Acetaminophen-Related Overdose Deaths Down In UK Due To Law – BMJ

Legislation in the UK limiting the package sizes for acetaminophen and aspirin has reduced the number of deaths from overdose since its enactment in 1998, a study in the Oct. 29 British Medical Journal says.

The law "has significantly reduced the size of overdoses, with consequent reductions in morbidity and mortality," Keith Hawton, University of Oxford, et al., conclude.

The authors say "a further small reduction in pack sizes of paracetamol [acetaminophen] and salicylates would be unlikely to inconvenience users and could have further beneficial effects in preventing deaths from self-poisoning."

The British Department of Health reduced the number of tablets of acetaminophen and aspirin that could be sold in general retail outlets to 16-count packages following legislation that became effective in September 1998 (¹ (Also see "U.K. to require paracetamol overdose information on OTC labeling effective September 1998." - Pink Sheet, 8 Sep, 1997.), p. 5).

Previously, aspirin was sold in up to 100-count packs, while acetaminophen was sold in 48-count units. Prior to the legislation, DoH estimated that 100 to 150 deaths took place annually in the UK due to self-poisoning.

Study authors gathered data on drug-related deaths from 1993 to 2001 in England and Wales from the Office of National Statistics. Data also were collected from hospital monitoring systems on the number of patients admitted for acetaminophen overdose or liver transplant in England and Scotland between 1996 and 2002.

The researchers claim "199 deaths were avoided in the three years after the legislation - 118 involving paracetamol and 81 involving salicylates" based on analysis of drug-related deaths taking place in the five years preceding the legislation.

The reduction of paracetamol- and aspirin-related poisonings was more significant than a decrease found with other drugs, the authors maintain.

"Analysis of all deaths due to poisoning also showed a downward step change corresponding to the timing of the legislation. The change was much smaller, however, than those for the drugs covered by the legislation," Hawton et al. state.

The study identifies ibuprofen as a potential substitute for self-poisoning. In the five years prior to the legislation, seven "open verdict" or "suicide" deaths due to ibuprofen occurred. The number rose to nine ibuprofen-related deaths in the three years following the legislation's enactment. However, the study says "there is no evidence that [the substitution] has affected mortality."

"Although some substitution of self-poisoning with ibuprofen may have occurred, few deaths due to poisoning with ibuprofen may have occurred, and in all cases other drugs were involved," the authors explain. In addition, ibuprofen "is known to be relatively safe in overdose and is therefore unlikely to have been the cause of death," they add.

The numbers of tablets used in ibuprofen overdoses "did not change significantly after the legislation was introduced, suggesting that the legislation's effect on overdose size was restricted to the targeted drugs," the researchers note.

The study identifies a 30% reduction in the number of hospital admissions due to acetaminophen hepatotoxicity during the first (1998-2000) and second (2000-2002) periods following the legislation's enactment.

The mean annual admissions for acetaminophen poisoning decreased from 349 in the two years before the legislation to 230 in the four years afterwards. A 30% reduction also occurred during the period for the number of liver transplants.

There was a 15% reduction in non-fatal self-poisonings at hospitals in the year after the legislation was enacted, "but no reduction in subsequent years." The number of aspirin overdoses did not change during that period, while the number of ibuprofen overdoses increased by 27%, Hawton et al. claim.

The authors acknowledge that limiting product package size is not a definitive means to reducing suicide, but is a valid approach.

"Clearly the legislation does not prevent an individual intent on obtaining large supplies from purchasing through multiple outlets. Self- poisoning is, however, often impulsive and involves tablets readily available in households," they state.