It is pleasing to see error bars on a graph in a mainstream publication. It's very nice to have them saying that the study was small and there are more questions to be asked.
It's good that they mentioned the severe toxicity of paracetamol in overdose. It does kill many people, and it's not a pleasant death. It also accounts for many organ transplants.
It would have been nice if they'd said that, taken carefully and with no over dose, paracetamol is a very safe and very effective medication. It's very cheap. (At least here in the UK, I found it bafflingly expensive in the US.)
Cultural note: In the UK most medication is dispensed in blister packs. You can buy paracetamol off the shelf but you can only get limited quantities. Most shops will only sell you 16 tablets (at 500 g each) or 32 if you buy it from a person. You can get 100 if you see a pharmacist and persuade them you need them, but that'll be a struggle in most places. You can get large amounts if you have a prescription. 16 tablets at 500 g each would cost around £0.20 (for budget pills). Blister packs was an effective suicide control measure, reducing the number of pills taken and the number of overdoses attempted. Reduced quantities of pills sold had an initial success in reducing suicide rates, but number have since risen. Pills in the homes of old people are especially dangerous. This is because they're not locked away, and young children visiting sometimes take the pills. And also because suicide rates among old people are depressingly high.
In Switzerland, I _can't_ buy more than ~2 [1] packages with 16 pills (500mg acetaminophen/paracetamol) at a time without a prescription from my doctor. And the biggest package size is 100, but that always needs a prescription. Also, you can only buy it at a pharmacy anyway.
[1]: it depends a bit on the pharmacy/pharmacist, sometimes you can get away with 3, but they start asking questions and propose you just come back again when you used up the 2 packages they are willing to sell to you.
It's not a joke! In Canada, go to the pharmacy section of any large supermarket and you can easily find large bottles with 500 tablets of 500mg acetaminophen/paracetamol. Even small pharmacies carry bottles with 100-200 tablets of Tylenol (branded product) or a generic version.
you can buy paracetamol in packs of 200? jeez. isn't this one of the main killers, though overdoses (many accidental)? i'm pretty sure size for otc sale is regulated in other countries.
paracetamol is nasty stuff - dying from it is not pleasant, and it's surprisingly easy to do.
I believe there isn't currently any mechanism for the U.S. FDA to restrict number of pills sold of OTC medication, only the contents of each individual pill and the dosage instructions. The assumption is that OTC means purchase itself is unregulated, so you can order a truck-load if you really want to stock up.
The only cases I'm aware of where purchase numbers are limited for OTC drugs is when separate laws targeting drug precursors impact them, which is why you can't buy large numbers of pseudoephedrine tablets at once (they can be used to manufacture meth).
The FDA does seem to be reducing the maximum dosage of each tablet, though: from 2014 the maximum will be 325mg, so the 500mg tablets linked above will be phased out. But that change seems aimed at reducing accidental liver damage from excessive "normal" use, rather than aimed at reducing suicides from deliberate overdoses.
I believe there isn't currently any mechanism for the U.S. FDA to restrict number of pills sold of OTC medication
There are exceptions (but I'm not sure if they're from the Law Enforcement side, or the FDA). For example, you can't buy Sudafed (whose active ingredient, pseudoephederine(?), is used to make meth) without severe restrictions: not more than a pack a day, need a valid ID, etc.
While the limit is indeed bizarrely chosen, I think that one falls into the fairly common case of the FDA setting a per-pill maximum, not a limit on overall quantities. There's a limit of 100mg potassium per pill, but afaict there aren't any controls on buying the supplements in bulk, so you could order thousands of the pills if you wanted. The total-quantity limits seem to only be on things where the DEA has gained some authority over the substance.
