tag:theconversation.com,2011:/id/topics/paracetamol-1940/articlesParacetamol – The Conversation2023-04-26T19:58:22Ztag:theconversation.com,2011:article/2042402023-04-26T19:58:22Z2023-04-26T19:58:22ZAcetaminophen overdose is a leading cause of liver injury, but it is largely preventable<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/acetaminophen-overdose-is-a-leading-cause-of-liver-injury--but-it-is-largely-preventable" width="100%" height="400"></iframe>
<p>Larissa was a 21-year-old Canadian college student recovering from COVID-19 when she died from complications related to an accidental overdose of acetaminophen, a medication in probably every drug store and most medicine cabinets in the country. </p>
<p>At the time of Larissa’s death, her sister Darby was a second-year student at the University of Waterloo School of Pharmacy, where we cover this topic in class. </p>
<p>“We were shocked by how fast it happened,” Darby recalled. “Larissa was healthy and within a week of the overdose, her liver failed, she received a liver transplant, and died from complications. We still don’t know what happened. It’s hard because we realize we likely never will.”</p>
<p>Looking back, Darby recognizes that she will never know how Larissa overdosed, except that she did not mean to. It was probably an attempt to treat her COVID-19 symptoms at a time when she was not eating well. </p>
<p>As a liver specialist and pharmacists, we have cared for hundreds of people with acetaminophen overdoses and worked for years to raise awareness of the dangers of both accidental and intentional overdose. The three of us were developing <a href="https://uwaterloo.ca/pharmacy/resources-services-and-initiatives/health-resources/pharmacy5in5-resources#acetaminophen">educational tools on acetaminophen-related liver injury</a> for health-care providers when we first learned of Larissa’s story.</p>
<h2>Leading cause of acute liver injury</h2>
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<a href="https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An infographic describing the liver risks of acetaminophen" src="https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=976&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=976&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=976&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Acetaminophen is the most common cause of drug-related liver injury in Canada.</span>
<span class="attribution"><span class="source">(Kelly Grindrod)</span>, <span class="license">Author provided</span></span>
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<p>Acetaminophen is in more than 600 products, such as Tylenol, Percocet, Midol, Robaxacet and NeoCitran. Yet, it is also a <a href="https://www.canada.ca/en/health-canada/services/drugs-medical-devices/acetaminophen.html#s4">leading cause of acute liver injury</a>, which can be fatal without a rescue liver transplant. With millions around the world using acetaminophen every day, why are so few people aware of the dangers of overdose?</p>
<p>Approximately <a href="https://www.canada.ca/en/health-canada/services/drugs-medical-devices/acetaminophen.html#s4">4,500 Canadians are hospitalized</a> from acetaminophen overdose each year — 12 hospitalizations per day. Up to <a href="https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-40-no-4-2020/trends-emergency-visits-acetaminophen-poisonings-2011-2019.html">half of overdoses are accidental</a>, which is what Larissa’s family believes likely happened to her. </p>
<p>The risk is highest for people who regularly drink three or more alcoholic drinks daily or who are malnourished or fasting because for them, an overdose can occur at normal acetaminophen doses (for example, the maximum recommended 24-hour dose for adults is up to 4,000 milligrams, and lower in children). </p>
<p>A common error people make is combining over-the-counter and/or prescription drugs that contain acetaminophen. A <a href="https://doi.org/10.1371/journal.pone.0229070">2020 survey we conducted</a> also found that over half of respondents were not aware extra strength products contain up to twice the dose of acetaminophen compared to regular strength products.</p>
<p>More recently, the shortage of children’s pain and fever products raised concerns about the <a href="https://ismpcanada.ca/wp-content/uploads/ISMPCSB2022-i11-Imported-Acetaminophen.pdf">risk of accidental overdose in children</a>, as parents and guardians looked to use adult products for their children. </p>
<h2>Toxicity and overdose</h2>
<p>Lower doses of acetaminophen are not toxic to the liver: <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498995/pdf/nihms690826.pdf">most of it is broken down safely by the liver and leaves the body in urine</a>. But the liver has a limited ability to break down acetaminophen.</p>
<p>When too much acetaminophen is taken in a 24-hour period, the liver cannot break it down fast enough. The extra acetaminophen spills over into a back-up pathway in the liver, and the liver breaks the excess down into another product that is toxic to it. The more acetaminophen taken at one time, the more toxic product is made.</p>
<p>In the first 24 hours after an overdose, there may only be mild symptoms such as nausea and vomiting, but many have no symptoms at all. </p>
<p>After one to two days, liver injury begins and symptoms may include abdominal pain, dark coloured urine, and yellow eyes and skin. After three days, symptoms such as bleeding, bruising, confusion and low blood sugar signal that the liver is failing and death can occur.</p>
<figure class="align-center ">
<img alt="A open bottle of acetaminophen lying on its side with caplets spilling out" src="https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=440&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=440&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=440&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When buying acetaminophen for common ailments like a headache or arthritis pain, reach for the regular strength product. Extra strength products increase the risk of accidental overdose.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>While the liver may heal itself, around <a href="https://www.canada.ca/en/health-canada/services/drugs-medical-devices/acetaminophen.html#s4">six per cent of people hospitalized for acetaminophen overdose develop liver failure</a>. </p>
<p>Prompt treatment is critical. An antidote is available (an intravenous medicine called N-acetylcysteine) but it is <a href="https://www.ncbi.nlm.nih.gov/books/NBK548162/">most effective if given within 24 hours of overdose</a>. A rescue liver transplant may be needed, especially if treatment is delayed, and many die waiting for a liver or due to complications after liver transplantation.</p>
<h2>Using acetaminophen safely</h2>
<p>Given that acetaminophen remains one of the most common medicines for treating pain and fever, people need to take steps to reduce their risk of liver injury.</p>
<p>Start by <a href="https://safemedicationuse.ca/tools_resources/tips_acetaminophen.html">reading all medication labels</a>. Never take more than one acetaminophen-containing product at a time. Pay close attention to products for arthritis, cold and flu, sleep, menstrual pain and back pain. Do not hesitate to ask the pharmacist for help.</p>
<p>Always check acetaminophen packages for the maximum single dose and 24-hour dose. If the first acetaminophen dose is taken at noon, the 24-hour window ends at noon the next day. Take less if you regularly have three or more alcoholic drinks a day or if you have difficulty eating regularly, such as with an eating disorder, frailty in older age, or during episodes of nausea or vomiting.</p>
<p>When buying acetaminophen for common ailments like a headache or arthritis pain, reach for the regular strength product. Extra strength products increase the risk of accidental overdose.</p>
<p>In the event of an overdose, call <a href="https://www.canada.ca/en/health-canada/news/2023/03/canada-launches-new-toll-free-1-844-poison-x-number-for-poison-centres.html">Health Canada’s toll-free poison control line</a> (1-844-POISON-X) or your local poison control centre for advice on next steps.</p><img src="https://counter.theconversation.com/content/204240/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kelly Grindrod has received research funding from the NSERC PromoScience, Public Health Agency of Canada, Canadian Institutes for Health Research, and the British Academy, and the Canadian Foundation for Pharmacy. </span></em></p><p class="fine-print"><em><span>Eric Yoshida is affiliated with the University of British Columbia and the Vancouver General Hospital. He has participated in clinical trials sponsored by Gilead Sciences, Madrigal, Pfizer, Allergan, Celgene, Genfit, Intercept, Novodisc. He has also received an unrestricted research grant from Paladin Laboratories. He has no conflicts of interest with this current article.</span></em></p><p class="fine-print"><em><span>Trana Hussaini does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Acetaminophen is one of the most commonly used drugs, yet acetaminophen overdose is a leading cause of liver damage. It can be easily prevented.Kelly Grindrod, Associate Professor, School of Pharmacy, University of WaterlooEric Yoshida, Professor of Medicine, University of British ColumbiaTrana Hussaini, Clinical associate professor, Faculty of Pharmaceutical Sciences, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1997952023-02-27T13:31:11Z2023-02-27T13:31:11ZCough syrup can harm children: experts warn of contamination risks<figure><img src="https://images.theconversation.com/files/511675/original/file-20230222-20-qw2pr6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>The recent deaths of over <a href="https://www.theguardian.com/world/2023/jan/24/who-urges-action-after-cough-syrups-linked-to-more-than-300-child-deaths">300 children</a> in Africa and Asia have prompted the World Health Organization (WHO) to <a href="https://www.who.int/news/item/23-01-2023-who-urges-action-to-protect-children-from-contaminated-medicines">warn</a> about the use of “substandard and falsified” medical products. The organisation called for more efforts to protect children from contaminated medicine. Toxicologists Winston Morgan and Shazma Bashir unpack the story.</em></p>
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<h2>What caused the WHO to issue these warnings?</h2>
<p>Over the last five months the WHO has issued three alerts warning people not to use specific over-the-counter medicine for children. The warnings came after the deaths of at least <a href="https://www.theguardian.com/world/2023/jan/24/who-urges-action-after-cough-syrups-linked-to-more-than-300-child-deaths">300 children</a> in various countries including The Gambia, Indonesia and Uzbekistan. </p>
<p>Medical product alerts were released in <a href="https://www.who.int/news/item/05-10-2022-medical-product-alert-n-6-2022-substandard-(contaminated)-paediatric-medicines">October 2022</a> for Africa, <a href="https://www.who.int/news/item/02-11-2022-medical-product-alert-n-7-2022-substandard-(contaminated)-paediatric-liquid-dosage-medicines">November 2022</a> for south-east Asia and for the European region in <a href="https://www.who.int/news/item/11-01-2023-medical-product-alert-n-1-2023-substandard-(contaminated)-liquid-dosage-medicines">January 2023</a>. </p>
<p>The WHO issues these warnings only when independent laboratory analysis has confirmed that the product is substandard or falsified and that it poses a significant threat to public health. The threat must also extend beyond one country. </p>
<p>The children died after consuming cough syrup contaminated with ethylene glycol and diethylene glycol, leading to the WHO medical product alerts. Some of the children were as young as five. Cases were reported in at least seven countries. </p>
<h2>What are ethylene glycol and diethylene glycol?</h2>
<p>Ethylene glycol and diethylene glycol are toxic alcohols with a slightly sweet taste. They are widely used in windscreen wiper fluids and engine coolants. </p>
<p>These compounds are sometimes also found at very low levels as contaminants in many food ingredients and medical solvents (including propylene glycol, polyethylene glycol, sorbitol and glycerin/glycerol). This happens when there are poor standards of manufacturing and testing. </p>
<p>Medical solvents are widely used to dissolve the ingredients of a medicine. Ethylene glycol and diethylene glycol contamination poisonings over the years have mainly been associated with solutions containing paracetamol.</p>
<p>Paracetamol in cough syrups is good and safe for children with infections. It is a pain killer which is good at reducing fever, without causing gastric irritation like aspirin or ibruprofen may do. </p>
<h2>Are they dangerous?</h2>
<p>Both ethylene glycol and diethylene glycol are seen as toxic. A <a href="https://pubmed.ncbi.nlm.nih.gov/7613408/">fatal oral dose</a> is about 1,000-1,500 milligrams per kilogram. For a small child weighing 20kg a fatal single dose would be about 28 millilitres or about 6 teaspoons of pure ethylene glycol. However it is also possible to cause toxicity by consuming much lower doses over several days and weeks. That is why the WHO safe level for these chemicals is only 0.5 milligrams per kilogram per day. That’s the equivalent of 1/15th of a teaspoon per day. </p>
<p>What makes these glycols <a href="https://pubmed.ncbi.nlm.nih.gov/9555756/">potentially so dangerous</a> is that toxicity comes from the consumption of relatively large amounts before symptoms of contamination appear. </p>
<p>The additional danger from <a href="https://pubmed.ncbi.nlm.nih.gov/11242827/">cough syrups</a> is that symptoms of ethylene glycol and diethylene glycol <a href="https://pubmed.ncbi.nlm.nih.gov/20010509/">contamination</a>, such as drowsiness, are sometimes observed in children who have not taken contaminated medicine, and can be misinterpreted as normal in a child with a cough or fever. Guardians and medical professionals may not notice what’s wrong until it’s too late.</p>
<h2>What’s the role of paracetamol?</h2>
<p>To understand the potential role of paracetamol in these poisonings, we need to understand what happens to ethylene glycol and diethylene glycol in the body. </p>
<p>To be toxic, these glycols must be converted to a compound called glycoaldehyde, and then to glyoxylic acid. Glyoxylic acid can concentrate in and damage the kidneys – leading to death from renal failure. </p>
<p>The conversion is triggered by a certain concentration of a coenzyme called nicotinamide adenine dinucleotide (NAD+). NAD+ is regulated by mitochondria – small structures in human cells which regulate many chemical reactions in the body.</p>
<p>In a <a href="https://pubmed.ncbi.nlm.nih.gov/36379307/">recent study</a>, we demonstrated that at the normal dose required to treat fever, paracetamol inhibits mitochondria. Thus it affects the level of NAD+ and, in turn, the conversion of glycols to toxins. Children taking paracetamol preparations contaminated with the glycols could potentially be in danger. </p>
<p>We believe that the combination of medicines containing paracetamol and glycols, even when the contamination is relatively low but above the WHO acceptable limit of 0.5 mg/kg of body weight per day, could be lethal. </p>
<p>Unlike other medications or food products which do not disrupt mitochondrial function, preparations containing standard levels of paracetamol are more likely to lead to adverse outcomes for children, because of the increased metabolism of ethylene glycol and diethylene glycol. </p>
<p>Other medicines and foods contaminated with low levels of ethylene glycol and diethylene glycol probably go unnoticed because they don’t contain paracetamol.</p>
<h2>What must be done to prevent future deaths?</h2>
<p>If spotted early enough, ethylene glycol and diethylene glycol poisoning can be treated. The two most widely used antidotes for overdose are fomepizole and ethanol. Both reduce the amount of toxic ethylene glycol and diethylene glycol metabolite produced in the body.</p>
<p>Incidents of mass poisonings highlight the need for greater vigilance in monitoring preparations containing paracetamol. </p>
<p>Medications containing paracetamol are normally very safe for children. But to avoid deaths related to cough syrup in future, both parents and medical professionals should consider glycol poisoning as a possibility if children start to display symptoms of intoxication and drowsiness after taking the medicine. </p>
<p>These incidents generally happen in countries categorised as the global south. Manufacturers and regulatory authorities in these countries also have a responsibility to protect children.</p><img src="https://counter.theconversation.com/content/199795/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Winston Morgan receives funding from University of East London and UKRI</span></em></p><p class="fine-print"><em><span>Shazma Bashir does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The danger from contaminated cough syrups is that early symptoms of poisoning, such as drowsiness, are sometimes observed in children without contamination.Winston Morgan, Professor of Toxicology, Equity and Inclusive Practice, Director of Impact and Innovation, University of East LondonShazma Bashir, Postdoctoral fellow, University of East LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1910672022-09-28T20:02:24Z2022-09-28T20:02:24ZThe TGA is considering paracetamol restrictions due to poisonings – but what does that mean for consumers?<figure><img src="https://images.theconversation.com/files/486715/original/file-20220927-26-1t2wx3.jpg?ixlib=rb-1.1.0&rect=57%2C32%2C5406%2C3604&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/sick-ill-depressed-man-holding-600w-1095874343.jpg">Shutterstock</a></span></figcaption></figure><p>Paracetamol is Australia’s most widely used pain medicine, with <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">65 million packs sold</a> across the country in 2021. It is available everywhere from toilet vending machines, convenience stores, supermarkets, and pharmacies.</p>
<p>The Therapeutic Goods Administration (TGA) is now undertaking a <a href="https://www.tga.gov.au/resources/consultation/consultation-proposed-amendments-poisons-standard-relation-paracetamol-acms-meeting-november-2022">public consultation</a> into access to paracetamol in the community due to concerns about poisonings, especially among young people. </p>
<h2>What is paracetamol and what is it used for?</h2>
<p>Paracetamol (commonly marketed as Panadol, Panamax or Dymadon) is a <a href="https://europepmc.org/article/med/14758787">medicine used</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/15662295">treat pain</a> and reduce fever. </p>
<p>Outside of pharmacies, paracetamol is <a href="https://www.legislation.gov.au/Details/F2022L00730">available in packs of up to 20 tablets</a> (or capsules), while pharmacies stock packs of up to 100 tablets and a range of formulations, including liquids and suppositories. Paracetamol’s wide availability and low cost make it a convenient option for people to self-treat pain without a doctor’s appointment or prescription. </p>
<p>At therapeutic doses, paracetamol is <a href="https://link.springer.com/article/10.2165/00002018-200528030-00004">considered safe for most people</a>, with few side effects when used as directed. </p>
<p>However, it can be dangerous at high doses, resulting in <a href="https://link.springer.com/article/10.2165/00002018-200124070-00003">acute liver toxicity</a>, which in severe cases may lead to death. Although there are <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003328.pub3/full?highlightAbstract=paracetamol">treatments to reverse paracetamol overdose</a>, they need to be given within 2-8 hours to be most effective. </p>
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<h2>Why is the TGA reviewing paracetamol access?</h2>
<p>The TGA is concerned about harms from paracetamol poisoning, particularly intentional overdoses among young people, which have been seen in <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja2.50296">Australia</a> as well as <a href="https://www.sciencedirect.com/science/article/abs/pii/S0165032720325362?via%3Dihub">internationally</a>. In response, the TGA requested an <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">independent expert report</a> to support its review of paracetamol access. </p>
<p>The report found that between 2007 and 2020, there were 40–50 deaths each year in Australia from paracetamol poisoning. From 2009 to 2017, hospital admissions due to paracetamol poisoning increased from 8,617 to 11,697. They decreased to 8,723 in 2019–20. </p>
<p>Around 80% of these admissions were due to intentional self-poisoning, with young people aged between 10–24 years accounting for 40–50% of these incidents. Hospitalisations among young people due to intentional overdoses from any medicine also increased over this period. Calls to Australian Poisons Information Centres about self-poisonings involving paracetamol also increased over the last decade. </p>
<p>It is important to note that the number of harmful events is low compared to the amount of paracetamol sold in Australia. For every million packs of paracetamol sold, there were 100 hospital admissions for intentional self-poisoning, three hospital admissions for liver injury, and less than one death. And in recent years, both unintentional and intentional self-poisoning admissions per million packs of paracetamol sold have been decreasing. </p>
