High Capacity Tylenol Bottles Must Go!!

[BaiHu]

I really wish people wouldn't send me stupid sh*t like this, b/c then I feel compelled to warn you all of this stupid sh*t I've just learned.


We need to make it harder to buy pills in bottles of 50 or 100 that can be easily dumped out and swallowed. We should not be selling big bottles of Tylenol and other drugs that are typically implicated in overdoses, like prescription painkillers and Valium-type drugs, called benzodiazepines. Pills should be packaged in blister packs of 16 or 25. Anyone who wanted 50 would have to buy numerous blister packages and sit down and push out the pills one by one. Turns out you really, really have to want to commit suicide to push out 50 pills. And most people are not that committed.

http://opinionator.blogs.nytimes.com/2013/06/02/a-simple-way-to-reduce-suicides/?hp

1525

[archangel]

Never mind the colossal inconvenience to, you know, legitimate users.

There's an OTC medication that I take every day. At one point I had to get it in a blister pack. Not just the "push and it pops out the back" kind, but one with a stiff backing that you have peel off first by pulling on the almost microscopic flap in the corner (and hope that the flap doesn't just tear off leaving you with no way to open the stupid thing). I don't think I have to tell you what a mother kittening pain in the kitten that was.

[will_1400]

And when people decide to dive in front of subway trains or jump from the Brooklyn and George Washington bridges, then what? Wait, this is NYC I'm talking about. I'm surprised the average person in that city even remembers to breathe.

[John Ralston]

Even more disturbing than the piece itself are the comments that agree with him. Those bottles are not responsible for accidental deaths either...who accidentally swallows 20 Tylenol? If I wanted to kill myself the size of the bottle would have very little to do with it, as I can leap from one of a million rooftops and get the job done.

[Chuck Haggard]

A few days ago we had a gal walk right in front of a freight train.

That left a mark.

I supposed we need to shut down the rail roads now?

[Kyle Reese]

A few days ago we had a gal walk right in front of a freight train.

That left a mark.

I supposed we need to shut down the rail roads now?

No, just impose a 7 day cooling off period for ticket purchasers, and eliminate the ticket loophole.

[Nephrology]

To be fair, acetominophen results in a pretty colossal level of acute liver failure (literally the highest in the united states) and associated morbidity/mortality is incredibly taxing on American medical services. Additionally, the therapeutic index of acetominophen is really quite slim - that means, the dose required to have a clinical effect (analgesia, or relief from pain) is not very far from the dose required to cause cirrhosis. Additionally, it is the over the counter medication that is responsible for the most accidental deaths in the United States per annum. See below:

http://www.ncbi.nlm.nih.gov/pubmed/23055123

Frankly it is a substance that most people underestimate and in my opinion it is a little bit silly to be upset about having to use a blister pack. I think the fact that we are discussing this drug so flippantly underlies the misunderstanding of just exactly how serious acetominophen overdose can be.

[Nephrology]

Even more disturbing than the piece itself are the comments that agree with him. Those bottles are not responsible for accidental deaths either...who accidentally swallows 20 Tylenol? If I wanted to kill myself the size of the bottle would have very little to do with it, as I can leap from one of a million rooftops and get the job done.

You do not need to take 20 tylenol to induce hepatoxicity. When you exceed 4g/day you begin to experience a dose dependent toxicity. Additionally, depending on a number of factors, a dose that may leave no lasting effects on a given individual might be sufficient to induce permanent damage from the liver toxicity that follows. Please see below for further reading if you are curious.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3618971/

[John Ralston]

You do not need to take 20 tylenol to induce hepatoxicity. When you exceed 4g/day you begin to experience a dose dependent toxicity. Additionally, depending on a number of factors, a dose that may leave no lasting effects on a given individual might be sufficient to induce permanent damage from the liver toxicity that follows. Please see below for further reading if you are curious.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3618971/

I am sure you are correct, but I highly doubt a blister pack is going to change that.

[ToddG]

I am sure you are correct, but I highly doubt a blister pack is going to change that.

Really? Let's take a step back from the implied comparison to firearms feeding devices for a second.

How often have you seen someone tip a bottle of <insert OTC drug here> into his hand and pop however many came out? Two, three, five, whatever. He takes a small handful of pills.

Or the guy who doesn't read the label and just takes however many he thinks is "good."

Now contrast that with someone who is handed a sheet of ten 2-pill blister packs. How many of those pills is he probably going to take? Two. Sure he could take more, but then he's making a pretty conscious decision to overdose on purpose.

Do I think blister packs will prevent suicides? No. That's utterly stupid. But will they probably reduce accidental, inadvertent, and/or ignorant overdosing? Yeah, I do.

As Nephrology said, most people simply aren't aware of the potential issues involved with overdosing OTC drugs. As someone who can't take NSAIDs and is basically limited to Tylenol for OTC pain medication, its potential for liver damage is something I pay a lot of attention to.

[Corlissimo]

A few days ago we had a gal walk right in front of a freight train.

That left a mark.

I supposed we need to shut down the rail roads now?

Not all the railroads, just the "high capacity" ones, you know... the ones with more than seven cars.


~ Typos brought to you by my laziness & in attention to detail.

[LHS]

Fair enough, but if we're really pushing for personal responsibility, it's incumbent upon the consumer to read the bloody warning labels. If they have to put really big labels on there saying "DO NOT EXCEED RECOMMENDED DOSE OR YOU MAY VERY WELL DIE SCREAMING FROM IRREVERSIBLE LIVER FAILURE", then so be it. At some point people have to be allowed to be their own boss.


Really? Let's take a step back from the implied comparison to firearms feeding devices for a second.

How often have you seen someone tip a bottle of <insert OTC drug here> into his hand and pop however many came out? Two, three, five, whatever. He takes a small handful of pills.

