Letters

Limitation of over the counter sales of paracetamol

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7173.1657 (Published 12 December 1998) Cite this as: BMJ 1998;317:1657

Packaging policy is unlikely to achieve its aim of reducing suicide

  1. Mike Cranney, General practitioner,
  2. Julie Cranney, Health visitor (retired),
  3. Helen Stubbs, Assistant pharmaceutical adviser
  1. St Helens, Merseyside WA10 5HP
  2. Liverpool Health Authority, Liverpool L3 6AL
  3. Department of Medicine, Withybush General Hospital, Haverfordwest, Pembrokeshire SA61 2PZ

    EDITOR—New regulations to limit the availability of aspirin and paracetamol came into effect on 16 September.1 The number of tablets or capsules per pack has been limited to 16 in supermarkets and 32 in pharmacies, although multiple packs can be bought. Pharmacists can provide up to 100 tablets at their discretion for patients with chronic conditions, but greater amounts now require a prescription. Supermarkets may also sell 100 tablets, albeit in packs of 16.

    The health of the nation target was a 15% reduction in overall suicide rates by 2000.2 These packaging regulations aspire to reduce the incidence of deliberate and accidental overdose, but we believe that their effect will be limited. No single intervention was found to reduce suicide.3 The authors commented that measures to reduce the quantity of medicines available over the counter should be evaluated but suggested that only interventions of proved effectiveness should be introduced.3 Currently there is no such evidence available to justify these major changes.

    Thirty two paracetamol tablets is sufficient to commit suicide, and this amount is available in one container from pharmacies and in two from supermarkets. An adult requires only 12 g to achieve a toxic dose.4 On one day we purchased eight packs of paracetamol from four different supermarkets, obtaining 128 tablets within half an hour without any difficulty or questioning. Clearly the regulations prevent no obstacle to the acquisition of lethal doses.

    Since the implementation of the new regulations the cost of paracetamol over the counter has roughly doubled. This extra cost is partly due to the new packaging and has been passed on directly to consumers. The same considerations apply to aspirin, including the low dose preparation (75 mg). Patients entitled to free prescriptions may be more likely to approach their general practitioner to obtain these drugs because of this price increase. This will generate more work for general practitioners.

    We are all encouraged to practice evidence based medicine, with rational prescribing being one result of such an approach. The same principles should apply to policy making. The health of the nation strategy is full of good intentions,5 but more effective policies are needed for suicide to be reduced. These changes represent laudable aspirations but are a paternalistic folly. We believe that they are unlikely to succeed and will only inconvenience the vast majority of people, who use these drugs appropriately and responsibly, and add to the workload of general practitioners and pharmacists.

    Footnotes

    • Conflict of interest None

    References

    Restriction to 16 g will not prevent overdose and is unhelpful for patients with chronic disease

    1. Nigel I Jowett, Consultant physician
    1. St Helens, Merseyside WA10 5HP
    2. Liverpool Health Authority, Liverpool L3 6AL
    3. Department of Medicine, Withybush General Hospital, Haverfordwest, Pembrokeshire SA61 2PZ

      EDITOR—From September 1998 over the counter sales of paracetamol have been limited to 32 tablets. Notice of this restriction and the reasoning behind it have not been widely publicised since the Medicines Control Agency sought comments in 1996. I often recommend (and take) regular paracetamol to enhance the efficacy and reduce the side effects of non-steroidal anti-inflammatory agents. Since the recommended initial treatment for degenerative arthritis is 2-4 g paracetamol daily,1 those affected now have painful walks to the pharmacist twice weekly to buy the same drug at more than double the price. Although the human and financial cost of paracetamol poisoning is high, these restrictions are not only inconvenient but an unfair financial burden on the millions of people who adhere to the recommended doses and derive enormous therapeutic benefit from the drug. The success of rationing will largely depend on deterring those likely to take overdoses, but self poisoning is usually impulsive and seldom entails a planned purchase.2 Additionally, selective restriction of one drug will lead to an alternative being chosen or to the more familiar scenario of “overdose cocktails,” which are more dangerous because of multiple drug toxicity and interaction. Although paracetamol overdose remains common, most episodes result in subtoxic plasma concentrations and few clinical sequelae,3 and since as little as 10-15 g of paracetamol may be lethal, this token restriction of 16 g seems unhelpful. What should be addressed is the prevention of repetitive overdoses, the increase in poisoning by prescribed drugs,4 and the adverse effect that cases of trivial overdose have on the ability to provide acute medical care to those who may be in greater need.

      References

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