Regular Article
Identification of Factors Necessary for Gatekeeper of Overdose
2024 年 47 巻 1 号 p. 112-119
詳細
2024 年 47 巻 1 号 p. 112-119
Overdose has become a global social problem. The Japanese government requires gatekeeper training to detect and prevent indicators of overdose and suicide. However, knowledge of necessary factors for the gatekeeper of overdose (patient intervention) is limited. This study aimed to investigate the characteristics of individuals who experienced intervening persons expected to overdose, and to identify the factors required of gatekeepers. A Google form was used to survey 298 pharmacists and registered sellers in Japan. We searched for factors by logistic analysis. Knowledge of prescription drugs used for overdose was higher among pharmacists than among registered sellers. Conversely, pharmacists and registered sellers had similar knowledge about OTC drugs. Overall multivariate logistic regression analysis revealed countermeasures against overdose at their workplace (odds ratio (OR): 4.01, 95% confidence interval (CI): 2.25–7.15, p < 0.01) and knowledge that overdose is on the rise (OR: 1.93, 95% CI: 1.04–3.69, p < 0.05) to be significantly associated with intervention experience as a gatekeeper. Countermeasures against overdose at their workplace (OR: 2.40, 95% CI: 1.10–5.25, p < 0.05) in pharmacists and years of work experience (OR: 1.13, 95% CI: 1.04–1.24, p < 0.05), countermeasure against overdose at their workplace (OR: 3.43, 95% CI: 1.18–10.0, p < 0.05), and willingness to participate in study sessions and workshops on overdose (OR: 3.50, 95% CI: 1.51–8.10, p < 0.05) in registered seller were significantly associated with intervention experience as a gatekeeper. These results are useful evidences for countermeasures and gatekeeper training for overdose at pharmacies and drugstores in the community.
Drug overdose due to self-harm has devastating consequences for the body.1) Drugs frequently used for overdose include prescribed psychotropic drugs (antipsychotics, antidepressants, benzodiazepines, and mood stabilizers).2) OTC drug overdose has been increasing in recent years.3–6) In addition, the stress of the coronavirus disease-2019 (COVID-19) pandemic had increased overdose mortality in the United States and Canada.7) Furthermore, drug overdose is a method of committing suicide.8)
Overdose may cause tracheal intubation due to drug action, which may cause serious symptoms.9) Furthermore, self-harm overdose is associated with increased mortality from subsequent suicide.8,10) A study reported that the number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose by increasing the total amount of psychotropics ingested.11) Hence, “awareness” and “attentive hearing” of the target person’s symptoms of overdose are important to prevent overdose.
Target 3.5 of UN Sustainable Development Goal (SDG) 3 sets out a commitment by governments to strengthen substance abuse prevention and treatment.12) People who play a role in preventing suicide are called “gatekeepers,” and the Ministry of Health, Labor and Welfare requires pharmacists to play an active role as gatekeepers.13) Specifically, “a pharmacist who has many opportunities to come into contact with information on the health status of residents through dispensing, drug sales, etc.” is stated as an example of a gatekeeper.13) Pharmacists and registered sellers, who are likely to hand over the drug just before the overdose is performed, are important gatekeepers, especially for drug overdoses. Studies in the United States investigated the recognition and problems of opioid overdoses for pharmacists as gatekeepers,14) but no studies have explored the factors required to be gatekeepers of overdose. Therefore, evidence is needed to serve as a gatekeeper. This study aimed to identify the factors required of gatekeepers based on the experience of intervening in patients as gatekeepers for drug overdose among pharmacists and registered sellers.
We conducted a survey of pharmacists and registered sellers at pharmacies and drug stores, who may be immediately involved before the overdose, to grasp the experience and knowledge of clinical interventions related to a drug overdose. A total of 298 responded in Japan, including 162 pharmacists and 136 registered sellers (Table 1). The research was explained and requested to the respondents in writing, and respondents provided the research consent by checking “I agree” in the questionnaire.
