Less is more and science matters

February 9, 2013 2:41 AM

The introduction of a limit on the number of tablets sold in packets of paracetamol has led to a 43% reduction in the number of poisoning deaths. People often question what stops someone from going to different chemists and buying as much paracetamol as they want. However, this question misses the point of the 1998 legislation. The thinking behind the limit on paracetamol pack sizes is that most suicidal behaviour is impulsive. People often use what is closest at hand. So making paracetamol packs smaller means that it is less likely a suicidal person would have ready access to dangerous amounts of paracetamol.

And, as a side note, Behind the Headlines is a fantastic resource. From generosity reducing your risk of death to chewing gum helping concentration. It's about health stories that make the news and provides the source and an analysis of the science. If you want to know how to read health stories and how to combat the Daily Mail’s ongoing effort to classify every inanimate object into those that cause cancer and those that prevent it then put it in your rss reader now.

Behind the Headlines previously on metafilter.

posted by Gilgongo (50 comments total)

And of course paracetamol is a horrendous way to commit suicide, rarely immediately fatal but if taken an overdose, resulting in a lingering, painful death over several weeks, if you're unlucky.
posted by MartinWisse at 3:42 AM on February 9, 2013 [10 favorites]

I feel silly now for having asked that same question, "Why wouldn't you just buy lots of packets?" several times, despite knowing that suicide is often an impulsive act and having read well-backed up stories that other changes, like switching from coal gas to natural gas in ovens, have also reduced the suicide rate. (I know this story isn't about the absolute rate of suicides, just the rate of poisoning deaths.) Somehow I didn't put those pieces together before now.

Behind the Headlines looks great. Thanks for the link!
posted by daisyk at 4:03 AM on February 9, 2013 [1 favorite]

Packets sold in pharmacies can now contain a maximum of 32 tablets and those sold outside pharmacies can contain no more than 16 tablets.

Meanwhile in the US you can buy a jumbo thing of 500 generic brand caplets from Amazon for $10.18. Prior to reading about this study I would have thought that it was a ripoff to be forced to buy these tiny packages at insane markups, but it seems it's doing some good.
posted by Rhomboid at 4:31 AM on February 9, 2013

Can we do the same thing with bullets? Like maybe package each one in its own nearly-impossible-to-open-without-cutting-yourself plastic clamshell blister pack?
posted by RonButNotStupid at 5:02 AM on February 9, 2013 [59 favorites]

As a former paramedic here, I would just like to say to anybody here, please do not ever try to kill yourself with paracetamol - please don't try to kill yourself anyway, but especially don't try to kill yourself with Tylenol. It is truly one of the worst ways a human being can die - slowly, after the fact, with days and weeks to fully contemplate and regret your decision.
posted by Tiresias at 5:07 AM on February 9, 2013 [29 favorites]

Why does paracetamol take so long to kill people? If days and weeks elapse, isn't that enough time for doctors to counteract it?
posted by nooneyouknow at 5:34 AM on February 9, 2013

If days and weeks elapse, isn't that enough time for doctors to counteract it?

It destroys your liver, and you ultimately die of blood poisoning because your liver can't clear naturally occuring metabolic products. The only way to counteract that is to get a liver transplant in time. The FPP article mentions that in additionto suicide rates, overdose-related liver transplants were tallied.

Also, would it be too much for any of these articles to mention that this is the drug known to much of the world by the brand name Tylenol?
posted by localroger at 5:40 AM on February 9, 2013 [8 favorites]

Acetaminophen needs huge warnings plastered all over it. DO NOT DRINK. DO NOT TAKE MORE THAN SIX A DAY, EVER. Pictures of livers. Etc.

It's incredibly toxic and shouldn't be in any medications except by prescription. In those cases only as a last resort because you have problems with other analgesics. It's considered safer than asprin and ibuprofen because it doesn't cause gut inflammation, but the LD50 is so close to the effective dose that it's like taking a one-axle-wide mountain pass with no guardrail because the paving there is better for your tires.

Also, would it be too much for any of these articles to mention that this is the drug known to much of the world by the brand name Tylenol?

