An Easy Way to Cut Down on Pill Suicides?

(Photo: Sage Ross)

Ezekiel Emanuel, who’s popped up in our blog and podcasts, writes in the Times about a simple way to reduce suicides:

We need to make it harder to buy pills in bottles of 50 or 100 that can be easily dumped out and swallowed. We should not be selling big bottles of Tylenol and other drugs that are typically implicated in overdoses, like prescription painkillers and Valium-type drugs, called benzodiazepines. Pills should be packaged in blister packs of 16 or 25. Anyone who wanted 50 would have to buy numerous blister packages and sit down and push out the pills one by one. Turns out you really, really have to want to commit suicide to push out 50 pills. And most people are not that committed.

Emanuel cites an Oxford University study which found a 43 percent decline in suicide death by Tylenol overdose after Britain changed the required packaging for paracetamol (the active ingredient in Tylenol). FWIW, we blogged about this a couple years ago. Also, it’s worth noting that most Times commenters think the idea is daft.

(HT: The Dish)


Jordan

43% decline means nothing without broader context: were the people that would have used acetaminophen using another method instead? It seems like an additional comparative statistic in a broader comparison, such as "% decline in deaths due to OTC/prescription drug overdose)", would also be needed to discern if there is a corollary of the decline towards overall suicides, or if it just meant that people resorted to other methods.

I remember hearing a statistic that males have a significantly better success rate when it comes to suicide attempts, because the preferred methods of suicide for males (weapons, jumping off things) had less opportunity for people to seek emergency treatment or be saved compared to females' preferred methods. (overdoses) Maybe an additional statistic worth looking at is if that 43% decline correlates to a shift in these "success rate" statistics; a correlated increase in success rate by females would imply that the method is simply being replaced by different, more deadly methods.

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Mike B

As much as experts and participants claim otherwise, I have a tough time believing that someone who chooses a suicide method that is well known to be ineffective has the same conscious or subconscious level of desire to end their own lives as someone who chooses a more effective method. The study showing a reduction in pill suicide deaths by the use of blister packaging can be seen as evidence for a lack of commitment by those that choose to use pills.

Enter your name...

Most people don't bother to find out whether their preferred method will work. Suicides are largely impulsive. Most of them go from "I'm going to kill myself" to taking action on it within minutes. They don't stop long enough to look up things like the fact that Tylenol is a slow (no effect for several hours) and ultimately painful way to die. (And, no, you don't 'fall asleep' like you would from an opiate overdose: you're awake for every single minute of that pain.)

Mike B

Instead of forcing people to live lives they aren't interested in wouldn't a better way of reducing "pill suicides", which are often ineffective and result in public medical costs, be to instead offer more reliable suicide on demand services? In additional to being consistent with the ideals of self-determination and liberty it would also result in significant savings for public pension and healthcare funds.

Enter your name...

We're not talking about people who are thinking this through here. We're talking about people who swallow a bottle of Tylenol and then are surprised to discover that it hurts when your liver dies. We're talking about people who change their minds if they have an unexpected ten-minute delay because the first store won't sell enough of the drug to them and so they have to go to a second store.

There are some highly reliable, inexpensive, and painless methods of killing yourself, but this type of program is aimed at the many, many people who are being stupid about their suicide attempts, not at the people who are willing to spend even an hour or two planning it.

Mike B

Anyone who doesn't "think through" something as important as taking their own life is probably a danger to themselves or others.

Mark

A study was done on suicide and it's an oddly impulse decision. Putting a fence up on a bridge dramatically reduced the deaths by suicide but didn't significantly increase the deaths by other reasons. Likewise when stoves stopped running on city gas(a mixture of hydrogen and carbon monoxide) suicides went down but never went back up.

Resumé
by Dorothy Parker

Razors pain you;
Rivers are damp;
Acids stain you;
And drugs cause cramp.
Guns aren't lawful;
Nooses give;
Gas smells awful;
You might as well live.

Joe Dokes

I've seen this "mythical" study mentioned on the internet a multitude of times. But I have yet to see a link to the study nor any other evidence. I remain unconvinced.