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<a href="https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hand holds two pills" src="https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">More paracetamol involved in intentional self-poisoning was already in the home.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/eindhoven-netherlands-april-14-2022-600w-2147449853.jpg">Shutterstock</a></span>
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<strong>
Read more:
<a href="https://theconversation.com/australia-has-a-paracetamol-poisoning-problem-this-is-what-we-should-be-doing-to-reduce-harm-122532">Australia has a paracetamol poisoning problem. This is what we should be doing to reduce harm</a>
</strong>
</em>
</p>
<hr>
<h2>How might paracetamol access change?</h2>
<p>The expert panel made several <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">recommendations</a> including: </p>
<ul>
<li>limiting pack sizes </li>
<li>introducing purchase limits</li>
<li>requiring a prescription to purchase higher amounts and modified-release products (such as Panadol Osteo)</li>
<li>requiring a prescription for people under 18. </li>
</ul>
<p><a href="https://consultations.tga.gov.au/tga/paracetamol_november_2022_acms/user_uploads/pre-meeting-public-notice---paracetamol---november-2022-3.pdf">Additional measures</a> being considered include changes to packaging and how paracetamol is displayed in stores. At the moment, there are no recommendations to make all paracetamol products prescription-only, or to restrict their sale to pharmacies only.</p>
<p>Many of these strategies are focused on reducing potential harm by limiting the amount of paracetamol available. The change to pack sizes available outside of pharmacies would bring Australia in line with countries such as Denmark, Ireland and the United Kingdom. These countries have had restricted pack sizes (maximum 10–16 tablets) for sale outside pharmacies for many years and seen <a href="https://www.bmj.com/content/329/7474/1076">reductions</a> in <a href="https://www.sciencedirect.com/science/article/pii/S016503271932957X?via%3Dihub">hospital admissions</a> and <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040105">deaths</a>. Poisonings among people aged 10–17 years <a href="https://www.sciencedirect.com/science/article/pii/S016503271932957X?via%3Dihub">also went down</a> in Denmark after age restrictions were introduced in 2011. </p>
<p>The <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">expert report found</a> most cases of self-poisoning involve medicines already present at home. So the benefits of these measures may be limited. But limiting pack sizes may help to reduce the overall quantity of medicines available in the home and the risk of a fatal poisoning. </p>
<p>The expert panel also recommended better follow-up care after self-poisoning events. Developing <a href="https://journals.sagepub.com/doi/full/10.1177/0004867415620024">preventative</a> <a href="https://staging.mja.com.au/system/files/issues/198_09_200513/chr11793_fm.pdf">strategies</a> and <a href="https://apo.org.au/node/260121">increasing mental</a> <a href="https://journals.sagepub.com/doi/full/10.1177/0004867418817381">health support</a> is vital to address the drivers of intentional self-poisonings more broadly. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-three-people-with-chronic-pain-have-difficulty-accessing-ongoing-prescriptions-for-opioids-182678">One in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids</a>
</strong>
</em>
</p>
<hr>
<h2>What next?</h2>
<p>Ready access to paracetamol allows people to conveniently self-treat their pain at minimal cost and without visiting a health professional. Reduced paracetamol availability may prompt people to switch to using other pain medicines, such as ibuprofen, which <a href="https://www.healthdirect.gov.au/ibuprofen">carries its own risks</a> and may not be suitable for everyone. </p>
<p>Although limiting harms due to paracetamol poisoning is important, at the same time, the TGA will need to ensure paracetamol remains accessible to those in need. By keeping paracetamol on the shelves of supermarkets and pharmacies in reduced pack sizes, the TGA will be aiming to strike a balance between accessibility and safety. </p>
<p>The biggest potential impact for people living with chronic pain would be brought about by reducing larger pack sizes currently only available in pharmacies (such as those containing 50–100 tablets) and making modified-release paracetamol products prescription-only. The <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">expert report</a> notes that at 665 mg, the modified-release formulation in particular is linked to larger overdoses. As these products are currently only available from pharmacies, authorities would need to show how these changes would significantly reduce harm, without overly burdening people in pain.</p>
<p>The <a href="https://consultations.tga.gov.au/tga/paracetamol_november_2022_acms/consultation/subpage.2020-08-24.4118714205/">TGA is seeking feedback</a> until mid-October to guide its decision. After that the TGA’s expert advisory committee will consider whether to amend the Poisons Standard to change how paracetamol can be accessed. For now, paracetamol is available as usual. </p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/191067/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasa Gisev receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Ria Hopkins receives funding from the National Health and Medical Research Council and the National Drug and Alcohol Research Centre.</span></em></p>Australians bought more than 65 million packs of paracetamol pain relief last year. TGA efforts to reduce its potential harms will need to take those who use it to manage pain into consideration.Natasa Gisev, Clinical pharmacist and Scientia Senior Lecturer at the National Drug and Alcohol Research Centre, UNSW SydneyRia Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1687472021-09-28T06:54:57Z2021-09-28T06:54:57ZTake care with paracetamol when pregnant — but don’t let pain or fever go unchecked<figure><img src="https://images.theconversation.com/files/423465/original/file-20210928-13-6txwri.jpg?ixlib=rb-1.1.0&rect=19%2C6%2C4219%2C2815&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/pregnancy-people-health-care-concept-260nw-1015659301.jpg">Shutterstock</a></span></figcaption></figure><p>Pregnancy comes with aches and pains and heightened anxiety about what we put into the body. </p>
<p>A new article published in <a href="https://www.nature.com/articles/s41574-021-00553-7">Nature Reviews Endocrinology</a> has urged caution around taking paracetamol during pregnancy. The paper is a “consensus statement” that brings together analysis by a panel of experts who looked at evidence from human and animal studies of paracetamol use in pregnancy. </p>
<p>Paracetamol use during pregnancy may alter fetal development, say the authors, with long-lasting effects on child health. The authors call for improved education for health-care professionals and patients, less paracetamol use during pregnancy and further research.</p>
<h2>Alert but not alarmed</h2>
<p>At first glance, calls to minimise paracetamol use during pregnancy are alarming. For those who have taken paracetamol (commonly marketed in Australia as Panadol, Herron Paracetamol, Panamax, Chemist Own or Dymadon) during pregnancy, this could cause anxiety. </p>
<p>This new consensus statement calls for caution, but not concern. The proposed recommendations are largely consistent with <a href="https://www.nps.org.au/australian-prescriber/articles/analgesics-and-pain-relief-in-pregnancy-and-breastfeeding-1">current advice</a> provided to pregnant women in Australia. </p>
<p>With any medication in pregnancy, there needs to be a careful balance between treating a maternal condition and protecting the unborn. A trusted health care provider can help reach an informed decision. Paracetamol is no different. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pill packet" src="https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Paracetamol is the active ingredient in hundreds of prescription and non-prescription medications.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/siegen-north-rhinewestphaliagermany-01-02-260nw-1633257661.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What are the concerns?</h2>
<p>Worldwide, <a href="https://academic.oup.com/ije/article/45/6/2009/2724482">more than 50% of pregnant women</a> use paracetamol to treat pain and/or fever. Paracetamol is the active ingredient in hundreds of prescription and non-prescription products. It has been widely regarded for many years as safe to use during pregnancy.</p>
<p>Some, but not all, observational studies in humans suggest paracetamol use during pregnancy may <a href="https://pubmed.ncbi.nlm.nih.gov/25851072/">alter fetal development</a>. The new statement notes that paracetamol has been linked to increased risk of certain <a href="https://www.nature.com/articles/%20s41574-021-00553-7">neurodevelopmental, reproductive and urogenital disorders</a>.</p>
<p>But these studies have limitations. Researchers have found it hard to distinguish the effects of paracetamol from the effects of underlying illness. And there are potential inaccuracies in recording the amount and timing of paracetamol use across an entire pregnancy as are highlighted in the accompanying <a href="https://www.nature.com/articles/s41574-021-00567-1">editorial</a>.</p>
<p>Possible risks of paracetamol use in pregnancy are supported by a number of animal studies, the authors say. For this reason, caution regarding paracetamol use has been advised until a definitive link can be proven or disproven.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1441082949965795336"}"></div></p>
<p>It’s worth noting the available evidence suggests any possible harms of paracetamol are likely to be dose-related. As highlighted by the review article, most increased risks have been linked with use in pregnancy for <a href="https://www.nature.com/articles/s41574-021-00553-7">more than two or four weeks</a>. Current evidence suggests limited risks to unborn babies when paracetamol is taken short term. </p>
<p>Timing is also important. Taking paracetamol during the first trimester has been linked to an increased risk of reproductive and urogenital disorders. Neurodevelopmental disorders have been linked to use in the second or third trimester. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/domperidone-can-boost-breast-milk-supply-heres-what-you-need-know-88648">Domperidone can boost breast milk supply – here's what you need know</a>
</strong>
</em>
</p>
<hr>
<h2>When the benefits outweigh the risks</h2>
<p>The potential benefits of taking medication need to be weighed against any possible risks. Paracetamol is recognised as an important medication for treating pain and fever during pregnancy. </p>
<p>If left untreated, these conditions could harm the fetus or the pregnant person (the Nature <a href="https://www.nature.com/articles/s41574-021-00567-1">editorial</a> and <a href="https://www.nature.com/articles/s41574-021-00553-7">statement</a> say the expert advice is “relevant for all people who wish to become pregnant, including transgender individuals, non-binary people and intersex people”). </p>
<p>The review authors recognise the <a href="https://www.nature.com/articles/s41574-021-00553-7">potential benefits of paracetamol use</a> and note untreated pain has been linked to increased risks of depression or anxiety as well as hypertension during pregnancy. Fever in pregnancy is a risk factor for multiple neonatal and childhood disorders, including certain birth defects and miscarriage. There is evidence to suggest that use of paracetamol may reduce these risks. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/using-cannabis-during-pregnancy-could-be-bad-news-for-your-baby-new-research-140443">Using cannabis during pregnancy could be bad news for your baby: new research</a>
</strong>
</em>
</p>
<hr>
<h2>What are the alternatives?</h2>
<p>The optimal management of pain or fever during pregnancy has not been well studied and treatment options remain limited. </p>
<p>Non-steroidal anti-inflammatory medications (such as ibuprofen) have been linked to <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15510">miscarriage</a> when used in the first trimester, whereas use after 30 weeks’ gestation can negatively impact <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15510">kidney and heart/lung function</a> in the fetus. For this reason non-steroidal anti-inflammatory medications are <a href="https://www.medicinesinpregnancy.org/Medicine--pregnancy/Ibuprofen/">best avoided</a> unless advised by a healthcare professional. The same goes for strong pain medications such as opioids, which should be <a href="https://www.nps.org.au/australian-prescriber/articles/analgesics-and-pain-relief-in-pregnancy-and-breastfeeding-1">reserved for the management of severe pain</a>. Paracetamol remains the best choice for the short-term treatment of pain and/or fever during pregnancy. </p>
<p>It is also important to identify the cause of the pain or fever, particularly during pregnancy. Discussions about paracetamol use can lead to further investigation, recommendations for non-medication treatments or the need for different medications. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pregnant woman with sore back" src="https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Safe options for pain management during pregnancy are limited.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/pregnant-woman-suffering-lower-back-260nw-786703240.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weight-gain-during-pregnancy-how-much-is-too-much-89016">Weight gain during pregnancy: how much is too much?</a>
</strong>
</em>
</p>
<hr>
<h2>The bottom line</h2>
<p>The new consensus statement does not alter existing recommendations regarding paracetamol use during pregnancy. But it does highlight the importance of thinking carefully before using any medications during pregnancy and raises greater awareness about how challenging making informed decisions about medication use can be. </p>
<p>Better evidence is needed to support decision-making during pregnancy and reduce unnecessary anxiety and concern.</p>
<p>Paracetamol use during pregnancy should be discussed with a health-care professional and used at the lowest effective dose for the shortest possible duration. Non-medication therapies for treating pain or fever should be tried before or in addition to paracetamol. When indicated, short-term use of paracetamol remains the safest medication for the treatment of pain and/or fever during pregnancy.</p><img src="https://counter.theconversation.com/content/168747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Grzeskowiak receives funding from the Channel 7 Children's Research Foundation, The Hospital Research Foundation, and National Health and Medical Research Foundation</span></em></p><p class="fine-print"><em><span>Debra Kennedy is affiliated with MotherSafe, the NSW Statewide Medications in Pregnancy and Lactation Advisory Service at the Royal Hospital for Women. </span></em></p>A panel of experts has urged caution regarding paracetamol during pregnancy. But that doesn’t change current advice to discuss pain relief with your doctor or pharmacist.Luke Grzeskowiak, Channel 7 Children's Research Foundation Fellow in Medicines Use and Safety - Flinders University & South Australian Health & Medical Research Institute, Flinders UniversityDebra Kennedy, Senior lecturer, School of Women's and Children's Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1603572021-05-16T19:55:36Z2021-05-16T19:55:36ZI’m over 50 and can now get my COVID vaccine. Can I talk to the GP first? Do I need a painkiller? What else do I need to know?<figure><img src="https://images.theconversation.com/files/400439/original/file-20210513-15-1d1vv8f.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-smiling-young-caucasian-woman-nurse-1769848013">from www.shutterstock.com</a></span></figcaption></figure><p>People aged 50 and over <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/getting-vaccinated-for-covid-19/when-will-i-get-a-covid-19-vaccine">are now officially eligible</a> to receive the AstraZeneca COVID-19 vaccine from selected GPs. </p>
<p>Although some practices have had permission to <a href="https://www1.racgp.org.au/newsgp/clinical/gps-with-astrazeneca-stockpile-turn-attention-to-v">provide the vaccine early</a> if they had excess stock, this marks a major step forward in Australia’s vaccination program.</p>
<p>People over 50 now have a choice of where to get vaccinated: their own GP (if taking part in the vaccination rollout), another GP practice (if their own GP is not), or respiratory clinics and mass vaccination hubs in some states.</p>
<p>Here are some practical things to think about when booking an appointment.</p>
<h2>Can I speak to the GP first?</h2>
<p>As a GP, I have been recommending patients access a vaccine from wherever is the most convenient for them. This may be from a mass vaccination hub or respiratory clinic, and not actually from a GP. However, some patients are hesitant and/or still have questions. If so, they do need to speak to a GP before they book for a vaccine. </p>
<p>The time to raise questions is not when you have turned up for your injection; most facilities allocate around 3-5 minutes for the doctor or nurse to spend with each patient. This does not allow time for prolonged discussion. </p>
<p>Instead, in the days before your vaccine, discuss concerns with your regular GP (if you have one). They know you and your medical history so are better placed to tailor advice to your individual situation. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/im-over-50-and-can-now-get-my-covid-vaccine-is-the-astrazeneca-vaccine-safe-does-it-work-what-else-do-i-need-to-know-159814">I'm over 50 and can now get my COVID vaccine. Is the AstraZeneca vaccine safe? Does it work? What else do I need to know?</a>
</strong>
</em>
</p>
<hr>
<p>If your GP is not one of the practices administering the vaccine, or if you don’t have a regular GP, you may want to book an appointment with a GP at the practice where you plan to get it, with the sole purpose of discussing your concerns.</p>
<p>Even if you book your vaccine through a GP clinic, it may not be a GP administering the vaccine. It may be a practice nurse, who is experienced at giving a range of vaccines and will have taken <a href="https://www.health.gov.au/covid-19-vaccination-training-program">the same mandatory training</a> as a GP in administering COVID-19 vaccines.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-asthma-diabetes-or-another-illness-can-i-get-my-covid-vaccine-yet-160602">I have asthma, diabetes or another illness — can I get my COVID vaccine yet?</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1235&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1235&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1235&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396995/original/file-20210426-15-1wlylft.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Department of Health/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>What’s the best time to have my vaccine?</h2>
<p>The best time to get vaccinated against COVID-19 is as soon as possible, once you have had all your questions answered. However, there are a few things you may need to consider.</p>
<p><strong>If you feel unwell</strong></p>
<p>If you feel very unwell on the day, especially if you have a high fever (over 38°C), you need to postpone your vaccine. This is partly because your immune system may not respond optimally to the vaccine, and partly so symptoms after the vaccine <a href="https://www.immunize.org/askexperts/contraindications-precautions.asp">aren’t confused with symptoms</a> from an underlying illness.</p>
<p><strong>If you want the flu vaccine too</strong></p>
<p>It’s best to leave <a href="https://www.health.gov.au/resources/publications/covid-19-vaccination-atagi-advice-on-influenza-and-covid-19-vaccines">at least 14 days</a> between your influenza and COVID-19 vaccines. It’s likely safe to have them both together, however this is <a href="https://www.uhbw.nhs.uk/assets/1/comflucov_faqs.pdf">still being tested</a>. Also, if you happen to get a reaction to one of them, you will know which one you have reacted to.</p>
<p><strong>If it’s time for your mammogram</strong></p>
<p>As the vaccine can cause a temporary swelling of the lymph nodes in the armpit, women are <a href="https://theconversation.com/covid-vaccine-may-lead-to-a-harmless-lump-in-your-armpit-so-women-advised-to-delay-mammograms-for-6-weeks-159529">advised</a> to either have a mammogram first, or delay it until six weeks after vaccination. This advice is particularly relevant as we start to vaccinate women 50 and over, the key target group for Australia’s <a href="https://www.health.gov.au/initiatives-and-programs/breastscreen-australia-program">breast cancer screening</a> program.</p>
<p><strong>If you can, book before a scheduled day off</strong></p>