By North Americans, maybe. This is a british article, though. Across the atlantic "Tylenol" is as unfamiliar as "paracetamol" is to us. Think "band aids" vs. "plasters".
posted by clarknova at 5:44 AM on February 9, 2013 [15 favorites]

What about paracetamol-narcotic combination products? Do they still sell those in the UK? They account for a number of unintentional overdoses in the US at least.
posted by orme at 5:49 AM on February 9, 2013

Yeah, we don't have Tylenol as a brand name here. I've obviously heard of it, but until now wouldn't have known if it was referring to paracetamol, aspirin or ibuprofen.

It's good to know the change made such an impact. I'll be less annoyed at the small packets next time I run out of pain killers now.
posted by spectrevsrector at 6:04 AM on February 9, 2013 [1 favorite]

Why can't you find aspirin in the jungle?

Because the Tylenol.

It just doesn't work does it?
posted by biffa at 6:19 AM on February 9, 2013 [21 favorites]

As I recall a warning about combining with alcohol was placed on Tylenol, and somehow the same warning was required on both aspirin and ibuprofen even though it didn't apply.
posted by StickyCarpet at 6:21 AM on February 9, 2013

Ok so, I just woke up, and this was literally the first thing I read. I'll admit I didn't know what paracetemol is, and when I read "tablets sold in packs of", I was thinking of like, iPads and stuff with those Do Not Eat packed in, and was thinking "wait, people not only kill themselves with those things, but they were making them BIG enough to overdose on them lately??

I'll be back later after I have my coffee, sorry guys.
posted by Uther Bentrazor at 6:38 AM on February 9, 2013 [3 favorites]

What about paracetamol-narcotic combination products?

Yes, combining something that kills you if you take too much with an addictive narcotic seems to be a rather American style bit of cruelty.
posted by localroger at 6:40 AM on February 9, 2013 [12 favorites]

Rhomboid, the tiny packets aren't sold for an insane markup. Generic paracetamol is sold at 1p per tablet (16p per pack) so the argument isn't economic, it's purely a matter of size.
posted by goo at 6:41 AM on February 9, 2013

I've mentioned this on MeFi before, but one of my cousins tried to kill herself by overdosing on Tylenol when she was 18-19 years old. It was indeed an impulsive act, a typical teenage attention-seeking thing. She did not die, but she suffered so much liver damage that she had to go on permanent disability. She is now in her early 40s, and had a series of strokes a few years ago and can no longer live independently, has suffered significant cognitive impairment, etc. So, in the end, she did manage to destroy her life, it has just taken a couple of decades of suffering to get there.
posted by briank at 6:51 AM on February 9, 2013 [3 favorites]

I also had a dear friend try to kill herself with Tylenol. Fortunately we found her in time to force her to the hospital to save her life (and liver function), but she was still seriously ill and has health issues related to it to this day. It never ceases to amaze me that you can buy something so ridiculously toxic over the counter, but birth control is treated like the deadliest thing ever.

I know that they say suicide is an impulsive act so this is incremental good news, but you would think they would plaster the stuff with cigarette package level of warnings if they won't make it by prescription only.
posted by winna at 6:52 AM on February 9, 2013 [4 favorites]

Yeah, what's ridiculous about this is that Tylenol is added to many opioids (drugs like codeine) in an attempt to prevent addiction and misuse. But if you overdose on an opioid, you'll generally either die within a few hours painlessly from slowly stopping breathing or if someone revives you with the antidote, you'll live and be pretty much no worse for it. Opioids don't destroy the liver or other organs— and if you are so far gone that you are brain-damaged from lack of oxygen, you typically won't be able to be revived with the antidote. The liver damage from Tylenol, however, can be irreversible.

The opioid antidote, btw, is called naloxone (Narcan), it's nontoxic and non-addictive and a recent study found it could cut overdose deaths by nearly 50% in communities that distribute it and educate enough people about it.

There is actually an antidote to Tylenol but apparently it doesn't help all that much once serious damage has already occurred. It's a natural amino acid called n-acetylcystine and I think you can buy it as as supplement.
posted by Maias at 7:12 AM on February 9, 2013 [8 favorites]

What about paracetamol-narcotic combination products?

Co-codamol is available in low strengths over the counter, but higher strengths only with a prescription.