Or the guy who doesn't read the label and just takes however many he thinks is "good."

Now contrast that with someone who is handed a sheet of ten 2-pill blister packs. How many of those pills is he probably going to take? Two. Sure he could take more, but then he's making a pretty conscious decision to overdose on purpose.

Do I think blister packs will prevent suicides? No. That's utterly stupid. But will they probably reduce accidental, inadvertent, and/or ignorant overdosing? Yeah, I do.

As Nephrology said, most people simply aren't aware of the potential issues involved with overdosing OTC drugs. As someone who can't take NSAIDs and is basically limited to Tylenol for OTC pain medication, its potential for liver damage is something I pay a lot of attention to.

[John Ralston]

Fair enough, but if we're really pushing for personal responsibility, it's incumbent upon the consumer to read the bloody warning labels. If they have to put really big labels on there saying "DO NOT EXCEED RECOMMENDED DOSE OR YOU MAY VERY WELL DIE SCREAMING FROM IRREVERSIBLE LIVER FAILURE", then so be it. At some point people have to be allowed to be their own boss.


Agreed - and the point I was really trying to make. People do all kinds of things that have potentially life ending consequences, but they are free to do that. I know a guy that puts a loaded gun down the front of his pants - just sayin...

[hufnagel]

Really? Let's take a step back from the implied comparison to firearms feeding devices for a second.

How often have you seen someone tip a bottle of <insert OTC drug here> into his hand and pop however many came out? Two, three, five, whatever. He takes a small handful of pills.

Or the guy who doesn't read the label and just takes however many he thinks is "good."


High speed, low drag, low information pill popper.

If such a person can't be bothered to take a couple seconds and read the instructions on the proper use/consumption of a DRUG, then the consequences are deserved.

[Nephrology]

Really? Let's take a step back from the implied comparison to firearms feeding devices for a second.

How often have you seen someone tip a bottle of <insert OTC drug here> into his hand and pop however many came out? Two, three, five, whatever. He takes a small handful of pills.

Or the guy who doesn't read the label and just takes however many he thinks is "good."

Now contrast that with someone who is handed a sheet of ten 2-pill blister packs. How many of those pills is he probably going to take? Two. Sure he could take more, but then he's making a pretty conscious decision to overdose on purpose.

Do I think blister packs will prevent suicides? No. That's utterly stupid. But will they probably reduce accidental, inadvertent, and/or ignorant overdosing? Yeah, I do.

As Nephrology said, most people simply aren't aware of the potential issues involved with overdosing OTC drugs. As someone who can't take NSAIDs and is basically limited to Tylenol for OTC pain medication, its potential for liver damage is something I pay a lot of attention to.

I agree with the above. Those unfortunately stupid enough to choose the incredibly prolonged and painful method of suicide by Tylenol overdose are probably not going to be deterred by a blister pack .Those who are simply taking a few pills to ease a back ache, however, might be at least made to pause (or to have their behavior guided by the packaging) if it is in a 2x10 blister pack. It is a pretty well established psychological trick that is exploited by the packaging to keep individuals from accidentally consuming more than they are intended to.

This is even a bigger concern in prescription medications in which acetominophen is mixed with an opiate narcotic like oxycodone or hydrocodone. People prescribed these medications, especially chronically, often take increasing dosages over time to combat their rise in tolerance to the narcotic. The acetominophen remains no less deadly. Furthermore, drugs known to cloud judgement and impair memory formation like opiates often result in accidental double-dosing from a traditional bottle. Blister packs serve as a visual reminder of how many of the tablets the patient has taken.



High speed, low drag, low information pill popper.

If such a person can't be bothered to take a couple seconds and read the instructions on the proper use/consumption of a DRUG, then the consequences are deserved.

Are you really going to take the notion of individual liberty to this ridiculous extreme? I am no Hollywood liberal, but I still have an issue with this immediate application of the concept of liberty to a basic safety measure.

There is no infringement upon your ability to take Tylenol if it is sold in blister packs. Take 2, 20, 200 - whatever floats your boat (or, scars your liver, po-tay-to,po-tah-to). The only difference is a blister pack. Given that a single dose maximum is advised at 1g, this is ~3 regular strength (350mg APAP) or 2 extra strength (500mg APAP) tablets. So a pretty minimal effort is required to get at the recommended dosage. Thus for a responsible individual no harm, no foul. For those who might accidentally take too many - those in chronic pain, those with impaired mental faculties, children, etc - there is a small but important barrier to their instant access to an entire package's worth of the drug. There is also a visual indicator of how much of the package has been consumed which can be useful for those in pain and on other drugs like narcotics or anxiolytics/muscle relaxants which are often prescribed in instances in which an NSAID might be indicated as well. I am curious as to why you see this change to be so offensive to individual liberties. Unlike the second amendment, there is no constitutional right to blister pack-less medications, as far as I can tell....

Additionally, I think you highly overestimate the ability of the average individual to judge the deadliness of tylenol. Like I said, a strong but typical effective single dose is ~1g. It has a ~2 hour half life, so within two to 3 hours you have already excreted most of an active dose. In an average waking 14 hour day, that means you can easily hit the maximum per diem dosage. Assume you increase the dose by just 1 tylenol per dosage -350mg- you are now at just over 5 grams of APAP, a dose sufficient to induce hepatotoxic effects. Add an extra strength, 500mg, and now we're at 2 grams on top of the 4 gram maximum. Depending on the individual, that could be sufficient to induce liver damage.