For example this "study" is used as an excuse for gun control.

And now in this context it is being used for "pill control."

A long time ago I was in favor of manny "Nanny" laws, like helmet laws, seatbelt laws, laws that restricted smoking. I have come to the conclusion that these are not simply "Nanny" laws that create a nanny state, but these laws are infantilizing all citizens.

Citizens can't be trusted to do the right thing so we must enact a law, whether it be a law that bans smoking, a law that bans firearms, a law that bans pills, a law that forces us to eat broccoli.

When Elana Kagen was nominated to the Supreme Court one of the questions she faced was whether Congress could enact a law that required the eating of broccoli. She said the law was stupid, but she never said it was unconstitutional. I am becoming less and less sure that I want to live in a society that has the power to force me to eat broccoli. Whether it in fact does so or not.

Regards,
Joe Dokes

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Matt

If the authors had ever had to deal with arthritis, they would know that even popping one pill out of its blister can be an ordeal for some people.

teh_drewski

Do people take paracetamol for arthritis? I would have assumed one of the anti-inflammatory painkillers would be the drug of choice, such as ibuprofen.

Mark

One other quick thought. There is a trade off. Roughly 25 billion doses are taken per year(24.6 in 2008 per FDA). If it takes 20 seconds to open a blister pack (close enough and the math is easier ) That is 5 billion minutes of time lost or 9500 years. Assuming 70 years of lost life, will this save 135 people per year? If not, it will end up killing people. This doesn't even take into account the extra costs and pollution of the packaging which will end up killing more people. I buy the mega bottle of Tylenol because I save $5 or $6, which is 45 minutes at minimum wage. You're killing me.

Mark

Oops, my math was based on 12 seconds (5 per minute)

I checked the numbers. 500 successful APAP suicides per year. It seems to make sense to do, unless the packaging numbers come in terribly.

Mark Wolfinger

1) Small packages waste packaging material. This idea is environmentally unsound.

2) Small packages are expensive anr economically unjustified.

3) Sadly, people who want to kill themselves have many alternatives.

Enter your name...

What's the environmental cost of spending a week in the hospital while dying? What's the environmental cost of a liver transplant and a lifetime of anti-rejection drugs?

James

There's (at least) one statement in that article which suggests the author has limited experience of the world: "...The other main reason is that some consumers — notably people with arthritis — might find it challenging to open the packages." Now I don't have arthritis - in fact, I'm pretty darned athletic - and I still find it a challenge.

As for accidental poisonings, don't those big bottles already have child-proof caps? While I can certainly imagine a kid getting intrigued by the pretty candies in the shiny pack, and spending an hour or so popping them out one by one.

SAO

No! I hate the blister packs with only 10 pills. Even if you have a couple of packs, this is what happens: someone in the family uses one or two every now and then. Then the flu makes the rounds. Suddenly, you have more than one person eating 2 pills every 4 hours. In one day, you've gone through two10-pill packs and someone has to dash out to the drug store late at night in the pouring rain.

I live in Europe and by my NSAIDs in the US, where I can get a big bottle.

teh_drewski

Is there any reason they can't sell bulk boxes of drugs in blister packs? I can get 100 pill boxes of paracetamol, ie. 10 x blister pack of 10 in one box.

The convenience of bulk with the inconvenience of it still taking a long time to pop enough pills to kill yourself.

Enter your name...

The UK limits the number of pills that you can buy from a store in the same trip. They do this so that people who are trying to kill themselves have to go to two stores. The research shows that by the time these would-be suicides make it to the second store, they've changed their minds.

Mignon

Reducing the size/number of medication packets is a standard component of suicide prevention strategies & is associated with reduced use of that method, & overall reduced suicide rates.  

Generally anything that delays or stops a suicide attempt helps reduce the rate. And no, peope don't just replace a method that's a bit 'harder' with an easier one.

Mignon

The other thing is that about 80% of suicides occur among people with mental illness, especially depression, which are treatable conditions. The person is often in emotional distress & not thinking straight, so any intervention that makes it harder helps to save lives. 

Check out the research by Beautrais.