| Overall (n) | Pharmacist (n) | Registered seller (n) | |
|---|---|---|---|
| Question 0. “Prefecture” where you work | |||
| Tokyo | 84 | 46 | 38 |
| Chiba | 71 | 69 | 2 |
| Shiga | 46 | 1 | 45 |
| Kanagawa | 30 | 11 | 19 |
| Aichi | 17 | 5 | 12 |
| Ibaraki | 11 | 11 | 0 |
| Saitama | 7 | 3 | 4 |
| Gifu | 4 | 0 | 4 |
| Hyogo | 3 | 1 | 2 |
| Shizuoka | 3 | 2 | 1 |
| Hokkaido | 3 | 3 | 0 |
| Kagawa | 2 | 2 | 0 |
| Gunma | 2 | 1 | 1 |
| Miyagi | 2 | 0 | 2 |
| Osaka | 2 | 2 | 0 |
| Nagano | 2 | 2 | 0 |
| Kyoto | 1 | 0 | 1 |
| Fukuoka | 1 | 1 | 0 |
| Miyazaki | 1 | 0 | 1 |
| Toyama | 1 | 0 | 1 |
| Hiroshima | 1 | 0 | 1 |
| Nara | 1 | 1 | 0 |
| Tochigi | 1 | 1 | 0 |
| Nagasaki | 1 | 0 | 1 |
| Mie | 1 | 0 | 1 |
| Total | 298 | 162 | 136 |
The collection rates were 65% (pharmacist; 115/177) and 80% (registered seller; 136/170), although they are rough estimates that can be obtained within the range because the questionnaire was published on the Web.
Survey of Drug Overdose for Pharmacists and Registered SellersA Google form was used to answer questions and provide free-form responses. The reliability of respondents being pharmacists or registered sellers were guaranteed through (1) their answers to Question 1 and (2) cautionary note on the Web survey. Table 2 shows questions and answers. Additionally, items were indicated by the total number for which multiple answers were possible. Question 5 was concerning the knowledge of the epidemic of overdose and Question 6 was regarding the knowledge of overdose itself. The logistic analysis used knowledge levels, including “know well” scored as 2, “I have heard about it” as 1, and “do not know much” as 0. These scores were the respondent's subjective score about overdose.
| Overall | Pharmacist | Registered seller | p | |
|---|---|---|---|---|
| Question 1. What are your license? | 298 | 162 | 136 | |
| Question 2. How many years of work experience about question 1? Mean±S.D. | 13.2±10.0 | 17.1±11.2 | 8.7±5.4 | |
| Question 3. How old are you? Mean±S.D. | 42.3±11.4 | 44.1±12.0 | 40.1±10.3 | |
| Question 4. Please select with work experience. n (%) | ||||
| Pharmacy | 142 (47.7) | 131 (80.9) | 11 (8.0) | <0.01 |
| Drugstore | 195 (65.4) | 62 (38.3) | 133 (97.1) | <0.01 |
| Hospital/Clinic | 38 (12.8) | 33 (20.4) | 5 (3.6) | <0.01 |
| Enterprises (pharmaceutical companies, CROs) | 26 (8.7) | 22 (13.6) | 4 (2.9) | <0.01 |
| Question 5. Did you know that overdose is on the rise? n (%) | ||||
| Know well | 73 (24.5) | 48 (29.6) | 25 (18.2) | 0.03 |
| I have heard about it | 198 (66.4) | 101 (62.3) | 97 (70.8) | 0.09 |
| Do not know much | 27 (9.1) | 13 (8.0) | 14 (10.2) | 0.39 |
| Question 6. How much do you know about overdoses? n (%) | ||||
| know well | 64 (21.5) | 44 (27.2) | 20 (14.6) | 0.01 |
| I have heard about it | 194 (65.1) | 108 (66.7) | 86 (62.8) | 0.57 |
| Do not know much | 40 (13.4) | 10 (6.2) | 30 (21.9) | 0.39 |
| Question 7. Have you ever witnessed a patient with suspected overdose during your work? n (%) | ||||
| Yes | 156 (52.3) | 67 (41.4) | 89 (65.0) | <0.01 |
| No | 142 (47.7) | 95 (58.6) | 47 (34.3) | |
| Question 8. Have you ever been intervention in a patient with suspected overdose during your work? (attentive hearing or inhibition) n (%) | ||||
| Yes | 103 (34.6) | 45 (27.8) | 58 (42.3) | <0.01 |
| No | 195 (65.4) | 117 (72.2) | 78 (56.9) | |
| Question 9. Do you have countermeasure against overdose at your workplace? n (%) | ||||
| Yes | 160 (53.7) | 56 (34.6) | 104 (75.9) | <0.01 |
| No | 138 (46.3) | 106 (65.4) | 32 (30.8) | |
