One Paracetamol too many

Dr. Waruna Gunathilake

A sharp rise in pharmaceutical poisoning, with Paracetamol leading the list of the poisoning agents used, has raised serious concerns among medical authorities. New studies reveal stress and depression arising from social issues as contributory factors to this dangerous trend, further compounded by the media, the ready availability of non prescription over the counter drugs, and distribution in bulk form. Underscoring this fact, research studies by the Poisons Information Unit of the National Hospital Sri Lanka (NHSL) recently revealed that 99% of the patients admitted to the NHSL for pharmaceutical from January to April 2015, were for abuse or overuse of Paracetamol poisoning. Incidentally, pharmaceutical poisoning accounts for 47 percent of patients admitted to the National Hospital. What is the reason for this growing trend? Who are those at risk? Who is to blame? How can this dangerous development be stopped? Dr. Waruna Gunathilake, Head of the National Poisons Information Unit responds.

Q: Medicinal drug overuse is now an increasing trend. What has been the increase in the past 5 to 10 years? Is it only happening in Sri Lanka or is it a global trend?

Q: Why is this happening? What causes an apparently healthy person to suddenly take an overdose of Paracetamol? Who are those most at risk?

A: Since many factors are involved in this issue, let me discuss them according to the two groups where its usage peaks the most - those between 19 - 40 years and adolescents - from 14-19 years.

In the former group, the causes stem mainly from frustration, change of employment, depression, stress due to their work pressure, and the ingrained habit of taking Paracetamol for the slightest ailment from their childhood.

The vast majority (99%) of this group incidentally swallows an overdose of the drug deliberately.

In the case of adolescents, many are driven to take this drug because of their impulsive behaviour and inability to control their feelings, a common trait among young persons.

A. Broken love affairs, failure at exams, especially at the A/L exam, inability to meet their parents' expectations, broken family units.

The social fabric has changed radically with divorces reaching a new high even in our conservative society. Living in an increasingly competitive society, young adolescents who are unable to cope with such pressures do the next easiest thing by drowning themselves in Paracetamol, because it is so readily available.

Q: Instances of overuse of prescribed drugs for those with chronic illnesses e.g. diabetes, hypertension and heart problems, is also on the rise. Your comments?

A: The most vulnerable group are the elderly who are most at risk of these diseases. Most of them overdose themselves accidentally. Storing their drugs in ill ventilated places where they cannot see the drugs they are taking properly, could lead to an overdose. Or again due to poor storage, they could accidentally take the wrong drugs, especially if they are suffering from more than just one chronic disease. This could lead to them ingesting a mixed number of drugs which could have a multiple dangerous effect on their health. Further, if they have a month's supply of say Paracetamol, which is given to them by some state hospitals, they could overdose themselves with this drug for a headache for some trivial reason, even though it has been prescribed for a specific cause. Hence it is important that elderly persons, especially those with poor memory and poor eye sight, only take their drugs under supervision of another family member.

How to prevent Paracetamol poisoning

Pharmaceutical poisoning is the most common and preventable type of poisoning.There are many ways you can end this threat, particularly poisoning from Paracetamol, to human life. They are:

* Restricting the sale of all over the counter drugs and selling them in blister packs instead of in bulk. This is done in European countries where patients are given only packs of 1-12 tablets each in a limited form. So if they want to have 100 tablets they will have to buy ten packs. In our country, even hospitals distribute them in bulk form and you can buy any amount of tablets even in loose form in a private drug store

* Reduce the number of brands under which Paracetamol is sold, so patients don't keep changing the brands after each visit to their doctor.

* Have a colour code for each commonly used drug. Have separate boxes with compartments for each of the seven days of the week, so that elderly patients won’t mix up their tablets. or take an overdose.

* See that the tablets are stored properly. Some drugs have to be in a dark colour because they have to be protected from sunlight. Avoid putting cotton inside the bottles as cotton absorbs moisture and decays tablets like TNT used for potential heart patients.

* See that the tablets are well sealed. Check their expiry dates.

* Make sure each container is dry and clean.

* Since Paracetamol poisoning is so common today, we suggest that attention be given by the authorities to introduce some proper regulations with regard to its distribution especially in bulk form.

* Unethical advertising of this product must stop. The media, whether print or electronic is to blame for popularising Paracetamol. Take the advertisement that says “Menstrual pains? Take a Paracetamol”? Or a Three Wheeler saying , “I'm ready to start my day now that I have taken a Paracetamol.” All this is misleading information. But it creates an impression on impressionable minds, especially young persons.

A: Old age drug toxicity is more serious because their bodies are not so resilient to fight back, as the various ailments they are suffering from has undermined and compromised their health system. If they are malnourished as well, they will be unable to fight these adverse effects, some of which could even be fatal. An overdose of a diabetic drug could lead to a sudden lowering of the sugar levels resulting in the patient going into a coma. Blood pressure lowering tablets can also be dangerous and the patient could collapse.

A: These are prescribed drugs. However, if a person who goes into depression he may take an overdose as he is not thinking clearly. Similarly someone with an incurable disease may take an overdose deliberately to end his life. But such cases are rare.

Q: What is the treatment now given to patients admitted to the NHSL for pharmaceutical poisoning?

A. Generally we administer two types of antidotes - Nocetyl Cystine and Methonin - to counter diagnose the side effects of such overuse. This treatment and the management of in patients is very costly and is a huge drain on the health budget

A: Yes. If they accidentally swallow drugs prescribed for diabetes or hypertension, which has been stored within their reach.

Q: Parents also dose their children with Paracetamol for the slightest fever. Your comments?

A: They could suffer from the effects of a supra therapeutic dose. As you say, most mothers who want to bring down fever in their children quickly dose them with Paracetamol, without a doctor's advice.

If the fever continues, they go 'doctor shopping' with each doctor giving them a different brand of Paracetamol.

The result is the child receives a supra therapeutic dose which can lead to liver failure. This is common in children under 12 years.

Q: Since overuse of drugs leads to so many adverse effects, what is your opinion on alternative methods of relieving stress, pain and depression which don't require any drugs... non-conventional methods such as acupuncture, touch therapy, oil massage, heat treatment, electropathy, ice packs which are now becoming quite popular?

A: There is nothing wrong with using these methods as long as the physician or therapist in charge knows you are already taking drugs for certain ailments.

Some of the reports we have received seem to show they have had positive results. Certainly they are better than popping a Paracetamol into your mouth for a headache or pain! If however Paracetamol is recommended by a physician for certain conditions such as severe arthritis, you can take it but only according to the number prescribed.