As much as we'd all like to pretend we are all nobel prize winners immune from making mistakes, let's be realistic here. How many of you have drank to the point of a hangover? Any hands? I am sure none of you started the night with the hopes that you'd spend the next morning throwing up for hours on end. But that said, doesn't everyone know that beer, wine, and spirits cause hangovers? So why did you get to that point? Probably because you weren't thinking. This is a problem intrinsic to the human condition. Unlike a hangover, however, APAP (Tylenol) toxicity is permanent, incredibly terrible, and costs the taxpayer and/or hospital system a crapload of money every year. Unlike alcohol, you can't tell when you've had too much - it's easy to swallow 6-8 without thinking, and the effects aren't noticed until it's too late. I don't think it's a big sacrifice to use safety packaging, guys. This is a legitimate epidemiological problem with a legitimate epidemiological solution supported by lots and lots of case studies. Not some thumb sucking liberal's safety blanket, but a legitimate medical concern.

PS - ToddG - I too am restricted to Tylenol for OTC pain control, for the same reason (and also why I have gotten into this field!). Not sure if your docs told you this, but the other NSAIDs - ibuprofen, aspirin - reduce your glomerular filtration rate, which I imagine is something you are trying hard to preserve. If you ever have any questions about your renal health or just want some good kidney puns, feel free to shoot me a PM.

[Erik]

...or just want some good kidney puns, feel free to shoot me a PM.

Those should be made public. For the children.

[MDS]

I'm not qualified to comment on the blister pack controversy. I'm having a hard time getting worked up about it, when there are so many other regulatory/policy/governmental issues we can work on that are no less clearly broken, and much more urgent.

[Nephrology]

Those should be made public. For the children.

I do a lot of kidneying around. Urine for a treat.

[TGS]

I agree with the above. Those unfortunately stupid enough to choose the incredibly prolonged and painful method of suicide by Tylenol overdose are probably not going to be deterred by a blister pack .Those who are simply taking a few pills to ease a back ache, however, might be at least made to pause (or to have their behavior guided by the packaging) if it is in a 2x10 blister pack. It is a pretty well established psychological trick that is exploited by the packaging to keep individuals from accidentally consuming more than they are intended to.

This is even a bigger concern in prescription medications in which acetominophen is mixed with an opiate narcotic like oxycodone or hydrocodone. People prescribed these medications, especially chronically, often take increasing dosages over time to combat their rise in tolerance to the narcotic. The acetominophen remains no less deadly. Furthermore, drugs known to cloud judgement and impair memory formation like opiates often result in accidental double-dosing from a traditional bottle. Blister packs serve as a visual reminder of how many of the tablets the patient has taken.




Are you really going to take the notion of individual liberty to this ridiculous extreme? I am no Hollywood liberal, but I still have an issue with this immediate application of the concept of liberty to a basic safety measure.

There is no infringement upon your ability to take Tylenol if it is sold in blister packs. Take 2, 20, 200 - whatever floats your boat (or, scars your liver, po-tay-to,po-tah-to). The only difference is a blister pack. Given that a single dose maximum is advised at 1g, this is ~3 regular strength (350mg APAP) or 2 extra strength (500mg APAP) tablets. So a pretty minimal effort is required to get at the recommended dosage. Thus for a responsible individual no harm, no foul. For those who might accidentally take too many - those in chronic pain, those with impaired mental faculties, children, etc - there is a small but important barrier to their instant access to an entire package's worth of the drug. There is also a visual indicator of how much of the package has been consumed which can be useful for those in pain and on other drugs like narcotics or anxiolytics/muscle relaxants which are often prescribed in instances in which an NSAID might be indicated as well. I am curious as to why you see this change to be so offensive to individual liberties. Unlike the second amendment, there is no constitutional right to blister pack-less medications, as far as I can tell....

Additionally, I think you highly overestimate the ability of the average individual to judge the deadliness of tylenol. Like I said, a strong but typical effective single dose is ~1g. It has a ~2 hour half life, so within two to 3 hours you have already excreted most of an active dose. In an average waking 14 hour day, that means you can easily hit the maximum per diem dosage. Assume you increase the dose by just 1 tylenol per dosage -350mg- you are now at just over 5 grams of APAP, a dose sufficient to induce hepatotoxic effects. Add an extra strength, 500mg, and now we're at 2 grams on top of the 4 gram maximum. Depending on the individual, that could be sufficient to induce liver damage.

As much as we'd all like to pretend we are all nobel prize winners immune from making mistakes, let's be realistic here. How many of you have drank to the point of a hangover? Any hands? I am sure none of you started the night with the hopes that you'd spend the next morning throwing up for hours on end. But that said, doesn't everyone know that beer, wine, and spirits cause hangovers? So why did you get to that point? Probably because you weren't thinking. This is a problem intrinsic to the human condition. Unlike a hangover, however, APAP (Tylenol) toxicity is permanent, incredibly terrible, and costs the taxpayer and/or hospital system a crapload of money every year. Unlike alcohol, you can't tell when you've had too much - it's easy to swallow 6-8 without thinking, and the effects aren't noticed until it's too late. I don't think it's a big sacrifice to use safety packaging, guys. This is a legitimate epidemiological problem with a legitimate epidemiological solution supported by lots and lots of case studies. Not some thumb sucking liberal's safety blanket, but a legitimate medical concern.

PS - ToddG - I too am restricted to Tylenol for OTC pain control, for the same reason (and also why I have gotten into this field!). Not sure if your docs told you this, but the other NSAIDs - ibuprofen, aspirin - reduce your glomerular filtration rate, which I imagine is something you are trying hard to preserve. If you ever have any questions about your renal health or just want some good kidney puns, feel free to shoot me a PM.

Nephrology,

I think you make some very valid points. However, I don't think anyone is claiming "protection" from the blister-pack onslaught through constitutional or legal means. Rather, I think, people are slapping their foreheads over the nanny-government, save-me-from-myself way of thinking. The more we legislate away our responsibility, the further down our society falls from being responsible for themselves. The end result is still a society doing stupid shit, and killing themselves anyway (accidentally) through other means, for a net result pretty much the same; blister packs be damned. Darwinism cannot be defeated through legislation, and the mindset that thinks it does will lead our society down a path that many of us do not want to go.