| Question 10. Do you have study sessions or workshops about overdose at your workplace? n (%) | ||||
| Yes | 30 (10.1) | 11 (6.8) | 19 (13.9) | <0.01 |
| No | 232 (77.9) | 151 (93.2) | 117 (85.4) | |
| Question 11. Willingness to participate in study sessions and workshops on overdose n (%) | ||||
| I want to participate | 232 (77.9) | 151 (93.2) | 81 (59.1) | <0.01 |
| I do not want to participate | 66 (22.1) | 11 (6.8) | 55 (40.1) | |
| Question 12. Do you think the spread of COVID-19 has had an impact on overdose? n (%) | ||||
| Yes | 112 (37.6) | 79 (48.8) | 33 (24.1) | <0.01 |
| No | 26 (8.7) | 13 (8.0) | 13 (9.5) | 0.64 |
| Do not know | 160 (53.7) | 70 (43.2) | 90 (65.7) | <0.01 |
| Question 13. How do you think the spread of COVID-19 had affected overdose? (multiple answers possible) n (%) | ||||
| Effects of isolation such as restrictions on going out (social impact) | 209 (70.1) | 128 (79.0) | 81 (59.6) | <0.01 |
| Mentality impact | 233 (78.2) | 132 (81.5) | 101 (74.3) | 0.14 |
| Action impact | 87 (29.2) | 52 (32.1) | 35 (25.7) | 0.27 |
| Economic impact | 70 (23.5) | 48 (29.6) | 22 (16.2) | <0.01 |
| Do not know | 3 (1.0) | 1 (0.6) | 2 (1.5) | 0.46 |
| Question 14. Had the spread of COVID-19 affected the types of OTC medicines you sell? n (%) | ||||
| Yes | 109 (36.6) | 50 (30.9) | 59 (43.4) | 0.02 |
| No | 74 (24.8) | 57 (35.2) | 17 (12.5) | <0.01 |
| Do not know | 115 (38.6) | 55 (34.0) | 60 (44.1) | 0.06 |
| Question 15. Had the spread of COVID-19 affected the amount of OTC medicines you sell? n (%) | ||||
| Yes | 121 (40.6) | 58 (35.8) | 63 (46.3) | 0.06 |
| No | 69 (23.2) | 51 (31.5) | 18 (13.2) | <0.01 |
| Do not know | 108 (36.2) | 53 (32.7) | 55 (40.4) | 0.14 |
| Question 16. Had the spread of COVID-19 affected the client of OTC medicines you sell? n (%) | ||||
| Yes | 51 (17.1) | 28 (17.3) | 23 (16.9) | 0.96 |
| No | 129 (43.3) | 79 (48.8) | 50 (36.8) | 0.04 |
| Do not know | 118 (39.6) | 55 (34.0) | 63 (46.3) | 0.02 |
| Question 17. Had the spread of COVID-19 affected your product-related questions and inquiries from your client? n (%) | ||||
| Yes | 127 (42.6) | 62 (38.3) | 65 (47.8) | 0.08 |
| No | 98 (32.9) | 59 (36.4) | 39 (28.7) | 0.19 |
| Do not know | 73 (24.5) | 41 (25.3) | 32 (23.5) | 0.81 |
| Question 18. What drugs do you think are used for overdoses? (multiple answers possible) n (%) | ||||
| Diabetes drug | 14 (4.7) | 11 (6.8) | 3 (2.2) | 0.06 |
| Antihypertensive drug | 10 (3.4) | 3 (1.9) | 7 (5.1) | 0.12 |
| Antipsychotic drug | 180 (60.4) | 112 (69.1) | 68 (50.0) | <0.01 |
| Antidepressant drug | 191 (64.1) | 117 (72.2) | 74 (54.4) | <0.01 |
| Benzodiazepine | 152 (51.0) | 135 (83.3) | 17 (12.5) | <0.01 |
| Anticonvulsant drug | 36 (12.1) | 32 (19.8) | 4 (2.9) | <0.01 |
| Narcotic drug | 85 (28.5) | 27 (16.7) | 58 (42.6) | <0.01 |
| Caffeine | 179 (60.1) | 99 (61.1) | 80 (58.8) | 0.73 |
| OTC drugs | 217 (72.8) | 113 (69.8) | 104 (76.5) | 0.18 |
| Question 19. Select all that match your opinion about information about overdose. (multiple answers possible) n (%) | ||||
| No effective means of obtaining knowledge about overdose | 93 (31.2) | 49 (30.2) | 44 (32.1) | 0.63 |
| No effective opportunity of obtaining knowledge about overdose | 157 (52.7) | 77 (47.5) | 80 (58.4) | 0.05 |
| There is no countermeasure or information for overdose | 155 (52.0) | 89 (54.9) | 66 (48.2) | 0.30 |
| Lack of information on specific doses of drugs that lead to overdose | 159 (53.4) | 91 (56.2) | 68 (49.6) | 0.32 |
| No information on drugs used for overdose | 102 (34.2) | 50 (30.9) | 52 (38.0) | 0.16 |
