Why Can’t You Buy a Big Bottle of Headache Pills in England?

Last time I was in London I had a headache, and went to the nearest Boots to buy something for it.

Photo: vvvracer

In U.S. drugstores, I’m accustomed to finding half an aisle devoted to headache pills, with bottles ranging from small to very large — at least 200 pills in them. So that’s what I went looking for in Boots, but no such bottle was to be found. The only options were cardboard packets containing maybe 20 pills, with each pill in its own blister packet. (The pills were also larger than U.S. pills.) Hmm, I thought. I guess Boots finds it can charge a lot for a small amount of headache medicine since most people, when they have a headache, aren’t very price-conscious.

But I recently learned the real reason for this phenomenon while interviewing David Lester, a psychologist at the Richard Stockton College of New Jersey who is the dean of suicide (and death) research. (We are producing an hour-long Freakonomics Radio special on suicide.) We were discussing the efficacy of SSRI’s on treating depression (and fighting suicide) when he explained why it’s hard to find a big bottle of headache pills in England:

LESTER: And although there was a lot of publicity in recent years about the dangers of the SSRI, the serotonin reuptake inhibitors, like Paxil, and Zoloft, and Prozac, the death rate of people taking those medications is much less than people taking the older antidepressants. They’re much safer. There are fewer suicides, and there are fewer accidental overdoses. There still is some concern about adolescents, but on the whole they’re the much safer ones. In England and Europe, Tylenol is sold under the name Paracetamol, and that’s used for huge numbers of overdoses, which on the whole aren’t lethal but leave the people with kidney damage and often of dialysis for the rest of their lives.

DUBNER: That’s interesting, yeah. I was in London recently and had a headache, and went to buy some acetaminophen or ibuprofen and noticed that in a drugstore I couldn’t seem to find anything larger than a container of maybe twenty or twenty-five pills in those foil sheets where you have to punch one out.

LESTER: They started doing that about five years ago, and they restrict the numbers, and they put them in plastic blisters so you have to tear them out. And again, you’d think all I have to do is go to six drugstores, you know, buy packets in each of them, all I have to do is just tear them out. But it has cut down the number of overdoses. It’s also cut down the number of serious overdoses that have led to kidney damage. Now, very few people died of an acetaminophen overdose. So it’s been hard to document that it cut the number of deaths, but certainly the number of attempts. The overdoses with it have been cut dramatically. And they did think about other things. You know, they did think about putting bitter tasting substances in it, or a substance that would make you vomit if you took too many. But they decided that was perhaps…That would interfere with the appropriate use of an analgesic such as Tylenol or aspirin. You know, the people who really needed them for headache would find it unpleasant to take them. … It’s been remarkable, a success, that.

DUBNER: Now, let me ask you…

LESTER: I’m glad you had that experience. It shows that it’s, that the drugstores are actually applying it, I mean they are following the rules.

It is of course a larger question as to how valuable such a rule is. But I’m happy to at least have an explanation.

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COMMENTS: 36


  1. Murray says:

    Hidden due to low comment rating. Click here to see.

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    • Richard of York says:

      Ibrobufen is an anti-infammatory and does not have the same problem with overdosing as Paracetamol.

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      • Otto says:

        Ibuprofen in large doses can cause kidney problems, including kidney failure. It isn’t nearly as dangerous as acetaminophen, but it’s happened. Google “Alonzo Mourning kidney failure.”

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  2. jonathan says:

    The son of my father’s partner took too many tylenol and destroyed his liver. I don’t know the rate of occurrence.

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  3. Richard of York says:

    This is true and shows how you can get an unexpected behaviour from changing packaging (i.e. for people who really want to suicide, you would not expect them to have a problem with going to 6 pharmacies and emptying the blister pack, would you?).

    Which, therefore, begs the question: how many of the prior cases were highly based on “impulse” – doing this with no planning? And the moment you place a small planning obstacle, they don’t do it? If this is the case, then there are MANY examples where we could think about interfering with peoples lives to give us better EXPECTED outcomes! Slightly un-American but “hey ho”!

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  4. Mr. Moon says:

    The same logic also applies to why we British are only allow to buy rope in lengths of one metre at a time.

