OTC medicine – when convenience can be deadly.

There was a very sad item in the UK news yesterday, telling of a 20 year old mother who died of liver failure after taking too many tablets of paracetamol, a widely used over the counter (OTC) medicine.

This was not an intentional overdose - indeed, the victim didn’t at any stage take one large dose of the drug. Instead she suffered a ‘staggered overdose’ by taking as her father stated ‘a few extra tablets’ over the course of a few days to alleviate some post-operative pain.

This is a stark reminder of the danger of ignoring the warnings on easily available medicines. Just a few extra tablets were the difference between life and death for this young woman. Although a cheap and intrinsically safe analgesic when taken within the recommended daily dose, paracetamol can be highly hepatotoxic after overdose causing liver damage, failure and ultimately death. Aspirin can also be highly toxic when taken inappropriately, leading to potentially fatal stomach bleeds.

When I first started practising pharmacy, more years ago than I care to admit, very few OTC drugs could be purchased outside pharmacies. I actually think this was a good thing. In the same way that cheap booze available round the clock from supermarkets has potentially increased alcohol abuse, over-use of painkillers and cold remedies can lead to problems.
 
In 1998 legislation was introduced to reduce the pack size of analgesics such as Paracetamol and Aspirin sold over the counter in the UK. You can now only buy packs of up to 32 tablets in pharmacies and 16 in retail outlets. Within the first year this had a dramatic effect in reducing mortality of Paractemamol overdoses by 20%. Liver unit admissions and transplants were reduced by 30% and non-fatal overdoses by 29% in the four years following the legislation. The effect on reducing large overdoses with aspirin was also significant with a reduction of 34%.

This proves that restricting availability of potentially lethal substances has a positive effect but presents the health legislators with a dilemma. We all like to convenience of nipping to the local shop/garage/supermarket to pick up cold remedies and painkillers and an estimated 30 million paracetamol tablets are consumed annually in the UK. But does that familiarity cause contempt? If a medication is only available either from a pharmacy or under the supervision of the pharmacist, then even if the purchaser doesn’t read the label properly they understand that there is a potential hazard lurking within the blister pack or bottle.

The general public need to be aware of these dangers, but we have to be careful not to give the vulnerable a recipe for suicide by clarifying the toxic effects of some readily available substances. However the majority of OTC related non-fatal overdoses are unintentional and the long term effects can be life-limiting and devastating.

Education may play a key role in improving patient compliance with all types of medication and maybe school is a good place to start to teach the importance of respecting the directions on packs of OTC medicine. Emphasising the safety message to all potential consumers should be the shared responsibility of the pharmaceutical industry, retailers and public health organisations.