| Question 20. What information do you need to know to manage overdose? (multiple answers possible) n (%) | ||||
| Toxicity information for 1 tablet or 1 whole package (1 box, 1 bottle, etc.) of each drug | 150 (50.3) | 87 (53.7) | 63 (46.0) | 0.23 |
| Information on the names of drugs that can be dangerous if overdosed | 217 (72.8) | 126 (77.8) | 91 (66.4) | 0.04 |
| Information on drugs with increased use for overdose | 227 (76.2) | 122 (75.3) | 105 (76.6) | 0.68 |
| Legal information about overdose | 140 (47.0) | 70 (43.2) | 70 (51.1) | 0.14 |
・p-Value was Pearson’s chi-square test. ・The answer of “multiple answers possible” indicate total number. ・Percentages were shown by occupation.
The questionnaire was distributed at the Chiba City Pharmacists Association, Itabashi Ward Pharmacists Association, the Japan Association of Chain Drug Store, and the 56th Japan Pharmacists Association Congress of Pharmacy and Pharmaceutical Science.
Data Collection PeriodSeptember 2022 to February 2023
Statistical AnalysisJMP Pro 15 (SAS Institute Inc., NC, U.S.A.) was used for Pearson’s chi-square test, Spearman’s rank correlation coefficient test and logistic analysis. The significance level was set at 0.05.
Ethical ConsiderationsThe Teikyo University Medical Research Ethics Committee approved this research (Approval Number: 22-071).
Table 2 shows a list of questions and answers. A total of 298 responses were gathered, including 162 pharmacists and 136 registered sellers. Responses were from 25 prefectures, from the Hokkaido region to the Kyushu region, regarding the facility location to which the respondents belonged (Table 1).
Experience Witnessing and Intervening with the Person Suspected of OverdosingQuestions 7 and 8 were used, which are about witnessing and intervening with the person suspected of overdoses, to explore respondents’ experiences. Overall, 52.3% (yes : no = 156/142) witnessed a person with a suspected overdose, including 41.4% (67/95) of pharmacists and 65.0% (89/47) of registered sellers. Additionally, 34.6% (103/195) of respondents experienced intervening with a person suspected of a drug overdose, including 27.8% (45/117) among pharmacists and 42.3% (58/78) among registered sellers. The percentage of registered sellers was higher than that of pharmacists in each case (Fig. 1A).
(A) Witnessing and intervening in overdose. (B) The answered ratio of the spread of COVID-19 had an impact on overdose. (C) Percentage of respondents who believe each drug is frequently used for overdosing. Black indicates pharmacist and gray indicate registered seller. * p < 0.05.
Question 12 determines the impact of the COVID-19 pandemic on drug overdose. Overall, 37.6% (112 respondents) respondents answered that the overdose had been affected by the spread of COVID-19, and 53.7% (160 respondents) respondents answered that they do not know (Table 2, Question 12). The ratio of respondents who answered that the spread of COVID-19 affected the overdose was followed in the survey, including the effects of isolation, such as restrictions on going out (social impact) by 70.1% (209 respondents), mentality impact by 78.2% (233 respondents), action impact by 29.2% (87 respondents), and economic impact by 23.5% (70 respondents). The following respondents believed that OTC products sold were affected by the spread of COVID-19: types of OTC medicines by 36.6% (106 respondents), amount of OTC medicines by 40.6% (121 respondents), and the client of OTC medicines by 17.1% (51 respondents) (Fig. 1B).