Me personally, I prefer blister packs. They're easier to keep in my various snivel kits, instead of bottles which remain home. I happen to use the meds in my snivel kits more, as I prefer to not cut short my activities due to loose stools, headaches, bee stings, ect. So, in the sense of packaging it's not a big deal to me. What bothers me is more an existential thing, with the mindset thinking we can save ourselves from ourselves....or need corporations or the government to do it for us (which bothers me more).

Thanks for the great info.

[Nephrology]

Nephrology,

I think you make some very valid points. However, I don't think anyone is claiming "protection" from the blister-pack onslaught through constitutional or legal means. Rather, I think, people are slapping their foreheads over the nanny-government, save-me-from-myself way of thinking. The more we legislate away our responsibility, the further down our society falls from being responsible for themselves. The end result is still a society doing stupid shit, and killing themselves anyway (accidentally) through other means, for a net result pretty much the same; blister packs be damned. Darwinism cannot be defeated through legislation, and the mindset that thinks it does will lead our society down a path that many of us do not want to go.

Me personally, I prefer blister packs. They're easier to keep in my various snivel kits, instead of bottles which remain home. I happen to use the meds in my snivel kits more, as I prefer to not cut short my activities due to loose stools, headaches, bee stings, ect. So, in the sense of packaging it's not a big deal to me. What bothers me is more an existential thing, with the mindset thinking we can save ourselves from ourselves....or need corporations or the government to do it for us (which bothers me more).

Thanks for the great info.

Thanks, TGS. I do understand the fear that we are legislating away responsibility, and I do think there are instances in which we go overboard. It is possible that here, too, this might be a case of it. It is probably just my particular vantage point, as I have met patients in both professional and volunteer capacities who have either experienced organ damage or complete organ failure due to APAP overdose. I'll admit, many of them were not the sharpest tools in the shed, and several of them (especially teens) intentionally overdosed as they had no understanding of what their chosen method of suicide would lead to (namely, not instant death, but a very slow and painful physical decline). I'll also confess many of them may not have been any better off had their doses come in blister packs. Still, it is hard for me to see such human suffering and not at least consider some sort of structural intervention.

We design lots of things for the lowest common denominator. In this instance, I merely want to draw attention to the toll that APAP overdoses take. Many earlier posts were fairly flippant about APAP overdoses perhaps because tylenol is so common and most people know to be careful with their dose. Still, of all of the drugs with which I am familiar, tylenol is the one that I have seen to cause the most damage unintentionally. Narcotics, by comparison, are actually fairly difficult to overdose on unless you mix them with alcohol or sedatives. Tylenol is something of a silent danger, and I want to make sure that people understand it is actually a fairly serious drug with fairly serious consequences if it is used improperly, something pretty easy to do.

[Byron]

Frankly [acetominophen] is a substance that most people underestimate and in my opinion it is a little bit silly to be upset about having to use a blister pack. I think the fact that we are discussing this drug so flippantly underlies the misunderstanding of just exactly how serious acetominophen overdose can be.
Years ago, I watched my ex-girlfriend's grandfather die a long, miserable death, ostensibly due to lung cancer. His symptoms, however, seemed to be more extensive than what you might "traditionally" expect from someone with his prognosis.

It wasn't until after his death that his wife mentioned, oh yea, he had been popping Tylenol like Tic Tacs. (For the record, no: I don't know why this wasn't discovered by his doctor. I have no idea how often he was seeing his doc, nor how long he had been abusing Tylenol.)

The old guy was very anti-drug, and therefore didn't want to take any pain meds prescribed by his doctor. Since Tylenol is just an OTC "headache pill" though (not a "drug"), he reasoned that it was a safe alternative. It turned out that his nasty death was ultimately caused by a cascade of organ failures, all rooted in his gross abuse of Tylenol. Had he not been so stubborn about avoiding prescription pain meds, he would have lived longer, and ultimately suffered far less.

I'll never forget seeing him less than 24 hours before his death; what he looked like, what he sounded like, etc.

I'm completely agnostic about the blister pack proposal. I just felt compelled to share a short story that will haunt me forever, and always serve as a solid reminder how deadly "everyday" OTC meds can be.



(On an unrelated note: if I'm going to spend energy getting worked up over OTC restrictions, my main beef would surround pseudoephedrine and the fact that it's harder for me to get than my prescriptions. I'm not even exaggerating for dramatic effect: I mean that I literally jump through more hoops and spend significantly more time trying to purchase a box of Sudafed than I do for "controlled substances.")

[hufnagel]

Are you really going to take the notion of individual liberty to this ridiculous extreme? I am no Hollywood liberal, but I still have an issue with this immediate application of the concept of liberty to a basic safety measure.


I reject your premise of it being rediculous or exteme. Yes, if a person does not possess the baseline mental acuity to take 10 seconds and read the directions on the bottle (which btw I checked, ALL of mine clearly say some variation of "do not take more than X in Y hours", and several explicitly list LIVER FAILURE in the warnings right below the aforementioned X/Y listing) and if they have a medical problem because of THEIR FAILURE to follow simple directions, so be it. I'm am not interested in being the world's nanny. Play stupid games, win stupid prizes.

Any item in excessive concentrations can be deadly. If someone does not wish to take the care needed then so be it.

[LittleLebowski]

Funny how the guy that wrote this article (http://en.wikipedia.org/wiki/Ezekiel_Emanuel) is related to another control freak (http://en.wikipedia.org/wiki/Rahm_Emanuel). Odd, that.