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    • Peter says:

      That’s not true. Would you like to provide a source?

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    • Simon Farnsworth says:

      The last time I bought rope, from the Homebase store at postcode OX3 7JN, I was able to buy a 10 metre length, rated to carry 200kg of weight. Ideal for the purpose I had in mind (lifting heavy objects into the loft space, but contradicts your claim.

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      • Mr. Moon says:

        Peter, Simon,

        I apologise – it was a stinking lie designed to make somebody crack a smile. I was applying the same logic to other possible methods of suicides; the joke in this instance being its impracticality.

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      • Peter says:

        I guessed that as soon as I had replied. Sorry! Sarcasm can be easily missed online. But the rope example is different as these drugs are still very useful in packets of 20, unlike a short rope.

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  5. Paul says:

    Ibuprfen is much safer in overdose hence you can buy up to 96(even in packs of 96-38g ibuprofen) however paracetamol/acetaminophen containing products are usually restricted to about 16g. Which could be a toxic dose but probably not lethal if treated in most people.

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  6. Ivo says:

    I doubt that this analysis fully explains the smaller packaging. In the Netherlands, I’ve never, in at least 20 years, seen a package containing more than 40 painkillers. When I was in the US, I was amazed that they sold these bottles with hundreds of pills. Why on earth would I want those? I don’t use more than maybe 15 painkillers a year and the vast majority of people shouldn’t. A large stockpile can go bad, get lost, be spilled, etc. It just doesn’t make any sense to me to buy such a large amount of painkillers. So I think it’s largely a cultural thing, in line with the common saying ‘In the US, everything is bigger’. That at least holds for the average car, steak and bottle of painkillers.

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    • Uthor says:

      Because it’s cheaper per pill, duh!

      (not taking into account all the pills you would waste by not using them all, of course)

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    • Enter your name says:

      Some of the notion is that you don’t have to buy the drugs as frequently:

      You might easily imagine a household in which two adults who each take two aspirin about twice a week. That’s about 200 pills a year. Similarly, you might have an adult taking one daily low-dose aspirin (to slightly reduce the risk of a heart attack); each adult in the household needs 365 pills per year for this purpose. Rather than remembering to buy one small, overpackaged box of 20 pills every three weeks, why not buy one 200-pill bottle every six months?

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    • Tracy says:

      In the US, people are expected to work despite their pain. More so than other countries? I don’t know, but that might be interesting to find out. Meanwhile people I know, finish big bottles of OTC painkillers all the time without getting near the expiry date. Aspirin goes with vitamins and coffee every morning. Or would the worker rather lose his job?

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  7. mfebber says:

    I bought PeptoBismol-type chew tablets at a Boots in Heathrow. Had to ask for them from the pharmacist since it was “behind” the counter and had to sign a paper – they said the signing was due to aspirin in the tabs. Not sure if this was due to bleeding from overdose or what. Trying to imagine a purposeful overdose attempt chewing hundreds of chalky, chewy PB tabs.

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  8. Jay - London says:

    The above reason is correct regarding limits of medicine to prevent suicides and self harm. I used to work in a Boots store in London and customers were not allowed to purchase more than 100 tablets at once (four boxes of 25 – usually Neurofen Plus/Ibuprofen and Codeine). In fact the till would flash up in a red screen, and you would have to clear the sale with the Pharmacist before hand.

    This however does not stop customers leaving the store and coming back to purchase a further 100 tablets from a different Sales Assistant, or from the same Sales Assistant. It just did not allow more than 100 in ONE transaction. Other interesting sales would be addicts purchasing Kaolin and Morphine but asking you not to shake the bottle before hand, so that they would not have to wait so long to filter out the morphine for their fix.

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  9. Joe W. says:

    Hi Stephen,

    you say “I guess Boots finds it can charge a lot for a small amount of headache medicine”, but did you really find that to be the case?

    Typically when I’m buying paracetomol here in England they come in little tubs at a scandalously low 30-50p for around 20 of them. There are brand name products like Nurofen but the generic paracetomol and ibuprofen products are dirt cheap.

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  10. Therese Norén says:

    It’s hard to take someone seriously when he doesn’t know which organ paracetamol/acetaminophen usually cause damage to. Yes, there are cases of kidney damage from paracetamol, but it’s rare. Paracetamol is the second most common agent causing _liver_ damage (after alcohol).