<p>About <a href="https://www.ausvaxsafety.org.au/safety-data/covid-19-vaccines">20% of people report missing work</a>, study or routine duties for a short period after their first AstraZeneca vaccine. So have your vaccine the day before a scheduled day off work if possible.</p>
<h2>Should I take a painkiller directly before or after my vaccine?</h2>
<p>Unless you take common painkillers such as paracetamol, ibuprofen or aspirin to regularly to treat an underlying illness, do not take medications that control pain and/or fevers before your vaccine. </p>
<p>You may use them after the shot but only if you need to treat symptoms that are worrying you. Overall it is best to avoid taking them at all as they may curb your immune response.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person taking painkillers with glass of water" src="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/400448/original/file-20210513-15-78opp5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Taking common over-the-counter painkillers can curb your immune response.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-girl-holding-pill-glass-water-718784776">from www.shutterstock.com</a></span>
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<p>Both paracetamol and ibuprofen can <a href="https://journals.lww.com/ebp/Citation/2021/03000/Does_premedication_with_ibuprofen_affect_the.19.aspx">reduce the immune response to other vaccines</a>, particularly in children, although we’re not certain how much this affects their overall immunity to that disease.</p>
<p>One <a href="http://s0.uploads.ru/IHedb.pdf">study</a> showed taking aspirin, paracetamol or ibuprofen resulted in suppression of part of our immune response to viruses. And another study, this time in <a href="https://jvi.asm.org/content/95/7/e00014-21">mice</a>, revealed anti-inflammatory medications can impair production of some immune molecules after COVID-19 infection. </p>
<p>While none of this is strong evidence against taking these medications around a COVID-19 vaccine, the take-home message is not to take them if you don’t need to.</p>
<h2>What about exercise before and after the vaccine?</h2>
<p>Being physically fit can help you <a href="https://bjsm.bmj.com/content/45/12/987">fight off upper respiratory tract infections</a>. However does that translate to exercise also helping your immune response to vaccines? In other words, if you exercise before or after a vaccination will it work better? </p>
<p>There is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159113005023?via%3Dihub">evidence</a> exercise can help improve the response to some vaccines, particularly the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159119306518">influenza</a> ones, but this does <a href="https://cmr.asm.org/content/32/2/e00084-18">not apply to all vaccines</a>. </p>
<p>While the jury is still out on whether your COVID-19 vaccine will work better if you exercise around the time of having it, here is my suggestion: don’t exercise more than you usually do in the days before or after your shot. </p>
<p>Muscle pain and fatigue are two of the commonest side-effects from the COVID-19 vaccine, and are also normal responses to increasing your exercise. Avoid complicating the picture by maintaining your usual fitness regimen, and give yourself some leeway in the days after the vaccination where you may be feeling the side-effects from it.</p>
<p>The US Centers for Disease Control <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html">recommends</a> using or exercising your arm after the shot to help reduce pain and discomfort (although not to help the vaccine work better).</p>
<hr>
<p><em>Use the government’s <a href="https://www.health.gov.au/resources/apps-and-tools/covid-19-vaccine-eligibility-checker">vaccine eligibility checker</a> to see if you’re next in line for the COVID-19 vaccine, and where you can get vaccinated.</em></p><img src="https://counter.theconversation.com/content/160357/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasha Yates is affiliated with RACGP. </span></em></p>Australians over 50 can get their AstraZeneca vaccine from a GP clinic from today. Here’s what you need to know when you book yourself in.Natasha Yates, Assistant Professor, General Practice, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1268782020-02-07T12:04:52Z2020-02-07T12:04:52ZDo drugs go off? What happens to medicines after their use-by dates<figure><img src="https://images.theconversation.com/files/312837/original/file-20200130-41495-nehn0b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-prescription-treatment-medication-pharmaceutical-medicament-769176202">Shutterstock/BukhtaYurii</a></span></figcaption></figure><p>It is estimated that there is <a href="http://www.medicinewaste.com/help">a staggering £300m</a> worth of medicine unused in the UK every year. But is it safe to take these medicines if they are past their expiry date? </p>
<p>Expiry dates are put in place after rigorous trialling and controlled experiments to ensure the safety and effectiveness of the drugs people take. In short, they guarantee the potency of the drug. Medicinal drugs are all chemicals and the rate at which they go off will depend upon their chemical structure, the drug preparation, how they are packaged, environmental conditions, whether they are subject to microbial contamination and their exposure to heat, light, oxygen and water.</p>
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<strong>
Read more:
<a href="https://theconversation.com/medicine-shortages-are-already-a-reality-but-a-no-deal-brexit-could-make-it-worse-102218">Medicine shortages are already a reality but a no deal Brexit could make it worse</a>
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<p>The drugs are sold in a variety of containers including bottles, blister packs, tubes and ampules. They are relatively secure while sealed. But once the seal is broken, the process of “going off” accelerates.</p>
<h2>Common painkillers</h2>
<p>Let’s look at an everyday drug like <a href="https://theconversation.com/whats-the-point-of-paracetamol-66808">paracetamol</a>. This is an “over the counter” medicine, freely available, which helps to reduce pain or a fever. Paracetamol is sometimes sold in brown sealed bottles. The seal keeps moisture and atmospheric oxygen out. The brown bottle keeps UV light out as this can also cause the drug to breakdown. Once the seal is broken, the tablets are exposed to water and oxygen in the air and breakdown begins.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312839/original/file-20200130-41503-8kbscj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Paracetamol comes in bottles and blister packs and can be bought over the counter.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendering-paracetamol-pills-on-blister-765786244">Shutterstock/AleksandraGigowska</a></span>
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<p>Paracetamol is also sold in blister packs. These packs are permeable to water and oxygen so they are covered in, for example, polyvinylidene chloride (PVDC). This protects the contents and slows down the decomposition process but is still slightly permeable so doesn’t prevent it altogether.</p>
<p>The consequence of this is that, despite the protection of the packaging, the drug content slowly declines. <a href="https://mfprac.com/web2019/07literature/literature/Misc/ExpirationDates_ed.pdf">Research shows</a> that when paracetomol based medicines go past their expiry date, up to 30% of the drug may break down in between 12 and 24 months.</p>
<h2>Cold remedies and antibiotics</h2>
<p>Cold remedies contain both paracetamol and a decongestant (usually phenylephrine hydrochloride). These can be sold as powders, capsules, oral solutions or nasal sprays.</p>
<p>While drugs in dry powder and capsule form may be relatively stable, those in liquid form may go off more quickly. For example, cold remedies such as nasal sprays contain both preservatives and antioxidants that only work at lower temperatures. They are considerably less effective above 40°C. </p>
<p>Similarly, antibiotics such as amoxicillin and erythromycin can be prescribed as an oral suspension in water. The dry powder form of the drug is, again, relatively stable. But the shelf life of the drug mixed with water by the pharmacist may only be seven to ten days – even when kept in a fridge.</p>
<p>Some drugs in liquid form have a considerably shorter shelf life. For example, nitroglycerin (glyceryltrinitrate) is used to treat angina and coronary heart disease. Formulations include liquids, tablets and capsules. Nitrate esters, of which this drug is an example, readily break down in the presence of water, rendering the drug ineffective.</p>
<p>Some formulations of nitroglycerin contain stabilisers to reduce this and are contained in protective packaging. But even these formulations only have a shelf life of about three months. Users often divide up their doses into pill boxes. The shelf life of nitroglycerin, once out of protective packaging, is reduced down to less than a week because of the rapid rate of drug breakdown.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312840/original/file-20200130-41527-1xb3ipj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Taking pills out of their packs and putting them in boxes can reduce their shelf life.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-man-counts-out-his-pills-354226556">Shutterstock/JeffBaumgart</a></span>
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</figure>
<p>Even large, macromolecular drugs, like insulin, present problems. Insulin is a polypeptide used in the maintenance of blood glucose levels and the management of diabetes. </p>
<p>The drug is dissolved in water and when stored in a refrigerator (typically around 4°C) spoiling can be slowed. The solutions also contain preservatives to reduce the rate of spoiling. However, as they are small proteins, the drug molecules may break down in water, and in some instances bacteria can start to grow and break down the protein. This is why the shelf life of drugs such as insulin is very limited.</p>
<h2>Safety</h2>
<p>So is it safe to take medicines after their expiration date? The answer depends on the drug in question but, generally, no. Drugs like nitroglycerin may, in some instances, be life saving. But the actual drug content of out-of-date medicines such as this may mean that there is no effective medicine left in what is being taken. So there will be no effect on the target condition. </p>
<p>In the case of liquid antibiotics the concentration of the drug may be so reduced that it is not effective. To make things worse, <a href="https://www.sciencedaily.com/releases/2018/04/180423085415.htm">studies have shown</a> that the bacteria the antibiotic is being used to treat may, at lower concentrations of the drug, develop resistance that could render the antibiotic ineffective.</p>
<p>In other cases, like paracetamol, the consequences may not be so severe. But the drug content won’t be known. So if in doubt, check with pharmacists and doctors and try your best to keep drugs in date.</p><img src="https://counter.theconversation.com/content/126878/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Cole has received funding from the EPSRC, EU (Framework V), EU AGIS programme, Botswanan Government and South African Police Service for carrying out research on the analysis and profiling of controlled substances, including those which contain over the counter medicines.</span></em></p>An estimated £300m worth of medicine goes unused in the UK every year. But is it safe to take drugs past their expiry date?Michael Cole, Professor of Forensic Science, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1233922019-09-16T12:45:46Z2019-09-16T12:45:46ZTaking paracetamol during pregnancy may affect the child’s behaviour in early years<figure><img src="https://images.theconversation.com/files/292452/original/file-20190913-8701-tru792.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/765786226?src=xsEXAMOzh2j8QoRyfuC_DQ-1-1&size=medium_jpg">Aleksandra Gigowska/Shutterstock</a></span></figcaption></figure><p>In the early 1960s, thousands of babies were born with malformed limbs as a result of their mother taking <a href="http://broughttolife.sciencemuseum.org.uk/broughttolife/themes/controversies/thalidomide">thalidomide</a> – a drug used to treat morning sickness. The tragedy rocked the medical establishment and made doctors wonder what other drugs might have foetus-harming effects. </p>
<p><a href="https://eu-rd-platform.jrc.ec.europa.eu/eurocat">Several studies</a> were launched to try to spot other foetus-harming (teratogenic) drugs. However, these studies were based on the assumption that any harm would be obvious at birth or soon after. So subtle effects, or those where an effect would not be obvious until the child was older (a teenager or even an adult), would be unlikely to be spotted.</p>
<p>More recently, scientists have <a href="https://pdfs.semanticscholar.org/345f/98d5dc558776599cfd75d23ddc8ab552dc8a.pdf#page=8">begun to wonder</a> whether paracetamol (a painkiller) could have a teratogenic effect. This is an important question as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5832562/table/t0010/">at least half</a> of all pregnant women in Europe and the US take the drug during pregnancy – even if only occasionally. </p>
<p>There have been several studies, starting in the 1990s, designed to monitor mothers during pregnancy and then follow up their children. The most notable have taken place in <a href="https://www.fhi.no/en/studies/moba/">Norway</a> and <a href="https://www.dnbc.dk/">Denmark</a>. The researchers noted which drugs were taken in pregnancy, whether prescribed or bought over the counter, and followed up the children. Both studies found associations between mothers taking paracetamol in pregnancy and later behavioural problems, such as <a href="https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/">attention deficit hyperactivity disorder</a> (ADHD), in the child. </p>
<p>Our <a href="https://onlinelibrary.wiley.com/journal/13653016">latest study</a>, published in the journal Paediatric and Perinatal Epidemiology, also looked at the potential effects of taking paracetamol during pregnancy. Although our sample size is smaller than the Scandinavian studies mentioned earlier (almost 14,000 children, rather than 60,000 or more), we had more data on the children and it was collected more often.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/thalidomide-the-drug-with-a-dark-side-but-an-enigmatic-future-50330">Thalidomide: the drug with a dark side but an enigmatic future</a>
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<h2>Avon study</h2>
<p>In our study, the Avon Longitudinal Study of Parents and Children, we considered maternal paracetamol intake during a defined period – from 18 to 32 weeks of pregnancy, for which we had the best information on the reasons the drug was taken. We wanted to know whether children whose mothers had taken paracetamol during these three months of pregnancy had different temperaments, behaviours or IQ compared with children whose mothers had not taken paracetamol during this time.</p>
<p>We explored 135 different outcomes in these children. For cognition (the ability to think and reason), we used tests administered by psychologists. And for temperament and behaviour, we considered scales in questionnaires that the mothers had completed about their children annually during the first ten years of their lives. In particular, we assessed the children’s hyperactivity and attention, aggression, emotional problems, difficulties relating to peers, sociability and a composite score of difficult behaviour. </p>
<p>In parallel, and oblivious to the answers given by the mothers, their teachers completed similar questionnaire scales on the children’s behaviour at ages seven and eight years and ten and 11 years.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292460/original/file-20190913-8697-10ciz6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Psychologists administered the cognition tests.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/499584073?src=XTYBcJMPUny0E_OVikIT3Q-1-2&size=medium_jpg">Monkey Business Images/Shutterstock</a></span>
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<p>Of the 135 outcomes we investigated, we found only one associated with cognition. But 12 outcomes were associated with differences in behaviour and temperament. And these associations couldn’t be explained by things like headache, backache, infection, income and lifestyle as we’d taken these factors into account in our statistical analysis.</p>
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Read more:
<a href="https://theconversation.com/whats-the-point-of-paracetamol-66808">What's the point of paracetamol?</a>
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<p>These results were mostly concerned with difficult behaviour and hyperactivity, as well as poor attention span. We found that as the child got older, the associations weakened. They were strongest among those aged three and four but had disappeared by age eight, whether we used the reports from mothers or teachers.</p>
<p>The fact that the children outgrew these difficult behaviours is reassuring, but it raises the question of whether other associations will be found in teenage years. Meanwhile, it is sensible to suggest that pregnant women should reduce their intake of drugs, including over-the-counter drugs, whenever possible, since no drug can be proven to be entirely safe for the unborn child.</p><img src="https://counter.theconversation.com/content/123392/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jean Golding does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New study finds a link between taking paracetamol during pregnancy and behaviour problems up to age eight.Jean Golding, Emeritus Professor, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225322019-09-01T19:48:55Z2019-09-01T19:48:55ZAustralia has a paracetamol poisoning problem. This is what we should be doing to reduce harm<figure><img src="https://images.theconversation.com/files/290237/original/file-20190830-115387-2lcq5f.jpg?ixlib=rb-1.1.0&rect=5%2C10%2C3438%2C2282&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paracetamol overdoses can cause serious liver damage.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Most of us take paracetamol every now and again to reduce pain or fever. As far as medications go, it’s one we’re unlikely to associate with harm.</p>
<p>But in a study published today in the <a href="https://www.mja.com.au/journal/2019/211/5/paracetamol-poisoning-related-hospital-admissions-and-deaths-australia-2004-2017">Medical Journal of Australia</a>, my colleagues and I reveal a concerning increase in paracetamol poisonings, and resulting liver damage, in Australia over the last decade.</p>
<p>In fact, paracetamol is actually the <a href="https://www.mja.com.au/journal/2018/209/2/patterns-poisoning-exposure-different-ages-2015-annual-report-australian-poisons">number one pharmaceutical</a> Australian poisons centres receive calls about.</p>
<p>Paracetamol is safe if used appropriately, at a maximum of four grams per day in adults (equivalent to eight 500mg tablets, or six 665mg modified release tablets). However when this dose is exceeded, there is a potential for harm. And the bigger the dose, the greater the risk.</p>
<p>It’s time to consider restrictions, including reducing pack sizes and changing the way paracetamol is sold. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-paracetamol-may-be-our-favourite-mild-painkiller-but-it-doesnt-work-for-everything-57967">Weekly Dose: paracetamol may be our favourite mild painkiller, but it doesn't work for everything</a>
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</p>
<hr>
<h2>Our study</h2>
<p>We analysed data from national hospital admissions, poisons centre calls, and coroners’ records to examine poisonings, liver injuries, and deaths. </p>
<p>The annual number of cases of paracetamol poisoning increased by 44% from 2007-2008 to 2016-2017. </p>
<p>In that time, we recorded more than 95,000 paracetamol-related hospitalisations.</p>
<p>Liver injury from paracetamol has doubled over the same period. This is likely because people are taking more tablets when they overdose than in previous years, increasing the risk of liver failure. </p>
<p>More than 200 people died from paracetamol poisoning in Australia in the ten year period.</p>
<h2>What a paracetamol overdose does to your body</h2>
<p>Paracetamol itself is not toxic, but in large amounts it overwhelms the body’s ability to process it safely. This can lead to build up of a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637612/">toxic metabolite</a> (or break-down product), which binds to liver cells, causing these cells to die. </p>
<p>The quantity that constitutes a toxic dose depends on circumstances including the time period in which the paracetamol is taken, and the person’s weight. But any adult ingesting more than four grams in a day could be at risk.</p>
<p>In severe cases, liver failure means the person will need a liver transplant, or they won’t survive.</p>
<p>Paracetamol is the leading cause of <a href="https://www.ncbi.nlm.nih.gov/pubmed/16317692">acute liver failure</a> in the Western world. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-to-talk-about-this-paracetamol-problem-dont-we-19051">We need to talk about this paracetamol problem....don't we?</a>
</strong>
</em>
</p>