[Nephrology]

I reject your premise of it being rediculous or exteme. Yes, if a person does not possess the baseline mental acuity to take 10 seconds and read the directions on the bottle (which btw I checked, ALL of mine clearly say some variation of "do not take more than X in Y hours", and several explicitly list LIVER FAILURE in the warnings right below the aforementioned X/Y listing) and if they have a medical problem because of THEIR FAILURE to follow simple directions, so be it. I'm am not interested in being the world's nanny. Play stupid games, win stupid prizes.

Any item in excessive concentrations can be deadly. If someone does not wish to take the care needed then so be it.

So you read the user manual for all of the products you purchase? Besides, I don't think anybody was trying to rope you into being the world's nanny. A change of packaging is not going to really require you to do much at all, unless you are in the pharmaceutical industry. Additionally, your objection doesn't apply to those who are of reduced mental capacity - a common side effect of chronic pain, particularly among those taking prescription narcotics for pain control. Chronic pain has been proven repeatedly to induce confusion and memory loss (http://www.ncbi.nlm.nih.gov/pubmed/23707355). If your mind is so addled by pain that you can't remember the last time you took tylenol, is it really a nanny state move to ask that they come in packaging that makes it obvious how much of the package they've ingetsed?

How do you feel about medications that already come in blister packs? (diphenhydramine HCl/Bendryl, etc) Is that something that you find irksome as well? Or, how about the cardboard slips that protect razor blades? Is that nanny state material, too? Fireproof caps on bottles of high molarity ethanol? Safety bags in cars? I am curious as to where you draw the line, I hope you do not take my questions as disrespectful.

Sure, I agree with you in principle, but I am much more interested in the ends than the means. If it means as a nation we admit far fewer patients with ALF, and pocket the savings, I am all for it.

[Corlissimo]

Any item in excessive concentrations can be deadly. If someone does not wish to take the care needed then so be it.

Truth.
I can't get too excited about this issue either, except for the fact that it will likely result in more of the same "common sense" safe guards in other areas. Whose "common sense" will be the benchmark?

The problem I see with creating policies using the "lowest common denominator" approach is that the lowest common denominator keeps getting lower. Ever seen "Idiocracy"? It used to just be a silly, stupid movie. I fear it really was a scary, prophetic documentary.

[jetfire]

As someone who can't take NSAIDs and is basically limited to Tylenol for OTC pain medication

One of my recurring nightmares is the doctor telling me that I can't take ibuprofen any more. I have chronic pain from multiple injuries that never really healed quite right, and unfortunately I'm not a crotchety super-genius like Dr. House so I can't go around popping vicodin like skittles.

As an adult, I've been terrified of tylenol in no small part to hearing horror stories during college about how it would interact with alcohol and murder my soul if I ever took it while I was drinking. While there may have been some hyperbole in those stories, it was enough to scare me off Tylenol pretty much for good.

[Nephrology]

Truth.
I can't get too excited about this issue either, except for the fact that it will likely result in more of the same "common sense" safe guards in other areas. Whose "common sense" will be the benchmark?

The problem I see with creating policies using the "lowest common denominator" approach is that the lowest common denominator keeps getting lower. Ever seen "Idiocracy"? It used to just be a silly, stupid movie. I fear it really was a scary, prophetic documentary.

Just to put this into context, there are already other, safer medications that are sold only in blister packs. Anti-histamines, for example, like diphenhydramine HCl (Benadryl), birth control, etc. There are also a number of other benefits, including increased adherence to a specific medication regimen (in the case of estrogen-derived birth control drugs, it is to ensure that the timing of the steroid hormone dose is appropriate. The days on which no dose is needed, a simple sugar pill is substituted on the date of the drug). Additionally, pseudoephedrine (which is already over-regulated, as someone has pointed out) came in blister packs prior to the highly publicized baseball deaths in the mid-2000s and its subsequent restriction.

To me, it is more surprising that we haven't already begun to sell tylenol in blister packs, if only because its therapeutic index is much narrower than something like Bendaryl, and the potential for harm much higher. Bottom line - I don't really think blister packaging is anything new or worth getting excited about. Well, except for me, obviously, as I spend far too much time thinking about drug dosage and patient adherence as is.... even without the internet's help!

[hufnagel]

So you read the user manual for all of the products you purchase? Besides, I don't think anybody was trying to rope you into being the world's nanny. A change of packaging is not going to really require you to do much at all, unless you are in the pharmaceutical industry. Additionally, your objection doesn't apply to those who are of reduced mental capacity - a common side effect of chronic pain, particularly among those taking prescription narcotics for pain control. Chronic pain has been proven repeatedly to induce confusion and memory loss (http://www.ncbi.nlm.nih.gov/pubmed/23707355). If your mind is so addled by pain that you can't remember the last time you took tylenol, is it really a nanny state move to ask that they come in packaging that makes it obvious how much of the package they've ingetsed?

How do you feel about medications that already come in blister packs? (diphenhydramine HCl/Bendryl, etc) Is that something that you find irksome as well? Or, how about the cardboard slips that protect razor blades? Is that nanny state material, too? Fireproof caps on bottles of high molarity ethanol? Safety bags in cars? I am curious as to where you draw the line, I hope you do not take my questions as disrespectful.

Sure, I agree with you in principle, but I am much more interested in the ends than the means. If it means as a nation we admit far fewer patients with ALF, and pocket the savings, I am all for it.

For the most part, yes. If I have any questions or concerns that's what it's there for, afterall. And if I CHOOSE NOT to read the instructions for a particular item (or medication) and CHOOSE to utilize it without full knowledge then it's MY FAULT if something goes wrong.

Yes most blister packs piss me off. But then I started keeping a sharp instrument in the bathroom to cut them out if needed. If anything the blister packs are MORE dangerous now due to the possible injury I might sustain from the need to use a sharp instrument. Again though it is my CHOICE to use that method of retrieval.