Not that easy, can take a couple of days while your liver shuts down. If a family member gets the person to a hospital, they can survive easily enough, but it does some damage to the liver. Horrible way to go :/
One study [1] gives these annual numbers: 56,000 emergency room visits, 26,000 hospitalizations, and 458 fatalities. They further estimate about 75% of the fatalities are intentional overdoses, and 25% unintentional. Though I recall reading elsewhere that the majority of the non-fatal cases are accidental overdoses, e.g. from unwittingly taking multiple products that have acetaminophen as a component.
So, the incidence rate for accidental overdose is something like .048 per hundred thousand persons, compared to murder which is 4.7 per hundred thousand persons. You are 100 times more likely to be murdered than accidentally overdose on Tylenol. I'm not sure why there is so much concern over this?
To be honest, I find the UK law to be absolutely stupid in this regard. I needed to buy 10 packs of paracetamol, and at local morrisons I was told I couldn't, maximum was 2 packs(16 tablets each). So I bought two packs, went out of the store, came back in, bought another two, repeated the process 5x and got my ten packs. The whole law is just an annoyance, nothing else. If I wanted to kill myself with paracetamol I could easily get even a 1000 tablets, would just need to drive around a few supermarkets but this law would not stop me from doing it.
> The whole law is just an annoyance, nothing else.
This is not true. It's about preventing impulsive suicides, not premeditated ones. If a depressed person is having an episode and all they have in their house is 16 pills, then it removes the opportunity: maybe by the time they've make it to the shops and buy more, the moment will have passed, and a life would be saved.
It's been shown time and time again that you can reduce absolute suicide rates by removing opportunities like this. If I remember correctly, there was something similar involving gas ovens, though I can't find the reference now. Guns, bridges, etc. are all similar too.
When it comes down to it, if someone's determined enough to kill themselves, they will, but the truth is most people aren't and doing things like only selling small quantities of pills really can prevent suicides.
>The switch from coal gas to natural gas also had one unexpected effect. During the ‘50s and ‘60s, about half of the suicides in Britain were by coal gas. By the ‘70s, when the transition to natural gas was complete, the number of gas suicides had dropped to zero and the overall suicide rate was down a third. Even the suicidal appreciate convenience. If it's too much trouble, as Dorothy Parker said, "You might as well live."
Also, regarding my above post (which I can't edit now), I didn't mean to imply that "just" 16 pills was even remotely safe because I'm sure it's not (I'm not a doctor) but the general point stands...
BBC article following reductions in successful suicides
(interestingly it says no reduction in number of overdoses. But we have a pretty good reversal for paracetamol-induced overdose - N-acetyl-Cystine - so they should have a pretty good recovery)
Yes, but it's very important that anyone with an overdose gets treatment as soon as possible, even if they feel no ill effects at that time.
Death from paracetamol overdose is by liver failure, and that takes a week or so to happen, but after the first 24 hours there's not much you can do to prevent it apart from liver transplant.
Paracetamol overdose is a small number of liver transplants in the UK, but a significant number of the 'super urgent' transplants.
The UK law is stupid. My sister took her life using paracetamol. She just drove to 3 different pharmacies and bought the max amount at each. She also bought sleeping tablets so that the pain of her dying liver would not wake her.
A few days before this, my family had tried to have her sectioned as mentally ill (she was suicidal from post-natal depression). They psychiatrists kept her in for observation for 48 hours, then released her. 24 hours later she was dead, and her child an orphan.
All the law did was slow her down for maybe 15 minutes in her suicide attempt.
No law can prevent all such tragedies. But failing to have prevented this one doesn't make the law stupid, or worthless. It does successfully prevent other cases. What happened with your sister is certainly horrible, but you can't generalise from that to every case.
Would you also say murder laws are stupid because they only reduce the incidence of murder, not eliminate it? Of course these laws aren't going to stop a planned suicide, but they will prevent spur-of-the-moment ones that use this method, of which there are plenty. I'm sorry for your loss, but the answer isn't railing against measures which may help others.