Also, this is a very important reason never to use the name "Tylenol". Paracetamol and co-codamol are very different things, and to have the same name with only a number after them seems like an absurd dereliction.
posted by Jehan at 7:18 AM on February 9, 2013

Think "band aids" vs. "plasters".

Oh, that's what plasters are.
posted by Foosnark at 8:05 AM on February 9, 2013

Yeah, "Plasters of Paris" is a well known brand you may have heard off even in the US.
posted by MartinWisse at 8:11 AM on February 9, 2013 [1 favorite]

Yeah, "Plasters of Paris" is a well known brand you may have heard off even in the US.

Ha hAaaa.
posted by adamdschneider at 8:15 AM on February 9, 2013

Yeah, what's ridiculous about this is that Tylenol is added to many opioids (drugs like codeine) in an attempt to prevent addiction and misuse.

That's not the only reason, by my understanding. Combining a smaller amount of the opioid alongside a non-opioid analgesic produces effective pain control at much lower doses of the opioid, for many patients. Less opioid = less risk of respiratory depression. The same thing is done with aspirin (Percodan --> Oxycodone & aspirin) and ibuprofen (Combunox --> Oxycodone & Ibu; Vicoprofen --> Hydrocodone & Ibu).

Acetaminophen's a nasty drug though, for sure. You have to watch the doses given in those combo drugs carefully if you're taking straight up Tylenol as well.
posted by Pantengliopoli at 8:30 AM on February 9, 2013 [1 favorite]

The paracetamol/acetaminophen/Tylenol overdoses we saw on the ambulance were almost aways impulsive suicides by people who just took whatever was lying around. The thing is, NSAID overdoses typically don't cause any loss in awareness (unless they're taken with alcohol) but you'd get people who had swallowed a quarter of a bottle of, say, Advil and would be rolling around the floor, mumbling, with one eye kind of open watching the whole scene. They were acting out a script for what they thought a suicide would look like; these were not planned, thoughtful suicides, but rather the impulsive acts of people who had somehow reached a desperate emotional impasse in their life that they felt required an appropriately desperate response. And so they swallowed whatever they had lying around, and acted out how they thought a suicide was meant to go.

The common phrase for this kind of largely-unharmful attempt is 'a cry for help', but it seemed to me to be a bit more like a personal, emotional theatre; that these people needed a way to externalize their pain and to show the people around them how bad they felt inside.

Overdosing on aspirin or ibuprofen is actually not that harmful, to the point where it was barely even discussed in paramedic school except as something you might pick up on an ECG, or why your patient suddenly had tinnitus. Even acetaminophen overdoses are surprisingly reversable if caught in time, using a drug called n-acetylcysteine that the higher level medics carried on their trucks for just these purposes.

But there is a window of opportunity for the antidote to work; if you were lucky and your parents immediately walked in on you right after you had done it, and you admitted what you had done, and an ambulance was called, you would probably be fine. We rarely saw the ones who weren't lucky, because it wasn't until well after the fact that they realized that something might be wrong, but you would hear stories about them from the ER nurses. These are people who had done it alone, maybe washed down a bottle of Tylenol with a bottle of vodka and were never found; they would wake up a day or two later, feeling terrible, and then walk themselves down to the closest hospital. If they were particularly unlucky, they would find out there that their liver had been destroyed; and if a transplant couldn't be found, they would get to watch themselves die slowly, terribly, painfully.

So in this context, reducing the packet sizes of acetaminophen makes complete and absolute sense; if someone wants to commit suicide, then sure, they'll find another way to do it. There are very, very effective ways to die using various combinations of drugs, prescription or otherwise. But usually, people who overdose on household drugs don't really want to die, per se, but they do feel the need to do something, anything, that feels as bad and drastic as they do. So they open up the medicine chest and see what's lying around; and typically, what's lying around is OTC painkillers. It's stupid, maybe even a little bit childish, but you can see how it would make sense to somebody who was hurting that badly. Unfortunately, sometimes these hurting people actually succeed in doing what they were truthfully only pretending to do.

