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EXPERTS are calling for a greater commitment to prevention efforts from the pharmaceutical industry, GPs and policymakers to combat what has been described as a growing epidemic of paracetamol poisoning.
Professor Nicholas Buckley, a professor of clinical pharmacology at the University of Sydney, told MJA InSight that the current “lack of controls on pharmacy sales is the weakest link in Australian regulation in terms of preventing poisoning”.
He said that the cheapest paracetamol tablets and the largest pack sizes were found in pharmacies, particularly discount pharmacies where boxes of 100 tablets were available for less than $2.
“Most very large overdoses involve ingestion of these products, rather than tablets from a supermarket.”
Professor Buckley coauthored updated guidelines for the management of paracetamol poisoning, published today in the MJA. (1)
The guidelines’ authors wrote that paracetamol was the leading pharmaceutical agent responsible for calls to Poisons Information Centres in Australia and New Zealand, with a large proportion of incidents involving accidental paediatric exposures and deliberate self-poisoning.
The management of patients with paracetamol overdose was usually straightforward, but acute deliberate self-poisoning, accidental paediatric exposure and inadvertent repeated supratherapeutic ingestions all required specific approaches to risk assessment and management.
The authors said that the key factors to consider in paracetamol poisoning were the ingested dose and serum paracetamol concentration early on, or clinical and laboratory features which indicated liver damage later.
The main changes from the previous management guidelines included the indications for administration of activate charcoal; the management of patients taking large or massive overdoses; modified-release and supratherapeutic ingestions; and paediatric liquid paracetamol ingestion.
Associate Professor Martin Weltman, a senior staff gastroenterologist at Nepean Hospital, Sydney, told MJA InSight that paracetamol poisoning was becoming “very commonplace” and cases usually fell into one of two categories.
The first included people who consumed a chronic excess of paracetamol, with or without alcohol, and could be taking the drug every day without realising its potential harm. The other group included those who took paracetamol as a combination drug, often with codeine.
“This is becoming an epidemic — people consuming a huge amount of paracetamol on a day-to-day basis and, because codeine is addictive, they become addicted to this combination.”
Professor Weltman said that even among people who only drank alcohol at moderate levels, low doses of paracetamol could cause toxicity.
Professor Buckley said that both GPs and pharmacists could play an important role in reducing the misuse of paracetamol and paracetamol/codeine combinations.
“In many cases this should involve referral for maintenance opioid treatment, as some of these patients are often surprisingly dependent on opiates and have great difficulty in stopping otherwise.”
Professor Buckley said that the Therapeutic Goods Administration had already made changes in 2013 to decrease the maximum paracetamol pack size that could be sold by retailers other than pharmacies from 25 to 20 tablets. (2)
“[However,] it is yet to be seen if this will translate into improved health outcomes, and it should be noted that these restrictions do not apply to pharmacies, and thus may not have the desired effect”, he told MJA InSight.
Professor Weltman agreed that GPs played an important role in preventing paracetamol poisoning, but added “I don’t know if GPs are always aware of what their patients are doing and taking”.
He said that for prevention efforts to be truly effective, the risks of paracetamol consumption must receive more public attention and be a part of health awareness campaigns, which should especially target young people.
“For example, parents need to be aware. They already know about drinking and talk to their kids about that, but they also should be having a discussion about paracetamol”, Professor Weltman said.
However, Professor Buckley cautioned that it was important to reassure the public that “paracetamol is a very safe drug in the correct doses, safer than all the alternative analgesics”.
“We do not want to do anything that might prevent people achieving adequate pain relief, or encourage them to use alternatives with many more side effects such as opiates and NSAIDs [non-steroidal anti-inflammatory drugs]”, he said.
(Photo: Photographee.eu / shutterstock)
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There is no “epidemic” of paracetamol poisoning. It may be the agent most commonly responsible for poison information centre calls, but that is for two easily identifiable reasons: 1. It’s use is almost ubiquitous, and 2. there is heightened awareness in the community. With due respect to Prof Buckley, when one works in toxicology, one only thinks about toxicity. As a front-line ED clinician for over thirty years, no epidemic has manifested where I work.
The facts are: paracetamol is one of the safest medications available to us – safer than NSAIDs, alcohol, maybe even peanuts. For the number of doses taken worldwide, the amount of harm is truly miniscule. IN particular, children are more tolerant – true toxicity in children is very uncommon.
As others have said, chronic pain is a real problem. The community is correctly concerned about the amount of high-potency narcotic being prescribed – with toxicity and side-effects that are orders of magnitude greater than -paracetamol. Let’s retain some perspective. Please.
Since Opium and Laudanum were introduced in the western armametarum of pain medicines none of the modern (so called ‘less addictive’) formulation have been more efficient to alleviate the suffering of pain (Alcohol is doing poorly in this area but is still elected/prefered by some sufferes). Legislation varies in different countries which conveys false assumptions as well about the level of care in these countries.
Why is pain so poorly managed in the 21st century is my question as a practicing pharmacist? Is the patient/person listen to when they are asked to tell their story (so many times)? Why are the referrals so long to come through?
Is the human condition to stay in a suffering status (to be easily manipulated)? ls the women’s condition to give birth in pain (so widely spread is the statement by the most poverful government on Earth)?
At a time where vidence base practice prevails should we not be wiser if not more knowledgeable? or have we just forgotten that were are human beings first and foremost, and then a professional?
A Carer for a Sufferer
Why not look at why are people landing in ER having paracetamol poisioning, its all very well to say its happening but why??
Most people who end up in ER are usually taking prescription pain medication too, suffer from chronic pain, are not being properly treated/managed by their primary Dr, so take OTCs to help manage their pain, or they are in extreme pain & need help and the Drs in ER treat them like drug seeking addicts, instead of people with REAL conditions that need help.
So how about the government do some better education programs, for the community about the dangers of taking to much pain medication, especially when taken with prescription pain medication.
And better education programs for ER Drs & nurse to treat those patients who come in with chronic pain conditons with DIGNITY & RESPECT, along with proticols in how to manage the patient.
Chronic pain sufferer
For many people paracetamol is fairly useless as a pain reliever, and the insistence on relying on this only, or even as a baseline before anything else is added, for pain relief makes no sense to many people with chronic pain. 6-8/day are not infrequently recommended, and these may still not give adequate relief, so it is no surprise that combination painkillers (codeine or anti-inflammatory + paracetamol) are often also bought. I often wonder if prescribers of pain relief have ever suffered chronic pain themselves.
Why not simply add NAC or methionine to the formulation… they’ll then become safe… Regulators have known this for decades, but have never mandated it…
If I want 40 tabs and they only come in packs of 20 then I simply buy two packs…