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  11. Trent says:

    Just to correct something above from David Lester: (acute) overdoses of acetaminophen notably cause liver failure, not kidney failure, and it can be fatal at low doses in alcoholics (who probably are more likely to try suicide). There may be concurrent kidney impairment, but not always, and it’s the liver problems that kill you. Long term high dose acetaminophen (not the type used in suicide attempts) use can cause kidney impairment, but is much more likely in non-steroidal analgesics, like aspirin and ibuprofen.

    Ask any physician how you die from Tylenol (or do a google search), and they will answer liver failure. If the patient is otherwise healthy, they usually fully recover without lasting effects, so I don’t know where the bit about lifelong dialysis comes from (though it may be necessary short-term as the patient recovers).

    When a supposed expert makes errors like this, it makes me wonder about the rest of what they are saying.

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  12. MEU says:

    There’s a good NPR article that explores the motive/opportunity components of suicide. One anecdote sticks with me:

    “In England, death by asphyxiation from breathing oven fumes had accounted for roughly half of all suicides up until the 1970s, when Britain began converting ovens from coal gas, which contains lots of carbon monoxide, to natural gas, which has almost none. During that time, suicides plummeted roughly 30 percent — and the numbers haven’t changed since.”

    http://www.npr.org/templates/story/story.php?storyId=92319314

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  13. Jeff says:

    The same restrictions apply in South Africa. You would think if you knew enough to kill yourself with an overdose of Tylenol, you would know enough to buy enough bottles to do the trick. Hard to believe this regulation has actually reduced suicides.

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    • NIc says:

      I bought a massive (30 boxes) shrink wrapped pack of paracetamol boxes each with 16 500mg tablets from Macro no problem at all – Shop owners need to get stock from somewhere. Is there a correlation between small shop owners and kidney failure??

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    • Enter your name says:

      The vast majority of people who attempt suicide spent less than an hour thinking about it or planning it before doing it. A quarter of them spend less than five minutes thinking about it. If committing suicide required going to even two stores, most attempts wouldn’t be made.

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  14. James says:

    Same is true in Switzerland (or was when I lived there a few years ago): aspirin was available only in packets of about 10, at about 12 francs (about $8-9 at the time).

    As for why people would want large bottles, a daily aspirin has been shown to reduce heart disease, some kinds of cancers, delay incidence of Alzheimer’s disease, etc. So a bottle of a couple hundred tablets for a few bucks seems pretty cheap health insurance :-)

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  15. John says:

    So, are there similar restrictions on condom purchases in the UK?

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  16. Kathryn Jordan says:

    The really really stupid thing about this is that there IS something that can be added to paracetamol that will stop it irreparably damaging the liver on overdose, but, while – according to this article -they’ll consider adding something to make it bitter tasting or make you vomit if you take too many, they won’t add this compound. From memory the guy who ‘invented’ paracetamol recommended that the additive be included in commercially prepared formulations, but the pharmaceutical companies declined – presumably in an effort to cut costs. And haven’t they won nicely?

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  17. Anne says:

    This would have made an incredible difference to us when our son made a very serious suicide attempt some years ago. He swallowed 75 extra strength Tylenols and came very close to dying…liver failure, kidney failure, etc. When it is an impulsive act, anything that slows a person down is to be applauded. Besides, maybe if that bit of wisdom had been something I’d known about, law or no law, there wouldn’t have been a large bottle of it in the house. Here in N America, the logic of buying the large bottle for the savings is so dominant that it wouldn’t have (indeed, didn’t) even occur to me.

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  18. crquack says:

    The problem with paracetamol OD is that the death from acute liver failure follows only after several days and is rather unpleasant. Often people who have taken a lethal dose change their mind before the drug effects become obvious and by then it is too late. Alcoholics need quite small doses of the drug for this to happen.

    The lower the dose taken and the earlier such change of mind occurs the easier it is to treat and prevent catastrophic sequelae.

    I do not know about now but in the 1980s admissions with paracetamol OD were very common. A daily intake of acute cases in an internal medicine ward often had 10-40% of them.