<hr>
<p>There is an antidote to paracetamol toxicity, called N-acetylcysteine (NAC), which is given as an intravenous infusion in hospital. Importantly, NAC works best when given early: it should be started before any symptoms appear. Symptoms of paracetamol poisoning – nausea, vomiting and abdominal pain – indicate damage has already started to occur. </p>
<p>Patients who take <a href="https://www.ncbi.nlm.nih.gov/pubmed/28644687">very large overdoses</a>, and overdoses with <a href="https://www.ncbi.nlm.nih.gov/pubmed/29451045">modified release paracetamol</a>, are more likely to sustain liver failure despite treatment with the antidote.</p>
<p>Modified release paracetamol comes in a higher strength, designed to be released over a longer period, which can be confusing and result in overdose. </p>
<h2>Accidental vs intentional overdosing</h2>
<p>Overdoses can be either accidental or intentional, and our figures include both. </p>
<p>Paracetamol is not a drug people become addicted to, or dependent on, in the same way people do with opioids or other drugs.</p>
<p>Intentional poisonings occur when people knowingly take too much paracetamol as a form of <a href="https://bmjopen.bmj.com/content/9/2/e026001">self-harm</a>. In our research, about three-quarters of cases were intentional. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dosing mistakes can occur when parents are giving paracetamol to their children.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>People might accidentally overdose because they are in pain, and believe because paracetamol is so widely available, it must be safe. They take more than the recommended dose, or take multiple different paracetamol-containing products together, resulting in harm. </p>
<p>Poisons centres also receive calls about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447018/">children having too much paracetamol</a>, usually due to dosing errors or a child finding and ingesting the medicine. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/research-check-does-paracetamol-in-pregnancy-cause-child-behavioural-problems-63994">Research Check: does paracetamol in pregnancy cause child behavioural problems?</a>
</strong>
</em>
</p>
<hr>
<h2>Some tips to avoid accidentally overdosing</h2>
<p>It’s important to be aware of the many brands of paracetamol-containing products, including cold and flu products, to avoid doubling up. People should also read the pack and ensure they follow the dosing instructions.</p>
<p>Parents should consider the following to avoid overdosing in children: </p>
<ul>
<li>paracetamol should be stored out of reach (for example, don’t leave it on the bench or change table after use)</li>
<li>paracetamol can be dosed every four to six hours, but must not exceed four doses in a 24 hour period</li>
<li>keep track of doses given and when by writing them down</li>
<li>read the label carefully and ensure you understand how to use the syringe/dosing device correctly.</li>
</ul>
<h2>Changing the way paracetamol is sold</h2>
<p>Paracetamol poisoning and resultant liver injury is preventable, and some simple public health measures could have a significant impact. </p>
<p>In Australia, paracetamol can be purchased outside of pharmacies (for example, in supermarkets) in packs of 20 tablets. In pharmacies, packs of 100 can be purchased without needing to speak to a pharmacist. </p>
<p>In both cases, there are no legal restrictions on the number of packs one person can purchase. This is out of step with many other countries, especially the UK and Europe.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-ok-to-give-children-pain-killers-we-asked-five-experts-95148">Is it ok to give children pain killers? We asked five experts</a>
</strong>
</em>
</p>
<hr>
<p>The UK restricted packs to 32 tablets in pharmacies and 16 tablets outside of pharmacies in 1998, as a response to increasing deaths from paracetamol. This resulted in a <a href="https://www.bmj.com/content/346/bmj.f403">long-term reduction</a> in paracetamol poisonings, liver injury, and deaths.</p>
<p>Many <a href="https://www.ncbi.nlm.nih.gov/pubmed/29319222">European counties</a> don’t allow non-pharmacy sales of paracetamol, and have small packs in pharmacies. Denmark has gone one step further, restricting paracetamol sales to those aged <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/bcpt.13003">18 and over</a>.</p>
<h2>Modified release paracetamol</h2>
<p>In our study, modified release paracetamol overdoses increased by 38% each year, and were disproportionately involved in deaths. </p>
<p>Modified release paracetamol has been <a href="https://www.ema.europa.eu/en/medicines/human/referrals/paracetamol-modified-release">completely banned</a> in Europe. This is due to documented harms, including increased risk of liver failure and death. </p>
<p>The Therapeutic Goods Administration <a href="https://www.tga.gov.au/changes-way-modified-release-paracetamol-products-are-supplied-questions-and-answers">recently announced</a> modified release paracetamol would become Schedule 3 in 2020, meaning it will be behind the pharmacist’s counter.</p>
<p>This restriction is a step in the right direction, but ignores the fact regular paracetamol can be purchased in large quantities without consultation with a health-care professional. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-how-does-pain-medicine-work-in-the-body-82495">Curious Kids: How does pain medicine work in the body?</a>
</strong>
</em>
</p>
<hr>
<p>Due to its widespread use, paracetamol is likely to remain a common source of poisoning. Our study shows it’s increasingly important we take measures to reduce harm from these events. </p>
<p>Restricting pack sizes and restricting availability of modified release paracetamol are crucial first steps. We also need increased public awareness of how to use paracetamol safely.</p>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14. For advice on suspected paracetamol overdose, call the <a href="https://www.poisonsinfo.nsw.gov.au/">Poisons Information Centre</a> on 13 11 26.</em></p><img src="https://counter.theconversation.com/content/122532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose Cairns receives funding from the NHMRC to study suicide prevention.</span></em></p>The annual number of paracetamol poisoning cases in Australia has increased by 44% over the last decade. To tackle this problem, we need tighter regulation around the way paracetamol is sold.Rose Cairns, Lecturer in Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/824952018-02-13T23:35:33Z2018-02-13T23:35:33ZCurious Kids: How does pain medicine work in the body?<p><em>This is an article from <a href="https://theconversation.com/au/topics/curious-kids-36782">Curious Kids</a>, a series for children. The Conversation is asking kids to send in questions they’d like an expert to answer. All questions are welcome – serious, weird or wacky!</em> </p>
<hr>
<blockquote>
<p><strong>I want to understand how pain medicine like Panadol works in our body. – Freddie, age 6, Melbourne.</strong></p>
</blockquote>
<hr>
<p>In short, pain medicine is able to block the processes that cause the feeling of pain. To understand why, we need to explain a bit more about how pain works.</p>
<p>Pain happens when electrical signals travel from the spot where you hurt yourself up your nerves, to the spinal cord and then up to the brain. </p>
<p>When the pain signal gets to the brain, it lets your brain know there’s a big problem happening so we can respond. </p>
<p>So when we feel pain from a burnt hand, we quickly remove it from a fire. Or if a dog bites us, the pain tells us to run away.</p>
<p>So even though pain hurts, pain is important. It can protect us from more injury. Feeling no pain at all is actually quite dangerous.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-do-animals-sleep-like-people-do-snails-sleep-in-their-shells-90941">Curious Kids: Do animals sleep like people? Do snails sleep in their shells?</a>
</strong>
</em>
</p>
<hr>
<p>But your question was about pain medicine like Panadol. Panadol is just one brand of medicine called <em>paracetamol</em> – there are a lot of different brands.</p>
<p>Inside our bodies, paracetamol is able to block the processes that cause the feeling of pain.</p>
<p>Paracetamol not only acts at the site of the pain (like your burnt hand or sore arm) but also in the brain where the pain is felt.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/curious-kids-why-dont-cats-wear-shoes-75308">Curious Kids: Why don’t cats wear shoes?</a>
</strong>
</em>
</p>
<hr>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1556&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1556&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1556&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1956&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1956&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196449/original/file-20171127-2055-1j57ten.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1956&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Paracetamol, and also other pain medicines such as ibuprofen (you might know it as Nurofen), block the formation of prostaglandins.</span>
<span class="attribution"><span class="source">Marcella Cheng/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>At the place where pain starts, such as a sore throat, a burnt finger or a broken arm, a lot of chemicals are made and released. These chemicals make you feel pain and also make your body send more blood flowing to the painful area. This is why the painful area is often red and swollen. </p>
<p>The extra blood flowing to the area includes white blood cells – special parts of our blood that fight disease. These white blood cells bring important chemicals. One of these chemicals goes by the name of “prostaglandin”. It increases pain and inflammation (swelling).</p>
<p>Paracetamol, and also other pain medicines such as ibuprofen (you might know it as Nurofen), stop your body from making prostaglandins. </p>
<p>When you swallow some paracetamol, it dissolves in your tummy and most of it is absorbed into your blood. The paracetamol then travels around the body to reach both the painful spot and your brain, where it then starts to reduce the feeling of pain. </p>
<p>Paracetamol is very safe if the dose taken over 24 hours (that’s one day and one night) is kept below a maximum amount. It is very important not to take too much paracetamol, as it can be very dangerous if you take too much. </p>
<p>So make sure to never, ever take paracetamol without being sure that the dose has been checked by an adult who has read the instructions on the box. Otherwise you could take too much and get very sick or even die.</p>
<hr>
<p><em>Hello, curious kids! Have you got a question you’d like an expert to answer? Ask an adult to send your question to us. They can:</em></p>
<p><em>* Email your question to curiouskids@theconversation.edu.au
<br>
* Tell us on <a href="https://twitter.com/ConversationEDU">Twitter</a> by tagging <a href="https://twitter.com/ConversationEDU">@ConversationEDU</a> with the hashtag #curiouskids, or
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* Tell us on <a href="http://www.facebook.com/conversationEDU">Facebook</a></em></p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=472&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=472&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168011/original/file-20170505-21620-huq4lj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=472&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p><em>Please tell us your name, age, and which city you live in. You can send an audio recording of your question too, if you want. Send as many questions as you like! We won’t be able to answer every question but we will do our best.</em></p><img src="https://counter.theconversation.com/content/82495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Day has received consulting fees, paid to his institution, from
GlaxoSmithKline Australia, and fees for meeting participation from Reckitt
Benckiser.</span></em></p><p class="fine-print"><em><span>Garry Graham has received support from GlaxoSmithKline for research on paracetamol.</span></em></p>In short, pain medicine is able to block the processes that cause the feeling of pain. To understand why, you need to know a bit about how pain works.Ric Day, Professor of Clinical Pharmacology, UNSW SydneyGarry Graham, Honorary Professor of Pharmacology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/714332017-02-06T10:34:01Z2017-02-06T10:34:01ZAre over-the-counter painkillers a waste of money?<figure><img src="https://images.theconversation.com/files/154035/original/image-20170124-465-125m2sp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Horses for courses?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paracetamol-on-white-background-382039522?src=IPwPgPK4D9nnVUMq0XwMew-1-1">Shutterstock</a></span></figcaption></figure><p>Simple painkillers (such as aspirin, paracetamol and ibuprofen) are widely bought over the counter and prescribed by doctors. But the stark truth is that most of these medicines don’t work very well. </p>
<p>Professionals can’t be satisfied advising consumers and patients to take ineffective medicines. And consumers and patients can’t be happy that they’re spending cash or NHS resources on something that doesn’t do the job. But those with minor ailments who opt for such drugs aren’t necessarily wasting their money – and may well be saving yours by reducing the burden on health services.</p>
<p>An evidence-based approach to pain relief must consider realistic alternatives. Trials demonstrate that simple over-the-counter (OTC) painkillers, such as <a href="http://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain">paracetamol for low back pain</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011888.pub2/abstract">aspirin for episodic tension-type headaches in adults</a>, work no better than placebo. But in practice, we need to consider how harmful this really is – and what people would do if they weren’t popping their favourite pills. </p>
<p>Cochrane reviews are internationally-recognised <a href="http://uk.cochrane.org/about-us">systematic reviews</a>. The most recent <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011888.pub2/abstract">review of asprin</a> for the treatment of occasional, acute, tension-type headache tells us that patients taking active medication are unlikely to be pain free. However, over half the patients taking aspirin were satisfied with their treatment, as were one third taking placebo. </p>
<p>Similarly, in a <a href="http://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain">Cochrane review</a> of paracetamol for the treatment of acute low back pain, 4g of paracetamol daily was found to be no more effective than placebo. </p>
<p>In both studies, active and placebo treatments had similarly low rates of side-effects. </p>
<h2>More placebo, please</h2>
<p>This isn’t a good situation, but the placebo effect itself is often overlooked or treated with disdain. Which is a pity – it could be better employed in the fight against pain. <a href="https://www.ncbi.nlm.nih.gov/pubmed/12406519">A 2002 review</a> of placebo effects in clinical pain killer trials concluded: </p>
<blockquote>
<p>If the factors that contribute to placebo analgesia are identified, they could be optimised in clinical practice whereby the general effectiveness of pain treatments could be enhanced.</p>
</blockquote>
<p>And placebo effects were greater when studies specifically tried to investigate how placebos work. In another context, a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19246102">2009 meta-analysis of anti-depressant trials</a> concluded: </p>
<blockquote>
<p>The placebo effect accounted for 68% of the effect in the drug groups. Whereas clinical trials need to control the placebo effect, clinical practice should attempt to use its full power.</p>
</blockquote>
<p>Patient demand for pain relief in the UK is clear, around <a href="http://www.pagb.co.uk/consumer-healthcare-industry/">£575m a year is spent on OTC analgesics</a> and another £567m on analgesics prescribed in <a href="http://content.digital.nhs.uk/catalogue/PUB20200/pres-cost-anal-eng-2015-rep.pdf">primary care</a>. The primary care spend includes £90m on products that could be bought OTC and £115m on compound painkillers that are the next step up the pain ladder. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=318&fit=crop&dpr=1 600w, https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=318&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=318&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=400&fit=crop&dpr=1 754w, https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=400&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/154036/original/image-20170124-455-1bs097w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=400&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It could all be in the mind.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-man-holding-paracetamol-pill-tablet-525244381?src=IPwPgPK4D9nnVUMq0XwMew-1-7">Shutterstock</a></span>
</figcaption>
</figure>
<p>Indeed, people may be willing to pay significant sums for pain relief, which is a measure of economic benefit – a few pounds to relieve everyday pain, tens of pounds to relieve post-operative pain, and hundreds of pounds to relieve chronic pain. </p>
<p>But the current supermarket price for paracetamol is little more than 1p per tablet – and stronger painkillers use codeine and related drugs, which significantly increase the risk of harmful side-effects. </p>
<p>For acute pain, simple safe painkillers are cheap (it’s certainly worth <a href="https://theconversation.com/why-do-people-choose-expensive-branded-drugs-over-cheap-generics-52461">buying generic</a> rather than more expensive branded varieties) and promote active self-management of minor ailments. They may also help to engage the placebo effect. The evidence for effectiveness beyond the placebo effect is mixed (as the Cochrane reviews demonstrate), but doing something <a href="http://www.nhs.uk/Conditions/Back-pain/Pages/Treatment.aspx">does have an effect</a> and painkillers may actively help in some cases. </p>
<p>When people buy these painkillers, they also save the NHS – and taxpayers – the expense of visiting a doctor and having them prescribed. Generic paracetamol costs 19-30p for 16 in the supermarket and 35p on prescription. However, consultation and dispensing costs are considerable.</p>
<p>The spend on OTC painkillers might therefore be like buying a lottery ticket – they will work really well for some people, and rather less well for others. Either way, the losses are insignificant. If there’s a chance that they’ll work for you, then it’s a small price to pay.</p>
<h2>The bigger picture</h2>
<p>Nevertheless, non-pharmacological actions (for example, rest, fluids, change in activities) are equally or more helpful than painkillers <a href="http://www.nhs.uk/conditions/Headache/Pages/Introduction.aspx">in many cases</a>. So people should buy, obtain or use their painkillers in a supportive environment. For example, non-branded medicines are nearly as cheap in pharmacies as supermarkets, and your pharmacist should be able to talk you through the options and offer other advice, too. Doctors, meanwhile, need more time to explore problems with patients and shouldn’t need to write prescriptions to signal the end of a consultation. Their time could be better spent.</p>
<p>Imagine there was enough evidence to ban the OTC sale and prescription supply of simple painkillers. The supply of tea and sympathy would certainly have to increase. It is likely that the demand for compound pain killers or untested treatments would also increase, which risks more serious harm. There would also likely be an increase in visits to the doctor.</p>
<p>A goal to reduce the use of ineffective medicines is desirable. But we must also consider the alternatives and consequences. The treatment of pain isn’t the only area of clinical practice where hope is maximised over effectiveness. Improving the safety and effectiveness of chronic pain relief is a higher priority than reducing acute painkiller consumption. For now, people will keep using cheap (perhaps even quite expensive) OTC painkillers – and it’s hard to say they’re acting irrationally.</p><img src="https://counter.theconversation.com/content/71433/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Silcock receives funding from the National Institute for Health Research. He provides advice to Health Education England about pharmacy training reforms. He is a member of the Royal Pharmaceutical Society. </span></em></p>They’re often no more effective than placebo, but that shouldn’t necessarily stop us using them.Jonathan Silcock, Senior Lecturer in Pharmacy Practice, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722832017-02-06T04:51:07Z2017-02-06T04:51:07ZOuch! The drugs don’t work for back pain, but here’s what does<figure><img src="https://images.theconversation.com/files/155399/original/image-20170202-1685-1i6mbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Common over-the-counter drugs such as paracetamol and ibuprofen offer little proven relief for back pain. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/245834140?size=huge_jpg">from shutterstock.com </a></span></figcaption></figure><p>How’s your back? About a quarter of Australia’s population experience a <a href="https://www.ncbi.nlm.nih.gov/pubmed/15148462">back pain</a> episode at any point in time, and nearly all of us (<a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60610-7/abstract">around 85%</a>) will have at least one lifetime experience with back pain.</p>
