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Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f403 (Published 07 February 2013) Cite this as: BMJ 2013;346:f403

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Re: Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses

The data provided in this study is obviously very encouraging and it is clear that the limit in pack size is clearly having an effect on the number of both paracetamol poisoning deaths and liver transplant activity.

Although, interestingly there are many countries that do not have this restriction and yet still continue to show a reduction in paracetamol overdose mortality1. Subsequently it would seem prudent to explore the other factors that may contribute to this encouraging trend.

Results from a patient interview study looking at those whom had previously attempted a paracetamol overdose showed that 53.3% already had the paracetamol tablets at home2. Therefore it is possible that restriction in pack sizes would not have affected the overdose attempt.

Education is another factor that should be considered, not only to the person buying the tablets but the people selling them. One study looking at the availability of paracetamol in pharmacy and non-pharmacy outlets showed that the researcher was able to purchase paracetamol in excess of statutory limit in 81.8% of newsagents/mini-markets compared the 50.0% in pharmacies3.

Greater awareness by doctors of suicidal intent may also be playing a role in the decrease in suicide attempts. Awareness groups have more than doubled over the last twenty years and the stigma around mental health is on the decline. It is possible that these are playing an important role in patients seeking help for depression and hopelessness at a much earlier stage, therefore possibly preventing people from taking a paracetamol overdose in the first place.

In summary the evidence shown is this study is very encouraging and it seems that limiting pack size has played a key role in this. However for rates to continue to drop at a rapid rate we must take a multi-factorial approach and remember this when we treat our patients.

References:
1) Li C, Martn BC. Trends in emergency department visits attributable to acetaminophen overdoses in the United States: 1993-2007. Pharmacoepidemiol Drug Saf.2011;20(8):810-8
2) Simkin S, Hawton K, Kapur N, Gunnell D. What can be done to reduce mortality from paracetamol overdoses? A patient interview study. QJM.2012;105(1):41-51
3) Ni Mhaolain AM, Davoren M, Kelly BD, Breen E, Casey P. Paracetamol availability in pharmacy and non-pharmacy outlets in Dublin, Ireland. Ir J Med Sci.2009;179(1):79-82

Competing interests: No competing interests

17 February 2013
Mark Willis
Fourth Year Medical Student
Nicholas D. Gollop, Academic FY1 Doctor, Norfolk and Norwich University Hospital.
University of Manchester
UHSM, Southmoor Road, Manchester, M23 9LT