A Simple Way to Reduce Suicides

This article was published, June 2, on the New Times blog and then published in the New York Times, page A21 on June 3. Ezekiel J. Emanuel on health policy and other topics.

Ezekiel J. Emanuel

By Ezekiel J. Emanuel, New York Times, June 2, 2013

Every year about a million Americans attempt suicide. More than 38,000 succeed. In addition, each year there are around 33,000 unintentional deaths by poisonings. Taken together, that’s more than twice the number of people who die annually in car accidents.

The tragedy is that while motor vehicle deaths have been dropping, suicides and poisonings from medications have been steadily rising since 1999. About half of suicides are committed with firearms, and nearly 20 percent by poisoning. A good way to kill yourself is by overdosing on Tylenol or other pills. About 90 percent of the deaths from unintentional poisonings occur because of drugs, and not because of things like household cleaners or bleach.

There is a simple way to make medication less accessible for those who would deliberately or accidentally overdose — and that is packaging.

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.

Sound ridiculous? Consider some data.

In September 1998, Britain changed the packaging for paracetamol, the active ingredient in Tylenol, to require blister packs for packages of 16 pills when sold over the counter in places like convenience stores, and for packages of 32 pills in pharmacies. The result: a study by Oxford University researchers showed that over the subsequent 11 or so years, suicide deaths from Tylenol overdoses declined by 43 percent, and a similar decline was found in accidental deaths from medication poisonings. In addition, there was a 61 percent reduction in liver transplants attributed to Tylenol toxicities. (Although it was a long and detailed study, some studies got a different result. One in Ireland, for example, found no reduction in overdoses.)

Not only can blister packs reduce suicide attempts by adults, but also poisonings of children. After the Food and Drug Administration required blister packaging for iron pills, which cause poisoning death in young children, the number of iron-ingestion calls to poison control centers in the country dropped by about 33 percent and the number of deaths went almost to zero.

Why haven’t we seen more blister packages? One reason is money. Manufacturers would have to redesign packaging, and the blister packaging would cost more compared with loose pills in a bottle. The other main reason is that some consumers — notably people with arthritis — might find it challenging to open the packages.


But considering the tens of thousands of deaths and emergency room visits, these reasons seem a bit feeble. The packaging should be changed.

Previous articles concerning suicide that were published on this blog:
- Canadian study proves that the suicide contagion effect exists.
- Suicide rate in Oregon continues to rise faster than the national average.
- Pro-suicide advocacy in the Globe and Mail.