<p>But treating it seems very difficult. Backing up a <a href="http://www.bmj.com/content/350/bmj.h1225">2015 study</a> showing paracetamol is ineffective for back pain, our <a href="http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab">latest research</a> shows non-steroidal anti-inflammatory drugs (NSAIDs), such as Nurofen and Voltaren, provide minimal benefits and high risk of side effects.</p>
<p>Yet it’s not a cause for despair. There are effective approaches to managing back pain, but they’re not as simple as taking a pill.</p>
<h2>A move away from oral painkillers</h2>
<p>People with back pain are usually told by their health care practitioners to take <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415588">analgesic medications</a> to relieve their pain.</p>
<p>Out of date <a href="https://www.nhmrc.gov.au/guidelines-publications/cp94-cp95">Australian guidelines</a> for managing back pain recommend paracetamol as first choice analgesic, NSAIDs as second, and oral opioids as the third line medicines. Paracetamol is still the <a href="http://www.aihw.gov.au/publication-detail/?id=60129549469">most purchased</a> over-the-counter painkiller in Australia, but we’ve shown it to be <a href="http://www.bmj.com/content/350/bmj.h1225">ineffective for back pain</a>. </p>
<p>The UK 2017 National Institute for Health and Care Excellence (<a href="https://www.nice.org.uk/guidance/ng59">NICE</a>) guidelines now no longer recommend paracetamol as a stand-alone intervention for back pain. In the UK, NSAIDs are recommended as the analgesic of first choice for back pain, and opioids as second.</p>
<p>However in <a href="http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab">research</a> published last week, we show NSAIDs like ibuprofen (such as Nurofen) and diclofenac (such as Voltaren) offer only marginal relief from back pain compared to a placebo (sugar pill). Only one in six patients treated with NSAIDs achieved any significant reduction in pain.</p>
<p>We also found people taking NSAIDs are more than twice as likely to experience vomiting, nausea, stomach ulcers or bleeding compared to those taking placebo.</p>
<p>The study raises the question of whether the benefits of NSAIDs outweigh the risk of side effects offered by these drugs.</p>
<p>These results were obtained by reviewing 35 studies of 6,065 people with various types of spinal pain, including lower back pain, neck pain and sciatica (pain that extends into the leg, often experienced as pins and needles, reduced sensation or loss of strength).</p>
<p>Opioids such as oxycodone should also be avoided for back pain, since they have shown to increase the chances of having serious <a href="http://jamanetwork.com/journals/jama/fullarticle/2503508">side effects</a>, including misuse, overdose and dependency. In Australia, about 20% of people who see a GP for back pain are prescribed an <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415588">opioid painkiller</a>, but recent research has shown it provides <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2522397">minimal benefit</a> for people with back pain.</p>
<h2>Other treatments and activities that don’t help</h2>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007612.pub2/abstract">Bed rest</a> is not helpful for back pain, and might even slow recovery. However <a href="https://www.ncbi.nlm.nih.gov/pubmed/19136234">heavy physical work</a> should also be avoided in the first few days after a back pain episode starts. </p>
<p>Other treatment options – including acupuncture, ultrasound, electrical nerve simulation, and corsets or foot orthotics – are <a href="https://www.nice.org.uk/guidance/ng59">not recommended</a>, since there is no strong evidence supporting their use.</p>
<p>Even if the cause of back pain is unknown, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60172-0/abstract">imaging</a> (x-rays, MRI) is unlikely to influence management or provide meaningful information.</p>
<h2>Help, I’ve got back pain!</h2>
<p>Back pain is a problem we need to solve. Treatment costs are almost <a href="http://trove.nla.gov.au/work/185011445?selectedversion=NBD51957119">A$5 billion</a> every year in Australia, and it is the main health condition forcing older people to <a href="https://www.mja.com.au/journal/2008/189/8/chronic-disease-and-labour-force-participation-among-older-australians">retire prematurely</a>. In the United States, loss of workdays due to back pain cost <a href="https://www.ncbi.nlm.nih.gov/pubmed/16595438">US$100 billion annually</a>.</p>
<p>So, if the most commonly used medications and interventions for managing back pain do not work, what should people do instead?</p>
<p>First, there needs to be a stronger focus on preventing back pain. We know <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2481158">education and exercise programs</a> can substantially reduce the risk of developing a new episode of back pain. In addition, we also know what can trigger back pain, such as manual tasks involving heavy loads, awkward postures and <a href="http://www.thespinejournalonline.com/article/S1529-9430(16)30851-8/fulltext">being fatigued or tired during an activity</a>.</p>
<p>Second, once people have back pain, they should be given tailored advice and information to help them self-manage their condition. Patients should be reminded of the <a href="http://onlinelibrary.wiley.com/doi/10.1002/art.24853/abstract;jsessionid=B29F8971F60D05982D3A0652B545CCF7.f04t03">benign nature of back pain</a>. Most of us will have some pain in our lower back but very rare cases will be associated with more serious causes (cancer, fracture). Reminding people of the importance of keeping active within their own limitations is also crucial. This includes going for a short walk or avoiding prolonged sitting.</p>
<p>Further, people with back pain should consider <a href="https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/kei242">physiotherapy treatments</a> and engage in exercise programs, including <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000335.pub2/abstract">aerobic exercises, strengthening, stretching</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010265.pub2/abstract">Pilates</a> or <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010671.pub2/abstract">yoga</a>. These interventions have small but <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract">proven</a> efficacy in relieving back pain symptoms with small or no side effects.</p>
<p>For people with ongoing or persistent back pain, an alternative to taking “strong” painkillers such as opioids is to become part of a <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract">pain management program</a>. These treatments are delivered by practitioners from different clinical backgrounds and include components that target not only physical issues but also psychosocial factors, such as depression, stress and anxiety.</p>
<p>Back pain has many causes and presentation scenarios, and a quick fix is not the answer. Although we would all like back pain to be resolved with painkillers, evidence points us to a different direction.</p>
<p>Controlling our body weight, having a healthy diet, engaging in regular physical activity, and lowering stress and anxiety are likely to offer long term benefits not only to people’s lower back, but also to their <a href="https://www.ncbi.nlm.nih.gov/pubmed/16639173">health</a> in general.</p><img src="https://counter.theconversation.com/content/72283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gustavo Machado received funding from Australian Department of Education and Training. </span></em></p><p class="fine-print"><em><span>Manuela L Ferreira receives funding from government and industry for unrelated research. Her fellowship is also supported by Sydney Medical Foundation/The University of Sydney. </span></em></p>Although common, back pain has many causes, and a quick drug fix is not the answer. But there are things you can do to get back on track.Gustavo Machado, Research fellow, George Institute for Global HealthManuela Ferreira, Associate Professor in Medicine, The University of Sydney, Sydney Medical Foundation Fellow & Senior Research Fellow, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/668082016-10-24T09:33:38Z2016-10-24T09:33:38ZWhat’s the point of paracetamol?<figure><img src="https://images.theconversation.com/files/142554/original/image-20161020-8855-1seo2vn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-387405238/stock-photo-oral-medicine-paracetamolwhite-pills-black-and-white.html?src=-fkkx0GebYZqVw6EBdaZng-1-33">KP Photograph/Shutterstock.com</a></span></figcaption></figure><p>Paracetamol has been around for over 50 years. It’s safe and many guidelines recommend it as the go-to treatment. At least, that’s the conventional view of the drug. It’s a view so ingrained that it’s rarely questioned. The trouble is that the conventional view is probably wrong.</p>
<p>Huge amounts of paracetamol are used to treat pain, measured not in how many tablets are used but in the thousands of tons. For the UK, an estimate of the amount of paracetamol sold is <a href="http://link.springer.com/article/10.1007%2Fs40264-012-0013-7">just under 6,300 tonnes a year</a>. That’s 35 tonnes per million of population: 35 grams or 70 paracetamol tablets each, every year. </p>
<h2>But does it work?</h2>
<p>The evidence is that it probably does not work at all for chronic pain. Large, good and independent clinical trials and <a href="http://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain">reviews from the Cochrane Library</a> show paracetamol to be no better than placebo for <a href="http://www.bmj.com/content/350/bmj.h1225">chronic back pain</a> or <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30002-2/abstract">arthritis</a>. This is at the maximum daily dose in trials lasting for three months, so it has been pretty thoroughly tested.</p>
<p>Acute pains are sudden in onset and go away after a while (headache or pain after an operation, for instance). For these, reviews from the Cochrane Library show that paracetamol can provide pain relief, but only for a small number of people. For postoperative pain, perhaps one in four people benefit; for headache perhaps one in ten. This evidence comes from systematic reviews, often of large numbers of good clinical trials.</p>
<p>These are robust and trustworthy results. If paracetamol works for you, that’s great. But for most, it won’t.</p>
<h2>Is it safe?</h2>
<p>Safety boils down to examining really bad things happening to a very small number of people who take a drug. Unless the rate of the very bad thing is vanishingly small, the authorities won’t let us buy the drug from a petrol station. If we want to study those rare events, then we need study large numbers of people. Partly because paracetamol is such an old drug these studies have largely not been done until recently. </p>
<p>Those we have tell us that paracetamol use is associated with <a href="http://ard.bmj.com/content/75/3/552">increased rates</a> of death, heart attack, stomach bleeding and kidney failure. Paracetamol is known to cause liver failure in overdose, but it also causes liver failure in people <a href="http://link.springer.com/article/10.1007%2Fs40264-012-0013-7">taking standard doses</a> for pain relief. The risk is only about one in a million, but it is a risk. All these different risks stack up.</p>
<h2>Are we competent to take analgesics?</h2>
<p>There are some scary facts about how much we, as ordinary members of the public, know about painkillers. Here are a few. </p>
<p>Many people don’t know what is in their analgesics. A study in a London emergency department found that half of the patients <a href="http://emj.bmj.com/content/27/11/829">thought ibuprofen contained paracetamol</a>. In the US, half of a similar group did not know that the popular brand of paracetamol, Tylenol, actually <a href="http://emj.bmj.com/content/25/4/213.abstract">contained paracetamol</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=518&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=518&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=518&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=651&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=651&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142648/original/image-20161021-1751-173ab1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=651&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Half of a sample of Americans didn’t know that Tylenol contained paracetamol.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=1rUCGq4JlBXTGQfmEU9bqQ-1-8&id=199792625&size=medium_jpg">dcwcreations/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Most people have no idea of the maximum daily dose of paracetamol. In the UK about one in four people frequently exceed the maximum daily dose (it’s 4,000mg, or eight tablets, by the way). In the US, half did not know the maximum daily dose, and one in 20 thought it as high as 10,000mg.</p>
<p>Paracetamol is not just in paracetamol, but all sorts of cold and flu medicines as well, and headache tablets. Around 200m packs of paracetamol are sold without prescription in the UK every year, though <a href="http://onlinelibrary.wiley.com/doi/10.1002/pds.701/abstract">sales fell after pack size restriction</a>. In the US <a href="https://c.ymcdn.com/sites/www.acpm.org/resource/resmgr/timetools-files/otcmedsclinicalreference.pdf">it could be one billion</a> (but different pack sizes and tablet doses). </p>
<p>The conundrum is what to do with this information for a drug with limited effect but dangerous in overdose. It’s a headache for regulators and licensing authorities, not to mention organisations like NICE trying to help doctors make sensible treatment decisions. Nor is there a simple alternative. Non-pharmacological methods of treating pain are largely without good evidence. Other drugs may work better, but they have side effects too. </p>
<p>Let’s not rush to judgement here and dismiss paracetamol entirely. But a rethink is surely timely.</p><img src="https://counter.theconversation.com/content/66808/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Moore has been a consultant for and/or received research grants from RB, Novartis, Grünenthal, and Menarini, some of whose products might be competitors of paracetamol is some circumstances. Andrew Moore is an author and editor for the Cochrane Pain, Palliative, and Supportive care group, and until recently was the chairman of the International Study of Pain special interest group on systematic reviews and evidence. </span></em></p>All the guidelines recommend paracetamol for pain relief despite the lack of evidence for the drug’s effectiveness.Andrew Moore, Honorary Senior Research Fellow, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/639942016-08-19T03:28:29Z2016-08-19T03:28:29ZResearch Check: does paracetamol in pregnancy cause child behavioural problems?<figure><img src="https://images.theconversation.com/files/134571/original/image-20160818-12292-1bm0kx5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The use of paracetamol in pregnancy is low risk.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-353346353/stock-photo-pregnancy.html?src=HflySInMSlKDzRaMb2FhWA-1-75">Svetlana Iakusheva/Shutterstock</a></span></figcaption></figure><p>Paracetamol is widely used in all stages of pregnancy to reduce a high temperature and relieve pain. It should be taken only when needed, but is generally considered safe for the baby. </p>
<p>A <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=2543281">study published on Tuesday</a> in the journal JAMA Pediatrics linked the drug to behavioural problems in childhood, generating alarming headlines such as <a href="http://www.businessinsider.com.au/science-says-taking-paracetamol-when-pregnant-can-lead-to-hyperactive-children-2016-8">“Science says taking paracetamol when pregnant can lead to hyperactive children”</a> and <a href="http://www.mirror.co.uk/lifestyle/health/pregnant-women-could-put-babies-8636929">“Pregnant women ‘could put babies at risk of developing behavioural problems if they take paracetamol after 18 weeks’ ”</a>.</p>
<p>So, are the headlines right?</p>
<p>The short answer is no. This paper does not provide any evidence that paracetamol causes childhood behavioural problems. </p>
<p>A more practical question is whether pregnant women and their doctors should change their use of paracetamol (also known as acetaminophen in the United States) on the basis of this paper. The answer to this is also no.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1012&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1012&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1012&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1272&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1272&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134746/original/image-20160819-12292-pag6pz.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1272&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<h2>How was the study conducted?</h2>
<p>The researchers studied pregnant women who had taken paracetamol during pregnancy and the behaviour of their children at seven years of age. </p>
<p>The study tracked 7,796 mothers enrolled between 1991 and 1992 together with their children and partners in the Avon Longitudinal Study of Parents and Children (ALSPAC). </p>
<p>At 18 and 32 weeks of pregnancy, the mothers were asked to recall if they had used paracetamol in the preceding three months. </p>
<p>The mothers weren’t asked about dose or duration of treatment but were asked to recall the reason for taking paracetamol. These included: muscle and joint problems, infections (including cold or flu, urinary or other infections), migraine or headaches. </p>
<p>However, these reasons were not analysed separately in relation to the behavioural outcomes in the children. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134716/original/image-20160819-12284-vj6zv8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women reported on their paracetamol use in the previous three months.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-282560084/stock-photo-forefront-of-a-white-medicine-pills-in-blister-pack.html?src=I9DEzVBuMUmkdeNbMYcOXQ-2-95">pedrosala/Shutterstock</a></span>
</figcaption>
</figure>
<p>When the children were 61 months (five years) old, the mothers and their partners were asked the same questions about paracetamol use in the previous three months. </p>
<p>When the children were aged seven, the mothers completed the <a href="http://www.sdqinfo.org/a0.html">Strengths and Difficulties Questionnaire</a> (SDQ) about their children’s behaviour to determine whether they exhibited problems in five domains: </p>
<ul>
<li>emotional symptoms (for example, “nervous or clingy in new situations”)</li>
<li>conduct problems (“often has temper tantrums or hot tempers”)</li>
<li>hyperactivity symptoms (“constantly fidgeting or squirming”) </li>
<li>peer relationship problems (“rather solitary, tends to play alone”) </li>
<li>prosocial behaviours (“shares well with other children”).</li>
</ul>
<p>Each item is scored as Not True (0/2 points, depending on whether the behaviour is negative or positive), Somewhat True (1 point) or Certainly True (2/0 points). </p>
<p>The scores from four of the domains (20 questions excluding the prosocial scale) are then combined to give a single SDQ total of 0-40. Children with scores of 17 and above are deemed to have a behavioural problem. </p>
<h2>What were the results?</h2>
<p>At 18 weeks, 4,415 (53%) mothers and at 32 weeks 3,381 (42%) mothers reported having taken paracetamol. The paper doesn’t say if any mother had taken paracetamol during both periods, or if they had taken any other medications. </p>
<p>The authors reported that 5% of the seven-year-olds whose mothers had ingested paracetamol at 18 or 32 weeks exhibited behavioural problems. </p>
<h2>What’s the problem?</h2>
<p>It’s possible to find <a href="https://www.amazon.com/Spurious-Correlations-Tyler-Vigen/dp/0316339431">associations between all sorts of things</a>. Spending in the US on science, space and technology, for instance, is estimated to have a 99.79% correlation with suicides by hanging, strangulation and suffocation. But this correlation is meaningless. US spending on science doesn’t cause these forms of suicide.</p>
<p>Maternal paracetamol use in pregnancy causing behavioural problems in children is a plausible association. But based on this research, it’s not possible to say one causes the other. Proving causation requires an entirely different set of scientific experiments. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134718/original/image-20160819-12284-1s5as0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The study suggests a link but doesn’t show one thing causes another.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-311664224.html">Nadezhda1906/Shutterstock</a></span>
</figcaption>
</figure>