So, what I'm saying is: if you feel desperate and want to do something desperate: I understand that impulse. I absolutely understand that impulse and would never judge you for it. I won't say anything as trite as 'get help instead!', though I might feel that, but I will say: if you ever reach that point, just remember this post. Remember how badly you can hurt yourself, how terribly you can die. Don't open up that medicine cabinet. Think it through.

(Also, in case it needs to be clarified, paracetamol and acetaminophen are the exact same thing using different terminology; acetaminophen is the preferred nomenclature in North America, while paracetamol tends to be used in the UK where I now live. 'Tylenol' is the name brand of the most popular acetaminophen manufacturer, and the name likely most familiar to consumers.)
posted by Tiresias at 8:46 AM on February 9, 2013 [40 favorites]

THis is a great example of a public health paradigm in action. I would love it if there were more literacy, in general, about the behavioral truths that govern a surprising portion of human behavior. When acting on an impulse is truly inconvenient, usually the moment will pass. Making it easy to do the right thing, and difficult to do the thing we don't want, is a basic principle that has a lot of power to improve social conditions. This is one the main refutations for the anti-gun-law arguments we hear, too: simply making something less convenient - without outlawing it at all - can create a significant dropoff in its incidence.
posted by Miko at 9:13 AM on February 9, 2013 [9 favorites]

Yes, combining something that kills you if you take too much with an addictive narcotic seems to be a rather American style bit of cruelty.

Junkies I've known have a conspiracy theory: it's the establishment's way of weeding out undesirables.

They also swear by grinding APAP/opiate tablets, mixing them thoroughly with water, and then drinking off the water when the powder settles. Supposedly it spares them from consuming most of the acetaminophen.

I just consulted with a doctor and she says it's not total bullshit, either. At 20° C a deciliter of water is saturated at a mere gram of APAP, which is a safe dose for most people.

Of course I'm not a doctor and it would be stupid of you to try out recipes with dangerous drugs that you read about in forum comments. So don't.
posted by clarknova at 9:48 AM on February 9, 2013

This thread plus the recent herd immunity demonstration thread made me a happy public health nerd metafilter reader this morning.

completely echo other posters (esp Miko) that this effect is important for more people to understand - behavior in aggregate, across large populations. rather than it being about what an individual can or might do, it's about what tends to happen to a percentage of people, given a certain set of circumstances.
posted by entropone at 10:24 AM on February 9, 2013

From Wikipedia, emphasis added:

Paracetamol toxicity is the foremost cause of acute liver failure in the Western world, and accounts for most drug overdoses in the United States, the United Kingdom, Australia and New Zealand.

posted by mistersquid at 10:58 AM on February 9, 2013

I've got a bottle of Tylenol right here on my desk, and it contains no paracetamol. It's just acetaminophen. And it just says "Tylenol Regular Strength" on it.
posted by kafziel at 11:48 AM on February 9, 2013

kafziel, acetaminophen is the American name for paracetamol.
posted by teraflop at 11:54 AM on February 9, 2013 [5 favorites]

mistersquid: "From Wikipedia, emphasis added:

Paracetamol toxicity is the foremost cause of acute liver failure in the Western world, and accounts for most drug overdoses in the United States, the United Kingdom, Australia and New Zealand".

Not to dispute wikipedia, but I don't believe that statement about drug overdoses is correct, at least not for the United States. And yes, I did spend part of my day yesterday data crunching drug overdose death data from CDC WONDER. Although if you include the opiate-containing meds, it may be accurate, I suppose, but it's usually the opiates that kill someone in a vicodin OD.
posted by gingerbeer at 12:19 PM on February 9, 2013

They also swear by grinding APAP/opiate tablets, mixing them thoroughly with water, and then drinking off the water when the powder settles. Supposedly it spares them from consuming most of the acetaminophen.

That's essentially a feeble attempt at a cold water extraction. The (correct) theory being that acetaminophen and opiates have greatly different solubility in cold water. So you grind up the tablet and dissolve it completely in like 6oz of room temperature water. Then you gradually cool the water to near freezing as in a refrigerator. Virtually all of the acetaminophen precipitates out of the water while most of the opiate remains in solution. Strain off the precipitate and, depending on the purity you're looking for, repeat. Discard the precipitate.

