Impact of Restricting Paracetamol Pack Sizes on Paracetamol Poisoning in the United Kingdom

Abstract

Paracetamol (acetaminophen) is the most common drug taken in overdose in the UK, accounting for 48% of poisoning admissions to hospital and being involved in an estimated 100-200 deaths per year. In 1998, the UK government introduced legislation that reduced the maximum pack size of all non-effervescent tablets and capsules containing aspirin (acetylsalicylic acid) or paracetamol that can be sold or supplied from outlets other than registered pharmacies from 25 to 16 tablets or capsules. This article reviews the literature to determine the effectiveness of the legislation, focusing specifically on paracetamol poisoning. Seventeen studies on this subject were identified. Three studies found reductions in mortality rates; one study found an increase in mortality rates, while one found an initial reduction followed by an eventual increase; three found no significant difference in mortality rates before and after introduction of the legislation. Five studies found reductions in admissions to liver units, three of these finding a reduction in liver transplantation rates; two further studies found no change in liver function tests and rates of paracetamol-induced acute liver injury or failure. Four studies found a sustained decrease in hospital admissions, while two found an initial decrease followed by an eventual increase. One study found a decline in admissions for paracetamol poisoning and an increase in admissions for non-paracetamol poisoning. Sales data are conflicting, with two studies finding no significant difference in paracetamol sales before and after the introduction of the legislation and one reporting a decline. The severity of overdose appears to have decreased since the maximum permitted packet size was reduced, with five studies reporting a reduction in the number of severe overdoses (measured by numbers of tablets ingested, serum paracetamol concentrations and usage of antidotes). Only two studies reported an increase in the number of severe overdoses.Paracetamol-associated mortality rates, admissions to liver units/liver transplants, hospital admissions and the severity of paracetamol overdose appear to have been decreasing since 1998. However, one study showed that the reductions in mortality and hospital admissions began in 1997; therefore, the contribution of the 1998 legislation to the observed changes is unclear. Most of the studies are based on short-term follow-up so it is difficult to draw any conclusions regarding long-term trends. Many of the studies were also restricted to relatively small areas of the UK; this, combined with a variety of outcome measures, makes it difficult to distinguish any conclusive trends. The studies also suffer from a lack of comparison and control groups. Some studies do not clearly differentiate between the paracetamol preparations covered by the legislation and those not. The limited number of studies to date, combined with a variety of outcome measures, make it difficult to determine with accuracy whether or not the legislation has been a success. More long-t...

Detailed analyses of self‐poisoning episodes presenting to a large regional teaching hospital in the UK

“…The efficacy of the 1998 legislation is not yet clear as the majority of studies looking at its effects are based on short-term follow up in specific areas of the UK [23]. There is agreement that the severity of paracetamol selfpoisoning has reduced but the initial reduction in its frequency may not have been maintained [20,[24][25][26][27][28].…”

Simultaneous Determination of Paracetamol and Tramadol in Pharmaceutical Tablets by Derivative UV-Vis Absorption Spectrophotometry

“…It can also lead to serious condition if it is taken it with alcohol. It is considered as the primary reason for toxemia in USA, UK and the New Zealand [4][5][6][7].…”

Compliance packaging for over-the-counter drug products

“…Hawkins et al (2007) note that paracetamol (the UK name for acetaminophen) is the most common drug taken in overdose in the UK, accounting for 48% of poisoning admissions to hospital, and is involved in an estimated 100-200 deaths per year. Turvill et al (2000) report that paracetamol is the most common cause of intentional selfharm in the UK, with an estimated 70,000 cases per year, and represents a heavy burden to emergency, medical, and psychiatric services.…”

“…Hawkins et al (2007) reviewed 17 studies and concluded that the legislation has predominantly reduced mortality rates, admissions to liver units/liver transplants, hospital admissions and the severity of paracetamol overdoses since 1998, although more long-term studies are needed to fully assess the impact of the legislation. 3 Before-and-after studies by Hawton et al in 2001 and, evaluating data from September 1996 to September 1999 and September 1993 to September 2002, respectively, concluded that the pack-size restrictions have been beneficial-suicidal deaths from paracetamol and salicylates were reduced by 22% in the year after the change in legislation (September 1998), and this reduction persisted in the next 2 years.…”