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

Abstract

Objective To assess the long term effect of United Kingdom legislation introduced in September 1998 to restrict pack sizes of paracetamol on deaths from paracetamol poisoning and liver unit activity.Design Interrupted time series analyses to assess mean quarterly changes from October 1998 to the end of 2009 relative to projected deaths without the legislation based on pre-legislation trends.Setting Mortality (1993Mortality ( -2009 and liver unit activity (1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009) in England and Wales, using information from the Office for National Statistics and NHS Blood and Transplant, respectively. Participants Residents of England and Wales.Main outcome measures Suicide, deaths of undetermined intent, and accidental poisoning deaths involving single drug ingestion of paracetamol and paracetamol compounds in people aged 10 years and over, and liver unit registrations and transplantations for paracetamol induced hepatotoxicity.Results Compared with the pre-legislation level, following the legislation there was an estimated average reduction of 17 (95% confidence interval −25 to −9) deaths per quarter in England and Wales involving paracetamol alone (with or without alcohol) that received suicide or undetermined verdicts. This decrease represented a 43% reduction or an estimated 765 fewer deaths over the 11¼ years after the legislation. A similar effect was found when accidental poisoning deaths were included, and when a conservative method of analysis was used. This decrease was largely unaltered after controlling for a non-significant reduction in deaths involving other methods of poisoning and also suicides by all methods. There was a 61% reduction in registrations for liver transplantation for paracetamol induced hepatotoxicity (−11 (−20 to −1) registrations per quarter). But no reduction was seen in actual transplantations (−3 (−12 to 6)), nor in registrations after a conservative method of analysis was used.Conclusions UK legislation to reduce pack sizes of paracetamol was followed by significant reductions in deaths due to paracetamol overdose, with some indication of fewer registrations for transplantation at liver units during the 11 years after the legislation. The continuing toll of deaths suggests, however, that further preventive measures should be sought. IntroductionIn many countries, self poisoning with paracetamol (acetaminophen) is a common method of suicide and non-fatal self harm, it is responsible for many accidental deaths, and is a frequent cause of hepatotoxicity and liver unit admissions. [1][2][3][4][5] Legislation was introduced by the United Kingdom government, following recommendations by the UK Medicines Control Agency (later the Medicines and Healthcare Products Regulatory Agency) in September 1998 that restricted pack sizes of paracetamol (including compounds) sold over the counter. Packs were restricted to a maximum of 32 tablets in pharmacies and to 16 tablets for non-pharmacy sales. 6 7 This policy w...

Epidemiology of Acute Liver Failure from a Regional Liver Transplant Center in Portugal

“…Conversely, in the UK, para­cetamol-related ALF may represent about 65% of all cases [3]. This issue has largely to do with cultural differences regarding the public use of paracetamol; in the UK this has been associated with suicide attempts [13]. In Portugal, this phenomenon does not have the same relevance in terms of public health.…”

Are we finally making progress with suicide and self-harm? An overview of the history, epidemiology and evidence for prevention

“…In the United Kingdom, legislation restricting pack sizes of paracetamol and salicylate was introduced in 1998 and the following year saw a 21% reduction in the number of deaths from paracetamol poisoning and a 48% reduction in deaths from salicylates (Hawton et al 2001). Over the following 11 ¼ years, deaths from paracetamol overdose decreased by 43% in England and Wales (Hawton et al 2013), making paracetamol pack size legislation one of the most effective public health interventions in all of medicine.…”

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

“…We have disseminated our research findings through publications 22,37,79,85,[169][170][171][172][173][174][175][176][177][178][179][180][181][182][183] (submitted paper: Hawton K, Simkin S, Yu L-M, Omar O, Gichuru P, Kapur N, et al Did UK legislation restricting pack sizes of analgesics result in increased gastro-intestinal disorders due to greater use of NSAIDs? ), our programme website (www.…”