But cooling the water is the key step in the process. Just swirling around your glass and letting some powder settle out doesn't cut it. Points for effort though, I guess.
posted by Justinian at 1:12 PM on February 9, 2013 [1 favorite]

Once and for all: acetaminophen = paracetamol
posted by yellowcandy at 1:31 PM on February 9, 2013

Acetaminophen needs huge warnings plastered all over it. DO NOT DRINK. DO NOT TAKE MORE THAN SIX A DAY, EVER. Pictures of livers. Etc.

I think you're overstating the danger. The drug has been in use for many decades and its effects are well-known. You can give acetaminophen to infants. Otherwise healthy adults with conditions like arthritis or hernia can and do take up to 4g (8 extra-strength) spaced over 24 hours for an extended period of time.

But I agree people need to know more about its effects on the liver. I had a friend who was into opiates a few years ago and would eat 8-12 Tylenol 3s some evenings with a bottle of wine. I had to tell him, the acetaminophen+wine is probably riskier than the codeine. He had no idea about the risk, or what was in those pills, beyond the codeine.
posted by Pruitt-Igoe at 2:48 PM on February 9, 2013

See here for a list of names for paracetomol / acetaminophen around the world.

In Australia it's called
Panadol
Panamax
Herron
Hedanol.

I was with a friend when he told his teenage daughter about the bad effects of taking too much Panadol. She was shocked. Downing a packet had been on her depressed mind's agenda.
posted by Kerasia at 2:56 PM on February 9, 2013

The drug has been in use for many decades and its effects are well-known.

This is most assuredly NOT true. About 15 years ago a coworker of mine nearly got into bad trouble by total accident. He was having back pain and taking 10-15 Extra Strength Tylenol a day, and he was losing energy and libido and having other distressing problems. His doctor did tests and tests and tests all of which revealed he was losing liver function, and toward the beginning of this he told the doc he was taking a lot of Tylenol and the doc said something like "Oh,that's OTC, no problem."

Finally the guy went to specialist mark 4 or 5 who happened to ask about Tylenol, and when S told the doc how much he was taking the doc said STOP THAT RIGHT NOW and S's problems miraculously self-cured over the next few months.

So maybe the effects are well known somewhere, but not to everyone and not even to all doctors.

And considering what a fucking dangerous drug this is maybe someone should think about standardizing the nomenclature so we know what fucking dangerous drug we're talking about in the warnings.
posted by localroger at 2:57 PM on February 9, 2013 [3 favorites]

"Oh,that's OTC, no problem."

That's a terrible doctor right there. Should I run out and take a whole pack of Gravol (Dramamine)? It's OTC too.

A bottle of extra-strength acetaminophen, in Canada at least, says not to exceed 8 in a 24-hour period. That's a warning for both doctor and patient.
posted by Pruitt-Igoe at 3:08 PM on February 9, 2013

This is most assuredly NOT true.

And a lot of people can't seem to keep track of the differences between OTC painkillers. A coworker's wife died of an acetaminophen overdose a year or so ago, and coworkers were shocked to learn how dangerous the stuff could be. A year later, some of them have gotten all the painkillers mixed up in their minds and I'll occasionally hear one person caution another that ibuprofen is the dangerous one that might ruin their liver. If someone corrects them, they don't seem to know that acetaminophen and ibuprofen are totally different things.
posted by Blue Jello Elf at 3:09 PM on February 9, 2013 [1 favorite]

Ibuprofen damages kidneys, not livers.

Not the same thing as being safe.
posted by Lexica at 5:18 PM on February 9, 2013 [4 favorites]

We have that localroger - it's N-(4-hydroxyphenyl)ethanamide. Take two tablets every 6 hours with oxidane.
posted by Kid Charlemagne at 6:37 PM on February 9, 2013 [2 favorites]

I don't know, in my experience the risk is overstated. I've taken paracetamol then gone out drinking, and i've taken more than I should have when it's been prescribed, and i'm ok. Others may obviously have different experiences, but i'm yet to experience any sort of major liver damage and paracetamol is my regular painkiller of choice, because it works. I'm very sorry to hear of anyone who has chosen to cause themselves damage this way, but it takes a great deal of effort in my experience, it doesn't happen by accident. Paracetamol overdose isn't accidental.
posted by goo at 7:10 PM on February 9, 2013