I thought the cardboard around the blades was to keep them from sticking together, and make them package nicer in the box, given the thicker tops they have. The bulk pack ones that are trapezoidal and constant-thickness however have no separation and can be quite interesting to segregate once the "lube" between them gets older. I'm not complaining about it though, I deal with it effectively and safely.

Never seen a fireproof cap on ethanol so no comment there.

While I appreciate the invention of airbags (and before them, seatbelts) and the improvement in accident survivalbility they afford, I do take objection to the culture they created of "oh i drive a SAFE CAR... so I can drive like an asshole." I also have a problem with them being mandated... if a car maker wishes to NOT use them that should be their choice, just as it is MY choice to (not) purchase their car based on the presence or lack thereof of an airbag. Again it's a Nanny State issue. (Note I have commented before about vehicle safety issues, also surrounding the use of helmets for motorcyclists. If Insurance wishes to take issue with your use or lack of safety equipment then that too is their choice as well. You then get to choose cheap coverage, expensive coverage, or no coverage.)

Finally, your questions do not engender feelings of respect or disrespect. :) They are questions. Questions lead to answers (and sometimes more questions.) Answers (and questions) lead to knowledge. Knowledge, and it's effective and appropriate application, is the ultimate goal. My primary point in most of my commentaries is FREEDOM OF CHOICE. Stop taking away my choices.

[ToddG]

Fair enough, but if we're really pushing for personal responsibility, it's incumbent upon the consumer to read the bloody warning labels. If they have to put really big labels on there saying "DO NOT EXCEED RECOMMENDED DOSE OR YOU MAY VERY WELL DIE SCREAMING FROM IRREVERSIBLE LIVER FAILURE", then so be it. At some point people have to be allowed to be their own boss.


Agreed - and the point I was really trying to make. People do all kinds of things that have potentially life ending consequences, but they are free to do that. I know a guy that puts a loaded gun down the front of his pants - just sayin...


High speed, low drag, low information pill popper.

If such a person can't be bothered to take a couple seconds and read the instructions on the proper use/consumption of a DRUG, then the consequences are deserved.

Are you guys also opposed to seatbelt laws and regulations mandating airbags in cars? How about laws requiring parents to use car seats? How about laws requiring people to have their dogs & cats immunized against rabies?

How about regulations that seek to guarantee that our food and water supplies are safe? Or that drugs being offered to the public have to be safe and efficacious?

Heck, how about stop lights? I mean, shouldn't intelligent reasonable adults be able to figure out how to get through a 4-way intersection rationally?

http://www.chicagonow.com/cheaper-than-therapy/files/2011/07/traffic-jam-624x468.jpg

Having a knee-jerk reaction to these things as "OMG Nanny State!" is just silly.

How about some simple, reasonable person assessment?
Benefits of blister packs: reduced chance of accidental death or injury.
Disadvantages of blister packs: uses up tin foil that nanny-conspiracy theorists need

[Byron]

Or that drugs being offered to the public have to be safe and efficacious?
We should go back to the good ol' days™ when you could purchase "Warner's Safe Cure for Diabetes (http://www.fda.gov/AboutFDA/WhatWeDo/History/Overviews/ucm056044.htm)" off the shelf.

[NickA]

We just had a similar situation to what Byron related, with my FIL. Short version is he hurt his back, and at or around the same time had a stroke, which the doctors somehow missed. He was on a heavy dose of ibuprofen (I think), and one day he was just completely out of it, barely coherent. Turns out MIL was accidentally giving him the pills too often (language barrier induced), compounded by the fact that he didn't tell the doc he usually starts each day with a shot or two of tequila (and has for pretty much ever, and that's pretty much the only alcohol he drinks). They got it squared away, but for a day or two he was in a bad way from a bad combo of items found in basically every home.

[Nephrology]

For the most part, yes. If I have any questions or concerns that's what it's there for, afterall. And if I CHOOSE NOT to read the instructions for a particular item (or medication) and CHOOSE to utilize it without full knowledge then it's MY FAULT if something goes wrong.

Yes most blister packs piss me off. But then I started keeping a sharp instrument in the bathroom to cut them out if needed. If anything the blister packs are MORE dangerous now due to the possible injury I might sustain from the need to use a sharp instrument. Again though it is my CHOICE to use that method of retrieval.

I thought the cardboard around the blades was to keep them from sticking together, and make them package nicer in the box, given the thicker tops they have. The bulk pack ones that are trapezoidal and constant-thickness however have no separation and can be quite interesting to segregate once the "lube" between them gets older. I'm not complaining about it though, I deal with it effectively and safely.

Never seen a fireproof cap on ethanol so no comment there.

While I appreciate the invention of airbags (and before them, seatbelts) and the improvement in accident survivalbility they afford, I do take objection to the culture they created of "oh i drive a SAFE CAR... so I can drive like an asshole." I also have a problem with them being mandated... if a car maker wishes to NOT use them that should be their choice, just as it is MY choice to (not) purchase their car based on the presence or lack thereof of an airbag. Again it's a Nanny State issue. (Note I have commented before about vehicle safety issues, also surrounding the use of helmets for motorcyclists. If Insurance wishes to take issue with your use or lack of safety equipment then that too is their choice as well. You then get to choose cheap coverage, expensive coverage, or no coverage.)

Finally, your questions do not engender feelings of respect or disrespect. :) They are questions. Questions lead to answers (and sometimes more questions.) Answers (and questions) lead to knowledge. Knowledge, and it's effective and appropriate application, is the ultimate goal. My primary point in most of my commentaries is FREEDOM OF CHOICE. Stop taking away my choices.

How about blister packs as a useful tool to improve a patient's adherence to medication? For example, in individuals with reduced cognitive abilities due to a medical condition, opiate narcotics or other hypnotics/sedatives, chronic pain, certain chemotherapies, or a combination of all of the above (very commonplace). Do you think that the benefit that these people would get is outweighed by your freedom of choice? How about the sale of blister packs and traditional pill bottles side by side?