My dad lives in a really remote region and doesn't go out much, so he asked me to buy like a yearly supply of paracetamol for him(along with a trunk full of food). What I did not expect, was that it's going to be such an annoying problem. As I said, I did buy what I wanted, except that it took me 10 minutes instead of 2. If you want to make it hard for people,just make every medicine prescription-only.
Laws are usually a compromise. I would say that preventing some suicides at the expense of forcing you to spend ten minutes to buy a year’s worth of painkillers is a very decent compromise.
I can understand that, especially given the "my dad" part. For all we know, his dad is not allowed to drive a car and not the quickest on his foot anymore. "Really remote" is a relative thing.
I still think that 10 packs of Paracetamol, if I had them in my home, would last me not for a year, but easily for the rest of my life. But maybe I am still too young and healthy to judge that.
Oh, my dad is easily taking a pill of paracetamol per day, he tried other drugs but because of other medications he is taking for his cancer his choice is really limited and he is in pain for most of the time. What I bought him won't even last a year. And sure, if he absolutely needed to, he probably would be able to get some on his own, but it was a more convenient for me to do a massive shop and buy him supplies that will last him a while.
The laws are frustrating for people like your father.
He could get it added to a prescription, which makes getting the quantity easy but it then becomes more expensive. (Unless he qualifies for free 'scripts.)
Or you could just haggle with a pharmacist.
But, yes, it's an added hassle at a time when you very much don't need the extra hassle.
It's all relative. The UK does include some remote isles of Scotland such as Shetland, however, with up to 10 flights a day, it may not be considered too remote in regards to access to supplies!
There are very few places that come close to feeling remote, certainly. And it's only getting more crowded =/
confused old people die from paracetamol overdoses. this helps reduce that, afaik (no evidence to hand, but read up on painkillers not long ago as i needed to take them over a fairly long period). and given that you could work around it easily, it seems that the cost to others is not so high...
My mom has Alzheimer's, and recently started hallucinating. After several (!) trips to the ER and doctor, someone finally thought to do a blood test, and found that she had a severe sodium|potassium deficiency (now I don't remember which). Turns out she was thirsty due to the dry climate and it being winter, and she kept drinking water, forgetting that she had just finished a glass, which led to the mineral deficiency, which caused the hallucinations.
I can't imagine how hard it would to control be if she was taking painkillers on an as-needed basis for a long time. People with dementia are often surprisingly clever and resourceful, considering the disease.
Dementia is a bug in the program. The program is powerful, and the bug is a small change that makes it powerfully wrong.
It is amazing that someone could drink that much water, without a restroom bream or just not feeling thirsty anymore. But I can imagine overdrinking over a course of days in response to feeling dryness, and not realizing that she is overdoing it.
It's expensive in the UK too if you buy a brand name painkiller. It's depressing that they can still sell them when the identical generic medication is next to them on the shelf and is 1/10 of the price.
You may feel better about this if you take some Tylenol ;-)
I don't see how there's anything wrong with selling brand-name drugs next to generics. In fact people that believe brand name drugs are more effective will have a better response to the more expensive drug because of the placebo effect. If anything, they're getting a better response to the same dose of the same drug than the rest of us plebs that know better than to pay a multiple of the cost of the generic.
> Oh, it's not wrong, just embarrassing as a human being. ;)
Care to explain why?
I buy Tylenol branded acetaminophen. Granted, I only buy one bottle every three years or so, but I'm perfectly fine spending a few dollars more. While acetaminophen is acetaminophen, when I buy Tylenol, I'm buying into their quality control and the experience that has come with that company, over many years. It's worth a few dollars to me to make sure that I'm getting what I'm buying and nothing more.
Do explain how brand loyalty is "embarrassing" to humanity.
It may feel like it's safer, but personally, I doubt it. You're paying mostly for a feeling, and that's somewhat irrational.
Medicine is a relatively good place for paranoia though, and for feeling safe. Most brand loyalty is even sillier. Don't get me started about designer clothing.
