Friday, 4 January 2013

The paracetamol paradox

I'll often bang on about how "natural" does not necessarily mean safe, and you'll often hear me muttering about how new drugs can be a cause for concern because of lack of safety data. Today, however, I want to talk about some problems with one of our oldest, most reliable friends in the drug world: paracetamol (acetaminophen to our US friends).

Paracetamol appears to have first been used clinically as far back as 1887. It's very widely used in the UK and is very easily accessbile: packs of 16 tablets are classed as GSL medicines, meaning they can be sold pretty much anywhere. Its accepted as a social norm: adults take paracetamol for headaches, and they give their children Calpol (a branded liquid paracetamol) at the first sign of illness.

And herein lies my first point: its almost so widely available that I think people are starting to forget that it works. I've come across patients and friends who instantly dismiss paracetamol for their pain because "its not strong enough" or "it won't work, this headache's too bad". I'm starting to think that its dismissed offhand without trying it because its so well accepted its almost forgotten in the general public's mind that it is still a medicine, and one that works well. People are too quick to dismiss plain old paracetamol in favour of a shiny new combination product which costs more but works less well, or they're taken in by the promise of a "stronger" painkiller like co-codamol (with little evidence of benefit over paracetamol alone, but a whole lot more problems). Paracetamol has hardly any significant side effects, and it does actually work well for mild to moderate (and even some types of severe) pain, but many people won't even give it a chance. I'm interested to know what you guys think of this and whether or not you would agree that this is the case- do let me know by leaving a comment or tweeting me @SparkleWildfire. Do you think this yourself, or have friends that do? If you're a pharmacist or another healthcare professional, have you noticed a similar attitude? Or is it just me?

More scary, though,  is my second point: Because people seem to be sort-of-forgetting its a medicine, they are forgetting that it can be dangerous. Horrifically so, in actual fact. Whilst it has few side effects with normal, recommended use, it's horribly toxic in overdose.

Overdose? Lets have a think about that word. It immediately brings to mind suicide attempts, right? So that wouldn't apply to most people, right? Very much wrong. In the last few weeks and months (it being the cold season and all), I've noticed a few of my friends on social media rather jokingly saying things like how they've taken a few extra doses of paracetamol, or they're taking lots of Lemsips because they like the taste, or they're combining a branded cold and flu product with paracetamol tablets, and I've felt the need to intervene and ask them to be careful about the amounts that they are taking. Would they consider themselves to be taking "overdoses"? I fear not. I also don't think they're taking me seriously, to be honest, and I think they think "what's a few extra doses going to do, it's just paracetamol after all". What they don't realise is that this sort of therapeutic excess or staggered overdose scenario can be just as-if not more-serious than a classsic, acute self-harm attempt-type of overdose. And the sort of toxicity that happens is not pleasant, and ultimately, in the worst case scenario could mean a slow, painful death, or a liver transplant. The antidote to paracetamol poisoning (although its not always able to be used, particularly in these sorts of cases) isn't a walk in the park either. It's a lengthy course of an IV drug (in the UK, anyway) which could mean at least a few days hospital stay.

Unfortunately, its easy to accidentally take too much paracetamol. There's so many branded products that require a fair amount of package-reading before you work out that they contain paracetamol.  I think its also easy for people to feel blase about the way they're using it, because if its available everywhere and its "just paracetamol" its safe to take more than is directed. Maybe people think taking extra paracetamol "proves" that their pain is more severe than other people's pain, who knows. I think many of us would agree that we've heard anecdotal reports of parents putting Calpol in babies' bottles, or leaving the bottle with a child to self-administer overnight, or giving their child Calpol "to make them sleep" (it would have no direct effects to promote sleep).It's just so pervasive that it's almost become like vitamins or a foodstuff in some peoples' mind, or so it would seem.

Just because a drug is as old as the hills, and its safe in everyday use, and it works, doesn't mean that its innocuous and we can throw caution to the wind when we're using it and have as much as we like, whenever we like.

Why am I on about this? Well, part of my day job involves advising on management of poisoning cases, and as a result I see a lot of these types of cases. And it can be really sad and frustrating and sometimes scary to hear of how commonly this sort of thing happens, and the variety of reasons for it.

So my point is: if you're taking paracetamol, please take no more than 4 grams per 24 hour period, and please check for other sources of paracetamol in cold remedies or other branded products first.

H xxx