23 May 2011

Rational Tylenol Packaging

This is interesting: from the Freakonomics blog:

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

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.

[...] 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. 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.

Hmm. Leaving aside the fact that APAP causes liver failure, not kidney failure, a factual error which makes this ER doctor cringe, this is actually kind of clever. They do something similar with kid's tylenol, which is deliberately sold in small bottles. Children's and Infant's Tylenol generally is sold in concentrations and quantities of 3g or so. The result is that if a curious 20-kg toddler decides to drink an entire bottle, they'll be getting a dose of 150 mg/kg, which is right at the threshold of serious toxicity -- and more importantly, is in an easily treatable range, even in a smaller child.

This makes sense to apply to the adult market. Tylenol is involved in at least 140,000 overdoses in the US annually (according to poison center databases (PDF); it may be much higher since many ER docs do not report tylenol overdoses, since many are non-toxic and we are very comfortable with treating them without poison center guidance).  Of lethal overdoses, tylenol is in the top three, behind only opiates as a class, and cardiovascular drugs. So it's a non-trivial problem. 

Would I, as a consumer, be annoyed at having to peel one of those damned blister packs to take a tylenol? Yes. It would be really irritating. But that's the point. The reason tylenol is so commonly implicated in overdoses is because it's convenient and readily accessible. Fairly few people who gulp half a bottle of tylenol are actually trying to die, few have any clue what the toxic OD is, and most are surprised when I tell them they took a potential lethal dose. It's perceived as a very safe drug. Some patients repetitively OD on tylenol precisely because they beleive from prior experience that it's safe. Putting tylenol in the blister packs woud not cut stop someone who is really determined and who does their homework, but those folks are hard to deter in any event. But it would certainyl cut down on the accidental/opportunistic overdoses.

It would be easy to do and it makes good sense. Which is why I'm quite sure that it'll never happen here in the US. 


  1. Here in the UK paracetamol is indeed mostly sold in general stores in blister packs of 16 (ie 8 grammes) after legislation in 1998 (or packs of 32 in pharmacies).

    But this paper concludes: 'Paracetamol pack size limitation as applied in the United Kingdom has not reduced paracetamol-related death. Reasons postulated for this failure include patient avoidance of the legislation's intentions, patient confusion, and ineffectiveness of the regulations as conceived and implemented.'

    Clin Toxicol (Phila). 2009 Jul;47(6):536-41.
    Limiting paracetamol pack size: has it worked in the UK?

    One reason may be that if you buy supermarket own-brand pills it's incredibly cheap - say 25 cents for a pack of 16 500mg tablets.

  2. I agree that from a purely clinical/public health perspective, low quantity blister packs make sense. From an environmental/solid waste perspective, its just one more ultra short term consumer item in wasteful packaging that will never disappear. I realize that there are many other culprits, and many with less reasonable grounds for metal foil/PE plastic inside cardboard box packaging, but perhaps we could strike a bargain. Cds/DVDs in biodegradable corn starch cardboard packages, and medications in turtle choking, landfill clogging, cut-your-hand and-end-up-in-the-ER-anyway packs.

  3. I can't remember the last time I bought a CD...

  4. I've saying Tylenol should only be sold in small quantaties with bright warning labels for twenty years. Never happen, makes too m

  5. insert "been" above where it seems appropriate. The rest should read "makes too much sense."

    I should avoid posting mobile.

  6. My brother (a Dentist) told me he believed that if Aspirin were developed/discovered today (I don't know which term would be correct) it would definitely require a prescription to obtain, because of all the things it does. Is the same likely true of Tylenol? With the risks it poses, if it were introduced today, would it require a prescription?

  7. I was an orderly in a hospital surgery in 1971 or thereabouts when I met up with a McNeil rep who was there to sell drugs to the gas passers and cutters and I was gifted with one of the fancy presentation bottles of Tylenol that they were passing out to docs. IIRC it initially was a Rx drug but was quickly made OTC about that time.

    As to the OD aspect, at least acetylcysteine is available and works if treatment is timely and pretreatment levels not too extreme. The psych aspect is often the real problem in the long run as redo's are not uncommon without serious interventions.

    Sadly there is way too much untreated major mental pathology running about loose in the world. So Doc, keep your OG tubes, charcoal, naloxone and acetylcysteine handy in the meantime. Maybe a bit of haloperidol and a few straps as well. Some nights are a bit wilder than others in the ER. BTDT

  8. Another reason for small packaging, same package size represents the equivalent of a car downpayment.

    If you ever buy an otc pain pill in germany (in the pharmacy not a supermarket), you may want to compare US$/mg. In the US, you can probably buy a bottle of 500x300mg store-brand Aspirines for the price of 20 generic 200mg Aspirines in Germany.

  9. Scam are flying everywhere nowadays so we should be extra vigilant about it. packaging peanuts


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