This makes no sense to me. If I have a good experience with a company, then any subsequent experience is far more likely to be good than a random selection?
The entire point behind brands is consistent experience.
If we're being pedantic, that's inductive reasoning. See the problem of induction [1]; you cannot justify any inference about future experiences of a product based on past experiences of it alone.
Brand loyalty is broader and can potentially be justified.
I can't think of anything I where I don't pay for a feeling. I could live in a closet and eat the bare minimum to survive, but I like to feel cozy and feel that my food is tasty.
Something like ADHD medication can make a difference. One of the most difficult months I've had has been a month where I tried the generic and the side effects were way worse than the brand name at same dosage.
I once took a medication through a skin patch. The same issue: the generic did not deliver the medication consistently at all. The patch was supposed to be replaced every three days, so I'd get a huge rush of medication the first day and next to nothing the last day. What was worse was that there were two generics. One was as described, the other actually was fine.
The moral, for me, is to be very cautious with generics. I believe most of them are fine (I would never pay full price for Tylenol :), but the more critical the medication is to me, the more research I will do on the generic.
I'm no expert on this, but just guessing here: have pills been around longer than patches? Perhaps manufacturing pills is better understood/easier to get right, so you are probably safe with generics in pill form, but will want to double-check on generics in any other form.
That's very true. Creating an instant release generic is nowhere near as difficult as producing an extended release or transdermal formulation.
The FDA recently pulled a 300mg generic bupropion generic because the extended release formation produced nowhere near what the branded medication did.
Most generics are equivalent to the branded medication, but there are exceptions out there.
FYI generic testing isn't as nearly as extensive as for new drugs. Also fentanyl isn't the only transdermal medication that exists. It's not even the most common. Nicotine, clonidine, birth control and hormone therapy can all be given in patch format.
In generics they can change the inactive ingredients and obviously they don't always use the same equipment or facilities to produce it. Some people have allergies to inactive ingredients which may explain the different side effects.
But in my mind the generics are just as good as name brand, albeit sometimes different. I guess I'd be just as likely to react poorly to the inactive ingredients in the name brand and might find a generic better in some cases.
Actually that's not true. Generics (at least in Canada but probably true elsewhere as well) only have to give between 85%-120% of the dose of the brand name drug, this is despite having the same official dosage as printed on the label. The difference comes from preparation, pill coatings, and inactive ingredients.
Also, my friend who works at a pharma factory says brand names have much tighter quality control - more batches are tested with far less tolerance.
In addition, some of the details of the chemicals (such as I guess the angles of the molecules) may be different, because the generic manufacturer imperfectly reverse engineers the process used to make the drug.
Clinical trials to validate the generic are less strict.
That's right. The impact that this has on the quality of the medication is dependent on the dose-response curve. I wouldn't expect this to be a big deal for painkillers, for instance, but it could easily cause noticeable differences elsewhere.
It's good that they mentioned the severe toxicity of paracetamol in overdose. It does kill many people, and it's not a pleasant death. It also accounts for many organ transplants.
It would have been nice if they'd said that, taken carefully and with no over dose, paracetamol is a very safe and very effective medication. It's very cheap. (At least here in the UK, I found it bafflingly expensive in the US.)
Cultural note: In the UK most medication is dispensed in blister packs. You can buy paracetamol off the shelf but you can only get limited quantities. Most shops will only sell you 16 tablets (at 500 g each) or 32 if you buy it from a person. You can get 100 if you see a pharmacist and persuade them you need them, but that'll be a struggle in most places. You can get large amounts if you have a prescription. 16 tablets at 500 g each would cost around £0.20 (for budget pills). Blister packs was an effective suicide control measure, reducing the number of pills taken and the number of overdoses attempted. Reduced quantities of pills sold had an initial success in reducing suicide rates, but number have since risen. Pills in the homes of old people are especially dangerous. This is because they're not locked away, and young children visiting sometimes take the pills. And also because suicide rates among old people are depressingly high.