Stopping suicide and self-harm: changing painkillers on our
|Type of research
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
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
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.