    However, at least in Canada, acetaminophen (Tylenol, Paracetamol) in appropriate doses is considered the first line and safest drug treatment for chronic pain including osteoarthritis etc. Thus large quantities of pills need be available. The article does not mention if such quantities are available on prescription in UK.

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    • MW says:

      Paracetamol packaging in New Zealand and Australia is similar – max 20 per pack, in my experience. I’ve never tried to buy more than two at a time, so I don’t know if there are limits on how many you can buy.

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  19. Peppa says:

    I think this technique works well because of the nature of depression and its link to suicide. Severly depressed people are more likely to commit suicide, having pre-planned it, be more successful, etc etc. However, depression not only causes suicidal feeling but also inactivity/inability to motivate oneself to do tasks. Supposedly someone is more likely to commit suicide in the couple of weeks after starting anti-depressants when they have more energy to seek suicidal methods whilst still feeling depressed. But if previously they were unable to go to the shops to get paracetamol/tyelnol, its even more of an effort to have to go to three shops to get a sufficient dosage of drugs with which to successfully commit suicide.

    Also impulse suicides are reduced because of the time it takes to get all the pills. Even if someone had enough pills in the house with which to commit suicide, they would still have to spend 2 minutes or so popping the pills out of the packaging during which they would hopefully reconsider their actions whereas if you have a bottle of pills you can just swallow them very quickly once youve considered suicide.

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  20. Shane says:

    Fascinating. I know that certain occupations have higher than average suicide rates, related to access to lethal means. Vets, for example, have access to barbituates, knowledge about their adminstration (and, some add, a familiarity with the concept of using a peaceful death to end suffering). I read a report once which said that suicide among soldiers was most common when they were alone, armed and usually in the morning. Perhaps simple adjustments can be made in some cases to reduce these risks: having soldiers patrol in pairs for example.

    Sticking with UK for a minute, there was an interesting case some years ago when BBC’s hospital drama Casualty featured a suicide attempt using an overdose of paracetamol:

    “The number of people attempting overdoses jumped 17% in the week after an episode of Casualty featuring a similar suicide bid, according to a scathing study…. As well as the overall rise in overdoses, incidents involving paracetamol increased, they said…. The 17% increase in overdoses in the first week after the programme was followed by a 9% increase in the second week. Levels were back to normal in the third week.”
    http://news.bbc.co.uk/2/hi/health/314416.stm

    So suicide is a strange phenomenon, influenced by unexpected factors like its representation on TV and the availability of lethal means.

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  21. E Gardarsson says:

    The blister packs greatly reduce the chance of overdosing by mistake, as it’ll be much easier to estimate the rate of consumption by simply counting the empty blisters. “Have I taken 5 in the past 24 hours? 10?” That’s a huge difference, when it comes to things like Paracetamol. The difference between a therapeutic dose and a toxic one is very small. The term for this is a “narrow therapeutic index”. Permanent liver damage can result from only 2-3x the recommended maximum dose for a very short duration.

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  22. Pup, MD says:

    The concern with acetaminophen overdose is liver toxicity and the need for emergent transplant, not renal failure and dialysis, which is a real but much more secondary concern.

    As a psychiatrist, I find this rule absolutely brilliant. Some suicide attempts are planned. Others are impulsive. Making it harder to do impulsive things makes it harder to commit suicide impulsively.

    I’ve heard Tylenol is packaged this way in England, but I wonder about NSAIDs. Acute NSAID overdoses are much less dangerous. I’ve had quite a few conversations with adolescents and young adults in the ICU telling them if they just grabbed the bottle of Motrin instead of the bottle of Tylenol after their girlfriend/boyfriend dumped them, they wouldn’t be waiting to find out whether they are going to need a new liver or not.

    In Freakonomics terms, people are much more likely to impulsively shoot themselves in the head than they are to impulsively drown themselves in the swimming pool.

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  23. Richard, UK says:

    When I worked on the till in a supermarket about five years ago I was not allowed to sell more than two of these small packets in one transaction.

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  24. Robert says:

    Does anyone have evidence that Amaerican’s are dieing by the thousands, be able to buy aspirin in bottles of 500 tabs? Strikes me as yet another silly Nanny state limitation.

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