<p>The authors mention that 5% of children whose mother took paracetamol had behavioural problems. They don’t mention that nearly as many children of mothers who had never taken paracetamol also showed behavioural problems at the same age of seven. (The actual figures are not in the paper but are in the <a href="http://archpedi.jamanetwork.com/data/Journals/PEDS/0/POI160049supp1_prod.pdf">supplementary etables</a>.)</p>
<p>For paracetamol use at 18 weeks’ gestation, the total incidence of behavioural difficulties (abnormal SDQ scores) at age seven was 5.6% compared with 4.8% for children whose mothers had not taken paracetamol (eTable 1). </p>
<p>At 32 weeks, the figures were 6.3% for the paracetamol group and 4.3% for the non-paracetamol group (eTable 1). </p>
<p>For the mothers’ use of paracetamol when their child was aged five, the percentages of behavioural problems weren’t much different: 5.3% for the mothers who took paracetamol and 4.1% for the children of mothers who did not take paracetamol (eTable 1). </p>
<p>It’s hard to imagine how a mother’s or partner’s paracetamol use when the children were five – and presumably not breastfeeding – could have any effect on their behaviour two years later. </p>
<p>The similarity of the percentages at the three reporting points suggests the mothers’ paracetamol use in pregnancy was unlikely to be involved in the behavioural problems of the children.</p>
<p>Even if it was accepted that paracetamol might be having an effect, only a very small number of children would be affected. At 18 weeks, for example, the difference between children whose mothers had taken paracetamol and those who had not was 0.8%, or one child in 125. </p>
<p>The study also has some technical problems, such as discrepancies between figures in the text and tables. </p>
<h2>What does it all mean?</h2>
<p>All medication is a balance between risks of side-effects and potential benefits. </p>
<p>In this case, providing paracetamol is used for a good clinical reason, at the dose specified and for the shortest possible time, the risk is low. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134722/original/image-20160819-12274-az5rz0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Paracetamol should be used for the shortest time and at the specified dose.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-166682585/stock-photo-pregnant-woman-taking-pills.html?src=-9JtEq04xpa4WSQA0n6-Vg-1-44">nata-lunata/Shutterstock</a></span>
</figcaption>
</figure>
<p>The lack of evidence of a causal relationship and the marginal differences in incidence between paracetamol and non-paracetamol groups suggest that this report should be consigned to the large black hole of inadequate research. <strong>– Norman Saunders and Mark Habgood</strong></p>
<hr>
<h2>Peer review</h2>
<p>This Research Check accurately summarises the key finding of the JAMA Pediatrics paper, and correctly identifies the technical issues that will be of most concern to pregnant women. </p>
<p>It also fairly translates the paper into terms that are more understandable to the lay reader. </p>
<p>If anything, the Research Check fails to convey the frustration that even experienced researchers would have trying to derive actual numbers of affected children in the control and paracetamol arms. </p>
<p>The Research Check correctly states that the actual proportion of children with behavioural issues were very similar between mothers who had never consumed paracetamol and those who did, and that the increased risk was small. </p>
<p>One aspect that was not emphasised is the statistics. There is a lot of variation in the data, and some of the behaviours reported as being increased are of marginal significance, especially the 18-week results.</p>
<p>The Research Check notes there is no information on the amount of paracetamol ingested and how often. This makes interpreting the risk due to paracetamol even more problematic. </p>
<p>The Research Check correctly states that even if there is an effect of paracetamol, it is very small. The relevance of these findings to modern paracetamol usage is also limited. </p>
<p>The JAMA Pediatrics study took place in the 1990s in the United Kingdom. In 1998, the UK changed its regulations on pack sizes to reduce accidental and deliberate overdose. This move was successful and women in the UK are now less likely to be exposed to as much paracetamol as they were in the 1990s. </p>
<p>The current Australian recommendations on amount of paracetamol to take and the length of time to take it, as well as the modern pack sizes, mean pregnant women in Australia are potentially exposed to less paracetamol than in the JAMA Pediatrics study. <strong>– Ian Musgrave</strong></p><img src="https://counter.theconversation.com/content/63994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Musgrave receives funding from the National Health and Medical Research Council to study adulterants and contaminants of herbal medicines, and has received past funding from the Australian Research Council to study nutracueticals and amyloid toxicity.</span></em></p><p class="fine-print"><em><span>Mark Habgood and Norman Saunders do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some of the headlines are alarming but pregnant women and their doctors should not change their current use of paracetamol on the basis of this paper.Norman Saunders, Professorial Fellow in Neuroscience, The University of MelbourneMark Habgood, Senior Research Fellow, Developmental Neuroscience and Neurotrauma, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/579672016-05-04T05:09:43Z2016-05-04T05:09:43ZWeekly Dose: paracetamol may be our favourite mild painkiller, but it doesn’t work for everything<figure><img src="https://images.theconversation.com/files/120139/original/image-20160426-1344-eqylg8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paracetamol has been found to be no more effective than a placebo for low back pain and arthritis. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Paracetamol is one of the most widely used medicines in Australia and around the world. Millions of doses are administered worldwide each day. Paracetamol was number six on the <a href="http://www.pbs.gov.au/info/statistics/asm/asm-2014">list of top ten subsidised medicines</a> in Australia with 36 defined daily doses per 1,000 people per day (including 6.8 million prescriptions in 2014). </p>
<p>These data do not include over-the-counter purchases in pharmacies or supermarkets (where small pack sizes are available), nor combination products that contain paracetamol. </p>
<p>Paracetamol is an analgesic (pain relief) and antipyretic (reduced fever). It is often found in combination with stronger analgesics such as codeine or in combination cold and flu products. Paracetamol is likely to be found in the medicine cabinet of most Australian homes and gets used for a variety of indications, most commonly for mild pain and fever.</p>
<p>Paracetamol is included on the <a href="http://www.who.int/medicines/publications/essentialmedicines/en/">World Health Organisation’s list of Essential Medicines</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=955&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=955&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=955&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1200&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1200&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120793/original/image-20160502-28139-des1t6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1200&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<h2>How it works</h2>
<p>Despite being one of the most widely used medicines in the world, debate continues about the exact mechanism of action of paracetamol. The consensus suggests paracetamol achieves its <a href="http://www.ncbi.nlm.nih.gov/pubmed/23719833">pharmacological effects</a> by inhibiting the enzyme (cyclooxygenase) in the brain and painful site that produces the compounds (<a href="https://en.wikipedia.org/wiki/Prostaglandin">prostaglandins</a>) involved in inflammation and repair after injury. Thus it reduces pain intensity and fever.</p>
<p>This is a similar action to <a href="https://theconversation.com/weekly-dose-ibuprofen-just-because-its-freely-available-doesnt-make-it-safe-56346">non-steroidal anti-inflammatory</a> drugs, but paracetamol has less of an effect on severe inflammation than anti-inflammatories of this kind.</p>
<h2>How it was developed</h2>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/11319582">Paracetamol</a> was first made in 1877 and was recognised to be a product of two analgesics in common use at the time, phenacetin and acetanilide. Clinical testing in 1893 showed paracetamol was as effective but better tolerated than these analgesics.</p>
<p>Phenacetin was implicated (along with aspirin and caffeine) in contributing to <a href="http://www.australianprescriber.com/magazine/23/1/17/9">kidney damage</a> and withdrawn from the market. </p>
<p>Paracetamol was first commercially released in the 1950s in the United States and later in Australia. </p>
<h2>Cost</h2>
<p>Paracetamol is relatively inexpensive at just a few cents a tablet and (unfortunately) some brands can often be found “on sale” in discount pharmacy stores. Confusingly for many consumers, the price of paracetamol can vary depending on the product and the company that makes it. </p>
<p>This year paracetamol (and a range of other over-the-counter medicines) was <a href="http://www.nps.org.au/publications/consumer/medicinewise-living/2015/some-otc-medicines-lose-pbs-subsidy">delisted</a> from the Pharmaceutical Benefits Scheme (PBS). Consumers were encouraged to buy it at the pharmacy rather than have it dispensed on prescription. </p>
<p>This was a decision designed to limit PBS expenditure on a medicine that is considered relatively inexpensive in the pharmacy. This strategy has been <a href="http://www.abc.net.au/news/2015-05-08/panadol-on-the-pbs/6434462">questioned</a>, though, because most people who receive a PBS prescription for paracetamol use the more expensive slow-release products for chronic painful conditions such as arthritis.</p>
<h2>Past uses</h2>
<p>In the past, paracetamol has been recommended as first-line treatment for low back pain and osteoarthritis. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381278/">Recent data</a>, including a <a href="https://theconversation.com/put-down-the-paracetamol-its-just-a-placebo-for-low-back-pain-29572">trial from Australia</a>, show paracetamol is no better than placebo in these conditions, forcing a rethink about its use.</p>
<h2>Reactions and side effects</h2>
<p>Paracetamol is effective at treating many types of acute pain and reducing fever. It is often preferred to other simple analgesics (such as non-steroidal anti-inflammatories) because it has few serious side effects or drug interactions. </p>
<p>Paracetamol is generally well tolerated at recommended doses (adjusted for body weight in children), but can be lethal in overdose, leading to liver failure and death. Paracetamol can have an effect on liver function, but this is reversible and not associated with harmful outcomes.</p>
<p>Many of the harms of paracetamol can be avoided by careful dose adjustment or selecting an alternative analgesic for people at highest risk of adverse effects. The people at higher risk of paracetamol-related harms include people with a history of chronic liver, kidney or heart disease, chronic alcohol abuse and malnourishment. </p>
<p>The risk of inadvertent double or multiple dosing with paracetamol remains a challenge because of the plethora of products in which it is contained.
Managing people with overdose of paracetamol is supported by clear <a href="https://www.mja.com.au/journal/2015/203/5/summary-statement-new-guidelines-management-paracetamol-poisoning-australia-and">guidelines</a>, but overdose remains an important and urgent medical problem in the health system. </p>
<p>The use of blister packing and limiting pack sizes have helped reduce the burden of paracetamol overdose in Australia when compared to other countries, such as the United States.</p>
<h2>Controversies</h2>
<p>In recent years, the makers of paracetamol and ibuprofen have been <a href="https://www.choice.com.au/health-and-body/medicines-and-supplements/prescription-medicines/articles/pain-relief-drugs-panadol-and-nurofen">challenged about labelling</a> of their products that suggests these medicines can specifically target different types or areas of pain. This led to action taken by the ACCC. </p>
<p>This has also led to consumer groups challenging the complex pricing of different products containing these medicines, which in clinical terms are really no different.</p><img src="https://counter.theconversation.com/content/57967/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew McLachlan was an investigator and author on the PACE trial investigating the effect of paracetamol in people with acute low back pain which was published in the Lancet. The PACE trial was jointly funded by NHMRC and GlaxoSmithKline (the makers of Panadol). </span></em></p>Paracetamol is one of the most widely used medicines in Australia and around the world with millions of doses administered worldwide each day.Andrew McLachlan, Professor of Pharmacy (Aged Care), University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/539682016-03-02T01:44:40Z2016-03-02T01:44:40ZWhy advertisers use pictures to sell pharmaceuticals – and shouldn’t<figure><img src="https://images.theconversation.com/files/111068/original/image-20160211-29214-1my7oo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Happy pictures make people believe drugs are safer and more effective.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-374081920/stock-photo-happy-woman-enjoying-the-summer-outdoors-in-the-meadow-of-yellow-flowers.html?src=9JOIao79NOQtqrWUJqzQgg-1-104">Shutterstock/Evgeny Atamanenko</a></span></figcaption></figure><p>On a winter’s night in 1993 I was crouched in the back of an ambulance as it hurtled through the hedgerows and lanes of West Dorset. But I was oblivious to Thomas Hardy’s snowy fields. </p>
<p>I was a doctor and my charge was a teenage girl, unconscious and bleeding. We were speeding to London’s King’s College Hospital where the liver transplant unit was on standby. </p>
<p>She didn’t have hepatitis or some rare syndrome. Her problem was altogether different and the cause of 40% of all cases of sudden and severe liver failure. She had overdosed on the humble painkiller paracetamol.</p>
<p>My patient intended self-harm. But it’s a reminder that all pharmaceuticals carry risk, and why people who advertise them are made to rein in their notorious penchant for spruiking the positive.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=533&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=533&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=533&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=670&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=670&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111603/original/image-20160216-22550-6rgu7i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=670&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">All pharmaceuticals carry risk.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-376843255/stock-photo-packings-of-pills-and-capsules-of-medicines-on-white-background.html?src=1jH_i8VuTQ7D3kpZ-DrnSg-1-4">topnatthapon/Shutterstock</a></span>
</figcaption>
</figure>
<p>Under Australia’s <a href="https://www.tga.gov.au/publication/therapeutic-goods-advertising-code">Therapeutic Goods Advertising Code</a>, ads for over-the-counter medicines must not say a drug is always effective, has no side effects, or guarantees cure.</p>
<p>The visuals dominate most ads, but make no statement or claim about the drug and so don’t explicitly “say” anything. Yet colleague <a href="https://media.illinois.edu/patrick-vargas">Patrick Vargas</a> and I <a href="http://link.springer.com/article/10.1007%2Fs11673-016-9702-8">recently discovered</a> that what drugs ads <em>don’t</em> say may contain the most powerful message of all.</p>
<p>We had people listen to 15 statements about the flu and a fictional flu drug called Fluvent. We told them Fluvent works better than other drugs but can cause nausea, headache, diarrhoea and rash. </p>
<p>To convince them Fluvent was real we dressed it up in a snazzy box with a blue and yellow rising sun logo. Participants saw a small picture of the Fluvent box superimposed over a bigger background picture, which changed as each statement was read out. </p>
<p>Then we made it interesting. One-third of participants saw the Fluvent box over nice background pictures such as women bathing under a waterfall and a pancake dripping with syrup. </p>
<p>Another third saw the Fluvent box with humdrum pictures including a glass mug and some rubber bands. </p>
<p>The last third did it tough. They saw Fluvent backed with gut-churning images of seals bludgeoned to death on an ice floe and doctors rushing a bloodied disaster victim from danger. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111602/original/image-20160216-22563-gs19x4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Visuals can make you feel warm and fuzzy.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-374491192/stock-photo-pancake-folded-stack-of-with-liquid-honey-on-wooden-background-selective-focus.html?src=V0bGIze0FC6cp9hEWcfInw-2-10">Stolyevych Yuliya/Shutterstock</a></span>
</figcaption>
</figure>
<p>Then we got them to rate Fluvent. What we found left us in little doubt about the persuasive power of pictures.</p>
<p>People who saw happy pictures not only felt better about Fluvent, but believed it to be safer and more effective than those who saw the gruesome pictures. They were also more likely to ask their doctor for Fluvent if they got sick. This was despite each group getting exactly the same information.</p>
<p>Social psychologists won’t be surprised. It’s called <a href="http://www.ncbi.nlm.nih.gov/pubmed/20438144">evaluative conditioning</a>, a variant of Pavlov’s classical conditioning. Pavlov rang a bell when he gave dogs meat powder and eventually he just had to ring the bell to get them to drool. It turns out you can do a similar thing with feelings.</p>
<p>Pair something for which you have no special feelings, like a new flu drug, with something that makes you feel great, like a delectable pancake, and eventually your positive feelings for the flapjack rub off onto the drug. Research on this has been done with <a href="http://psycnet.apa.org/journals/xlm/33/1/130/">toothpaste</a>, <a href="http://jcr.oxfordjournals.org/content/37/3/473.abstract">beer</a> and many other commercial products. </p>
<p>But, to our knowledge, it’s never been done with pharmaceuticals before. And there are several reasons why regulators should take our findings seriously.</p>
<p>First, regulation focuses on the overt statements and claims ads make about a drug’s benefits and risks. But ads are full of imagery, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23557035">which is mostly unregulated</a>. Our study shows those visuals don’t just make you feel warm and fuzzy. They shift your beliefs.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111601/original/image-20160216-8211-bolyvw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Images help shift your beliefs.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-357096719/stock-photo-a-young-woman-practicing-yoga-outdoors-in-front-of-the-beautiful-waterfall.html?src=_XIu7zciXZCu38pYwyuiSA-1-118">Anton Jankovoy/Shutterstock</a></span>
</figcaption>
</figure>
<p>Second, drug beliefs born of sparkling waterfalls and plump pancakes can have only an accidental relationship with what the drug actually does. And so drug ads, often chock-a-block with scenes of sunlight and gaiety, will foster unjustified beliefs.</p>
<p>Third, the stakes go up dramatically in the United States and New Zealand where direct-to-consumer advertising of the more dangerous prescription medicines is allowed. In the US, the average citizen sees <a href="http://www.ncbi.nlm.nih.gov/pubmed/15764448">15 hours</a> of prescription drug ads each year and 95% of them contain <a href="http://www.ncbi.nlm.nih.gov/pubmed/17261859">positive emotional appeals</a>.</p>
<p>Finally, Australian doctors are exposed to prescription drug ads in medical journals that use similar techniques. While medicos will be less prone to conditioning effects, they are <a href="http://www.australianprescriber.com/magazine/37/5/163/6">unlikely to be immune</a>.</p>
<p>We live in an era of unprecedented emphasis on accurate health communication to help consumers make autonomous choices in their best interests. Yet unregulated advertising content may promote unrealistic beliefs about drugs. </p>
<p>If we are serious about protecting the public, regulation must target the visual content of ads to ensure it does not foster unwarranted expectations of drug safety and effectiveness. </p>