Otherwise I agree pretty much 100% with ToddG's previous post, but as ToddG he is entitled to use more snark than I am :)

[LHS]

As a matter of fact, I am opposed to seatbelt and helmet laws for adults of sound mind. I would never ride in a car without a seatbelt, nor a motorcycle without a helmet, but that's MY choice to make.

[Erik]

I do a lot of kidneying around. Urine for a treat.

This is gonna be wicked pisser.

[Nephrology]

This is gonna be wicked pisser.

I take my kidney puns renal seriously.

[RoyGBiv]

As a matter of fact, I am opposed to seatbelt and helmet laws for adults of sound mind. I would never ride in a car without a seatbelt, nor a motorcycle without a helmet, but that's MY choice to make.

But would you support medical insurance companies being allowed to reduce benefits (or charging a premium for providing coverage) to motorcycle riders who choose not to wear a helmet? What about medical coverage/costs for the obese? Smokers?

And back on topic.... how much of this additional inconvenience do we heap on (by legislative or regulatory fiat) those who choose to go uninformed (or make bad decisions despite knowing the risk) vs. allowing market forces to reach a solution independently?

I would argue that government intervention of this type ("Saving me from myself laws"), whether by regulation or by law, on its face, goes far beyond anything the Founders intended. I certainly see a the responsibility of government to inform me, but not prohibit me. Why not limit the FDA to being a watchdog for efficacy and disclosure, rather than todays' role that grants them the power to prevent an informed patient from making an informed decision? (I know it's not Black/White, but it's quicker to type the example that way)

I will give separate consideration to the role of government to regulate things I may choose to do that have a likelihood of harming other people... Driving drunk, building an unsafe building...

[BaiHu]

I'm okay with the gov't over seeing the bulk quantity of goods services for safety's sake such as water supply, food supply, Air Supply (nyuk nyuk), b/c bulk items such as those can have massive consequences on the population instantly.

However, once it gets into the hands of the citizen, back the eff up. Make sure Red Bull isn't poison? Yes, please do. Making Red Bull responsible for little 8 year old Timmy drinking a case of them in one day? Back the eff up.

I believe there is a constant lowering of the bar of what people should be responsible for and it is not good for our species. If you want to solve the problem of dosage mistakes, we already have a solution:

1528

My grandfather had one of these in the early 1980's.

If there's a problem, encourage the market and consumer to fix it, not the gubmint...

[hufnagel]

But would you support medical insurance companies being allowed to reduce benefits (or charging a premium for providing coverage) to motorcycle riders who choose not to wear a helmet? What about medical coverage/costs for the obese? Smokers?


Yes.
Auto insurance companies already adjust your rate based on your age, sex, race, married condition, past history, vehicle driven, mileage usage per year, etc. Health insurance companies do much the same thing, and I believe in many cases should have a wider scope to determination of rates. I also believe that insurance should not be mandatory or compulsory.

[hufnagel]

BaiHu: well put.

[RoyGBiv]

I also believe that insurance should not be mandatory or compulsory.
Trying to wrap my head around that one...
Where does that leave victims of UIM-caused accidents?

If you have no insurance and cause an accident, you're SOL on your own car and open to civil liability for to the victim?
And if you're the victim, you carry UIM to cover you?

Not sure I agree with that, but I'll noodle on it.

[ToddG]

It's interesting watching how different people approach the concept of societal contract.

Let's look at cars again. How about states that mandate cars meet certain inspection standards to be on public roads? That's onerous. One could certainly argue, "I have a right to drive an unsafe car or an unreliable car!"

But what happens when that unreliable car craps out on the GW Bridge at rush hour on Friday evening? How many thousands of people are affected?

What happens when that car with lousy brakes goes off the road and hits a kid on a bike, killing him? Are the parents just going to sue and that will make up for it? And how much money does the guy with no insurance probably have?

I'm fine for getting rid of seatbelt and helmet laws. What I want in exchange is a law that says if I'm in an accident and someone is injured because he wasn't wearing a seatbelt or wearing a helmet, regardless of who is at fault for the accident I cannot be held liable for the injury or any harm that comes therefrom. Lost your $5M/yr job as an eyebrow model because yours are now strewn across fifty feet of asphalt? Tough... should have worn a helmet.

The idea that community-oriented laws only recently trumped uninhibited personal freedom is so utterly bereft of historical accuracy as to be laughable.

[hufnagel]

I'll make comments to the specific sections below, but in general you're mixing cases of one-and-many...

With the original tylenol argument it's a case of a vanishingly small number of people abusing something that the rest of the people seem to utilize correctly. We do NOT need legislation for the vanishingly small quantity of stupid (or suicidal) people. Let them die.

Now for the rest...


It's interesting watching how different people approach the concept of societal contract.

Let's look at cars again. How about states that mandate cars meet certain inspection standards to be on public roads? That's onerous. One could certainly argue, "I have a right to drive an unsafe car or an unreliable car!"

But what happens when that unreliable car craps out on the GW Bridge at rush hour on Friday evening? How many thousands of people are affected?

There should be and are penalties for such blatant failure of social contract. If needed they can be made harsher.

What happens when that car with lousy brakes goes off the road and hits a kid on a bike, killing him? Are the parents just going to sue and that will make up for it? And how much money does the guy with no insurance probably have?

See above comment. Also I'm in favor of indentured servitude for persons who cannot cover their debt caused by such failures of social contract.

I'm fine for getting rid of seatbelt and helmet laws. What I want in exchange is a law that says if I'm in an accident and someone is injured because he wasn't wearing a seatbelt or wearing a helmet, regardless of who is at fault for the accident I cannot be held liable for the injury or any harm that comes therefrom. Lost your $5M/yr job as an eyebrow model because yours are now strewn across fifty feet of asphalt? Tough... should have worn a helmet.

