant Intentional/ Mortality size poisoning affected age marital status employment Unintentional Afshari et al., 2004 Khorasan 71589 Pharmaceuticals (CNS Mean age of Female Not mentioned Not mentioned Intentional 0.6% July 2017; Vol 42No4 July 2017;Vol Razavi (Mashhad) drugs) 22.3 Eslami et al., 2014 East 988 Pharmaceuticals 21-30 years Male Married Unemployed Intentional Most of the Azerbaijan (Tabriz) (benzodiazepines) (65.1%) (55.36%) cases were discharged with recovery (97.2%). Hashemnezhad and Fatehi Karaj 172 Pharmaceuticals 20-25 years Male and females Married Not mentioned All were 5.8% 2014 (benzodiazepines) were equal (55.8%) intentional Sobhani et al., 2000 Guilan (Rasht) 1215 Organophosphates