<p>And the girl in the ambulance? I ran into her a few months later in a venerable old Wessex pub Hardy may well have frequented. Perhaps not the best place for someone who has just sidestepped a liver transplant but, all power to Old Blighty’s NHS, she seemed OK.</p><img src="https://counter.theconversation.com/content/53968/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Biegler has received funding from the Australian Research Council. He is a former emergency physician and the author of The Ethical Treatment of Depression: Autonomy through Psychotherapy (MIT Press 2011) which won the Australian Museum Eureka Prize for Research in Ethics.</span></em></p>Some advertising content bypasses regulations to promote unrealistic beliefs about drugs.Paul Biegler, Adjunct Research Fellow in Bioethics, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/364812015-05-08T03:45:39Z2015-05-08T03:45:39ZThe low-down on ‘cold and flu’ tablets<figure><img src="https://images.theconversation.com/files/80271/original/image-20150504-2081-1htuo8r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cold and flu tablets won’t cure a cold.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/_flood_/6414786713">Flood G./Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Winter is approaching. Your nose is stuffy and you feel a cold coming on. You head to the pharmacy to find an aisle full of cold and flu tablets. </p>
<p>Each year Australians spend more than <a href="http://www.asmi.com.au/media/12687/asmi945_ar_13-14-single_pages_final.pdf">A$500 million</a> on cold and flu medicines. Choosing between the <a href="http://www.tga.gov.au/otc-cough-and-cold-medicines-available-australia">hundreds of different</a> cold and flu tablets available in Australia can be difficult, as each product may contain three or four different medicines. </p>
<p>So, which product is the best one for your symptoms? And will it really help you feel better?</p>
<h2>No cure</h2>
<p>Cold and flu tablets won’t cure a cold. Colds are <a href="https://theconversation.com/health-check-when-is-the-flu-really-a-cold-25150">caused by viruses</a> and symptoms <a href="http://www.nps.org.au/conditions/respiratory-problems/respiratory-tract-infections/for-individuals/conditions/common-cold/for-individuals/symptoms">generally resolve</a> within ten days. Getting plenty of rest and keeping your fluids up may help you feel better.</p>
<p>There is <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004976.pub3/abstract">some evidence</a> that combination cold and flu tablets may provide relief from general symptoms in adults but not everyone will benefit. </p>
<p>The small benefits from treatment also need to be weighed up against the risk of side effects and the cost of the medicine.</p>
<h2>How do cold and flu tablets work?</h2>
<p>Cold and flu tablets may contain decongestants, pain relievers, antihistamines and cough suppressants. And tablets marketed for “daytime” symptoms often contain different medicines to “night-time” tablets.</p>
<p><strong>Decongestants</strong> such as <a href="http://www.nps.org.au/medicines/respiratory-system/cough-and-cold-medicines/for-individuals/cough-and-cold-medicines-active-ingredients/phenylephrine-hydrochloride-cough-and-cold-medicines">phenylephrine</a> or <a href="http://www.nps.org.au/medicines/respiratory-system/cough-and-cold-medicines/for-individuals/cough-and-cold-medicines-active-ingredients/pseudoephedrine-hydrochloride">pseudoephedrine</a> may help to relieve a blocked nose. These medicines work by narrowing the blood vessels. The reduction in blood flow reduces swelling and congestion in the nose. </p>
<p>Decongestant tablets can have effects beyond the nose and may exacerbate other medical conditions such as <a href="http://archinte.jamanetwork.com/article.aspx?articleid=765664">high blood pressure</a>, so speak to your pharmacist before taking these medicines. These medicines can also cause sleeplessness, nervousness or dizziness. </p>
<p>In Australia, cold and flu tablets containing phenylephrine can be purchased from the pharmacy or supermarket. Products containing pseudoephedrine can only be supplied after consultation with the pharmacist or on a prescription.</p>
<p>Cold and flu tablets often contain <strong>paracetamol</strong> for relieving aches and pains. Other products marketed for joint pain, headaches, back pain and period pain also contain <a href="http://www.nps.org.au/medicines/pain-relief/simple-pain-reliever-and-fever-medicines/paracetamol">paracetamol</a>, so check labels carefully to avoid taking more than recommended.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80272/original/image-20150504-2077-hr7fuy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Decongestant tablets can have effects beyond the nose.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/micahrr/5386083144">findingtheobvious/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p><strong>Antihistamines</strong> such as <a href="https://www.nps.org.au/medicines/respiratory-system/cough-and-cold-medicines/for-individuals/cough-and-cold-medicines-active-ingredients/chlorpheniramine-maleate-phenylephrine-hydrochloride">chlorpheniramine</a>, <a href="http://www.nps.org.au/medicines/allergic-disorders/antihistamine-medicines/dexchlorpheniramine-maleate">dexchlorpheniramine</a> or <a href="http://www.nps.org.au/medicines/brain-and-nervous-system/sedatives-and-medicines-for-sleep-problems/doxylamine-succinate">doxylamine</a> may help with allergic symptoms such as sneezing. These medicines work by blocking the effects of histamine in the body. </p>
<p>Antihistamines can cause drowsiness and are often included in “night-time” cold and flu tablets. If your sleep is affected by decongestant tablets, try avoiding the decongestant late in the day or switch to a decongestant nasal spray, rather than taking a tablet containing an antihistamine and a decongestant.</p>
<p>Cold and flu tablets may also contain <strong>cough suppressants</strong> such as <a href="http://www.nps.org.au/medicines/respiratory-system/cough-and-cold-medicines/for-individuals/cough-and-cold-medicines-active-ingredients/dextromethorphan-hydrobromide">dextromethorphan</a>. These medicines are used to relieve symptoms from a dry cough by acting on the “cough centre” in the brain. </p>
<p>Cough suppressants can sometimes cause drowsiness and are best avoided when coughing up mucous (a “wet” cough).</p>
<h2>Which cold and flu product is best for me?</h2>
<p>Think about your main symptoms when selecting a product and read the label carefully. </p>
<p>Avoiding medicines you don’t need will reduce the risk of side effects. A decongestant-only tablet or nasal spray, for instance, may be better than a combination product when your main symptom is a blocked nose. </p>
<p>It’s best not to use more than one cold and flu product at the same time without checking with your doctor or pharmacist.</p>
<p>Cold and flu products may not be suitable for some people. Always ask your pharmacist for advice if you have pre-existing medical conditions, or you are pregnant or breastfeeding. </p>
<p>Cold and flu medicines are <a href="http://www.tga.gov.au/behind-news/cough-and-cold-medicines-children-changes">not suitable</a> for children under six years of age and should only be given to children aged six to 11 years after discussion with a doctor or pharmacist.</p>
<h2>The fine print</h2>
<p>Cold and flu products are intended for short-term use only. <a href="https://www.nps.org.au/__data/assets/pdf_file/0004/211567/NPS-Cold-and-Flu-Brochure-May-2014.pdf">See your doctor</a> if your symptoms get worse.</p>
<hr>
<p><em>If you have specific questions about cold and flu tablets, ask your pharmacist for further advice, check the <a href="http://www.nps.org.au/topics/how-to-be-medicinewise/finding-information-on-medicines/what-is-consumer-medicine-information">consumer medicines information</a> (CMI) for the specific product, or call <a href="http://www.nps.org.au/contact-us/medicines-line">Medicines Line</a> on 1300 633 424.</em></p><img src="https://counter.theconversation.com/content/36481/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Sluggett has received funding from the Australian Commission on Safety and Quality in Health Care, and works on a national quality improvement program funded by the Australian Government Department of Veterans' Affairs. Janet is a member of a national working group that makes recommendations about the advisory labels affixed to medicines when they are dispensed.</span></em></p>Pharmacies have aisles full of cold and flu tablets. But which product is the best one for you? And will it really help you feel better?Janet Sluggett, Research Fellow: Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute for Health Research, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/347452015-04-30T05:09:59Z2015-04-30T05:09:59ZWhy making codeine products prescription-only is a good idea<figure><img src="https://images.theconversation.com/files/79730/original/image-20150429-23400-d5dyrm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Codeine-containing painkillers may soon no longer be available over the counter in Australian pharmacies. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/hippie/2357792973">Philippa Willitts/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Australia’s drug regulator is looking into <a href="http://www.smh.com.au/national/health/overthecounter-sale-of-codeine-pain-killers-such-as-nurofen-plus-and-panadeine-may-end-20150425-1mt2fl.html">reclassifying about 150 codeine-based drugs as prescription-only</a>. This means they will no longer be available for purchase over the pharmacy counter. The easy and widespread availability of these opioid medicines is causing a substantial level of harm. </p>
<p>Currently, lower-strength painkillers such as paracetamol, ibuprofen and aspirin can be bought almost anywhere, while drugs such as Nurofen Plus or Panadeine Forte can be bought only at pharmacies. These combine codeine with paracetamol or ibuprofen in order to tackle more severe pain.</p>
<p>These drugs may soon join the next, stronger level of painkillers, which require a doctor’s prescription because they pose an increased risk of side effects or addiction. </p>
<h2>A stand-out case</h2>
<p>Codeine’s potential for addiction is well documented. There have been <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988526/">calls from physicians</a> in Australia, New Zealand and Canada to withdraw it from the market altogether. </p>
<p>Although the drug’s side effects can range from mild to more serious, it’s often the accompanying paracetamol or ibuprofen that’s more harmful to the internal organs. Potentially life-threatening complications include internal bleeding and kidney and liver failure. This increased risk of toxicity combined with the addictive effects of codeine is what makes these drugs so problematic.</p>
<p>Australia is unlike many other countries in allowing the purchase of codeine-based narcotics without a prescription. In some countries, such as the Maldives and the United Arab Emirates, possessing a codeine-based drug without an authenticated doctor’s prescription can potentially lead to deportation or imprisonment. In Greece, any amount of codeine is illegal. Travellers can only bring it into the country if they have a valid prescription.</p>
<p>Codeine-based painkillers are only supposed to be supplied by Australian pharmacists following assessment of need and risk of addiction. But patient interaction is often very basic and retail pharmacy is competitive, so <a href="http://atdc.org.au/wp-content/uploads/2011/02/OTC_CODEINE_REPORT.pdf">punters are almost never refused sales</a>.</p>
<p>What’s more, some pharmacists are unsure how to assess if a person is seeking drugs beyond their therapeutic need, or how to manage “codeine tantrums” when sale is refused. Some Australians take “<a href="http://www.pharmacynews.com.au/news/latest-news/codeine-road-trips-demand-project-stop">codeine road trips</a>” – travelling long distances to visit multiple pharmacies and purchase large quantities of these drugs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=252&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=252&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=252&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=317&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=317&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79729/original/image-20150429-23379-b9p891.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=317&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some Australians take ‘codeine road trips’ to visit many pharmacies and purchase large quantities of codeine-containing drugs.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/chrisfp/12777458553">Chris/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Sensible use</h2>
<p>Codeine by itself is a weak pain reliever. Most of its painkilling effect is produced when some of the drug is broken down or metabolised by the liver into morphine. But there’s <a href="http://www.australianprescriber.com/magazine/34/5/133/5">quite a lot of variability</a> in how different people metabolise codeine, which can significantly influence how much morphine they produce.</p>
<p>Some <a href="http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Codeine_containing_medicinal_products/Recommendation_provided_by_Pharmacovigilance_Risk_Assessment_Committee/WC500147065.pdf">people are hypermetabolisers</a>, putting them at risk of serious and sometimes life-threatening toxicity. Others might get negligible amounts. But since codeine-combination painkillers are available without a prescription, there’s a common misbelief in the community that they’re inherently safe.</p>
<p>For most people, no more than six tablets in 24 hours is still safe if they don’t use the drug for any longer than three days. But <a href="http://www.abc.net.au/triplej/hack/stories/s3944204.htm">others become addicted</a> and use more than a whole pack each day.</p>
<p>Most people just trying to ease their pain are often <a href="http://www.ncbi.nlm.nih.gov/pubmed/21534912">unaware of the risk of addiction</a> and possible life-threatening effects of codeine-combination painkillers.</p>
<p>One of the <a href="https://www.mja.com.au/journal/2010/193/5/serious-morbidity-associated-misuse-over-counter-codeine-ibuprofen-analgesics">first Australian studies</a> that showed the serious effects of codeine-based narcotics looked at patients presenting for opioid dependence in nine hospitals across Melbourne and rural Victoria between 2005 and 2008. It showed that 27 Australians had to go on opioid-replacement therapy, usually reserved for heroin addicts, just to get off codeine. </p>
<p>Seven years later, many more Australians have <a href="http://www.smh.com.au/nsw/doctors-and-pharmacists-call-for-tighter-controls-on-codeine-due-to-rise-in-addiction-20140913-10g0um.html">sought treatment for addiction or serious injury</a> as a result of these painkillers. Making codeine-based painkillers prescription-only will help put a stop to this preventable but lethal problem.</p>
<p>The take-home message here is that just because codeine-combination painkillers are still available without prescription doesn’t mean they’re safe! People must use them strictly as directed and be aware of their potential addictive and toxic effects. </p>
<p>These drugs should be used for the shortest time possible at the lowest dose. Use should not be continued if they don’t seem to be working. </p>
<p>The change will not disadvantage people in acute pain because newer medicines that combine <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010210.pub2/abstract">paracetamol with ibuprofen provide better pain relief</a> - without the risk of codeine addiction and its dire consequences.</p><img src="https://counter.theconversation.com/content/34745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Pilgrim does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australia’s drug regulator is looking into reclassifying codeine-based drugs as prescription-only. This is a good idea because the easy availability of these pinkillers is causing substantial harm.Jennifer Pilgrim, Postdoctoral researcher in Forensic Toxicology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/395762015-04-01T04:30:28Z2015-04-01T04:30:28ZUsing paracetamol for low back pain does more harm than good<figure><img src="https://images.theconversation.com/files/76720/original/image-20150401-1249-63rkta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Low back pain is one of the leading causes of disability in the world.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/chaparral/4038478934">Kendra/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Around a quarter of the world’s population is affected by low back pain, one of the ten leading causes of disability globally. But the painkiller routinely prescribed to most of these people may not only be unhelpful, it may actually be causing harm.</p>
<p>Apart from the obvious discomfort it causes, low back pain is among the main reasons for work absenteeism. <a href="http://www.who.int/medicines/areas/priority_medicines/en/">According to the World Health Organization</a>, it’s responsible for more than 100 million workdays lost per year in the United Kingdom and the loss of 149 million workdays or US$200 billion a year in the United States. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18928439">In Australia</a>, it’s the main medical condition keeping older people away from the workforce, and it’s associated with treatment costs of almost A$5 billion every year.</p>
<h2>On the wrong track</h2>
<p>Approximately nine out of ten people visiting a doctor because of low back pain don’t have a serious problem with their spine, such as a fracture, for instance, or any involvement of nerve tissue. For these patients, back pain is likely the result of strain or stress to lumbar spinal structures, including the muscles, ligaments or discs or a combination of all three. </p>
<p>Although it’s not possible to pinpoint the exact cause of low back pain in most people, <a href="http://www.bmj.com/content/350/bmj.h1225">we do know</a> that the pain will resolve within six weeks for more than six out of ten. <a href="http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp94.pdf">Clinical practice guidelines</a>, which doctors use to help treat their patients, recommend that people suffering from low back pain should, in the first instance, be given a prescription for painkillers, such as paracetamol. </p>
<p>But <a href="http://www.bmj.com/content/350/bmj.h1225">research my colleagues and I published today in the BMJ</a> shows paracetamol in particular is not only ineffective for treating low back pain, it may actually lead to toxicity in the liver when used. Not surprisingly, we think it’s time to review current recommendations for managing low back pain. </p>
<p>The study we published was a review of 13 trials published around the world, and reported on the effects of paracetamol based on more than 5,000 patients. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/76723/original/image-20150401-1240-zwuohm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prolonged use of paracetamol causes harm.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/mdales/5439371123">Michael Dales/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Significantly, the research highlights that a greater proportion of people being treated with paracetamol will have abnormal liver function tests, which might indicate liver toxicity. We also found paracetamol was neither effective nor safe for the treatment of osteoarthritis.</p>
<h2>Better ways</h2>
<p>Our findings are published <a href="http://ard.bmj.com/content/early/2015/02/09/annrheumdis-2014-206914.full.pdf+html?sid=6d43da09-6952-4eea-8f39-ae5c9dad29f3">weeks after another study confirmed</a> an association between paracetamol use and increased risk of premature death, and cardiovascular, gastrointestinal and kidney disease. This link became apparent after four weeks of using the painkiller, and after 22 days of use, the risk of hypertension doubled.</p>
<p>This research also suggests reviewing the recommendations about prescribing paracetamol. </p>
<p>We do have other treatments for low back pain that are safe and effective. We know, for instance, that <a href="http://www.cochrane.org/CD007612/BACK_advice-to-rest-in-bed-versus-advice-to-stay-active-for-acute-low-back-pain-and-sciatica">reassuring people with a new episode of low back pain</a> of the benign nature of their condition, and impressing the importance of keeping up with normal daily activities will speed their recovery. </p>
<p>People with low back pain should discuss safer, more effective non-pharmacological options, such as physiotherapy, with their doctors. For those who fail to recover within six weeks, treatment options might need to include long-term lifestyle changes, including exercise and weight loss. They may also consider changing how they deal with the pain they’re feeling by focusing more on what they can do, rather than on what they can’t. </p>
<p>So while there might not be a quick fix for low back pain, there are ways to help people get better. Being more active and keeping your weight in a healthy range are two things that will help and they are also recommended for other chronic non-communicable diseases. These measures have excellent impacts on general well-being as well.</p><img src="https://counter.theconversation.com/content/39576/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Manuela L Ferreira receives funding from Sydney Medical Foundation and Arthritis Australia. These are in no way related to the work discussed in this piece. </span></em></p>People seeing a doctor for low back pain are often told to take paracetamol. But a study published today shows the drug is ineffective for the condition and its prolonged use has harmful side effects.Manuela Ferreira, Associate Professor in Medicine, The University of Sydney, Sydney Medical Foundation Fellow & Senior Research Fellow, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/295722014-07-24T04:44:16Z2014-07-24T04:44:16ZPut down the paracetamol, it’s just a placebo for low back pain<figure><img src="https://images.theconversation.com/files/54741/original/xy4dhrr6-1406170330.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Up to 90% of the population will experience lower back pain over their life time; around 25% will have it on any given day.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/yamagatacamille/5240315494">Flickr: Christian Bucad</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>People with lower back pain are usually told to take some paracetamol for relief. But <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60805-9/abstract">research published today</a> shows that this almost universal advice is misguided.</p>