We're already in agreement on this aspect; it falls under the stupid games/stupid prizes mantra.

The idea that community-oriented laws only recently trumped uninhibited personal freedom is so utterly bereft of historical accuracy as to be laughable.

Community-oriented laws that inhibit the many due to the actions of a few should be considered null and void, not to mention a breaking of the social contract between the people and their elected officials with grounds for their removal from office. To me that is what the Bill of Rights was specifically designed to enumerate.

[Kobalt60]

Not just that Todd, but also the taxpayers and hospital patients/insurance companies end up footing the bill for all the vegetables that were coming out of our ER's from not wearing seatbelts and helmets. Somewhere along the way, we got this notion that people who can't afford to pay shouldn't be turned away from emergency services that could save their lives. I'm guessing that Thurston Howell III watched Trading Places or Life Stinks and thought "damn, what if that happened to me and I got hit by a car!" and then thought "they would let me die because I'd lost my wallet!"

Contrary to popular opinion... we've had universal healthcare in this country for decades. Its just horrible and unbelievably expensive.

[Kobalt60]

I'll make comments to the specific sections below, but in general you're mixing cases of one-and-many...

With the original tylenol argument it's a case of a vanishingly small number of people abusing something that the rest of the people seem to utilize correctly. We do NOT need legislation for the vanishingly small quantity of stupid (or suicidal) people. Let them die.

Now for the rest...



Community-oriented laws that inhibit the many due to the actions of a few should be considered null and void, not to mention a breaking of the social contract between the people and their elected officials with grounds for their removal from office. To me that is what the Bill of Rights was specifically designed to enumerate.

At the same time, why require guard rails on balconies or on bridges? Lets get rid of speed limits! Drunk driving laws? bah. Nanny state BS.

[TGS]

Deleted. Read the last half of a sentence wrong.

[Nephrology]

Not just that Todd, but also the taxpayers and hospital patients/insurance companies end up footing the bill for all the vegetables that were coming out of our ER's from not wearing seatbelts and helmets. Somewhere along the way, we got this notion that people who can't afford to pay shouldn't be turned away from emergency services that could save their lives. I'm guessing that Thurston Howell III watched Trading Places or Life Stinks and thought "damn, what if that happened to me and I got hit by a car!" and then thought "they would let me die because I'd lost my wallet!"

Contrary to popular opinion... we've had universal healthcare in this country for decades. Its just horrible and unbelievably expensive.

Indeed. It can be summed up in one word - dialysis.

[John Ralston]

Indeed. It can be summed up in one word - dialysis.

Given that the liver can be so easily damaged with tylenol, would someone who has taken too much already have problems or would it manifest itself later in life?

[Nephrology]

Given that the liver can be so easily damaged with tylenol, would someone who has taken too much already have problems or would it manifest itself later in life?

What do you mean? Acute Liver Failure (ALF) can come about from a single, very high dosage of APAP. Chronic damage can accumulate from excessive APAP intake as well particularly in conjunction with alcohol and other lifestyle considerations and/or underlying medical conditions. Chronic APAP intake has been associated with poorer outcomes than acute, single dose induced ALF in pediatric patients. Neither are good for you. The average amount that any of us probably take for a headache for ore back (1-3g max per diem, 1g max every 4h) is almost always fine*, unless you're topping it off with a handle of rum.


*YMMV and FYI none of this is medical counsel, just a whole lotta internet. Here is a good source of information that is again presented only for entertainment:

http://xa.yimg.com/kq/groups/22038980/2115709304/name/Acetaminophen%2520Hepatotoxicity%2520and%2520Acute %2520Liver%2520Failure.pdf

[John Ralston]

What do you mean?

If you F'ed up your liver, would you already be on Dialysis or would you find out later in life?

[Nephrology]

If you F'ed up your liver, would you already be on Dialysis or would you find out later in life?

Oh. Well, dialysis is a therapy for kidney failure, not liver failure. If your liver is so destroyed that it cannot perform its basic functions you will be in liver failure and your existence will not be fun. There are means by which to manage liver failure but none approach the efficacy with which dialysis replaces your kidneys (and dialysis does not do a super great job replacing your kidneys). Liver transplantation is the only option for those with advance ALF. And that, you would know right away.

[ford.304]

Really seems like more of a cultural education failure to me. Yes, there's a warning label, but there are warning labels on *everything*. In general, most people don't consider tylenol dangerous, in many ways *because* of these overabundance of laws and warnings surrounding other drugs. If I have to pass a background check to buy sudafed, then the stuff I can buy by the 100-pack should be safe, right, whatever the warning label says? Personally I may just be ignorant, but I'd never heard that liver failure from acetaminophen was something you could do without downing the whole bottle. I'll certainly be more careful now that I know this... no blister pack needed.

As for the all of the car comparisons... it's all about what risk you are placing on other people. I feel it's reasonable to restrict direct costs you place on other people. Justifying restriction using indirect costs on other people (as in, I have decided to pay your ER visit, therefore anything that affects your health affects my pocketbook) just seem like a slippery slope with no bottom.

[John Ralston]

Oh. Well, dialysis is a therapy for kidney failure, not liver failure. If your liver is so destroyed that it cannot perform its basic functions you will be in liver failure and your existence will not be fun. There are means by which to manage liver failure but none approach the efficacy with which dialysis replaces your kidneys (and dialysis does not do a super great job replacing your kidneys). Liver transplantation is the only option for those with advance ALF. And that, you would know right away.

That's what I get for trying to make logical statements after 10 hrs in the shop...

[Nephrology]

That's what I get for trying to make logical statements after 10 hrs in the shop...

No worries!