Knowledge of Drugs Used in OverdosesQuestion 18 explored the knowledge of medications used for overdosing. Drugs, other than antidiabetic and antihypertensive drugs in this item, were drugs with many reports of being used for overdose. The knowledge of pharmacists about overdose was significantly higher than registered sellers, including antipsychotic drugs (112 vs. 68, p < 0.05), antidepressant drugs (117 vs. 74, p < 0.05), benzodiazepine (135 vs. 17, p < 0.05), and anticonvulsant drugs (32 vs. 4, p < 0.05). Additionally, no significant difference in the percentage of people who knew that they were overdosing on OTC drugs was found between pharmacists and registered sellers, accounting for approximately 70% for both. Conversely, narcotics (27 vs. 58, p < 0.05) were significantly answered more by registered sellers (Fig. 1C).
Correlation between Subjective Score of Knowledge about Drug Overdose (Questions 5 and 6) and Knowledge of Drugs Used for Drug Overdose (Question 18)To examine the correlation between respondents’ subjective knowledge scores (Questions 5 and 6) and Question 18, Spearman’s rank correlation coefficient was calculated (Fig. 2). For Question 18, six drugs (antipsychotics, antidepressants, BZs, anticonvulsants, caffeine, and OTC drugs) were commonly reported to be used for overdose. We investigated the number of choices made by these respondents and verified the correlation. First, the answers to Questions 5 and 6 were correlated in overall (Fig. 2A, ρ = 0.65, p < 0.05), pharmacists (ρ = 0.60, p < 0.05), and registered sellers (ρ = 0.68, p < 0.05). On the contrary, the correlation coefficient for Questions 6 and 18 was very low; overall (ρ = 0.21, p < 0.05), pharmacists (Fig. 2B, ρ = 0.17, p = 0.03), and registered sellers (Fig. 2C, ρ = 0.12, p = 0.17).
(A) Questions 5 and 6 in overall. ρ = 0.65, p < 0.05. (B) Questions 6 and 18 (the number of correct answers) in pharmacist. ρ = 0.17, p < 0.05. (C) Questions 6 and 18 (the number of correct answers) in registered sellers. ρ = 0.12, p = 0.17. Spearman’s rank correlation coefficient was used. The darkness of the color indicates the density of the number of responses. The maximum number of correct answers for Question 18 was 6.
Question 20 searched for drug information necessary for the gatekeeper for countermeasures against overdose. “Information on the names of drugs that can be dangerous if overdosed” and “Information on drugs with increased use for overdose” were answered by 72.8% (217 respondents) and 76.2% (227 respondents) to be necessary, respectively (the total number of respondents). Moreover, 50.3% (150 respondents) and 47.0% (140 respondents) answered that “Toxicity information for 1 tablet or 1 whole package (1 box, 1 bottle, etc.) of each drug” and “Legal information about overdose” are necessary, respectively (the total number of respondents).
Identification of Factors Necessary for Overdose Gatekeepers (Overall)Logistic analysis was performed with the experience of intervening in patients suspected of overdosing (Question 8) as the objective variable to explore the factors necessary for the gatekeeper of overdose. Years of work experience (Question 2), age (Question 3), knowledge that overdose is on the rise (Question 5), knowledge about overdose (Question 6), countermeasures against overdose at your workplace (Question 9), study sessions or workshops about overdose at your workplace (Question 10), and willingness to participate in study sessions and workshops on overdose (Question 11) were used as explanatory variables (Table 3.).
| Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|
| Crude OR (95%CI) | p-Value | Adjusted OR (95%CI) | p-Value | |
| Age | 1.02 (1.00–1.04) | 0.07 | 1.02 (0.98–1.05) | 0.29 |
| Years of work experience | 1.02 (1.00–1.04) | 0.07 | 1.01 (0.98–1.05) | 0.48 |
| Countermeasure against overdose at your workplace | 3.47 (2.06–5.82) | <0.01* | 4.01 (2.25–7.15) | <0.01* |
| Study sessions or workshops about overdose at your workplace | 2.38 (1.11–5.09) | 0.03* | 1.34 (0.57–3.14) | 0.5 |
| Knowledge that overdose is on the rise | 2.10 (1.35–3.32) | <0.01* | 1.93 (1.04–3.69) | 0.04* |
| Knowledge about overdose | 1.60 (1.06–2.45) | 0.03* | 0.86 (0.47–1.57) | 0.63 |
| Willingness to participate in study sessions and workshops on overdose | 1.54 (0.84–2.82) | 0.16 | 1.92 (0.99–3.75) | 0.05 |
* p < 0.05. Logistic regression analysis.