Jeff

I certainly agree that this would decrease OTC pill suicide attempts. However it would increase the cost of production. Increased cost of production would likely force more jobs to be outsourced or eliminated. If profit margins decline drug makers will simply make less of medications that are unprofitable. The end result would be drug shortages for these necessary drugs. The industry is currently seeing the phenomena and basic life savings meds are on back order nation wide. Currently premature babies are doing without many of the necessary components of TPN the intravenous feeding solution among other basic emergency drug shortages. All this to reduce the incidence of attempted suicide by pill. How many of these attempts are successful? How many lives are at steak? How many of these attempts cause long term damage that the socio-medical system must endure the cost, contributing to the overall increase in health care delivery? Ultimately this is a great case to show the negative impacts on the overall system when ill considered governmental regulations are levied to prevent a high profile low incidence occurrence.

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Brian Knight

Toxicity from acetaminophen (Tylenol , paracetamol) could also be reduced by adding N-Acetyl Cysteine to each pill. NAC is the antidote to acetaminophen poisoning. This would not affect the potency and would only slightly increase the price.

cd

Wikipedia: "Although both IV and oral acetylcysteine are equally effective for this indication, oral administration is poorly tolerated because high oral doses are required due to low oral bioavailability, because of its very unpleasant taste and odour, and because of adverse effects, particularly nausea and vomiting."

Not effective, not marketable, not a good option.

B

I am curious how many human life hours would be saved by this move. It would lower rates of suicide via one specific (less effective) mechanism but increase pill taking time for the rest of the population by a miniscule amount.

B

For the record I would probably support such legislation.

Ryan N

What are the economic benefits of preventing people who want to kill themselves from doing so?

Enter your name...

Assuming that (as usually is the case) most of these people who "want to kill themselves" are actually younger people dealing with a passing fancy ("I can't believe he said that to me. I'll show him! I'll kill myself!") rather than a settled, determined wish, then the economic cost is approximately the same as any other premature death: Society spent tens of thousands of dollars providing education, medical care, and basic needs, and you killed yourself before repaying society's investment in you.

Mark

Here in Japan, Tylenol is sold in blister packs, with about 15-20 capsules per box. (Coincidentally, the World Health Organization ranks Japan tenth on its list of countries by suicide rate. )

Prescription drugs in Japan are sold in blister packs. I've never seen such medications sold in plastic bottles. Bottled pills tend to be vitamins, supplements and the like. Aspirin and similar drugs, cough medicines and so on are all sold behind the counter – you need to ask the pharmacist to hand it to you.

By the way, jumping in front of trains is the preferred suicide method in Japan.
Families of those who commit suicide are usually charged a fee. (One anti-suicide method is blue lights on platforms.)
Other suicide techniques in Japan: leaping off the roof of tall buildings; hanging.
Here is an article on my blog about the blue lights in Japan.
http://goo.gl/9TfFs

K

Just let them kill themselves, why make their lives even more miserable?

RGJ

Just thrown out without a viewpoint, but Britain is so different from the US in so many ways in these matters it is hard to even start the discussion. Europeans would take this discussion to turn it to the number of handgun suicides in the US.

But Tylenol with codeine is sold over-the-counter in the UK. Most people in the UK that kill themselves do so by hanging, I believe I've heard. Can't put everything in bubble-wrap....

Tracy

From what I saw of the comments to the original _Times_ opinion, the US respondents quickly chose guns over pills as the better targets for their tax dollars. Didn't have to be from UK or Europe to have that priority.
Suicide is cultural, certainly, I won't deny that. It can be local to an area, such as a particular bridge, etc.

Jon

Unfortunately with some blister packets you have to work to get out one pill. I hate those things.

Griff

Already in place in the UK as noted.

This recent news story shows good results from it:

http://www.bbc.co.uk/news/health-21370910

Danny

In our algorithm dominated world, I think we need to worry less about what the tiny fraction of the population that might commit suicide, versus the broader population that prefers ease of getting pain pills and a low cost per pill average.

In other words, if giant bottles of pain killers cause people to kill themselves. it's too bad. Let's move on.