I'm glad you've been lucky, but one person's luck says nothing about overall statistical risk. The article in the FPP seems to refer to aggregate statistics, which are a truer picture of risk than anecdote.
posted by Miko at 7:21 PM on February 9, 2013 [3 favorites]

goo, you are dancing on a ledge. You do not feel liver damage, you only feel the effects when your liver can no longer clear your bloodstream of toxins. You can function for a long time in a chronic failure mode where it doesn't take much more to push you over the edge, without ever knowing how close you are to that ledge.
posted by localroger at 7:25 PM on February 9, 2013 [3 favorites]

Ibuprofen damages kidneys, not livers.

If you destroy your kidneys they have dialysis machines to step in. For your liver, not so much.
posted by localroger at 7:32 PM on February 9, 2013

Yes, I have been lucky, and I will continue to be so after 36 years of using paracetamol safely, without any risk to myself or others. If I'm walking a knife edge I'm certainly not alone...
posted by goo at 7:45 PM on February 9, 2013

You can function for a long time in a chronic failure mode where it doesn't take much more to push you over the edge, without ever knowing how close you are to that ledge.

Repeated for emphasis. Now that I'm getting longer in the tooth, I look around at all the smokers with breathing problems, the over-eager drinkers with liver damage, the bull riders and others who thought they were immortal and would never have something come around and bite them in the ass, or lungs, or liver, or arthritic joints, and am astounded that every generation thinks they don't need to heed the warnings...


Everything in moderation, folks. Cut down on the salt, fat, exercise, etc. Makes getting older so much less shitty.
posted by BlueHorse at 9:37 PM on February 9, 2013

without any risk to myself

Actual medical, scientific evidence says otherwise, but of course your anecdata is more accurate.

If I'm walking a knife edge I'm certainly not alone...

Which obviously makes it not a problem!

As someone or -ones mentioned above, part of the problem is that the margin between "safe, therapeutic dose" and "will fuck you up but good" is very narrow, and is made narrower by alcohol. It is a kind of knife edge. Unless there's a reason why you can't either switch painkillers or stop drinking, why walk it? It's not like there's an absence of other OTC painkillers that won't land you on a transplant list because you tried to take care of a hangover. Christ, you're not being brave and daring, you're just being stubborn. That's a silly reason to risk needing a new liver.
posted by rtha at 9:46 PM on February 9, 2013 [4 favorites]

If you destroy your kidneys they have dialysis machines to step in. For your liver, not so much.
posted by localroger at 10:32 PM on February 9 [+] [!]

You do not want to live on dialysis. It is a horrible way to survive. Also, taking too many NSAIDs has been shown to cause kidney cancer as well as just damage. Kidney cancer is a cancer that has very little by way of treatment and can return even years post nephrectomy.

The risks of APAP and NSAIDs is why I get so pissed at them treating narcotics like they are evil. Narcotics are much less worse for you than tylenol or ibuprofen.
posted by SuzySmith at 11:02 PM on February 9, 2013

Limmy tries to buy two packets of paracetemol.
posted by caek at 11:11 PM on February 9, 2013 [1 favorite]

No more than three grams per day, folks. No need to panic or foam at the mouth. Very rare cases of toxicity with doses under this level. Personally I stick to the old limit of four grams/day, but I rarely take it for more than a day or two at that level, usually when I have cold or flu.

Very good backgrounder on acetaminophen here

FDA has recently lowered maximum daily dose to 3 grams from 4. This drug is so old that the FDA may not be able to order manufacturers to make changes to their labeling, but they are still able to pressure them.

Also, FDA has directed/pressured manufacturers to stop making combination acetaminophen/opioid pills, because of risks to chronic users and abusers, but instead make pure opioid pills available. Great idea.

I agree that APAP should be sold in blister packs to reduce risk of impulsive suicide.

But it's a very useful drug, which I administer every day. I also give it intravenously to my patients.

Use as directed. Your mileage may vary.
posted by etherist at 7:17 AM on February 10, 2013 [2 favorites]