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The Royal College of Psychiatrists Improving the lives of people with mental illness

The Science of Psychiatry: Making an Impact

       

This piece of research was taken from 'Research and psychiatry - making an impact'

Stopping suicide and self-harm: changing painkillers on our shelves

University
Oxford
Type of research
Translational
Topic
Suicide, self-harm
Impact on
Standards
Therapy type
Pharmacological
 

Over one million people die by suicide each year, and in the UK it is the leading cause of death for men under the age of 35. Researchers discovered that hundreds of lives could be saved by simply changing the size of packs and swapping from one painkiller to another.

Suicide is so prevalent that even small changes can have profound effects, as Professor Keith Hawton and his team from the University of Oxford’s Centre for Suicide Research have shown. First, in a major study published in 1997, the scientists monitored self-harm and suicide over an 11 year period. They showed that by 1995 paracetamol was used in almost half of all overdoses - it was easily available and could be used in impulsive suicides.

The researchers spotted that deaths due to paracetamol overdose were lower in France where pack sizes were smaller. The team recommended reducing pack sizes which led to legislation reducing the maximum pack size of over-the-counter sales from 100 tablets to 32; with a limit of one pack per sale. Even tighter controls were applied to non-pharmacy outlets. This has led not only to hundreds fewer deliberate deaths but also fewer liver transplants and accidental deaths due to paracetamol poisoning. Other countries have followed suit and all reduced paracetamol pack sizes as a result.

It is not just the size of the pack that has been under scrutiny though, it is also the type of drug. Co–proxamol is a combination of an opiate dextropropoxyphene and paracetamol. It is a prescription-only painkiller that was commonly prescribed in the 1980s and early 1990s. Professor Hawton and his colleagues discovered that co- proxamol was the most commonly used drug for suicide in England and Wales, accounting for 18% of fatalities. They also found that overdoses involving co-proxamol were 28 times more likely to lead to death than those involving paracetamol. The research was published in the British Medical Journal in 2003 and prompted the Medicines and Healthcare Products Regulatory Agency (MHRA) and the Committee for the Safety of Medicines (CSM) to take a closer look at co-proxamol in 2004.

At the same time, the team performed a study of 123 cases of co-proxamol suicide to determine the circumstances involved. This revealed that in the vast majority of cases (80%) the co-proxamol was prescribed for the individual’s own use, rather than for someone else. It also showed that even relatively small overdoses could prove fatal and that in most cases death occurred before the patient reached hospital.

It was decided that co-proxamol should be withdrawn and between 2005 and 2007 its use was gradually phased out with no new patients being prescribed the drug. By 2008 it had been completely withdrawn. Thankfully, Keith Hawton’s team found that not only did suicides using co- proxamol reduce, but there was no accompanying switch to overdoses involving other drugs.

This research has had far reaching consequences. As a result of Keith Hawton’s work the European Medicines Agency (EMEA) recommended that dextropropoxyphene, the toxic component of co-proxamol, should not be prescribed within the EU. Subsequently, the authorities in the USA, Canada, New Zealand, Singapore and Taiwan have all acted to withdraw dextropropoxyphene.

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