<p>Up to 90% of the population will experience lower back pain over their life time; around 25% will have it on any given day. </p>
<p>“Non-specific low back pain” - so called because it’s not caused by a serious condition, such as a fracture, cancer or infection - accounts for around 95% of all cases. It includes people with so-called slipped discs, spinal misalignment, facet joint problems, spinal instability and, in some cases, back pain radiating into the leg.</p>
<p>In <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60805-9/abstract">research published in The Lancet today</a>, we show that paracetamol doesn’t speed recovery, or reduce pain for people with lower back pain any more than a placebo does. Our results raise questions about the value of pain medications for managing low back pain.</p>
<h2>What we did</h2>
<p>Paracetamol is universally recommended in treatment guidelines for treating non-specific low back pain. But this recommendation isn’t actually based on direct evidence of benefit; it’s just been compared to other medicines and is preferred because it’s a safe pain killer with few, if any, side effects. And because it was assumed to help.</p>
<p>In a study involving 1,643 people with lower back pain, we directly tested paracetamol against placebo and also compared two ways of taking it - regularly and intermittently. Many people do the latter, following advice of taking paracetamol “as needed”. We thought they would need to take it regularly to benefit. </p>
<p>All our subjects took their respective medicine for up to four weeks. And all of them were also given general advice and reassured that they would recover. </p>
<p>We followed them all up for three months, and found both methods of taking paracetamol (regularly and intermittently) were completely ineffective. What’s more, we found that people did just as well taking a sugar pill (our placebo) as taking paracetamol for lower back pain.</p>
<p>It’s clearly time to reconsider the recommendation for taking this drug and more generally, the contribution of pain-relief medicines in helping people manage acute lower back pain.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/54731/original/5c22f738-1406169488.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Paracetamol is universally suggested in treatment guidelines for treating non-specific lower back pain, but there is no direct evidence to support this recommendation.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/arleach84/7727106004/in/photostream/">Flickr: Leach84</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<h2>What this means</h2>
<p>So, what do our results mean for managing lower back pain, and what, if anything, should people do instead of taking paracetamol?</p>
<p>First, if you haven’t started any treatment and are deciding what to do about about your lower back pain, our study shows paracetamol will neither help you recover quicker or dull your pain. So, there’s no point in taking it and no justification for your doctor to recommend it. </p>
<p>Second, if you are taking paracetamol for acute lower back pain and feel it’s helping, you should continue to take it. But if your pain doesn’t improve after a week or two, we suggest you see a doctor about it.</p>
<p>What our results don’t suggest is that it’s better to take other pain killers instead of paracetamol. It’s important to remember that the purpose of taking pain-relief medicine for lower back pain is so people can stay as active as possible. If you take very strong pain medication, it can make you sleepy and drowsy, and it could limit what you’re able to do.</p>
<h2>You will recover</h2>
<p>What’s more, we actually have a very poor understanding of the benefits and harms of most of the pain medicines commonly used for acute back pain. </p>
<p>Two key examples are non-steroidal anti-inflammatory drugs and opioid analgesics. We simply don’t have large, well-conducted trials (like our study) that have tested these medicines so people with lower back pain and their doctors can make informed decisions about the balance of benefits and harms. </p>
<p>It’s not all bad news though. People with low back pain are usually told to maintain normal activity as much as possible, avoid bed rest and reassured that they’re likely to recover. And that’s exactly what happened in our study. </p>
<p>We provided this advice and reassurance to all our subjects and the vast majority of them recovered relatively quickly (about half recovered within two and a half weeks). These key messages need to be reinforced.</p>
<p>So, don’t be concerned if your doctor doesn’t prescribe medication for your back pain. It’s best to focus on the advice you’re given rather than a script for medication.</p><img src="https://counter.theconversation.com/content/29572/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Williams received funding from the NHMRC.</span></em></p><p class="fine-print"><em><span>Jane Latimer receives funding from The Australian Research Council (ARC) and The National Health and Medical Research Council (NHMRC). Industry partner GSK provided part funding for the paracetamol study.</span></em></p>People with lower back pain are usually told to take some paracetamol for relief. But research published today shows that this almost universal advice is misguided. Up to 90% of the population will experience…Christopher Williams, Research Fellow at Hunter Medical Research Institute &, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/248622014-03-27T06:12:51Z2014-03-27T06:12:51ZNew paracetamol overdose treatment costs millions but doesn’t save many lives<figure><img src="https://images.theconversation.com/files/44808/original/85fdgrfs-1395849634.jpg?ixlib=rb-1.1.0&rect=0%2C46%2C1000%2C684&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Underestimating paracetamol in remedies.</span> <span class="attribution"><span class="source">Pills by Shutterstock</span></span></figcaption></figure><p>Strict guidelines that were introduced 18 months ago following the death of a young woman have transformed the way paracetamol overdoses are managed, <a href="http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON178225">including the introduction</a> of the lowest threshold for antidote treatment anywhere in the world.</p>
<p>But at what cost? We carried out <a href="http://onlinelibrary.wiley.com/doi/10.1111/bcp.12362/abstract">the first analysis</a> of the impact of these changes and our study, published in the British Journal of Clinical Pharmacology, suggests that for every life saved, another 31,000 patients will be unnecessarily treated – and put at risk of serious side effects – at a cost of £17.4m.</p>
<p>Paracetamol is the most common over-the-counter painkiller bought in the UK and around 30m prescriptions are issued every year. It is relatively easy to combine drugs for different ailments – for example cold cures and headache tablets – and overdose accidentally, and while the vast majority of overdoses are associated with self-harm, a proportion of severe paracetamol poisonings result from people taking too much from different marketed products. </p>
<p>Overdose from paracetamol, accidental or otherwise, brings <a href="http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON178225">around 90,000</a> people a year into accident and emergency units in the UK each year and about a half of these will be admitted to hospital. This accounts for about a third of all hospital admissions due to drug overdoses.</p>
<p>Early intervention is vital to avoid death and permanent liver damage – about 95% of deaths from overdose happen because patients present too late to be treated. Many people wrongly believe that paracetamol causes you to feel sleepy, and so often think that they haven’t overdosed because they feel awake. </p>
<p>But overall, the survival rate from overdose over the past 40 years has been high because of a drug called acetylcysteine, which is given through a drip over 21 hours. As the antidote’s effectiveness is reduced the longer you wait after overdose, time is critical. Sadly sometimes treatment doesn’t come soon enough and patients die. </p>
<h2>Making changes</h2>
<p>Any death, particularly of a young person, is a tragedy, and some have suggested that every paracetamol overdose patient should be treated with the antidote. But while acetylcysteine is very effective, it can have serious side effects, particularly vomiting and severe allergic reactions. These side effects are far more common in patients with lower blood paracetamol, and therefore at lowest risk of death or liver damage.</p>
<p>Doctors used to assess whether to treat patients with the antidote based on risk factors such as history of alcohol use, diet, how much paracetamol was in the patient’s blood and the time that had elapsed since the drug was ingested. </p>
<p>Acting on advice, the MHRA, the UK medicines regulator, changed their guidance in 2012. Risk assessments were abandoned and all patients with a concentration of paracetamol in their blood above a certain threshold, or those who have ingested more than a specific amount, receive treatment. Both of these thresholds were lowered to below anywhere else in the world. The MHRA estimated the changes would save a life about every two years.</p>
<h2>An overreaction</h2>
<p>Yet unlike new drugs, these treatment policy changes didn’t undergo scrutiny by the National Institute for Health and Care Excellence, the NHS watchdog. And interestingly, the MHRA doesn’t have to consider the cost implications of their decisions. Our analysis, based on data from three large acute hospitals before and after changes were implemented, suggests that £17.4m will be spent every two years to save a life. </p>
<p>Clearly these guidelines will be placing a tremendous burden on already strained A&E resources. And in a financially stretched health service it seems pretty clear that the MHRA overreacted on this occasion.</p>
<p>Tackling the challenge of late presentation and changing the way products that contain paracetamol are labelled could potentially save many lives.</p>
<p>In addition, new research suggests there are now better markers than paracetamol blood level alone to predict who needs antidote therapy. These now need wider testing. And based on what our study found, there now clearly needs to be a review of how paracetamol poisoning is managed and a more effective way found to save lives with less health risks and cost. </p><img src="https://counter.theconversation.com/content/24862/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Bateman has received funding from the Chief Scientist Office of the Scottish Government for research on paracetamol overdose and its management.
He has no other conflicts to declare
</span></em></p>Strict guidelines that were introduced 18 months ago following the death of a young woman have transformed the way paracetamol overdoses are managed, including the introduction of the lowest threshold…Nick Bateman, Professor of Clinical Toxicology, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/207862013-11-27T01:01:40Z2013-11-27T01:01:40ZSalt in soluble drugs increases risk of heart attacks and strokes<figure><img src="https://images.theconversation.com/files/36226/original/njt5qbzz-1385512945.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Soluble versions of common medications such as aspirin may increase risk of cardiovascular problems. </span> <span class="attribution"><span class="source">Pierre Guinoiseau</span></span></figcaption></figure><p>The salt found in common effervescent and soluble drugs may be exposing consumers to an increased risk of heart problems, according to <a href="http://www.bmj.com/content/347/bmj.f6954">a study published in the BMJ</a> today. </p>
<p>The study found it’s possible to exceeded the recommended daily intake of salt of 2.4 grams just by consuming the maximum daily dose of some drugs.</p>
<p>Associate Professor in Pharmacology at Murdoch University, Ian Mullaney said salt is an essential ingredient in modern medicines. </p>
<p>“The drugs have properties that make them insoluble or don’t combine very well, and salt has been used since in the early days of medicine manufacture just to combine the ingredients of the medicine to make them soluble,” he said. </p>
<p>But <a href="https://theconversation.com/sodium-study-should-be-taken-with-a-large-pinch-of-salt-1051">excessive salt consumption</a> is harmful to heart health.</p>
<p>Professor of preventative cardiology & internal medicine at Griffith University, Ian Hamilton-Craig said excessive salt intake could raise blood pressure, which increases the risk of heart disease and stroke.</p>
<p>While tablets that easily dissolve in water are a convenient option for many consumers their high salt content is a hidden drawback.</p>
<p>The study authors tracked over 1.2 million people for 13 years. They found people taking these medicines had a 16% increased risk of heart attack, stroke or vascular death than those taking the non-sodium versions of the same drugs. </p>
<p>People taking these high-salt medicines were also seven times more likely to develop high blood pressure, a <a href="http://www.heartfoundation.org.au/your-heart/cardiovascular-conditions/Pages/blood-pressure.aspx">condition</a> affecting over 3.5 million Australians. </p>
<p>Mullaney pointed out that there were low-salt and high-salt varieties for common medications, so people concerned about their health had a choice. </p>
<p>“This is especially important for people with high blood pressure or heart failure, for whom low-salt varieties should be chosen,” Hamilton-Craig said.</p>
<p>The study authors have called for drug companies to list the salt content of medicines and for people taking high-salt medications to visit their doctor regularly.</p><img src="https://counter.theconversation.com/content/20786/count.gif" alt="The Conversation" width="1" height="1" />
The salt found in common effervescent and soluble drugs may be exposing consumers to an increased risk of heart problems, according to a study published in the BMJ today. The study found it’s possible…Aneeka Simonis, Editor, The ConversationRachel Worsley, EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/44372011-11-24T03:17:08Z2011-11-24T03:17:08ZNo cure for pain: study links excess paracetamol use to fatal liver damage<figure><img src="https://images.theconversation.com/files/5825/original/2476168474_d803b26ce3_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Life-threatening liver damage can occur without the intention of self harm in desperate patients trying to get some relief for pain.</span> <span class="attribution"><span class="source">Melissa Baldwin</span></span></figcaption></figure><p>Medicines need not only to be effective but also safe. Now a <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2011.04067.x/pdf">Scottish study</a> has shown that paracetamol, perhaps the most commonly consumed painkiller in the country, could lead to death if taken in large doses over a period of time.</p>
<p>In the last couple of days, we’ve also heard other adverse information about widely used painkillers, which raises concerns about the dwindling pool of available medicines for pain. And now it seems patients being led to apparently safer alternatives may be risking their lives.</p>
<p>Although the number of individual pain relieving medications on the market is very large, they all come from only a very small number of drug classes. We have the familiar paracetamol and aspirin, another group called the non-steroidal anti-inflammatory drugs (NSAIDS), opioids and adjuvant drugs, which include antidepressants and anti-epileptics.</p>
<p>Earlier this week, the Australian drug regulator, the <a href="http://www.tga.gov.au/index.htm">Therapeutic Goods Administration</a> (TGA), <a href="http://www.tga.gov.au/newsroom/media-2011-dextropropoxyphene-111122.htm">announced</a> it would be removing four products containing dextropropoxyphene – Capadex, Di-Gesic, Doloxene and Paradex – from the market by March 1. </p>
<p>The withdrawal follows adverse assessments from US and European regulators because of concerns about causing ECG changes, which could lead to cardiac arrest.</p>
<p>However, some years ago, when the availability of such drugs was severely restricted in the United Kingdom, patients flooded back to their doctors because they weren’t able to get comparable relief from other products.</p>
<h2>Painkiller safety issues</h2>
<p>There’s increasing concern over the long-term safety of the opioids. The adverse effects of NSAIDS on the gastrointestinal and cardiovascular systems has been widely reported in the mainstream press. These effects have been the reason for high profile withdrawals, such as that of Merck’s Vioxx.</p>
<p>Aspirin is not used for pain very much given its well-recognised potential to cause ulcers and bleeding the gastrointestinal tract. So doctors like myself frequently advise patients to return to the ubiquitous and everyday paracetamol. At recommended doses paracetamol is remarkably safe although it’s known that even moderate excess can cause fatal hepatotoxicity or overdose death. </p>
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<img alt="" src="https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/5824/original/1093132052_13c3b70693_b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">Dennis Wegner</span></span>
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<p>As many of these overdoses have traditionally been impulsive, major reductions in mortality in the United Kingdom were brought about by the simple step of reducing pack size. </p>
<p>So doctors are familiar with advising patients not to exceed the recommended dose of 8 tablets a day. But an <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2011.04067.x/pdf">article</a> published yesterday in the <a href="http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-2125">British Journal of Clinical Pharmacology</a> has shown that inadvertent “overdoses” from consuming large quantities over a period of time in an attempt to control pain cause also cause life-threatening liver damage.</p>
<h2>Paracetamol study</h2>
<p>The authors of the paper looked at data from a large university-linked referral unit where patients showing probable or suspected paracetamol hepatotoxicity were treated. They compared patients with a typical “single overdose”, with patients who’d taken large doses of paracetamol over a period of a few days and suffered a “staggered overdose”. </p>
<p>The major reason for the single overdose was attempted suicide. But this was only the motive in one-third of the patients who had a staggered overdose. The majority of these people had simply been seeking pain relief. </p>
<p>Somewhat surprisingly, the average total dose in the staggered group (24 grams) was less than that in the single overdose (27 grams). And of greatest concern is that the minimum dose in the staggered group was 10 grams, which is only 20 tablets. </p>
<p>Clearly, the key message here is that life-threatening liver damage can occur without the intention of self harm in desperate patients trying to get some relief for pain. </p>
<h2>Taking care</h2>
<p>Although people recognise that the number of pills they can take at any given time may not be safely increased, they may take the drug at more frequent intervals than recommended, losing track of cumulative dose and unintentionally putting themselves at risk.</p>
<p>Unfortunately, it seems therapeutic options are being reduced by safety concerns – perhaps appropriately – but even the drugs thought to be relatively safe may unintentionally be posing a risk. </p>
<p>The key to preventing the problem of staggered paracetamol overdose is education and we are fortunate in Australia to have an organisation such as <a href="http://www.nps.org.au">National Prescribing Service (NPS)</a>, which is best placed to do this. </p>
<p>We also need education about how medicines may not produce adequate analgesia and that other approaches are needed. Ideally, a mixed approach will enable doctors to help patients manage their pain in the face of the shrinking number of safe therapeutic options.</p><img src="https://counter.theconversation.com/content/4437/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rolan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medicines need not only to be effective but also safe. Now a Scottish study has shown that paracetamol, perhaps the most commonly consumed painkiller in the country, could lead to death if taken in large…Paul Rolan, Professor of Clinical Pharmacology, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.