First, univariate logistic analysis across all respondents revealed that countermeasures against overdose at your workplace (odds ratio (OR): 3.47, 95% confidence interval (CI): 2.06–5.82, p < 0.05), study sessions or workshops about overdose at your workplace (OR: 2.38, 95% CI: 1.11–5.09, p < 0.05), knowledge that overdose is on the rise (OR: 2.10, 95% CI: 1.35–3.32, p < 0.05), and knowledge about overdose (OR: 1.60, 95% CI: 1.06–2.45, p < 0.05) were associated with experiences of intervening in overdose. Next, we selected the same number of explanatory variables and performed a multivariate logistic analysis as the sample size was sufficient. The result revealed that countermeasures against overdose at your workplace (OR: 4.01, 95% CI: 2.25–7.15, p < 0.05) and knowledge that overdose is on the rise (OR: 1.93, 95% CI: 1.04–3.69, p < 0.05) were associated with experiences of intervening in overdose.
Identification of Factors Necessary for Overdose Gatekeepers (Pharmacists)Next, a similar logistic analysis was conducted for pharmacists (Table 4). Univariate logistic analysis of pharmacists revealed that age (OR: 1.03, 95% CI: 1.00–1.06, p < 0.05), years of work experience (OR: 1.04, 95% CI: 1.01–1.07, p < 0.05), countermeasures against overdose at your workplace (OR: 2.66, 95% CI: 1.31–5.41, p < 0.05), and knowledge that overdose is on the rise (OR: 2.48, 95% CI: 1.33–4.78, p < 0.05) were associated with experiences of intervening in overdose. Furthermore, we selected the same number of explanatory variables and performed a multivariate logistic analysis as the sample size was sufficient. Results revealed that countermeasures against overdose at your workplace (OR: 2.40, 95% CI: 1.10–5.25, p < 0.05) were associated with experiences of intervening in overdose.
| Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|
| Crude OR (95%CI) | p-Value | Adjusted OR (95%CI) | p-Value | |
| Age | 1.03 (1.00–1.06) | 0.04* | 1.01 (0.94–1.09) | 0.51 |
| Years of work experience | 1.04 (1.01–1.07) | 0.02* | 1.02 (0.95–1.10) | 0.77 |
| Countermeasure against overdose at your workplace | 2.66 (1.31–5.41) | <0.01* | 2.40 (1.10–5.25) | 0.03* |
| Study sessions or workshops about overdose at your workplace | 3.45 (1.00–11.9) | 0.05 | 1.75 (0.42–7.21) | 0.44 |
| Knowledge that overdose is on the rise | 2.48 (1.33–4.78) | 0.01* | 2.23 (0.96–5.47) | 0.07 |
| Knowledge about overdose | 1.82 (0.95–3.52) | 0.07 | 0.90 (0.35–2.25) | 0.83 |
| Willingness to participate in study sessions and workshops on overdose | 1.79 (0.37–8.63) | 0.47 | 2.27 (0.40–12.8) | 0.35 |
* p < 0.05. Logistic regression analysis.
Furthermore, a similar logistic analysis was conducted for registered sellers (Table 5). Univariate logistic analysis of registered sellers revealed that age (OR: 1.11, 95% CI: 1.04–1.19, p < 0.05), countermeasures against overdose at your workplace (OR: 4.33, 95% CI: 1.65–11.4, p < 0.05), knowledge that overdose is on the rise (OR: 2.28, 95% CI: 1.17–4.69, p < 0.05), knowledge about overdose (OR: 2.04, 95% CI: 1.14–3.81, p < 0.05), and willingness to participate in study sessions and workshops on overdose (OR: 2.62, 95% CI: 1.27–5.43, p < 0.05) were associated with experiences of intervening in overdose. Furthermore, we selected the same number of explanatory variables and performed a multivariate logistic analysis as the sample size was sufficient. Results revealed that years of work experience (OR: 1.13, 95% CI: 1.04–1.24, p < 0.05), countermeasures against overdose at your workplace (OR: 3.43, 95% CI: 1.18–10.0, p < 0.05), and willingness to participate in study sessions and workshops on overdose (OR: 3.50, 95% CI: 1.51–8.10, p < 0.05) were associated with experiences of intervening in overdose.
| Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|
| Crude OR (95%CI) | p-Value | Adjusted OR (95%CI) | p-Value | |
| Age | 1.02 (0.99–1.05) | 0.26 | 1.00 (0.96–1.04) | 0.99 |
| Years of work experience | 1.11 (1.04–1.19) | <0.01* | 1.13 (1.04–1.24) | <0.01* |
| Countermeasure against overdose at your workplace | 4.33 (1.65–11.4) | <0.01* | 3.43 (1.18–10.0) | 0.02* |
| Study sessions or workshops about overdose at your workplace | 1.60 (0.60–4.23) | 0.35 | 0.84 (0.27–2.65) | 0.76 |
| Knowledge that overdose is on the rise | 2.28 (1.17–4.69) | 0.02* | 1.07 (0.37–3.08) | 0.90 |
| Knowledge about overdose | 2.04 (1.14–3.81) | 0.02* | 1.94 (0.74–5.30) | 0.18 |
| Willingness to participate in study sessions and workshops on overdose | 2.62 (1.27–5.43) | <0.01* | 3.50 (1.51–8.10) | <0.01* |
* p < 0.05. Logistic regression analysis.
The multivariate logistic analysis in this study revealed that “countermeasures against overdose at your workplace” and “knowledge that overdose is on the rise” in overall respondents, “countermeasure against overdose at your workplace” in pharmacists, and “years of work experience,” “countermeasures against overdose at your workplace,” and “willingness to participate in study sessions and workshops on overdose” in registered seller were associated with experiences of intervening in overdose. Differences in the factors required of gatekeepers for overdose were found by occupation.
The gatekeeper factor that caused the difference between pharmacists and registered sellers is “years of work experience,” practical training that is compulsory during the university pharmacy department (6 years) in the case of pharmacists, and the fact that pharmacists already have experience in the field when they become pharmacists. Conversely, practical training regulations or work experience as qualifications for examinations are not restricted to registered sellers, and practical experience required in the field may also have an effect. Regarding “willingness to participate in study sessions and workshops on overdose,” multivariate logistic analysis resulted in an OR of 3.5 for overdose interventions in registered sellers although it was not significant for pharmacists. Developing ways to encourage participation in training about overdose was considered necessary.
“Countermeasures against overdose at your workplace” indicated according to the free description of this study, when handing over the target drug, “confirmation of duplication of medicines by pharmacists using medicine notebooks,” “dialogue with patients with suspected overdose,” “restrictions on the number of sales of OTC drugs,” and “pop-up display on checkout” were described. Countermeasures against overdose must be considered in all pharmacies. Conversely, developing a new tool for preventing overdose is considered important as one of the countermeasures, considering that >46% of pharmacies and drugstores had not taken measures. Drug overdose in Japan tends to be low in narcotics,15) but opioid overdose is characteristic abroad.16–19) Local pharmacies in North Dakota demonstrated that pharmacists may be able to objectively determine the risk of opioid misuse using tools.20) A critical element of the tool was the use of the Opioid Risk Tool to screen all patients receiving opioid prescriptions for opioid use disorder.20) The author has constructed a “Drug database for overdose prevention” and has disclosed it on the Internet.21) Only the toxicity to humans of OTC drugs for domestic products is disclosed at present, but it may be a tool that can be used to help the activity as a gatekeeper of overdose. Furthermore, we have previously constructed an index for evaluating the acute toxicity of high-risk drugs among ethical drugs based on the acute toxicity value of mice and the number of ingredients contained in the product.22) Grasping the relative risk of acute toxicity of ethical drugs, especially psychotropic drugs, handed over by pharmacists is possible.22) This may be an indicator of acute toxicity risk when handing over ethical drugs. Furthermore, like Opioid Risk Tool,20) developing scores and tools that can assess patients with suspected overdoses of psychotropic drugs and OTC drugs are also necessary.
