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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  1. 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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  2. 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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  3. 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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  4. 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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  5. 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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  6. 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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  7. 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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  8. 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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