“Knowledge that overdose is on the rise” was associated with the experience of interventions in patients with suspected overdose when viewed by overall respondents. This may cause interventions against overdose by grasping public health information. In particular, the opioid epidemic emergency declaration has caused population-level policy and system building as a public health intervention in the United States, and this makes it easier for those concerned to grasp the status of the epidemic.23) Public health knowledge, such as the increasing number of patients with influenza, is used for intervention and diagnosis based on the Infectious Diseases Law in Japan. Public health interventions may be important for detecting signs of drug overdose and overdose patients in social situations. Conversely, careful notification to gatekeepers is considered necessary due to the possibility of stimulating suicide applicants by excessive reporting and the sensitivity of acts such as suicide and self-harm.24)
Differences in knowledge about “drugs” used for overdosing were observed between pharmacists and registered sellers. Pharmacists’ knowledge was significantly higher than registered sellers among prescription drugs that required dispensing based on a prescription: antipsychotics, antidepressants, benzodiazepines, and anticonvulsants. Conversely, no significant difference was found between pharmacists and registered sellers in the percentage of respondents who knew about OTC drugs, accounting for approximately 70% of both. This information is important for the activities of gatekeepers and should be well known to gatekeepers, but it is very dangerous information for those who are thinking of overdosing, thus it must be carefully handled. Of pharmacists, 93.2% answered the willingness to participate in a study session on overdose. Sustainable measures, such as improving knowledge, are necessary for education in pharmacy departments and training after employment about overdose from the viewpoint of proper use of medicines. Additionally, pharmacists with sufficient knowledge would need to act as gatekeepers for prescription drugs, which require dispensing based on prescriptions.
Actively intervening and attentively listening to a person as a gatekeeper is important because persons who overdose or attempt suicide can be psychologically stabilized by talking about their situation. A study reported that assertive case management prevents suicide recurrence.25,26) Pharmaceuticals can have beneficial effects on disease when used appropriately, but overdose can cause serious health problems and even death. Determining the signs and conditions of patients and leading to proper use, especially for prescription drugs that require dispensing, is important for pharmacists, who are specialists with sufficient knowledge of drugs. Community pharmacists are increasingly being recognized as potential partners in many public health activities,27) and this is also considered the same for “attentive hearing” about overdose. Additionally, both pharmacists and registered sellers may be required to act as gatekeepers against overdose regarding OTC drugs.
It became clear that the correlation between the respondents’ subjective score of knowledge about drug overdose (Question 6) and the number of correct answers in Question 18 was extremely low. Since the correlation between Questions 5 and 6 was high, it was thought that respondents had the knowledge of overdose being on the rise. Based on the above information, it can be inferred that accurate knowledge about “drugs that are often used in drug overdoses was lower than the subjective opinion of the respondents, and there is a need to receive appropriate education and training about drug overdoses.
A limitation is that this study conducted a domestic survey of gatekeepers for drug overdoses. Factors necessary for a gatekeeper for drug overdose may differ depending on the country’s situation (drugs that are more readily available due to differences in laws and regulations, background, etc.). Therefore, investigating the necessary data for each country and region is considered necessary. In addition, the content about the spread of COVID-19 was majorly based on the respondents’ opinions and should only be used as a reference. Regarding the impact of COVID-19 on overdoses, it has been reported that the increase of death rate due to drug overdose in the United States and Canada,7) and increase of OTC drug overdose in Japan.3) Accordingly, items related to COVID-19 of this questionnaire might be important as the clinical environment about overdose during the pandemic, but detailed verification is required.
This study revealed that “countermeasures against overdose at your workplace” in pharmacists and “years of work experience,” “countermeasures against overdose at your workplace,” and “willingness to participate in study sessions and workshops on overdose” in registered sellers, were associated with experiences of intervening in overdose. This result is useful evidence for overdose countermeasures and gatekeeper training for overdose at local pharmacies and drugstores.
This work was supported by Innovative Research Program on Suicide Countermeasure Grant Number JPSCIRS20230304 (for KN) and Grant of OTC self-medication promotion foundation Number 66-5-2 (for KN).
The authors thank the Chiba City Pharmacists Association, Itabashi Ward Pharmacists Association, and the Japan Association of Chain Drug Store for their cooperation regarding questionnaires.
KN conceptualized the study, statistically analyzed the data, and wrote the paper. KH, EN and KN collected data. MW and YS supervised the study and revised the paper. All authors read and revised the manuscript and accepted the submission. The authors read and approved the final manuscript.
The authors declare no conflict of interest.
The datasets that are used or analyzed, or both, during the current study are available on reasonable request.
